Evidence-based Decision-making in Healthcare by Clinical Practitioners
Phil Hassen, President of the Canadian Network for International Surgery; ISQua Fellowship Forum Moderator.
In the last Forum we focused on leadership and effective organizational decision-making principles and methods. In this Forum we will explore a critical set of knowledge related to evidence-based decision-making, encompassing clinical/medical commitments to the care processes in order to improve quality and safety to patients and families served.
What is evidence-based clinical medicine?
Evidence-based clinical medicine is the conscious integration of the best evidence currently available into daily practice. Sometimes it is the best practice known and agreed to by experts arrived at through a consensus decision-making process. The evidence incorporates the best systematic researched care plan(s) particularly taken from patient-centred research. This means that clinical care incorporates best practice or evidence related to prevention, diagnostics, clinical assessments, treatments and patient-centred care.
Clinical practice guidelines (CPGs) are one excellent example of using the best evidence in care practices. CPGs are systematically developed publications and tools based on evidence derived from journal articles and scientific publications. CPGs are intended to assist practitioners to make decisions about appropriate care given specific clinical circumstances. CPGs are reviewed and validated regularly to ensure clinical accuracy and are to be used as an adjunct to sound clinical decision-making. As one example of this work across Canada, I am familiar with the strong efforts of the Alberta Medical Association and how they support clinicians to create and update clinical practice guidelines. Teams of experts with a specific clinical focus are formed for the purpose of reviewing a broad base of the medical literature. The interdisciplinary team uses a systematic approach in selecting the most relevant and highest quality research for application to clinical practice. Health care practitioners from around the world can subscribe through this service provided by the Alberta Medical Association --- Toward Optimized Practice. (http://www.topalbertadoctors.org/cpgs/cpgupdatessubscribehere/)
What are challenges to incorporating best practice or evidence based care?
The application of contemporary evidence is a significant challenge for all practitioners. I certainly found this to be the case in my work as a CEO of hospitals and health systems, Deputy Minister and CEO of the Canadian Patient Safety Institute. It takes an extra-ordinary amount of time and effort for physicians to keep up-to-date with the improvements in clinical care through reviewing journals, attending conferences and many other forms of professional development. In addition, there are challenges associated with influencing physicians who have practiced a certain way for many years and now have them reconsider care and interventions to coincide with contemporary evidence and best practices. Health care practitioners (whether physicians or other clinical caregivers) may view themselves as “successful” with the continued application of clinical practices they were initially taught and still use years later.
In developing countries there are many more significant challenges to modifying care interventions consistent with current evidence and best practices. These challenges are in part due to the inadequate number of physicians, as well as related to the inability to attain and transfer contemporary knowledge being used in developed countries or large medical centres in developing countries.
What are some ways to increase the use of best practice or evidence based care?
Generally, practitioners are highly motivated to provide the best possible care to patients and families and want to maintain and use current knowledge. It is important to note that core competencies expected of all health care professionals is the application of quality improvement and improved patient safety methods and the integration of best research with clinical practice.
Focusing on physician leaders who are thoughtful, willing to be critical of their own practices and receptive to learning can influence others who struggle to change and retain outdated care practices. With role models, and IF given time, effort and an investment in learning, health care practitioners can and will adopt best practices. In my experience, I observed how some nurses and physicians eagerly moved in this direction, while others wanted to hold onto “old” (and no longer appropriate) practices when initially engaged in quality and safety improvement. Regularly, we would organize time for teams to review practices --- everyone would have an opportunity to discuss and demonstrate (with data and evidence) their practices, and then all would adopt the best practices based on evidence. The key was to be sure research based methods and data was utilized. When changing to new methods evidence, data and research must be shown that better patient-centred care can be achieved.
When consistent practices are adopted, quality and patient safety is improved – no question. There can be special circumstances for some patients’ care; these exceptions (variations) to standard practice can be considered and explained later when required. The motivation for focusing on best practices and evidenced based medicine should not be a means to cut costs – though cost benefits can often be attained by uniformly employing best practices.
Evidence based practice will result in better outcomes. In many ways this is still an evolving body of knowledge for achieving the best possible outcomes for patients and requires leadership and time. Yet from the patients' perspective, and for physicians, nurses and other clinical staff the systematic integration of evidence based, best practices will make you proud of your efforts and fulfill your professional commitment to lifelong learning and improvement of safety and quality of patient care.
1. Have you or your organization done any work in this area? Describe the areas of care and service and what best practices you have tried to implement?
2. What are some of the challenges faced by practitioners in developed and/or developing countries to applying up-to-date evidence to clinical practice?
3. What are some initial steps you would recommend in leading a team to incorporate best practice/evidence based care? How would you go about developing a plan to influence practitioners to improve care and make it more evidence based?
4. Alternatively, given the importance of advancing the best patient care possible, what are some basic things you can do to improve the quality of care by means of helping yourself and others in adopting best practices?
5. In order to better understand these concepts and their applications, which articles or books have you/will you read to gain better insight into evidence based best practices?
- “Evidence Based Medicine: What It Is and What It isn’t” – BMJ 1996; 312:71
- “Ten Commandments for Effective Clinical Decision Support: Making the Practice of Evidence-based Medicine a Reality – Journal of the American Medical Informatics Association; vol10, Issue 6, Pp 523-530; David W. Bates, et al; published on line 1 Nov. 2003