Implementing Evidence-Based Decision Making in the Private Practice Setting: The 4-Step Process

Article Outline

• Abstract
• Step 1. Define Your Practice Purpose
  • What is the ultimate purpose of your dental practice?
    • Bottom Line
• Step 2. Identify Your Ethical Practice Parameters
  • What are Ethical Practice Parameters?
  • Why do we need Ethical Practice Parameters?
• Step 3. Putting Ethical Practice Parameters to Work
  • Create Ethical Practice Parameter Score Cards
  • Restorative Therapy Example
    • Therapy/Procedure/Intervention
    • Method/Material/Type
  • Periodontal Therapy Example
    • Therapy/Procedure/Intervention
    • Method/Material/Type:
  • The Payoff—Analyze the Results
  • Educate and Communicate
    • Bottom Line
• Step 4. Get the Goods: Accessing the Evidence
  • Follow These Steps
    • Bottom Line
  • Putting It All Together
  • Conclusions
• References
• Copyright

An important goal of EBDM is to improve outcomes where it matters the most: at the point of care. All dental clinicians need practical tools that facilitate access to the clinical information needed to enable our patients to make better-informed choices. This article provides a 4-step guide for practical implementation of EBDM in the private practice setting. Step 1 is defining your practice purpose. Step 2 describes the use of Ethical Practice Parameters to guide clinical decision-making. Step 3 illustrates how to implement Ethical Practice Parameters. Step 4 describes a simple process for searching for scientific evidence. Online resources are provided and the benefits of the 4-step process are elucidated.

In the first article in this series, “Implementing Evidence-Based Decision-Making in the Private Practice Setting, Why do it?” we explored some of the advantages and benefits gained by using evidence-based decision-making (EBDM) in private practice.¹

The strong desire to both improve skills and knowledge and to keep up to date are other key reasons that resonate with the members of the San Francisco and Napa EBDM Interactive Learning Groups, described in a previous article.² Both groups are passionate about ensuring that we advise and treat patients in the best ways possible and this commitment to clinical excellence is a major driving force that motivates the entire group.

What follows is a 4-Step “How-to” practical method for implementing EBDM into your private practice. Ironically, this article is not based on scientific evidence; it is based on observational reporting and personal preferences. While this may seem out of place in the context of the Journal of Evidence-Based Dental Practice, we believe it is part of the EB approach since it clearly falls under the clinical judgment and experience component of EBDM and it is an example of how to approach a problem when insufficient evidence is available.

Some of what follows may seem quite ordinary and some of it requires effort and change on the part of the clinician. However, all of what is described is fundamental to developing a successful program. Although there probably are other paths to take, following these 4 steps will get most of you where you want to go.

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Step 1. Define Your Practice Purpose 

What is the ultimate purpose of your dental practice? 

For the clinician motivated to implement EBDM in private practice, the answer to this focused question is simply to provide the best possible dental health care for people who need and/or want it. It is all about putting the patient first. Stated differently, this is the primary outcome of practice.

There are many important tangible secondary outcomes in practice. These include:

Private practice dentistry is a business and it needs to be profitable in order to survive and thrive. However, for the EBDM-oriented practice, the primary purpose needs to be at the forefront of the minds of the entire dental team on a daily basis. It should not be an afterthought or quietly assumed.

In no uncertain terms, putting the patient first and effectively using EBDM can be a profitable “win-win” enterprise. However, not prioritizing this primary purpose for the dental team allows secondary outcomes to predominate. When this happens the daily practice routine often shifts focus to things like production and salesmanship. Patients today are increasingly savvy consumers and they value knowing that their health comes first in your practice.^3., ^4.

Implementing EBDM in your practice is about putting the patient first. Revisit your practice mission statement. If you don't have one, now is a good time to write one. Remember the old admonition: “If you don't know where you're going, you're sure to get there.”

Your mission statement should lucidly state that putting the patient first is the primary practice purpose. Share this with your team. They need to believe in you and your clear practice vision. On a daily basis, the dentist(s) and the entire dental team need to engrain this concept. Believe, reiterate, and refocus on this reason-to-be. A great team project is to develop a list of creative ways to increase your community's awareness of your practice purpose.

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Step 2. Identify Your Ethical Practice Parameters 

What are Ethical Practice Parameters? 

These are the philosophical parameters, the boundaries that you decide your practice will not go beyond. They clarify the risks we choose to avoid in our practice setting. They color and influence almost all clinical decisions. Consider the delineation of your practice's Ethical Practice Parameters as professional “boundary setting.”

Two core clinical Ethical Practice Parameters that override clinical care delivery are:

Why do we need Ethical Practice Parameters? 

They provide a higher-level perspective from which to assess the multitude of therapeutic choices we have to make on a daily basis. From treatment recommendations to product selection and clinical care delivery, Ethical Practice Parameters are the conscience of the practice. EBDM is better viewed through the lens of Ethical Practice Parameters.

“Evidence alone is never sufficient to make a clinical decision. Decision makers must always trade the benefits and risks, inconvenience, and costs associated with alternative management strategies and in doing so consider the patient's values.”⁵

Because of the scarceness of high-level scientific evidence and the complexity of many clinical decisions, implementing the evidence-based approach in dental clinical practice is challenging.⁶ But despite these limitations, ethical clinicians must do the best they can. Three solid reasons to have clearly delineated Ethical Practice Parameters in your practice are:

Using Ethical Practice Parameters is not a new way of framing decision making. In medicine, it can be traced back to the phrase “First Do No Harm” originated by Hippocrates in his work, “Of the Epidemics,” Book I, Section XI (400 BCE).⁷

Recently introduced, the Translational Clinical Practice System (TCPS) is a practice model designed to facilitate the challenging task of translating best available scientific evidence information into appropriate clinical care. It introduced the facilitation of Ethical Practice Parameters to assist the clinician in evidence-based decision making.⁶ See Diagram A.

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• Diagram A. 

  The Translational Clinical Practice System (TCPS).

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Step 3. Putting Ethical Practice Parameters to Work 

Create Ethical Practice Parameter Score Cards 

Ethical Practice Parameters not only consider the patients' welfare, but also that of the dental team, the dentists themselves, and the dental practice business.

Although it would be ideal to critically view all aspects of patient care through the light of EBDM and your Ethical Practice Parameters, this would be an overwhelming project to initially undertake.

Implementing Step 3 requires several active components. An approach we have used starts the process with the practice's Top 5 production therapies/procedures/interventions. These are the most vital to daily business operations. Fill out Ethical Practice Parameter Score Cards for your practice's “Top 5” group (seeFig. 1). Below are examples of how to use these score cards for 2 typical Top 5 production items.

Figure 1. Ethical Practice Parameter Score Card.

Restorative Therapy Example 

Posterior Restorative Crowns

For posterior crowns, there are 4 types that you might want to score:

Here's what you do:

Periodontal Therapy Example 

Perhaps nonsurgical periodontal therapy is in your Top 5 production procedures. For patients with periodontitis you might want to assess Scaling and Root Planing (SRP), local drug delivery, systemic drug therapy, and subgingival irrigation for clinically significant outcomes, as well as safety, effectiveness, and long-term value.

Nonsurgical Periodontal Therapy

Here's what you do:

The Payoff—Analyze the Results 

Now you can make decisions on the basis of your analysis:

Educate and Communicate 

The dental team and the patients need to understand and appreciate that our clinical decision making is based on the complex interplay of Ethical Practice Parameters; best available scientific evidence; clinician judgment and experience; and patient preference and values. Here are a few practical tips for you to consider:

Start assessing your care delivery through the perspective of the Ethical Practice Parameters.

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Step 4. Get the Goods: Accessing the Evidence 

Next we acquire the best evidence for our Top 5 production procedures. This is most efficiently done online using filtered (pre-appraised) sources and, as needed, unfiltered sources.

Using pre-appraised sources is much more efficient compared to unfiltered sources, and will provide additional information useful for making management decisions. The Journal of Evidence-Based Dental Practice, the Evidence-Based Dentistry journal, and the Cochrane Database of Systematic Reviews (see Fig. 2) are excellent pre-appraised sources of evidence for the busy clinician.

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• Figure 2. 

  High-Quality Online EBDM Sources.

With an unfiltered source, such as Medline, the clinician can query through an electronic search engine like PubMed.⁸ However, using an unfiltered source can be more time consuming if one is not very familiar with proper search protocols. From an expediency point-of-view, I recommend using PubMed only if you cannot find what you are looking for through the pre-appraised sources. Searches should be guided by PICO-formatted clinical questions.⁹ The PubMed online tutorials guide you through the process.

See Fig. 2 for a list and description of high-quality online resources.

Follow These Steps 

Searching for evidence is a terrific reality check process that will greatly benefit your patients, your employees, and your practice. In your consultations, your patients will feel more confident knowing your practice is committed to recommending procedures that:

Accessing the evidence (Step 4) is a time investment. Be patient: it is incredibly rewarding. Make it a priority and set aside time to do this on a regular basis. Perhaps you do 1 search per week. Maybe it's 1 per month. No matter. Start the process with your highest production procedures because it makes the process much more reality-based and tangible for you.

Putting It All Together 

You have defined your practice mission, identified your Ethical Practice Parameters, assessed your Top 5 production procedures for appropriate evidence and filtered them through your Ethical Practice Parameters. Your dental team understands this process and is confident in communicating it to your patients.

Undoubtedly, certain of your Top 5 production items have been well-validated and you now feel more confident in your recommendations. You may discover that others should be changed or discontinued. Please do so and replace with better-validated methodologies that pass according to your Ethical Practice Parameters Score Card.

Simply repeat this process with your next Top 5 grouping. Continue until you complete your review of procedures.

Congratulations! You have officially indoctrinated a powerful EBDM model into your practice. With the dental team understanding the process, change will now be much easier to implement and communicate.

Conclusions 

Embrace the concept that clinicians who choose to incorporate EBDM into their practices are perpetual students, life-long learners: they are never done improving care delivery!

Make the process of accessing evidence and improving care delivery a routine professional activity. In the near future, dental clinicians will have available more clinical decision support and efficient therapeutic assessment tools that will be readily accessed at chair side, at the point of care.

By staying up to date with your online resources, you will automatically make changes and improvements in your care based on the strength of evidence, Ethical Practice Parameters, and your clinical experience and judgments, all the while focusing on the patients' preferences and values.

Your employees, both clinical and administrative, will be better empowered and feel more confident in their recommendations and explanations. The process of putting the patient first, having in place Ethical Practice Parameters, and providing care that is supported by the best available evidence is empowering: your patients and team will have greater trust in you and your practice.

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References 

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7. Hippocrates, of the epidemics, book 1, section XI (400 BCE). Available at: http://www.geocities.com/everwild7/noharm.htmlAccessed May 7, 2006
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8. National Library of Medicine, National Institutes of Health. PubMed. Available at: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?DB=pubmedAccessed September 2, 2006
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