Saturday, November 20, 2010

Rethinking EBP

"Evidence-based practice" and "best practices" are lionized as the key to improvement of more or less everything. To an extent, that claim has tremendous validity. There is also a Dark Side.

As an evidence-based practice fellow, I've discovered that if the question is at all complex, figuring out "what the evidence says we should do" is a labyrinthine process that can lead to no real answers. What does the evidence say? Who decides? In my effort to determine the best evidence-supported strategies for preventing patient falls, some of the most scholarly of the research demonstrated the most glaring misunderstandings of such concepts as "risk factors" and the conditions needed to truly test the "specificity" of a tool.
"Best practices" have a similar shortcoming. Often, such practices are "best" only in proscribed circumstances, which may or may not have anything to do with the problem you're trying to solve or the process you're trying to improve.
Both approaches are also time-consuming, whether they yield useful results or not. In the increasingly dynamic environment all industries (including health care) find themselves, is the expenditure of limited resources in such endeavors an investment, or merely a gamble? Is there another way?

Perhaps instead of chasing the horizon or falling into perfectionistic paralysis trying to identify "best practices," we can make faster progress seeking and implementing better practices:
  • Is there something, however small, you could be doing better?
  • Does an alternative have research supporting it, or at least make prima facie sense (sometimes, that's as good as it gets)?
  • Instead of sweeping, large scale changes, can changes be made incrementally?
  • Is there a story that supports the change?

This last item is important: there must be a compelling story for a change to be supported and new patterns established. Data and facts do not change minds, the truth doesn't speak for itself, nor does it set you free. There needs to be an emotionally engaging story to sell the change, no matter how much research supports it.

Evidence-based best practices have a well-earned place among quality improvement techniques. However, progress and improvement can also be impeded by the perfectionistic pursuit of that one best practice, or endlessly delayed while evidence is gathered and analyzed, by which time there is new evidence to be considered. Identifying and implementing "better practices" may better allow progress to be pursued with agility and alacrity.

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