I want to begin by asking you a series of questions.
- Do you have a framework or methodology for practice? Is this something you have ever thought of?
- How do you know that you are providing the best, appropriate care for patients?
- How often do you intentionally self-reflect on the options and advice you provide for your patients?
- Are you connected to a team of people or alumni that can support you in the decision-making process aligned to clinical practice?
If your answer to any of the above is no, the following information may assist you to improve your own effectiveness as a practitioner and the outcomes of your patients.
Clinical Practice Guidelines:
Over the last 24 months I have been creating Clinical Practice Guidelines (CPG's) for anxiety, depression and addiction. I made the decision to include this framework as a method to improve:
- My effectiveness as a clinician
- Enhance quality care for my patients
- Decrease variations in clinical practice
- Decrease costly, preventable mistakes
So what is a CPG? A CPG includes a statement, for example, guidelines for the management of patients with anxiety. A statement is then followed with recommendations that are informed by best, appropriate evidence, with the intention to optimise patient care. Best, appropriate evidence is currently regarded as informed by systematic review. A systematic review is a type of literature review that is designed to collect information for critical appraisal. Information is then produced to qualify the most effective tools for practice. Recommendation is considered most effective when the benefits and harms associated with an intervention have been thoroughly assessed.
So, when practicing, do you have a statement or series of statements that you refer to in order to provide patients with the most effective, appropriate mode of care? Are the recommendations which follow a statement informed by a systematic review of evidence and assessment of the benefits and harms of the recommended intervention?
Now, my intention behind each of the questions I have proposed, is to drawn from you, a clear answer as to whether you are providing the best, appropriate care for a patient. It is understood that one of the major priorities linked to patient values and preferences is to receive intervention which is informed by best available evidence. This being so, if we are to deliver best practice for our patients, clinical practice should be informed by the values and preferences indicated to practitioners by their patients.
So What Does a CPG Look Like
A CPG begins by asking the question, who does this clinical practice guideline refer to?
- Example: Guidelines for the management of patients diagnosed with Generalised Anxiety Disorder.
Once you are clear on who the CPG applies to, a clear descriptor of the diagnosis is necessary. Alternatively, a clear descriptor for the population you intend to apply the CPG to.
- Example: A relentless feeling of discomfort, overwhelm, associated with a feeling of breathless, regardless of stress or demanding situations. Behaviours associated with Generalised Anxiety Disorder (GAD) may include agitation, repetitive chatter, hand tremor, frequent pacing, and disconnection from family and friends. Disconnection may present as workaholism, addictive tendencies, frequent cleaning, and/or fanatical exercise. Patients may experience back, neck and shoulder pain, and live with a haze of constant fatigue.
- Alternative Example: Guidelines for the Management of Generalised Anxiety Disorder for Post-Menopausal Women, following Bilateral Oophorectomy.
Following the creation of a clear descriptor, it is then necessary to begin summarising evidence for a recommendation. It is important to summarise evidence in a structured way, making transparent judgements about the quality of the evidence - so that the recommendation made has undergone rigoruous scrunity prior to recommendation.
- Example: One way of summarising data is to use a summary table, Nutritional and Herbal Interventions for Anxiety Disorders.
When making transparent judgements I encourage practitioners to utilise a PICO method. PICO stands for Population, Intervention, Comparator and Outcome of Interest. Use of this method allows you to determine such things as, is the population you aim to to investigate outlined in the study, is the intervention safe, was the intervention compared, i.e. across a range of groups or against a conventional mode of therapy. In addition, this method provides you with a framework to better determine whether the outcome of an intervention is worth its effectiveness i.e. cost to the patient, risk to the patient or convenience of use.
- Example: Although the study examined the intervention of Withania Somnifera for patients diagnosed with Generalised Anxiety Disorder, it did not speak to, or specify, use in post-menopausal women. Further, the effects of Withania Somnifera demonstrate a positive outcome only when combined in conjunction with cognitive behaviour therapy and breathwork. For this reason, such findings are unlikely to effect change for my chosen statement, i.e. Guidelines for the Management of Generalised Anxiety Disorder for Post-Menopausal Women, following Bilateral Oophorectomy.
As the evidence is summarised, it is important to consider the data's local relevance. The following questions may arise -
- Is it possible to obtain the intervention recommended within a study? Perhaps the intervention is not yet approved or available within your district.
- Will the intervention recommended, within a study, meet the needs of a local community, i.e. cost of intervention, accessibility to services, patient values and preferences?
It is important to remember that best practice is not exclusive to use of the best intervention. Best practice is about utilising the most appropriate intervention, contextualised for your audience, i.e. local patients, that is informed by the best available evidence.
Once you have your evidence summarised, prior to making a recommendation, I encourage practitioners to discuss their recommendations with other practitioners, as part of an improvement team. Improvement teams consist of 3 to 9 practitioners who routinely work in the care process under investigation. By coordinating the efforts of a number of practitioners, recommendation is not based upon the sole action of a single clinician, however well-intentioned or skilled. Such efforts help to safeguard applications of weak recommendations that may demonstrate low quality evidence or compelling evidence of harm.
Use of such strategies develops the groundwork for structured quality improvement, leading to:
- New, potentially relevant evidence based on the critique of others.
- Modifications of summary tables where necessary, post feedback.
- Evaluation and continued validity of practice.
- Recommendations that do not exclude perspectives on efficacy or adverse effect.
In summary, CPG's provide a sound framework for expected practice, they provide a benchmark or standards for practitioners against which the practitioner can be audited and most importantly it can assist the practitioner to compare and eventually improve their practice.
Mark Hinchey has worked as a registered Clinical Supervisor for 6 years. Mark has participated in a series of clinical supervisory course work, through a range of organisations, and holds academic membership with the Journal, The Clinical Supervisor. Mark is available for clinical supervision and practitioner training.