PainLink Presents

Hot off the Press

February 2001

Featured Article: Brown, SJ (2001). Managing the complexity of best practice health care. Journal of Nursing Care Quality. 15 (2): 1-8.

All of us have been challenged to identify the best ways to individualize care while implementing pain management policies and critical pathways. As we struggle to help staff adopt evidence-based pain management practices, I thought Dr. Brown's article offered an interesting way of thinking about best practices. Her "Best Practices Health Care Map" integrates both institutional and the clinical perspectives to design care that is most likely to result in positive patient outcomes. She uses the word design deliberately to reflect the care and deliberation that are required for defining evidence-based care for populations of patients and delivering such care to individual patients.

Pathways, clinical practice guidelines, protocols, and other tools that define care for a particular patient population are what she calls "Pre-specification Design". In essence, these tools address common, predictable aspects of care for a clinical population and rely heavily on research findings, quality improvement data, and incorporate system or institutional factors such as policies and resources. Clinicians' experiential knowledge can help with some aspects of pre-specified care such as system or clinical factors that will affect implementation of a guideline or subsets of patients whose care needs are likely to vary from interventions in the guideline.

"Point-of-Care Design" refers to a clinician's efforts to integrate pre-specified interventions with his or her knowledge of a particular patient. Point of care design means that clinicians must be able to tailor the care based on their knowledge of the patient. Thus, clinicians are faced with deciding when and how to implement pre-specified care, whether to modify the pre-specified plan, and when and how to create plans for problems that are not addressed by the pre-specified plan. Clinicians are accountable for the decisions they make to modify pre-specified care.

Brown is quick to point out that pre-specification design is "not 'cookbook' practice; rather it is a realistic way of achieving consistent, evidence-based practice amidst busy and demanding schedules and workloads." Brown offers some practical strategies that organizations and clinicians can employ to integrate institutional interests in research-based efforts to improve care with the clinician's interest in individualizing patient care. She maintains that both types of care design require expertise and institutional support such as research and clinical expertise, access to evidence sources, and computer resources. In pain management, we don't talk much about what it takes to get the job done. how many hours we spend in committee meetings, developing policies and procedures, and otherwise trying to institutionalize pain management on top of already busy clinical jobs. Brown gives us a way of understanding our efforts to institutionalize pain management practices that leave room for individualizing care. As pain management becomes a focus of JCAHO visits, her analysis also helps us think about the nature of the resources we will need to help staff meet those standards.
(Commentary by Judy Spross).

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Last Updated: February 15, 2001