Academic journal article Journal of Allied Health

Barriers to and Opportunities for the Implementation of Best Practice Recommendations in Chiropractic: Report of a Focus Group

Academic journal article Journal of Allied Health

Barriers to and Opportunities for the Implementation of Best Practice Recommendations in Chiropractic: Report of a Focus Group

Article excerpt

The objective of this study was to describe the perspectives of stakeholders in leadership positions within the chiropractic profession regarding implementation of best practice guidelines. Eight individuals involved in leadership positions within the chiropractic profession participated. The setting was a single 2-hour meeting held at a national chiropractic research/educational conference. Our findings suggest that delivery capacity can be strengthened if the system as a whole is taken into consideration and a multifaceted strategy is used for the dissemination and implementation of the best practice recommendations. The perspectives of stakeholders in leadership positions in chiropractic about the implementation of best practice recommendations are presented. The data generated from the focus group will guide the development of an implementation strategy for best practices for the chiropractic profession. Lessons learned may benefit the broader complementary and alternative medicine community. J Allied Health 2008; 37:82-89.

CLINICAL PRACTICE GUIDELINES and best practice recommendations, no matter how detailed, are of limited use if they are poorly implemented or ignored by the profession to which they are directed. At the same time, it must be acknowledged that a great deal of time and energy is placed in the development of guidelines and recommendations, and should they be used indiscriminately or fail to be used at all, the cost of development will outweigh any benefits of implementation. Unfortunately, there is no one best method for the implementation of best practice recommendations or clinical guidelines. Valiant efforts have been made in many disciplines both in complementary and alternative medicine and across the medical realm, resulting in huge outpourings of time, energy, and expense1-3 but revealing only limited success.

There is inconsistent evidence to demonstrate that guidelines or best practice recommendations have been successful in improving care, and failures have been noted.4,5 As Shiffman et al have indicated, sometimes implementation failures occurred due to factors external to the recommendations,6 although at other times there have been problems in the guidelines themselves. Implementation of the so-called "Mercy guidelines"7 met with such opposition from within the chiropractic profession that some of those opposed developed counterguidelines8 and the profession was left confused about which to follow. Unaddressed political issues trumped scientific concerns and rendered the documents useless. Ultimately, neither document has made a meaningful impact on the profession. Certainly, some managed care organizations opted to use a set from one group or the other, but many did not. Implementation therefore was a failure in that there was not universal adoption of either guideline by stakeholders. The effect on patient care was negligible.

The Institute for Medicine defines guideline implementation as "the concrete activities and interventions undertaken to turn policies into desired results."9 Lynch and Cox10 offer an operating definition of best practices as "activities that (we) have witnessed, taken part in, or have reliable reports on, that have a proven track record in terms of improving the situation, and that can be described in terms of the effectiveness they had on consequences during and following an emergency situation." While this is an informal definition, it captures the essence of best practices: what has been observed to work best and be most effective. In their study, a matrix of practice procedures was matched to performance indicators and benchmarks.

Ideally, guidelines are informed by research outcomes and professional dialogue in an effort to build a practice construct that is accepted and relied on by all stakeholders, including doctors, patients, managed care companies, and insurance providers. The overarching goal is the enhancement of patient care, something that should be of interest all practitioners. …

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