ORIGINAL ARTICLE
Scotland’s Knowledge Network: translating knowledge into action to improve quality of care A Wales*, S Graham†, K Rooney‡ and A Crawford§ *Programme Director for Knowledge Management, NHS Education for Scotland, Glasgow, Scotland, UK; †Senior Knowledge Manager, NHS Education for Scotland, Glasgow, Scotland, UK; ‡Professor of Care Improvement and Consultant Anaesthetist, University of the West of Scotland and NHS Greater Glasgow and Clyde, Royal Alexandra Hospital, Paisley, Scotland, UK; §Head of Clinical Governance, NHS Greater Glasgow and Clyde, Southern General Hospital, Glasgow, Scotland, UK E-mail:
[email protected]
Abstract The Knowledge Network (www.knowledge.scot.nhs.uk) is Scotland’s online knowledge service for health and social care. It is designed to support practitioners to apply knowledge in frontline delivery of care, helping to translate knowledge into better health-care outcomes through safe, effective, person-centred care. The Knowledge Network helps to combine the worlds of evidence-based practice and quality improvement by providing access to knowledge about the effectiveness of clinical interventions (‘know-what’) and knowledge about how to implement this knowledge to support individual patients in working health-care environments (‘know-how’). An ‘evidence and guidance’ search enables clinicians to quickly access quality-assured evidence and best practice, while point of care and mobile solutions provide knowledge in actionable formats to embed in clinical workflow. This research-based knowledge is complemented by social networking services and improvement tools which support the capture and exchange of knowledge from experience, facilitating practice change and systems improvement. In these cases, the Knowledge Network supports key components of the knowledge-to-action cycle – acquiring, creating, sharing and disseminating knowledge to improve performance and innovate. It provides a vehicle for implementing the recommendations of the national Knowledge into Action review, which outlines a new national approach to embedding knowledge in frontline practice and systems improvement. Keywords: knowledge translation, knowledge management, knowledge network, quality improvement, communities of practice Knowing is not enough; we must apply. Willing is not enough; we must do. —Johann Wolfgang von Goethe (1749–1832)
Introduction Scotland’s Healthcare Quality Strategy1 sets out a vision of Scotland as a world leader in health-care quality. Its ‘quality ambitions’ based upon the Institute of Medicine’s internationally recognized six dimensions of health-care quality – namely, health care that is person-centred, safe, effective, efficient, equitable and timely.2 A large study from the USA reports that the ‘defect rate’ in the technical quality of health care is 45%, in other words, only 55% of patients are receiving the recommended care.3 In the Netherlands, it has similarly been estimated that 30– 40% of health care is not based on best available scientific evidence.4 Lomas et al. 5 calculated a five-year gap between publication of guidelines and changes to routine practice in Western health-care systems. Addressing these challenges to realize the Quality Strategy ambitions for Scotland depends on enabling clinicians to translate knowledge more effectively into reliable decisions and actions in frontline delivery of care. DOI: 10.1258/smj.2012.012122
During 2011, National Health Service (NHS) Education for Scotland (NES) reviewed The Knowledge Network (www.knowledge.scot.nhs.uk) – its national online knowledge service for health and social care – to optimize its support for translating knowledge into action to support the aims of the Quality Strategy. The Knowledge Network aims to be the resource of choice for NHS Scotland’s frontline clinicians and service managers to find, share and use knowledge to improve quality of care. It is designed to support key stages of the cycle of translating knowledge into practice as outlined by Straus et al.6 – creating, acquiring and disseminating knowledge, to manage and expedite the flow of knowledge into practice.
Overview of Knowledge Network support for health-care quality The Knowledge Network provides a single, integrated point of access to over 12 million quality-assured information and learning resources – evidence, guidance, journal articles, books, e-learning and other web resources. These are organized into topic areas and portals to support specific audiences and health-care issues. This organized Scottish Medical Journal 2012; 57: 221 –224
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access to knowledge is complemented by online community and social networking tools to support creation, exchange and dissemination of knowledge. In order to help embed knowledge in safe, effective, person-centred care as outlined in the Quality Strategy, during 2011 the Knowledge Network optimized its provision of ‘know-what’ – i.e. validated evidence and guidance for safe and effective care – and ‘know-how’ – i.e. evidence about effective implementation methods – together with tools, measures and examples to support implementation. This combination of knowledge about interventions and about implementation creates the capacity for the Knowledge Network to facilitate improvement in practice rather than being solely a repository of knowledge.
‘Know-what’: research evidence for effective interventions The Knowledge Network aims to support frontline clinicians in responding to questions arising at the point of care. Estimates of frequency of clinical questions range from 0.23 to 1.27 per patient in different specialties and circumstances, with an average of 0.47 per patient.7 Clinicians seek solutions for only 29–57% of these questions, but an estimated 35% of their unanswered questions would have a substantial impact on their patient management decisions.8 – 10 The strongest determinants for clinicians pursuing a question arising at the point of care are: time required for retrieval; perceived availability of an answer and importance of the question.11 Clinicians’ perception that no answer is available, and therefore that it is often not worth following up questions is partly due to gaps in awareness or usage of available knowledge sources.11 Time is the most critical factor – speed of retrieval takes precedence over the quality and relevance of the information for clinicians in the practice setting.12 Knowledge should be presented to the clinician within a maximum of two minutes of identifying the need.13 Sackett’s14evidence cart study suggested that knowledge had to be accessible in less than 30 seconds in order for it to be used at the bedside. The Knowledge Network aims to address the challenge of speed of retrieval from the complex, dispersed knowledge base of health care by providing a focused Google-type ‘Evidence and Guidance’ search option. This search filters out from the global Knowledge Network search only quality-assured evidence, guidance and best practice. Sources integrated into this search range from Royal College and Society guidelines to Scottish Intercollegiate Guidelines Network (SIGN) and other Healthcare Improvement Scotland (HIS) resources, National Institute for Health and Clinical Excellence (NICE), Health Protection Scotland, the Cochrane Library, the English NHS Evidence collections, and licensed resources such as Dynamed and the Joanna Briggs Initiative. It prioritizes ‘actionable knowledge’ – validated evidence with clear recommendations and support for immediate application to practice. All resources in this search are immediately accessible Scottish Medical Journal
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without any requirement for a password within NHS Net in Scotland. The search results ranking algorithm ensures that the most relevant results come to the top of the list, and filters enable users to select resources relevant to the Scottish context whenever possible (e.g. SIGN and HIS). The evidence shows that 38% of clinical questions are likely to be about therapy, 24% about diagnosis and 11% about medicines.15 The Knowledge Network’s Evidence and Guidance search therefore provides a ‘Stages of Care’ filter which allows clinicians to focus in on content relevant to a particular stage of the patient journey. The Evidence and Guidance search incorporates all content from the British National Formulary and British National Formulary for Children as well as the European Medicines Compendium and other medicines information sources. The Knowledge Network recognizes that, in reality, even improving efficiency of retrieval of actionable knowledge in these ways, not all clinical questions can be answered in the ideal two minutes. Research shows that summarized sources of evidence may only answer a disappointing 20% of complex clinical questions and less than 50% of general care management questions.16 The primary literature sources such as MEDLINE, which call for more specific, time-consuming searches, answers 95% of the complex questions and 85% of the general clinical management questions. In order to support clinicians who cannot find answers quickly enough using the Evidence and Guidance Search, the Knowledge Network therefore also offers a librarian-mediated online clinical enquiry service (CLEAR www.knowledge.scot.nhs.uk/ clear) managed by information specialists in HIS in partnership with the NHS librarian network. In addition, where the focused Evidence and Guidance search does not provide an adequate response, clinicians can readily re-run their query on the wider knowledge base of primary research and other sources provided by the full Knowledge Network. They may also access any of the portals providing in-depth knowledge support for key issues in safe, effective, person-centred care (e.g. care of older people, early years and dementia).
‘Know-how’: evidence from experience and support for implementation Improving quality of care depends as much on knowledge from practice and experience as it does on published research knowledge. ‘Know-what’ helps the clinician answer the question ‘Can this intervention work?’, while ‘know-how’ answers the question ‘Can it work here, for this patient?’ or, more importantly, ‘How can I make it work better, in this context and for this patient?’ The Knowledge Network search and topic areas therefore provide access to narratives and examples of innovation and implementation, from the UK (e.g. from NHS Institute for Innovation and Improvement) and the international arena (e.g. from the Institute of Healthcare Improvement [IHI]). The human dynamics of communication and collaboration are key enablers of translating knowledge into practice. These depend on the sharing and articulation
Scotland’s Knowledge Network
of ‘tacit’ knowledge from experience. The Knowledge Network provides NHS Scotland health-care staff with access to NES’s Community Builder Toolkit, which provides social networking (Web 2.0 technology) tools to enable communities, networks and collaboratives to work and learn together, share resources, expertise and experience of efforts to implement improvement locally. Examples of such communities include: the Scottish Patient Safety Programme Fellows (http://www.knowledge. scot.nhs.uk/spspfellows); the Scottish Patient Safety Paediatrics Programme (http://www.knowledge.scot. nhs.uk/spsppaediatricprogramme) and the Improving Primary Care Community (http://www.knowledge.scot. nhs.uk/sipc-participants2). The Knowledge Network’s focus on applied knowledge to support frontline improvement calls for new types of knowledge, in ‘actionable’ format, designed for use as part of day-to-day clinical workflow. The Point of Care Knowledge area (http://www.knowledge.scot.nhs.uk/ home/point-of-care) offers a range of services providing summaries of evaluated evidence for doctors, nurses and
Box 1 How does the Knowledge Network support frontline improvement? A case study Clostridium difficile infection rates have been falling in Scotland, and Richard, a Senior Charge Nurse responsible for a General Ward in a busy acute hospital, wants to ensure his team are doing all they can to keep the risk of C. difficile infection to a minimum. Richard initially tries a Google search for ‘Clostridium difficile’ which provides over a million results, from a bewildering mix of sources, many of questionable quality. A colleague suggests that he tries the Knowledge Network, which focuses on best quality evidence for clinical decisions and implementation. He chooses the ‘Evidence and Guidance’ search option on the Knowledge Network homepage, and enters the phrase ‘Clostridium difficile.’ He receives 55 search results which are accompanied by filters to refine his search. Richard can quickly identify many resources that will be of use to him, including an Evidence Bundle, Evidence Summaries and Quality Improvement resources from Health Protection Scotland and HIS. He selects the ‘Evidence Bundles’ filter and goes to the Health Protection Scotland resource which advise him of all the bundle elements, which if applied collectively, reliably and continuously will minimise the risk of C. difficile infection. The search results also provide him with a number of practical tools, such as the C. difficile Infection Trigger Tool and the Hand Hygiene monitoring tool from Health Protection Scotland. Richard returns to his ‘Clostridium difficile’ search results page, selects the ‘Quality Improvement Resources’ filter and identifies an improvement story published by IHI. Equipped with new information and ideas for implementing practical changes within his ward, Richard wonders what others are doing with respect to minimizing C. difficile infection in their workplace. Richard accesses the Communities area of The Knowledge Network and discovers a number of Infection Control communities where colleagues in other parts of NHS Scotland share their accounts of improving infection control. He summarizes his findings and prepares a presentation to share them at the next Senior Charge Nurse meeting.
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allied health professionals. It offers a gateway to mobile health-care knowledge resources (http://www.knowledge. scot.nhs.uk/home/tools-and-apps/mobile-knowledge), including the Knowledge Network’s Mobile Decision Support Search (m.decisionsearch.scot.nhs.uk) of international evidence and guidance. This area is being developed to incorporate local guidelines and pathways, and can also be embedded in web browsers. At the heart of organization-wide quality improvement in health care is the need to build knowledge for improvement that complements knowledge about clinical practice. The Knowledge Network supports the ‘profound knowledge’, or knowledge required for improvement, as defined by Deming in terms of four dimensions:17 appreciation of a system, knowledge of variation, theory of knowledge and knowledge of human factors. Its Google-style technology draws into one place guidance, learning resources and practical tools for innovation and improvement from many sources, including the IHI, the NHS Institute for Innovation and Improvement, the Scottish Government Improvement and Support Team, NES, HIS, the Scottish Government Quality and Efficiency Support team (QuEST) and the National Patient Safety Agency. In June 2012, the Quality Improvement Hub portal (www. qihub.scot.nhs.uk) was launched within the Knowledge Network. This portal has been developed by the Quality Improvement Hub partners who collaborate to build capacity and capability for quality improvement across NHS Scotland – NES, HIS, Health Scotland, the Information and Statistics Division and QuEST. At the heart of the Hub portal is a Knowledge Centre which brings together guidance, tools and learning resources for implementation and improvement (Box 1).
Looking to the future: a framework for getting knowledge into action to improve quality of care The strategic vision behind the Knowledge Network is of a knowledge management system which enables clinicians not only to access but also to apply best knowledge into practice at the point of care.18 It already provides several core components of the knowledge translation cycle: † Acquiring knowledge: through its powerful search and integration platform, harvesting knowledge about effectiveness and implementation into one place. † Creating and capturing knowledge: from experience (tacit knowledge) – through narratives of patient and practitioner experience; support for communities expressing their experience of implementing change in practice; and sharing local resources and tools for implementation. † Sharing and disseminating knowledge: through the collaboration and knowledge exchange tools within the community builder toolkit. † Performance and innovation: all the preceding stages of knowledge translation culminate in application of knowledge to achieve innovation and improve performance. The implementation, change management tools and Scottish Medical Journal
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learning resources within the Knowledge Network support this final goal of delivering beneficial change in practice. Community websites such as Leading Better Care and Releasing Time to Care already provide outcome measures to evaluate delivery of change, and the intention is to expand this focus on measurement in future. The Knowledge Network will provide a central vehicle for implementing the recommendations of the NHS Scotland Knowledge into Action Review.19 This review aimed to design and test a new knowledge management system which goes beyond accessing and organizing information to bridge the knowledge – practice gap, by: † Enabling practitioners to apply knowledge to frontline practice to deliver better health care; † Embedding knowledge in health-care improvement. The review defines a new knowledge into action model based on combining research knowledge, which forms the mainstay of evidence-based practice with the improvement knowledge derived from practice and experience. It recommends a change package of key activities which the evidence base indicates can help to translate knowledge into practice.20 Key elements of this change package include: † Provision of knowledge in actionable format for embedding in day-to-day clinical practice (e.g. clinical pathways, decision support, evidence bundles and mobile apps); † Facilitating social exchange and dissemination of knowledge (e.g. through communities of practice, social networking and educational outreach). Future development of the Knowledge Network will focus on supporting this model and these activities by enhancing its support for: † Capturing knowledge from practice and experience (e.g. practitioner and patient narratives, and combining this with research knowledge); † Creating and publishing actionable knowledge; † Person-to-person sharing and spreading knowledge within communities and networks.
Conclusion The Knowledge Network breaks new ground, and provides a model for future knowledge services by combining clinical and improvement knowledge. It helps to support clinicians through the stages of translating knowledge into action in order to improve the quality of care in frontline practice. It lays foundations for a composite knowledge base derived from research, practice and experience, relevant equally to safe and effective clinical practice and to implementation and improvement. Its community tools for communication and collaboration engage clinicians in working and learning together to create, capture and disseminate knowledge, expediting the flow of knowledge into change in practice. In all these ways, the Knowledge Network helps to bring together the worlds of evidence and implementation, supporting evidence-based practice rooted in an understanding of context, and of patient and practitioner experience. Scottish Medical Journal
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Grounding delivery of care in knowledge of effectiveness and implementation in this way provides a strong foundation for realising Scotland’s ambitions to become a world leader in health-care quality. The Knowledge Network is a key service which supports clinicians to embed knowledge in safe, effective and person-centred delivery of care.
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