• research knowledge
• quality improvement

In 1810 a British merchant who supplied food to the Royal Navy discovered how to preserve food safely in tin cans. The military advantages of a portable long lasting food source packaged in containers that do not break were obvious and the popularity of canned foods dramatically increased during the American Civil War. The benefits for the general population were also readily apparent and this led to further growth in the canned food industry. Yet the drive to produce and package canned food safely was not matched by an equivalent focus on safe extraction of the contents of the can. Soldiers used pocket knives, bayonets, or even rifle fire to break into cans. A can of veal taken on an Arctic expedition by the British explorer Sir William Parry carried the instruction “Cut round on the top with a chisel and hammer”. It wasn’t until nearly 50 years after the invention of tin canisters that the first patent for a can opener was issued.¹

This technology lag has some remarkable similarities to the current situation with research transfer and uptake in health care. We are able to produce research—reams and reams of it. The average practising clinician is flooded with information; in 1992 it was estimated that to keep up to date the dedicated general physician would need to read about 17 articles a day, every day of the year.² In response to this information overload we have become more adept at reporting and packaging research. There is now a significant industry devoted to improving the production of evidence based guidance and delivering this information in ways that are more readily accessible to clinicians. Examples are the evolution of the Cochrane Library,³ the development of abstracting journals such as Evidence Based Medicine,⁴ and the production of concise sources of reliable information like Clinical Evidence,⁵ a publication that aims to find, critically appraise, and summarise evidence about common or important clinical conditions seen in primary and hospital care. Information technology and knowledge management systems are being used to improve timely access to the best available knowledge.⁶ But efficient knowledge packaging and delivery systems, although a critical component of the path to knowledge uptake, are not enough. We still lack the can openers that will help us easily and quickly to get research findings used to benefit patients.

We are not the only industry where this is an issue. The “knowing-doing gap” has been identified as a core problem for many companies from a number of industries.⁷ So why does it happen and what can we do about it? As with all complex issues there are no easy answers; knowledge remains unused in practice for a whole host of reasons but there are some recurrent themes that emerge from all that has been written on this topic. The messages from other industries that seek to apply knowledge in practice include:

• involve the end user from the start of the research process;

• diagnose the reasons for failure to adopt best practice;

• match interventions to barriers;

• focus on action;

• be prepared to learn from mistakes rather than punish them;

• work cooperatively; and

• measure what matters.

A core theme that underpins all these messages is the importance of a culture that is committed to improving performance and that values action as well as understanding. Health care has a mixed record in this respect. It is not short on knowledge and it is not lacking in action; the challenge for those trying to improve performance is to increase the linkages between the two.

There are some astonishing examples of slowness to implement knowledge even when the benefits for patients and the healthcare system are clear. Handwashing is a simple, virtually risk free action that helps prevent hospital acquired infection—a condition that carries substantial mortality, morbidity and cost.⁸ The benefits of handwashing have been repeatedly demonstrated over the past 150 years.⁹ Yet healthcare workers in general do not wash their hands; a review of 11 studies published in 2000 noted that the level of compliance with basic handwashing ranged from 16% to 81%.¹⁰ The barriers to uptake have been clearly described¹¹ but, in most cases, the system appears paralysed in terms of its ability to take effective action. A compelling external threat can bring sudden change; it took little more than 2 weeks after the first patient with a case of severe acute respiratory syndrome (SARS) was admitted to Mount Sinai Hospital in Toronto for frequent handwashing to become an institutional requirement,¹² but it is unlikely that these measures will spread to areas where SARS is unknown.

In contrast, there are several other areas in health care that have been characterised by rapid diffusion of innovation; countless new technologies have been embraced with a passionate zeal resulting in widespread uptake. The problem is that rapid uptake is not necessarily linked to good evidence. There are many instances where unwarranted enthusiastic adoption of unproven technology—“fashions” in operations and drug use—or behaviours such as bottle feeding instead of breast feeding has led to harm.¹³ Twenty years ago McKinley mapped the career of a medical innovation¹⁴ and advocated for policy makers to use evidence of effectiveness in decisions about allocation of healthcare resources. We still have a lot to learn about how to harness individual and organisational enthusiasm for adopting innovation and to direct this energy into areas where there is sound evidence of value to be gained from increased uptake.

Making better connections between knowledge generation, knowledge delivery, and practical action is the challenge that now faces the healthcare industry if it wants to improve performance and deliver better care. Our efforts this century should focus on designing the can and the can opener in parallel.