Evidence-Based Health and Aged Care

Introduction

The health and care of the global population is a complex issue in today’s society with wealthy countries facing low fertility rates and ageing populations, and poorer countries facing the burden of infectious disease and chronic illness brought about by the HIV/AIDS epidemic. With problems such as healthcare worker shortages, inappropriate skill-mix and gaps in service, there is a need to develop methods to eliminate or at least reduce these concerns.¹

Contemporary approaches to the delivery of health and aged care – including accreditation, audit, practice improvement and a growing range of initiatives – focus on developing and using frameworks that identify “best practice” and facilitate their use through audit, quality management systems and decision support for clinicians as they deliver care and managers, in their quality improvement role.

"Best outcomes" for patients/residents/clients are achieved by:

• Nurses, carers, allied health professionals and medical practitioners engaging in a comprehensive, ongoing assessment of a patient’s/resident’s/client’s needs;
• Constructing and continually evaluating and updating comprehensive plans or strategies based on the needs identified in assessment;
• Delivering care interventions that are justifiable in terms of international evidence of their feasibility, appropriateness, meaningfulness, effectiveness and cost benefit;
• Embedding the concept of "best practice" within the every day culture and
• Establishing systems that support these approaches and are consistent with a commitment to leadership, evaluation and continuous quality improvement.

The pursuit of quality involves self-assessment by practitioners and organisations of all of their activities, interventions and operations as a basis for planning and implementing strategies for improvement.

Improving Clinical Care: Evidence Based Practice, “Best Practice” and Continuous Quality Improvement

Evidence-based practice is the foundation of best practice and continuous quality improvement (CQI) in professional practice. The clinical CQI process provides a framework for health and aged care services and practitioners to audit and improve the quality of direct care. Critical to this approach is the need for practitioners (of medicine, nursing and the allied health professions) and carers to be actively and explicitly making judgements about how to achieve the best outcomes for patients, residents or clients and to be making clinical decisions that are based on the best available knowledge.

The pursuit of quality includes consideration of the systems and management processes within a given health care service. Quality improvement from a systems/management perspective involves the self-assessment by each organisation of all aspects of its operations to enable it to plan and implement strategies for improvement. This cycle must be continuous and standards or quality audits are conducted to look for evidence that strategies for improvement are in place. The objective of a standards or quality audit is to check that an organisation has systems in place, that those systems are being implemented, and that they do in fact sustain quality outcomes in the organisation.

However, it is not uncommon for even the most effective organisations to concentrate on “best practice” in terms of the systems, management processes and documentation in place within the organisation and to overlook the central role of “best practice” in terms of the professional practice of medical, nursing and allied health professionals (often assuming that this is well established in the professions) and of care workers. A commitment to “best practice” is fundamentally related to the identification of the best available evidence on the feasibility, appropriateness, meaningfulness and effectiveness of interventions and care practices. It should be ensured that this evidence is accessible to those who plan and implement care to support the decisions they make in partnership with the patient/resident/client, their families and members of the multi-disciplinary team.

Establishing and maintaining evidence-based practice requires a continuous review of evidence and the production and dissemination of condensed information to service users (consumers), care workers, nurses, doctors and allied health professionals.

“Best Practice”

Best practice is defined in many ways but essentially it means engaging in practices that are based on the best available evidence. Best practice in terms of systems frequently involves “benchmarking” between similar organisations. Best practice in terms of professional practice involves benchmarking between similar practice fields but, more importantly, it involves benchmarking against international evidence generated through research – or Evidence-Based Practice.

Evidence-Based Practice

The rapid development of medical, nursing and health science over the past fifty years has led to an enormous growth in knowledge. As a result, the expansion in the range of interventions and knowledge available to assist health professionals and care workers in their clinical decision making and to inform service users in making care choices is unprecedented. This burgeoning of knowledge has not, however, led to an increase in the availability of knowledge to clinical practitioners² and the need to embed evidence in practice settings is now considered to be a significant challenge for health care services and health professionals. Merely disseminating information has been found to have little effect on changing practice.³

Overcoming this challenge is a central component of most clinical improvement programs and there is some evidence emerging that suggests that, to be effective, dissemination needs to be planned; to follow a series of steps that involves those who use the information; and to be accompanied by a commitment to manage change. Funk et al suggest that research based information presented in such a way as to overcome corporate and individual barriers and good presentation of the material are facilitating factors of importance in this process.

Barnsteiner² argues for the use of systematic methods for enhancing practitioner access to research, and the promotion of behaviours where clinicians are encouraged to critique their practice against standards arising out of research evidence to promote research utilisation processes. Others^4,5,6 assert that, if it is embedded in practice, the best available information (at best, derived from high quality research) will improve practice, reduce variability in practice and improve the cost effectiveness of care delivery.

The benefits of evidence utilisation are well described in the international literature and most modern health systems are increasingly demanding an approach from practitioners that explicitly values and pursues quality based on evidence of feasibility, appropriateness, meaningfulness clinical effectiveness and cost effectiveness⁷.

Evidence suggests that a focus on best practice can be achieved in health care through introducing an ongoing “Best Practice” program that includes:

1. Identifying common care practices/interventions and conducting evidence reviews of published international research on those identified;
2. Developing condensed information sheets and practice guidelines based on the review of published international research and making these available within the facility;
3. Providing access for all staff to a comprehensive database of evidence reviews and best practice guides;
4. Developing an organisational policy and practice manual based on the review of evidence and ensuring that this manual is readily accessible to all within the facility; and
5. Conducting regular clinical audit/feedback/improvement cycles to establish the degree to which existing practice complies with “best practice” and to generate practice change to improve the quality of care practices.

Establishing Evidence-Based Clinical Practice Improvement

Clearly, if every health care facility established a “Best Practice” program that included all of the five components listed previously, a great deal of staff time would be needed and the costs associated with evidence reviews and the identification of best practice would be enormous.

The Joanna Briggs Institute COnNECT offers an ongoing customer-focused service to health care services and practitioners to establish and maintain an evidence-based approach to clinical practice improvement.

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