Elevating the Delivery of Chiropractic Care

Mention "best practice" to a colleague and you will probably be surprised by the response. Most practitioners can recount in vivid detail their success in reducing or eliminating a particular patient's long suffering, restoring another's function, improving an athlete's performance, or even saving a life through extraordinary diagnostic skill and treatment. These and many other similar testimonials are the memorable rewards of serving the public with chiropractic care. We can take pride in recounting these great results. However, best practices must meet a different standard.

The Public Health Agency of Canada recently defined best practice as: "[I]nterventions, programs/services, strategies or policies which have demonstrated desired changes through the use of appropriate well-documented research or evaluation methodologies. They have the ability to be replicated and the potential to be adapted and transferred. A best practice is one that is most suitable given the available evidence and particular situation or context."

Concerns about sustainability and the allocation of quality health care resources has motivated some politicians, third-party insurers and other stakeholders to consider disinvesting from ineffective or inappropriately applied health care practices. For instance, the Mayo Clinic recently introduced a new course in professionalism because it found "the public trust in the medical profession has declined and with it physician morale and well-being."

In 2007, the University of Toronto Health Network reported a serious gap between recommended care and the actual care that is provided to Canadians with chronic disease. The study suggested that current morbidity and mortality rates could be reduced through significant changes in the management of chronic disease prevention, detection and the implementation of best practices. Dorothy Hung, et al., of the University of California, Berkeley found that even though visits to the doctor's office should serve as an appropriate opportunity to discuss health prevention behaviours with patients, the topic rarely comes up unless doctors are already oriented in that direction, prompted by their staff or respond to a reminder message embedded in the electronic health record system.

Doctors of chiropractic are powerful patient advocates with the responsibility of maintaining quality care. To achieve this effectively and efficiently demands the cultivation of certain personal characteristics that are essential to heightened performance. Feifer from the University of Southern California and Flocke at Case Western Reserve University utilized qualitative and quantitative measures to identify practice and practitioner characteristics. They describe a number of basic archetypes of performance in clinical practice that may prove to be useful in directing future quality improvements in health care delivery. It is important to note that these findings are preliminary, but they do suggest a direction for possible consideration. Here are three unique archetypes to consider:

Technophile (Efficiency-Minded) Archetype: This type of doctor runs a practice that is quick to adopt new tools. The goal is to facilitate problem-based templates that improve adherence to recommended guidelines and that help doctors to consistently perform and record routine assessments, outcomes and follow-up protocols. Communication between staff and patients is swift and follows standardized terminology to minimize confounding and error. This type of practice serves an average volume of patients very well, with high satisfaction ratings from both staff and patients. The doctors in this archetype are rarely diverted from their daily routine, appear better organized and not rushed, and can even accommodate unscheduled patients if necessary. This type of practice appears to be a model of efficiency.

Illness-Focused Archetype: It was observed at baseline that some doctors and their staff disagreed with clinical guidelines or lacked personal incentive to make the effort to implement recommended changes in their style of practice. Prevention, patient education, and adherence to clinical guidelines were rarely followed. This type of practice was considered chaotic and satisfaction levels were low. Scheduled appointment times were rarely kept, patients were not encouraged to follow healthy behaviours or attend for timely follow-up visits. Even though most of the doctors and staff did not feel compelled to embrace change in their practice or to use the medical record to its fullest potential, payment bonuses and at least one champion in the practice helped to raise the performance of the whole practice. Over time, the higher quality of care becomes its own motivation and the extra effort is seen to be in the best interest of patients. Financial rewards and a higher-than-average practice volume distinguish this archetype.

Wellness Care Archetype: Everyone in this practice style is focused on service, risk management and frequent "well-care" follow-up visits. Case management is comprehensive, guideline-compliant and patient-friendly. Practice volume is generally lower than average because more time is spent performing assessments and in-patient education. Appointment times are often behind schedule, but patient satisfaction is generally high.

Health care reform will be an important part of the worldwide response to the global economic crisis. All countries, including Canada, must find effective ways to manage the costs of health care, while at the same time improving the quality of health care delivery. Sharing and disseminating best practices in chiropractic with the rest of the health care community will help to support overall prevention and wellness programs. An improved environment of knowledge translation will favourably impact patient outcomes. The systematic sharing of electronic health records through information and communication technologies will reduce barriers and improve timely access to appropriate care. Eliminating wait times and minimizing repetitive assessments will reduce treatment errors, while maximizing efficiency, productivity and cost containment.