From Knowledge Transfer to Action: An Example of a Community of Practice for First-Episode Psychosis in Lyon, France

Early intervention services are dedicated to reducing the duration of untreated psychosis and to providing care coordination according to patients’ needs. As noted by the authors of a recent meta-analysis (1), the effectiveness of early intervention in psychosis no longer needs to be demonstrated. However, the dissemination of such models remains limited worldwide. Implementation of early intervention services in France could be improved (2), because no specific national guidelines are available.

There is a gap between research evidence and practice in the health care system, which can be addressed by knowledge translation strategies (3). Knowledge translation is a framework that can be used to overcome the insufficient impact of continuing medical education and professional development. Bridging this gap may require the intervention of a knowledge broker to assess needs and help find and interpret relevant sources of knowledge (4).

Starting with seminal work by Wenger in the early 1990s, increased attention has been focused on communities of practice, and research has flourished (5), including studies on communities of practice in health care. Communities of practice could be an appropriate driver to foster early intervention services for FEP. However, to the best of our knowledge no previous reports on this application have been published. This column reports the implementation of a community of practice as a tool for knowledge transfer about FEP in one of the largest psychiatric hospitals in France.

The Community of Practice in Lyon

We used a narrative case study approach to describe how we generated our community of practice. The time frame of the study was from 2017 to 2019. We based our work on Graham and colleagues’ (6) model of a knowledge-to-action cycle, which identified seven actions: determine the know/do gap; adapt knowledge to the local context; assess barriers and facilitators to knowledge use; select, tailor, and implement the intervention; monitor knowledge use; evaluate outcomes; and sustain knowledge use.

The study took place in a university department of the local psychiatric hospital (Vinatier Hospital), with a catchment area of more than half the population of the Greater Lyon area (1.8 million inhabitants, including the city of Lyon and some of its suburbs). Several data sources were used in the study. First, a reflective analysis was undertaken of documents and materials produced during the process of conceiving and developing the community of practice, including e-mails about collaboration and organization of the community of practice, meeting reports, slides and articles discussed, and notes from informal discussions. Second, notes from participant observation conducted by two authors (S.E.O. and F.H.) were reviewed. Third, responses to a satisfaction survey of members of the community of practice, using a questionnaire that was proposed to members in November 2018, were also reviewed.

Below we describe the process of building the community of practice and its functioning. Planning for the community of practice was based on the Canadian Institutes of Health Research (CIHR) knowledge transfer tool (7). Issues and challenges encountered during the process are also described, and results of the survey questionnaire are presented. The analysis was built on the different steps of the knowledge-to-action framework as operationalized by the CIHR. (A table showing how the CIHR framework informs the design of the community of practice is included in an online supplement to this column.)

Implementation and Evaluation

Determine the know/do gap.

The first phase of questioning emerged thanks to one of the authors (F.H.), who had worked for a year in the research network of an FEP clinic in Quebec City, where early intervention services are structured by national guidelines. Awareness of the gap within psychiatric health care in France highlighted the need for change.

In an effort to identify individuals who might help implement early intervention services for psychosis in France, an influential senior psychiatrist at our hospital was contacted. This individual is involved in large clinical, teaching, and research networks targeting psychotic disorders. Afterward, a small group of early adopters of early intervention approaches started sharing knowledge about the subject to elaborate and conceptualize transformation of care pathways. Group members spontaneously aggregated into what can be regarded as a community of practice. The group was seen as a concrete way to transfer and disseminate knowledge for practice change. Thereafter, the project took shape as a prototype of a community of practice, which relied on the small starting group and on contacts in Quebec City and a stakeholder in the United Kingdom.

Adaptation to the local context

The group collaboratively defined the rules of functioning and objectives of the meetings for the community of practice. The two underlying objectives were to create dedicated units and care pathways for FEP in Greater Lyon and to share knowledge and improve professional practices in FEP. Building the community of practice collaboratively served as a powerful means to adapt to the local context. The community of practice was established in September 2018, with the aim of spreading and sharing information and discussing and broadening the interaction fields among stakeholders for patients with FEP.

Different categories of stakeholders were identified. Service users worked with the founders of the community of practice and helped them set priorities according to their needs. Researchers assessed the state of early intervention at a local level in light of international data on early intervention services. Academics played the role of knowledge brokers by bridging the gap between bibliographic sources and participants. Care providers helped to identify practical issues and to prioritize actions. Psychiatrists in close connection with administrators and local mental health policy makers acted as facilitators for the implementation of new care pathways.

The community of practice is physically based in the Vinatier Hospital in Greater Lyon and has 69 members from three other areas in France and from Quebec City and London. Members can connect via a videoconferencing system, bringing together mental health teams with different levels of development in the care process for FEP across France and worldwide. The most advanced teams share and discuss their implementation history, elements of their general functioning, and the day-to-day management of their patients. About 20 to 25 participants frequently attend meetings of the community of practice, and the other members stay informed. Thus, our community of practice can be seen as a companion implementation model. The members from Greater Lyon’s health care system (catchment area of 1.8 million inhabitants) have key roles in targeting each step of the FEP care pathways, including inpatient care, care in psychiatric emergency departments, ambulatory psychiatric community care, university student health services, and vocational and housing services. Through their involvement in the community of practice, these professionals contribute continuously to improving services through a back-and-forth knowledge transfer and exchange process.

Because the specific management of FEP is new in Greater Lyon, speakers with greater experience are invited to share their ideas and advice. Meetings are held monthly to discuss the literature and to exchange views about clinical cases encountered by participants. Questions emerging from participants’ personal practice are shared and discussed by the community of practice members. Answers to specific questions provide information that is then adapted to individual needs. Knowledge that can be used to address recurring issues is also shared collectively via e-mail or social networks.

Barriers and facilitators to knowledge use

To assess implementation barriers and facilitators, we sent a survey to 54 participants (with a 33% participation rate). Most respondents were psychiatrists or psychiatric nurses. Results emphasized that even when attendance at meetings is supported by administrators and colleagues, it is hampered by busy schedules. This was the most important barrier identified in the survey. The second most-cited barrier was related to technical issues (i.e., videoconferencing systems), which sometimes cause delays during the meetings, complicating the management of busy schedules.

Respondents also identified facilitators. Many noted that the meetings were useful and could help improve their practice, providing a strong motivation for attendance. Half the respondents expected that integration of specific tools and resources would help them care for patients with FEP, and this integration was subsequently achieved. Participation of experienced speakers from France and abroad made it possible to better meet the needs of the participants and to increase their commitment to the community of practice.

Selecting and tailoring the intervention

Training was one of the priorities of the community of practice participants, along with establishing a clear pathway to care in Lyon. To date, four vocational training sessions have been implemented by members of the community of practice to increase specific skills, promote the culture of early intervention services, and prepare participants for the institutional change required to establish a dedicated unit in Lyon. The teaching staff was composed of professionals from France and abroad.

Monitoring and sustaining knowledge use

Eighteen community of practice monthly meetings have taken place at the Vinatier Hospital, and four vocational training sessions have been organized. The quick growth of our community of practice has placed the topic of FEP at the center of institutional debates. This attention has had a visible impact on mental health care organization with the creation in January 2019 of a unit dedicated to FEP in the Vinatier Hospital, PEP’S-LyU, which has a catchment area of 297,359 inhabitants. PEPS-LyU is a continuing care unit offering intensive case management for FEP patients. To date, 50 patients (new incident cases of FEP in the catchment area) are involved in this unit. More FEP units are needed to extend the coverage of early intervention services in Greater Lyon, and our community of practice is prepared to play a leading role as an institutional support to accompany the implementation of these units.

PEP’S-LyU works along with the community of practice to serve any person with questions about FEP in Greater Lyon, to monitor knowledge use by stakeholders, and to promote the unit’s sustainability over time. Currently, two other units are being conceptualized, with a planned opening at the end of 2020. The three units of Vinatier Hospital will cover a territory of 839,890 inhabitants. Thus, it is estimated that 150 to 180 FEP patients per year will be served, based on data from our first unit and epidemiologic data from the local health information system. Furthermore, community of practice members have improved the services involved in the management of FEP. For example, members helped improve admission to the psychiatric emergency unit for young adults with FEP. Nurses and psychiatric residents aided in the creation of an FEP admission pharmacological guideline for the emergency department. The guideline, along with a fast-track pathway with the FEP unit, was implemented in the two main psychiatric emergency departments in the area. Since February 2019, this admission process has been used for two patients per month in relation to PEPS-LyU. With the planned opening of the two new units in 2020, an increase in the number of patients benefiting from these practices is expected.

To reduce delays in ambulatory community units, community of practice members proposed the promotion of an early-access pathway dedicated to young adults under age 30 in three community mental health centers. Links between the hospital and vocational services, which were formerly ineffective, have been operationalized to facilitate early access to individual placement and support for patients. Community of practice members also implemented a specific course on evidence-based practices for FEP in the initial curriculum for psychiatric residents (24 residents in 2019) and in the continuing education curriculum for psychiatric nurses (40 nurses in 2019) and peer workers (37 workers in 2020).

Recently, local mental health policy makers have appointed a representative to be involved as a member of the community of practice, allowing the group to influence the mental health organization plan. The inclusion of a local policy maker in the group led to the creation of a work group with an official mandate to improve care pathways for FEP in Greater Lyon. One of the authors (F.H.) is the medical leader of this work group. Within the community of practice network and through the legitimization of the aforementioned official workgroup, community of practice members are continuously improving care pathways and implementing recovery-oriented evidence-based practice in Greater Lyon by following a back-and-forth knowledge transfer process.

Conclusions

In this column, we have described the community of practice model as a useful tool for implementing new care paradigms, particularly early intervention services in complex and already well-established health systems. Creation of a community of practice in Lyon was a useful way to transfer knowledge about FEP among practitioners, raise awareness of the importance of dedicated units, and broaden local mental health services. Along with knowledge brokering, the community of practice has become a lever of practice change. However, it does not address all behavioral determinants of its participants, such as those related to management issues. These factors can be addressed by various models of behavior change and implementation strategies (8, 9), taking into account internal and environmental mechanisms underlying the behavior.

The FEP community of practice has helped promote at least four of the 10 guiding principles of youth mental health service development (10): employ evidence-informed practice, ensure smooth pathways and ease of access into services, collaborate with other services, and take an integrated approach with a focus on recovery.