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A program to advance the science and practice of KT in a local hospital network: results of a 3-year pilot

Background:

Hamilton Health Sciences (HHS) is a local hospital network that is world-renowned for healthcare research, with a strong focus on evidence-based practice and continuous quality improvement. However, many gaps remain between what is known from research evidence and what is done in practice. HHS established a program to optimize the use of clinical and knowledge translation (KT) research to address evidence-practice gaps and health-related challenges at HHS hospitals and improve patient care.

Methods:

The Centre for Evidence-Based Implementation (CEBI) (www.hhscebi.ca) was initiated in 2016, with initial funding provided by HHS for a three-year pilot phase. The program comprises a scientific director, a program manager, and two project coordinators. An advisory committee including HHS administrative and clinical leaders and researchers provided advice regarding CEBI’s strategic direction and project prioritization. Core activities included actively participating in HHS-initiated implementation and quality improvement projects, providing KT consultation, and providing training in KT science and practice for HHS leaders, physicians and staff. Key aspects of implementation for which CEBI provided assistance included project planning, barrier and facilitator assessment, selection and design of appropriate implementation strategies, evaluation, and sustainability planning. Projects ranged in scope from single unit projects to HHS-wide initiatives. CEBI worked alongside other HHS groups including:  quality and value improvement, patient experience and safety, health information technology services, the health sciences library, and communications.

Results:

During the three-year pilot phase, CEBI actively contributed to five core projects, including projects intended to reduce patient violence towards hospital staff, reduce harms associated with procedural sedation, decrease the incidence of hospital-acquired infections, improve rehabilitation of critically ill children, and improve patient safety related to cardiac investigations. Consultation services were provided to multiple project teams and forty-nine participants attended CEBI-led KT training sessions. Informal feedback from HHS stakeholders about CEBI’s involvement in HHS projects was positive. Key challenges included building a culture that values implementation based on best evidence from KT science, project delays due to resource limitations and competing priorities of clinical teams, limitations of data to measure clinical outcomes, and difficulty in measuring the direct impact of CEBI’s contribution to projects. Changes to CEBI’s mandate and funding model beyond the pilot phase is resulting in a transition from assistance with hospital-led quality improvement projects to implementation of impactful HHS-led research findings in the HHS community.

Conclusions:

The CEBI program can serve as a model for similar programs in other hospital networks. Positive results of the program’s three-year pilot phase suggest that a hospital network-funded program to assist with evidence-based implementation and quality improvement projects, to provide consultation from a KT perspective, and to build KT capacity among hospital clinicians and staff, is feasible and effective for advancing practice that is based on the best available clinical and KT research evidence. As the CEBI program continues and evolves, it seeks to build linkages with similar programs across Canada to identify opportunities for collaboration and shared learning.

 

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A theory-informed and integrated KT approach for selecting and implementing a clinically relevant screening tool

Background:

In 2015, the Canadian Heart and Stroke Foundation published a new pediatric stroke clinical practice guideline. An urban pediatric rehabilitation hospital that sees approximately 300 children and youth with stroke a year, aimed to select and implement appropriate recommendations to align evidence-based stroke care across inpatient, day patient and outpatient care settings.

 

Methods:

To navigate the complexities of real-world implementation, the hospital’s knowledge translation team used the Theoretical Domains Framework (TDF) (Cane et al., 2012) and an integrated KT approach to develop and carry out an implementation strategy for one selected recommendation. The TDF is a meta-framework that combines 84 constructs and 14 domains from 33 psychological theories relevant to behaviour change. An integrated KT approach was used to optimize the relevancy and quality of implementation processes, resources and strategies to facilitate uptake. An iterative six step process was employed; (i) stakeholder engagement, (ii) recommendation selection, (iii) supporting literature review, (iv) implementation needs assessment, (v) implementation strategy development and execution (vi) process monitoring and evaluation using the Determinants of Implementation Behavior Questionnaire (DIBQ) (Michie et al., 2005).

 

Results:

Managing post-stroke depression was identified as the first area of need by clinicians, patients and their families.  The team selected the self-report and proxy versions of the Patient Reported Outcomes Measures Information Systems (PROMIS) Pediatric Depression Screening tool to use with children between the ages of 5 – 17 across care settings at standardized points in care. To facilitate implementation, cut-off scores were generated by in-house psychologists. As appropriate, patients were referred for further investigation as identified through the tool and clinical expertise. Implementation strategies selected included; group training, case study role-play, electronic medical record modification, decision making guide, score interpretation guide, screening tool introduction scripts, clinical team check-ins, and local opinion leaders. DIBQ results showed that 90% believed that using the tool will strengthen the collaboration between professionals in the patient’s circle of care and that 80% have the knowledge, skills and confidence to deliver the tool. This highlights that clinicians feel they have the capacity and motivation to use the tool. However, for many, barriers still exist to remember to do the tool as part of their regular practice with stroke patients.

 

Conclusions:

An implementation process based on the TDF and an integrated KT approach garnered frontline engagement and facilitated implementation by addressing knowledge, skill and confidence factors for screening tool use. Using a theory-informed approach in planning and evaluation highlighted tangible areas to improve upon. Findings from the DBIQ are being used to further tailor implementation efforts, such as addressing the need for greater automaticity to prompt use of the screening tool.

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A rapid evidence response program: An integrated KT intervention to inform standards of care

Background:

There is a lack of evidence to guide clinical practice in pediatric rehabilitation that is optimally packaged, easily accessible, and relevant to childhood disability. Front–line clinicians also express a lack of confidence and time in finding, reviewing and synthesizing potentially relevant research. KT experts and clinicians need to partner to create evidence-informed products to inform standards of care that address complex clinical questions and support decision making.

Methods:

A rapid response program was developed to create evidence-informed KT products to facilitate standard of care development and decision-making. The program is based on the ‘knowledge funnel’ component of the knowledge to action cycle, rapid review principles, and an integrated KT approach. This funnel starts with identifying a problem, moving to knowledge inquiry, knowledge synthesis and finally KT product creation to present evidence in a concise and understandable format that is tailored to meet the needs of knowledge users (Graham et al., 2006). Rapid reviews are a type of knowledge synthesis in which the systematic review process is simplified to enhance timeliness of evidence production (Tricco et al., 2015). The program uses an integrated KT approach to bring together the diverse and complimentary expertise within our hospital. This includes Collaborative Practice (clinical decision makers) Evidence to Care (knowledge translation team) and the Clinical Working Group (front-line clinicians).

Results:

This process-oriented program includes the following steps: (i) prioritize a clinical topic based on selection criteria, (ii) establish an interprofessional working group, (iii) develop a preliminary review question, (iv) identify relevant clinical practice guidelines and reviews, (v) specify the review question using the PICO or PCC method, (vi) create the review protocol, (vii) synthesize the evidence. Partnering with Collaborative Practice and the Clinical Working Group was crucial as their perspectives reflect high priority and need-based topics as well as practice-informed knowledge. Their perspectives were captured through their participation in selecting and refining the review topic, outlining inclusion and exclusion criteria, and consulting on the interpretation of review findings. This program has supported the development of four standards of care: Managing stoma complications, serial casting, bowel management, and infant care.

Conclusions:

A rapid response program informed by knowledge translation activities and principles offers a practical solution for tackling complex practice-based questions. The program enables the development of robust, timely and evidence-informed KT products for clinicians. In sharing these processes, the hope is that other organizations can adopt/adapt them to inform policy development.

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Identifying feasibility factors to delivering cycling interventions during hemodialysis: A Theoretical Domains Framework-informed qualitative study

Background:

Exercising while on hemodialysis (intradialytic exercise, IDE) is associated with positive health outcomes for people living with end stage kidney disease including improved functional status, aerobic capacity, and dialysis clearance. Though there is growing evidence supporting the benefits of IDE, larger-scale trials are needed to demonstrate feasibility and inform clinical practice. Few studies have comprehensively assessed barriers and enablers across multiple sites or have addressed how identified barriers and enablers can be addressed using strategies rooted in behaviour change theory. We aimed to identify barriers and enablers to taking part in, and supporting, an intradialytic cycling program, and to develop fit for purpose strategies to optimise the design and delivery of a planned Ontario-wide cluster trial of IDE.

Methods: 

Guided by the Theoretical Domains Framework, we used semi-structured interviews to gain an in-depth understanding of the factors that may enable or impede IDE from the perspective of unit staff (e.g., nurses, administrators, nephrologists, exercise specialists) and adults on hemodialysis. Data were analyzed using a directed content analysis. We then identified possible strategies for addressing barriers, informed by the Behaviour Change Techniques taxonomy, and developed a feasibility assessment tool to enable trialists to identify potential ways to optimise IDE delivery across units in future trials.

Results:

We conducted 43 interviews (September 2018 to October 2019) across twelve Ontario hospitals. We interviewed 17 people who were on hemodialysis and 26 health care providers, including nurses (n = 10), nephrologists (n = 6), clinical managers and administrators (n = 5), exercise specialists (n = 3) and personal support workers and technicians (n = 2).

We identified eight relevant theoretical domains (knowledge, skills, beliefs about consequences, beliefs about capabilities, environmental context and resources, goals, social/professional role and identity, and social influences) represented by three overarching categories: 1) Knowledge, skills and expectations: this category represented concerns over staff lacking expertise to oversee exercise, potential exercise risks, minimal patient interest, uncertainty regarding expected benefits, and knowledge gaps regarding exercise eligibility; 2) Human, material and logistical resources: this category captured concerns over staff workload, the belief that exercise professionals should supervise IDE, and challenges related to space constraints, access to equipment, and scheduling conflicts; 3) Social dynamics of the unit: this category described how local champions and patient stories were thought to contribute to IDE sustainability.

We developed a list of actionable solutions by mapping the identified barriers and enablers to IDE to established behavior change techniques. To facilitate IDE delivery in diverse settings, we developed a feasibility checklist of 47 questions identifying key factors to be addressed prior to launching IDE programs.

Conclusions:

Barriers that may seem insurmountable at face value may be modifiable when associated factors influencing behaviour change are considered. This study describes a first attempt at generating evidence-based solutions to identified barriers and enablers to IDE. The developed strategies and feasibility checklist may help recruit and support units, staff, and patients and address key challenges to the delivery of IDE in diverse clinical and research settings.

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Using the Theoretical Domains Framework and the Theoretical Framework of Acceptability to understand gay, bisexual, and other men who have sex with men’s willingness to participate in a plasma donation program

Background:

Men who have had sex with a man in the previous three months are not eligible to donate blood or plasma in Canada. Canada is considering reducing restrictions to plasma donation by gay, bisexual, and other men who have sex with men (gbMSM) as an incremental step to redressing policies that are viewed as discriminatory by LGBT2Q+ communities. Such a change may be beneficial to addressing Canada’s insufficient supply of domestically collected plasma.  The present study is part of a larger project that aims to: 1) evaluate the acceptability and feasibility of new screening processes for plasma donation by gbMSM from the perspectives of gbMSM and donor centre staff; and 2) to co-develop strategies to address any barriers and enablers to donation and implementation should changes to eligibility for gbMSM be approved. The objective of the present study was to investigate how gbMSM’s views on current and proposed plasma donation policies may affect their willingness to donate in the future.

Methods:

The study is rooted in an integrated knowledge translation approach and involves close collaboration with Canadian Blood Services, one of Canada’s two national blood operators, ensuring the research activities remain aligned with and simultaneously inform progress made in changing donation policies over time. We also take a participatory research approach and have engaged a public involvement research group of seven gbMSM who are active partners in the research. This was a qualitative study focused in a medium-sized city that will be one of the sites for first implementation of new screening processes if approved. We invited gbMSM to participate in two consecutive semi-structured interviews to explore their views on blood and plasma donation policy, plasma donation, and the proposed Canadian plasma donation program for gbMSM. Interview transcripts were analysed thematically, guided by the Theoretical Domains Framework (TDF) and the Theoretical Framework of Acceptability (TFA).

Results:

Seventeen men identifying as gay, bisexual, or as having sex with men participated in 33 interviews. The proposed screening processes were viewed as discriminatory. Acceptability of the proposed program was a key environmental barrier to donation intention in this population. This was influenced by the perceived high opportunity costs of putting aside one’s values of fair treatment for oneself and one’s community and associated negative emotions in order to participate in the proposed program and donate plasma. Opportunities to lessen perception of the conflict between one’s values of equity and one’s desire to contribute through donation will be discussed.

Conclusions:

Findings highlight the blood ban in Canada as a unique and critical part of the context of donation behaviour among gbMSM. Combining the TDF and TFA enabled connections between beliefs and emotions about donation within the broader social and environmental context. This research will help inform the development of strategies to support possible implementation. The continued engagement of the blood operator and gbMSM communities in this research will ensure that the strategies developed are sensitive, appropriate and effective.

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Scoping reviews on climate-health topics: Recommendations for methods development

Background:

Climate change has been described as the greatest global health threat of the 21st century.  Direct impacts on human health will include changing concentrations of particulate matter and aeroallergens, or changes in the geographic range or seasonality of infectious diseases.  Indirect impacts will include increased stress on existing health system weaknesses and disproportionate impacts on marginalized and vulnerable populations.  Due to the complexity of this area, relevant evidence is complex, heterogenous and potentially unbounded.

 

Scoping reviews of climate-health topics can be used to develop a broad sense of literature relevant to a research question, and determine patterns and trends.  In recent years, several scoping reviews have been published on the health impacts of climate change and extreme weather events.  However, there are limitations to available methodological guidelines for conducting scoping reviews in climate-health topics; specific recommendations would improve the rigour and utility of reviews.  This presentation will consider challenges to conducting scoping reviews of climate-health topics and present recommendations for future methods.

Methods:

We conducted a scoping review of scoping reviews on climate-health topics.  We extracted the research question or objective, the methods guidance the authors cited, and the definition (if any) of climate change that was used.  We combined the findings from this review with the experience of authors on this team to make recommendations.

Results:

We identified several areas where further guidance would be useful, including:

Establishing definitions of key terms, including climate change and climate change adaptation, that are workable for evidence synthesis purposes.  Climate change, and climate change adaptation, are not simple or straightforward topics.  Many scoping reviews equate evidence on the health impacts of extreme weather events as being evidence of the health impacts of climate change itself; however, this approach may not adequately respond to the dynamic nature of climate change-related impacts over the coming years and decades.

Sources of evidence.  Existing literature may not always be sufficient to answer particular questions, and scoping review teams may therefore need to find alternative sources, such as expert knowledge, input from members of relevant populations and Indigenous knowledge.  Appropriate methods for incorporating this additional input into the scoping review are needed.

Balancing breadth and feasibility of what is included in the scoping review.  The health impacts of climate change are, in many cases, not new, but rather differences in existing patterns of disease, exacerbations in pressures on health care systems, etc.  This can mean that studies that are relevant to the research question of a scoping review may not be framed from a climate change perspective, and the scoping review will have to be designed to encompass literature from a wide range of disciplines.  Review teams may have to consider how to deal with large quantities of citations for screening, and data for inclusion.

Conclusions:

Modifications to existing methodological guidelines for conducting scoping reviews are needed to improve the rigour and utility of reviews of climate-health topics.

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Evidence syntheses for assessing the health impacts of climate change: The key role of developing search strategies

Background:

Climate change has been described as the greatest health threat of the 21st century. Adaptation involves adjusting to the current and predicted effects of climate change, to reduce vulnerability to harmful effects. Strategies for adaptation can have both direct and indirect health benefits. However, research to date includes limited recognition of health impacts and limited study incorporating a health perspective. Attributing health outcomes to adaptation interventions can be challenging for many reasons. Evidence synthesis collating data on the effectiveness of adaptation interventions is therefore of strong interest to the health community and the public at large. Effective search strategies are a cornerstone of high-quality syntheses so appropriate methods are crucial.

 

The objective of this presentation is to present the challenges in creating a search strategy for a scoping review to evaluate the effectiveness of climate change adaptation measures in creating health impacts.

Methods:

The primary research question is, ‘Globally, what adaptation measures have been effective in reducing the negative impacts of climate change on human health?’ We designed search strategies for OVID Medline, OVID Embase, and Web of Science, as well as for numerous grey literature sources, EBSCO Open Dissertations and Google Scholar.

Results:

Numerous iterations of the search strategy were required for this scoping review. Challenges included:

– developing a working definition and list of search terms to adequately cover the broad concept of ‘health impacts’;

– incorporating search terms for a wide range of study designs (not just clinical studies) that are measuring effectiveness of adaptation initiatives;

– encompassing the wide range of activities that can be considered as adaptation initiatives with direct or indirect health co-benefits;

– capturing studies that are relevant but that are not explicitly described as being related to climate change;

– teasing out health benefits from other social, economic and/or environmental benefits.

Conclusions:

The impacts of climate change will be more deeply felt around the world in the coming decades, so it is essential to establish what is effective for protecting human health. Relevant interventions are planned, delivered and implemented in a highly complex space, given that the long-term impacts of climate change are still unknown and the huge variability of the social and economic systems in which the interventions are unfolding.

 

Developing high-quality evidence syntheses about the health impacts of climate change will be an important contribution to global adaptation planning. Well-designed search strategies are a fundamental component of this work, and the complexities of designing them must be thoroughly explored.

 

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Incorporating Intersectionality in Knowledge Translation Practice: Usability Testing of Tools to Facilitate Uptake in Intervention Design and Implementation

Background:

Implementation science has been criticized for neglecting contextual and social considerations that influence health equity. Intersectionality is a concept introduced by Black feminist scholars that can advance equity considerations. Intersectionality emphasizes that human experience is shaped by a combination of social categories (e.g., ethnicity, gender), embedded in systemic power structures. Using an intersectional approach offers a way to improve the applicability of implementation interventions, however, intersectionality is critiqued for being difficult to apply. The objective of this study was to develop and conduct usability testing of tools to support implementation intervention developers in applying intersectionality in three key phases of implementation: identifying the gap; assessing barriers to knowledge use, and selecting, tailoring, and implementing interventions.

Methods:

We used an integrated knowledge translation approach throughout the project. We assembled a development committee to develop draft tools for each of the three key implementation phases. The development committee included scholars trained in intersectionality and adult education, implementation researchers and practitioners, and health research funders. We used a mixed methods approach to revise and test the usability of each draft tool, which included semi-structured qualitative interviews with implementation intervention developers using the think-aloud method and completion of the System Usability Scale (SUS). We calculated an average summary score for each draft tool. We coded interview data using the framework method focusing on actionable feedback. The development committee used the actionable feedback to revise tools. The final tools were formatted by a graphic designer and underwent a final review.

Results:

Nine people working in Canada joined the development committee. They drafted a primer on intersectionality and one tool for each of the three key implementation phases that included recommendations, activities, reflection prompts, and resources. Thirty-one people with experience developing implementation interventions from three countries participated in usability testing. Average SUS scores of the draft tools ranged between 60 and 78/ 100. Most participants reported an intention to use the tools. They wanted tools to be shorter, contain more visualizations, and use less jargon. They identified that the “select, tailor, and implement interventions” tool included an overwhelming volume of content. The development committee significantly revised this tool to focus on “selecting and tailoring interventions”, shortened and clarified all tools, and added two one-page summary documents. The final toolkit includes six documents.

Conclusions:

We developed and evaluated practical tools for to help embed intersectionality into implementation interventions. Future work should develop guidance for enhancing social justice in intersectionality-enhanced implementation, and exploring how to meaningfully center Indigenous considerations in an intersectional approach.

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Exercise and Physical Activity Interventions for People with Lower Limb Amputations: A Scoping Review

Background: 

People with lower limb amputations (LLAs) living in the community have persistent challenges with mobility and have low levels of participation in physical activity (PA). Exercise and PA interventions have potential to improve quality of life and reduce cardiovascular risk factors in a growing population of Canadians with LLAs. The objective of this scoping review is to examine what is known about exercise and PA interventions delivered in outpatient or community-based settings for people with LLAs. We identified the types of research studies conducted; the characteristics of adults with LLAs included in studies; and characteristics of exercise/PA interventions and outcomes.

Methods:

The following databases were searched from inception: PsycINFO, Embase, CINAHL, Medline, SPORTDiscus, and the Cochrane Central Register Controlled Trials. Articles were included if they met the following criteria: PA and/or exercise interventions for people with major LLA (amputations above the ankle) who were ≥18 years of age and living in a community setting. Only English language studies were included. Two independent reviewers screened the articles for inclusion, and disagreements were resolved by consensus. The reviewers independently extracted the following data from the included articles: study design, sample characteristics, description and characteristics of the intervention, and study outcomes.

Results:

We retrieved 11,855 studies following removal of duplicates. After review of titles and abstracts, 115 full text articles were assessed and 42 articles were included in the study. Sixteen studies were randomized controlled trials (RCTs) (two papers reporting on the same trial), two studies with a non-amputee control group, 13 single group design studies with pre-test and post-test comparisons of outcomes, and 10 case studies. There were a total of 881 study participants across studies (range N=1-154). Of studies which reported sex, 71.2% of participants were males. The mean/median age was < 50 years in 19 studies, 50-65 years in 16 studies and > 65 years in 5 studies. The studies included people with LLA from multiple causes, most commonly trauma (n=28), dysvascular/infection (n=19) or cancer (n=11). Eighteen studies reported all or >50% of participants had transtibial amputations, 15 studies reported that all or >50% of participants had transfemoral amputations. Interventions commonly included strength training (19 studies), balance exercises (17 studies), and arm or leg ergometry (13 studies). While most studies reported promising results with some improvements in outcomes, there was considerable variation in the outcomes commonly assessed, which included aerobic capacity (12 studies), walking endurance (11 studies), gait parameters (16 studies), functional performance measures (12 studies), balance performance (nine studies), and strength (seven studies).

Conclusion:

This scoping review identified that exercise and PA interventions in community settings for people with LLA have not been widely studied, particularly using experimental study designs. Studies were consistently limited by small sample sizes. There was heterogeneity across studies in the patient populations, intervention characteristics, and outcome measures. To inform clinical practice, additional research is needed to enhance our understanding of the effectiveness of specific exercise/PA interventions for people with LLA.

N=487 (max 500)

 

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Allied Health—Translating Research into Practice (AH-TRIP): a multidisciplinary initiative to improve clinician-led knowledge translation.

Background:

Knowledge production, adoption, and building research capacity is central to the healthcare workforce; however, there is a paucity of evidence around how best to support health professionals (knowledge end-users) to undertake knowledge translation (KT). The Allied Health—Translating Research into Practice (AH-TRIP) initiative aims to embed KT within the usual business of hospital health services through capacity building of frontline AH workforce using education, support and recognition. This abstract aims to describe the development of the AH-TRIP initiative and presents evaluation data from the first year of the program.

Methods:

The AH-TRIP initiative was designed by clinician-researchers in Queensland, Australia, based on evidence from the literature, local research and KT capacity building experience, and a needs assessment with end-users (AH professionals working in hospitals across practice settings). This needs assessment informed AH-TRIP methodologies and highlighted low confidence in KT, high interest in gaining knowledge and support, and a need for a multi-modal program to meet diverse needs across a large geographical area. The AH-TRIP initiative was trialled in 2019 and consisted of four pillars: (1) KT education (including online accessible resources); (2) KT project support; (3) AH-TRIP clinician champions; (4) showcase and recognition. The AH-TRIP initiative was trialled in two metropolitan health service districts (all AH disciplines) and statewide in a single discipline (Dietetics). The RE-AIM framework underpins the program evaluation, with early evaluation data available for reach, adoption and implementation.

Results:

We developed a low-cost, multi-modal initiative, with the following outputs: (1) online training program of 27 webinars and 13 case studies across the KT action process (foundation/introductory content; identify a clinical problem; evidence to support change; planning for change; implementation; evaluating the change; and sustainability) in collaboration with multidisciplinary, multi-agency, international contributors. The website has achieved over 12,000 unique page views between March to December; (2) a group telementoring strategy with KT experts was established to engage four clinical teams (n= 9 AH professionals) in diverse geographical locations, with participants reporting improvement in confidence and skills to plan and deliver projects; (3) clinician champions (n=190) enlisted across 14 hospitals and health services to facilitate capacity building and sustainability of AH-TRIP within local teams; (4) showcase and recognition of 12 KT projects at a statewide forum, reaching &gt;295 AH professionals from &gt;50 sites. Eighty-one percent of audience members reported it stimulated critical reflection of their current practice, and 71% reported increased understanding of KT. AH-TRIP has been embedded in statewide and local AH professional, operational and research strategic plans. Success factors included significant stakeholder engagement, visionary leadership and dynamic teams to support the delivery of this innovative initiative.

Conclusion:

The AH-TRIP initiative addresses clinicians’ demand for KT training and offers a unique opportunity to improve health systems and facilitate organisational capacity building. As AH-TRIP evolves, the challenge will be to upscale sustainably in a way that maintains robust competencies while addressing local needs in the context of diverse and complex health systems.

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