The Toronto East Network Knowledge Champion Project
Colleen McCarthy, Project Manager, The Toronto East Network Knowledge Champion Project
Katie Dainty, Project Administrator, The Toronto East Network Knowledge Champion Project
The Toronto East Network Knowledge Champion Project was designed to cultivate educationally influential hospital physicians to become agents of knowledge translation (KT). The project was a 24-month program of small group workshops and focused on case-based, data-driven learning in topic areas with known gaps between evidence and practice, as well as general skill development in interpreting data, applying evidence effectively, and KT theory. The first cohort of knowledge champions has reported significant changes in some of their participating hospitals, and has formed a community of learning to share best practices across their institutions.
The translation of knowledge from the research community to the practitioner is complex and riddled with challenges. It can take years for research findings to become common knowledge and even longer for practice to actually change. The practice of evidence-based medicine is an ongoing concern within health care as individuals and organizations struggle to review, revamp, and revitalize care practices to reflect up-to-date knowledge generated through research.
Although it is recognized that clinicians should be central to such initiatives, they are rarely personally provided with the tools needed to create and sustain any real change in practice. Yet the literature indicates that "knowledge champions," or educationally influential physicians, can best influence KT by raising awareness and communicating information within their professional networks.1 Such individuals are trusted and respected by their peers and their knowledge, willingness to answer questions, and communication style, are recognized as attributes which informally facilitate KT and practice behaviour change.2
The Toronto East Network Knowledge Champion Project was born out of a hospital-focused utilization review within the departments of medicine in the Toronto East Network (TEN) of hospitals. This review discovered a huge variance in outcomes for similar clinical conditions across the network. While such differences created obvious concern around quality and continuity of care issues, they also created an opportunity to develop an evidence-based education system that would create and support local knowledge champions, potentially reducing costs and improving care across the network.
In partnership with the University of Toronto Knowledge Translation Program, the Canadian Health Information Management Association (CHIMA), and the Canadian Institute for Health Information (CIHI), members of seven TEN hospital departments of medicine designed, implemented and evaluated a program that found, evaluated and disseminated evidence with a capacity to improve care; and provided innovative strategies to incorporate this evidence into daily practice through the development of local knowledge champions.
The KT initiative
The knowledge champion project cultivated physicians who were considered to be educationally influential faculty based on their interest in leading change and by peer nomination—both considered essential attributes in the change process. An education doctoral student specializing in teaching, learning, and curriculum provided the original curriculum design. A fluid framework was initially developed for selecting and designing educational interventions in topic areas where gaps between evidence and practice had been found in the utilization review. Theories of adult education were incorporated into the learning tools, learning needs were continuously evaluated, and both formal and informal learning opportunities were included in the program.
The program involved small group workshops with experts in each topic over a 24-month period. Workshops generally occurred monthly, with an independent module often assigned as follow-up to allow for learning transfer. A case-based, data-driven approach with "just-in-time learning" was used to improve skills such as interpretation of utilization data and evidence, clinical process mapping, identifying and selecting priorities for change, applying evidence for effective improvement, and applied change management and KT theory and applied methodology. Knowledge and content expert teachers were drawn from their fields of expertise. All faculty encouraged interactive, hands-on learning and where possible, allowed for immediate learning application.
One clinician per hospital was chosen to participate, and, as part of the expectations for the program, completed a practice review within their hospital by applying the knowledge from the workshops to determine best practice for a selected case mix group. The physicians sought out data of interest to them and their specialty and were able to study comparative data between hospitals, which provided them with a foundation of evidence with which to begin the change process. At the end of the program the physicians presented their case studies, which included data utilization and KT strategies.
In addition to the formal case studies, physicians were encouraged to bring information or issues from their practices and institutions to provide relevance to their learning and to facilitate continued application of the theory learned after the session. For example, when partners from the Ontario Guidelines Advisory Committee came to present on guideline development, participants brought in examples of guidelines from their hospitals which needed work.
Unique to this initiative is that it was the first inter-hospital project to make use of eCHAP, a secure web-based tool developed by CIHI with powerful query capabilities. eCHAP can provide physicians with the capacity to quickly and easily "drill down" into their hospital's utilization data and carry out comparisons with TEN-specific regional and national comparators. The physicians involved in the knowledge champion project are now able to apply their newly acquired tools to the data in order to support their findings and plan for best practice changes. For instance, some physicians looked into the data and determined that a length of stay variance occurred when patients were admitted on different days of the week. Physicians then compared their care practices to those they found in literature, in guidelines and in affiliated professional organizations.
Paralleled with the educational sessions, inter-professional partnerships between several groups within each hospital were encouraged, such as with health librarians, health record professionals, CHIMA, CIHI, and the Knowledge Translation Program at the University of Toronto. An external vendor, Ovid Technologies, also fully supported the project by enabling the purchase of handheld PDAs for all participating physicians. The PDAs provide easy access to Ovid information database systems, the Guidelines Advisory Committee guidelines and evidence-based medicine resources.
Results of the KT initiative
Participants reported heightened awareness of best practice opportunities and ongoing use of the tools to facilitate use and dissemination of evidence-based medicine.
The most significant measure of success of this project is that it continues to evolve, improve, and spread as the need increases. Participants reported heightened awareness of best practice opportunities and ongoing use of the tools to facilitate use and dissemination of evidence-based medicine to change practice within their home institutions.
Results include an increased understanding of change management for participating physicians, significant practice changes in some hospitals based on the data case studies, and others more actively assessing information to determine where practice changes are required. Participants also reported an increase in questions and interaction from colleagues and that the theories learned were very useful in facilitating other system changes. Most importantly, these physicians formed a learning community. They were able to support each other's efforts and improvements by understanding similar barriers and challenges and by working on solutions together, as a team.
The key to the overall success of this project was the physician commitment, willingness to learn and excitement about the opportunities to expand their knowledge.
The key to the overall success of this project was the physician commitment, willingness to learn and excitement about the opportunities to expand their knowledge and implement evidence-based medicine on an ongoing basis. While some of the physicians received a financial incentive to support their involvement in the program, it is important to note that the physicians who received no incentive remain as involved and active as those who did.
Equally vital to the continued commitment of the knowledge champions was a supportive organizational environment. The organizational support enabled the physician participants to attend meetings, have access to appropriate evidence, review the present practice, and develop and present a case study for change. This, like all things in health care, benefited from teamwork, continuous communication and evaluation, and an understanding of the physicians' environment and work. The role of a project manager or resource support person should also not be minimized, as there must be a dedicated team member who can be focused on moving the work forward and supporting the physicians.
Conclusions and implications
As a result of their work in the knowledge champion project, this group of physicians continues to identify further opportunities to strengthen the translation of evidence-based medicine into practice. Sustainability as a community of learning is evident as the physicians are now developing an e-hospital project which will allow virtual access to best practice guidelines and standardized order sets across the TEN network. The guidelines and order sets will be evidence-based, updated regularly with the click of a button, and easily accessible at the point of care using e-solutions. The commitment of this team to expand cross-institutional sharing of best practices has now been recognized by funding from a peer-reviewed granting agency.
1 Young, J. M., M. J. Hollands, J. Ward, C. D'Arcy, and J. Holman. 2003. Role for opinion leaders in promoting evidence-based surgery. Arch Surg 138:785-91.
2 Wright, F. C., D. P. Ryan, J. E. Dodge, L. D. Last, C. H. Law, and A. J. Smith. 2004. Identifying educationally influential specialists: Issues arising from the use of "classic" criteria. J Contin Educ Health Prof 24:213-26.
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