KT08
Banff
June 2008
Sick or what?
A social constructivist view of
collective knowledge
transformation in primary care
practice
John Gabbay
Andrée le May
Levels of knowledge translation
4 Patient
3 Clinician
2 Local policy
1 Centre/ EBP / KT
2
Level 1: (e.g. the “Evidence-based..” movement)
Identify a client-centred problem
Frame a focused question
Search thoroughly for research derived evidence
Appraise the evidence for its validity & relevance
Seek and incorporate users’ views
Use the evidence to help solve the problem
Evaluate effectiveness against planned criteria
3
Level 2: Policy group processes
4
Gabbay, le May, Jefferson et al: Health 2003 Vol 7 283-310
Level 3: The clinician
Practitioners’
“mindlines”
General
Individual
Patient’s
view
5
Gabbay, le May, BMJ 2004;329:1013
Mindlines are:
– internalised collectively reinforced tacit guidelines-inthe-head that clinicians use to guide their practice
– one person’s mental embodiment of their knowledgein-practice
– linked socially and organisationally to other people’s
mindlines
6
Clinical world
Research world
tacit knowledge
Socialisation
Externalisation
explicit
tacit
Research
based
information
knowledge
potential for use
as “knowledge in
practice”
Other worlds
Internalisation
Combination
explicit knowledge
Centre (eg DH)
Patients
Industry
SECI
etc….
(Nonaka & Takeuchi 1995)
Gabbay 2008 (in press)
7
The story so far:
Pt
3 Clinician
Identify a client-centred problem
Frame a focused question
Search thoroughly for research derived evidence
2
Local policy
Appraise the evidence for its validity & relevance
Seek and incorporate users’ views
Use the evidence to help solve the problem
1 Centre/ EBP/ KT
Evaluate effectiveness against planned criteria
8
Design and methods
• Practice: “Lawndale”
– 8-partner GP practice plus 3 nurses and others
– leading-edge practice
– small UK rural seaside town
• Ethnography:
– 2 years surgeries, clinics etc;
– nearly 7 years formal/ informal practice meetings
– observation (participant/ non-participant)
– interviews
• open/ semi-structured
• individual/ group/ multi-professional
• informal discussions / chats
• Brief “check” ethnography in an urban practice
• Thematic analysis
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One finding: multiple roles of GPs, e.g.:
clinical
domain
managerial
domain
public health
domain
professional
domain
diagnosing
managing resources,
personnel and logistics
disease prevention
keeping up to date
prescribing
monitoring and improving
quality
screening
reviewing practice
investigating
developing the IT system
health promotion
teaching and
training
advising and explaining
complying with
contractual and legal
requirements
health education
nurturing collegial
networks
referring
handling the Primary Care
Trust
disease surveillance
promoting general
practice
(e.g. ’union’ work)
advocating
training practice staff
knowing the local
district
sustaining credibility
10
This phase of ethnography (2005-7)
• Monthly practice meetings (multi-professional)
• Aimed at meeting requirements for new GP contract
11
The GP contract to implement
new practice in chronic kidney disease (CKD)
For maximum remuneration for managing CKD:
• Produce a register of all their adult patients with stages 3-5
of CKD (i.e. with an eGFR of <60ml/min/1.73m2)
• >90% have record of their blood pressure
• >70% record blood pressure <140/85
• >80% of CKD registered patients with hypertension on
appropriate treatment or good reason why not.
12
Transferring knowledge via new
contractual arrangements (a caricature)
Identify an area of suboptimal practice
Commission expert evidence based review
Negotiate rigour vs pragmatism
Reduce to key performance indicators
Link desired change to financial incentives
Make financial reward part of new contract
Monitor contract against imposed criteria
13
When is CKD not CKD?
Ensuring that we identify and register
all renal patients will secure QOF
points and ££s
With training we can find ways within
the rules to recode those with eGFR
30-60
Key:
Managerial
Public health
Clinical
Professional
Results of routine screening
will overburden resources with
little or no resulting health
improvement
Results of routine screening will
unnecessarily alarm patients
Our prevalence seems
comparatively low – we may be
missing too many renal patients
Accept all at Stage 3
threshold
It won’t be practicable to carry out all
the required new tests
We need to avoid unnecessary
workload – both within practice and
elsewhere (e.g. the laboratory service
and hospital nephrologists)
Ignore most at Stage 3
It’s generally agreed that US basis of
eGFR makes it unhelpful for elderly
UK populations. And low scores in
Stage 3 are especially dubious. So
why comply?
We are already giving the right
care to most CKD because of
the good follow up on their
related illnesses
We fail patients with high creatinines in ways
that aren’t even mentioned in the QOF
and in other guidelines (e.g. medicines
management). So let’s focus on those, not just
QOF items.
We will become better at managing
patients with renal disease
Maybe we currently fail to identify
renal patients who may therefore miss
out on important follow-up care
But the Practice “has only
had one death from CKD
in the last 10 years!”
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Conclusions
•
•
•
•
•
“Knowledge in practice” = “mindlines”
Multiple cues to amend mindlines
Little direct translation of new knowledge (SECI)
Social, collective construction of mindlines
Mindlines structured, shaped, sustained by
contextual demands, opportunities, constraints
• Linkage between roles, goals, activities and
knowledge-in-practice (missed by this KT)
• The roles being played influence the way the
mindlines are “laid down” and used
• CKD is being reconstructed by this process
Gabbay J, Le May A. In: (Ed) le May A. Communities of practice in health and social care
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2008. Oxford: Blackwell (in press).
Implications for KT Forum:
• Individuals tend to work and learn
collectively (e.g. in communities of practice)
• They transform knowledge, not translate it,
constructing knowledge-in-practice that suits
their complex, multi-role needs
• Inevitably subversion, therefore, of “topdown” KT if it doesn’t suit those complex
needs (as also happened with most top-down
guidelines in our study…)
• Individuals’ use of knowledge-in-practice
needs to be the driving force of KT
• KT needs to start by understanding the
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recipients as active agents