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INTRODUCTION

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Things could be worse. Suppose your errors were counted and published every day, like those of a baseball player.

—Unknown

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*Mr. Ketterman's Case

I've worked hard to learn how to improve my care for patients like Mr. Ketterman. Is there some way I can find out if my interventions are effective over time? Should I be encouraging my colleagues to make the same changes? (See Appendix for Mr. Ketterman's health history.)

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In previous chapters of this book, you have had the opportunity to gain competence in the nuts and bolts of evidence-based practice (EBP). That is, you have used published research and other forms of evidence to increase your knowledge and skills in determining the diagnostic and prognostic value of tests and measures, evaluating clinical diagnostic strategies, making accurate prognoses, and deciding on the most efficacious treatment interventions for your patient. You are now ready for the next step in the EBP process: implementation of this newfound competence into your everyday practice. By implementing EBP, your increased competence and knowledge will potentially change your attitude about your approach to patients by not only considering what the latest evidence has to offer but actually realigning your behavior when appropriate, as measured by your own clinical performance. This EBP paradigm is illustrated in Figure 19-1.

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Figure 19-1

The EBP Paradigm. Knowledge obtained through the EBP process should eventually lead to attitude changes and eventually to behavior change. Knowledge, skill, and attitude can be tested through competency assessment. Adherence to best practice standards is best measured through clinical performance assessment.

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Achieving Change in Performance

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It becomes very important to distinguish between clinical competence and clinical performance in the evidence based process. We cannot assume that competence (e.g., knowledge of best practice principles and skill of administering) immediately translates to evidence based clinical performance, where the latter depends on aligning clinical behavior to be consistent with best practice principles.

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The evidence is very clear that the translation of evidence into clinical performance is lagging in our health care system, a fact best illustrated by the Institute of Medicine's (IOM) characterization of the "Quality Chasm."1 The extent of disparity between best practice standards and clinical performance is an unfortunate fact that transcends all health professions, including physical therapy. For example, in 1994 the Agency for Health Care Policy and Research (now known as the Agency for Health Care Research and Quality) published evidence based practice guidelines for managing acute low back pain, some of which were highly relevant to physical therapy.2 Among the myriad of interventions for acute low back pain, two interventional procedures were assessed that fell well within the scope of practice for physical therapy: use of physical agents (e.g., heat, cold) and manual therapy. The guideline recommended against ...

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