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DEFINITIONS OF KEY TERMS 34 such as clinical indicators, practice parameters, norms, and practice policies (Meyer, 1989). Some people may treat certain of these terms as synonymous; others may make strong conceptual or practical distinctions. Given this abundance of terminology and meaning, it is helpful to recall what Donabedian (1981:409) said when discussing norms, criteria, and standards: "we have used these words in so many different ways that we no longer clearly understand each other when we say them. But we. . .do not have the liberty of abandoning them. . . . Our more reasonable course. . . TABLE 2-1 Influence of Context on Terminology Context Influence Users Users may be practitioners, payers, or consumers. Common practitioner terms include "practice guidelines" and "algorithms." Consumer terms include "patient information" (such as ''postoperative instructions"). For insurers, terms such as "medical necessity" and "standard practice" are used in discussions of health plan coverage, and lawyers refer to "community standards" in malpractice cases. Purposes Purposes may include practice management, practitioner or patient education, quality assessment, and payment determination. Purposes and users overlap to some extent, but even a single user such as a clinician may talk at one time about "protocols" or "indications" for an intervention and at another time about "clinical indicators" or "occurrence screens" to flag potential problems for further review in quality assurance programs. Timing Prospective, concurrent, or retrospective uses may require very different formulations. Practice management guidelines are intended to guide care prospectively, and "precertification criteria" are used to review proposed care on a case-by-case basis. Continued stay review has employed "length of stay norms." Retrospective review may use "screens" and analyses of practice patterns. Consensus A number of terminological distinctions have been based on the strength of scientific evidence or expert consensus about what is effective or ineffective medical care. One formulation uses "standard," "guideline," and "option" to indicate decreasing levels of information about the likely outcomes of an intervention and decreasing levels of consensus about preferences for different outcomes. Other frameworks use gradations such as class I, II, and III to indicate conditions for which the application is justified, for which there is divergent opinion, and for which it is unjustified. Still other classifications use such terms as "appropriate," "equivocal," and "inappropriate." Complexity At one extreme are "rules of thumb" and "dicta," which are often stated very tersely. At the other extreme lie detailed algorithms, decision trees, and "criteria maps."
DEFINITIONS OF KEY TERMS 35 is to see whether we can clarify the existing nomenclature, barnacled and misshapen though it may be with the encrustation of careless past usage." Guided by the spirit of this observation, the committee's objectives are limited: to provide definitions that are clear, realistic, and practical for use with expert panels, contractors, and others. These definitions are not expected to serve all users for all purposes; however, they should permit clear communication between the Forum and the many organizations and interests with which it must work. THE COMMITTEE'S APPROACH The committee began its definitional exercise by consulting the literature on practice guidelines, quality of care, and related topics. This body of work contains a number of thoughtful efforts by practitioners, researchers, policy analysts, and others to define and explain key terms. In addition, the committee used standard English and American dictionaries, which provided common uses of the four terms. Congressional and agency staff were also consulted. In proposing definitions, the committee wanted to make its rationale and purposes explicit. To that end, it identified six desirable, although not fully compatible, characteristics of a definition. 1. Each definition should be parsimonious; that is, it should include the minimum necessary distinguishing characteristics of the concept in question. It should exclude elements that are not essential to make the definition clear and useful (for example, priorities for action, contingencies, or desired characteristics for "good" instances of the concept). 2. Each definition should be consistent with customary social and professional usage, insofar as reasonable given other objectives. 3. Each definition should be consistent with legislative language, insofar as reasonable. 4. Each definition should be practically and symbolically acceptable to important interests, insofar as reasonable. 5. Each definition should not be easily misunderstood or misused, insofar as reasonable. 6. A word or phrase should not be defined in terms of itself (for example, a practice guideline should not be defined using words such as "guiding medical practice"); the definition should not be tautological . With these criteria in mind, the committee reviewed definitions in common and professional use, developed draft definitions of terms, and then revised the definitions based on committee discussion. The following sections of the chapter describe the results of this process for each of the four key terms.
