Health care knowledge and technology have expanded more than health care funding.At the same time, unexplained geographical variations in style, delivery, and costs have been clearly identified. Clearly defined policies and practice parameters, if utilized as intended, are ideal strategies for reducing unnecessary expenditure. Policies and practice parameters provide a defense for limiting diagnostic testing and management strategies to only those which have been proven beneficial.
Outcomes are inversely related to practice variability ( Shapiro l995), i.e. the more variation that exists in practice, the worse the outcomes. Practice policies and parameters are an important part of a total quality management program—by encouraging consistency in practice, reducing unsubstantiated deviations from best clinical evidence, and providing a flow pattern that streamlines the process of monitoring, review, and revision.
Well-developed guidelines do not provide a 'cookbook' approach to health care. While practice parameters promote the use of the current best evidence to guide decision-making, they also require practitioners to assess clinical situations correctly and to use clinical judgment to support actions. When combined with clinical expertise that includes experience, proficiency, and the ability to make clinical judgments, practice parameters promote quality care.
Day-to-day use of practice parameters must be monitored and evaluated, and the process reviewed and revised on a regular basis to ensure consistency with current evidence. The benefit of practice parameters will depend to a large degree upon the quality of the parameter developed. Their quality can be judged according to the Institute of Medicine's eight criteria, which include validity, reliability, applicability, flexibility, clarity, development in a multidisciplinary process, scheduled reviews, and careful documentation (Fieldand LohrJ990). Alternatively, parameters can be evaluated according to Eddy's criteria, which state that they should be accurate, accountable, predictable, defensible, and usable ( Eddy1990).
Collaborative practice between health disciplines improves outcomes ( Knaus ef a/ 1986). No single health care discipline practices in isolation; therefore careful attention to collaborative development, education, implementation, and evaluation is paramount in the success of any policy or practice parameter. Valid policies and practice parameters should be based on research evidence and expert interpretation. Consequently, policies or guidelines should complement standards for any specific discipline. Inconsistencies in parameters from one discipline to another can render even the most well-designed parameter impotent.
Liability has previously been measured by comparing practice with 'expert opinion'. Unfortunately, expert opinion varies and is predominately subjective; it may also be entrenched in past practices versus best clinical evidence. As a result of increasing support by national organizations to develop practice parameters, complying with published practice parameters may become the standard for measurement of clinical practice in the courts.
As national bodies develop and publish increasing numbers of practice parameters, individual agencies will benefit from already completed projects. The role of the individual units will be to apply practice parameters to their own specific policies and guidelines. Local practice parameters may exceed national standards. For example, if a particular disease were more prevalent in the area serviced by a given unit, it might be appropriate to initiate additional diagnostic screening tests.
As experience and new evidence develop relating to any specific area of practice, one can anticipate that the 'best practice' will be quite different in the future compared with now. Practitioners will need to link closely with organizations developing practice parameters to keep those agencies abreast of new research evidence or practice changes. The need to review practice parameters regularly, to identify barriers to implementation, or to revise outdated practices will be the greatest future challenge. The merits of policies and practice parameters are summarized in Table,,,?,.
Table 2 The merits and limitations of policies and practice parameters
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