Standards and Evidence-based Guidelines
Standards are explicit statements of expected quality in the performance of a health care activity. They may take the form of procedures, clinical practice guidelines, treatment protocols, critical paths, algorithms, standard operating procedures, or statements of expected health care outcomes, among other formats. Standards communicate expectations for how a particular health care activity will be performed in order that it achieve the desired results and define, for both health workers and clients, what is needed to produce quality services. Standards are thus the cornerstone of most health care improvement approaches, including accreditation of health facilities, external quality evaluation, continuous quality improvement, and performance improvement.
In fields like health care that are continuously evolving with the development of new technologies, drugs, and procedures and that have an enormous body of scientific evidence available to support clinical decision-making, ensuring that standards are regularly updated and “evidence-based” is critical to assuring health care effectiveness and outcomes. Adherence to evidence-based standards has been shown to be associated with improved health outcomes. Moreover, failure to provide clinical care in accordance with standards has serious negative effects on patient outcomes. Having in place processes for regularly updating standards to reflect current evidence and for communicating revised standards to health care providers is essential for any health care delivery organization.
To achieve expected health outcomes, standards must be clearly presented, achievable, and available to health care workers. For many areas of health care, international evidence-based standards are readily available, including standards adapted to low-resource settings. Ensuring that standards are achievable in the health care setting where they are to be applied is particularly important: standards must be locally appropriate and reflect both the expected competencies of health care providers in that setting as well as the equipment, drugs and supplies available to them.
Barriers to Achieving Compliance with Standards
However, even when locally appropriate, evidence-based standards exist, many health workers do not follow them routinely. Motivating and enabling health workers to perform according to standards is thus one of the biggest challenges to producing quality health care.
A substantial body of research on guidelines implementation suggests many reasons why standards-based performance is often difficult to achieve and sustain. At the most basic level, health workers may simply not be familiar with standards because these have not been clearly communicated. In other cases, health workers may lack the necessary supplies or equipment to perform according to standards. Commonly, providers are aware of standards but may hold beliefs or attitudes that inhibit them from adhering to standards. Health workers may doubt the efficacy of or disagree with specific standards or reject the idea of explicit standards in general, believing that practice guidelines restrict provider autonomy or compromise the “art” of medicine. Even when health workers recognize the appropriateness of standards, they may believe that they, personally, are unable to carry them out or may not do so out of habit or lack of motivation to change their behavior.
A related problem is maintaining performance according to standards once such performance has been achieved. Performance may reach desired levels immediately following training or other performance improvement intervention, but deteriorate over time.
The nature of health care activities and the setting where they are implemented also affect performance according to standards. Some health care tasks, such as prescribing medications and preventive services like immunization, readily lend themselves to standardization. In contrast, the appropriateness of many diagnostic procedures is strongly influenced by the characteristics of individual patients. The greater specialization of health workers within hospitals, where providers often limit their focus to certain procedures or clinical areas, facilitates awareness of and performance according to standards in a narrow specialty. In contrast, at the primary health care level, individual providers are often confronted with a wide variety of complaints and ailments, and their practice behavior may be more strongly influenced by patient preferences. Patients may show preference for practices that are inconsistent with established standards. Health workers may not comply with standards because they observe that their peers or co-workers do not. Financial disincentives may exist, such as lack of payment for certain services or tests and greater profitability of treatments that are not suggested by practice guidelines.
Interventions to Achieve Performance According to Standards
Several systematic reviews of the effects of clinical guidelines and other interventions to improve adherence to standards have been published in the international medical literature. This research shows consistently that interventions based solely on information transfer, such as the distribution of printed guidelines, manuals, pamphlets, and audio-visual materials, have little or no effect in inducing performance according to standards (Davis, Thomson, Oxman, & Haynes, 1992; Davis, Thomson, Oxman, & Haynes, 1995; Grimshaw & Russell, 1993; Hulscher, Wensing, Grol, van der Weijden, & van Weel, 1999; Oxman, Thomson, Davis, & Haynes, 1995; Soumerai, McLaughlin, & Avorn, 1989; Wensing & Grol, 1994). However, when guidelines and print materials were coupled with other intervention strategies, such as discussion groups, self-audit, reminders, or improvement approaches, adherence to standards increased. Similarly, mass communication methods (such as mass distribution of guidelines or media campaigns) have not been effective for inducing health care providers to adhere to standards in the absence of other strategies to overcome administrative, educational, patient-centered, economic, and other barriers to performance according to standards.
Thus, while the existence and availability of evidence-based standards is a necessary condition for effective health care, the provision of written standards or guidelines alone are not sufficient to induce health worker compliance with these standards. Successful interventions to induce performance according to standards tend to have several common elements, including well-designed graphic aids, opportunity for individual discussion of needs and barriers, clinically relevant and understandable recommendations for positive alternative actions, repetition of messages, and reinforcement of improved practice patterns over time.