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An Interdisciplinary Team Approach to Best Practices Development

I Introduction
II Why Develop Best Practices?
III Interpretations of 'Best Practices'
IV The Interdisciplinary Method of Best Practice Development
V Who Makes Up the Interdisciplinary Team?
VI The Dichotomies
VII The Role of Evidence in Best Practices Development
VIII Conclusion
IX References

In this feature article, Sharon Kirkpatrick reports on a presentation made by Rishia Burke of the Association of Ontario Health Centres (AOHC) at the Ontario Health Promotion Summer School in June 2001. AOHC is one of four partners of the Best Practices Partnership, as well as a member of the Best Practices Work Group at the Centre for Health Promotion (University of Toronto). They have been a contributor to the development of the Interactive Domain Model best practices approach to health promotion (which has been pilot tested by a CHC, hospital, and public health department). The AOHC has also developed its own approach to best practices, toolkit and training workshop, based specifically on the Community Health Centres experience as described in the article. Additional information about the interdisciplinary Team Approach Tool Kit and training program has been provided by Shelley Walkerley of Stonegate CHC and Loralee Gillis of the AOHC. See OHPE 235.2 for related OHPE Bulletins and information on the AOHC and other resources.

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I Introduction

Best practices in health promotion are "those sets of processes and activities that are consistent with health promotion values, theories, evidence and understanding of the environment, and that are most likely to achieve health promotion goals in any given situation" (Kahan and Goodstadt, 2001). Best practices involve the gathering and application of knowledge about what is working and not working in different situations and contexts through feedback, learning and reflection (Burke, 2001; UNAIDS, 2001).

AOHC has developed and tested a model and Tool Kit for the development of best practices by interdisciplinary teams. The model, presented at the Ontario Health Promotion Summer School in June 2001, was developed for community health centres, and is relevant to others working in interdisciplinary and multidisciplinary settings such as public health units, hospitals, and family resource programs.

II Why Develop Best Practices?

Best practices can help to push our services and programs towards higher efficiency and effectiveness, as well as providing opportunities to learn from other's experiences, thus avoiding reinventing the wheel. Best practice development also helps to identify objectives, outcomes and indicators, facilitating evaluation. Further, best practice development aids in the evolution of new and creative solutions to common problems.

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III Interpretations of 'Best Practices'

There is currently no accepted protocol for the development of best practices; rather, there are a variety of approaches as outlined by the Centre for Health Promotion's Best Practices Working Group:
* Principles Approach - best practices based on values and principles considered to be fundamental to health promotion are used to evaluate programs and initiatives
* Guidelines Approach - general conditions, including types of activities and attitudes, are determined to be required for best practices to occur
* Service Standards Approach - best practices defining expectations for services are set, either internally or externally
* Outcomes Approach - best practices are based on expected or desired outcomes
* "What Works" Approach - best practices are set based on reports of what works from the literature or other organizations
* "Tell Me What To Do" Approach - best practices that list steps to be followed to achieve desired results

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IV The Interdisciplinary Method of Best Practice Development

Why develop best practices using an interdisciplinary team approach? The rationale for the development of the interdisciplinary model and Tool Kit by the Association of Ontario Health Centres was that many problems encountered in health promotion are so complex that solutions can only be identified through the combined knowledge and experience of several disciplines (Burke, 2001). Using this approach, providers from a variety of disciplines, usually within the same centre or organization, come together to share ideas about the same issues from different perspectives. This model, based on dichotomies, is outlined in the Interdisciplinary Team Tool Kit, a workbook to facilitate the best practices development process, and in the accompanying two day training workshop.

According to this approach, best practices include the incorporation of philosophy and values, evidence-based guidelines, indicators of positive intervention, and processes of staff, volunteer and community involvement. Further, best practices are dynamic and are not simply attempts to standardize practice.

Dynamic process
+ People
+ Community
+ Guidelines
+ Evidence
+ Values/Principles
_____________________
= Best Practices

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V Who Makes Up the Interdisciplinary Team?

The team is made up of providers who are involved with the service for which best practices are being developed, or who would be best involved in planning, implementing, and evaluating that service. The team may also include community partners, volunteers, management, evaluator, member of target group, etc. For the best practices development process to be effective and efficient, all team members must understand his or her role in the team, and the important contribution that he/she and all other team members can make.

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VI Steps in the Interdisciplinary Model to Best Practice Development

In the 2 day workshop on using the Tool Kit, the team works through a variety of strategies. The first day is spent on developing a common understanding of terms (e.g. what is meant by "evidence") and outcomes, their current practices (or hypothetical situations) and desired practices, and their roles in team work. On the second day, the team work through five domains in the model, where each represents areas of tension or dichotomies for community health centres. For each of the five tensions there is a series of questions that helps the team determine their "best practice" or guidelines they will use and supporting evidence. The workshop and the Tool Kit follow a series of steps to explore the model.

1. Preliminary research (several hours to a week) -- identify evidence to be used through development process
2. Read and discuss model (2-4 hour team meeting)
3. Assess current practices (2-4 hour team meeting) -- clarify values, compare practices with mission and values, map process by describing each member's roles/responsibilities
4. Dichotomies 1 & 2 (3-4 hour team meeting)
5. Dichotomy 3 (2 hour team meeting)
6. Dichotomies 4 & 5 (3-4 hour team meeting)
7. Implementation/Wrap Up

*It is also recommended that team members read through the Tool Kit and conduct individual preparation for each team meeting.

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VI The Dichotomies

The model includes five dichotomies or tensions, the resolution of which are essential to the development of best practices:

1. Outcomes versus process - the balance between the value of and need to produce outcomes with the valuable but less tangible process;
2. Standardized practice versus adaptation to community context
3. Participant responsibility versus addressing systemic issues - balance between the responsibility of the client/ participant/ community for their own health and the existence of issues that present barriers to their participation
4. Multidisciplinary (providers work on their specific parts of the project, and share outcomes from each discipline) versus interdisciplinary (providers work on their specific part of the project, but there is sharing of ideas about implementation and outcomes) approach
5. Guidelines versus practitioner experience/involvement - balance between evidence-based practice and experience-based practice that may lead to innovative and creative approaches to issues

Resolving each dichotomy requires work at three levels:
1. Figuring out the fundamentals -- understanding where the group stands on each dichotomy -- "what is different, what do we know about this issue, locale?"
2. Coming to consensus on values, principles and resources -- "what is there now? what is needed?"
3. Advancing to action -- "Is the action concrete and measurable?"

The Tool Kit provides questions to facilitate the team in working through each of the three levels for each of the dichotomies. While resolution of each of the dichotomies is crucial to helping the team to conceptualize what the best practices will look like and how they will be used, the process is also dependent on evidence.

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VII The Role of Evidence in Best Practices Development

Evidence is essential to the development of best practices - it provides information about the effectiveness and impact of initiatives, and guides the implementation of ideas. The Association of Ontario Health Centres identifies three categories of evidence:
1. Knowledge of community - based on observation, needs assessment, stories from community leaders, etc.
2. Literature - empirical studies, clinical practice guidelines, theories and models used by other organizations, etc.
3. Indicators - measurable and tangible gauges used to evaluate programs or services.

(from "Unpacking Evidence in Health Promotion" by Burke, Johnson and Arai published by AOHC 2000.)

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VIII Conclusion

Interdisciplinary approaches to best practices development require committed team members along with a substantial time commitment. The AOHC Interdisciplinary Team Tool Kit provides comprehensive, detailed guidelines for each step of the way, greatly facilitating the process. Each time the Tool Kit is used, and the workshops held (so far, there
have been five sessions with rural and urban CHCs), the model is enriched and the Tool Kit made more useful. Further, the use of a common approach to best practice development such as this may facilitate the sharing of information within and between organizations and disciplines, contributing to the advancement of best practices and health promotion, with the potential to lead to new solutions for old problems.

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IX References

Burke, R. (2001). An Interdisciplinary Team Approach to Best Practice Development - Ontario Health Promotion Summer School Handouts.

Kahan, B. and Goodstadt, M. (2001). The Interactive Domain Model of Best Practices in Health Promotion: Developing and Implementing a Best Practices Approach to Health Promotion. Health Promotion Practice, 2(1), 43-67.

Kahan, B. Goodstadt M. and Rajkumar, E. (1999). Best Practices in Health Promotion: a scan of needs and capacities in Ontario. Centre for Health Promotion, University of Toronto. http://www.frcentre.net/library/BPscanOntario.pdf

The following two items are available to members of AOHC through the website at http://www.aohc.org in Our Views, scroll to Best Practices (articles in French and English).

* Association of Ontario Health Centres. Interdisciplinary Team Tool Kit For the Development of Best Practices. (2001). A detailed Tool Kit with a description of each stage of the process in best practice development by an interdisciplinary team.

* Burke, Rishia; Johnson, Suzanne; Arai, Susan. (2001) "Unpacking Evidence in Health Promotion" (Best Practices Discussion Paper 2). Association of Ontario Health Centres. A discussion of the importance of and sources of evidence for the development of best practices.

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