Addressing Issues

Professional Training: Preparing Health Care Professionals for Systems Change

Different Levels of Practice Recommendations

The rigor with which change is sought in existing clinical practices must be tempered by the strength of data supporting the change.

Three levels of recommendations currently exist - standards of care that must be followed in almost all cases, practice guidelines that are followed in most cases, and treatment options that are at the health care professional's discretion.2

• Standards of care are practice recommendations that must be followed in virtually all cases. Providers need to document reasons for any deviation — for example, if aspirin was not given early in the treatment of an acute myocardial infarction because of an existing allergy. There is unanimity of opinion among experts that standards of care are the best clinical recommendations. The health and sometimes even the economic consequences of these standards are well known. "Strict" indications or contraindications exist that make them clearly "appropriate" or "inappropriate" practices. Very few interventions rise to this level.
• Practice Guidelines represent recommendations that should be followed in most cases. They are intended to be more flexible than standards of care, with deviations being fairly common. Deviations are justified by a difference in circumstance and patient preference. Practice guidelines represent what an appreciable majority of health care professionals believe and are tailored to fit the individual needs of patients. Only "relative" indications and contraindications exist for their implementation. For example, practice guidelines help health care professionals make appropriate decisions with patients about starting ACE inhibitors to prevent progression of renal disease in people with diabetes, or about the frequency of blood glucose monitoring to optimize metabolic control.
• Treatment options are practices for which the literature, when critically appraised, is neither supportive of nor critical of a particular clinical intervention. It is important for health care professionals to be aware of available options for interventions, but they are free to choose any appropriate course.

When working to improve the implementation of standards of care, education should focus on "how" the standards can best be carried out within the clinical setting - especially within the political culture. When guidelines are being promoted, education needs to focus on both the "how" and the "why" of the proposed clinical improvement. Education about treatment options should focus on awareness of new developments.

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