AAC Evidence-Based Decisions - 4 Steps toward Optimized Outcomes
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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.
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.