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Grace Warner, Ph'D'


Grace Warner, Ph.D. Dalhousie University. Integrated Care Conference March 2008 ... communication barriers to implementation. Thank You! ... – PowerPoint PPT presentation

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Title: Grace Warner, Ph'D'

Facilitation strategies enhance the use of
evidence in integrated stroke care
  • Grace Warner, Ph.D.
  • Dalhousie University
  • Integrated Care Conference March 2008

  • Project 1Canadian Stroke Network Atlantic
    Canada Integrated Stroke Strategy (ACISS)
    Research Project
  • Project 2CIHR Knowledge to Action Grant
    Applying Knowledge Translation Theory to Transfer
    Stroke Prevention and Treatment Knowledge to
    Rural Health Professionals.

Problems Implementing this evidence
  • Integrated stroke care requires system level
    changes which in Canada require the support of
  • Provincial politicians ,
  • Provincial health care decision makers,
  • District-level health care administrators, and
  • Practitioners from various sectors.

  • Research evidence has identified practices across
    the care continuum which can improve the chronic
    condition of stroke however, challenges remain
    to implementing this evidence. The two research
    projects evaluated whether facilitation
    strategies increased awareness and use of
    evidence in order to improve stroke care.

Questions we asked ourselves
  • How to apply the evidence from the knowledge
    translation/transfer/exchange literature?
  • How do we measure our efficacy in using this KT
    evidence to affect changes in processes and

Theoretical Framework
  • Research from the Promoting Action on Research
    Implementation in Health Services (PARiHS) model
    has demonstrated that even in contexts that are
    not receptive to new evidence, good facilitation
    can create evidence-based change
  • (Rycroft-Malone, 2002)

Best Practice Guidelines
  • The Canadian Stroke Strategy released best
    practice recommendations for stroke care across
    the continuum in 2006.
  • Recommendations are based on over ten years of
    accumulated evidence.
  • Web site

Project Descriptions
  • Research projects were conducted in primarily
    rural areas of Canada
  • Project one description
  • Facilitation strategy knowledge network
    centralized around a knowledge broker
  • Goal increased awareness of evidence for
    improving stroke care by the health system,
    achievement of specified goals

Project two description
  • Facilitation strategy research partnership with
    district health care system to create interactive
  • Goal increase communication across sectors,
    practitioner increased awareness of best practice
    recommendations for the secondary prevention of
    stroke, identification of barriers to

  • The incidence of a first-time stroke has been
    estimated to be 200 per 100,000 however, if the
    individual has already experienced a stroke (or
    transient ischemic attack (TIA)) the risk
    increases to 17-18 within the first three
    months after the event.
  • (Coull, BMJ 2004)

  • Coordinated interdisciplinary care on specialized
    stroke units (stroke-unit care) improves function
    for persons with stroke.
  • (Stroke Unit Trialists' Collaboration, 2001)
  • Intravenous administration of tissue-plasminogen
    activator (t-PA) within three hours after onset
    of an acute ischemic stroke may alleviate
  • (The National Institute of Neurological Disease
    and Stroke rt-PA Stroke Study Group. 1995)

Project 1-Knowledge Network
  • Provincial network
  • Management team-High level representation from
    Healthcare decision makers and Advocacy
  • Provincial Advisory groups
  • Regional Network of four provinces
  • Research team, regular networking/education
  • National links
  • Information and implementation models

  • Survey on stroke care provided in acute care
    facilities (93 response rate).
  • Most hospitals (81) did not provide thrombolytic
    therapy or have protocols in place to care for
    acute stroke patients (77). Stroke patients
    were usually managed on general medical wards
    where coordinated interdisciplinary care was the
    exception (19) rather than the rule

Provincial Network
  • Management Team
  • Created province-specific goals for increasing
    evidence-informed decision making of their
    provincial health care system
  • Money provided to hire, supervise and direct
    outcomes for Knowledge Broker
  • Provincial Advisory Groups
  • Information resource, dissemination
  • Examined evidence within the provincial context
  • Monitored/informed the work of the Knowledge

  • Three provinces created … a framework for an
    integrated stroke strategy for this
    province…doing some of the baseline data
    collection…and where do we need to be going…
  • One province already had a framework… liaison
    between the partners in fostering communication,
    in identifying various perspectives, and helping
    to develop and enhance that partnership…

Evaluation of Facilitation
  • Case-study methodology evaluated how well the
    knowledge broker centred network facilitated
    attaining goals
  • Qualitative interviews with management team and
    knowledge brokers
  • Triangulation with historical document review

  • Qualitative Themes
  • Contextual environment affected each healthcare
    decision maker ability to make health system
    changes, initial low receptivity to evidence
  • Qualities of a knowledge broker (roles and
    responsibilities, applicable to other situations,
    location, time it took to make change)
  • Knowledge network (management team, provincial
    advisory groups, regional network, national
  • Outcomes (unintended and measured).

Knowledge Broker
  • Roles
  • DOH Rep…It still hinges around a key person
    that can act as a facilitator, an enabler of
  • Effectiveness working within or outside of
    government is more effective
  • DOH rep …it is sort of viewed as a sanctioned
    activity…so they medical community will come to
    the table.

Provincial Network
  • Management Team
  • AO rep I think the relationship between the
    partners was rocky at best in the beginning
    because of the …lack of understanding and respect
    of each persons role…But I have no doubt that
    the Department will continue to work with the
    advocacy organization.

Provincial Network
  • Purpose of advisory committee
  • DOH rep There needs to be an interest at the
    District and a willingness and an understanding
    of how it integrates into work that they
    currently do, and how they can do what they do

Regional Network
  • The importance of regular forums share concerns
    and strategies, provided a unified group for
    national interaction
  • AO rep I dont think it is the policy planner
    knowledge broker so much that has helped the
    project participants ... I think it is the
    research team who has pulled folks together.
  • KB …I think it would be very isolating to have
    done this actually ourselves…I have learned from
    discussions we have had and information they
    share with me.

National Links
  • Provided evidence/information and implementation
  • AO rep So I think what they are able to
    provide…in the high end, the access that they
    have to experts across the country…
  • KB …And we can apply the same concept, best
    practices (call it what you want)... How it
    rolls out in your province, that is where it

Unmeasured Outcomes
  • DOH rep
  • …I think that everyone thinks the key outcome
    of this project is going to be the stroke
    strategy. But you know what? Some of the key
    outcomes of this project are already
    happening…Its so interesting, just by starting
    to talk about what should be happening in the
    system here, and having the right players at the
    table advisory group…the quality of care is
    being improved as we speak.

Measured Outcomes
  • Strategy documents adapting best practices were
    created and presented to governments for funding
  • Relationships created between advocacy
    organization and provincial decision makers
  • Sustainability of Knowledge Brokers-two continued
    working for provincial government on improving
    stroke care, all continue to participate in a
    national roundtable on improving stroke care

Project 2
  • Target Audience- Rural Family Practitioners
  • Facilitation Partnership with district health
    system and creation of interactive workshop
  • Interactive Workshop
  • Created by collaborative team-district-level
    decision makers, specialists and general
  • Local champion promoted change
  • Debated evidence, discussed proposed changes
  • Evaluation
  • Questionnaires/follow up interviews

Context-Gaps in Care
  • Gaps existed in the use of evidence-based
    medications for the secondary prevention of
    stroke in southwestern rural Nova Scotia with
    only 79 of patients receiving an anti-thrombotic
    medication post-stroke, 40 an anti-lipemic and
    71 receiving at least one antihypertensive
    medication. (Sketris in revisions)

  • Decision maker partner
  • District implementing new stroke clinic in
  • District wanted increased involvement of family
  • Resistance of family practitioners to new
  • Local family practitioner engaged as champion
    helped with creation of the workshop and
    recruitment of family practitioners

Interactive workshop
  • Contrast and discuss post-stroke and heart attack
    secondary prevention recommendations
  • Locally derived case-based discussion
  • Presentation of the political environment
    supporting change
  • Discussion of district level stroke clinic

  • Recording of comments during workshop
  • Questionnaire post workshop
  • Follow-up interviews (3-4 months) by phone with
    practitioners, decision maker, champion, and
    research collaborators

  • Comments in workshop (e.g. resistance to stroke
  • Followed up by questionnaire- (e.g. not as much
    support for health promotion recommendations)
  • Followed up with specific questions in
    interviews-(e.g. scope of practice)

Follow-up Interviews
  • Practitioners who participated in workshop
  • Health care decision maker
  • Champion
  • Research partners

  • Communication barriers
  • Between health district and family practitioners
  • Across professions
  • Scope of practice and continuity of care

Disconnect between health district and family
  • Champion
  • I think the health system administrators are
    very focused on primary care and moving things
    forward as out-patient basis, and sort of an
    idealistic approach to healthcare. And the
    healthcare practitioners are very much in the
    moment, here is this individual patient, how can
    we give him care so he doesnt die, and so that
    he does the best he can do, and how can we get
    him placed.

Barriers across professions
  • Family practitioner on research team
  • you have to assure that the people who are in
    control of those pieces of equipment
    radiologists are bought into the whole schema
    of change. Otherwise, theyre operating out of
    their own standards and guidelines, you know… And
    it may not be a question of being aware of the
    guidelines as much as engaged in accepting that
    they other health professionals are a key
    component in the activation of a guideline.

Confusion over scope of practice and continuity
of care
  • Participants commented during the workshop that
    family practitioners often have an established
    history with their patients such that they know
    their patients better than other health
    providers. One participant noted that sending a
    patient to Stroke Clinic, where the family
    physician gets back a brief written summary
    report of findings, may not be the most effective
    way to maximize care with these patients.

Scope of Practice
  • R3 And in terms of counseling on nutritional
    and this and that, I personally dont feel I am
    as qualified as a nutritionist or someone who is
    chronically working with the certain types of
    diets. Like I dont… Even though it would be
    preferable to think that you would take the time
    to do it with them, I dont think that I would… I
    think that that need can be better serviced by
    someone else.

Project Two Results
  • Identified areas of mis-communication
  • Practitioners felt workshop was relevant
  • Workshop discussion resulted in increased
    involvement of practitioners in local guideline
  • Identification of communication challenges
    documented in report and presented to health

Research Limitations
  • Limited sample sizes
  • Qualitative methodology
  • appropriate methodology for evaluation
  • provides rich data
  • methodology respected by medical community?
  • Strategies were time intensive and required
    extensive collaboration

  • The knowledge broker/network increased
  • government awareness of evidence,
  • created communication networks
  • facilitated improvements in care
  • The partnership and workshop increased
  • knowledge of best practice recommendations
  • support for health system changes necessary for
    integrated stroke care
  • identified communication barriers to

Thank You!