reducing the holes in the swiss cheese of access to evidence and knowledge.

Interesting commentary in BMJ this past week:

Degos L, Amalberti R, Bacou J, Carlet J, Bruneau C. Breaking the mould inpatient safety. BMJ. 2009 Jun 29;338:b2585. http://dx.doi.org/10.1136/bmj.b2585

In this piece that calls for a broader approach to understanding and improving patient safety, the authors state:

"Safety may be defined as increasing the patient’s chance of receiving appropriate care that is in line with evidence based medicine. Any obstacle to such access is considered as a loss of chance and a potential failure of the health care system."

How many of our organization consider the potential failures associated with this statement?

Doesn't this quote beg for those of us that deal with the more explicit side of knowledge delivery (ie access to the published literature, guidelines etc) get more involved in helping organizations understand the obstacles to deliving care that is in line with evidence based medicine due to lack of access to the evidence that informs that care?

I recently had discussions with members of a team I work with that were frustrated with the lack of access to a primary scientific journal via their large academic insitutions library. We had to work around the system, ask yet another team member to send us what we needed. One article I need I still don't have. Good thing it wasn't for emergent clinical care, eh? Does that sort of inefficiency and evidence access failure have the potential to contribute to care problems? Interesting question.

We need to, as Susan Carr. editor of PSQH recently stated "shine our light" and weigh in on discussions involving access to knowledge and the "evidence" to understand how they impact safety. We should participate in blogs, online communities, and other tools to share what we know. If we have a seat at the "patient safety table" at our organizations, we should try and ask the right questions to help our peers and clinical colleagues understand this type of failure. We need to generate interest to help generate primary research opportunities and proactive failure analyses to understand how to best focus our efforts in this area.

If there are activities looking at the problems arrising from failure to access the appropriate bibliographic evidence in real time, please share your news about them here. I have to believe that someone out there is looking at this issue and is hopefully involving a myriad of professionals and individuals with personal (read patients and families) and work experience (read clinicians, administrators and "blunt end" professionals) in sorting out the problems. We all have a stake in making this piece of the safety pie less full of holes ;-).

Dialogue: a new tool for librarians to facilitate the sharing of knowledge

Today’s environment for sharing information and knowledge is complicated. The variety of tools, styles, formats available affect our ability to communicate clearly and efficiently. Time is an issue as well. Nonetheless, with the plethora of technologies that can be customized for our specific needs, one would think communicating ideas would be easier – but alas, its not.

One method often relied upon to share the information and knowledge (Depending on how you define it) is the written text – in whatever format it is delivered. The management of explicit items is certainly the "mental model" most conjured up when librarianship is mentioned. But is that the only way we can contribute to knowledge sharing? Think again. I recently had a colleague profess that librarians needed to embrace dialogue as a tool to share knowledge rather than just providing articles and other explicit knowledge artifacts. He saw this as a way to remain viable in today's information rich environment.

This is an intriguing concept. It certainly builds on the KM notions outlined by Nancy Dixon in her book Common Knowledge (ISBN: 0875849040) where she present a structured process of team discussion and feedback as a mechanism for knowledge transfer in the corporate environment. So let’s think on how this concept might play out in health care.

Certainly the idea of transferring knowledge in small groups rings true in safety circles. With the recent interest in debriefs, daily huddles, collaborative rounding, walkarounds, and regular team / unit meetings, meeting to share "what the knower knows" enables a richness of exchange that helps create a mindfulness around both the work at hand and bigger picture issues that affect the safety of care. In addition, mindfulness is enhanced by these communication mechanisms that facilitate knowledge and information to be shared in real time in a context that allows for visible impact of that exchange.

In response to my colleague, then, can and should information professionals in health care facilitate and contribute to this activity? If you like this idea, then, what is the best marriage of our skill set with the function of dialogue? I recognize that it can’t happen always – especially at the sharp end of clinical care -- but the closer librarians are to the clinical team -- the more likely it is to happen. Certainly participating in these front line information exchange activities from time to time will inform any dialogue that takes place regarding information services. Having regular dialogue with front line staff may help improve the reliability of care process through more effective evidence delivery. A bridge to the "sharp end" dialogue process may be to participate in committee work. We should do this not only from a information service perspective but as an information and knowledge strategist. In addition – don’t forget to set up opportunities to talk to patients and families. Even if you don’t serve them directly, their needs and ideas should be folded into any health care knowledge sharing initiative: nothing about them, without them.

To close -- dialogue is also a key systems thinking tool. If info pros are to seen as systems thinkers, shouldn't’t they be comfortable demonstrating AND explaining the art of dialogue as a tool in THEIR information and knowledge sharing arsenal? I think so.

Dr House's knowledge sharing strategy.

Any thoughts here? The poll that came out a few weeks back on TV doctors and their impact on the perception of physicians was interesting. For those of us who watch "House," we aren't surprised that Dr. Gregory House was seen by physicians as detrimental to their public persona.

However one feels about that, my query is more oriented to how House shares "what he knows" and thusly trains his staff to think the way he does -- both in good and bad ways. Now, I am not advocating that we all become gruff, pill popping professionals -- but what lessons can we learn from this character about effective knowledge transfer?

high reliablity in literature search work

This issue has been of interest to me for a while.

Sampson M, McGowan J, Cogo E, Grimshaw J, Moher D, Lefebvre C.
An evidence-based practice guideline for the peer review of electronic search strategies.
J Clin Epidemiol. 2009 Feb 18. [Epub ahead of print]

The notion of the reliability of the evidence identification process has been of keen interest ever since the Hopkins IRB incident where a good intentioned researcher missed important information that was a part of the failure spiral that resulted in the death of a healthy research volunteer.

This article discussed the use of peer review and checklists (used to improve reliability in other facets of medical work) as a potential improvement mechanism for the evidence retrieval process. I hope by the time I get through the article, others have too - and we can chat about it here.

I hope Sampson and colleagues provide us all with backgound that will lend support to some failure analysis work in this area. I've been talking that up and pitching it for years --- perhaps a door will open now for the study this gap requires to fully understand it.

Nice example of CoP outcomes

This free article illustrates some of the power of what can come from collaborative work for safety and quality improvement via the launch and support of a community of practice (CoP). As a knowledge sharing mechanism, I think CoPs can provide great opportunities for multidisplinary, multi-location teams to come together to get work done that might not get accomplished by one organization or one team.

Enjoy -

Alliance for Pediatric Quality: Creating a Community of Practice to Improve Health Care for America's Children
Paul V. Miles, Marlene Miller, Donna M. Payne, Robert Perelman, Mimi Saffer, Edward Zimmerman for the Alliance for Pediatric Quality
Pediatrics 2009; 123: S64-S66

KM in hospitals session

I hope you'll join us for this session in Utah April 16-17th, 2009. We are excited about building on our successful 2007 Chicago workshop with a 1.5 event that engages teams from organizations (a librarian and a peer from outside the library) to help with developing KM strategies through the application of Appreciative Inquiry and Plan-Do-Study-Act mechanisms.

http://nnlm.gov/mcr/education/classes_knowledge_management.html

There is an application process for teams to be considered to participate and the deadline for submitting paperwork is Feb 6th.

Keeping track of external info to support internal learning

I just wanted to bring these two articles to the group's attention:

Could it happen here? Learning from other organizations' safety errors.
Conway J. Healthc Exec. 2008;23:64-67.

Using external errors to signal a clear and present danger.
ISMP Medication Safety Alert! Acute Care Edition. November 6, 2008;13:1-2.

They both advocate for defined strategies to be implemented to help with the identification, dissemination and learning from published reports, news and stories about failure. I thought readers of this blog may find them useful in their efforts to get involved in safety work at their organizations.

Enjoy!