Introduction: Clinician’s Handbook of Evidence-Based Practice Guidelines: The Role of Practice Guidelines in Systematic Quality Improvement

Abstract

In this chapter we will: (1) argue that clinical practice is difficult. Consistently delivering high quality treatments is very demanding; (2) discuss some of the major problems associated with quality clinical practice as well as place these problems in the context of similar problems with general healthcare delivery in the United States; (3) argue that although the exact quality of contemporary behavioral healthcare is unknown-including a detailed understanding of areas of improvement or of excellence-there is evidence to suggest that it is problematic; (4) argue that systematic and thoroughgoing adoption of quality improvement strategies and techniques is the major solution. This solution focuses on systems and common causes of undesirable variation (Walton, 1986) within systems instead of auditing or policing systems to detect and punish "bad apple" individuals. This quality improvement orientation and practice has had tremendous benefits in many industries (consumer electronics, retailing, auto industry) but behavioral healthcare has been very slow, at best, to adopt these practices; and (5) argue that practice guidelines-the focus of this book-are an important component of quality improvement systems but, in themselves, are not meant to be either a panacea for problems of quality or exempt from these quality improvement processes. In addition, we will argue for the following conclusions which we anticipate will be somewhat controversial: That too much discussion that pertains to quality practice has been oriented toward the role of science in clinical practice (see O'Donohue and Lilienfeld, in press). This abstract discussion is interesting and important but it has in all likelihood had all the beneficial effects on participants that it likely to have. Some of the problem may be that this level is too abstract as it raises philosophical questions about what is science, what are the limits of science when applied to human behavior, and what some research literature actually implies for practice. Instead we will argue more focus should be placed on the implementation of sound quality improvement systems which can refine any starting point, including both science-based and nonscience- based points, to more common end points (see for example McFall, 1991). That much of the controversy over practice guidelines and evidence-based practice has assumed a static model in which, for example, the practice guideline with all its inadequacies constrains clinical practice for some prolonged period. Instead within a quality improvement system, errors and limitation in the practice guideline are continually searched for and improvements, both big and small, are constantly sought. Thus, over time-and the organizations or individuals that are better at quality improvement have a competititive advantage in an increasingly difficult marketplace-these should converge on a practice that more clearly meets specifications and exceeds customers' expectations. That a quality improvement system should consist of an overall philosophy (see below for a primer); as well as a practice technology which includes management understanding and buy in; accurately understanding customers' expectations and dissatisfactions; continuing education for quality for all members of the organization; designation of quality indicators; useful information technology; learning loops, transparent report cards; etc. More education is needed for management, academics, managed care personnel, and practitioners on quality improvement. Currently, some of the key components of best practices in healthcare delivery consist of: 1. basic education in quality improvement philosophy and practices for all members of an organization 2. technologies to understand consumers' expectation, needs, desires, and dissatisfactions 3. understanding the processes in the organization that affect outcome. The focus is in improving processes through "profound knowledge" of these rather than on detecting "bad apple" individuals 4. designations of quality indicators such as patient satisfaction, clinical change, safety, improved functioning, cost impact, among others 5. reliable and affordable, information systems that capture quality indicators 6. evidence-based practice guidelines that are continually improved. Learning trials are used to provide feedback that improves all components of the system 7. incentive systems for meeting or exceeding quality goals as well as for rewarding suggestions that work 8. benchmarking to compare to national averages, ideals, competitors, etc 9. transparent report cards so that purchasers, among others, can be educated on the quality of the services provided In addition, we argue that there should be an ethical mandate that all behavioral health practice be delivered in a context of a sound quality improvement system. To be specific: the American Psychological Association should change its Ethical Code. The new principle should state that: "All psychological services should only be offered in the context of a meaningful quality improvement system". "By meaningful quality improvement system", we mean a system which has transparent report cards, benchmarking, continuing education around QI, etc. © 2006 Springer Science+Business Media, LLC.