"Knowledge Translation at the
Canadian Institutes of Health Research"
NCDDR Webcast #5
December 6, 2006, 2:00-3:33 PM CST
Presenters: Liz Stirling and Jacqueline Tetroe

Edited Transcript

>> JOANN:  Good afternoon, everyone. And thank you for joining the webcast on Knowledge Translation at the Canadian Institutes of Health Research. My name is Joann Starks and I'm with the National Center for the Dissemination of Disability Research, or NCDDR, based at the Southwest Educational Development Laboratory in Austin, Texas. I'll be moderating today's webcast and getting your questions to our presenters. Before we get started, I want to be sure to thank our partners at ILRU in Houston for helping with the technical side of the webcast. 

There are some materials accompanying the webcast that can be found on ILRU's Web site. These include a PowerPoint file with a corresponding Word version for accessibility. The PowerPoint will be shown as part of the webcast although you may prefer to print and use a paper copy. Real-time captioning will also be provided today in a separate window. 

If you would like to ask a question, you can click the "Submit Question" button at the bottom of your RealOne or Windows Media Player screen, or you can send e-mail to webcast@ncddr.org. You can also call us toll-free at 800-266-1832 and ask your question, which will then be shared with our presenters. Please feel free to submit questions at any time during the webcast and the presenters will answer them. We have also set aside a question and answer period at the end of the presentation. 

If you should have any technical difficulties during today's webcast, please call ILRU at 713-520-0232 and dial 0 for the operator to ask for assistance. This number is both voice and TTY capable. 

Today's webcast addresses knowledge translation, or KT, a broad concept that encompasses all steps between the creation of new knowledge and its application to yield beneficial outcomes for society. The Canadian Institutes of Health Research, also called CIHR, was instrumental in developing this concept. Our funding agency in the U.S. Department of Education, the National Institute on Disability and Rehabilitation Research-NIDRR-has identified KT as an important part of its research agenda. Evidence-based knowledge technologies and applications from NIDRR-funded research must be translated to inform disability and rehabilitation policy and improve practice for the purpose of enhancing the lives of individuals with disabilities. 

We are privileged to have as our presenters two members of the Knowledge Translation Branch of the CIHR. They are Ms. Liz Stirling and Ms. Jacqueline Tetroe. They will discuss the current status of KT within the context of the Canadian Institutes of Health Research. Now, a little bit about our presenters:

Liz Stirling is working on the implementation of CIHR's five-year strategic plan in knowledge translation. Before she joined CIHR, Ms. Stirling worked in a variety of health and public policy roles including at one of Canada's largest teaching and research hospitals in Ottawa. In 2004, she was on assignment to the Canadian Health Services Research Foundation. She also served as a member of NIDRR's Knowledge Translation Planning Panel in June of 2005. Trained as an occupational therapist, Ms. Stirling earned a BSc and a Masters in Health Science from the University of Toronto. 

Jacqueline Tetroe joined the Knowledge Translation Branch of CIHR as a senior policy analyst in September of this year. Prior to that, she was the research program manager in the Clinical Epidemiology Program of the Ottawa Health Research Institute, where she worked closely with Jeremy Grimshaw and Ian Graham on their shared research agenda. Her educational background is in cognitive psychology and education. 

Welcome, Liz and Jacqueline, and I want to thank both of you, as well as CIHR, for your participation in the webcast today. Now I'm going to hand things over to Liz Stirling, who will start our presentation. 

>> LIZ:  Thanks so much, Joann. As Joann mentioned, the CIHR-NIDRR dialogue started in June of 2005 with NIDRR convening a knowledge translation panel, which I was privileged to be a member of. And since that time, the NCDDR has asked us some interesting questions about knowledge translation; what it means to us at CIHR, how it works. Jacqueline, as a KT expert, has since joined our Knowledge Translation Branch, thereby enabling us to respond to these questions in a clear fashion. We hope that the webcast will help you to move your knowledge translation agendas forward in each of your own work or academic contexts. 

I will start and Jacqueline will take over part way through the presentation. We have seven sections to the presentation and I'll begin with slide 2. Knowledge translation at CIHR; definitions, purpose, and rationale. So slide 3 highlights the section that we're on. 

So I'll move you to slide 4. The definition and framework developed at CIHR was created with help from our institute advisory boards, in particular our health services and policy research advisory board; some of our governing council members, and a variety of CIHR staff in the 2001-2002 time frame. So you'll see the definition of knowledge translation, which I know NIDRR has used: 

"The exchange, synthesis, and ethically sound application of knowledge within a complex system of interactions among researchers and users to accelerate the capture of the benefits of research for Canadians through improved healthcare, more effective services and products, and a strengthened health care system." The three outcomes are derived directly from the CIHR Act, which is an Act of Parliament created in the year 2000. Ian Graham, our new vice president of knowledge translation, may tweak this definition a little bit over the coming months so stay tuned to our Web site for potential slight modifications.

Slide 5 provides the context for the CIHR definition. As I mentioned, the CIHR Act was passed in Parliament in the year 2000. It's worth noting that it was created in a majority government situation and with the creation of this organization came an unspoken agreement to substantially increase the budget for health research funding in Canada. And we've come part way in that vein, our budget increasing to $750 million, but the original intent in the research community was to have that budget reach a billion dollars, which was seen to be more in keeping with the global benchmark and we've yet to realize that goal. 

As described in the Act, KT is a broad concept. It encompasses all the steps between the creation of new knowledge and its application to yield beneficial outcomes for society. And for CIHR, it includes a range of things and we've also accepted that there are a number of terms that at times are used synonymously with knowledge translation. The KT umbrella includes dissemination, communication, technology transfer, knowledge management, knowledge utilization, a two way exchange, et cetera. Depending on the area of research that we fund-we fund basic biomedical research, clinical research, health services and policy research, and population health research-and the KT context in each of those areas is different. 

Slide 6 highlights that the key point is that interaction between researchers and stakeholders may vary in intensity, complexity, and the level of engagement depending on the nature of the research results and on the needs of the particular stakeholder. And for CIHR, increasingly our institutes and their advisory boards are becoming more committed to knowledge translation, to the stakeholder engagement aspect of it, and helping the organization realize the KT mandate as a whole. 

Slide 7 talks about what is not KT. And this was thought about in consultation with Ian Graham, as he brings a deep knowledge of KT research to the organization. KT is not continuing medical education, continuing professional development, or translational research and on slide 8 I'll explain each of those-each of the rationales. 

(Slide 8) Continuing medical education generally refers to planned educational activities intended to further the education and training of specific health professionals for the enhancement of practice, education, administration, and research or professional development. So it's a traditional activity that is excluded from the KT definition. 

>> JACQUELINE:  If I could interject, it's similar in many ways, but where KT is different from continuing medical education is that it's very much broader in its scope. Continuing medical education is something that is just traditionally targeted at health professionals or health care providers and we're thinking of knowledge translation as being much broader than that in terms of who is engaged in it. 

>> LIZ:  (Slide 9) Thanks, Jacqueline. Continuing professional development on slide 9 includes educational methods beyond the didactic, embodies concepts of self-directed learning and personal development, and considers organizational and system factors. 

And on slide 10,"What is translational research?" There are a couple of slides to deal with this. Translational research is about finding solutions to clinical problems. Ideally, it involves two-way interactions between basic or fundamental scientists and clinicians and requires moving between scientific discoveries and clinical applications. 

On slide 11, the distinction between translational research and KT is that KT is the next step in the process. The widespread dissemination of the clinical application once it has been proven beneficial by clinical research would be considered KT. So translational research ends with the development and/or testing of the clinical application and does not include its widespread promotion. 

On slide 12, the rationale for KT at CIHR is two-fold, the creation of new knowledge often does not, by itself, lead to its widespread adoption or impact health, and I think funders around the world have recognized that they perhaps need to look more broadly at what it is they do and try to contribute to this impact aspect. Today you will see the United Kingdom has released the Cooksey Report to the Chancellor of the Exchequer in the UK. The advice that Cooksey has given the Chancellor is to look at a structure that is akin to the CIHR structure and indeed, to include some of the knowledge translation elements that CIHR has tried to include in its mandates, and CIHR is referred to in that report. 

Secondly, increased emphasis on research governance and accountability from many levels-federal and provincial, as well as the public. This has been a big driver for us as we look to realize the KT mandate; the government and policy-maker audience is an important one. 

Slide 13. The mandate of CIHR includes KT and it is a fundamental aspect of the CIHR Act. The Act has a long section about a whole variety of things that CIHR is intended to do and it goes well beyond simply funding research, but paraphrased, ultimately we have a role to play in moving research into practice or action and ultimately improving the health of Canadians, which was a considerable leap forward from the old mandate of the Medical Research Council of Canada. 

Slide 14, the historical perspective of KT in Canada is that the Alberta-one of our provinces-the Alberta Heritage Foundation for Medical Research was established by that provincial government in the early '90's and they actually coined the term-used the term "research in practice" and developed a model for such. And then subsequently, the Canadian Health Services Research Foundation was created in 1996 through an endowment that they need to spend down by the year 2012, I think it is. That organization was struck to focus specifically on linkage and exchange and they've also had a real focus on knowledge brokering in the health services research community. And that community is very interested in knowledge translation and we have taken a lot of our learnings here at CIHR from that organization and that community. 

Slide 15, I'm going to move into section 2 of the presentation, "How widely can the concept of knowledge translation be applied?" 

So on slide 16 you asked whether KT was an issue at the local, national, and international level and we believe that it is. And what distinguishes the level is the end user or target audience. Regardless of the level, the process is essentially the same and the impact of KT can filter up or down the levels. In our view, we need to "link globally and act locally" which is a phrase coined by Ian Graham, our VP. 

And finally, for me, slide 17: KT is not unique to medical research. The concept has been used in many other disciplines and is known by other names: tech transfer, knowledge management, change management, et cetera. The process that is knowledge translation is appropriate to any discipline. It is about facilitating the uptake of research, but while the process is universal, the content and context does vary. So with that, I will hand it over to Jacqueline and slide 18. 

>> JACQUELINE: (Slide 18) Which is another organizational slide so that you can track through where we've been and where we're going with our discussion this afternoon. So having understood what our definition is at CIHR, and the context for how and where that definition was developed, and our idea of the kind of universality of knowledge translation as a concept; let's think a bit more about what knowledge translation really means. As many of you are aware and as Liz alluded to earlier, there are a lot of different words out there for knowledge translation, a lot of different terminology. You know, there is diffusion and dissemination and transfer and tech transfer and it goes on and on and on. 

(Slide 19) But one term that does come up a lot that I would like to just spend a little bit of time differentiating knowledge translation from, is the term research utilization. And the question comes up sometimes: "How does knowledge translation differ from research utilization?" Without trying to seem too slippery on this, I'd have to say it really depends on how you define research and how one defines knowledge. Those of you who have studied philosophy and epistemology know that even talking about how one defines knowledge can be a 3-day, you know, all-nighter discussion, so we won't get into that too deeply. But let's just say we think of research as being a subset of knowledge. We think of it somewhat like research findings-what you're finding as a result of your research study-whereas knowledge is more the construction that you make of that research; those research findings in your head. 

In terms of evidence, we're not going to get involved in the debate over the definition of evidence. For those of you who aren't familiar with that, the CEO of the Canadian Health Services Research Foundation, Jonathan Lomas, has been giving a series of talks and written a few papers trying to get people to rethink what is meant by evidence and to broaden our conceptualization of evidence and there is a link at the bottom of the slide -- this is slide 19 -- sorry I forgot to be telling the slide numbers. I'll try to get on that from the CHSRF Web site. If any of you want to e-mail me later, I can send you the link or in fact some of the documents that do discuss what evidence is. 

But moving on from that to slide 20, to try to compare and contrast knowledge translation and research utilization, starting in the early '70's, the term research utilization was used to describe the incorporation of research evidence into clinical practice. And since then many nursing models of research utilization have been developed. 

(Slide 21) To me, when I hear the term research utilization, I'm thinking it's something -- it's a term predominantly used by the nursing professions for whatever reason, and if you Google "definition research utilization"-I'm on slide 21--if you Google the term research utilization and start to look at that over time, you see that it has become more precise. Titler et al in 1999, defined it as "a process of using findings from conducting research, to guide practice" and Brown in the same year, in 1999, defined it as "the process by which scientifically produced knowledge is transferred to practice." 

If you move to the next slide, slide 22, you'll see three definitions of research utilization all from Carole Estabrooks, who is a Canadian who has a center on nursing knowledge translation or research utilization (Knowledge Utilization Studies Program) at the University of Alberta. If you Google her you'll find lots of good information. She initially in 1998 defined research utilization as "the use of research findings in any and all aspects of one's work as a registered nurse." So she there is really settling that within the nursing profession. Then in 2003, she's defining it as "a process by which specific research-based knowledge -- with the word science in brackets -- is implemented in practice." So she's taking it out of the nursing realm there and making sure that it's research-based knowledge or research findings. Then finally in 2006-she has developed a lexicon on her Web site of clinical terms and knowledge translation terms-and in that lexicon she defines research utilization as "a specific kind of knowledge utilization whereby the knowledge has a research base to substantiate it. It is a complex process in which knowledge in the form of research is transformed from the findings of one or more studies into instrumental, conceptual, and persuasive utilization." So you can't get much more refined than that in terms of a definition. And that was slide 22, by the way.

If we move on to slide 23, you'll see I put check marks besides these various terms: research utilization, evidence-based practice, which many people feel is-research utilization has transformed itself into the term evidence-based practice, and that's a term that's been adopted by all sorts of clinicians, not just nurses. Also, moving knowledge to practice, knowledge to action. The specific words aren't really important and I think in the long run, what's important is how these terms are operationalized, and that's true for all of the terminology within knowledge translation. Because there are so many words out there and they mean different things to different people and they are used differently, I think the key thing for all of us is to be sure to define our terms operationally and then we'll be able to communicate well and be really clear about what we mean.  

In slide 24, I'm trying to raise the point that Ian Graham, who is our new vice-president of knowledge translation, uses the term knowledge to action. And many of you-or some of you-may have had a chance to take a look at a paper that was published this year in the Journal of Continuing Education in the Health Professions where Ian was the first author. It's called "Lost in translation, time for a map?" In that paper Ian introduces this concept of knowledge to action and which I'm going to be talking about it in some detail today. In our view, knowledge to action is an organic process with defined steps and it's a process. So we're going to be using the term knowledge to action to talk about the whole knowledge translation process and we're using these words because they have been quite nicely defined in the paper that I just described to you. 

So moving on now to another one of the organization slides, slide 25, you'll see that where we're at is point four of the presentation, knowledge to action, where I'm going to try to describe to you this model and explain to you how it was derived and what it actually means. 

If you move to slide 26 you can see the knowledge to action model as it was presented in the "Lost in translation" paper. And for those of you who don't have PowerPoint because I realize some people are just working from a Word document, I'm going to try to describe what this slide looks like quickly. So those of you who have this in front of you, bear with me, and you can rate me afterwards about how good a job I did in telling you what it looks like. In the center of the slide there is a triangle with the bottom point -- sort of looking like a funnel. And at the top of that funnel is Knowledge Inquiry. Further down is Knowledge Synthesis, and then towards the point of the funnel is Knowledge Tools and Products. And this is representing an increased distillation of knowledge. Think of it -- for those of you who know anything about maple syrup, you know you start out with this very dilute lightly flavored sap, which you get from the maple tree. Then you boil it and boil it down until you get this very thick, very tasty syrup, which is kind of the distillate of the sap you get from the tree. Well, similarly in this triangle/funnel I'm trying to describe, at the bottom of the funnel you get the essence of the knowledge that has been created after it's been synthesized and then developed into a tool of some sort. For example, a practice guideline or a care pathway or a decision aid. That's what I mean by knowledge tool or product. 

So there we have in the center of the model, the knowledge piece; what's involved in creating knowledge and synthesizing knowledge for application into real world practice. So the knowledge creation piece is key and in the end you have a very tailored set of knowledge to try to put into practice. So now around this triangle/funnel, that is how to create knowledge, are various steps in moving that knowledge into action. They are represented by a series of boxes that are arranged around this knowledge triangle. And the boxes are identifying the problem; identify or review and select the knowledge; adapting knowledge to a local context; assessing barriers to knowledge use; select, tailor, implement your intervention; monitor knowledge use, evaluate outcomes; and sustain knowledge use. These boxes are all linked by an arrow so that one box influences the next influences the next and so on, coming back to the initial box of identifying the problem. The idea of setting the model out this way was to try to give the impression of this being a very iterative, organic kind of process. I hope those of you without PowerPoint have some sense of what this model looks like. And I'd like to talk a little bit about how the model was derived. 

First -- and this is on slide 27 -- first, the knowledge creation funnel, and then the action cycle. 

So slide 28 now, please, we're thinking about how was the knowledge creation funnel derived? Well, if you think back to my analogy to making maple syrup, we're assuming that one needs to have synthesized knowledge to put into practice because we want to be clear that the knowledge is-the practice that you're trying to implement has been well vetted, that it has been contextualized within the local, the community, the world literature; that we know this is a good thing to do, that it fits with the rest of the literature. So it's important to synthesize knowledge before you put it into practice-to contextualize and integrate the findings. This can be done through a number of methods. It can be done through a systematic review, or following the very transparent and reproducible methods that have been developed by the Cochrane or the Campbell Collaborations. They can use quantitative or qualitative methods, or the synthesis can result from a consensus conference or an expert panel, with people who know the literature, coming to a table, who also have a lot of clinical expertise to bring to bear on the problem, and then they bring both of these sorts of evidence to bear on synthesizing what is best practice. 

(Slide 29) Conducting systematic reviews, which is a point I think is important; and it's on slide 29. They are a very useful tool to create the more intense knowledge that you find in a knowledge tool like a practice guideline or so on, and to provide the data contents for incorporation into practice guidelines. Systematic reviews are important to determine best practice that needs to be implemented, and to create a context for and establish an evidence base for the knowledge to be translated. Basically, they are showing us that this is a good thing to do; there is some history to it. It's scientifically rigorous and it's not a one off kind of a study, where somebody found some kind of a fortuitous result; it is well contextualized within the world literature. 

(Slide 30) And while we're talking about systematic reviews, the question sometimes comes up -- which I'm talking about in slide 30 now - about the importance of grading evidence in a systematic review. For those of you who are familiar with the Cochrane Collaboration, this is an important step in the reviews that they conduct. They are often looking for randomized controlled trials, which are at the top of the heap as the most objective, reproducible evidence. I think it's an important step to grade the evidence that's contained in systematic reviews because some sorts of evidence are more generalizable than others. When we're combining the evidence, we need to be able to weigh the stronger and the less strong research methodologies in determining the weight of given studies included in a systematic review. 

This essentially creates a hierarchy of types of evidence. For example, these sorts of hierarchies not only in Cochrane's systematic reviews, but in the next steps down from synthesis-creating knowledge tools-grading levels of evidence becomes useful in picking out recommendations from a practice guideline. I'm sure those of you involved in disability research are looking at practice guidelines all of the time. Lots of times the recommendations in those guidelines are based on different grades and levels of evidence and I think that becomes useful information in judging whether a recommendation would be applicable in your setting or not. 

Moving on to slide 31 now, and continuing with my monologue here on how this model was developed, the knowledge to action model that you see in the "Lost in translation" paper. Moving on to part 2 now, the Action Cycle, which was the boxes I described that go around a circle around the triangle, with arrows linking them to show how interconnected they are. So how did we get these boxes and where did they come from? Well, first I'm going to digress a little for a small lesson on implementation theories. And why would I do that? Well, because the boxes that are included in the action cycle were derived from a study that Ian Graham and others, including myself, were involved in where we tried to look at planned action theories. 

And by planned action theories, I mean theories that were designed to specifically be used to bring about change. And I contrast those with more classical theories that are more passive descriptive models, like Rogers' diffusion theory, if any of you are familiar with that. They are used or developed to retrospectively understand change. So we're interested in seeing how many models there were out there that were specifically guiding people to change either patient or practitioner behavior. Why did we want to do this?  Because we had a sense there were a lot of them out there and we wanted to get a sense of what the degree of overlap was, and we were also interested because of this whole issue that has become a recurring theme in our talk today about the different terminologies and words that are used for this process of creating change or moving knowledge into action. So we did a search and found actually 31 different theories that we would call planned action theories. 

Let's move on to slide 32 now where I'd like to just show you one example of a planned action theory, and that's the Ottawa Model of Research Use. This just so happens to have been developed by Ian Graham and one of his close colleagues, Jo Logan, who has just recently retired from the University of Ottawa Faculty of Health Sciences, School of Nursing; I know people are sensitive about these terms. It's nursing, anyway. Their model is about moving research findings or evidence into practice. There are other good models; as I said, we found 31. This is just an example, and I imagine you can all understand why I chose that example. 

If you move to slide 33, you'll see the model -- the Revised Ottawa Model of Research Use and here I go to try to describe this to those of you without a PowerPoint slide of this. In the Revised Ottawa Model of Research Use, at the very top -- these are key elements to moving research into practice: Assessing the barriers and supports to change; Monitoring the interventions that you've devised for change and the degree that these interventions are actually used; and then Evaluating the outcomes. So these are three processes that are overriding the entire model, and they are sitting at the top of the model. 

Then, down the right-hand side, if you can imagine a PowerPoint slide, you would see-actually it's the left-hand side, I have right/left dyslexia; sorry. Down the left-hand side of the page, you'll see three boxes. One says "Evidence-based innovation." The next one down says the "Potential adopters" and the next one down says the "Practice environment." And these are the three elements of implementing change that one needs to think of. You need to think about what the change is, how it was developed, what the attributes of the change are-like how different is it from what everybody is doing, how testable is it, how "trialable'" is it, that sort of thing. 

You need to think in terms of the potential adopters: How aware they are of the change? What attitudes do they have towards it, how ready are they for change? Do they see the need for change?; this sort of thing. The practice environment-by this we mean the patients, the culture, the organizational culture at the hospital-economic setting, this sort of thing. Then the next box over from these three boxes on the left -- yes, I got it -- I was going to say 'right' this time, but that would be a stupid pun -- I got it correct this time. The implementation of the intervention strategies: This is how you're actually trying to implement the change. After that, the next box over is "Adoption of the change strategy," and then finally, "Outcomes." 

So without dwelling too much on this Ottawa Model of Research Use, I just wanted to show you this is the kind of thing that we're collecting. We collected 31 of these sorts of things-if you could excuse me using that word. What we did was, we collected all of the concepts that were contained in each model. So for example, for the Ottawa Model, still on slide 33, one of our concepts would be evidence-based innovation. Another one would be potential adopters. Another concept would be practice environment and so on. So from each of those 31 models we collected all of those concepts and we put them all into a big pile and then we tried to divide them up into similar concepts. 

This was an extraordinarily difficult thing to do. All of the terms were defined differently and we had to really think about what was common amongst the concepts and what were they actually saying that we should do. Liz is telling me I need to move on here because time is flying by. I'm sorry, I get really carried a way with this. It is just so interesting to me. In any case, it took us forever to come up with these categories and we'd leave the meetings not speaking to each other and wishing there would never be another one of these meetings again, but in the end we got the work done.

If you move to slides 34 and 35, you'll see the categories -- the action categories that we derived from all of these constructs or concepts. Which just to read through them quickly were: identify the problem; identify the need for change; identify change agents; identify your target audience; assess the barriers to change; review the evidence or literature or develop the innovation; tailor or develop the intervention for making the change; linkage-and by this we mean linking among the various players in the intervention endeavor-between the people you're trying to change, their supervisors, their patients, everybody involved. There were a lot of constructs around actually implementing and then some around evaluating, whether that's developing an evaluation plan, pilot testing, evaluating the process, or evaluating outcomes. Then maintaining the change, and then disseminating the results of your implementation effort. 

If you move to slide 36 now I'm showing you again the knowledge to action model and then you can see how those categories that we derived have been distilled into the boxes that you see going around the knowledge creation triangle in the model. We have fewer boxes than those actual steps that I described to you on slides 34 and 35, because we could represent it in kind of a circle and suggest the "organicocity" of the whole process. We were able to represent it a little bit more tidily. Now over to Liz. 

>> LIZ:  (Slide 37) Thank you. We're on section 5 of the seven sections in the presentation, and this one is entitled "Knowledge translation, good in theory, how can it work in practice?" 

(Slide 38) Who is responsible for what in the knowledge translation process?" That's a question that CIHR as an organization is still trying to grapple with. At what point should CIHR engage users and other stakeholders and what are the responsibilities of all of us in this goal of knowledge translation? It depends on the particular situation. 

The key process to keep in mind is linkage or communication with key stakeholders. One of the things that we've invested in much more heavily as an organization over the last five years is funding linkage and exchange activities through the creation of the IAB's (Institute Advisory Boards), which meet with local research communities on a regular basis through the funding of workshops and symposia to bring users and researchers together to talk about research problems and questions, and perhaps to talk about implementation. 

In cases where implementation is required, you need agreement on the need for change, the evidence for change, methods, and the evaluation of the impact of the change as well as who should do what. And we've chosen over the years a couple of projects that have been more along the implementation lines. I can talk a bit more about that in a question period if people are interested. 

Slide 39, "In what ways can researchers best contribute to the KT process?" This is a big question for us because the research community has grown; we've built capacity quite a bit in Canada. Our application pressure is getting increasingly higher and higher, and all of these researchers are, I think, feeling a need to participate in the KT process. But it's not always clear, depending on the theme area in particular, biomedical vs. the health services and population health areas-what are the best ways those researchers can contribute. So there is a list hereof things that they can do. They can contribute to the science as well as the practice of KT; conduct needs assessments; conduct systematic reviews pointing to a need for change, create an appetite for research results; keep communication lines open; conduct research with a ready audience having a perceived need for the research results; be knowledge brokers; and be systematic and rigorous. Some of that requires quite a culture change and we're still every day grappling with how to engender such a culture change in Canada. 

Slide 40, "What is the role of consumers in knowledge translation?" How they can contribute depends on their role. Are they on the receiving end or are they the drivers of change? In Canada, there are examples of vocal lobby groups driving political agendas. Because of the difference in coverage that we have in Canada and the U.S., I think that our population is much less savvy as consumers of health care, but at the same time CIHR is, I think, trying to drive that agenda to some extent where research is concerned by contemplating and actively engaging "consumers" or community representatives in peer review. Also, trying to engage consumers with institute advisory boards in a number of different settings and contexts. One example is one of our 13 institutes, the Institute for Musculoskeletal Health and Arthritis, has involved consumers in a direct way through a subcommittee called the Knowledge Exchange Task Force where various voluntary health organization representatives come together three or four times a year to talk at a real grassroots level about the issues facing those communities and what the research implications might be. They are engaged in the crafting of RFA's (requests for applications) in some cases and are then ready participants in the uptake of research results. Back to Jacqueline on slide 41, for section 6. 

>> JACQUELINE:  (Slide 41) The next thing I'm going to try to describe to you is this whole notion of how to measure the impact of knowledge translation. 

On slide 42 you'll see that I've said it's the 6 million-dollar question, whether you're asking how to measure the KT process, or how to measure the impact of knowledge translation. How to measure it really depends on your definition of knowledge translation and on the perspective of the particular stakeholders involved. We're very interested at CIHR in how to measure the impact of knowledge translation because knowledge translation is part of our mandate and it's part of our mission to, you know, improve the health of Canadians and improve health services. We have very specific things we have to do and we need to be able to know how to assess that. Returning to the last point on slide42, if you're thinking about measuring the KT process and thinking about the knowledge translation process as being knowledge to action, as I have just described the knowledge to action model, we don't have any empirical data really to suggest how to weight the various components in that model. 

By the components, I mean those boxes that are going around the outside of the triangle and also the components of synthesizing the knowledge. We don't really know how important each of those different components is under different circumstances. What we can do is assess the degree of activity or linkage or use of knowledge at each of those action steps that I described; but it really is an empirical question-how important they are. And I suspect that they may be different, the importance may vary from one context to the next. 

(Slide 43) When you're considering not the process, but the impact of knowledge translation, as I'm trying to describe on slide 43 now, there are these different kinds of impact, just to make things more complicated for us. Beyer, in the reference for the Journal of Management Inquiry in 1997, described very cleanly, I think, the different sorts of impact that knowledge can have. And these aren't brand new ideas, they've been around. 

People have been playing around with them before he put them down so nicely, but he does talk about instrumental, conceptual, and symbolic use of knowledge. So instrumental use is applying research results in specific, direct ways. Conceptual use is using research results for general enlightenment. Results can influence actions but more indirectly and less specifically than in instrumental use. And then symbolic use, which is using research results to legitimate and sustain predetermined positions. That's something I've always called "decision-based evidence-making," another way of thinking about it. A little play on the words of "evidence-based decision-making." But there are these different sorts of impact and instrumental impact would obviously be the easiest thing to measure. Quite often I think what happens as a result of research that really takes off is its conceptual use. People read about research results and it changes the way that they are thinking of it or it affects their attitudes in some way. How are we ever going to get at that to measure that sort of impact? And the symbolic use -- well, you know, maybe we don't even want to go there. 

Moving on to slide 44, again, thinking about how to measure the impact of knowledge translation, while I said that CIHR -- we have been working on this and we do have an evaluation branch that's part of our knowledge translation portfolio here, there are two other organizations that I know of -- and I don't know everything that's going on in Canada along these lines. The Canadian Health Services Research Foundation and the Alberta Heritage Foundation for Medical Research-both of which have come up before today in our talk-they've both been making some progress on the question of assessing impact. And I think we're all trying to work collaboratively on this because it is a very difficult task. 

(Slide 45) Now, CIHR has developed a framework for evaluation, and you can find it on the CIHR Web site and it's called "Developing a CIHR framework to Measure the Impact of Health Research." And there is also a smaller paper on that which if anyone is interested, I can send you the link for that smaller paper as well. We're on slide 45 now. Slides 45 and 46 are basically the frameworks developed by CIHR on measuring the impact of the health research that we have funded. There are two columns there. We're looking, as I said before-or maybe it was in Liz's part of the talk-we have to think about stakeholders, and knowledge translation is really; the impact of research-it's going to really depend on the different stakeholders and their perspectives. 

(Slides 45-46) In terms of CIHR, we perceive our stakeholders to be the higher education sector, health professionals and administrators, society at large, industry, and government. And they each have different perspectives, the higher education sector, for example, is going to be looking for academic excellence, knowledge production and capacity building. Whereas industry is going to be, you know, what's meaningful to them is commercial potential and health professionals and administrators - forgive me, I'm kind of flipping between slides 45 and 46 here, health professionals and administrators are going to be looking at the research, the impact of health research from the perspective of effective treatments and diagnostics, or the effectiveness and the efficiency of the health care system. So it is important to realize who your stakeholders are and what their perspectives are when you're thinking about how to measure impacts because it's going to really vary for all of those. 

And on slide 47, I give some examples of sources of data for measuring impact. These sources of data, of course, which one you would use would vary on the stakeholder and the perspective that they have. There are things like citation impact analyses, which are see essentially bibliometric studies, which means you look at a research result and you see where it's published. Then you see who is citing that publication and you just kind of track all of those citations. You look at what journals they are being published in and what the citation impact, what the impact factor is of those journals, and so on. So you can see what the audience is that you're reaching.

There is also end of grant reports; case studies; you can do interviews and surveys of different stakeholders. You can look at administrative databases like hospital admissions or discharge or physician billing, this sort of thing, to see if there is any change in the prevalence of a certain disease as a result of a remarkable new discovery. You can do document analysis, whether it's policy documents or research reports, just different sorts of document analysis. So that's how you can measure it. It's not easy, and these sources of data are pretty well going to be looking at instrumental research use, but I don't know that we can go that much further than that except with in-depth interviews. 

So moving on to slide 48, our organizing slide again. I'm moving into the last section now, "Moving knowledge to action, best practice for wound care" in which I'm trying to use an example of how this model can be applied to moving research into practice. For a real life example, again, I don't know why, but I just decided to pick an example of Ian Graham's research, just because he is our vice-president of knowledge translation and he's done a lot of really great applied research. So the example is based on his work with Margaret Harrison.

I'm on slide 49 now, where they were doing some work with community care of venous leg ulcers. For those of you who know about these, they are really ugly, awful things that people get on their legs because their circulation isn't very good and they are very difficult to heal. Family doctors tend not to see enough of them to know what to do with them and they are usually dealt with by nurses who do home visits with people. The healing rate in the care just has been kind of disorganized and not very effective. So Ian Graham and his colleague, Margaret Harrison, who is a PhD nurse, decided to use a collaborative interdisciplinary approach to try to improve care of leg ulcers. If you wanted to read about this, their case was featured in a CIHR Casebook where people could submit good examples of good success stories for knowledge translation. There are several of them on the CIHR Web site and for those of you who have the PowerPoint slide, you can see the link there. 

(Slide 50) If you move on to the next slide, you'll just see an example -- a new iteration of the model and the first step in the model is identifying the problem or identifying and reviewing and select the knowledge. 

(Slide 51) So what Margaret Harrison and Ian did in this case was -- moving on to slide 51 now -- they realized that leg ulcers are common, costly, and complex problems. They are recurring and chronic; they are debilitating, isolating and most of the care is in community, delivered by nurses. 

On slide 52 you see that the research team did a lot of background work to understand what the local population was, who the providers were, what the practice environment was, and what the gaps were in regards to evidence-based practice. And then they formed an alliance between the decision makers, the clinicians, and the researchers for planning in how to design and conduct a needs assessment. 

They found, as we go to slide 53, a high level of evidence for assessment and management of venous ulcers, which was fortunate. They didn't have to conduct a systematic review of the evidence and there were lots of practice guidelines available. So that was the first step that they did.

Now, on slide 54, you see the next step in the knowledge to action cycle is "Adapting the knowledge to the local context." 

Slide 55 is kind of a busy slide and because we're running really short on time here, I'm not going to try to describe it for those of you who don't have PowerPoint, but it illustrates the process that Ian Graham developed on how to develop practice guidelines. It goes through ten steps, which I'm going to have to just skip over now. If there is time at the end I can discuss it in more detail if anybody is interested in knowing more about that process of adapting guidelines for local use. It is quite a long process, but in the end, you've taught people involved in the process how to evaluate a guideline; what the good guidelines are; what evidence is all about; you teach them about hierarchies of evidence; and you get them to really think about the recommendations that they're going to try to put in place in the guideline program. 

So next, slide 56 is just showing you we're on to the next box in the knowledge to action cycle, "Assessing barriers to knowledge use." 

In slide 57, I'll remind you that in the Ottawa Model of Research Use-or we call it OMRU-we know that we need to assess barriers at the level of the guideline, the potential adopters, and practice environment. 

In slide 58, you'll see how Margaret Harrison and Ian Graham did this in their work on leg ulcers. They conducted knowledge, attitude and practice surveys of the nurses and physicians. They got practitioner and policymaker feedback on their adapted care protocol. This is the result of them going through the guideline adaptation process. Then they engaged in discussions with providers and managers. 

And in slide 59 you'll see now we're on to selecting, tailoring, and implementing the interventions. 

In slide 60 we see what they did to implement the interventions. They developed some training for nurses and they actually got the nursing organization to reorganize the way that they delivered care for venous ulcers and they developed a dedicated leg ulcer team who would work at home or in a clinic. They bought them the equipment. They figured out how to pay them because it would have changed their pay schedule, and they changed the process for referrals to specialists. It was kind of a huge reorganization process to be able to do this. It's difficult to engage in this kind of process because even in the amount of time that they were engaged in trying to reorganize care and train the nurses, the people in charge in the nursing organization changed their jobs. So they had to develop new relationships with the decision makers that they were engaged in and every step of the way it just seemed to be something would come up. But this is what it's all about, this is knowledge to action. This is what you have to deal with. 

Now on slide 61, we're at the box "Monitoring knowledge use." 

On slide 62 you can see the results of some of the data that they were able to measure to see if this knowledge that they had developed and adapted and so on was actually being put into practice and having any real effect. On slide 62 you see that there was quite a bit of improvement pre- and post-guideline adoption on these various outcomes that they thought were important. And I won't go into the details of those outcomes. I'll be glad to entertain questions on those after the end of our talk. 

The next step on slide 63, "Evaluating outcomes." 

(Slide 64) Well, you can see on slide 64 a nice chart of the pre and post outcomes in terms of percentage of patients healed, pre and post the implementation of the guideline, and there is quite a comfortable difference there, quite an improvement.

You see on slide 65 the three-month healing rate went up from 23 percent to 56 percent. So, in other words, 56 percent of their patients were healed at three months. It decreased the number of nursing visits and it really significantly decreased the supply costs. 

Then on the next box in slide 66, "Sustaining knowledge use," and slide 67, I'm saying that the sustainability question is still under investigation. They are still trying to roll the protocol out further and there is a randomized control trial underway of home versus clinic care, and of two different compression bandaging technologies. 

(Slide 68) In this example that I've showed you -- and we're on slide 68 now -- you can see that moving to knowledge to action is an iterative process, which I know I say over and over again, and it's the process of using external evidence and producing local evidence for planning. Successful implementation requires strategic alliances between researchers in the health setting or the decision makers with whom you're engaging, it requires mobilizing population health principles, needs-based planning, and working at both the clinical and the health services levels. 

On slide 69, you see that it also moving research to action, the role of the researcher is to create and facilitate a strategic alliance and a problem-focused collaboration to bring the "science of synthesis" to practice; that's the knowledge funnel piece of the model. The researcher needs to use rigorous methods for each step, and to use conceptual frameworks to underpin the research. Because if you don't do that, you can't really understand where you've failed or what you haven't thought of to try to address in your implementation efforts. 

And on slide 70, in conclusion:  Knowledge translation -- What is it? It's collaborative; there is that word again, it's iterative; it's complex,; it's time consuming; and it's never really completed. It requires persistence, patience, expertise with multiple research methods, problem solving skills, and people skills. I rest my case. 

>> JOANN:  Well, thank you very much, Jacqueline and Liz. This was a tremendous amount of information that you've given to us and I think it was very well organized. I really appreciate you putting in the example there at the end, demonstrating how that model could be implemented in the context of that research study. That was very helpful, I think, to make it real. But your final slide does show that there is -- it's such a big and complex picture that it is a little bit overwhelming. I really appreciate your time and effort in developing this presentation. We have not received any questions recently, but I do have a couple of questions that I had thought of in just thinking about your coming to visit with us today. And some of your talk did stir a couple of thoughts, too. 

One of the questions that I had is that you mentioned systematic reviews a couple of times as part of the KT process, and I was wondering, does CIHR support systematic reviews, in terms of, do you have proposals to write a systematic review, do you have some funding to support people carrying out systematic reviews? I know that with the Cochrane Collaboration, it seems to be done on more of a voluntary basis and so I was just wondering what is CIHR's take on the systematic review, in that way?

>> LIZ:  This is Liz, and I'll respond by saying that, yes, we have in the last two years undertaken to fund synthesis and we have a couple of RFA's posted that can identify both the call and then a link to who we've funded to do some syntheses. Some of those are scoping reviews as we've defined them and some of them are systematic reviews, which is a slightly bigger undertaking. The KT branch at CIHR is going to continue to invest a million dollars a year in one-year grants of up to $100,000 to continue scoping and systematic reviews in any of our research theme areas. Sometimes we have institutes partnering with us because they are looking for a systematic review in a particular area. 

In addition, CIHR agreed at the beginning of this year to fund the Cochrane Collaboration in Canada for a million dollars a year for the next five years. We undertook an international review of a proposal from the Canadian Cochrane network. The international review was very good and so on that basis we've agreed to fund the Canadian Cochrane Centre, which is coincidentally housed here in Ottawa by virtue of the Canadian lead for that group. In Canada we have 6 or 7 collaborative Review Groups that happen to be based here. So this is a voluntary international collaboration and of the 50 or so collaborative review groups, each focusing on a particular-tends to be clinical areas-6 of those are based in Canada. So we have the Back group here, we have a Gastro group here, we have a Musculoskeletal and Arthritis collaborative review group here in Canada. We have a Stroke collaborative review group; we have a Child Health field, and a Methods field, which is just a slightly different category for Cochrane. 

>> JACQUELINE:  And EPOC . . .The Effective Practice and Organisation of Care group.

>> LIZ:  Those review groups through our grant to Cochrane each received some funds for infrastructure. The idea is that our money is to support teaching at universities in how to do systematic reviews and it funds some networking activities as well. So, yes, we've recently invested heavily. Prior to CIHR supporting this, the Medical Research Council of Canada and Health Canada, our federal department, co-funded the Cochrane Collaboration in Canada, again for the five years up to 2006, I guess. 

>> JOANN:  Great, that was actually one of my next questions, what your relationship was with the Cochrane Collaboration. What about the Campbell Collaboration? Do you have any relationships developing there or developed already?

>> LIZ:  We don't have any formal relationships with Campbell to my knowledge. That's not to say that our Institute of Population and Public Health might not have some interactions with Campbell. Campbell hasn't, again to my knowledge, asked CIHR formally for funding support. I don't know -- I think the Canadian Campbell folks are based at McMaster University, but our knowledge translation portfolio isn't supporting Campbell in any formal way at this stage. 

>> JOANN:  Okay, I do have a question that's come in here. Let me get this. This is a question for Liz. Can you provide a reference for the article on the 31 models? I guess the 31 models that were reviewed to come up with the planned action theories. 

>> LIZ:  That was Jacqueline. I'll let her answer that. 

>> JACQUELINE:  No. I can't provide a reference right now, but I can provide something even better. If that person who was asking the question would e-mail me --

>> JOANN:  Okay, we can do that. 

>> JACQUELINE:  What is coming up in the very, very, very near future, like maybe even before Christmas, is we are going to launch on the Web site at the Ottawa Health Research Institute, where I used to work with Ian Graham before he came to be the vice-president of knowledge translation here, we are going to be posting an Access database and in that Access database it will have the references to all 31 models. It will have data extraction sheets of all of those models, so it lays out the concepts or the constructs in the models, it defines them. It has a set of common information that we extracted from every one of those models. And it has a kind of a "users guide" to the models. So while we don't have the reference, hopefully the person who is asking that question will find that even more useful than the reference. 

>> JOANN:  It sounds like it would be very useful. We'll keep a watch on that. 

>> JACQUELINE:  A paper is coming, but we haven't got around to writing that yet. 

>> JOANN:  Okay. We'll keep our eyes open for when that becomes available, too. And I also wondered -- you had mentioned that there was another small paper that you could give us a reference for and that was on slide 44. I think that was talking about the CIHR framework to measure the impact of health research, but you said there was another paper. 

>> JACQUELINE:  That's right, and I can't tell you that right now. I'm not at my desk, I'm at Liz' desk. Perhaps I can e-mail you the link to that; it's on the CIHR Web site.
UPDATE, 12/12/06:  A framework to measure the impact of investments in health research (Alan Bernstein et al, 2006)

>> JOANN:  Sure, that would be great. 

>> JACQUELINE:  And you can perhaps put a link to that on your Web site. 

>> JOANN:  Yes, because we already have a Web page set up for this webcast and then we can add that information after the fact, along with the transcript and the link to the audio file and so forth. We'll make sure that that gets posted. 

>> JACQUELINE:  Sorry, I don't have that on the top of my head. Our Web site is not the easiest one to navigate through, either. So I'll send you the right link. 

>> JOANN:  That is true. I have looked there several times and found something and I wasn't been able to find it when I went back. 

>> JACQUELINE:  I feel your pain. We do have a lot of information there.

>> JOANN:  Then sometimes I have stumbled over it again incidentally, when I went back. It's true there really is a lot of information there. Another question that I had from before is "Do you have any insight into why do you think this whole concept of knowledge translation emerged in Canada?" Because it wasn't just one place, I mean, you had several different centers that you mentioned and several different researchers in some different areas. And I was just curious if you had any thoughts about that. 

>> JACQUELINE:  I'll go while you're thinking. I think we had some very cutting edge funding organizations, and we had some cutting edge researchers who started to think about these problems. So as I mentioned, we had the Alberta Heritage Foundation for Medical Research who started thinking about this quite awhile before anyone else and actually trying to do something about it. And they called it knowledge to practice, I think was the term they used. And then we also had researchers like Jonathan Lomas and John Lavis in Canada who started to think really ahead of the pack about why all this research wasn't getting into practice. They started to look at practice variations within our provinces or across Canada on various things, like for Jonathan Lomas, I believe it was on Cesarean rates across Ontario. There is a huge variation in practice, but there is very clear evidence as to when a Cesarean rate is called for.

So he just started to think, well, what is it? Why is it that these clear research findings are not being put into practice? He started to develop a lot of work along those lines and was in an influential position as the chairman of a policy subgroup within McMaster and was well connected to try to get other people to think about these problems. Then he subsequently became the CEO of the Canadian Health Services Research Foundation who really put that at the head of what they were -- at the head of their mission and so on. So why Canada? I don't know, I can't really explain it. It could just be fortuitous. I know that everybody as we travel around and talk to different people, I know people really look to Canada in this area of knowledge translation and I can't really explain why. We are just -- we're just an accountable lot. We just don't understand if something is rational and it's really clear what it is we're supposed to do, why isn't that happening?  So then we're asking ourselves these questions. 

>> JOANN:  Well, I think it is really notable and definitely it looks like you're continuing to be at the leading edge of the whole field of the research to practice or knowledge to action arena. 

>> JACQUELINE:  Did you have anything you wanted to add, Liz?

>> LIZ:  I agree with what Jacqueline said. I think that there were a few champions, Jonathan Lomas was one of them, and I think another champion for change was the brother of the prime minister, actually, who is a health researcher. And, I think that there was some underfunding in health research in Canada and so in thinking about having a government invest more, in a more serious way in health research, I think researchers had to think about what it was that that increased funding could also do to benefit Canadians. That funding crisis combined with a few champions starting to think, you know, about the future in a different way, led to thoughts about a new organization that would have a different mandate. Then we had a government, the liberal government, seize that opportunity to increase funding and at the same time create a new organization that could implement this new vision. So I guess that's my personal view. I'm sure that others who were much closer to that change would also have a particular view that might not necessarily match mine. 

>> JOANN:  Well, since you've been active in the process for a while, we do appreciate your thoughts because we know that you've seen a lot and we really appreciate that. I do have a couple of other questions that have come in. One comments: "Glad to hear you mention such scholars as Lavis and Lomas, there is another one I think named Landry who focuses on research use among Canadian policy makers. With such a critical mass of scholars and thinkers there, I wonder if you sponsor collaborative or national sort of "state of the science conferences" on KT, or would consider sponsoring such if you have not done so?

>> JACQUELINE:  Funny you should say that...

>> LIZ:  We're glad to know that if we did so, we might have some attendance from some of your colleagues. I think it's something that we might come to at some point within the next few years. We haven't -- we don't have any specific plans, but I think with some of the increased capacity we have here at CIHR in Ian and Jacqueline and others, as we continue to increase our staff a little bit in this area that we may have -- we may ourselves have the capacity and the expertise to try and lead something like that with partners and exactly some of those researchers who have been leaders in the field publishing. So we'll let you know. 

>> JOANN:  We would love to either partner with you or participate in such a thing, I'm sure. 

>> LIZ:  All right. Perfect. 

>> JOANN:  Let's see if we have -- I think I had another question that came in. You did mention that your Web site had some information about awards for KT. I guess that would be funding for specific KT projects and then you said there were links to -- I don't know if it's the reports or the outcomes of those. Can you guide us to where we would find that info?

>> LIZ:  Again, we might have to send you the links.

>> JOANN:  Okay, that would be fine. Then we can go ahead and answer the question and put the link up. 

>> LIZ: There are two things. One is the KT Casebook -- well, there are two KT Casebooks published by CIHR. We're not actually a publisher of much, but we had two institutes put out a call for KT Casebooks and these stories are published -- one book around population and public health KT stories, and the other about health services and policy research stories. You can download those stories from our Web site. In addition, as an organization, we have an annual call for a KT Award and there is a national award and a regional award given out. They are grants. The larger one for $100,000, and the regional one is $20,000 for a grant. We adjudicate this in-house and we ask for nominations and so researchers or organizations get nominated where the nominator feels they've done an exemplary job in knowledge translation. It's sort of broadly defined and you can see that call on our Web site, and we've given out that award now four times. We do that annually at the Canada Health Research Awards, which are hosted at a gala here in Ottawa. 

>> JOANN:  Great. I guess one of the other questions that I had prior to the webcast today was if you could identify some other successful examples of KT, something along the lines of what you did in your presentation, but again maybe you have some links to some of those, or if you have reports or some kind of feedback on some of the KT projects that you have funded in the past?

>> LIZ:  I guess again the KT Casebooks will give you about, in each book, around 20 cases apiece. So there are 40 KT cases. We actually called for both examples of good KT and examples where the KT effort didn't work so well. We got fewer of those negative cases, and these are KT efforts that were undertaken by researchers with partners. We didn't necessarily fund those efforts. We're simply trying to publish the cases in an effort to help the community understand what knowledge translation is, try to bring about that culture change, and help people define KT in those two theme areas of health services research and population health research. We're now thinking about relaunching that KT Casebook call, that would ask for cases from amongst our 13 institute theme areas, and we'll look to do something like that in the new year. 

>> JACQUELINE:  And there are the KT awards. 

>> LIZ:  Right. So there are short pieces about the KT award winners and what it is that they've done, on our Web site. In terms of efforts that have been undertaken by the KT branch I referred to one around an adverse events project. There has not been anything published or reported, beyond our CIHR annual report, that describes very well any of the efforts and investments that we've undertaken as an organization directly in KT. I could tell you a bit about it. It's sort of a case unto itself that we didn't actually publish. I do have a paper that wasn't published, but describes the process that we went about, and we did invest $100,000 in this particular KT case that CIHR undertook. As institutes continue to get more engaged in knowledge translation, they may start investing in more of that sort of activity and evaluating it. I think we'll see more of that over the next five years of the life of CIHR. 

>> JOANN:  So it's like you really provide more support and help to the actual institutes than necessarily calling for those things yourself from your branch, is that what I'm understanding?

>> LIZ:  I guess we're still struggling as an organization with trying to figure out how much we require of researchers in their applications around the KT piece. In the upcoming funding opportunities announcement December 15th, coming from CIHR, if you comb through some of the RFA's that are coming from institutes, in some cases they are offering research teams an additional $25,000 as part of their grant to engage in this KT activity. We are also asking a team who were to get such a grant to have an evaluation component. So we are starting to actively fund more knowledge translation activity. In addition, we have a tool that we're going to invest $2 million a year in, which is called a knowledge to action tool and that is, again, providing combinations of researchers and decision makers who apply together for a grant to do some of this actual KT work beyond any primary research that they might do. Research has to form the basis for the project and so we have -- we're just about to sort of fully fund the first set of ten teams who will undertake to do this. Then at some point we'll have to evaluate the value-added of investing in that sort of activity. So we're sort of at the early stages of that. 

>>JOANN:  I would assume that the funding amount you mentioned, for example, the $25,000 -- is that just sort of money that was available and let's go ahead and make it available, rather than "this is how much we think it's going to cost?"

>> LIZ:  They have to submit a budget that identifies what it is that they're going do with that money. There are certain allowable costs at CIHR that we will pay. So it includes funding for staff so that a coordinator with expertise in the area can be engaged. There is funding for networking activities, dissemination costs and so there are sort of varying -- it's up to each team to determine what their budget should be in each of those categories and it depends on the context for the particular grant and the knowledge to action piece that they're trying to undertake. So the costs would vary depending on the context. It's up to them to pitch it.

Then the other thing that we're doing is working with some researchers in the community to think about how we assess knowledge translation in peer review. So it's hard for our peer reviewers unless they are really from this quite small KT research community, it's hard for peer reviewers to receive applications in any of our 50 odd committees and to evaluate in an objective or systematic way the KT component. So that's something we're getting some advice on now and trying to provide guidance to the peer review process around that. 

>> JOANN:  Okay, I think we are just about out of time now. Do you have any closing comments that either of you would like to make?

>> JACQUELINE: I guess I'd like to just make one point, which I don't think I made very well in the context of all of this huge number of slides, and that is that any individual researcher should not feel that they need to be Ian Graham and do every step of all of the process that I've been describing here. Different people can come in and step in, in different parts of the process, and do whatever it is that they are good at. Whether it's knowledge synthesis or whether it's creating knowledge or whether it's adapting knowledge, we all have our areas of expertise and through our connections and what it is that we do every day. I think it's unreasonable to expect every researcher funded by CIHR to engage in this entire elaborative, and let me say again, iterative process, and I don't want to give people the impression that only doing everything is knowledge translation. Bits of it are knowledge translation as well, and it's all about deciding what's appropriate for the particular piece of knowledge that it is that you're dealing with. 

>> JOANN:  Well, thank you. I think that was a really important thing to wrap up with, because that's definitely one of the thoughts I had, is just how overwhelming the whole thing is to look at all those pieces and parts. But I think it is really important for you to stress that; that every part that any of us can do is contributive. 

>> JACQUELINE: It's all good, it's all good! 

>> LIZ:  Joann, I'd just like to acknowledge Jacqueline's efforts in preparing this presentation. My name is on the first slide, but really I had very little to do with the content. So I want to acknowledge Jacqueline's expertise and efforts in pulling this together and it's really been a pleasure to work with you. You folks are very organized in these webcasts and it's a first for us, but I want to thank you for giving us the opportunity as well. And if there are further things we can think about together, we would welcome doing that. 

>> JOANN:  I know that we would love to do that and continue working with you. I want to thank both of you, Liz and Jacqueline, for your work today, and to thank everyone who participated in the webcast this afternoon. An audio file and a transcript of the webcast will be available on ILRU's Web site archive page within a couple of days. You can find this by searching at: www.ilru.org 

I also want to thank the National Institute on Disability and Rehabilitation Research that provided funding for the webcast and I especially thank the staff at ILRU, because without their efforts the webcast could not have taken place. We hope you'll join us for our next webcast, which is scheduled for January 10th, 2007. The presentation led by Dr. Mario Hernandez will discuss a NIDRR-funded project at the University of South Florida that addresses culturally competent research on children's mental health with Latino communities. Again, thanks very much, everyone. Goodbye.