Introduction

The evaluation of client care is an ongoing process aimed at improving clinical outcomes, as well as advancing clinical practice, yet there is a dearth of literature to guide clinicians through this process. In order to improve individual health and wellbeing, and to improve the process and outcomes of care, CAM practitioners must be informed of the importance of client review and the range of methods capable of appraising clinical practice. Before presenting these approaches, however, the concept of review needs to be defined.

Defining review

Review, or evaluation, is defined as ‘attributing value to an intervention by gathering reliable and valid information about it in a systematic way, and by making comparisons, for the purposes of making more informed decisions or understanding causal mechanisms or general principles’.¹ The term is also described as ‘a deliberate, systematic process in which a judgement is made about the quality, value or worth of something by comparing it to previously identified criteria or standards’ (emphasis in the original).² In other words, review is a systematic process that uses valid and reliable instrumentation to quantify changes in a parameter in order to facilitate decision making. In clinical terms, review determines whether a client’s presenting condition or state of imbalance improved after the delivery of care, which factors attributed to the client’s outcome, whether the client moved towards expected outcomes or goals, whether the interventions were safe and effective, and whether the underlying cause of the complaint had been resolved.^3–5 Review can thus be likened to the evidence-based practice process in that the best available information on the client is gathered and appraised in order to inform practice. Research is another useful analogy, with the planning phase of care being akin to the generation of a hypothesis or expected outcome, and the review phase involving the testing of that expected endpoint.⁶

The importance of review

Increasing demand for quality healthcare and evidence-based practice^7,8 suggests that CAM providers can no longer discount the evaluation of client care. As well as the increase in public pressure, the review of practice is also being driven by a need to quantify client outcomes, CAM practitioner performance and healthcare efficiency. This review of healthcare interventions and client outcomes not only provides useful feedback to improve the quality of care,^9,10 but by measuring the efficacy, cost-effectiveness and timeliness of healthcare,³ can also provide essential data to improve the delivery of CAM services and to benchmark against best practice. The purposeful ongoing appraisal of client outcomes before, during and/or after each client appointment, for example, may promptly identify delays in the achievement of expected outcomes (by comparing actual progress against expected progress) and thus more effectively determine if a treatment needs to be modified or altered to better meet client needs and to deliver best practice care. The review of practice may also reduce treatment costs and client suffering by highlighting interventions that are neither safe nor useful¹¹ and, in some cases, determine if referral to another healthcare professional, either within or outside the integrative healthcare team, is needed. Put simply, the appraisal of CAM practice may improve the quality of client care by determining whether clinical outcomes have been achieved in the most beneficial, efficient and cost-effective manner.^7,10

Practitioners who use review techniques may over time contribute significantly to the professional advancement of CAM. The evaluation of practice, for instance, encourages new ways of thinking and practising,¹² which, in turn, filters useful knowledge back into the profession.⁹ This knowledge could help to improve personal and professional standards,¹⁰ create new benchmarks for best practice care, and through subsequent improvements in client outcomes and client satisfaction, generate a more widely accepted, client-centred and ethically sound profession.

From the perspective of the clinician, practice review ensures that CAM practitioners maintain a sense of accountability for care given.³ In other words, by self-appraising performance, competence, knowledge, experience and decision-making ability, a practitioner can identify areas for personal and professional development and thereby improve client care.^5,12,13 Given that CAM practitioners have a duty to deliver high-quality best practice care to all individuals, the importance of self-appraisal cannot be overemphasised.

From an ethical point of view, the critical appraisal of client outcomes provides some assurance that clinicians practise in a beneficent and non-maleficent manner. Nevertheless, for individual benefits to be seen, CAM practitioners need to not only measure the outcomes of care, but also to change practice when indicated.¹⁰ Thus, review requires not only critical thinking and client interaction, but also action.

Practice review can also create mutual benefits for clinician and client. Fundamentally, evaluation provides useful information that facilitates shared decision making^9,14 and ameliorates client–practitioner communication.⁷ These outcomes could lead to improvements in client rapport, which may further improve client health and wellbeing, and the efficiency of CAM services.¹⁵

Strategies for reviewing practice

The review of clinical practice often requires a number of tools or outcome measures to effectively answer the clinical questions posed.⁷ The use of multiple assessment methods is particularly important, including approaches that generate quantitative and qualitative data, to ensure that observer bias is minimised and practitioner confidence in findings can be increased.¹⁶ Yet there is a limited number of freely available evaluation tools, with demonstrated validity and reliability, that can effectively review client outcomes in a clear, concise and quantifiable manner. Where suitable instruments are available, client outcomes should be evaluated using the same tools that were used during assessment³ in order to improve the validity of inferences made about the efficacy of treatment¹⁷ (see chapter 3).

Even though these evaluation instruments are useful in the review process, they are not the only source of information that can be drawn upon. CAM practitioners can, for instance, monitor the effectiveness of treatment through client interviews, physical assessment,¹⁸ medical imaging and/or functional, pathology, invasive and miscellaneous tests. Client self-reporting through questionnaires and diaries is also adequate for monitoring and evaluating client outcomes and clinical progress.^7,19 As such, data for client review can be derived from a number of sources, including the client, family, caregivers, pertinent documentation, questionnaires, literature, other healthcare professionals, observations and objective measures such as blood pressure monitoring and pathology testing. Hence, depending on the type of data required and the timing of expected outcomes, information may be collected for review before, during and/or after client consultation. Other instruments that can be used to monitor individual progress are listed in Table 8.1.

Table 8.1 Examples of clinical review instruments