Dietlinde Schrey-Dern
President of CPLOL
Email: schrey@dbl-ev.de

CPLOL has chosen this subject as central topic of the FORUM because it seems to be of high relevance world-wide. The following introduction presents a minimum agreement on an international terminology as well as some major aspects from the point of view of CPLOL.

As most of our western countries have a specific concern for strictly carried out budgets, and as neuro-sciences induced a substantial evolution of scientific concepts in Human Sciences, among other factors, speech and language therapy has come to a reflection on its goals and modes of action.

Giving evidence of its efficacy and efficiency in socio-economic terms has become a priority nowadays. Besides this socio-economic aspect speech and language therapists have to take into account the demand of quality in speech and language therapy.

Some countries (Great Britain or North American countries for example) have been directly confronted to this crucial issue earlier than other countries and have therefore proceeded into a reflection and experimentation attitude for several years. Perhaps they are able to answer the following questions concerning us now:

• What are the results of scientific research to this day?
• What are the quality criteria of research projects already realized?
• Who determines the quality criteria in your country?
• What is the role of an speech and language therapist concerning applied and pure research in the field of Speech-Language Pathology?
• In which areas of Speech-Language Pathology have speech and language therapists already obtained outcomes measurement or a guide for good practice?
• How can professionals in Europe profit of the results already obtained in research?
• How is it possible to establish a research in Speech-Language Pathology while considering at the same time the demands for quality as well as the socio-economic conditions in every European country?

The following reflections on the signification of the terms "quality", "efficacy" and "efficiency" in connection with Speech-Language Pathology, are meant to clarify further the topic of the FORUM.

The concept of quality in the field of medical care covers three different terms with quite different meanings: structure, process and evaluation-outcome (cited after Donabedian 1966).

Considering the structure, we have to differentiate between the level of initial and continuing education, the different settings in which treatment is realized, the conditions of multiprofessional work and teamwork.

As far as initial and continuing education are concerned, professionals in Europe can influence directly the quality criteria by defining guidelines. The minimum standards of CPLOL based on the guidelines of IALP (International Association for Logopedics and Phoniatrics) represent one quality criterion which is not to be confounded with the various legal regulations in every country of the European Union. These minimum standards turn out to be more and more important for he professionals in those countries where no legal statutes of the profession exist or where already existing statutes have to be revised. The importance of continuing education for speech-language therapists is made clear by the Professional Profile (1990-1997) and the Code of Ethics and Professionnal Conduct of CPLOL (1992), documents which were set up and signed by all professional associations united in CPLOL. These documents underline the need for continuing education throughout the professional career, given the continuous progress of scientific research in the field of Speech-Language Pathology.

The other aspects of quality structure refer to the socio-economic conditions specific to each country. The organisation of the different places of work and the conditions for professional exercise are sometimes regulated in the contracts of employment between the trade unions and the employer’s federation; as for private practice, there may be contracts between the professionals and the health insurance funds. All these regulations are intended to guarantee that the work is carried out with the demands for quality in practice.

The second aspect of quality concerns the process of work i.e. a set of activities concerning diagnosis, different treatment methods, psychological interactions between practitioner and patient, e.g. counselling and supervision.

With regard to this quality aspect, the need for a specific Speech-Language Pathology nomenclature seems to be obvious. It is impossible to compare different assessment procedures or methods of treatment following diagnosis if beforehand one has not defined a specific Speech-Language Pathology nomenclature. At present there are different nomenclatures existing; these nomenclatures make reference to medicine, psychology or linguistics, the three basic disciplines for Speech-Language-Pathology. Regarding the "International Classification for Impairment, Disability, Handicap" (ICIDH) published by the World Health Organisation (WHO) in 1995, it seems to be evident that a classification in Speech-Language-Pathology has to abilities rather than the disabilities of communication. Concerning this point of view the ICIDH Beta Daft 2 Version seems to correspond better to our field of work. The existing variety of the different classification systems used in the field of Speech-Language-Pathology makes it difficult to exchange of scientific research results. If the professionals have not defined exactly the object of research beforehand, it seems to be risky to compare the results of scientific research projects realized in different countries. The principal aim of the commission "Education – Professional Exercise" to establish a European nomenclature heads in this direction. The professionals have to develop a common nomenclature to facilitate the communication throughout Europe, respecting at the same time the peculiarity of each country. The nomenclature of the WHO defined in the ICIDH Beta Draft 2 seems to be useful for these purposes.

The third aspect of quality concerns the outcome of intervention, an aspect which is mentioned the most these days but which seems to be studied least. Outcome measurement does not only concern the evaluation of intervention but also the development of assessment procedures to be used for evaluation in pure and applied research. Applied research concerns efficacy and efficiency at the same time and makes also reference to the results of pure research. Developments in the field of pure research are in close connection with applied research in Speech-Language Pathology. Specific theoretical outcomes offer criteria of evaluation of great importance e.g. to indicate whether logopedic intervention is necessary or not. Regarding applied research, Speech-Language Pathology needs to realize scientific research projects for the evaluation of intervention methods. This is not only a socio-economic question but also a question concerning the quality of work of speech and language therapists.

Referring to the evaluation of intervention methods, the terms "efficacy" and "efficiency" are often confused which makes it necessary to differentiate between terms, especially in the field of Speech-Language Pathology.

According to Frattali (1998:16-17) "Treatment efficacy involves the extent to which an intervention can be shown to beneficial". To show the efficacy of an intervention, single case studies represent the main research procedures.

The term "efficiency" indicates what kind of intervention works better than another, above all in terms of financial costs, pretending similar therapeutical results in different cases. The measurement of "efficiency" demands comparative experimental studies with case-controlled clinical groups. It is debatable whether the field of Speech-Language Pathology really corresponds to his type of clinical research comparing patient groups. Every professional knows the difficulty to form patient groups regarding the great diversity of disorders we have to face concerning aetiology, degree of severity of disorder and the individual kind of markedness with every patient.

So far, single case studies represent the favourite research method in the field of Speech-Language pathology, which shows the difficulty to establish a research aimed at proving the efficiency of intervention in Speech and Language Pathology.

Donabedian, A. (1966): Evaluating the Quality of Medical Care. Milbank Memorial Fund Quarterly 44, 166-203

Frattali, C.M. (1998 ): Chapter 1. Outcomes Measurement: Definitions, Dimensions, and Perspectives in Frattali, C.M. (Ed): Measuring Outcomes in Speech and Language Pathology. New York: Thieme. p.1-27.