Photos

‘Single Most Important Things’ from Australia

camel

It’s mid-October, and I’m home after five weeks in Australia, touring the country and giving talks, workshops, and meeting the people. Australia is a vast, beautiful and wondrous country, and requires countless more hours of exploration. I am committed to returning; to explore the land, to learn more from its peoples, and to revisit the people with whom I had the privilege of meeting – to learn what they were able to develop from our conversations and from the stories and evidence I shared with them. As in any good knowledge translation effort, the bottom line is impact – demonstrating that people knew what to do with the knowledge you shared.

I spent most of my time in Perth, a lovely city that sits perched on the Swan River in Western Australia. I visited Sydney in the eastern state of New South Wales, Broome in the northern Kimberley region, and Albany, on the south coast. Each place has its’ own beauty, treasures, and cultures.

I spoke about my own research and my implementation journey over the last 14 years. I shared new thinking about the role of KT in academic promotion, about what counts as “scholarly” in 2014, and how many North American universities have re-envisioned the modern day scholar and the role of the university in today’s society. I met and spoke with senior university leaders, senior managers in health and mental health care, and frontline service providers in health and mental health in urban and rural areas. At every occasion, audiences seemed poised to support systemic changes that would facilitate a new era of KT activities, funding and policy shifts, and scholarly recognition for this work across Australia. Canada is a great model for such a paradigm shift, having worked and developed funding, policy, research and practice initiatives to support KT science and practice for the better part of a decade or more. Here’s a summary of my impressions and what I hope to have left behind.

Invest in system wide outcome measurement, something that has been accomplished in many countries and jurisdictions. Without this, there is no basis for tracking change, and thus, no way of systematically assessing whether changes to evidence based practices are having the desired effects system wide. This is highly feasible. One need only look to models of success in Ontario, Michigan, New York, etc., plan on the change, and implement it.  Data systems are the backbone of service improvement, and it’s a huge oversight to try to improve systems through policy change or implementing evidence-based care without first building the infrastructure to support these efforts. Once analyzed, system level data needs to be shared back with the organizations that contributed the data in the first place; we need to close the loop. This encourages compliance, reflection, and utilization of data in service delivery. In the end, it’s about getting better outcomes, not about defending a program that you like or providing treatment that you believe works without actually going the extra step to assess your fidelity and outcomes.

Use data. Many organizations, including health service organizations and government departments, understand they need data.  And, for the most part, many of them collect data about service or system outcomes.  However, many don’t appear to use the data they collect in a meaningful wayUsing data to improve services needs to be a ‘deliberative process’.   If we are to achieve optimal utilization of the data we go to great lengths to collect, we need to be deliberate in our approach, and this requires us to change how we use our time, which means we must stop complaining that we don’t have the time.  How we allocate our time in health services is a feasible change.  In the same way that implementation of evidence-based practices requires time for planning and reflection, so too, does the deliberate use of administrative data.  On the policy side, government access to evidence is not the only issue; they must review and reflect on the data they receive, and share back what they learn. The data won’t tell a story on their own; data needs to be reviewed and reflected upon by those overseeing and providing services.  At present, much administrative data sit gathering dust, like many of our reports, and represent unrealized potential for change. In the words of Atul Gawande, count something, write it down, (reflect upon it), and tell someone about it. Look for opportunities for change.

Let go the ‘cherished notions’. Service providers need to drop the services that have no evidence to support them; their cherished notions.  They can only know whether their services are effective if they examine their data, and equally, if they collect their outcome data on a routine basis to begin withIt is time to heighten our accountability to the children and families we serve, and to be honest about the effectiveness of the services we provide.  For their part, recipients of mental health and health services need to ask their providers for evidence that their services work.  We do no less when we to go to hospital for treatment, or when we purchase other services.  Somehow, this question is not being asked by those seeking services for their kids’ mental health.  We need to empower them to do so.

Fund partnerships and change academic currency. Implementing evidence in practice requires partnerships between academia, government, and service delivery. For these partnerships to occur they have to be recognized as relevant by health funders and as scholarly and worthwhile pursuits for academics, and in many of Australia’s universities, they are not.  There are many universities, particularly in North America, that have adopted new formats and philosophies related to academic promotion, and have incorporated a new vision of scholarship that recognizes community engaged scholarship.  Australia needs to turn to these models and start the conversation for change.

Change how and what funders fund. A related and important driver for change is the role of the health research funder.  In Canada, the Canadian Institutes for Health Research has been an important driver for growth in KT and implementation science by way of tailored RFPs for KT science that specifically request joint research leadership between nominated principal applicants and nominated principal knowledge users, and by allowing for KT and implementation activities in research budgets (not only for travel and open access publications). Other provincial funders, including Alberta Innovates Health Solutions, Michael Smith Foundation for Health Research, and the Nova Scotia Health Research Foundation have followed suit to change their own funding mechanism and processes and to offer capacity building in KT, in partnership with SickKids and other collaborators. Australasian funding bodies can better support partnership and KT, including enabling this work to be resourced through their grants, beyond the discovery stage. This means appreciating the multiple forms of partnership, engagement, and KT strategies that better exemplify the scope of activities designed to create real world impacts from the science it funds.  Simply counting productivity outputs (grant funding, publications) does not encourage or capture the impact stories, nor demonstrate the real world impacts that have resulted from funding. These changes are low lying fruit; they are entirely feasible and need to be acted upon if Australia is to realize real change in practice stemming from effective KT and partnerships.

The impacts from my Australian journey are blossoming and will reveal themselves in time. Every new connection, every conversation, provided an opportunity for knowledge exchange, for uncovering similarities and differences, and the potential for further collaboration, outcomes and impact. Each meeting became part of my implementation journey, and via this account, part of the collective narrative of our global implementation journey.   There is some positive movement in these important areas.

Build organizational and scientist capacity for KT. Building KT capacity is essential if Australia is to move towards real world impacts for the science it funds and the services it provides. I ran a well-attended Scientist Knowledge Translation Training workshop for about 30 people across a range of health disciplines, sponsored by the Institute of Advance Studies and the School of Public Health at UWA – a big thank you to Susan Kateo at IAS and Dr. Lisa Wood at UWA. Senior university leaders from several universities heard me speak on new paradigms for academic promotion. They were very receptive to the ideas and models shared, and several are motivated to lead the charge. There is a commitment, expertise (KT Australia), and mechanisms in place to host professional development workshops in KT. A partnership between SickKids and KT Australia to provide the Scientist Knowledge Translation Training™ across Australia is in the making, with a view to realizing our first workshop in Fall 2015.

Change how and what funders fund. The funders with whom I met (i.e., Healthway, Cancer Australia, Department of Health) shared their thoughts on what they might do differently and demonstrated a readiness to explore how they might shift their funding processes and competition streams to encourage partnership, KT activity, and a focus on implementation and real world impacts. They view themselves as ‘small’ funders, but are open to the idea that they can, in their own right and through collaborative support, start a new movement. I remain hopeful about their vision and commitment, and have linked them with my contacts at AIHS and MSFHR, Canadian provincial funders who can provide coaching and models from their excellent work promoting KT and building capacity.

Build on KT successes. I met with several research teams: Dr. Hugh Dawkins and his team at Genome Australia; Drs. David Lawrence and Donna Cross and colleagues at Telethon Kids Institute; Dr. Lisa Wood and colleagues in the School of Public Health at UWA; and Dr. Fiona Bull and her team at the Centre for the Built Environment at UWA. Many of them are already working in this space, and they were receptive and eager expand their KT applications in their work, mindful that they need organizational supports and KT experts who can support the development of their KT skill set. There have been some false starts in some places, so perhaps my visit will reignite an awareness and commitment to move forward in knowledge translation within academic institutions. Shifts will need to happen in funding and promotion for this to really take hold in any meaningful way.

Explore innovative KT strategies to engage youth and share evidence. The practitioners in health and mental health services were welcoming of the KT perspective I shared, and whilst they juggle numerous difficulties in delivering services in geographically complex settings with hard to reach populations, there are some great innovations brewing. Youth counselors and clinicians at Alive and Kicking Goals in Broome are piloting a new software application called “I Bobbly” developed by the Black Dog Institute, to address the staggering rate of suicide among aboriginal youth – four times the national average. The I-bobbly smartphone app has been designed specifically for Aboriginal people living in remote communities, and the approach, according to Alive and Kicking Goal’s Joe Tighe, might be able reach people that traditional suicide prevention strategies aren’t.

The feasibility of using apps with this hard to reach population was also discussed with David Wild and Darren Grassick at Headspace, Australia’s National Youth Mental Health Foundation, also in Broome. Headspace is a national initiative with a focus on the mental health and well-being of Australians. As with many regional and national initiatives, collecting standardized data about service delivery is challenging, a sentiment shared by those providing environmental health services for the Broome area, who spoke of the “clunkiness of common metrics for collecting evidence of health outcomes and service contacts”. Standardized questionnaires delivered with iPad technology appear to offer a feasible solution for improving engagement with youth and hard to serve populations.

David and Darren spoke of the importance of context for assessing symptoms of mental health disorders, noting that some of the indigenous youth who manifested symptoms of ADHD in local schools were absent of these encumbrances when living in their native communities. We spoke about the implications of such revelations for capturing functioning, symptoms, and outcomes across systems of care, and the need for policy makers to become more aware of the importance of context and the challenges of applying state wide measures in complex environments. Policy makers need to work with service providers to develop better ways of collecting data – of capturing both snapshots of client functioning as well as process outcomes. At a minimum, providers can report on who receives service, which may present a minimum data set when tracking how kids improve as a result of the services they receive proves contextually challenging. David and Darren committed to bringing these issues for discussion at the upcoming Headspace meeting in Alice Springs in November, and I hope to follow up with them to continue the discussion.

Janice Forrester, coordinator for the local Rheumatic Heart Disease Service in Broome, shared information about their service, and the challenges they experience in sharing important information about RHD with their young patients and their families. RHD include heart disorders that can occur as a result of rheumatic fever, often resulting in heart valve damage. Her interest lay in learning how the service could better meet the needs of the regional population, and how they could more effectively disseminate key information about the disease, its treatment, and complications. If heart damage from rheumatic fever is identified in childhood or young adulthood, daily antibiotics may be required until the age of 25 or 30, to help prevent recurrence of rheumatic fever and avoid the development of infective bacterial infection of the heart valves or lining of the heart. Noting that their use of pamphlets or one-on-one consultation wasn’t always effective for knowledge translation, we discussed more engaged strategies they could use to share evidence about RHD, both to educate clinical staff and to empower families to identify the disease, seek out treatment, and comply with very long treatment regimens. Our collective brainstorming identified the potential for local indigenous ‘yarning groups’ , and Tamika moved us to discussing the potential of the upcoming kids telethon, in particular their ability to engage the participation of national actors to highlight certain health issues in ways that would seem very appealing to the countries’ youth. For instance, Home and Away, a highly popular Australian soap opera watched by aboriginal and non-aboriginal youth alike, could serve as a highly engaging and effective vehicle for sharing key health messages and knowledge. I think we left Janice feeling inspired, and considering some avenues for knowledge exchange that she could explore.

Close the Gap between Policy and Practice. In the policy realm, I met with the Acting Commissioner for Children and Young People and colleagues, and with clinical and policy staff at the Mental Health Commission of Australia. I spent a half day with Dr. Simon Davies and his team at CAMHS, teaching them about KT, and discussing our work supporting Ontario’s outcome initiative with CAFAS. By the end of my journey, we were poised to collaborate on research exploring renewed potential of their own system wide outcome initiative using the HoNOSCA, which while collected national wide has never been shared back with clinicians or with consumers.

Some common challenges emerged from our meeting with local CAMHS clinicians in Broome, who struggle with local application of policy in very difficult to serve communities. There typical model of service delivery is family structured individual therapy, which is difficult to implement in their rural, remote, and indigenous context. “They try hard to deliver the model, but the more rural you go, the less feasible that is. This is sole-destroying for the clinician, as there is no model that really fits the context.” In the first clinical session with the youth, the goal is to make a plan, write it down, and review a leaflet on rights and responsibilities; this is simply not feasible to accomplish at the first meeting in the absence of establishing a trusting therapeutic relationship. There is variable clinical supervision, which typically only involves case review, and new tele-health services are often staffed by adult psychiatrists with little pediatric experience. These are key challenges for service delivery in child and youth mental health.

There is a need for more liaison, capacity support, therapeutic group models, and consultation that are context relevant and feasible. Indigenous youth in regions “live in the community, not within the family”, and you can’t provide service without consent, and you can’t get consent from parents who are absent from the home for long periods of time, or who don’t have the capacity to provide consent. This is a quagmire that requires collaborative problem solving and clinical input from the field to retrofit a policy for service delivery that is not working in the given context.

“Social change is not going to come from just knowing more information, but from doing something with it” Pia Mancini, TEDGlobal 2014. I hope it’s not too immodest to hope that perhaps I left behind a new sense of urgency, motivation, and a clear pathway for change.

Acknowledgements

Thank you to Healthway who provided the funding for my visiting fellowship to Dr. Tamika Heiden at KT Australia, and Dr. Lisa Wood at the School of Public Health, University of Western Australia.

Image: Melanie Barwick and Tamika Heiden, Cable Beach, Broome, WA

Reflections on the Australian Implementation Conference 2014

AIC14 Gang

I spent this past week in beautiful Sydney, Australia, for the 2nd Biennial Implementation Conference. It was a great opportunity to learn about what’s happening across Australia in KT and implementation, and was attended by over 400 delegates. The conference was ‘successful’ by the first day, if only because it attracted a blend of researchers (33%), policy makers (24%), practitioners (19%) and others (24%).  Missing from the group, although there were a few, were Australia’s national health funders, who have an important role to play in supporting implementation science and the legitimization of KT and implementation work in academia.

The schedule was packed with perspectives of both practice and science in implementation, from a variety of speakers. Here are my take-aways from the conference.

Use Data

Many organizations, including health service delivery and government departments, have arrived at an understanding that they need data.  And, for the most part, a good many of them collect data about service outcomes, health, and well-being.  Problem is, they don’t use the data they collect in a meaningful wayDr. Fred Wulczyn, Senior Research Fellow at Chapin Hall, University of Chicago (USA) talked about how use of administrative data needs to be a ‘deliberative process’.   He encouraged us to ‘process the data, and process the narrative’ that emerges from the data.  We need to develop a consistency in leadership wherein there is a willingness to use evidence, as well as a capacity to generate evidence.  This resonated strongly for me, in the context of the data my team has produced for Ontario’s child and youth mental health sector over the last 14 years.  We produced numerous quarterly and annual reports, for service provider organizations and for government, but we were never convinced that the data were used for service planning; that providers or government policy makers actually took the time to review and reflect on the data and collectively arrive at a narrative of what the data suggested they should be doing to improve services.  These efforts represented an underutilized contribution; a missed opportunity for reflection and improvement in service delivery.

If we are to achieve optimal utilization of the data we go to great lengths to collect, we need to be deliberate in our approach, and this requires us to change how we use our time, which means we must stop complaining that we don’t have the time.  How we allocate our time in health services is a feasible change!  In the same way that implementation of evidence-based practices requires time for planning and reflection, so too, does the deliberate use of administrative data.  On the policy side, government access to evidence is not the only issue; they must review and reflect on the data they receive. The data won’t tell a story on its’ own; it needs to be reviewed and reflected upon by those overseeing and providing services.  At present, administrative outcome data sit gathering dust, much like all our reports, and represent unrealized potential for change. In the words of Atul Gawande, count something, write it down, and tell someone about it. Look for opportunities for change.  Good words to live by.

Let Go the ‘Cherished Notions’

Service providers need to drop the services that have no evidence to support them; what several speakers referred to as their cherished notions.  They can only know whether their services are effective if they examine their data, and equally, if they collect their outcome data on a routine basis to begin withIt is time to heighten our accountability to the children and families we serve, and to be honest about the effectiveness of the services we provide.  For their part, recipients of mental health and health services need to ask their providers for evidence that their services work.  We do no less when we to go to hospital for cardiac surgery, or when we purchase other services.  Somehow, this question is not being asked by families seeking services for their kids’ mental health.  We need to empower them to do so.

Governments also need to invest in system wide outcome measurement, something that has been accomplished in many countries and jurisdictions. Without this, there is no basis for tracking change, and thus, no way of systematically assessing whether changes to evidence based practices are having the desired effects system wide. This too, is highly feasible. One need only look to models of success in Ontario, Michigan, New York, etc., plan on the change, and implement it.  Data systems are the backbone of service improvement, and it’s a huge oversight to try to improve systems through implementing evidence-based care without first building the infrastructure to support these efforts.

In the end, said Wulczyn, it’s about getting better outcomes for kids, not about defending a program that you like or providing treatment that you believe works without actually going the extra step to assess your fidelity.  No matter how long they’ve been practicing, clinicians are not off the hook in demonstrating their impact on the clinical outcomes of the kids and families they serve.    Sadly, our current models of supervision are not holding us to this practiced reflection, and that’s not a good thing.

Link the Changes

Administrative changes in how we measure and use data will only take us so far, according to Fred Wulczyn; they only nudge the needle.  To achieve whole system change and improved outcomes we need to link administrative data with fiscal changes – incentives to do the right thing, and with evidence about how kids and families experience the service system. Without this linkage, each of these events represents only a chapter of the whole story.

The system wide changes we need to produce a more robust system were eloquently capture by Professor Brian Head, Program Leader in Policy Analysis at Queensland University. He identified 6 activities needed for building an effective policy system: collect data in a systematic and rigorous manner; utilize personnel with strong data analysis skills; improve institutional capacity to provide performance information and policy analysis of options; evaluate and review processes; open political culture and knowledge flows; and identify champions across all sectors to broker these changes.

Fund Partnerships and Change Academic Currency

A wonderful panel of women leaders were assembled to discuss the Australasian perspectives on solving complex policy problems for implementation of evidence, including Amanda Cattermole, General Manager Budget Policy Division, AUS Govt, The Treasury; Tricia Murray, CEO Wanslea Family Services; Sally Redman, AO, CEO Sax Institute, Maree Walk, Chief Exec, Community Service Division, NSW Department of Family and Community Services; and Clare Ward, Chief Exec, Families Commission, New Zealand.  They each shared their thoughts on how the implementation of evidence in practice requires partnerships between academia, government, and service delivery, and many had stories to share about how they’ve been involved with these efforts in their own jurisdictions.  Yet, they also said that for these partnerships to occur they have to be recognized as relevant by health funders and as scholarly and worthwhile pursuits for academics, and in many of Australia’s universities, they are not.  There are many universities, particularly in North America, that have adopted new formats and philosophies related to academic promotion, and have incorporated a new vision of scholarship that recognizes community engaged scholarship.  Australia needs to turn to these models and start the conversation for change.  I will be speaking on this topic at the University of Western Australia on September 30th, and will blog about my talk later this month.

A related and important driver for change are the health research funders.  In Canada, the Canadian Institutes for Health Research has been an important driver for growth in KT and implementation science by way of tailored RFPs for science in this area that specifically request joint research leadership between nominated principal applicants and nominated principal knowledge users, and  by allowances for KT activities in research budgets (not only for travel and open access publications). The National Health Medical Research Council and other Australasian funding bodies need to broaden and deepen their appreciation of KT by moving beyond the clinical guideline, to appreciating the multiple forms of partnership, engagement, and KT strategies that better exemplify the scope of activities designed to create real world impacts from the science it funds.  These changes are low lying fruit; they are entirely feasible and need to be acted upon if Australia is to realize real change in practice stemming from effective KT and partnerships.

Build the Triangle: Research on Implementation Drivers

Exciting work is happening to build on key innovations in implementation.  In particular, we have added to NIRN’s implementation triangle through our own CIHR funded research on KT in child and youth mental health, noting the emergence of supervision models as a key competency driver.   Bianca Albers described her doctoral work to develop the bottom of the triangle and expand on the role of leadership in driving implementation success.  This is an important and rather huge undertaking, given that the role of leadership in implementation pursuits is often poorly articulated and defined.  I know I will be following her work as it evolves, watching for new developments on this key driver.  Lastly, Jennifer Schroeder of the Implementation Group and Allison Metz from NIRN are doing interesting work on collective impact that looks promising for advancing our understanding of the right side of the triangle, the organizational drivers.

At the conclusion of the conference, I felt invigorated but also well aware that we have only touched the tip of the iceberg and have much collective work to do in this field as it continues to evolve and impact services.  As I look forward to the following four weeks in Perth, Broome, and Albany, the perspectives, challenges, and innovations highlighted at AIC2014 will percolate in my mind, and I look forward to sharing again as my Australian journeys in implementation continue.