AAC
Evidence-Based Decisions - 4 Steps toward Optimized Outcomes
4033 Forbes Tower
Pittsburgh, PA 16260
Day Phone: 412-383-6564
Fax: 412-383-6555
Email: khill@pitt.edu
Like most health care professionals, AAC
professionals are expected to follow the principles of evidence-based practice
(EBP) to achieve the best results (ASHA, 2001). For many AAC professionals,
applying EBP requires gaining new knowledge and skills. AAC teams soon
realize that EBP is not doing the same thing, but simply calling it a different
name. Making conscienteous and judious evidence-based decisions requires applying
scientific and principled approaches that have not been part of the authority-based
procedures or models of the past.
As with evidence-based medicine, EBP starts with
the client and ends with the client as practitioners hold the interests (values
and expectations) of the person who relies on AAC paramount. EBP has been defined
as "placing the client's benefits first, practitioners adopt a process of
life-long learning that involves continually posing specific questions of
direct practical importance to clients, searching objectively and efficiently
for the current best evidence relative to each question, and taking appropriate
action guided by evidence" (Gibbs, 2003). Since the essence of EBP
involves implementing principles and methods that have not been routine for
many team members, starting to incorporate EBP into decision-making appears to
be more time and labor intensive, especially with large caseloads and paperwork
requirements. However, as practitioners become more comfortable and efficient
with the skills for putting these basic principles into practice, the initial perceptions
of !
increased
time and effort fade. In addition, achieving improved performance and
outcomes translates into increased cost and time effectiveness and not having
to redo work.
Another factor that may discourage some teams
from moving through the processes involved with AAC evidence-based decisions, is the perception of the emphasis on the research
literature and having to search and appraise volumns
of research studies. Team members do not have to become researchers or
statisticians to make evidence-based decisions. Evidence-based practice
happens at the level of the practitioner and the client and is a synergy among
the three components of 1) clinical knowledge and skills, 2) external evidence,
and 3) personal evidence. An EBP model teaches a process of life-long
learning, while an authority-based model follows traditions and guidelines
which allow professionals to become out-of-date (Gibbs, 2003).
Regardless of experience with EBP, team members
from various educational and rehabilitational
professions working in a variety of settings providing AAC services can follow
a systems model of EBP and apply four basic steps to achieve better outcomes
(Hill & Romich, 2002).
Step 1: Asking meaningful, value-based
questions
Before
teams can formulate the best questions, they have to thoroughly characterize
the client and identify and prioritize the values and expections
of the client and family. Formulating meaningful questions requires
honoring the values and expections of the client.
A well-built question has four basic features in which the question
components come from the information obtained from the client encounter (Sackett, et. al., 2000). The question features
include, 1) the client/problem; 2) intervention; 3) comparison intervention(s);
and 4) desired performance/outcome.
Step 2: Locating and reviewing the
external evidence
Formulating well-built questions with key words
provides the most effective approach to searching and finding the best evidence
to answer the question. Teams need to commit to searching fairly and
thoroughly for evidence and reviwing evidence that
may confirm as well as refute their original opinions. Teams need to be
able to address the questions that clients and family members are asking about
the strength and quality of the evidence. Teams have to be honest and
truthful with what type and/or level of evidence was used to make a decision.
Step 3: Collecting and reviewing the
personal evidence
Personal evidence should be used to support
decisions. Personal evidence is needed to compare with any of the
external or research evidence being considered to support decisions. The
need for high quality personal evidence is particularly important when external
evidence is of a low level or may not be available. Following
simple, principled procedures for case summaries, teams can collect
quantitative data to monitor performance and outcomes and guide
decision-making. LAM (Language Activity Monitoring), which is the
automated recording of communication events, makes data collection possible
with almost any AAC intervention (Hill & Romich,
2001). Software tools for language sampling and single switch performance
measurement are quick and efficient options for reporting performance data to
use as personal evidence.
Step 4: Using the evidence for assessment
and intervention
Since EBP starts with the client and ends with
the client, teams will soon realize that these four steps start with asking a
client-focused question and end with applying the evidence in the best interest
of the client during assessment and/or intervention services. In order to
achieve the most effective communication possible, teams need to build skills
based on the dynamics of the complex nature of interactive communication (Hill,
2004). The most effective AAC teams evaluate services based on the
routine use of performance measurement to monitor results and make decisions
about the effectiveness of intervention. A growing pool of performance
data is available that documents outcomes and provides for comparison of AAC
intervention approaches.
A performance-based understanding of
communication competence has long been a basic aim for AAC intervention.
AAC teams applying the four steps of EBP see the results in documented
performance. Measuring language performance is paramount in order to achieve
the goal of AAC, the most effective communication possible.
References
American Speech-Language-Hearing Association
(ASHA). (2001).
Scope of Practice.
Gibbs, L. B. (2003). Evidence-based practice for
the helping professions: A practical guide with integrated multimedia.
Hill, K. (2004). AAC
evidence-based practice and language activity monitoring. Topics in
Language Disorders: Language and Augmented Communication, 24, 18-30.
Hill, K., & Romich,
B. (2001). A Language
Activity Monitor to support AAC evidence-based practice. Assistive
Technology, 13, 12-22.
Hill, K., & Romich,
B. (2002). AAC evidence-based clinical practice: A model for success.
Sackett,
D. L., Straus, S. E., Richardson, W. S., Rosenberg, W. M., & Haynes, R. B.
(2000). Evidence-based medicine: How to practice and teach EBM.
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