Slide by Dr Dave Davis from U of T KTP site
Today
I attended a presentation on the application of Knowledge Management to
changing the behaviour of doctors. The presenter, Dave Davis, a
long-time family doctor himself, accomplished the extraordinary: He
integrated leading-edge thinking about complex systems into a
pragmatic, modest program to persuade, and make it easy for, doctors to
manage knowledge better and hence make more informed, supportable
decisions.
It was the best presentation on knowledge management I have seen in over a decade.
He began, as all good presentations do, with a story that set the context, engaged the audience, and created a sense of urgency. It was the story of Vanessa Young,
who died seven years ago at the age of fifteen as a result of a
reaction to a stomach drug called Prepulsid she was prescribed. The
heart damage this drug can cause to patients with eating disorders was
known to some, but alas, not to her doctor. Vanessa died of knowledge
management failure.
Doctors are a conservative and sometimes
ornery group. They balance what they've learned in medical school,
personal experience, colleagues' experiences and judgements, their own
instincts, and whatever they can glean from current reading and
research they can fit into their schedule. They do their best, though
some do much better than others. Dr. Davis' goal is to help them do
better.
Traditional KM lore has it that you buy and deploy
appropriate knowledge content, processes, and technologies to bring
about 'culture change' and hence make people more effective in their
work. Davis takes a different approach: He starts by trying to
understand why doctors aren't already figuring out how to do their best with what's available. They are, after all, smart, motivated people.
So
he starts by looking for objective measures of the quality care 'gap':
the measurable difference between what is reasonably achievable in a
complex health system and what is actually being achieved. This gap is
analyzed into components:
- underuse of knowledge and tools (e.g. poor diagnosis and treatment of depression, alcoholism, pneumonia, and diabetes)
- overuse (e.g. of antibiotics, tranquilizer prescriptions to seniors)
- frequent misuse or error
Then, the possible sources and causes of the gap are identified:
- problems
originating with the clinician (e.g. age, training, disincentives, poor
self-directed learning skills, inability of some clinicians to
self-assess their knowledge well); there is a model called the Pathman model
that analyzes these problems into four sequential components:
awareness, agreement, adoption and adherence, and identifies reasons
for failures in each component
- problems with the continuing
medical education system (e.g. 'predispositional' just-in-case training
that tells you 'what you should do if' is ineffective, training that
isn't patient-mediated, doesn't have known thought leaders behind it,
or isn't reinforced at point-of-care rarely gets deployed)
- problems in the health care system (we all know about them)
- problems
with the evidence/knowledge (e.g. quality, useful format, credibility,
consistency, complexity of understanding and applying, cost, degree of
change to establish procedures, access)
- problems originating
with the patient or family (e.g. ignorance, unwillingness or inability
to follow a regimen, lack of engagement in their own health management)
The
next step is to identify the best available clinical evidence from the
firehose of research, reports, trials and other data. To do that,
they've created an organization called Guidelines Advisory Committee to
review everything written about the areas where the gap was identified
as being greatest, and assess, endorse and summarize Guidelines based
on research and other knowledge ('evidence') in those areas. You can
see what they've done on the GAC Canada website (take a look, for example, at their review of this Guideline on how to treat endometriosis). These reviews are governed by a rigorous system of evidence assessment called the AGREE system,
and are just one of the mechanisms that the GAC is sponsoring to
improve practices and policies informed by evidence. They are hoping to
extend their reach beyond direct-to-practitioner actions, to include
medical faculty development and curriculum reform, and to help nurses
and pharmacists, and eventually patients as well (though the Guidelines
are carefully written to be understandable and useful to the public,
and they are available to everyone on the GAC website).
And then, they look at what Davis calls the 'barriers' (yes, that's complex adaptive systems language)
to effective use of best available evidence -- i.e. knowledge transfer.
In other words, why are perfectly intelligent clinicians not already
using this best available evidence? Some reasons:
- too much information to keep up with (solution: distill it into endorsed Guideline summaries)
- delivered
just-in-case instead of just-in-time (solution: embed it in tools used
at point-of-care e.g. anaesthesia nozzles that are different sizes so
you can't accidentally connect the wrong gas to the patient's mask)
- not clearly communicated (solution: more effective education programs, multiple communication media)
- not consistently or completely delivered or implemented (solution: coordinated delivery programs)
Davis summarizes all this with his Seven Steps to Better Care:
- Collect
information and gain deep understanding of where the gaps are, what the
possible causes are, and why they are occurring despite the best
intentions of those in the system i.e. know what is happening today and
why
- Identify and collect the best available evidence relevant to each identified gap
- Conduct an analysis of the barriers that preclude this evidence from being effectively used
- Identify interventions, tools, methods and strategies to get around these barriers
- Use a combination of methods and media to communicate and implement these interventions, tools, methods and strategies
- Create
better linkages between the stakeholders in each process, to enable
reinforcement, feedback and evolution of the interventions and capture
additional evidence
- Create continuous measures of effectiveness of these interventions
These
seven steps won't work in every industry or environment, for reasons
I've written about elsewhere (best available evidence, like 'best
practices', only applies in situations where many people are doing, at
least some of the time, very similar activities, like diagnosing or
treating specific diseases). And Davis is pragmatic -- he sees the
value of intuition and personal judgement sometimes overriding what
best available evidence might suggest is appropriate, in specific
situations, as long as the best available evidence has at least been
considered.
I can see this approach working in quite a few
areas, at least by analogy, and I'm already at work seeing if it will
apply in the context of my current work project. If it could save some
of the victims of knowledge management failure, people like Vanessa
Young, it deserves serious study and consideration. In one hour Dr
Davis managed to change my perceptions about what KM can and cannot
achieve. Very impressive stuff.
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