Responding from Within: Women and Self-Harm

Full text

CIHR Institute of Health Services
and Policy Research
Evidence in action,
acting on evidence
A casebook of
health services and policy research
knowledge translation stories

CIHR Institute of Health Services
and Policy Research
Evidence in action,
acting on evidence
A casebook of
health services and policy research
knowledge translation stories

2
Canadian Institutes of Health Research
160 Elgin Street, 9th Floor
Address Locator 4809A
Ottawa, ON K1A 0W9 Canada
Also available on the Web in PDF and HTML formats
© Her Majesty the Queen in Right of Canada (2006)
Cat. No.: MR21-71/2006E-PDF
ISBN: 0-662-42562-6

3
TABLE OF CONTENTS
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Knowledge translation and patient safety: The Canadian Adverse Events Study . . . . . . . . . . . . . . . 9
Knowledge translation for practice change in children’s mental health . . . . . . . . . . . . . . . . . . . . . 13
A collaborative model of knowledge translation for sustainable practice change . . . . . . . . . . . . . . . 19
Developing a model for the shared care of chronic disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
SEARCH Canada: Building capacity in health organizations to create and use knowledge . . . . . . . 27
Responding from within: Women and self-harm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
A community-researcher alliance to improve chronic wound care . . . . . . . . . . . . . . . . . . . . . . . . . 37
PRISMA: Developing integrated services delivery for functional autonomy . . . . . . . . . . . . . . . . . . 43
The Canadian Neonatal Network™—a novel model for knowledge translation . . . . . . . . . . . . . . 47
Academic detailing in the Alberta Drug Utilization Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Piloting knowledge brokers to promote integrated stroke care in Atlantic Canada . . . . . . . . . . . . . 57
The Toronto East Network Knowledge Champion Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Advancing the nurse practitioner role in British Columbia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Adopting medication reconciliation and seamless care services . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Nation-wide knowledge translation to promote research on seniors’ independence . . . . . . . . . . . . 75
KT in action: Manitoba’s The Need To Know Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
On the rock, in a hard place: Challenges in working with advocacy and care provider groups . . . . . 85
Exploring culturally respectful care in Aboriginal communities . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Guideline dissemination through integrated care networks: Lessons from Ontario’s best practice
guidelines for stroke care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
CanChild Centre for Childhood Disability Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Expanding established knowledge translation networks to respond to a community in distress . . . .103
A multidisciplinary, multi-sectoral alliance to improve drug use in Nova Scotia . . . . . . . . . . . . . . .107
Using an ambassador program to improve the management of chronic pain . . . . . . . . . . . . . . . . .113
A collaborative evidence-based approach to improving workplace health and safety . . . . . . . . . . . .117

4
ACKNOWLEDGEMENTS
The CIHR Institute of Health Services and Policy Research (IHSPR) would like to acknowledge the following
individuals for their generous contribution of time and expertise to the inaugural IHSPR Knowledge
Translation Casebook.
•
The core project implementation team, including Michelle Gagnon, for overseeing and leading the project;
Heidi Matkovich, for working closely with the case authors, IHSPR Institute Advisory Board (IAB)
members, and staff to edit the Casebook; Leanne Moussa, for strategic communications advice; Lori Greco
and Liz Stirling, for knowledge translation expertise and support; and Kim Gaudreau, for assisting with the
case abstract review process.
•
The Casebook review committee, including Irving Gold, Suzanne Lawson, Anne McFarlane, and
Laurence Thompson (committee chair) from IHSPR’s IAB Knowledge Translation Working Group; and
Michèle O’Rouke and Heidi Matkovich, IHSPR staff, and Liz Stirling, CIHR Knowledge Translation
Branch, for reviewing the case abstracts.
•
Morris Barer, Scientific Director, IHSPR, Diane Watson, Associate Director, IHSPR, and
Laurence Thompson, member of the IHSPR Institute Advisory Board, for their advice and support.
The views expressed in this report do not necessarily represent the
views of the Canadian Institutes of Health Research.

5
CIHR MANDATE
The Canadian Institutes of Health Research (CIHR) is the Government of Canada’s agency for health research.
CIHR’s mission is to create new scientific knowledge and to catalyze its translation into improved health,
more effective health services and products, and a strengthened Canadian health care system. Composed of
13 Institutes, CIHR provides leadership and support to close to 10,000 health researchers and trainees
across Canada.
IHSPR MANDATE
The CIHR Institute of Health Services and Policy Research (IHSPR) is dedicated to supporting innovative
research, capacity-building and knowledge translation initiatives designed to improve the way health care
services are organized, regulated, managed, financed, paid for, used and delivered, in the interest of improving
the health and quality of life of all Canadians.

6
FOREWORD
Knowledge translation (KT) is a broad concept, encompassing all steps between the creation of new knowledge
and its application to yield beneficial outcomes for society. Successful KT strategies can include linkage and
exchange, communication and education, policy change, and program and practice improvement initiatives.
CIHR’s vision of successful KT is the exchange, synthesis, and ethically-sound application of knowledge within
a complex set of interactions among researchers and users—to accelerate the capture of the benefits of research
for Canadians through improved health, more effective services and products, and a strengthened health care
system. A core element of CIHR’s knowledge translation strategy is to support and recognize KT excellence,
and to act as a KT resource for Canada.
In early 2005, the CIHR Institute of Health Services and Policy Research issued a call for knowledge transla-
tion “stories” that illustrated both successful and less than successful examples of the collaborative development
and practical use of health services and policy research. We wanted to encourage and recognize KT activity and
provide a vehicle for publishing and sharing lessons from KT experiences.
We also wanted to highlight the potential impact of health services and policy research evidence in shaping
policy and practice change. There is growing interest among health services organizations, individual
researchers, and decision makers in learning more about KT experiences that lead to a greater understanding of
KT in action and its better practices.
We invited individuals, teams, and organizations working in health care services and policy, particularly in the
national priority areas for research and knowledge translation identified in Listening for Direction II,
*
to con-
tribute to this KT Casebook.
†
Cases were selected based on review of the abstracts submitted.
The collection represents a broad cross-section of experiences—from the preliminary development of partner-
ships for future knowledge translation in Aboriginal communities, to the use of established knowledge transla-
tion networks to rapidly respond to a community in crisis. Widely-acclaimed KT models, like SEARCH
Canada, PRISMA and Manitoba’s The Need to Know Team, are showcased, but the Casebook also highlights
efforts to develop new kinds of partnerships: between researchers and community-based organizations; between
researchers and advocacy groups; and between multiple partners and dedicated KT brokers and champions.
The cases in this Casebook are first-hand, personal stories. We asked contributors to be frank about their suc-
cesses and failures, and to report, from their own experiences, what worked, what didn’t and the lessons they
learned. This Casebook is not intended to be a replacement for insights gained from systematic reviews of the
growing knowledge translation literature. But many of these stories echo common themes about conducting
KT in the Canadian context.
* Listening for Direction II was a national consultation on health services and policy issues for 2004-2007.
The final report is available at http://www.cihr-irsc.gc.ca/e/20461.html.
†
The CIHR Institute of Population and Public Health, in partnership with the
Canadian Population Health Initiative, has concurrently produced a Knowledge Translation Casebook.

7
Lessons learned
• Effective KT requires long-term, sustained relationships. Such relationships are rarely well supported
by current funding models and mechanisms. Some of the most successful examples of KT have leveraged
existing relationships into funded programs with embedded KT aims. But in the initial stages of a KT
initiative, competitive funding cycles can create unrealistic timelines for building trust, understanding,
and common goals. This is particularly the case for activities with community partners, where a
significant front-end investment in time may be required to establish mutual understanding of
unfamiliar contexts, needs, and expectations.
• KT activities are nourished by face-to-face interactions. In almost all of the cases profiled here, some
form of in-person interaction between partners was crucial for success. Personal contact with
practitioners is the most valuable form of KT, particularly in training and educational initiatives. Yet it is
also one of the most costly and time-consuming elements of a KT strategy, and again, often not
adequately supported through existing funding models.
• KT is often conducted off the side of the desk. Frequently, KT is sustained by little more than a
personal commitment to the research, to practice change, or to a community, and with full recognition
that these activities are unlikely to be recognized by academic promotion and tenure committees.
Without belittling the need for change in this area, it is also worth noting that one of the benefits of
working in a partnership is the resulting synergy that can help fill resource gaps and provide less
tangible “job satisfaction.”
• KT activities alone are often not enough to effect change. KT must take place within supportive
organizational climates. Decision-making partners must have an interest in the research and the capacity
to absorb evidence. They must understand its implications for the specific decision-making environment
and be interested in engineering evidence-based change. Executive-level buy-in is crucial for KT
designed to effect program and policy changes. Building individual capacity to develop and use research
knowledge has far greater benefit within an organization that encourages individuals to use such
knowledge to make practice and program improvements.
• Peer-initiated change plays a major role. One important organizational element to consider, particularly
for training and education initiatives, is the role of peer-initiated change. At least three cases in this
Casebook focus on activities that utilize respected peers to promote the uptake and use of research
knowledge to influence practice change. Outside of an individual organization, front-line practitioners
can also independently pilot new, evidence-based practices and facilitate their uptake through peer
networks and member associations.
• KT activities can be too successful. It is encouraging, in one way, that the authors of two cases in this
Casebook were compelled to note that KT activities can be too successful. Partner organizations can
implement research findings prematurely, or respond wholeheartedly to identified problems before the
necessary research is complete. These important lessons signal a welcome maturity in the current level of
KT being conducted across the country.

8
We hope that this Casebook becomes a valuable resource for the diversity of health services and policy research
communities in Canada. While we intend that this will be the first of many such efforts to illustrate health
services and policy research-related knowledge translation in Canada, it is a pilot project, and will be evaluated
for its usefulness as a source of information about KT in action. We therefore welcome your comments on con-
tent, presentation, distribution, or any other aspects of this project.
Morris Barer
Scientific Director
CIHR Institute of Health Services and Policy Research

9
KNOWLEDGE TRANSLATION AND PATIENT SAFETY:
THE CANADIAN ADVERSE EVENTS STUDY
G. Ross Baker, PhD, University of Toronto
Peter Norton, MD, University of Calgary
Virginia Flintoft, MSc, University of Toronto
The Canadian Adverse Events Study was the first national study of adverse events in Canadian hospitals.
Learning from the controversy surrounding similar studies in other countries, the team engaged in extensive
knowledge translation (KT) activities throughout the life of the project. Using meetings, web-based communica-
tion, and other tools, the team successfully prepared most Canadian stakeholders for the study release, allowing
them to develop anticipatory patient safety initiatives. However, upon publication, the policy spotlight quickly
shifted to other issues and the long-term commitment needed to create safer health care is still uncertain.
Background
In the spring of 2002, a group of researchers from seven universities across Canada received funding for the
Canadian Adverse Events Study,
1
the first national study of adverse events in Canadian hospitals. Adverse
events are unintended injuries or complications that result in disability, death, or prolonged hospital stay, and
are caused by the care that patients receive, not an underlying disease or condition.
Studies of adverse events in other countries have uncovered unanticipated levels of injury—and have often had
unexpected effects. Premature announcement of the results of the Australian study by the country’s federal
minister of health soured relationships between the Australian Medical Association and the federal government
for several years. In the United States, the Harvard Medical Practice Study had little policy impact when it was
released in 1991. But data from this and other studies became a major news story in 1999 when they were
used to create the headline-grabbing press release of a report from the Institute of Medicine (IOM) that stated
between “44,000 to 98,000 Americans die in hospitals each year as a result of medical errors.”
2
Recognizing that the Canadian study would likely have a major impact on health care organizations and pro-
fessionals, the funders—the Canadian Institute of Health Information (CIHI) and CIHR—worked with the
research team to develop a KT strategy designed to prepare Canadian stakeholders for the release of the study.
The KT initiative
The goal of our KT strategy was to ensure that decision makers, representatives of
the health professions, health system managers, and through them, the general
public, would be informed of the study and its progress on an ongoing basis.
Bringing these groups together would also stimulate each organization’s efforts to
develop appropriate responses to the study and anticipatory initiatives.
Our activities began with the distribution of a media release to over 1,500 media
sources in French and English Canada shortly after funding for the study was
awarded. In June 2002, an invitational forum was held in Ottawa for national
stakeholders. The focus was on sharing knowledge from similar studies carried out
in other jurisdictions, and on defining issues that the study might generate for each
organization. CIHI also opened an interactive website to update stakeholders on
the progress of the research, which was maintained during the entire project.
Despite the large
number of media
stories across the
country, few
Canadians knew
much about the
adverse events study
and its results.

10
Knowledge translation and patient safety: The Canadian Adverse Events Study
A year later, in May 2003, a second forum for the same group of stakeholders was held to provide an update.
Participants were also given an opportunity to work in small groups to share information about their patient
safety policy planning and intended responses to the upcoming publication of the study. By this time, a num-
ber of organizations had already begun policy and educational initiatives designed to improve the knowledge
and skills of practitioners, managers and policy makers about patient safety.
On January 12, 2004, the principal investigators of the study, Drs. Ross Baker and Peter Norton, held a
webcast to update stakeholders on the progress. Discussions were already underway at this time with the
editors of the Canadian Medical Association Journal (CMAJ) to secure an agreement for expedited review and
publication of the study.
By mid-April 2004, the study’s publication date had been set for May 25, 2004. CMAJ policy was to provide
the media with embargoed copies of articles appearing in the journal one week prior to publication. So, on
May 20, members of the research team and representatives from CIHI and CIHR briefed the press and key
stakeholders on the results. The rate of adverse events for patients in Canadian hospitals was 7.5%, higher than
that found in similar U.S. studies, but lower than the rate reported in the Australian study. Just as important
was the level of disability and death associated with adverse events that indicated a considerable illness burden.
The paper appeared as scheduled on May 25, 2004 in the CMAJ, but news of the results were leaked three
days earlier when journalists from The Edmonton Journal and The National Post broke the embargo. Because
these papers had published the key results of the study, reporters from other media outlets had to scramble to
write stories on different aspects of the findings. Despite this, the study generated significant media coverage.
Drs. Norton and Baker each gave approximately 20 interviews, and more than 28 newspaper stories, 47 radio
items, and 19 TV news items were written or broadcast about the study. However, the announcement of the
federal election that weekend truncated the news coverage. An analysis by CIHI of the perceptions of major
news events in that period discovered that, despite the large number of media stories across the country, few
Canadians knew much about the adverse events study and its results.
Results of the KT experience
The success of the KT efforts linked to the Canadian Adverse Events
Study must be judged by the extent to which key stakeholders were
aware of the study results, and by the short- and long-term impacts on
patient safety policy initiatives.
In terms of the first question, the level of stakeholder knowledge about
the study, the KT efforts were largely successful. Representatives from
more than 35 ministries of heath, national professional organizations,
regulatory and policy authorities, and non-government organizations
attended the two stakeholder forums in 2002 and 2003. A large num-
ber also participated in the 2004 webcast. Feedback from the early
events was used to improve the interaction between stakeholders and
the researchers in later meetings and communications.
A count by CMAJ showed that the paper was downloaded from their website more than 25,000 times in the
first four days after its publication, a level of activity never before seen at the journal. In the year following
publication, the study team authors gave more than 50 presentations at meetings of professional groups and
health care organizations, and many more presentations to smaller groups of researchers, managers, and practi-
tioners. However, while practitioners and policy makers were clearly aware of the study and its results, the
abbreviated press coverage meant that the public were largely uninformed.
While practitioners and
policy makers were clearly
aware of the study and its
results, the abbreviated press
coverage meant that the
public were largely
uninformed.

11
Knowledge translation and patient safety: The Canadian Adverse Events Study
Work by many organizations in the two years between the first stakeholder forum and the release of the study
helped to advance patient safety efforts across Canada. Policy initiatives and education programs were devel-
oped by many professional organizations, including the Canadian Medical Association, the Canadian Nurses
Association, and the Canadian Healthcare Association. Following the study’s release, the Canadian Council on
Health Services Accreditation (CCHSA) created a Patient Safety Advisory Group (which includes both
Drs. Norton and Baker, along with other researchers and decision makers). This group has helped CCHSA
develop a set of patient safety goals and required organizational practices that will be implemented in
accreditation surveys beginning in 2006. Some observers have also speculated that the launch of the
Canadian Patient Safety Institute, recommended by the National Steering Committee on Patient Safety in
2002, was pushed forward in late 2003 because of the need to show a federal government commitment to
patient safety prior to the release of the study.
Lessons learned
While the study has clearly contributed to the awareness and engagement of many
organizations, professional groups, and individual practitioners and managers, there is
also the possibility that our KT efforts had the paradoxical effort of desensitizing some
parts of our audience.
Many organizations worked hard in 2002 and 2003 to develop policies, inform their
members, and create media strategies that demonstrated understanding of the issue. In
the aftermath of the study’s release, and the success of these organizations in their
anticipatory efforts, the policy spotlight may have shifted to other concerns. In
addition, the federal election was called in the same week as the study’s publication,
and the issues of waiting times and access were chosen as the key health care platform
for the federal Liberal Party’s campaign.
Did some organizations believe they had achieved what was needed (or what was possible) for patient safety by
May 2004? Did the emergence of waiting times and access as the key health care issues, and the funding that
was promised to address them, cut short the focus on patient safety? Did the early involvement of the
stakeholder groups in patient safety consultations lead to a waning of enthusiasm for further initiatives once
the study results were released?
These questions are difficult to answer. However, recent discussions of
the mixed success of the United States in improving patient safety,
prompted by the five-year anniversary of the IOM report, suggest that
patient safety issues will require continued attention.
Conclusions and implications
The KT efforts centred on the Canadian Adverse Events Study led to
a major shift in policy for many Canadian governments and health
care organizations. But KT alone has been insufficient to ensure the
necessary investment in new resources needed to create safer health
care. Other efforts, including the development of the “Safer
Healthcare Now!” campaign that targets the reduction of mortality
and morbidity from infections and adverse drug events, will be needed to demonstrate and help reduce the gap
between current performance and the potential for high reliability health care.
Did the early involvement of
the stakeholder groups in
patient safety consultations
lead to a waning of
enthusiasm for further
initiatives once the study
results were released?
There is also the
possibility that
our KT efforts
had the
paradoxical
effort of
desensitizing
some parts of
our audience.

12
Knowledge translation and patient safety: The Canadian Adverse Events Study
References
1
Baker, G. R., P. G. Norton, V. Flintoft, R. Blais, A. Brown, J. Cox, E. Etchells, et al. 2004.
The Canadian Adverse Events Study: The incidence of adverse events among hospital patients in Canada.
CMAJ 170 (11): 1678-86.
2
Kohn, L.T., J. M. Corrigan, and M. S. Donaldson, eds. 1999. To err is human: Building a safer health system.
Washington, DC: National Academy Press.

13
KNOWLEDGE TRANSLATION FOR PRACTICE
CHANGE IN CHILDREN
’S MENTAL HEALTH
Melanie Barwick, PhD, CPsych, The Hospital for Sick Children
Katherine Boydell, MHSc, PhD, The Hospital for Sick Children
Denice Basnett, MA, The Hospital for Sick Children
Brian O’Hara, Children’s Mental Health Ontario
H. Bruce Ferguson, PhD, CPsych, The Hospital for Sick Children
Rebecca Haines, MA, The Hospital for Sick Children
In 2000, Ontario mandated the use of two instruments for systematic screening and outcome measurement for
children’s mental health care organizations. A knowledge translation (KT) infrastructure was developed to sup-
port training in, and implementation of, the tools for service providers. Intensive face-to-face training was the
mode of KT most valued by practitioners, but was complemented by regional communities of practice and an in-
house train-the-trainer approach to facilitate ongoing collaborative professional education and practice change.
The tools have now been introduced to over 4,000 practitioners, with uptake in over 90% of organizations.
Background
All too frequently, children receive mental health care that is based on practices that have little supporting
evidence or, at worst, poor outcomes.
1,2
Yet there is substantial evidence that most children who receive an
empirically supported treatment, get significantly better and do so more quickly than with other forms of
treatment or no treatment at all.
3,4
In 2000, Ontario’s Ministry of Children and Youth Services mandated the use of two instruments for
systematic screening and outcome measurement as part of a provincial plan for children’s mental health.
Standardized screening practices in children’s mental health can lead to better outcomes, and can help to
manage long waiting lists by identifying children at greatest risk.
5
Measuring outcomes can demonstrate which
treatments are effective, enhance clinical practice, provide accountability and encourage practitioners to
examine service quality.
6,7
The screening tool, the Brief Child and Family Phone Interview
(BCFPI),
8
is a standardized intake instrument to screen behavioural and
emotional problems of clinical significance. The outcome tool, the Child
and Adolescent Functional Assessment Scale (CAFAS),
9
is a standardized
outcome instrument to assess level of functioning and monitor service
outcomes.
Both tools are IT-based and clinicians and intake workers require
specialized training in their use. The Ontario Ministry of Children and
Youth Services contracted with two organizations to deliver this training
and support implementation. BCFPI is supported by Children’s Mental
Health Ontario, an advocacy organization that promotes the well-being
of children, youth, and their families and CAFAS is supported by the
Community Health Systems Resource Group at The Hospital for Sick
Children, in consultation with an advisory group of service providers.
We recognized very early on
that transferring knowledge
about these new evidence-
based tools, and
implementing their use in
day-to-day work with
patients and families,
would be extremely
challenging.

14
Knowledge translation for practice change in children’s mental health
We recognized very early on that transferring knowledge about these new evidence-based tools, and
implementing their use in day-to-day work with patients and families, would be extremely challenging. We
therefore developed a formal KT infrastructure
10
to support our training and implementation program, which
was a composite of strategies developed from best practices evidence in the research literature, and evolved
according to the preferences of our participants and stakeholders.
Six years later, we attribute the success of training, implementation, and adoption of these two tools in over
100 service provider organizations across Ontario to this KT infrastructure, which focused primarily on active
stakeholder collaboration including providers, government, and implementers;
11
face-to-face relationships;
11,12
and the use of multiple methods of communication.
13,14
The KT initiative
Changing the way mental health care is delivered is a formidable, slow-moving task, often requiring
modifications in clinician behaviour, program restructuring, and an infusion of resources.
15
With this initiative,
organizations were also faced with challenges in accreditation, amalgamation, staff turnover, rising demands for
service, and computer literacy.
CAFAS rater reliability training is based around intensive two-day workshops for clinicians, with ongoing
website, email, and telephone support. These are delivered regionally by specialized CAFAS trainers and are
well received by clinicians.
This personalized approach, while highly effective, is time-consuming and
expensive, and cannot meet the differing needs of all service providers in a
geographical area. Training requirements occur in waves and are ongoing, due
to individual training preferences, the dynamic nature of group learning and
professional development and staff turnover.
In recognition of this, we introduced two strategies to facilitate ongoing
collaborative professional education, practice change, and KT: regional
“communities of practice” and an in-house “train-the-trainer” approach.
Communities of practice can be loosely defined as a group of people who come
together, either virtually or in person, around a topic. Our regional
communities of practice include Ministry program supervisors, implementers,
and practitioners in a unique partnership. The meetings began with our BCFPI
and CAFAS teams presenting data from an implementation perspective, but
have now evolved to focus on presentations by service providers who share their
knowledge on how the tools are being used in clinical practice. Lessons are then
transferred to the website where they can be viewed by other users.
Train-the-trainer sessions focus on training one or two people in each service provider organization to train
their own staff on CAFAS rater reliability. The CAFAS team certifies the trainers on an annual basis. We also
worked to introduce training of the CAFAS tool into colleges and universities to lessen the training burden of
service providers, as well as to develop a culture around outcome management in children’s mental health
service delivery.
Changing the way
mental health care is
delivered is a
formidable, slow-
moving task, often
requiring
modifications in
clinician behaviour,
program restructuring,
and an infusion of
resources.

15
Knowledge translation for practice change in children’s mental health
Other KT strategies included the development of guidelines to support the use of the CAFAS tool with special
populations, namely Aboriginal children and youth,
16
and communication materials describing the tools and
their use to patients and their families.
We also produce aggregate reporting of provincial and regional data generated by the tools to government and
service providers to elicit feedback and plan for system change.
Results of the KT experience
Over 4,100 child and youth workers, social workers, psychologists, and psychiatrists have now been trained to
reliably use the CAFAS tool. Upwards of 600 specialists have been trained on the BCFPI tool and about 250
workers now apply it across the province. The in-house train-the-trainer approach has proved to be a reliable
training method, with high correlations between practitioners trained by on-site practitioner-trainers and those
trained by our specialized CAFAS trainers.
17
This initiative has also provided the first ever wait list
management tool and outcome data for children aged six to seventeen years who receive mental health
treatment.
Our community of practice meetings have been repeatedly well attended and reportedly relevant to
participants. Practitioners report increasing buy-in and clinical utility, and service providers report increasing
usefulness of data for administrative and quality improvement purposes. Results to date show uptake of the
tools in 80-90% of mandated organizations. Practitioners, Ministry personnel, and implementation teams
continue to work together to determine current needs for training, support, and knowledge exchange. Research
funding is now being sought to evaluate the impact of communities of practice in effecting practice change and
the translation of new knowledge about use of the tools in practice.
Lessons learned
This initiative has generated several important lessons about the adoption of
evidence-based practices, and the KT strategies required to support them:
•Ongoing, clear, and direct communication is needed from funders, leaders,
and champions to all those involved (agency management, clinical
supervisors, and front line workers) to fully engage participants in a spirit of
meaningful collaboration. The absence of a communication plan,
particularly in the crucial early stages of this initiative, was a key barrier to
knowledge and uptake of these tools.
• Both a “carrot” and a “stick” have a role in the uptake of evidence-based practices. Use of the tools was
not included in service provider contracts until 2004 and, when they were, uptake increased.
• Communities of practice appear to be valuable in supporting the use and clinical application of
evidence-based practices. Pilot testing suggests time is needed to build a sense of trust among
community members to allow for the exchange of tacit knowledge and to contribute to the development
of a culture around new practices.
•To be most effective, even in a mandated context, KT strategies must be developed in accordance with
the individual and organizational state of readiness for change. Our approach has been to support all
organizations and practitioners, but to focus on those who have a higher level of readiness for the
adoption of new tools, which increases their chance of success. We highlight the successes of these “early
adopter” organizations in the community-of-practice venues and on the website so that “late adopters”
can share in their experiences.
Both a “carrot” and
a “stick” have a role
in the uptake of
evidence-based
practices.

16
Knowledge translation for practice change in children’s mental health
• The importance of face-to-face support cannot be overstated. Although
more costly, it is the mode of KT most valued by and beneficial to
practitioners. It is, in our view, most successful for sharing both the tacit
and explicit knowledge required to build a professional learning culture.
Conclusions and implications
Our work continues to introduce the BCFPI and CAFAS tools to a significant proportion of Ontario’s
children’s mental health care providers. We have implemented a targeted KT infrastructure that supports
significant practice change, and allows us to use our limited financial and human resources for training more
effectively, as well as for supporting a culture of practice change.
We hope to continue to learn how best to bring evidence-based practices to the field and how to support the
adoption of new and innovative approaches to mental health care for children. Anecdotal reports suggest
appreciation for the tools’ clinical contribution is growing with practitioner experience. However, real and
perceived barriers remain to be addressed, including the time required to use the tools, the importance of
assessing response to treatment and the extent to which the data generated are viewed as purely bureaucratic, as
opposed to meaningful for clients and service provider organizations. Whether we are successful in developing
a culture receptive to evidence-based practice and service delivery innovations in children’s mental health
remains to be seen: the journey continues.
References
1
Busch, A. B. 2002. Validity, reliability, and other key concepts in outcome assessment and services research.
In Outcome measurement in psychiatry: A critical review, ed. W. W. IsHak, T. Burt and L. I. Sederer, 35-55.
Washington, DC: American Psychiatric Publishing.
2
Dishion, T., J. McCord, and F. Poulin. 1999. When interventions harm: Peer groups and problem behavior.
Am Psychol 54:755-64.
3
Chambliss, D., and T. H. Ollendick. 2001. Empirically supported psychological interventions: Controversies
and evidence. Annu Rev Psychol 52:685-716.
4
JCCP. 1998. Empirically supported psychosocial interventions for children. Special issue,
J Clin Child Psychol 27:138-226.
5
Lambert, M. J., J. L. Whipple, D. W. Smart, D. A. Vermeersch, S. L. Nielsen, and E. J. Hawkins. 2001.
The effects of providing therapists with feedback on patient progress during psychotherapy: Are outcomes
enhanced? Psychother Res 11:49-68.
6
Barlow, D. H., S. C. Hayes, and R. O. Nelson. 1984. The scientist-practitioner: Research and accountability in
clinical and educational settings. New York, NY: Pergamon Press.
7
Ogles, B. M., M. J. Lambert, and K. S. Masters. 1996. Assessing outcome in clinical practice.
Boston, MA: Allyn & Bacon.
8
Cunningham, C. E., P. Pettingill, and M. Boyle. 2000. The brief child and family phone interview (BCFPI).
Training manual. Hamilton, ON: Canadian Centre for the Study of Children at Risk, Hamilton Health
Sciences Corporation, McMaster University.
9
Hodges, K. 2003. Child and adolescent functional assessment scale. 3rd ed. Training manual. Ypsilanti, MI:
Eastern Michigan University.
10
Barwick, M., K. Boydell, and C. Omrin. 2002. A knowledge transfer infrastructure for children’s mental
health in Ontario: Building capacity for research and practice. Report. Toronto, ON: The Hospital for Sick
Children.
The importance of
face-to-face support
cannot be overstated.

17
Knowledge translation for practice change in children’s mental health
11
Lomas, J. 2000. Using ‘linkage and exchange’ to move research into policy at a Canadian Foundation.
Health Affair 19 (3): 236-40.
12
Landry, R., M. Lamari, and N. Amara. 2003. Extent and determination of utilization of university research
in government agencies. Public Admin Rev 63 (2): 192-205.
13
Bero, L. A., R. Grilli, J. M. Grimshaw, E. Harvey, A. D. Oxman, and M. A. Thomson. 1998. Closing the
gap between research and practice: An overview of systematic reviews of interventions to promote the
implementation of research findings. BMJ 317:465-68.
14
Freemantle, N., and I. Watt. 1994. Dissemination: Implementing the findings of research. Health Libr Rev
11:133-37.
15
Huang, L. N., M. S. Hepburn, and R. C. Espiritu. 2003. To be or not to be evidence-based? In
Data Matters: An evaluation newsletter 6:1-3. National Technical Assistance Center for Children’s Mental
Health, Georgetown University Center for Child and Human Development.
http://gucchd.georgeto
wn.edu/fi
les/products_publications/datamatters6.pdf.
16
Barwick, M. A., Dilico Ojibway Child and Family Services, and K. Hodges. 2004. Culturally competent
evaluation: Clinical considerations for rating the Child and Adolescent Functional Assessment Scale with
Aboriginal children and youth. Report. Toronto, ON: The Hospital for Sick Children.
http://www
.cafasinontario.ca/html/..%5CDownloads%5CCAFAS_Aboriginal_Children.pdf.
17
Barwick, M. A., C. Omrin, and D. Basnett. Under review. Maintaining reliability in Ontario’s outcome
initiative: Training approaches and rater drift on the Child and Adolescent Functional Assessment Scale.
JBehav Health Sci Res.

18
Knowledge translation for practice change in children’s mental health

19
A COLLABORATIVE MODEL OF KNOWLEDGE TRANSLATION
FOR SUSTAINABLE PRACTICE CHANGE
Jennifer Baumbusch, RN, MSN, University of British Columbia
Heather McDonald, RN, MSc, University of British Columbia
Joan M. Anderson, RN, PhD, University of British Columbia
Sheryl Reimer Kirkham, RN, PhD, Trinity Western University
Koushambhi Basu Khan, PhD, University of British Columbia
Connie Blue, RN, BSN, University of British Columbia
Pat Semeniuk, RN, MA, Vancouver Coastal Health
Elsie Tan, RN, MSN, University of British Columbia
As part of a long-term research program on hospitalization and help-seeking experiences of diverse ethnocultural
groups, a collaborative model of knowledge translation (KT) was developed between researchers and decision
makers at a regional health authority in British Columbia. The model was based on a respectful relationship
between researchers and clinical leaders, with the sharing of emerging findings in real time to inform sustainable
practice changes. In addition to improvements in the practice setting, the partnership has resulted in constructive
changes to the clinical research process, in recognition of the integral role practitioners and decision makers play.
Background
The collaborative model of KT
1
presented in this case study illustrates how established partnerships between
researchers and leaders in the clinical environment can facilitate the uptake of research in health care settings.
Developed over the past two years between researchers and health care decision makers at one of British
Columbia’s regional health authorities, Vancouver Coastal Health, our KT activities were part of a six-year,
CIHR-funded program of research on hospitalization and help-seeking experiences of diverse ethnocultural
groups.
Our approach to KT was driven by requests from clinical leaders for timely access to research findings that
could inform ethically-sound decision making. Our KT model drew on both CIHR’s
2
and Lavis et al.’s
3
frameworks, which encourage the development of take-home messages as a starting point for interactive
dialogue with clinical leaders, and to use people seen as credible to clinical leaders to initiate that dialogue.
Our goal was to effect a cultural shift that would facilitate the ongoing use of research knowledge that
underscores how socioeconomic, historical, and contextual factors intersect to influence patients’
hospitalization and transition to home experiences. We aimed to produce sustainable transformations in
practice at Vancouver Coastal Health towards more equitable, efficient and effective health services.
The KT initiative
The main components of our KT model were the development of a context that supports KT, the synthesis
and use of research-based take-home messages as a point of engagement with clinical leaders and the
collaborative development of specific initiatives to address research findings.
The model is underpinned by a relationship between researchers and clinical leaders grounded in
accountability, reciprocity and respect for each other’s knowledge. Clinical leaders act as advocates for research
in the practice setting, while researchers actively participate in translating the research. Clinical partners provide

20
A collaborative model of knowledge translation for sustainable practice change
input from their practices into research questions, research data are collected and analyzed concurrently and
emerging findings are shared between research and clinical partners in “real time.”
Various strategies were used to bring researchers and clinical leaders together in open and creative dialogue.
These included holding meetings at times and locations that were conducive to the work schedules of clinical
leaders; inviting leaders from across the continuum of care to talk with researchers; ensuring the gap between
researchers and clinical leaders was bridged through team members with extensive experience in both academic
and clinical settings; and listening carefully to and acting on issues of interest to clinical leaders. Our most
effective dialogue occurred during informal breakfast meetings where we discussed emerging findings. These
meetings were pivotal, as specific initiatives designed to address the research findings grew out of the
collaborative discussions that took place.
Results of the KT experience
We developed initiatives that target sustainable changes in practice at both the systems level and the individual
practitioner level. We have initiated a number of projects at the systems level,
4
including two medical
interpreter programs and a quality improvement project that uses follow-up telephone calls to discharged
patients to provide continuity of care between the hospital and home. At the individual practitioner level, the
team has received CIHR funding for a three-year study of cultural safety and knowledge uptake in clinical
settings. This project will use “just-in-time” teaching
5,6
as a strategy to translate findings into practice.
In addition to changes in the practice setting, our KT experience has also led to changes in the research
process. It has demonstrated the integral role of clinical practitioners and decision makers in clinical research,
in particular, how their input ensures that the results of research are relevant to the current context of
health care.
For example, early in the project we were surprised to find that several patients were readmitted to hospital. A
number of issues were affecting patients’ experiences during the transition between hospital and home, such as
the timing and quality of discharge teaching, and communication when the patient couldn’t speak English. It
struck us that many of these readmissions might have been preventable, as illustrated by this recounting of
discharge teaching by a female Anglo-Canadian patient who was readmitted for constipation:
R: “So the information that the dietician gave you at the hospital was…?”
P: “Overwhelming…I broke into tears. Well, the stuff she told me was right; there was nothing
wrong with that. It’s just that you need to know where to start, when you go home.”
Clinical leaders were extremely interested in this finding because they had been unaware of the high rates of
hospital readmissions—patients were not necessarily readmitted to the original hospital where they had
received care, and readmission rates were not tracked across health authorities. They pushed us to provide more
concrete numerical data and to examine further why this was happening. The readmission data provided a
strong point of focus for collaboration and resulted in the development of systems-level KT initiatives to target
the issues contributing to unplanned readmissions.
Lessons learned
One important lesson of this process is that a long-term commitment from researchers and clinical leaders is
needed to effect sustainable transformations in health services. While members of our larger group have
changed, particularly the clinical leaders, core team members have been working together since 1998. This

21
A collaborative model of knowledge translation for sustainable practice change
ongoing relationship of trust and collaboration has proven important for the development of some of our
innovative initiatives.
There have been challenges around the development and use of this
approach to KT. Researchers and clinical leaders have had to shift away
from their traditional roles to embrace a collaborative, dynamic and
reciprocal process. Negotiating roles and responsibilities can be
complicated, especially in the demanding environment of the health care
system. Because the KT process requires ongoing face-to-face dialogue,
protected time for clinical leaders to participate is essential. An
organizational climate in the practice setting that supports KT is,
therefore, crucial.
An additional challenge has been bridging the understanding gap between researchers and clinical leaders.
Researchers and clinical leaders often speak different disciplinary languages and are affected by different and
sometimes competing pressures. Key to bridging this gap has been the use of “credible messengers” who are
well versed in both the clinical and academic worlds. Our team includes two doctoral students with strong
links to practice, who are funded from both the research and practice settings.
We found that our model was especially relevant for KT with qualitative research and critical perspectives: data
collection and analysis can occur concurrently, and can be flexible and responsive to priorities identified by
clinical partners. Findings from such research often reveal complicated structures and social processes. Yet,
researchers must be attuned to the kinds of findings that clinical leaders need to support decision making and
be willing to negotiate the research agenda.
For instance, when presenting the readmission data discussed earlier, researchers
were also asked to provide numerical data that could be translated into costs to the
health care system. At times, requests for such “bottom-line” information conflicted
with the more theoretical, contextual, and broad-based analyses that the researchers
employed. The shorter time frames for taking the findings back to practice also
presented a challenge for researchers used to more time for analysis. For the most
part, our challenges have been successfully mediated because of our carefully
cultivated collaborative relationship and the commitment of all team members to a
common goal.
Conclusions and implications
Over the past three years, we have integrated the KT model into presentations of
emerging findings at national conferences, public lectures, and meetings with
researchers, clinical leaders and policy makers. There is widespread interest in the
model’s applicability in a variety of health care settings that require creative and
innovative solutions to complex issues. We are careful to stress the level of
commitment and resources (mostly time) needed from all participants to make the
KT model work effectively, yet also celebrate the potential impact of this approach
on practice within the health care arena.
Our experience, along with that of other knowledge translators, suggests that collaborative partnerships such as
the one we have fostered, where clinical leaders have direct and real input into the research process, should be a
Researchers and clinical
leaders often speak different
disciplinary languages and
are affected by different
and sometimes competing
pressures.
Collaborative
partnership where
clinical leaders
have direct and
real input into the
research process,
should be a
cornerstone of
research in the
health care setting.

22
A collaborative model of knowledge translation for sustainable practice change
cornerstone of research in the health care setting. These partnerships enable the data collection and analysis
process to be responsive to the changing needs of the clinical setting, resulting in findings of immediate
importance. Clinical leaders are also eager to take up the findings because of their personal investment in the
research process. Effective dialogue can result in creative solutions to complex problems.
Although the funded component of this research project has now drawn to a close, our KT experience
continues. We recently received three years of funding to extend and refine our model to enable KT from this
program of research, as well as other research projects that similarly aim to highlight disparities in health care
delivery, with front-line practitioners.
References
1
Baumbusch, J. L., J. M. Anderson, S. Reimer-Kirkham, K. B. Khan, H. McDonald, P. Semeniuk, and E.
Tan. Manuscript in development. Pursuing common agendas: A collaborative model for knowledge
translation in clinical settings.
2
Canadian Institutes of Health Research. 2004. Overview of knowledge translation.
http://www
.cihr-irsc.gc.ca/e/22845.html.
3
Lavis, J. N., D. Robertson, J. M. Woodside, C. B. McLeod, J. Abelson, and the Knowledge Transfer Study
Group. 2003. How can research organizations more effectively transfer research knowledge to decision
makers? Milbank Q 81 (2): 221-48.
4
Baumbusch, J., P. Semeniuk, H. McDonald, K. B. Khan, S. Reimer-Kirkham, E. Tan, and J. M. Anderson.
Manuscript in development. Easing the transition between hospital and home: Translating knowledge
into action.
5
Canadian Health Services Research Foundation. 2001. Knowledge transfer: Looking beyond health.
Conference report. Ottawa, ON: CHSRF. http://www
.chsrf.ca/knowledge_transfer/pdf/ktransfer_e.pdf.
6
Canadian Health Services Research Foundation. 2002. Knowledge transfer in health. Conference report.
Ottawa, ON: CHSRF http://www
.chsrf.ca/knowledge_transfer/pdf/ktransfer2002_e.pdf.

23
DEVELOPING A MODEL FOR THE SHARED CARE OF
CHRONIC DISEASE
Dr. June S. Bergman, University of Calgary
Dr. Alun Edwards, University of Calgary and Calgary Health Region
Dr. Peter Sargious, University of Calgary and Calgary Health Region
Dr. Sandra Delon, Calgary Health Region
Ms. Carol Slauenwhite, Calgary Health Region
Researchers from the University of Calgary partnered with the Calgary Health Region and health care providers
in a three-year demonstration project to trial three different models of multidisciplinary team care for chronic
diseases. Focusing on common chronic diseases, each model was evaluated by appropriate lab indices, self-care
behaviours, and patient and provider satisfaction surveys. While all models demonstrated positive results, ongoing
input from providers and patients resulted in the development of a hybrid model for implementation in all fami-
ly physician offices across Calgary Health Region.
Background
Considerable evidence in the research literature demonstrates that multidisciplinary health care provider teams
result in better treatment of chronic disease. Since 1998, Calgary Health Region, in partnership with its
physicians and the Government of Alberta, has supported the development of primary care teams for managing
chronic disease through various funding initiatives, including the Health Transition Fund (HTF).
An early HTF funded-project involving Dr. June Bergman and Dr. Alun Edwards focused on multidisciplinary
team building, partnering with the Calgary Health Region through their public health and home care
portfolios. This two-year project involved six family physicians in their practices being partnered with home
care nurses and public health nurses for the ongoing care of selected chronic diseases, and allowed barriers of
union regulation and the development of shared practices to be worked through.
In 2000, the Calgary Health Region initiated a physician partnership program to support innovative ideas.
This program funded over 30 business cases, one of which was based in part on the successful HTF project,
and in part on a literature review and site visits of several multidisciplinary teams. This case, involving
researchers from the University of Calgary, was funded as a demonstration project by Alberta’s Health
Innovation Fund and Alberta Province-Wide Services. Formal partnerships with the region’s home care services,
diabetes clinic, hypertension clinic, specialist and generalist physicians, and others were struck, with an
intention to create a sustainable infrastructure if the project evolved favourably.
The KT initiative
Our goals for this demonstration project were: to demonstrate the value of multidisciplinary teamwork in the
care of people with chronic disease; the impact of the team on quality of work life for the team members; and
the impact of the model on the individual patient’s chronic disease. In partnership with the health care
professionals likely to be involved in the program, we operationalized the business plan developed earlier,
choosing three different models of multidisciplinary team care that seemed to fit the local environment. Each
model was funded for a period of three years.

24
Developing a model for the shared care of chronic disease
Model One (case management) was built on a partnership between a physician and a home care nurse who
initially partnered on the basis of overlapping practice, and then on a shared workload of chronic disease
patients. In Model Two (focused case management), identified patients were assigned to a nurse/dietitian team
over the period of the project. In Model Three (accessible expert), identified patients would be seen by an
expert team from the diabetes education centre (usually a nurse and dietitian) on a one-off basis. Model Three
also had specialist physician expertise available.
Each model was allocated to a group of approximately 20 primary care providers. Three common chronic
diseases—diabetes, dyslipidemia, and hypertension—were chosen for use in the models because they were well
studied in the literature, and allowed us to use intermediate indicators (such as hemoglobin A1C level in
diabetic patients) as a proxy for outcomes.
Teams were directed to use clinical practice guidelines for the chosen chronic diseases. These guidelines were
locally adapted by the generalist and specialist physicians initially, and later by the broader team. From the
guidelines, a clinical care pathway was developed by the full team, the various roles of the team members were
defined, and algorithms of care were developed for all the disease entities.
The models were evaluated by measuring appropriate lab indices, self-care, wellness scales, and patient
satisfaction surveys, at baseline, one year, and two year time points. The team members were also interviewed
in a structured manner for their perspectives on working in the team, particularly to identify strengths and
weaknesses.
Results of the KT experience
All models demonstrated positive results in most laboratory indices. Self-care
behaviours such as exercising, managing diet, and glucose testing, showed
improvement in all models at the one-year mark, but not all behaviours were
sustained throughout the two years. Wellness survey outcomes for the patients
did not demonstrate any statistically significant improvement. There was a
demonstrated loss of wellness perception that was assumed to arise from either
education resulting in a better appreciation of the disease, and/or the natural
downward course of the disease.
As a result of the evaluation, and from ongoing input from providers and
patients, we were able to demonstrate which of the models would best fit in the
Calgary Health Region. The proposed model, which is based on Model One
(case management), with support from Model Three (accessible expert), is now
the region’s chosen model for chronic disease management, and is being
implemented in all family physician offices across the Calgary Health Region.
Lessons learned
Partnerships at all working levels were an essential part of this project: within the care teams, within the
research group, and between the various policy making bodies that impacted on our initial ability to do the
project, and when it was successful, to roll out the results as a sustainable model for managing chronic disease
in the Calgary Health Region.
Because so many of the ideas were new, much time was spent ensuring everyone understood the project goals.
Initially, the two funding agencies, with their differing goals and objectives, were brought together to approve
The proposed model
is now the region’s
chosen model for
chronic disease
management, and is
being implemented
in all family
physician offices
across the Calgary
Health Region.

25
Developing a model for the shared care of chronic disease
the project. Some reporting deadlines and deliverables had to be adapted. There was a request for evaluation of
the team, another for the project to have a rural component, and another for a strong outcome consideration.
However, the evaluation of all models was richer as a result of the partnership.
Flexibility was also important. Nothing could be left unquestioned, whether it
was roles, clinical decisions, or policies. Over the three years of the project,
participants were actively engaged in molding the models. This produced a very
functional model, but was sometimes seen as a lack of strong leadership because
of the rapid change in focus for the models.
Engagement of both the project leaders and participants in many levels of policy
making were also crucial to the success of the project. Some held positions
within the Calgary Health Region that allowed them to influence policy and
budgetary decisions within their portfolios. Others worked within the health
professional groups to develop policies and direction to support continued
operation of multidisciplinary teams. In Alberta, this activity has resulted in
many ongoing alternative fee plans, a new fee for physicians participating in some teamwork (to speak to home
care nurses about patient care), the development of new local primary care networks of physicians and the
development of the Health Professions Act.
At the health care provider level, a number of important factors for success for working in team-based models
were identified. These included:
•Initial co-location of members
•Active engagement of all team members
•Open communication
•Shifting leadership roles, depending on expertise
•Trust and respect between team members
•Shared goals and readiness for change
• Confidence in team competence
•Evolution of roles and functions
•Promotion of the team
Discussions with the team members also determined that success in teamwork was enhanced if members
possessed professional assertiveness, strong clinical skills, communication skills, knowledge of the community
and home care systems, the ability to contribute in case conferences, IT skills, and experience working
in teams.
Physicians reported that their interest in participating in multidisciplinary teams was enhanced by prior
involvement in similar projects, positive patient outcomes, reduced workload, and the opportunity to
participate in system change. They noted a number of barriers to working within such models, however,
including reimbursement, space, and difficulty in maintaining strong leadership and direction.
Conclusions and implications
Our project was based on a rapid-cycle model of change, which raised many new questions and sparked
additional projects. Chronic disease management within the Calgary Health Region has now expanded from
the original three areas of diabetes, hypertension and dyslipidemia to include chronic obstructive pulmonary
Engagement of both
the project leaders
and participants
in many levels of
policy making were
crucial to the success
of the project.

26
Developing a model for the shared care of chronic disease
disease and congestive heart failure. Each of these conditions will be included in our blended chronic disease
management model now being implemented across the region. Calgary Health Region also has a new chronic
disease information management system, and is making early steps to support the province’s electronic
health record.
A team has also been working with patients to identify the need for community resources in education, diet,
and exercise for those with chronic diseases. This has resulted in a program in Calgary that provides safe places
for people with chronic disease to exercise, and is itself a partnership between the Calgary Health Region and
designated fitness and community facilities. People can be referred from the chronic disease program or can
self-refer, but in the spirit of the new partnership model, all people going through the program are required to
obtain their family physician’s approval prior to participating in the exercise program.
The case management model (Model One) is now being piloted in Ontario to determine if the principles of
multidisciplinary teamwork as outlined in Calgary are transferable across jurisdictions. This national
partnership project also has a significant information technology component, and is attempting to bring IT
to the team in a manner that enhances the work they do.

27
SEARCH CANADA: BUILDING CAPACITY IN HEALTH
ORGANIZATIONS TO CREATE AND USE KNOWLEDGE
Dr. Ann Casebeer, University of Calgary
Ms. Sarah Hayward, SEARCH Canada
Dr. Gail MacKean, University of Calgary
Ms. Sharon Matthias, SEARCH Canada
Dr. Rob Hayward, University of Alberta
(On behalf of the entire SEARCH Canada integrated faculty, staff, participants, and network).
Alberta’s SEARCH Canada is dedicated to implementing a system-wide approach to knowledge translation (KT)
and use. With a 24-month program to train community-based health professionals in applied health research,
SEARCH develops individual and organizational capacity for the ongoing use and development of research evi-
dence in decision making. Specific attention is paid to skill development in using information tools and technolo-
gy, participating in collaborative networks, and sustaining ongoing personal development as a scholar-practition-
er. SEARCH and its participants are now widely known in the Alberta health system, and the program has
attracted both national and international acclaim.
Background
SEARCH (Swift Efficient Application of Research in Community Health) Canada
*
is an Alberta-based public
service organization dedicated to knowledge access, creation, and use by health managers, health providers, and
their organizations.
SEARCH was launched by the Alberta Heritage Foundation for Medical Research (AHFMR) in 1996 as a
twenty-four-month program to train community-based health professionals in the "how-to's" of applied health
research, including accessing and assessing high quality information, and applying it in decision making. In
April 2005, SEARCH Canada began operating independently, governed and funded by member organizations,
which include AHFMR, Alberta's nine health regions, and the University of Calgary. Support is also provided
from Alberta Health and Wellness.
SEARCH develops capacities for, and communities of, practice-based learning and innovation, in practice and
research sectors across the province. SEARCH supports a network of health professionals and researchers, and
their respective organizations, all of which are dedicated to the creation of new knowledge and its translation
into better quality health care decisions.
1
The SEARCH story is about the experience of implementing a system-wide approach to KT and use. Through
SEARCH, we are learning that evidence-based decision making across a health care system requires more than
skills and information. It depends on people’s attitudes, values, and their daily interactions; it is as much a
matter of relationships as of information and is dependent on a culture of openness, exchange, respect, and
confidence.
*For more information about the SEARCH program, please visit http://www.ahfmr.ab.ca/search.php.

28
SEARCH Canada: Building capacity in health organizations to create and use knowledge
The KT initiative
The overall framework for learning and KT and exchange in SEARCH’s activities links three overlapping areas
of focus—choosing evidence, creating evidence, and using evidence—while always being mindful of the
complex context in which it is to be used. SEARCH’s philosophy embraces partnership and recognizes both
service and academic organizations as part of the health system.
SEARCH’s core activity is a cohort-based learning program that emphasizes the value of applied health
research, KT and exchange of knowledge across diverse sectors. A combination of residential sessions, practice-
based research projects and sophisticated web-based learning supports
2
target long-term, sustainable capacity
building of individuals and their organizations. Capacity in the academic sector is built through the core
faculty team and additional experts, who are drawn from university faculties of medicine, nursing, and
business, and the public and private sectors. Faculty are continuously involved in program design and delivery
and develop enduring relationships with participants.
Participants are established health professionals from many health care areas, including nursing, social work,
health promotion, mental health, family medicine, and health administration. They are selected by Alberta’s
health authorities and range from front line clinicians to senior managers. Participants continue in their
employment and their salaries remain guaranteed by their sponsoring organizations. Approximately half of
their time is allocated to learning and research-related activities.
SEARCH participants have ongoing access to a network of faculty and past participants through a web-based
communications system designed to facilitate knowledge sharing. Learning is promoted as a lifelong endeavour,
and support for using evidence to improve the quality of health care decisions continues well beyond the 24 -
month program. The foundations for ongoing use of research evidence in decision making are developed by
paying specific attention to skill development in using information tools and technologies, participating in
collaborative networks and personal development as a change agent and scholar-practitioner.
Direct managers of SEARCH participants are involved in prioritizing provincial project topics, definition of
local projects, and periodic meetings to discuss issues such as participant support and translation of individual
to organizational capacity. Participating organizations are also connected to research development advisors
based at colleges and universities across Alberta, for just-in-time advice and assistance.
Results of the KT experience
SEARCH program processes and outcomes are evaluated during and after each instructional module and at 12,
18, and 24 months using surveys and focus groups. To date, more than 125 health practitioners and 60 faculty
members have participated in SEARCH’s program. Seventy per cent of participants continue to be active in
research after four years.
Over 100 practice-based research projects have addressed a variety of pressing issues in health services, health
human resources, professional practice, health care management, and population health. These include
program evaluations of community health programs, change management capacity assessments, analysis of the
impact of the on-call burden on rural physicians and the value of telepsychiatry.

29
SEARCH Canada: Building capacity in health organizations to create and use knowledge
There are a number of levels—service delivery, academic, funding—and loci of change—individual, individual
in an organization, health care organization, health care system, and trans-sectoral system—through which
SEARCH activities can have an impact. Impacts of SEARCH for the individual, as perceived by managers and
participants,
3
include increased:
•Skills in research and research application. One small region has
identified over $750,000 in grants attributable to the capacity
introduced by SEARCH participants. Another region has identified over
$500,000 in successful grant applications.
• Career development and responsibility for activities linked to evidence-
based practice.
•Personal and professional networks.
• Leadership capacity and the ability to influence decision making.
•Job satisfaction, recognition, and respect.
•Research and evaluation activities.
•Publication and dissemination of research results.
Organizational level impacts reported by managers
4,5
include positive
changes in:
•Access to information resources and the ability to identify relevant information when needed.
•Skills and knowledge among staff.
• Leadership development.
•Capacity for individual and organizational collaboration. Some regions and organizations have become
active in province-wide and national initiatives due to expertise developed through SEARCH projects.
•Health research and evaluation activities.
•Supportive attitudes to research and evaluation.
•Culture shift. Many organizations identify SEARCH participants as catalysts for change towards a more
evaluative culture.
Lessons learned
SEARCH’s approach is not a quick fix. Rather, sustained learning
opportunities, ongoing connection to knowledge sources, linkages
across research and practice expertise, together with executive buy-
in, are critical to successful engagement in the exchange and use
of evidence to make a lasting difference. Some of the key
learnings throughout the early years of SEARCH include:
•Health professionals are determined to improve practice
and health outcomes through research, without academic
credit as an incentive.
•Managers are key to ensuring participants are supported in
the program and are often the advocates for evidence-based decisions within an organization.
•Senior executive engagement is critical for organizational-level impact and diffusion.
•Experience of priority-setting and collaboration among decision makers and researchers fundamentally
enhances evidence use and creation.
One small region has
identified over
$750,000 in grants
attributable to the
capacity introduced by
SEARCH participants.
Sustained learning opportunities,
ongoing connection to knowledge
sources, linkages across research
and practice expertise, together
with executive buy-in, are critical
to successful engagement in the
exchange and use of evidence.

30
SEARCH Canada: Building capacity in health organizations to create and use knowledge
• Learning and skill application takes time and needs to be seen as an
investment.
• The development of a flexible and distributed faculty with
organizational support is crucial—commitment to practice-based
learning and enjoyment in relationship-building are key.
•Projects reflecting local and provincial planning priorities provide a
powerful learning mode for individuals and an obvious benefit for
organizations.
•Viewing the participating organization (whether academic or service
sector) as the client, rather than the individual health professional,
transforms the potential for capacity development.
We have also identified a number of characteristics of the SEARCH program
that we believe have been crucial to its success:
• The creation of a strong, supportive network of people across the province.
•Exposure to and relationship-building with people from diverse settings and backgrounds.
• The opportunity to learn intensively, with a broad perspective.
• The opportunity to disengage from everyday work environments to focus on skill development
and learning.
•State-of-the-art communication and computerized networking to support collaboration and ongoing
communication.
• The emphasis on community-based issues, a population health perspective, and applied health services
decisions.
• The requirement to identify and complete projects relevant to the organizational setting.
Conclusions and implications
SEARCH has demonstrated the value of an integrated solution that builds
bridges between research and practice, develops health organizations’ research
capabilities, invests in new expertise for mid-career professionals across all
disciplines and supports academics with a passion for working with the service
delivery system. The result is a health system that is “research-savvy”, more
likely to generate research questions from practice, more able to collaborate in
research projects and more willing to use new knowledge to change policy and
practice.
The program and its participants are now widely known in the Alberta health
system. SEARCH has also attracted national and international attention, with
jurisdictions in other Canadian provinces, the United Kingdom, Australia, and
Uganda expressing interest in piloting SEARCH programs.
In conclusion, there is no better evidence that SEARCH is making a difference
than hearing from participants themselves. Years after their participation in a
SEARCH cohort, they continue to remain involved and to extend their
learning in practice. We let one of the first “SEARCHers” have the last word:
Projects reflecting local
and provincial
planning priorities
provide a powerful
learning mode for
individuals and an
obvious benefit for
organizations.
The result is a health
system that is
“research-savvy”, more
likely to generate
research questions from
practice, more able to
collaborate in research
projects and more
willing to use new
knowledge to change
policy and practice.

31
SEARCH Canada: Building capacity in health organizations to create and use knowledge
“ The concept of SEARCH has always been one of developing research capacity at the grass roots
level, something that was never going to be accomplished overnight. But less than 10 years after it
got off the ground, the program is reaching across the country; a fantastic accomplishment that
reflects the efforts of…everyone who has dedicated their time to the vision of the program.”
—Dan Richen, SEARCH I Participant
Manager, Environmental Public Health
David Thompson Health Region
References
1
Casebeer, A., S. Hayward, R. Hayward, and S. Matthias. 2003. SEARCH—A learning and communication
network. In Collaboration in context, ed. C. M. Scott and W. E. Thurston, 183-94. Calgary, AB: University
of Calgary.
2
Lau, F., and R. Hayward. 2000. Building a virtual network in a community health research training
program. J Am Med Inform Assn 7 (4): 361-77.
3
McCaffrey Consulting. 2004. The Swift Efficient Application of Research in Community Health
(SEARCH): Project Tracking Report. Developed for the Applied Health Research Programs, Alberta
Heritage Foundation for Medical Research. http://www
.ahfmr.ab.ca/publications.html.
4
Birdsell, J. M. and P. O’Connell. 2003. The Impact of SEARCH on Participating Organizations: Evaluation
Report. Developed for the Applied Health Research Programs, Alberta Heritage Foundation for Medical
Research. http://www
.ahfmr.ab.ca/publications.html.
5
McCaffrey Consulting. 2003. Long Term Evaluation of the Swift Efficient Application of Research in
Community Health (SEARCH) Program: Assessing Impact at the Individual Participant Level. Developed
for the Applied Health Research Programs, Alberta Heritage Foundation for Medical Research.
http://www
.ahfmr.ab.ca/publications.html.

32
SEARCH Canada: Building capacity in health organizations to create and use knowledge

33
RESPONDING FROM WITHIN: WOMEN AND SELF-HARM
Colleen Anne Dell, PhD, Carleton University and the Canadian Centre on Substance Abuse
Catherine Fillmore, PhD, University of Winnipeg
Darlene Johnson, Elizabeth Fry Society of Manitoba
Self-harm—any behaviour that a woman commits to intentionally cause herself harm—is a serious health issue,
especially among criminalized women. In 2001, the Elizabeth Fry Society of Manitoba (EFS) convened an
inclusive research team of community women, academics, and EFS staff to better understand and act on self-
harm. The initiative resulted in a holistic appreciation of the issue and sparked a series of partnered research ini-
tiatives with multi-sector involvement. Working in a team founded on diversity and committed to shared deci-
sion making was challenging but ultimately positive, and has led to ongoing research and knowledge translation
(KT) activities.
Background
The Elizabeth Fry Society of Manitoba (EFS) is a non-profit, community-based organization that actively seeks
to reduce the number of women and girls involved in the criminal justice system. In past years, the EFS
experienced an increase in self-harm among its adult female clientele in trouble with the law.
In 2001, the EFS convened an inclusive research team to gain an increased understanding of self-harm and to
translate that understanding into action. This team, which included incarcerated and community women who
had self-harmed, academics, and EFS staff, reflects an approach to KT that capitalizes on the strengths
contributed by all partners and actively shares decision-making power. This approach highlights the importance
of both process (e.g. effective communication among partners) and product (e.g. research findings that
benefit users).
Funded by the Prairie Women’s Health Centre of Excellence, the initial stage of our research focused on the
experiences of women in trouble with the law, their needs and the responses of community health, social
justice agencies, and correctional institutions. It resulted in a holistic definition of self-harm: any behaviour—
physical, social, emotional, or spiritual—that a woman commits to intentionally cause herself harm. It is also
recognized as a way of coping and surviving emotional pain and distress rooted in traumatic childhood and
adult experiences of abuse and violence. We concluded that community and institutional responses to women’s
self-harm were often detrimental and that there was a need for policy development on self-harm as a serious
health issue.
In 2003, these findings led to the second phase of our project, funded by the
National Crime Prevention Strategy (NCPS), which focused on knowledge
translation activities through the development of a Community Intersectoral
Committee on women’s self-harm. In 2004, the third project phase, again
funded by the NCPS, we developed an environmental scan. The results are due
to be released at a Manitoba community roundtable, with the expected
outcome being a compilation of guidelines for developing policy and
programming on self harm.
Awareness raising is a
prerequisite to policy
and program
development.

34
Responding from within: Women and self-harm
The KT initiative
We recognized early in the project that awareness raising is a prerequisite to policy and program development.
Our initial KT goal was therefore to increase awareness of women’s self-harm through promotion of our
research findings to the criminal justice, public health, social service and government sectors. Our activities
included a media release event to launch our initial report, wide distribution of a plain language summary of
our research, and presentations and publications in national and international academic forums and
community venues.
To take our awareness raising to the next level, in partnership with the community, we then established a
Community Intersectoral Committee, with representation from all our intended KT audiences: criminal justice
and public health policy analysts, government decision makers, academics, front line workers, and clients. We
were then able to better design our KT activities for each target audience:
• Government decision makers: We made presentations to the offices of the ministers of Justice and Health
in Ottawa, the provincial Department of Justice, and the Canadian Human Rights Commission on
federally sentenced women.
• Policy analysts: We held meetings with prison representatives from provincial correctional facilities and
federal corrections.
• Academia: We presented conference papers at several university association meetings, were guest lecturers
on university campuses and published articles and research reports in academic journals, newsletters, and
in a correctional encyclopaedia.
• Front line workers: We held community workshops, extensively distributed a plain language summary of
the research report, and collaborated with the Crossing Communities Art Project, a Manitoba
organization that develops arts programs as a healing approach for women who self-harm.
• Clients: We developed plain language summaries that offered short-term strategies designed to help
women and their loved ones deal with self-harm.
These activities (the products) and the diligent work of our team members (the process) guided our
development of the environmental scan in the project’s third phase. In this phase, our KT strategy moved
beyond awareness-raising to examining the perspectives of service providers in justice, health, and social
services on existing resources and the effectiveness of current programming and services.
Results of the KT experience
Our KT activities led to several instances of uptake of our research findings by those outside our original
collaboration and intended audiences. For example, a number of health providers who did not routinely deal
with criminalized women wanted to participate on our Community Intersectoral Committee. This reinforced
the importance of our research on self-harm as a health issue not only for women who were at risk, but also for
women in the general community.
A second example is policy action on self-harm by the Youth Solvent Addiction Committee (YSAC). YSAC’s
mission is to create a healthy recovery network of solvent treatment centres for First Nations and Inuit young
people, their families, and communities. YSAC adopted a self-harm policy for its treatment centres based on an
understanding of self-harm developed through our research. A similar policy statement was also formulated by
the Canadian Association of Elizabeth Fry Societies, which passed a national resolution on self-harm after the
publication of our research report.

35
Responding from within: Women and self-harm
Lessons learned
Our research team learned many lessons from our KT activities, which shaped the directions of later phases of
the project. The lessons were both positive and at times difficult.
Managing potential tensions
There was recognition that some organizational representatives of the team,
such as the EFS, who had been instrumental in launching a human rights
complaint against the Portage Correctional Jail, could understandably be
viewed with suspicion by some of our intended audiences (e.g. Manitoba
Justice). As a result, we set out to address potential misunderstandings by
identifying and matching presenters with various groups, or by shifting the
emphasis of what we presented to different groups. The success of this
approach was evident when key decision makers and policy makers from the
justice system and general health care sector participated on our Community
Intersectoral Committee alongside EFS staff and clientele.
Opposing views
For the most part, the team members’ breadth of experiences broadened our approach. But working on a team
founded on diversity and committed to the principle of equality in decision making required considerable give
and take. One example of group dissension occurred over the design of the research report cover. Some
members wanted to feature a picture of a restraint chair to bring attention to the inhumane treatment of
incarcerated women who self-harm. Others were concerned about an adverse reaction from justice and
correctional officials, which might impede our efforts to work with them in bringing about policy change.
There was also disquiet over sensationalizing and exploiting the women’s pain. Lengthy discussions followed on
the role of research as an advocacy tool. Eventually we agreed that the report cover would feature a symbolic
grey background with red lettering, and that the image of the restraint chair would be used in a separate
postcard campaign by one partner—the EFS—on the plight of Manitoba women in provincial custody.
Evaluation
We did not initially set up an adequate evaluative component of the effectiveness of our KT techniques and
their impact. In response to the needs of our funders (who want hard evidence that our efforts are making a
difference), we collected quantitative information on the number of reports distributed, the number of media
interviews held, papers published, etc. But we did not establish a framework to gain a qualitative
understanding of the effectiveness of our KT efforts (i.e. did we succeed in raising awareness?). Drawing on
this lesson, we are now in a position to set criteria of KT success to evaluate our efforts for the remainder of
the project.
Unanticipated happenings
The overarching lesson of this project is that working with a
diversity of partners, and attempting to translate findings into
awareness and action with an even broader representation of
community partners, brings with it a great deal of uncertainty.
The human elements—members leaving jobs, changing
governmental priorities, or even clients passing away—could
not be planned for, and we learned that the most effective
Working with a diversity of partners,
and attempting to translate findings
into awareness and action with an
even broader representation of
community partners, brings with it a
great deal of uncertainty.
Some organizational
representatives of the
team could
understandably be
viewed with suspicion
by some of our
intended audiences.

36
Responding from within: Women and self-harm
response was to be flexible and open to creative and collaborative solutions. In the end, these lived experiences
provided considerable wisdom to the team.
Conclusions and implications
Our team is now entering a new stage of its multi-phased project on self-harm, which will involve an
expansion of the research team and development of a community advisory group. This phase, which will
examine Aboriginal women’s drug use as a form of self-harm, will involve hosting a community roundtable to
discuss the findings of our environmental scan and to action plan next steps. Steps will also be taken to map
out an evaluative framework for our KT strategy.
These and related activities will remain consistent with our original KT foundation, capitalizing on the
strengths and diversity of our team members and sharing decision-making powers. This is of critical
importance to process as well as product, both of which are essential elements of our approach to KT.

37
A COMMUNITY-RESEARCHER ALLIANCE
TO IMPROVE CHRONIC WOUND CARE
Ian D. Graham, Ottawa Health Research Institute, University of Ottawa
Margaret B. Harrison, Queen’s University
Bob Cerniuk, Ottawa Victorian Order of Nurses
Sheila Bauer, Ottawa Community Care Access Centre
A partnership between health services researchers from Queen’s University and the University of Ottawa, a com-
munity nursing agency and a home care authority in Ottawa led to major improvements in the quality of care
for people with leg ulcers. The synthesis of both external and local evidence played a key role in the adoption of
an evidence-based protocol and provided the critical context to support a significant reorganization of the exist-
ing service delivery model. This case demonstrates that, with a collaborative-partnership approach, systematic
and transparent research processes can be rapidly developed to support policy change.
Background
Leg ulcers are a chronic, debilitating, costly and neglected condition. In 1999, the annual regional expenditures
for 192 individuals living in the Ottawa area and receiving home care for their leg ulcers was $1.3 million. This
group of individuals accounted for only 6% of all home care clients, but consumed 20% of the total supply
budget. Yet there is strong evidence from numerous randomized controlled trials that a thorough initial
assessment and application of compression bandages is a very effective treatment for healing venous leg ulcers.
1
Ottawa Community Care Access Centre (OCCAC), the home care authority in a region of approximately
750,000 people, became concerned about the growing demand for community care of wounds, burgeoning
wound-care supply budgets, and a shortage of nurses. In 1999, the OCCAC partnered with a not-for-profit
community nursing agency—the Ottawa Victorian Order of Nurses—and a team of health services researchers
from Queen’s University and the University of Ottawa to address their mutual concerns about care of
individuals with leg ulcers. The objective of the partnership was to improve both the quality of care and health
outcomes for individuals with leg ulcers.
This project involved both the community and tertiary sectors and was financially supported by the OCCAC,
the Ontario Ministry of Health and Long-Term Care through career scientist research allowances, and CIHR
through a grant to evaluate the effectiveness of home versus clinic care for leg ulcers.
The KT initiative
The partnership was formed with a common vision of developing a pragmatic, evidence-based approach to
bringing about practice and service changes. We approached the research as a collaborative and participatory
endeavour. The partnership has gone through a number of phases, each with a varying degree of knowledge
translation (KT) activity. Sometimes occurring simultaneously and often impacting each other, the phases of
the partnership included:
• The identification of the delivery of leg ulcer care as an important organizational issue by OCCAC,
community nursing agency managers, and policy makers;
•Researchers reviewing the literature on the effectiveness of leg ulcer care and service delivery models and
identifying best practices;

38
A community-researcher alliance to improve chronic wound care
• Conducting a regional prevalence and profiling study, environmental scan and practice audit with
OCCAC and the nursing agency to determine the magnitude of the problem and current practice;
2-4
• Conducting surveys of care providers to determine provider concerns and issues;
5,6
•Engaging OCCAC’s board with evidence from both the literature and locally derived data to support
their decision making;
•Forming an interdisciplinary group of providers and researchers which systematically reviewed the
quality and utility of existing practice guideline recommendations and adapted them for local use by
creating an evidence-based leg ulcer care protocol;
7,8
•Managers, policy makers and researchers coming together to redesign the service delivery model to
support best practice (a dedicated regional nurse led a leg ulcer team to provide care in home and clinic
settings);
•Managers finding innovative ways to overcome organizational inertia and financial and structural
barriers to make the redesign happen;
•Researchers, with the support of the agencies, creating opportunities for nurses to advance their wound
care knowledge and skills through an exchange program in the UK;
•Conducting a pre-post study of the impact of the implementation of the evidence-based protocol;
9
•Using the opportunity of preparing a grant proposal to seek peer-reviewed research funding to coalesce
researcher-policy maker synergies;
•Securing research funding to conduct a randomized controlled trial of the effectiveness of the service
model redesign.
Results of the KT experience
Qualitative feedback indicated the partnership process had positive effects for all
involved. A review of clients’ health records also indicated that the quality of care
improved.
10
The results of the pre-post implementation evaluation indicated that
the healing rate for leg ulcers at three months increased to 56% from 23%
following introduction of the evidence-based protocol, coupled with significant
reductions in nursing visits and supply costs.
9
The randomized controlled trial
evaluation of the effectiveness of home versus clinic care is in the last year of
follow-up and the results are currently being analyzed.
Perhaps most importantly, arrangements have been made to ensure the leg ulcer
service will continue to serve the region, even though the research study has
ended. The methodology used to evaluate and adapt existing guidelines
11
has been
adopted by the nursing agency to develop protocols for other conditions. It also
forms the foundation for best practice initiatives of the Canadian Strategy for Cancer Control, the Canadian
Stroke Network, and the Registered Nurses Association of Ontario.
12,13
Lessons learned
We encountered some major challenges throughout the partnership, but also learnt a number of important
lessons.
Change and commitment
Policy maker/manager partners changed frequently during the six-year period, meaning that we needed to
continually foster new relationships. There were also numerous reorganizations and leadership changes within
the regional home care and the home nursing agencies, making it challenging to keep the initiative on track.
Arrangements have
been made to
ensure the leg ulcer
service will
continue to serve
the region, even
though the research
study has ended.

39
A community-researcher alliance to improve chronic wound care
The end result of this partnership, however, was no less than the restructuring and
reorganization of service delivery to support the provision of evidence-based care.
This required a major organizational commitment from service providers as it
involved altering staffing and remuneration arrangements and procuring
additional provider education and training.
It was also labour intensive for the researchers. The research team was regularly
and actively engaged in the day-to-day ups and downs of the service and, at times,
took on an active role as implementation facilitators. The researchers who were
perceived as credible and neutral often had to work between the OCCAC and the
nursing agency to negotiate change. However, this direct contact helped to create
the common understanding and trust needed for the partnership to succeed.
While it can be frustrating to continually renegotiate and establish trust with new
personnel, having access to policy makers and being able to influence decision
making is ultimately very rewarding.
Making research evidence work for policy makers
As researchers, we had to develop methods of synthesizing and presenting external
and local evidence that were useful, user friendly, and timely for policy makers.
We also had to gain consensus on the value of “quick but good” research methods to meet the needs of the
policy makers for immediate answers, while respecting researchers’ concerns that the evidence be derived using
rigorous methods.
The critical success factor for the adoption of the evidence-based protocol was the
synthesis of external and local data. The external evidence from the literature
provided the clinical direction for the care that “ought” to be delivered. However,
the local data about current practice provided the critical contextual information
to enable the delivery of effective and efficient care.
Funding
Peer-reviewed research funding can be used to leverage change with organizations
that value research. However, it can also hold up things when resubmission to
granting agencies is required and work cannot proceed without external funding.
Conclusions and implications
The initiative was driven by a common goal of improving care and making service delivery more efficient,
using the best available evidence as the foundation. It demonstrates how policy making can become more
evidence-based when researchers and policy makers adopt a collaborative-partnership approach, and how this
approach can increase appreciation of each other’s worlds and perspectives, build trust, encourage learning from
each other and provide new opportunities to use research to improve decision making. It can be very rewarding
when a visible difference is made to a population receiving care, and when that change creates additional
successes.
While it can be
frustrating to
continually
renegotiate and
establish trust with
new personnel,
having access to
policy makers and
being able to
influence decision
making is
ultimately very
rewarding.
The critical success
factor for the
adoption of the
evidence-based
protocol was the
synthesis of external
and local data.

40
A community-researcher alliance to improve chronic wound care
The project also revealed it is possible to develop systematic, transparent and
relatively quick (e.g. the guideline evaluation and adaptation cycle) research
processes that can support policy making. As the results of the pre-post study
validating the effectiveness of the locally-developed leg ulcer protocol have only
just been released, it is premature to expect that it has been adopted elsewhere.
However, the protocol was updated
8
and formed the basis of an implementation
study in three other regions of Ontario. Although the data have not been
thoroughly analyzed, we do know that the protocol was adopted in two regions
but not the third: this was likely due to the fact that organizational changes
necessary to support delivery of the protocol were not made at the third site.
Important implications of this case study for future KT research include: the need
to focus on researcher-policy maker relationships and the factors that promote or
hinder the development of effective relationships; methods for synthesizing
external and local data for policy makers; and the role of researchers as change
agents and implementation facilitators.
References
1
Cullum, N., E. A. Nelson, A. W. Fletcher, and T. A. Sheldon. 2001. Compression for venous leg ulcers.
The Cochrane Database of Systematic Reviews 2:CD000265.
2
Harrison, M. B., I. D. Graham, E. Friedberg, K. Lorimer, and S. Vandevelde-Coke. 2001. Regional
planning study: Assessing the population with leg and foot ulcers. Can Nurse 97:18-23.
3
Friedberg, E. H., M. B. Harrison, and I. D. Graham. 2002. Current home care expenditures for persons
with leg ulcers. J Wound Ostomy Continence Nurs 29:186-92.
4
Graham, I. D., M. B. Harrison, E. A. Nelson, K. Lorimer, and A. Fisher. 2003. Prevalence of lower-limb
ulceration: A systematic review of prevalence studies. Adv Skin Wound Care 16 (6): 305-16.
5
Graham, I. D., M. B. Harrison, C. Moffat, and P. Franks. 2001. Leg ulcer care: Nursing attitudes and
knowledge. Can Nurse 97:19-24.
6
Graham, I. D., M. B. Harrison, M. Shafey, and D. Keast. 2003. Knowledge and attitudes regarding care
of leg ulcers: Survey of family physicians. Can Fam Physician 49:896-902.
7
Graham, I. D., K. Lorimer, M. B. Harrison, T. Pierscianowski, for the Leg Ulcer Protocol Tasks Force,
Leg Ulcer Protocol Task Force Working Group, et al. 2000. Evaluating the quality and content of
international clinical practice guidelines for leg ulcers: Preparing for Canadian adaptation.
CanAssoc Enterostomal Ther J 19 (3): 15-31.
8
Graham, I. D., M. B. Harrison, K. Lorimer, T. Pierscianowski, E. Friedberg, M. Buchanan, and C. Harris.
2005. Adapting National and International Leg Ulcer Practice Guidelines for Local Use: The Ontario Leg
Ulcer Community Care Protocol. Adv Skin Wound Care 18 (6): 307-18.
9
Harrison, M. B., I. D. Graham, K. Lorimer, E. Friedberg, T. Pierscianowski, and T. Brandys. 2005.
Leg-ulcer care in the community, before and after implementation of an evidence-based service.
CMAJ 172 (11): 1447-52.
10
Lorimer, K. 2004. Continuity through best practice: Design and implementation of a nurse-led community
leg-ulcer service. Can J Nurs Res 36 (2): 105-12.
11
Graham, I. D., M. B. Harrison, and M. Brouwers. 2003. Evaluating and adapting practice guidelines for
local use: A conceptual framework. In Clinical governance in practice, ed. S. Pickering and J. Thompson,
213-29. London: Harcourt.
It can be very
rewarding when a
visible difference is
made to a
population
receiving care, and
when that change
creates additional
successes.

41
A community-researcher alliance to improve chronic wound care
12
Graham, I. D., M. B. Harrison, M. Brouwers, B. L. Davies, and S. Dunn. 2002. Facilitating the use of
evidence in practice: Evaluating and adapting clinical practice guidelines for local use by health care
organizations. J Obstet Gynaecol Neonatal Nurs 31 (5): 599-611.
13
MacLeod, F. E., M. B. Harrison, and I. D. Graham. 2002. The process of developing best practice
guidelines for nurses in Ontario: Risk assessment and prevention of pressure ulcers. Ostomy Wound Manage
48 (10): 30-2, 34-8.

42
A community-researcher alliance to improve chronic wound care

43
PRISMA: DEVELOPING INTEGRATED SERVICES DELIVERY
FOR FUNCTIONAL AUTONOMY
Réjean Hébert, MD, MPhil, Université de Sherbrooke
André Tourigny, MD, MBA, Université Laval
Michel Tousignant, Pht, PhD, Université de Sherbrooke
Louis Demers, PhD, École nationale d’administration publique
Nicole Dubuc, RN, PhD, Université de Sherbrooke
Diane Morin, RN, PhD, Université Laval
Danièle Blanchette, PhD, CA, Université de Sherbrooke
Lucie Bonin, Agence régionale de santé et de services sociaux de Mauricie-Centre-du-Québec
Yves Couturier, Université de Sherbrooke
The PRISMA project is a collaborative research partnership designed to develop and implement mechanisms and
tools to enable integrated services delivery for frail older people. Involving researchers, policy makers, managers,
and clinical practitioners, the PRISMA group has developed a model that includes coordination mechanisms at
the governance, management, and clinical levels; a single-entry point for access to services; case management;
individualized service plans; a unique assessment tool; and a computerized clinical chart. The PRISMA model
has been successfully implemented in multiple regions and has significantly influenced the development of policy
and programs for the frail elderly in Quebec.
Background
Traditional hospital-centred care is inappropriate for many chronic illnesses that require ongoing, long-term
care. For these kinds of illnesses, which affect many elderly people, a different model of care, one that centres
on the users’ place of residence, may be more appropriate. Such a model calls for major changes in the
organization and delivery of health and social services, with a primary focus on front line health and home
care. Given the plethora of organizations and professionals involved, integrated services are crucial.
The PRISMA project aims to develop, implement, and evaluate mechanisms and tools to improve the
continuity of care and integrate health services for frail older people in Canada. The PRISMA model of
Integrated Service Delivery (ISD)
1
includes all public, private, or volunteer organizations that provide care and
services to frail elders, and consists of six components: coordination mechanisms at the governance,
management and clinical levels; a single-entry point for access to all services; case management; an
individualized service plan; a unique assessment tool with a case-mix classification management system; and a
computerized clinical chart.
The PRISMA group is led by Dr. Réjean Hébert from the Université de Sherbrooke’s Research Centre on
Aging and includes 15 researchers from both this centre and the Université Laval geriatric research team. These
two research teams work with the directors and managers of the health and social services network from the
Ministère de la Santé et des Services sociaux (MSSS), the Institut national de santé publique du Québec, five
Regional Health and Social Services Boards (RRSSSs), and the Sherbrooke Geriatric University Institute (a
hospital centre and long-term care facility). PRISMA represents a unique partnership of researchers, policy
makers, managers and clinical practitioners, who collaborate to define research objectives, design and carry out
protocols and introduce results back into the field through innovative services and programs.

44
PRISMA: Developing integrated services delivery for functional autonomy
The KT initiative
The PRISMA group develops, implements, and evaluates ISD mechanisms and tools primarily by studying
frail older people experiencing loss of autonomy. In the late 1990s, an initial project in the Bois-Francs area of
Quebec, which was led by the area’s RRSSS, requested support from researchers at an early stage to evaluate the
experiment and contribute to the development and piloting of project mechanisms and tools. A close
collaborative relationship was created between researchers, policy makers, health managers, and clinicians,
leading to the later development of the PRISMA model and its components.
The evaluation of this initial pilot project provided useful information to
decision makers, managers and clinical practitioners for current and future
implementations. A second initiative to implement an ISD, in the Estrie region,
involved the same pattern of collaborative work in designing, implementing,
and analysing the experiment, and transferring the results. Other RRSSSs
became interested in some components of the model and also joined the
PRISMA group.
The provincial PRISMA group includes representatives from the research team,
the MSSS, and the participant RRSSSs. It meets three times a year to overview
the work of the group; exchange knowledge on current issues, problems, and
results; determine future projects; and plan knowledge translation (KT)
activities. In each region, PRISMA teams meet more regularly to design and
implement experiments, monitor and analyse the results, and discuss translation strategies. A continuous
exchange process is in place to monitor change and respond to emerging needs.
We also conduct many activities to disseminate PRISMA’s results. We have held three colloquia, reaching over
600 clinicians, managers and policy makers in Quebec, and have also visited facilities wishing to implement
some of our tools. A regularly updated website provides information about PRISMA’s work, and a book
summarizing PRISMA’s work to date was recently published in both French
2
and English.
3
Results of the KT experience
PRISMA has developed and implemented many tools to support integrated services delivery and to facilitate a
shift to new professional practices and organizational change. During the Estrie implementation, for example,
case managers and clinical practitioners requested a simple screening tool to identify frail elders who might
eventually enter the ISD system. The research team designed and validated the PRISMA-7 questionnaire,
4
which is now used on a telephone health line, by voluntary agencies and in clinical settings to identify older
people who should be referred to case managers and more completely assessed.
During the Bois-Franc initiative, we recognized that it was vitally important to have a computerized clinical
chart that facilitated communication between health care workers and organizations. This information system,
the Système d’information géronto-gériatrique (SIGG), is a computerized version of the unique assessment tool
and includes the Système de mesure de l’autonomie fonctionnele (SMAF) disability scale. The SIGG uses an
existing secure health and social services communication network (RTSS) in Quebec and is accessible by
professionals in all institutions via the Internet to share information about clients.
We have also developed a case-mix classification system based on the SMAF scale—Iso-SMAF profiles—for
accountability and performance evaluation. These profiles classify patients according to functional autonomy
In each region,
PRISMA teams meet
more regularly to
design and implement
experiments, monitor
and analyse the
results, and discuss
translation strategies.

45
PRISMA: Developing integrated services delivery for functional autonomy
and aim to reconcile clinical evaluations with management information. The system is designed to avoid
redundant data collection and to coordinate recommended services, resource allocation, patient tracking,
quality evaluations and organizational accountability. These profiles been fully implemented to improve the
management of people receiving home care and institutional care in two experimental areas, and the MSSS is
now contemplating generalization of the profiles to all home care and institutional services.
Economic evaluation of the implementation and functioning of the PRISMA model
5
has also proved useful to
policy makers planning implementations of the model and quantifying the budget needed to support it.
Additional studies about the work of case managers were also used to better define new professional roles and
improve training.
6
For example, the Université de Sherbrooke developed a new graduate program for case
managers with the input of the PRISMA group.
Lessons learned
Working in close relationship with policy makers, managers and clinicians
ensures the relevance of the group’s research and its quick implementation
in the health care system. But synchronizing research with services and
policy is not always an easy task. Researchers no longer have total control
of the experiment, and mutual trust must be established to ensure that
policy makers and managers understand the research agenda. Budget
constraints have slowed the implementation of ISD in the Estrie area, and
of some tools (particularly SIGG), resulting in delays in many research
projects. In addition, occasionally our knowledge translation activities
were almost too effective, with some areas deciding to prematurely
implement PRISMA work without waiting for final results. This was also
true at the policy-making level, where the Ministère de la Santé et des Services sociaux included integration and
the PRISMA model in his policy for older people. This could have jeopardized our evaluation research, if the
selected comparison areas had immediately implemented the PRISMA model.
Conclusions and implications
By working closely with policy makers in Quebec, the PRISMA group has had
a major impact on the development of health department guidelines for frail
elders experiencing loss of independence
7
and an action plan for services to frail
older people. PRISMA’s work has also influenced the recent provincial reform
that set up integrated structures, the Centre de santé et de services sociaux
(CSSSs) (merging hospitals, community health centres and nursing homes).
The clinical projects for frail older people currently under development in all
ninety-five CSSSs will be greatly influenced by PRISMA’s work. PRISMA
members have also been invited to Ontario and British Columbia to advise
regional or provincial authorities on organizing services for older people, and
the group recently attended a European conference on providing integrated
health and social services for older persons as an international expert.
The PRISMA group continues its research. The Bois-Francs project has demonstrated statistically significant
effects on patient functional independence and the utilization of health services.
8
As a result of the Estrie study,
over the next few years we will be able to document the impact of ISD on health services consumption and
The PRISMA group
has had a major
impact on the
development of health
department guidelines
for frail elders
experiencing loss of
independence.
Occasionally our knowledge
translation activities were
almost too effective, with
some areas deciding to
prematurely implement
PRISMA work without
waiting for final results.

46
PRISMA: Developing integrated services delivery for functional autonomy
determine the related costs through a population-based approach. We will also study ISD impact on
professional practices and on frail elders and their immediate caregivers, and develop indicators to assess quality
of care within ISD. Indicators are also being developed to measure ISD impact on continuity of services, which
is the ultimate objective of integration.
The PRISMA group is also adapting the model for other patient populations, notably those with physical and
intellectual disabilities and mental health problems. The validity of the Iso-SMAF profiles has been verified
with other patients and their application to private nursing homes is now being tested.
This project demonstrates research can influence policy to improve the Canadian health and social system. The
PRISMA group may also have demonstrated the most effective way of combining research with action in order
to rapidly and effectively transform research data into new ways of delivering services, and conversely, to ensure
that decisions made by government officials and managers are based on solid data.
References
1
Hébert, R., P. J. Durand, N. Dubuc, A. Tourigny, and the PRISMA Group. 2003. Frail elderly patients.
New model for integrated service delivery. Can Fam Physician 49:992-97.
2
Hébert, R., A. Tourigny, et M. Gagnon. 2004. Intégrer les services pour le maintien de l’autonomie des
personnes. Quebec: Edisem.
3
Hébert, R., A. Tourigny, and M. Gagnon. 2005. Integrated service delivery to ensure persons’ functional
autonomy. Quebec: Edisem.
4
Raîche, M., R. Hébert, M-F. Dubois, and the PRISMA partners. User guide for the PRISMA-7
questionnaire to identify elderly people with severe loss of autonomy. In Integrated service delivery to ensure
persons’ functional autonomy, ed. R. Hébert, A. Tourigny, and M. Gagnon, 147-65. Quebec: Edisem.
5
Durand, S., D. Blanchette, and R. Hébert. 2005. Financial aspects of integrated services for the
maintenance of autonomy—implementation and operations. In Integrated service delivery to ensure persons’
functional autonomy, ed. R. Hébert, A. Tourigny, and M. Gagnon, 241-55. Quebec: Edisem.
6
Couturier, Y., S. Carrier, and I. Chouinard. 2005. The semantic field of integrating services: Issues for
clinical work and planning. Proceedings of the 3rd PRISMA scientific colloquium on integrated services.
PRISMA.
7
Ministère de la Santé et des Services sociaux. 2001. Orientations ministérielles sur les services offerts aux
personnes âgées en perte d’autonomie. Quebec: MSSS.
8
Tourigny, A., P. Durand, L. Bonin, R. Hébert, and L. Rochette. 2004. Quasi-experimental study of the
effectiveness of an integrated service delivery network for the frail elderly. Can J Aging. 23 (3): 231-46.

47
THE CANADIAN NEONATAL NETWORK
™
—
ANOVEL MODEL FOR KNOWLEDGE TRANSLATION
Shoo Lee, University of Alberta
Khalid Aziz, Memorial University of Newfoundland
Arne Ohlsson, University of Toronto
Catherine M. Cronin, University of Manitoba
Francine Lefebvre, Université de Montréal
Alexander Allen, Dalhousie University
Michael Dunn, University of Toronto
The Canadian Neonatal Network™
The Canadian Neonatal Network™ is an award-winning research and knowledge translation (KT) initiative
aimed at improving the health and quality of health care for newborn babies. Comprising researchers, clinicians,
and administrators from neonatal intensive care units and universities across Canada, the Network conducts evi-
dence-based collaborative research with an emphasis on implementation of practice and policy changes. Core
activities, such as providing outcomes feedback to individual hospitals, have led to significant practice improve-
ments. The Network has also contributed to the development of policies around the allocation of neonatal
resources in British Columbia and is internationally recognized as a driver for change.
Background
The Canadian Neonatal Network™ is a multidisciplinary group of researchers, clinicians, and administrators
from all 30 Canadian tertiary neonatal intensive care units (NICUs) and 16 universities across Canada. We
conduct evidence-based collaborative research to improve the health and quality of health care for newborn
babies, with an emphasis on KT and implementation of practice and policy changes. Our program of research
has resulted in many findings that have had significant impacts on patients, organizations, and health care
systems. In 2004, the Canadian Neonatal Network™ received the Knowledge Translation Award from CIHR.
The Network’s specific goals are to establish a national network of multidisciplinary Canadian researchers
interested in neonatal-perinatal research, establish and maintain a national neonatal-perinatal database and
provide the infrastructure to facilitate collaborative research. We are also interested in studying longitudinal
outcomes and variations in medical care, because NICU care is one of the largest components of child health
expenditures and exhibits large variations in mortality, morbidity, and costs. Overall, we aim to develop
innovative research methods that can lead to improvements in health and the quality of health care.
The Network was founded in 1995 and its membership now stands at 50 researchers, clinicians, and
administrators, and 20 trainees. Funding is provided by a partnership of hospitals (for data collection) and
research granting agencies (for research projects). We have also established a Neonatal-Perinatal
Interdisciplinary Capacity Enhancement (NICE) Team of multidisciplinary national experts who are funded by
CIHR to provide in-depth support for research conducted by the network.
The KT initiative
We use an integrated approach that combines research methodology with experienced clinical and management
expertise to identify health problems, find practical solutions, and implement and evaluate them. To do this,
we maintain a standardized national database of all babies admitted to Canadian NICUs. Each year, we publish
an audit report that monitors outcomes, treatment practices and health trends for newborn babies, and

48
The Canadian Neonatal Network™—a novel model for knowledge translation
provides feedback to individual institutions and regional health authorities. We establish research teams to
address health problems identified by the audit report and by members of the network at three levels—the
patient, the organization and the health care system. We are currently conducting ten peer-review funded
multi-centre studies aimed at improving neonatal outcomes.
We have published over 100 articles in scientific journals and have made over 100 presentations at national and
international scientific meetings. In addition, we effect KT directly through:
• Clinical care: At each hospital, a multidisciplinary team of health professionals led by Network members
monitors data feedback, and develops and implements change strategies.
• Practice guidelines: We work with professional societies (e.g. Canadian Pediatric Society) to generate and
evaluate practice guidelines.
• Policy and planning: We provide health authorities and provincial governments with policy
recommendations through targeted reports.
Results of the KT experience
Highlights of some of our research and KT activities include:
1. Identifying variations in NICU outcomes, practices, and best practices across Canada
We published the first comprehensive description of outcomes and practices in Canadian NICUs,
1
and
examined outcomes of important sub-populations at particularly high risk of long-term health complications,
such as extremely preterm infants.
2,3
Feedback of this information through an audit report to hospitals resulted
in significant action to address identified deficiencies. One hospital introduced measures that reduced the
infection rate in their NICU by more than half.
We also reported significant risk-adjusted variations in mortality and morbidity among Canadian NICUs.
4
These small area variations in outcomes can be used to examine the relative effectiveness of differing practices.
We found that each hospital had different strengths and weaknesses, and no hospital had uniformly superior
performance. This exposed the potential flaw of copying practices from reputable hospitals, since superior
performance in one area does not imply superior performance in other areas.
For one condition (intraventricular haemorrhage), we identified that variation in its incidence was attributable
to differences in four key NICU practices.
5
We then developed analytic methods for identifying and
quantifying the attributable risks associated with outcome variations at individual hospitals.
6
These
developments open the way for significantly improving current quality improvement methods which rely on
subjective observations of “best practices.”
2. Development of instruments to compare NICU outcomes
In collaboration with U.S. researchers, we developed and patented a neonatal illness severity score (SNAP-II)
and showed how risk adjustment can be used to make valid comparisons of NICU outcomes.
7,8
SNAP-II has
become the international standard for assessing the severity of neonatal illness and comparing hospital
outcomes for audit, accreditation, and quality improvement purposes. SNAP-II has also been licensed to
companies for risk assessment, setting insurance premiums, and incorporation into hospital patient monitoring
equipment.

49
The Canadian Neonatal Network™—a novel model for knowledge translation
We also developed the first validated instrument
9
for assessing infant transport outcomes. Using this system,
one hospital in Canada identified and solved a problem affecting 40% of their transported babies, who were
arriving at the destination hospital with temperatures below normal.
3. EPIC (evidence-based practice identification and change) system for quality improvement
We developed a scientific, objective method of quality improvement based on evidence in the published
literature, targeted intervention of specific practices for change, and the cumulative expertise of the Network.
This evidence-based practice identification and change (EPIC) system combines quantitative analysis with
qualitative methods to identify barriers to change, and uses multidisciplinary teams at each hospital to facilitate
practice change. By networking hospital teams, duplication of effort is avoided, lessons learned are quickly
shared, enthusiasm is maintained and KT is accomplished at the ground level.
EPIC changes the paradigm of quality improvement from a subjective exercise to an objective method that can
more efficiently and effectively improve quality of care. A multi-centre CIHR-funded study is underway to
evaluate the impact of EPIC on quality of care in the NICU.
4. Evaluation of clinical practice guidelines
We also use the database to evaluate practice guidelines and make recommendations for new ones. For
example, we found that one routine screening guideline for preterm infants was unnecessary for babies above a
certain birth weight.
10
These findings led the Canadian Paediatric Society to review its national screening
guidelines, with the potential to halve the number of infants routinely screened, and save hospital costs of over
$1 million annually.
We also developed a formula that enables a regional hospital to identify the
most cost-effective transport system for its jurisdiction, taking into account
local wage costs and transport needs.
11
Anecdotal communications indicate that
hospitals in other countries have also started using our system for making
transport system decisions.
5. Recommendations for policy and planning
Using the database, we have examined the adequacy and allocation of neonatal
resources in B.C. and submitted a report to the B.C. government with
recommendations for change.
12
We also examined and reported on the costs of
neonatal and perinatal care in B.C.
13,14
These reports have since been adopted
by the B.C. Ministry of Health Services and the Child Health Network for the
Greater Toronto Area as a basis for assessing the adequacy of high-risk perinatal
capacity and for planning regional resource allocation for the future.
Lessons learned
Networks that include researchers, clinicians, and administrators in the planning and execution of research
projects, and that execute practice and policy change at the ground level, as integral objectives of the project,
are effective vehicles for KT in health care. National networks add value because they pool expertise from a
wide variety of resources, permit coordinated initiatives that avoid duplication of effort and produce results
that are easily generalizable. Clinical and administrative health databases have important roles in health
research and can significantly reduce the cost and improve the effectiveness of health research.
National networks
add value because
they pool expertise
from a wide variety of
resources, permit
coordinated initiatives
that avoid duplication
of effort and produce
results that are easily
generalizable.

50
The Canadian Neonatal Network™—a novel model for knowledge translation
A major difficulty we encountered was that our initiatives were regarded by
some research peer-review committee members as quality improvement and
therefore not “real research,” and simultaneously regarded by some health
administrators as “research.” Thus, we often found ourselves in the no-man's
land between research and quality improvement, unable to access funding from
either the research granting agencies or the health care system.
Another major difficulty has been the lack of support for maintaining the
network infrastructure or the national database, from both granting agencies
and hospitals. Consequently the network infrastructure is unstable and
frequently disassembled and re-assembled depending on availability of financial
resources, with consequent disruption to surveillance and research. Yet the
network significantly reduces the cost of individual research projects by
providing common infrastructure and avoiding duplication of data collection.
Funding mechanisms that bridge traditional health research and management functions, and provide stability
for infrastructure support, are required.
Conclusions and implications
The Canadian Neonatal Network has been described as the archetype of
the KT network in Canada. It has also received international recognition as
a source of benchmarking data, a driver for change, and a powerful
teambuilding force. In 2003, the American Academy of Pediatrics
Neonatal-Perinatal Section of District VIII voted unanimously to join the
Network. Requests for assistance or collaboration have also come from
countries such as India, China, Malaysia, Mexico, and Australia, and we
have now established the International Neonatal Collaboration to facilitate
international research and collaboration.
References
1
Lee, S. K., D. D McMillan, A. Ohlsson, M. Pendray, A. Synnes, R. Whyte, L. Y. Chien, and J. Sale. 2000.
Variations in practice and outcomes in the Canadian NICU network: 1996-1997. Pediatrics 106:1070-79.
2
Chan, K., A. Ohlsson, A. Synnes, D. S. C. Lee, L. Y. Chien, S. K. Lee, and The Canadian Neonatal
Network. 2001. Survival, morbidity, and resource use of infants of 25 weeks’ gestational age or less.
AmJObstet Gynecol 185:220-26.
3
Chien, L. Y., R. Whyte, K. Aziz, P. Thiessen, D. Matthew, S. K. Lee, and The Canadian Neonatal Network.
2001. Improved outcome of preterm infants when delivered in tertiary care centers. Obstet Gynecol
98:247-52.
4
Sankaran, K., L. Y. Chien, R. Walker, M. Seshia, A. Ohlsson, and S. K. Lee. 2002. Variations in mortality
rates among Canadian neonatal intensive care units. CMAJ 166:173-78.
5
Synnes, A. R., L. Y. Chien, A. Peliowski, R. Baboolal, S. K. Lee, and The Canadian NICU Network. 2001.
Variations in intraventricular hemorrhage incidence rates among Canadian neonatal intensive care units.
JPediatr 138:525-31.
6
MacNab, Y., Z. Qiu, P. Gustafson, C. B. Dean, A. Ohlsson, and S. K. Lee. Forthcoming. Hierarchical Bayes
analysis of multilevel health services data. Health Serv Outcome Res.
We often found
ourselves in the no-
man's land between
research and quality
improvement, unable
to access funding from
either the research
granting agencies or
the health care system.
Funding mechanisms that
bridge traditional health
research and management
functions, and provide
stability for infrastructure
support, are required.

51
The Canadian Neonatal Network™—a novel model for knowledge translation
7
Richardson, D., W. O. Tarnow-Mordi, and S. K. Lee. 1999. Risk adjustment for quality improvement.
Pediatrics 103 (1 Suppl E): 255-65.
8
Richardson, D. K., J. D. Corcoran, G. J. Escobar, and S. K. Lee. 2001. SNAP-II and SNAPPE-II:
Simplified newborn illness severity and mortality risk scores. J Pediatr 138:92-100.
9
Lee, S. K., J. A. F. Zupancic, M. Pendray, P. Thiessen, B. Schmidt, R. Whyte, D. Shorten, S. Stewart, and
The Canadian Neonatal Network. 2001. Transport risk index of physiologic stability: A practical system for
assessing infant transport care. J Pediatr 139:220-26.
10
Lee, S. K., C. Normand, D. McMillan, A. Ohlsson, M. Vincer, C. Lyons, for the Canadian Neonatal
Network. 2001. Evidence for changing guidelines for routine screening for retinopathy of prematurity.
Arch Pediatr Adolesc Med 155:387-95.
11
Lee, S. K., J. A. Zupancic, J. Sale, M. Pendray, R. Whyte, D. Brabyn, R. Walker, and H. Whyte. 2002.
Cost-effectiveness and choice of infant transport systems. Med Care 40:705-16.
12
Lee, S. K., K. Cardiff, S. Stewart, and W. MacKenzie. 2002. Report on tertiary neonatal care in British
Columbia. Vancouver, BC: Centre for Healthcare Innovation and Improvement.
13
Lee, S. K., and L. Anderson. 2004. Report on tertiary neonatal costs in B.C. Vancouver, BC: Centre for
Healthcare Innovation and Improvement.
14
Lee, S. K., and L. Anderson. 2004. Report on tertiary perinatal costs in B.C. Vancouver, BC: Centre for
Healthcare Innovation and Improvement.

52
The Canadian Neonatal Network™—a novel model for knowledge translation

53
ACADEMIC DETAILING IN THE ALBERTA
DRUG UTILIZATION PROGRAM
Dr. Harold Lopatka, Program Director, Alberta Drug Utilization Program
The Alberta Drug Utilization Program runs a multi-faceted educational initiative, with academic detailing as
the centrepiece, to improve physician prescribing behaviour in Alberta. Noticeable improvements to clinical prac-
tice guidelines have been observed over the three years of its operation. Building and maintaining relationships—
between organizations, between physicians and academic detailers, and between physician peers—has been iden-
tified as key to the success of this initiative.
Background
The Alberta Drug Utilization Program (ADUP) was established in 1998 to develop, evaluate, and facilitate the
implementation of drug use management strategies that promote the health of Albertans.
Academic detailing—an educational intervention for improving professional practice—was identified as one
strategy that could improve the prescription and use of drugs in Alberta. The goal of academic detailing is to
optimize physician prescribing behaviour by communicating evidence-based, cost-effective and unbiased drug
information to providers.
However, approaches such as multi-faceted educational interventions and academic detailing may not be as
effective at influencing professional practice as once believed, due to unacknowledged factors.
1
In the
pharmaceutical industry, for example, significant attention is paid to the role of inter- and intra-organizational
and personal relationships in the success of knowledge translation (KT) interventions.
2,3
This has not been as
well explored in the medical literature.
ADUP was charged with implementing and evaluating a multi-faceted educational initiative, with academic
detailing as the centrepiece, through demonstration projects in Alberta’s regional health authorities. Our key
partner organizations were the Alberta Medical Association, the Alberta College of Physicians and Surgeons,
the Alberta College of Pharmacists, the Pharmacists Association of Alberta, The College of Family Physicians of
Canada, Alberta’s regional health authorities, Alberta Health and Wellness, Alberta Blue Cross, the University
of Alberta and the University of Calgary. The project was funded by Alberta Health and Wellness.
The KT initiative
The initiative began in the David Thompson Health Region in late 2001 and is now being launched in the
Calgary Health Region. The central goal is to improve family medicine physicians’ adherence to provincial and
national clinical practice guidelines for rational medication use. Specific topics are chosen by reviewing
prescription claims and physician billing data to determine potential care gaps and educational needs.
Literature reviews are conducted and the opinions of specialists are obtained when data is not available for
selecting topics.
A multi-faceted KT approach, including multidisciplinary continuing education, academic detailing by a
pharmacist, distribution of printed education materials, opinion leader consultation and comparative
prescribing feedback reports which show how consenting physicians prescribe in relation to peers in the region,
is used for each topic. The complete intervention occurs over four to six months.

54
Academic detailing in the Alberta Drug Utilization Program
Medical specialists deliver the continuing education, providing their perspective on important aspects of the
clinical practice guideline (e.g. key points, grey areas) and answering questions. The academic detailing occurs
after the continuing education, with the detailer conducting a 30-minute visit in the physician’s office to talk
about the guideline. Some time after the academic detailing visit, a small group session (usually at the
physician’s clinic) is scheduled with an opinion leader, a specialist, and the detailer to discuss cases. Opinion
leaders also provide advice to the detailers about interpreting critical evidence and help them prepare for a
topic by allowing them to attend outpatient clinics.
The clinical practice guidelines are produced and validated by the provincial clinical practice guidelines
program, Towards Optimal Practice (TOP), which develops new guidelines, validates national guidelines, or
updates older guidelines. TOP produces one-page guideline summaries for use in academic detailer and
opinion leader visits. After our visits and internal evaluations, we provide feedback from physicians on the
guidelines to TOP.
The University of Alberta assists in the organization and delivery of the continuing medical education
programs, coordinating promotion activities, registrations, handouts, tele-health broadcasts to rural sites,
attendance certificates, and evaluations.
The David Thompson Health Region and the Calgary Health Region also promote and market the initiative.
In the Calgary Health Region, it has been embedded structurally within the chronic disease management unit,
and physicians participating in the chronic disease management program are also recruited for academic
detailing.
We evaluated the success of the initiative through monitoring of academic detailer activities, physician
satisfaction and opinion surveys and through retrospective review of prescription drug claims (to assess
adherence to clinical practice guidelines).
Results of the KT experience
Overall, 250 visits were conducted by our pharmacist detailer on four broad
topics by the end of 2004. Physician participation increased from 10 physicians
for the first topic to over 55 for a later topic, and the regional centres (cities and
towns) we covered increased from two to 15. The initiative has been accepted
by local physicians (high levels of satisfaction have been reported by
participants) and has been successful in improving adherence to clinical practice
guidelines (10-13% improvements have been recorded in adherence to two
guidelines).
Lessons learned
We attribute the success of the initiative to the attention given to building and
maintaining relationships at both the system and front line levels. At the system
level, relationships with our key provincial partner organizations, such as the
health regions, Alberta Blue Cross, the University of Alberta, and TOP, were
critical for the delivery of our program. As a general operating principle, we
work on the premise that our activities should focus on front line delivery of
services and should not duplicate activities performed by other organizations.
We attribute our
success to our ability
to build relationships
with increasing
numbers of physicians,
and to foster in-depth
relationships with
physicians
participating in the
initiative.

55
Academic detailing in the Alberta Drug Utilization Program
At the front-line level, we attribute our success to our ability to build relationships with increasing numbers of
physicians, and to foster in-depth relationships with physicians participating in the initiative. For example:
•We recruited local physician champions to increase acceptance of the
initiative by their peers. As participation in the program is voluntary, the
involvement of a highly supportive local champion has made a significant
difference in physician recruitment and participation. In regional centres
where a local champion is present, physician participation in topics has
been as high as 100%. In centres without a local champion, or if the
centre is too large for a local champion to have an effect, participation is
approximately 10%.
•We hired local community pharmacists as academic detailers to improve
efficiency and increase physician participation. Initially, we began with
one Edmonton-based academic detailer. But the David Thompson
Health Region spans a very large geographic area and significant time
was spent traveling. So two local community pharmacists were hired to provide detailing services. Their
local familiarity and established relationships also allowed them to gain access to physicians who had
previously resisted participation in the initiative. One pharmacist increased physician participation by
more than 100% in one centre.
•Opinion leaders helped improve the credibility of the initiative. Our initial plan was to co-opt local
physicians to serve as opinion leaders and to have them consult with their peers about the guidelines.
However, we encountered difficulties in finding local opinion leaders and instead recruited an opinion
leader from Edmonton, an internal medicine specialist. This has proved to be a popular learning
approach with participating physicians. In Calgary, we have employed a different model, using topic-
specific opinion leaders.
•We offer physicians the opportunity to trial or sample the initiative before making a full commitment.
For example, newly recruited physicians can receive academic detailing and/or opinion leader
consultation, but not continuing education or comparative prescribing feedback reports. Approximately
10% of physicians receive sample or trial detailing visits.
•We foster long-term, individual relationships. As the relationships between detailers and individual
physicians mature beyond basic information exchange, and comfort levels increase, discussions became
more meaningful. Detailers are able to identify common uncertainties in family medicine practice and
specific educational needs relating to the clinical practice guidelines.
Considerable time and effort is required to create and maintain
relationships, but this was identified as critical to the success of
our early KT activities. As our initiative continues to mature and
expand, it is expected that additional challenges will need to be
addressed at both the system and front line levels. We need to
know more about the optimal structures and processes for
effective relationship building, and we need to be able to
determine if the interventions produce better outcomes when
they are conducted in settings where established relationships
exist. We also need to know if specific KT activities are more
effective than others where established relationships exist.
The involvement of a
highly supportive local
champion has made a
significant difference
in physician
recruitment and
participation.
As the relationships between
detailers and individual
physicians mature beyond basic
information exchange,
discussions became more
meaningful.

56
Academic detailing in the Alberta Drug Utilization Program
Conclusions and implications
Several encouraging developments suggest that our initiative will have broader uptake. First, another
government drug plan manager, Health Canada (First Nations and Inuit Health Branch–Alberta region), has
joined our group of key stakeholders because of their interest in the project. Second, five provinces conducting
academic detailing initiatives have joined forces to create the Canadian Academic Detailing Collaborative. This
group has secured funding from Health Canada to evaluate processes and outcomes resulting from national
collaboration. Third, the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) has
been created by the Canadian Coordinating Office for Health Technology Assessment to coordinate evidence-
based reviews and the development of change management tools. As COMPUS becomes operational it will
enhance our capacity to conduct KT activities by making tools available for KT, assessing KT strategies relating
to appropriate medication use, and reviewing methods for evaluating KT activities like academic detailing.
Fourth, at least two Alberta local primary care networks have integrated academic detailing as a service for
primary care physicians. In a recent external program evaluation of ADUP, an accelerated expansion of the
initiative was identified as a major strategic activity for our future plans.
References
1
Grimshaw, J. M., R. E. Thomas, G. MacLennan, C. Fraser, C. R. Ramsay, L. Vale, P. Whitty, et al. 2004.
Effectiveness and efficiency of guideline dissemination and implementation strategies.
Health Technol Assess 8 (6): 1-72.
2
Weitz, B. A., and K. D. Bradford. 1999. Personal selling and sales management: A relationship marketing
perspective. J Acad Market Sci 27:241-54.
3
Prounis, C. 2003. What doctors want. Pharmaceutical Executive, May (Suppl).

57
PILOTING KNOWLEDGE BROKERS TO PROMOTE INTEGRATED
STROKE CARE IN
ATLANTIC CANADA
Renee Lyons, PhD, Atlantic Health Promotion Research Centre, Dalhousie University
Grace Warner, PhD, Atlantic Health Promotion Research Centre, Dalhousie University
Lynn Langille, MA, Atlantic Health Promotion Research Centre, Dalhousie University
Stephen J. Phillips, MBBS, Dalhousie University
The use of knowledge brokers to increase interaction between researchers and decision makers has attracted
increasing attention as a knowledge translation (KT) approach. Researchers at the Atlantic Health Promotion
Research Centre and Dalhousie University investigated how knowledge brokers affected decision maker uptake of
best practices in integrated stroke care in the Atlantic provinces. They found that knowledge brokers can enhance
partner interactions, but needed to develop effective strategies for creating partnerships and engaging participants.
They also required excellent communication skills and a high level of proficiency in the subject matter.
Background
If individual and organizational change were easy, the KT process would be simple. But resistance to change is
widespread
1
and progress towards improving the health care system tends to be slow.
2
The knowledge translation literature suggests that health system change and the creation of evidence-based
policy can be enhanced by increasing interaction and communication between researchers and users of
research.
3
Knowledge brokering, which is defined by the Canadian Health Services Research Foundation as the
human force that makes knowledge transfer more effective by bringing people together, has gained currency as
one approach to help researchers and users of research work together more effectively.
4
Knowledge brokers can also be described as facilitators between two communities.
5
Their role is to make things
easier: by building relationships, uncovering needs, sharing ideas, and promoting action.
4
In 2003, the
Canadian Stroke Network funded the Atlantic Health Promotion Research Centre and Dalhousie University to
examine the effectiveness of using knowledge brokers for increasing exchange between stroke researchers and
the users of stroke research. The goal was to increase decision maker uptake of best practices in integrated
stroke care.
The KT initiative
Our primary objective was to observe and describe how knowledge brokers affected decision maker uptake of
new evidence supporting changes in stroke care in four provinces: New Brunswick, Newfoundland, Nova
Scotia, and Prince Edward Island. The project used work done in Ontario on integrated stroke care as a
template for how an integrated stroke strategy could be created and implemented in the Atlantic provinces.
To accomplish this, we established teams of representatives from each province’s department of health (who
had a policy making role) and each province’s Heart and Stroke Foundation branch (who, through their
awareness of stroke research, acted as a resource base). Each team was then responsible for hiring a knowledge
broker and articulating province-specific goals for the project. The teams drafted memoranda of agreement,
decided which partner would house the knowledge broker, identified goals for the knowledge broker and
outlined how the goals would be accomplished.

58
Piloting knowledge brokers to promote integrated stroke care in Atlantic Canada
Prince Edward Island, New Brunswick, and Newfoundland identified the creation of provincial integrated
stroke strategies as the goals for their knowledge brokers. In Nova Scotia, the Department of Health was
already considering whether to implement the Heart and Stroke Foundation’s recommendations for an
integrated stroke strategy. The goal for the Nova Scotia knowledge broker was, therefore, to improve
communication between the parties involved in implementing the strategy.
We provided the partners and the knowledge brokers with Atlantic-wide forums every six months. These
forums disseminated information on best practices for stroke care, shared implementation lessons from
Ontario, and provided networking time between teams. We also provided expert speakers on how telemedicine
technology could be used in stroke identification and care, and supported knowledge brokers’ travel to Ontario
(to see a facility that had already implemented an integrated stroke strategy) and Yarmouth, Nova Scotia (to
talk with researchers involved in the Yarmouth Stroke Project, an Atlantic Health Promotion Research Centre
initiative to implement an integrated stroke strategy in a rural location).
We also acted as a resource and support base for the knowledge brokers. Monthly meetings or teleconferences
provided an opportunity to share concerns and triumphs and to update researchers on what was going on in
the provinces. In addition, the project coordinator traveled to the provinces on a regular basis. The knowledge
brokers were also welcome to contact the researchers whenever they needed.
Results of the KT experience
Our project objectives were evaluated by analyzing data from key informant interviews and focus groups
conducted with the knowledge brokers and the team partners. Success was judged by whether the existence of
knowledge brokers increased knowledge exchange between the partners, increased decision maker uptake of
new evidence supporting changes in stroke care, and helped the provinces accomplish their goals. The project
formally finishes in March 2006, but improvements in partner communications and awareness of stroke care
best practices have already been observed.
Prince Edward Island, New Brunswick, and Newfoundland are on schedule to complete their provincial
integrated stroke strategies, which can be directly attributed to their knowledge brokers. As one
interviewee said:
“I don’t think without having somebody dedicated to the cause, it [the creation of an integrated
stroke strategy], necessarily would have gotten off the ground this year…People who have been
fighting for this kind of change for a number of years…were really feeling quite frustrated because
they weren’t getting the support they needed either from the Department of Health or from the
Heart and Stroke Foundation because they just didn’t have the resources…You really needed
somebody in this position to help tie it together and to push it along.”
In Nova Scotia, the provincial government has committed money to an integrated stroke strategy. Although
this decision cannot be directly attributed to having a knowledge broker, their broker did increase
understanding of the best practices on stroke care in the provincial health districts and, through this, generated
the support that was critical for moving ahead with an implementation strategy.
The knowledge brokers facilitated communication, cleared up misunderstandings and provided a dedicated
person working toward system changes in collaboration with others within the system. With much time and
effort the knowledge brokers also successfully formed multi-sectoral advisory committees, consisting of

59
Piloting knowledge brokers to promote integrated stroke care in Atlantic Canada
researchers, administrators, policy makers, and practitioners. This was a major task of most of the knowledge
brokers, and in addition to helping accomplish the partner goals, these committees had the unforeseen benefit
of being a good dissemination mechanism for best practices research to individuals outside the project.
Knowledge brokers were able to identify opportunities where best practices for stroke care could be integrated
into existing provincial initiatives and where training and education was needed to improve care. As a result,
decision makers are more aware of best practices for stroke care and researchers have a better understanding of
the context affecting decision makers’ uptake of research.
Lessons learned
This initiative has demonstrated that knowledge brokers can enhance partner
interactions, but brokers needed to develop effective strategies for creating
partnerships and engaging individuals to participate. They also needed excellent
communication skills and a high level of proficiency in the subject matter to
meet the diverse demands of the partners.
Establishing partnership teams took longer than expected. Despite a prior
commitment from the partners to work together, it took between 9 and 14
months for each team to agree on hiring the knowledge brokers. Critical factors
that contributed to this delay were political change, availability of in-kind
support, confidentiality concerns and questions about possible hidden agendas
among the partners.
Another obstacle was that most provinces had not identified stroke as a priority condition, and no money had
been dedicated to improving stroke care. This made the government partners hesitant to commit to the
partnership, because they did not have financial resources to implement health system changes in stroke care.
The provincial governments did have a mandate to improve chronic disease management and they eventually
examined evidence on stroke care under that framework. But there was still no guarantee that support would
be available for future health system changes. While the provincial Heart and Stroke Foundations were
supportive of the project, some wanted to wait until there was a firm government commitment before they
agreed to actively participate. In addition to these challenges, it was difficult for the researchers to be flexible
enough to set project goals collaboratively.
Even after hiring the knowledge broker, and despite jointly developed goals, the
teams often struggled because the partners had divergent mandates. The Heart
and Stroke Foundations felt obligated to promote funding for better prevention
and treatment of stroke in the provincial budgets. Although the Departments
of Health supported evidence-based care, they had limited resources available
and wanted to make sure expectations were realistic.
Conclusions and implications
The knowledge broker role could be adapted to other situations. To date, other
decision makers may not use them because of limited funds and a lack of
understanding about the importance of improving communication. When
finances are low, communication is usually not considered to be a priority,
especially when resources barely cover the current demands on the system. But
Knowledge brokers
can enhance partner
interactions, but need
to develop effective
strategies for creating
partnerships and
engaging individuals
to participate.
Even after hiring the
knowledge broker,
and despite jointly
developed goals, the
teams often struggled
because the partners
had divergent
mandates.

60
Piloting knowledge brokers to promote integrated stroke care in Atlantic Canada
ongoing partnerships between government and non-government agencies or
researchers need to be supported because governments usually do not have
enough resources to scan the horizon for evidence that goes beyond their
current needs. Conversely, in research, there is a continued need to understand
the context in which evidence-based policy can be implemented. An increased
understanding of context can help researchers identify processes to broaden
government receptivity for new evidence. In the future, funding should be
dedicated towards making this type of position financially sustainable because it
has the potential to improve the quality of health care.
References
1
Lyons, R., and G. Warner. 2005. Demystifying knowledge translation for stroke researchers; a primer on
theory and praxis. Online manuscript. Halifax, NS: Canadian Stroke Network.
http://www
.canadianstrokenetwork.ca/resear
ch/downloads/knowledge.translation.feb032005.pdf
2
Berwick, D. M. 2003. Improvement, trust, and the healthcare workforce. Qual Saf Health Care
12 (Suppl. no 1): i2-6.
3
Landry, R., N. Amara, and M. Lamari. 2001. Utilization of social science research knowledge in Canada.
Res Policy 30:333-49.
4
Canadian Health Services Research Foundation. 2003. The theory and practice of knowledge brokering in
Canada's health system. Report. Ottawa, ON: CHSRF.
5
Kitson, A., G. Harvey, and B. McCormack. 1998. Enabling the implementation of evidence based practice:
A conceptual framework. Qual Health Care 7:149-58.
Ongoing partnerships
between government
and non-government
agencies or researchers
need to be supported.

61
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 hos-
pital 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 partici-
pating hospitals, and has formed a community of learning to share best practices across their institutions.
Background
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

62
The Toronto East Network Knowledge Champion Project
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.

63
The Toronto East Network Knowledge Champion Project
Results of the KT initiative
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.
Lessons learned
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.
Participants reported
heightened awareness
of best practice
opportunities and
ongoing use of the
tools to facilitate use
and dissemination of
evidence-based
medicine.
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.

64
The Toronto East Network Knowledge Champion Project
References
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.

65
ADVANCING THE NURSE PRACTITIONER ROLE
IN
BRITISH COLUMBIA
Marjorie MacDonald, RN, PhD, School of Nursing, University of Victoria
Heather Davidson, PhD, British Columbia Ministry of Health Services
Rita Schreiber, RN, DNS, School of Nursing, University of Victoria
Jane Crickmore, RN, MPA, British Columbia Ministry of Health Services
Lesley Moss, MA, Vancouver Island Health Authority
Janet Pinelli, RN, DNS, McMaster University
Sandra Regan, RN, MSN, College of Registered Nurses of British Columbia
Bernadette Pauly, RN, MN, School of Nursing, University of Victoria
This project brought together a team of researchers and decision makers to conduct policy-relevant research to
support the introduction of advanced nursing practice roles in British Columbia. All team members, including
decision makers, were actively involved in the conceptualization, design, data collection, analysis and interpreta-
tion of the study. This level of engagement, coupled with ongoing knowledge translation (KT) activities, led to a
majority of the study’s recommendations being implemented by stakeholders. The results have since been used to
guide legislative and regulatory development, and to design a nurse practitioner education program.
Background
In 2001, the Canadian Health Services Research Foundation (CHSRF) funded us to study the opportunities
and challenges for advanced nursing practice (ANP) in British Columbia. Nurses working in ANP roles have
been shown to provide appropriate and cost-effective continuity of care.
1,2
However, widespread adoption of
advanced nursing practice has been hampered by considerable confusion and debate about definitions, roles
and functions, as well as the required competencies, practice environments, educational qualifications,
credentials, regulations and legislation.
3
This project aimed to bring researchers and decision makers together to conduct policy-relevant research that
would support the introduction of new ANP roles, including nurse practitioners, in B.C. Our research
objectives were to: clarify the understanding of ANP and related roles within the health care system; identify
the current status of ANP in B.C.; identify gaps in health care services that might be filled by the
expansion/introduction of new nursing roles; explore and describe models of ANP in other jurisdictions;
identify barriers to implementing new nursing service delivery models in B.C.; and, on the basis of the above
analysis, identify and recommend future policy directions for new nursing roles and models in B.C.
The project team, which was convened by the B.C. Ministry of Health, included researchers, educators,
government and health authority decision makers, and nursing regulators. An advisory group, who provided
advice and feedback on research methods and findings, included representatives of the public, other health
professions (e.g. midwifery, medicine, pharmacy) and other constituencies (e.g. seniors, First Nations and Inuit
Health Branch, British Columbia Nurses’ Union).
The CHSRF funding strategy required co-funding arrangements, involving both cash and in-kind
contributions from a variety of national, provincial and local sources. Our co-funders included the Nursing
Research Fund, the B.C. Health Research Foundation, the B.C. Ministry of Health, the Registered Nurses
Association of B.C., Capital Health Region in Victoria (now Vancouver Island Health Authority), and the

66
Advancing the nurse practitioner role in British Columbia
University of Victoria. Some of the funders were also research partners and appointed representatives to the
research team.
The KT initiative
Our study was carried out in three phases, with KT goals incorporated directly
into the research process. All team members, including decision makers, were
actively involved in the project throughout the study, from conceptualization
and design through to data collection, analysis, and interpretation.
In Phase 1, data were gathered through telephone interviews and focus groups
with nurses in a variety of roles and settings to determine how they understood
ANP and how nurses in ANP roles were deployed in B.C. An email survey was
conducted with employers to determine their understanding of ANP and to
identify health service priorities, gaps in service, and the potential for
introducing new ANP roles in their organizations.
In Phase 2, we conducted five case studies of models of ANP in other
jurisdictions to understand the nature and benefits of advanced practice, and to
determine the feasibility of various service models for B.C.
Phase 3, which also comprised our major KT activity, was a provincial think tank attended by almost 100 key
stakeholders to discuss preliminary research findings and generate policy recommendations. Not only did the
think tank provide important data for Phase 3, but it also provided for dissemination of the preliminary
findings to a broad stakeholder audience and acted as a mechanism to test the validity and relevance of our
results for informing policy recommendations.
Decision maker and researcher team members conducted interviews and observations and actively participated
in analyzing and interpreting the data. We learned from other research teams funded in the same CHSRF
competition that the full engagement of decision makers at all phases of the research was unusual, and we
believe that this level of involvement contributed to the successful use of the research findings.
Decision maker partners also took a leadership role in developing the overall KT plan and strategies that were
consistent with the information needs and preferred communication mechanisms of our audiences. Other KT
activities included:
•Regular status reports to senior administration in all partner organizations;
•Sharing interim and final reports with multiple audiences, including the Federal/Provincial/Territorial
Advisory Committee on Health Human Resources and all partner organizations;
•Creation of a website that included descriptions of the projects, regular updates, project reports, links to
other resources and a mechanism for visitor feedback; and
•Presentations by members of the research team to various partner organizations, including Ministry and
employer policy rounds.
The project’s advisory group was also an important mechanism for KT, through our ongoing communication
and their ability to distribute information through their networks. The advisory group also participated in the
think tank.
All team members,
including decision
makers, were actively
involved in the project
throughout the
study, from
conceptualization and
design through to data
collection, analysis,
and interpretation.

67
Advancing the nurse practitioner role in British Columbia
Results of the KT initiative
Our KT strategies resulted in substantial buy-in from stakeholders and facilitated implementation of a majority
of the study’s recommendations in the following two years. The results were used directly in an instrumental
fashion
4
to develop nurse practitioner competencies and practice standards, to guide legislative and regulatory
development and to inform the development of at least one nurse practitioner education program. Five articles
based on the study have been published to date.
5-9
Instrumental use of research findings, which is defined as acting on research in specific and direct ways, is
reported less frequently in the literature than conceptual or symbolic use.
4,10
Although we did not have a
formal evaluation plan to assess the KT strategies, we recognized that success indicators would include the
actual implementation of study recommendations and this did occur. In addition, the entire team engaged in a
reflective exercise on the benefits and challenges of the partnership experience.
Lessons learned
The research partnership was clearly a successful venture. Nonetheless, we had
to deal with the challenge of negotiating and mediating our differing interests.
Decision makers and researchers operate on very different time frames, with
decision makers often under pressure to produce swift results. In the time
between writing the original research proposal and getting it funded, the
political context changed dramatically and we were under pressure to produce
data much more quickly.
But the tension between the researchers’ needs to maintain scientific rigour and
the decision makers’ needs for information actually created an opportunity for
us to understand each other’s approaches, as well as the demands and
perspectives of our different work processes. At times, the researcher team
members were somewhat frustrated by the demand to speed up study timelines,
but through education, negotiation, and prioritizing, we developed strategies
(e.g. additional funding provided by government to focus on specific areas of
data collection) that met the decision makers’ time-sensitive information needs,
while maintaining scientific rigour.
Although there were clear research goals, each team member had a somewhat
different vision for the project and different reasons for engaging in the research
process. These differences added depth to the research, but also needed to be
negotiated as they emerged in subtle ways to create tensions and disagreements.
Autonomy and academic freedom are core values in universities. The ability to
speak openly and freely is both encouraged and expected. In the partner
organizations, decision makers operate within a policy context that explicitly and implicitly governs their work
and that may, at times, preclude the expression of opinion.
Within the research team, the same data also meant different things to different people and we needed to
negotiate how the data were interpreted, reported, and disseminated. To complicate the situation, universities
and organizations have differing reward systems, which influenced, more than we anticipated, the direction
each of us wanted to take on particular issues, such as the focus and slant of a particular journal article.
Decision makers and
researchers operate
on very different
time frames.
Tension between the
researchers’ needs to
maintain scientific
rigour and the
decision makers’ needs
for information
actually created an
opportunity for us to
understand each
other’s approaches.

68
Advancing the nurse practitioner role in British Columbia
Our ability to negotiate and mediate all of these differences was made possible
by several team characteristics, including:
• The steadfast commitment of all partners to the research enterprise and
the goals of the project;
• The willingness of team members to compromise;
•Trust and respect for each other based on established prior relationships;
•Researchers who had been policy makers and policy makers who had
been researchers, with understanding of the values and constraints faced
by each partner; and
•Decision maker team members with the authority and accountability to
make important decisions, and to make and honour commitments.
Conclusions and implications
Our research experience and our findings have been used extensively by our
own organizations to inform policy and program development. The results have also been used outside the
original partnership. For example, the Canadian Nurses Association held an invitational forum in the fall of
2005 on advanced nursing practice and some of our published research was used to inform the discussion and
debate about the direction of ANP in Canada. Our final report has been used and cited by other nursing
education institutions in the development of graduate programs in advanced nursing practice. On a national
level, the findings of this research have informed discussions of a Primary Health Care Nurse Practitioner
Education task force. Finally, this research provides the starting point of a longer-term program of research that
will include many of the original research team.
References
1
Horrocks, S., E. Anderson, and C. Salisbury. 2002. Systematic review of whether nurse practitioners
working in primary care can provide equivalent care to doctors. BMJ 324:819-23.
2
Safriet, B. J. 1992. Health care dollars and regulatory sense: the role of advanced practice nursing.
Yale J Regul 9:417-88.
3
Bryant-Lukosius, D., A. DiCenso, G. Browne, and J. Pinelli. 2004. Advanced practice nursing roles:
Development, implementation and evaluation. J Adv Nurs 48 (5): 519-29.
4
Lavis, J. N., D. Robertson, J. M. Woodside, C. B. MacLeod, J. Abelson, and the Knowledge Transfer Study
Group. 2003. How can research organizations more effectively transfer research knowledge to decision
makers? Milbank Q 81 (2): 221-48.
5
Schreiber, R. and M. MacDonald. 2003. Nurse anesthesia: The time has come. Can Nurse 99 (6): 20-3.
6
Pauly, B., R. Schreiber, M. MacDonald, H. Davidson, J. Crickmore, L. Moss, J. Pinelli, S. Regan, and C.
Hammond. 2004. Dancing to our own tune: Understandings of advanced nursing practice in British
Columbia. Can J Nurs Leadersh 17 (2): 47-57.
7
Schreiber, R., M. MacDonald, B. Pauly, H. Davidson, J. Crickmore, L. Moss, J. Pinelli, S. Regan, and C.
Hammond. 2005. Singing in different keys: Enactment of advanced nursing practice in British Columbia.
CJNL. Online exclusive (June).
http://www
.longwoods.com/website/NL/onlineExclusive/NL0605aSchreber.pdf.
8
MacDonald, M., R. Schreiber, H. Davidson, B. Pauly, L. Moss, J. Pinelli, S. Regan, J. Crickmore, and C.
Hammond. 2005. Moving towards harmony: Exemplars of advanced nursing practice for British Columbia.
CJNL. Online exclusive (June).
http://www
.longwoods.com/website/NL/onlineExclusive/NL0605MacDonald.pdf.
Within the research
team, the same data
also meant different
things to different
people and we needed
to negotiate how the
data were interpreted,
reported, and
disseminated.

69
Advancing the nurse practitioner role in British Columbia
9
Schreiber, R., M. MacDonald, B. Pauly, H. Davidson, J. Crickmore, L. Moss, J. Pinelli, and S. Regan.
2005. Singing from the same songbook: The future of advanced nursing practice in British Columbia.
CJNL. Online exclusive (June).
http://www
.longwoods.com/website/NL/onlineExclusive/NL0605bSchreiber.pdf.
10
Weiss, C. H. 1980. Knowledge creep and decision accretion. Knowledge: Creation, Diffusion, Utilization 1
(3): 381-404.

70
Advancing the nurse practitioner role in British Columbia

71
ADOPTING MEDICATION RECONCILIATION
AND SEAMLESS CARE SERVICES
Dr. Neil J. MacKinnon, College of Pharmacy, Dalhousie University
Medication reconciliation and seamless care services can dramatically reduce adverse outcomes resulting from gaps
in the medication use system. A long-running initiative to promote these services as standard care was sparked by
innovative hospital and community pharmacists, and subsequently taken up by two national pharmacy associa-
tions. A series of wide-ranging knowledge translation (KT) activities, including a joint task force on seamless
care, national and regional workshops and the publication and dissemination of educational materials, has
resulted in these services transitioning from isolated pilot projects to the focus of national patient safety efforts in
less than 10 years.
Background
As patients transition across the health care system, gaps in medication use between physical environments,
such as hospitals and community pharmacies, can adversely affect health outcomes. The provision of
medication reconciliation and seamless care services can dramatically reduce adverse outcomes such as drug-
related problems, inconsistencies, and omissions.
1
Seamless care is “the desirable continuity of care delivered to a patient in the health care system across the
spectrum of caregivers and their environments.”
2
Medication reconciliation, one component of seamless
pharmaceutical care, ensures the collection and communication of accurate patient medication information,
with a goal to facilitate continuity of pharmaceutical care for patients at the beginning and/or the end of
service.
3
These activities typically involve having a health professional, usually a clinical pharmacist, review the
patient’s medication profile prior to discharge to ensure the patient is taking the correct medications, doing a
full pharmaceutical care work-up and communicating relevant information to the next care provider.
This KT initiative consisted of understanding and addressing gaps in the medication use system through the
implementation of medication reconciliation and seamless care services. The goal was to move medication
reconciliation and seamless care from infrequently provided services to a recognized standard of care. The
audiences for this research include health care executives and administrators, health professionals, health care
regulatory agencies, and others involved in improving the safety and effectiveness of the medication use system.
The KT initiative
A wide variety of partners participated (and continue to participate) in this initiative. In the mid- to late 1990s,
innovative hospital and community pharmacists across Canada conducted several independent pilot projects
aimed at determining the feasibility of medication reconciliation and seamless care services. Sensing the need
for coordination of activities in this area, the Canadian Society of Hospital Pharmacists (CSHP) and the
Canadian Pharmacists Association (CPhA) formed a joint task force on seamless care and co-hosted a national
workshop in 1998 in Ontario. The aims of the workshop included increasing awareness of the experience of
providing seamless care and identifying mechanisms to move the seamless care effort forward.
2
A second
workshop was held in Quebec in 2000 to share and develop tools to assist in the delivery of seamless care.
4
Several regional workshops followed to share more success stories and to train other community and hospital
pharmacists. A randomized, controlled trial consisting of 253 patients testing these services was conducted over

72
Adopting medication reconciliation and seamless care services
2000-2002 at The Moncton Hospital in New Brunswick.
1
In this study, pharmacist-directed seamless care
services were found to have a significant impact on drug-related clinical outcomes and processes of care.
Learnings from these studies for others wishing to implement these services were incorporated into a “how-to”
book—Seamless Care: A Pharmacist’s Guide to Providing Continuous Care Programs
5
—that was published by
CPhA in 2003. A particular effort was made to ensure uptake of the book by the educational community by
obtaining sponsorship for its purchase for all the attendees of the Canadian Association of Pharmacy Students
and Interns 2003 Professional Development Week (approximately 550 students). Copies of the book were also
provided to the deans of Canada’s nine faculties of pharmacy, and faculty at the 2003 Canadian Pharmacy
Administration Teachers’ Conference.
Results of the KT initiative
This multi-pronged KT approach has had a substantial impact on the adoption
of medication reconciliation and seamless care services across Canada. In less
than 10 years, these services have progressed from being evaluated in pilot
studies to now being the focus of national patient safety efforts.
In 2004, CSHP released an official statement supporting the implementation
and provision of seamless care services.
6
Further evaluation of pharmacist-
directed seamless care services is presently occurring with a new randomized,
controlled study involving cancer patients in Newfoundland and Labrador.
Recently, much activity has focused on medication reconciliation, a subset of
seamless pharmaceutical care. The reason for this shift remains unclear but may,
in part, be due to the promotion of medication reconciliation in the
United States. Medication reconciliation services have been adopted in the 2005 Canadian Council on Health
Services Accreditation (CCHSA) patient safety goals, and in the Safer Healthcare Now! campaign of the
Canadian Patient Safety Institute (CPSI). These two initiatives will go a long way toward moving medication
reconciliation and seamless care into an accepted standard of practice. Hopefully, institutions or organizations
that adopt medication reconciliation practices will use them as stepping stones to the full implementation of
comprehensive seamless pharmaceutical care.
Still, there is much work to be done. While adoption of these services has
generally occurred at the hospital to community transition point, much effort
will be required to eliminate other gaps, such as those from the community to
hospital, hospital to long-term care facilities, and even at transition points
within hospitals. The inclusion of medication reconciliation services in the
CCHSA patient safety goals provides a powerful incentive for all hospitals to
provide these services, but also creates challenges for hospital pharmacy
directors and others involved in implementation, given the current shortage of
hospital pharmacists and budgetary restraints. Training programs, such as those
recently sponsored by the CPSI in Alberta in May 2005, should help overcome
some of the implementation barriers. There will also be operational and
workload considerations for community pharmacists; at this time, these have
not been adequately addressed.
The adoption of these
services beyond just
the pilot sites and the
initial participating
pharmacists has been
one of the most
satisfying aspects of
this KT initiative.
In less than 10 years,
these services have
progressed from being
evaluated in pilot
studies to now being
the focus of national
patient safety efforts.

73
Adopting medication reconciliation and seamless care services
One positive change is that these services are no longer being promoted primarily by the pharmacy profession.
Indeed, health care executives and other health professionals, such as physicians, nurses, and risk managers, are
now increasingly involved in their uptake. This provides further evidence of the success of this KT initiative—
it is no longer a discipline- or profession-specific activity, but instead is a valued service recognized by health
care decision makers, clinicians, and ultimately by patients, who experience it first-hand. The adoption of these
services beyond just the pilot sites and the initial participating pharmacists has been one of the most satisfying
aspects of this KT initiative.
Lessons learned
Looking back, what were the keys to success for this KT initiative? Several are apparent, and include:
• The uptake of seamless care and medication reconciliation by front line pharmacists who believed in
these concepts and were able to convince others of their value;
• The cooperation of hospital and community pharmacists at the local, provincial, and national levels;
•Engagement of the pharmacy practice research community, so evidence of the value of these services
could be obtained;
•A proactive effort to shift participation from the idea champions and change leaders to others through
the use of national and regional workshops; and
•Training future pharmacists on these services.
No KT initiative occurs in isolation and credit must also be given to external
events that influenced our activities. Hepler and Strand’s articulation of
pharmaceutical care as the practice model for the pharmacy profession in the
late 1980s and early 1990s did much to pave the way for increased
responsibilities for pharmacists in all practice settings.
7
More recently, the
awareness of patient safety issues, in both those working in the health care
system and in the general public, has risen considerably. In the past five years,
the publication of several sentinel reports in Canada and the United States, and
the creation of the CPSI, has done much to increase our knowledge about the
magnitude of preventable drug-related morbidity, medication errors, and other
adverse outcomes of medication use. The CPSI has also stimulated the search
for tools and techniques to improve the safety of the medication use system.
Despite these successes, there are still several goals related to seamless care and medication reconciliation that
have yet to be achieved. At this time, there are few published evaluations of these services in the peer-reviewed
literature. The National Association of Pharmacy Regulatory Authorities or the provincial regulatory bodies
have yet to mandate the provision of these services, and reimbursement or compensation for those providing
such services is still lacking. Additionally, technology such as linked prescription profiles and health cards could
potentially play a large role in facilitating these services, but at this time remain underutilized.
No KT initiative
occurs in isolation
and credit must also
be given to external
events that influenced
our activities.

74
Adopting medication reconciliation and seamless care services
Conclusions and implications
This initiative was an effective model for combining the efforts of national
professional associations, practitioners, and researchers. For the pharmacy
profession, it provides a powerful example of taking one small aspect of the
medication use system and ensuring that it is widely adopted. For those outside
the pharmacy profession, it provides a tangible example of how a simple, yet
essential, element of the health care system can move from the exception to the
norm in a relatively short period of time, through the partnership of front line
health professionals, health care management, professional associations and
researchers.
References
1
Nickerson, A., N. J. MacKinnon, N. Roberts, and L. Saulnier. Forthcoming.
Drug-therapy problems, inconsistencies and omissions identified during a medication reconciliation and
seamless care service. Healthc Q.
2
Canadian Society of Hospital Pharmacists and Canadian Pharmacists Association. 1998. Proceedings of the
Seamless Care Workshop. Ottawa, ON: Canadian Society of Hospital Pharmacists and Canadian
Pharmacists Association.
3
Canadian Council on Health Services Accreditation. 2005. CCHSA Patient/Client Safety Goals & Required
Organizational Practices. Frequently Asked Questions—Updated June 6, 2005.
http://www
.cchsa.ca/pdf/patientsafetyFAQJune062005.pdf.
4
Canadian Society of Hospital Pharmacists and Canadian Pharmacists Association. 2001. Seamless Care
Workshop: Highlights. Ottawa, ON: Canadian Society of Hospital Pharmacists and Canadian Pharmacists
Association.
5
MacKinnon, N. J., ed. 2003. Seamless Care: A Pharmacist’s Guide to Providing Continuous Care Programs.
Ottawa, ON: Canadian Pharmacists Association.
6
Canadian Society of Hospital Pharmacists. 2004. Statement on Seamless Care. Ottawa, ON: Canadian
Society of Hospital Pharmacists.
7
Hepler, C. D., and L. M. Strand. 1990. Opportunities and responsibilities in pharmaceutical care.
AmJHosp Pharm 47 (3): 533-43.
It provides a tangible
example of how a
simple, yet essential,
element of the health
care system can move
from the exception to
the norm in a
relatively short period
of time.

75
NATION-WIDE KNOWLEDGE TRANSLATION
TO PROMOTE RESEARCH ON SENIORS
’ INDEPENDENCE
Carol L. McWilliam, MScN, EdD, University of Western Ontario
Gloria Gutman, PhD, Simon Fraser University
Margaret Penning, PhD, University of Victoria
Rev. Bruce Mutch, Canadian Pensioners Concerned
Louise Plouffe, PhD, Health Canada
Miriam Stewart, PhD, University of Alberta
Robyn Tamblyn, McGill University
The end of multiple Canadian programs of research on seniors’ independence sparked a nation-wide knowledge
translation (KT) project to engage stakeholders in widespread uptake and application of the research. Bringing
policy makers, program planners, service providers, educators, seniors’ advocacy groups, and researchers together,
the project focused on knowledge spread, exchange, choice, and action. While knowledge spread and exchange
activities were highly successful, a focus on consensus-building actually reduced attention to the comprehensive
knowledge available for uptake. However, as the exercise progressed, valuable relationships and networks for col-
lective action emerged, achieving a previously unacknowledged goal of building social capital.
Background
In 1998, 14 Canadian programs of research on seniors’ independence came to a close. Both the Health Canada
funders and the researchers wanted to see the results used to promote the health and independence of aging
Canadians. Health Canada funded a three-year KT project to engage numerous stakeholders—policy makers,
program planners, service providers, educators, seniors’ advocacy groups, and researchers—in activities that
fostered widespread experiential learning and application of the research and to evaluate related knowledge
spread, exchange, choice and uptake.
The idea was to create a “community of knowing”
1
using a social interaction model of KT that exposes
researchers and the potential research users to each other’s worlds and needs. This model treats the users as
active individuals who interpret research evidence in light of what they already know.
1,2
Researchers, policy and
program planners, health services decision makers and professionals, senior consumers and advocacy groups,
educators, and the public would work together, as both the agents and architects of evidence-based change. We
wanted to spread knowledge across Canada; get people from all the stakeholder groups to exchange knowledge
about the evidence, issues, priorities and potential actions; get them to choose what key evidence they would
apply; and get them to act to improve health policy, services, and care. In accordance with other estimates of
people’s inclination to take up knowledge, we hoped to see 15% more people reporting an awareness of and
action on the research evidence, and a 15% increase in their self-reported levels of knowledge and action.
3,4
The KT initiative
The Health Canada funders and the researchers first constructed a list of opinion leaders for each of the
stakeholder groups, from which they then appointed a National Consensus Committee (NCC) to lead the
process. Members included 20 high-profile Canadians representing federal and provincial health, social service,
seniors, and economic policy personnel; service planners; health and social service providers and their
professional associations; seniors advocacy groups, senior consumers, and public representatives; and academics
from centres on aging and the diversity of health and social service fields.

76
Nation-wide knowledge translation to promote research on seniors’ independence
The committee developed a KT plan and involved other opinion leaders and their constituencies. The
Canadian Association on Gerontology (CAG), comprising 800 members representing all stakeholder groups,
facilitated connections and activities. The NCC then identified knowledge experts in four key research areas
and contracted teams of researchers to review the relevant research evidence.
5
From these academic research
syntheses, sub-committees identified key, actionable messages for each theme. These messages were posted on
an interactive website, shared at symposia at three annual scientific and educational meetings of the CAG, and
highlighted in lay print materials and theme-based policy fact sheets. The network of opinion leaders used their
connections and influence to disseminate these materials and to engage others in knowledge spread.
Knowledge exchange and choice were facilitated through the interactive website, symposia at annual CAG
meetings, and numerous discussions staged by participating organizations. Participants in both face-to-face
meetings and users of the website were asked to rate given priorities for policy developments and service and
practice refinements in each theme area, and the questionnaires were constantly reviewed and updated to reflect
their feedback.
These activities enabled participants to integrate their knowledge, values, and priorities with the research
evidence, and to work towards consensus on priorities and potential action. Four theme-related consensus
panels comprised of policy, programming, provider, academic, and senior consumer experts then synthesized
the selected messages and priorities, prepared recommendations for action, shared their reports and served,
along with the lead committee, as moderators, discussants and champions of change at theme-related symposia.
Subsequently, a single large consensus-building symposium brought the four thematic panels and a broader
audience together with the intent of optimizing social interaction and support for knowledge choice
and uptake.
Results of the KT experience
To measure knowledge spread, exchange, choice, and uptake, participants at both the CAG symposia and users
of the interactive website were surveyed as they joined the exercise, immediately after activities ended, and one
year later. Qualitative analysis of minutes and field notes of meetings and symposia and open-ended survey
answers also added insights.
We determined that research evidence was spread through 86 activities to 2,946 initial contacts who attended
the symposia or accessed the website, including 186 organizations, and through them, as reported in follow-up
questionnaires, to 63,387 people, an unaccountable percentage of whom represented additional organizations.
The website questionnaire series engaged 608 organizations and individuals. Several organizations and policy
and planning personnel used the fact sheets and sought out the experts identified therein as resources for
knowledge exchange activities. Academics and professionals used the print materials for foundational and
continuing professional education.
However, the target increases in the numbers of people reporting awareness and action, and their reported
levels of awareness of and action on the evidence were not met, perhaps because a high percentage of
participants was aware of the research evidence at the outset of the exercise. While there was positive change,
gains were small, and self-reported levels of awareness increased significantly in only one theme area. At the
outset, over half of those participating in each of the four theme areas indicated that they had already chosen to
use the research evidence for acting on issues or for informing previously-decided directions. Nevertheless,
requests for materials and expert resources for two years after the exercise ended suggested that knowledge
uptake continued. Qualitative findings revealed that the further goal of these knowledge spread activities, the

77
Nation-wide knowledge translation to promote research on seniors’ independence
consensus-building strategy, elicited frustration because of the repetitiveness of the knowledge choice activities
and concern about the priorities that emerged.
Lessons learned
Our knowledge spread and exchange activities were judged to be extremely successful and are still referenced by
Health Canada policy personnel. The consensus-building process, on the other hand, actually reduced
attention to the comprehensive knowledge available for uptake. In addition, participants sometimes replaced
issues and priorities premised on the research evidence with unrelated concerns, taking the discussions in
unanticipated and often contested directions.
As the exercise progressed, participants became less focused on knowledge uptake per se and more focused on
building relationships and networks for collective action.
6
Accordingly, the ultimate goal of fostering seniors’
independence was achieved as a process output rather than as concrete outcomes in the form of evidence-based
policies, programs, and practice change. Seniors, their advocates, and public opinion leaders ranked the
opportunity to be involved and to be heard as the most valuable aspect of the exercise. Receiving information
for making change and enhancing their own knowledge was less important to them.
If the goal of building social capital had been more widely acknowledged and accepted at the time, the value of
this KT exercise may have been more widely appreciated. While individual participation in such activities
normally declines over time, in this exercise, organizational participation was sustained, increased, and created
new activity.
Conclusions and implications
There is no easy way to ascertain how knowledge is spread through outreach
strategies or whether people who receive the information actually attend to it. In
fact, the assessment of knowledge choice and uptake in specific topic areas is
somewhat artificial, as each stakeholder group can do little or nothing about
issues beyond their mandate. Participants move in and out of knowledge
exchange and choice activities over time, making tracking of outcomes difficult.
Furthermore, the complexity and political nature of the policy process precludes
confident conclusions about outcomes. New approaches for evaluating the process
of KT are needed, with greater reliance on qualitative evaluation of the processes,
quantitative measurement of process outputs and more longitudinal follow-up of
outcomes.
Increasing action through building consensus across diverse stakeholder groups is
an elusive ideal demanding close attention to what values, and whose, come into
play.
7
The political nature of consensus-building was a huge challenge. But
political processes are an inevitable part of life and if we are committed to participatory democracy, we need to
build in enough time to allow it to transpire. Sequenced activities and longer timeframes to allow stakeholder
groups to build consensus between and among their respective constituencies might help.
For anyone committed to KT that fosters enlightened, empowered, and socially just effort on behalf of
vulnerable groups, this KT process is worthwhile. Rather than being a top-down, authoritative model, our
activities appealed to people at the grassroots of public policy and service delivery. And, who knows better than
those at the front lines experiencing and enacting public policy and delivering services what is most important,
There is no easy
way to ascertain
how knowledge is
spread through
outreach strategies
or whether people
who receive the
information
actually attend to it.

78
Nation-wide knowledge translation to promote research on seniors’ independence
how the research evidence fits with what will work and how the evidence can be used to make effective
refinements. On the other hand, the approach is process-focused; all participants share responsibility and
accountability for it, and its outcomes cannot be controlled. In a world where performance appraisal is
premised on measurable outcomes, this approach is not likely to advance the professional careers of academics,
or those of senior policy personnel, planners, and decision makers.
References
1
Broner, N., M. Franczak, C. Dye, and W. McAllister. 2001. Knowledge transfer, policymaking and
community empowerment: A consensus model approach for providing public mental health and substance
abuse services. Psychiatr Q 72 (1): 79-102.
2
Buxton, M., and S. Hanney. 1996. How can payback from health services be assessed?
J Health Serv Res Policy 1 (1): 35-43.
3
Prochaska, J. O., C. C. DiClemente, and J. C. Norcross. 1992. In search of how people change:
Applications to addictive behaviors. Am Psychol 47 (9): 1102-114.
4
Rogers, E. 1995. Diffusion of innovations. 4th ed. London, UK: Free Press.
5
Chappell, N. 2000. Setting an evidence-based policy agenda for seniors’ independence.
Can J Aging 19 (Suppl. no 1).
6
Editorial. 2001. Social capital. Isuma: Canadian Journal of Policy Research 2 (1): 6-7.
7
Milimo, J., A. Norton, and D. Owen. 1998. The impact of PRA approaches and methods on policy and
practice: The Zambia PPA. In Whose voice? Participatory research and policy change, ed. J. Holland and J.
Blackburn, 103-11. London, UK: Intermediate Technology.

79
KT IN ACTION:
MANITOBA’S THE NEED TO KNOW TEAM
Patricia J. Martens, PhD, Manitoba Centre for Health Policy, University of Manitoba
Sarah Bowen, PhD, University of Manitoba and the Winnipeg Regional Health Authority
Randy Fransoo, MSc, Manitoba Centre for Health Policy, University of Manitoba
The Need To Know Team
Manitoba’s The Need to Know Team fosters collaborative, population-based health research between rural and
regional health authorities, the province’s department of health, and researchers at the Manitoba Centre for
Health Policy. With a focus on new knowledge creation and development, individual and organizational capaci-
ty building, and research dissemination and application, the Team has made important contributions to rural
and regional health planning in the province, and has won national recognition as a best practice model for
knowledge translation (KT).
Background
Stories can be powerful motivators of change. Our story—the origins of Manitoba’s The Need To Know Team,
the successes and challenges we have experienced in KT and the outcomes of this collaboration—is about what
can be achieved when researchers and decision makers truly collaborate in research and its translation
into action.
The Need To Know Team is a collaboration of: the Manitoba Centre for Health
Policy (MCHP), a unit of the Department of Community Health Sciences,
University of Manitoba; the ten rural and northern Manitoba regional health
authorities (RHAs); and Manitoba Health. It is funded through CIHR’s
Community Alliances for Health Research program (2001-2006). The goal of
the team is to: create new knowledge directly relevant to rural and northern
RHAs; develop useful models for health information infrastructure, training,
and interaction that increase the capacity for collaborative research; and
disseminate and apply health research to increase the effectiveness of health
services and the health of RHA populations.
The Need To Know Team evolved out of a contractual relationship between
Manitoba Health and MCHP. Since 1991, MCHP has produced six research
projects a year on the health and health care use of Manitobans. To encourage research dissemination, in 1994
MCHP began offering an annual Rural and Northern Health Care Day that highlights research of relevance to
non-Winnipeg regions. In 1999, this workshop became highly interactive, with researchers facilitating RHA
roundtable discussions to encourage planning based on MCHP reports. This new approach also gave RHA
participants the opportunity to identify limitations in the research. The realization that better research could
result from user collaboration led to the vision, and eventual birth, of The Need To Know Team.
The KT initiative
The Need To Know Team’s KT vision is based upon three key themes: the need to undertake collaborative
research of relevance to the intended users; the importance of capacity building and effective working
The realization that
better research could
result from user
collaboration led to
the vision, and
eventual birth, of
The Need To Know
Team.

80
KT in action: Manitoba’s The Need To Know T eam
relationships; and the need for researchers and planners to communicate findings and plan strategies to
facilitate research that influences decision making.
The Need To Know Team includes MCHP academic researchers and graduate students, six planners
from Manitoba Health, and up to two high-level planners, selected by the CEOs, from each of the ten
non-Winnipeg RHAs, plus one Winnipeg RHA liaison. An advisory committee comprised of the director,
program evaluator, three elected Team representatives (from northern RHAs, southern RHAs, and Manitoba
Health), and representatives of key stakeholder groups (MCHP, Manitoba Health, the RHA CEOs, and a
health services researcher) guides the initiative.
Two-day meetings, held three times a year, serve as the focus for Team activities. These meetings provide the
forum for: selection, development and interpretation of Team research projects; participation in capacity-
building activities (for example, “101” sessions on research concepts and methods); planning for dissemination
of the research; and opportunities for both structured and informal networking. Capacity-building activities are
not limited to a focus on RHA Team members. Team meetings provide an opportunity for academics to
develop an understanding of the context faced by decision makers, as well as for decision makers to increase
their understanding of research.
The research projects are selected through consensus, and speak to the questions facing RHA decision makers.
They are grounded in strong health services and population health research methodologies and rely upon
population-based administrative claims data to produce cross-comparative, geographically-relevant information.
Three research projects have been completed to date: a regional indicators atlas
1
showing health status and
health care use patterns by RHA, district, and over time; a mental illness report
2
documenting the prevalence
and health care use patterns of people with mental illness; and a sex differences report
3
analyzing male/female
differences in health, health care use, and quality of care.
Between meetings, Team members undertake “homework” activities. Examples include consulting with RHA
management on future research topics and developing research dissemination plans. For example, in spring
2005, Team members from five different RHAs planned one-day interactive MCHP/RHA workshops to ensure
translation of the Team’s research projects at the organizational level.
Collaborative evaluation has been an essential guiding component of the project from the very beginning. A
variety of methods (key informant interviews, participant observation, pre- and post-test surveys, anonymous
workshop evaluations, unobtrusive measures) are used. A structured feedback process enables each stakeholder
group to review and provide input into the draft evaluation reports, and evaluation activities are used to model
research principles and concepts. The evaluation process and activities, along with key findings, have been
documented in two evaluation reports
4,5
and have contributed to further development of KT theory.
6
Results of the KT experience
Has The Need To Know Team been successful at meeting its objectives? We have succeeded in producing
research of high quality and relevance to rural and northern RHAs. RHA attention to research findings has
helped spur development of primary health care centres and nursing homes, cervical cancer screening
programs, regional injury prevention programs, and proposed changes to mental health services.
The regional indicators atlas is being used extensively in strategic planning, and the mental illness report is
contributing to regional, provincial, and national (through Senator Kirby’s commission) mental health service

81
KT in action: Manitoba’s The Need To Know T eam
planning. Team reports are in high demand, with seven times the number printed compared to typical MCHP
reports (1,500 versus 200 copies). Hits to MCHP’s website increased by 20,000 during the months when these
reports were released.
The Team’s reports are now released at the annual Rural and Northern Health Care Days. Attesting to the
workshop’s popularity, attendance has grown from around 30 in the 1990s to over 160 in the past two years.
RHAs encourage diverse groups to attend, including board members, CEOs, VPs of planning, medical health
officers, physicians, senior nurses, and front line workers. RHA Team members are now the principal
facilitators of the RHA discussion groups, co-facilitated by MCHP staff. According to evaluations, the RHA
Team members in this setting are indistinguishable from MCHP academics in understanding and interpreting
research findings for participants.
Lessons learned
We have found storytelling to be a powerful tool to affect change in decision-
making behaviour. The Need To Know Team members challenge each other to
look for stories, or “golden nuggets,” in each research report. This evidence-based
story-telling
7
helps identify important issues for RHA planners and decision
makers and becomes especially relevant at the annual Health Care Day
discussions.
Participant satisfaction with the project has been extremely high, with turnover
of Team members limited to those who have left employment with the RHA.
Evaluation indicates that this can be attributed to the benefits the Team members experience through
participation, the “way we are treated and feel valued,” and the opportunities for useful networking.
4-6
Other
essential elements in the Team’s success include development of trust, the quality of relationships, adequate
time commitment of partners, committed leadership, and genuine partnerships—mirroring previous literature
on researcher/user interactions.
8-13
RHA CEOs and the Ministry of Health also attest to The Need To Know
Team’s role in creating a culture that promotes KT and evidence-based decision making provincially.
4-5
But
have we found all the answers to KT?
The evaluation found that the first three years fostered
individual capacity building, relationship building, and
networking. But Team members also identified the need to
develop strategies for capacity building at the organizational
level to ensure sustainability. So in 2005, priority was given to
RHA site visits to build regional organizational capacity
beyond the Team members. The Team has also recently
received CIHR funding to identify and address organizational
challenges to KT in the RHAs. However, we continue to find
it challenging to convince traditional peer review panels to
fund a process rather than a product—the process of utilizing a strong team model with a proven track record to
conduct research in response to future needs.
We have found
storytelling to be a
powerful tool to affect
change in decision-
making behaviour.
Essential elements in the Team’s success
include development of trust, the
quality of relationships, adequate
time commitment of partners,
committed leadership, and
genuine partnerships.

82
KT in action: Manitoba’s The Need To Know T eam
Conclusions and implications
The Need To Know Team story has captured the imagination of researchers and
decision makers throughout Canada. The Team has become nationally
recognized, with over 80 oral and poster presentations by various Team
members. The evaluator (Sarah Bowen) has made important contributions to
the development of KT theory,
6
and receives many cross-country requests for
consultation. The Canadian Health Services Research Foundation (CHSRF)
considers this initiative a best practice model for KT, and has funded workshops
in Saskatchewan and Nova Scotia to discuss translating the model to other
provinces. The director (Pat Martens) receives numerous invitations to discuss
the Team model and its research, with groups such as CIHR’s scientific directors
and governing council, the University of Alberta, and CHSRF decision maker workshops. MCHP/The Need To
Know Team also received the CIHR KT Award (Regional) for 2005. But the success of our KT initiative can
best be summarized in the words of one RHA Team member, Sue Crockett:
“Although we work in different worlds, we can have a mutual relationship of respect. They can
learn from us and we can learn from them. If we work together, we can produce amazing
results—results that are meaningful, practical, and relevant.”
References
1
Martens, P. J., R. Fransoo, The Need To Know Team, E. Burland, L. Jebamani, C. Burchill, C. Black, et al.
2003. The Manitoba RHA indicators atlas: Population-based comparisons of health and health care use.
Winnipeg, MB: Manitoba Centre for Health Policy. http://www
.umanitoba.ca/centres/mchp/reports.htm.
2
Martens, P., R. Fransoo, N. McKeen, The Need to Know Team, E. Burland, L. Jebamani, C. Burchill, et al.
2004. Patterns of regional mental illness disorder diagnoses and service use in Manitoba: A population-based
study. Winnipeg, MB: Manitoba Centre for Health Policy.
http://www
.umanitoba.ca/centres/mchp/reports.htm.
3
Fransoo, R., P. Martens, The Need to Know Team, E. Burland, H. Prior. C. Burchill, D. Chateau, and R.
Walld. 2005. Sex differences in health status, health care use, outcomes and quality of care: A population-
based study for Manitoba's regional health authorities. Winnipeg, MB: Manitoba Centre for Health Policy.
http://www
.umanitoba.ca/centres/mchp/reports.htm.
4
Bowen, S. 2001. The Need to Know project evaluation 2001-2002 report. Winnipeg, MB: Manitoba
Centre for Health Policy. http://www
.rha.cpe.umanitoba.ca/data_resource.shtml.
5
Bowen, S. 2004. The Need to Know project evaluation 2002-2004 report. Winnipeg, MB: Manitoba
Centre for Health Policy. http://www
.rha.cpe.umanitoba.ca/data_resource.shtml.
6
Bowen, S., P. J. Martens, and The Need To Know Team. Forthcoming. Demystifying knowledge translation:
Learning from the community. J Health Serv Res Policy.
7
Rachlis, M. 2004. Prescription for excellence: How innovation is saving Canada’s health care system. Toronto,
ON: Harper Collins Canada.
8
Lomas, J. 1997. Improving research dissemination and uptake in the health sector: Beyond the sound of one
hand clapping. Health Policy Commentary Series. Hamilton, ON: McMaster University Centre for Health
Economics and Policy Analysis.
9
Casebeer, A., and D. Johnson. 2000. Potholes in the information highway: The use of health service
utilization data by Alberta health care managers. Healthc Manage Forum 13 (2): 58-64.
We continue to find it
challenging to
convince traditional
peer review panels to
fund a process rather
than a product.

83
KT in action: Manitoba’s The Need To Know T eam
10
Denis, J. L., and J. Lomas. 2003. Convergent evolution: The academic and policy roots of collaborative
research. Editorial. J Health Serv Res Policy 8 (Suppl. no. 2): 1-6.
11
Ross, S., J. Lavis, C. Rodriguez, J. Woodside, and J. L. Denis. 2003. Partnership experiences: involving
decision-makers in the research process. J Health Serv Res Policy 8 (Suppl. no 2): 26-34.
12
Golden-Biddle, K., T. Reay, S. Petz, C. Witt, A. Casebeer, A. Pablo, and C. R. Hinnings. 2003. Toward a
communicative perspective of collaborating in research: the case of the researcher-decision-maker
partnership. J Health Serv Res Policy 8 (Suppl. no. 2): 20-25.
13
Germann, K., and D. Wilson. 2004. Organizational capacity for community development in regional health
authorities: A conceptual model. Health Promot Int 19 (3): 289-298.

84
KT in action: Manitoba’s The Need To Know T eam

85
ON THE ROCK, IN A HARD PLACE: CHALLENGES IN WORKING
WITH ADVOCACY AND CARE PROVIDER GROUPS
Maria Mathews, PhD, Division of Community Health, Memorial University of Newfoundland
Sharon Buehler, PhD, Division of Community Health, Memorial University of Newfoundland
Roy West, PhD, Division of Community Health, Memorial University of Newfoundland
Researchers from the Memorial University of Newfoundland collaborated with a patient advocacy organization
and the provincial cancer care provider on a study showing substantial variation in out-of-pocket costs for
patients travelling to access cancer treatment. While the partnered research phase of the study proceeded smoothly,
the successful dissemination of the findings—and the resulting government and media interest—created pressure
for the provincial cancer care provider. They distanced themselves from the study and ended their role in what
has proved to be an otherwise successful partnership.
Background
In the fall of 2001, the Canadian Cancer Society–Newfoundland and Labrador Division (CCS), a non-
government patient advocacy organization, approached us to request a study of out-of-pocket costs for patients
who travel to access cancer treatment. Anecdotal evidence suggests that these costs influence the decisions
cancer patients make about their care.
1
The CCS had previously embarked on advocacy efforts on this issue,
but the provincial Department of Health and Community Services had cited the need for more research.
CIHR, the Newfoundland and Labrador Centre for Applied Health Research, and the Canadian Breast Cancer
Foundation–Atlantic Division funded the study, with data collection beginning in the fall of 2002. We
surveyed 484 cancer patients, interviewed 21 cancer care providers, and gathered information about medical
travel subsidy programs across Canada.
We found substantial variation in out-of-pocket costs for patients travelling to access cancer care. One-in-three
rural patients (those living more than one hour away from a cancer clinic) paid more than $200 for travel and
lodging during a single trip to an oncologist, with 9% incurring costs of more than $1,000 per trip. A
significantly larger proportion of rural residents had higher costs than their urban counterparts and said that
expenses for travel, drugs, and child care, and travel time, were important considerations in their care
decisions.
2
Patients’ cost-cutting strategies (including rationing medications, lengthening follow-up times, or
choosing in-patient palliative care) may compromise quality of care. We recommended that the restrictive
eligibility criteria of the provincial Medical Travel Assistance Program (the subsidy that reimburses patients for
medical care-related travel costs) be reviewed, and that cancer care be provided in smaller communities
wherever possible.
The primary audiences for our study were the CCS, the provincial cancer care provider—Newfoundland
Cancer Treatment and Research Foundation (NCTRF), and the Department of Health and Community
Services. We also wanted to communicate our findings to study participants, politicians, the public, cancer
advocates and care providers in Canada, and other researchers.

86
On the rock, in a hard place: Challenges in working with advocacy and care provider groups
The KT initiative
Our knowledge translation (KT) partners were the CCS and the NCTRF. The Department of Health and
Community Services declined direct involvement in the study, but asked to be kept informed through ongoing
interactions with the CCS and the NCTRF.
As researchers, our goal in engaging in KT activities was to provide rigorous, relevant, evidence-based
recommendations that would improve the accessibility and quality of cancer care in the province. The goal of
our partners, however, was to advocate for patients with high out-of-pocket costs, and especially to lobby for
change to the provincial Medical Travel Assistance Program. This required careful definition of the roles of all
partners throughout both the research and dissemination phases of the study.
The KT plan for the study included linkage and exchange activities and a multi-pronged dissemination
strategy. The goal of our linkage and exchange activities was to identify relevant research questions, inform our
partners of our progress, be responsive to changes in the decision-making environment, provide opportunities
for our partners to contribute to the interpretation of findings and the development of recommendations and
to continually discuss the roles of all partners.
To this end, we held a series of meetings with CCS and NCTRF staff to gain a better understanding of the
research problem, the provincial cancer care system, and the partners’ information needs. We also provided
regular updates through email, telephone conversations, and in-person presentations. Both partners provided
supporting documents and feedback on our research proposals, liaised with government to inform them the
study was underway, and updated us on developments relevant to the study. The NCTRF assisted in recruiting
study participants. Near the end of the research phase, we shared preliminary results and recommendations
with the CCS and the NCTRF. An NCTRF administrator, with whom we had been closely collaborating,
reviewed a near-final draft of the results and recommendations.
During the dissemination phase of the study, the CCS assumed responsibility for organizing the campaign to
increase public awareness of the study findings and to lobby politicians and government officials. The NCTRF
agreed to disseminate study findings to other cancer care agencies and to organize seminars with its own staff to
identify changes in clinical practice. We were responsible for presenting the data (in summary documents and
presentations), participating in interviews with the media, and meeting secondary dissemination goals, such as
debriefing participants, sharing findings with researchers, and identifying collaborators for future projects.
In the spring of 2004, we (the researchers and CCS, in accordance with the roles described above) held a press
conference to publicize the study findings; wrote a summary article for the CCS annual report (which was
included as a supplement in community newspapers across the province); pursued media coverage; presented
study results in non-technical language to community groups and Department of Health and Community
Services officials; sent a two-page summary (written in non-technical language and highlighting actionable
messages) to all members of the Newfoundland and Labrador House of Assembly and Department of Health
and Community Services officials; and held face-to-face meetings with politicians as well as Department of
Health and Community Services officials. The summary report was available on request and posted on the
Division of Community Health’s (Memorial University of Newfoundland) website.
Results of the KT experience
NCTRF initially shared the research findings with other care providers, but distanced itself from the study
when the provincial government requested information about its support programs and delivery of care. In its

87
On the rock, in a hard place: Challenges in working with advocacy and care provider groups
response to government and in letters to local newspapers, NCTRF
dismissed the study results and the partnership activities, and suggested
that it had already addressed the issue of out-of-pocket costs. One letter
to the editor noted that “Dr. Matthews’ [sic] recommendations are
neither new nor novel” and “it is important that researchers explore the
current situation so that recommendations can be more meaningful and
valuable.”
3
NCTRF abandoned its plans to disseminate the study
results to its staff.
At the time of writing, CCS had garnered strong support for the need
to change the Medical Travel Assistance Program, and we were invited
to present the study to the caucus of the governing Progressive
Conservative party. Our results were also used to support the
introduction of tele-oncology programs (the evaluation of which
includes an assessment of out-of-pocket travel costs). The nation-wide
CCS network has brought together collaborators and researchers in
other provinces and we are currently developing studies to examine
other issues affecting access to cancer care in Canada.
Lessons learned
This experience taught us valuable lessons about KT in practice.
Decision making and knowledge translation occur in a complex,
dynamic environment where the partners’ interest in, and perspective
towards, the research findings, the researchers, and other partners
continually evolve. The desire to use evidence in decision making competes with other organizational and
personal motivations, not the least of which are self-preservation and self-promotion. Health system
restructuring was looming in the fall of 2004, when it was widely expected that a new regional health authority
would assume responsibility for cancer services from the NCTRF (and the NCTRF would no longer exist as a
separate health board). Such an uncertain political climate would naturally motivate any administrator to
demonstrate the value of their organization, as well as their administrative and political skills, to government
decision makers.
The relationship between the CCS and the NCTRF had been difficult prior to
this study: both organizations wanted to position themselves as the leader in
cancer advocacy issues in the province. The pressure brought upon the NCTRF
by the CCS’s advocacy activities only heightened this tension. Although
organizations may be interested in realizing similar goals, there may be,
nonetheless, an unwillingness to sacrifice other interests to do so.
Our experience also highlights the potential vulnerability that KT can create
for researchers, particularly junior academics. KT demands a substantial
amount of time that could otherwise be used in activities that are more highly
rewarded by promotion and tenure committees. Moreover, no researcher,
particularly those early in their careers, can afford to have their professional
credibility publicly questioned.
Decision making and
knowledge translation occur
in a complex, dynamic
environment where the
partners’ interest in, and
perspective towards, the
research findings, the
researchers, and other
partners continually evolve.
The desire to use evidence in
decision making competes
with other organizational
and personal motivations,
not the least of which are self-
preservation and self-
promotion.
Although
organizations may be
interested in realizing
similar goals, there
may be, nonetheless,
an unwillingness to
sacrifice other interests
to do so.