Implementing Best Practice in Public Health or Healthcare
Since the early 1990s, the growth in evidence based medicine has led to a culture whereby the maintaining or improving of healthcare, public health and health policy requires an approach to utilizing evidence in decision making. Typically these approaches involve the application of a systematic review, evidence review or cost-effectiveness data to inform a decision. This may also take into account the context in which these interventions are set and whether or not they can be standardised across all localities. There are 'off the peg' or 'ready made' evidence, such as clinical practice guidelines or health technology assessments. For example, National Institute for Clinical Excellence (NICE) may have produced clinical guidelines or quality standards that can be applied and monitored against. However, as well as there being evidence of 'what works', equally there is evidence of quality improvements. Very often, this latter is referred to as 'best practice'.
What is best practice?
Interestingly, there isn't a consensus on a definition of 'best practice'. You will come across people who will ask for 'best practice' guidance (or protocols) to be shared or there will be a general practice or health department that is doing well in relation to their rates, targets or key performance indicators and others will ask for what they are doing. A definition I like is one by Ng & de Colombani (2015) whom define 'best practice' as an intervention that has shown evidence of effectiveness in a particular setting and is likely to be replicable to other situations.
Sometimes 'best practice' is used interchangeably with 'good' or 'good enough' practice, particularly if people want to avoid a debate about what constitutes a single perfect intervention. It is different to 'innovative practice' as this denotes a promising intervention that may be effective, not one that already has established its effectiveness. 'Best practice' represents quality care that is seen to be optimal based on a prevailing standard or point of view.
To clinicians, 'best practice' can be seen as being more than practice based on evidence. It has the advantage over research in that it has been used in 'real life' settings. In this regard, clinicians and their supporting staff view best practice guidance as providing tangible solutions to identified problems or needs. 'Best practice' guidance can be used for clinical practices, administrative, educational or conceptual work.
Best practice can be combined with research evidence to form clinical practice guidelines which are good tools for closing the research evidence‐practice gap.
Selecting best practice evidence to implement
Ng & de Colombani (2015) recommend that you select your best practice evidence in relation to the following criteria:
- Relevance to the needs and setting of the community
- Community participation
- Stakeholder collaboration
- Ethical soundness
Implementing 'best practice' should take into account the costs, ability of healthcare workers to deliver the intervention, social determinants of health and the social, political and environmental context. All of these can impede successful implementation.
Evaluating your best practice intervention
An evaluation of your best practice intervention will involve looking at your structure (inputs), process and outcomes (e.g. Donabedian Model). As with many public health initiatives, outcomes can be a long time coming so you may want to monitor process evaluation indicators as proxies. For example vaccination coverage rates or screening coverage rates can be proxies for the outcomes of decreased mortality and morbidity.
You could adopt the RE-AIM framework (first introduced in 1999) which combines process and outcome evaluation into:
- reach (i.e. proportion of target population receiving the intervention)
- efficacy (i.e. measurement of the size of change in a specific desirable outcome)
- adoption (i.e. proportion and representativeness of settings taking up the intervention)
- implementation (i.e. degree to which the intervention is carried out as planned)
- maintenance (i.e. sustainability of the intervention and its effects)
- efficiency (i.e. [reach X efficacy]/cost of the intervention)
Ng E & de Colombani P. Framework for selecting best practices in public health: a systematic literature review. Journal of Public Health Research (2015):4:577.
Perleth Mtthias & Jakubowski Eke & Busse R. What is 'best practice' in health care? State of the art and perspectives in improving the effectiveness and efficiency of the European health care systems. Health policy (2001):56:235-50.
Nelson A. Best practice in nursing: a concept analysis. Int J Nus Stud (2014) Nov;51(11):1507-16.
Gaglio B, Shoup J, Russell E. The Re-aim Framework: a systematic review of use over time. Am J Public Health (2013) June; 103(6): e38–e46.