The Reasons behind the (Non)Use of Feedback Reports for Quality Improvement in Physical Therapy: A Mixed-Method Study

Feasibility of a quality-improvement program based on routinely collected health outcomes in Dutch primary care physical therapist practice: a mixed-methods study

BACKGROUND

This study evaluates the feasibility of a nine-month advanced quality-improvement program aimed at enhancing the quality of care provided by primary care physical therapists in the Netherlands. The evaluation is based on routinely collected health outcomes of patients with nonspecific low back pain, assessing three feasibility domains: (1) appropriateness, feasibility, and acceptability for quality-improvement purposes; (2) impact on clinical performance; and (3) impact on learning and behavioral change.

METHODS

A mixed-methods quality-improvement study using a concurrent triangulation design was conducted in primary care physical therapist practice. Feedback reports on the processes and outcomes of care, peer assessment, and self-assessment were used in a Plan-Do-Study-Act cycle based on self-selected goals. The program's appropriateness, feasibility, and acceptability, as well as the impact on clinical performance, were evaluated using the Intervention Appropriate Measure, Feasibility Intervention Measure, Acceptability Intervention Measure (for these three measure, possible scores range from 4 to 20), and with a self-assessment of clinical performance (scored 0-10), respectively. The impact on learning and behavioral change was evaluated qualitatively with a directed content analysis.

RESULTS

Ten physical therapists from two practices participated in this study. They rated the program with a mean of 16.5 (SD 1.9) for appropriateness, 17.1 (SD 2.2) for feasibility, and 16.4 (SD 1.5) for acceptability. Participants gave their development in clinical performance a mean score of 6.7 (SD 1.8). Participants became aware of the potential value of using outcome data and gained insight into their own routines and motivations. They changed their data collection routines, implemented data in their routine practice, and explored the impact on their clinical behavior.

CONCLUSIONS

This explorative study demonstrated that a quality-improvement program, using health outcomes from a national registry, is judged to be feasible.

IMPACT STATEMENT

This study provides preliminary evidence on how physical therapists may use health outcomes to improve their quality, which can be further used in initiatives to improve outcome-based care in primary physical therapy.

A realist synthesis of multicentre comparative audit implementation: exploring what works and in which healthcare contexts

BACKGROUND

Multicentre comparative clinical audits have the potential to improve patient care, allow benchmarking and inform resource allocation. However, implementing effective and sustainable large-scale audit can be difficult within busy and resource-constrained contemporary healthcare settings. There are little data on what facilitates the successful implementation of multicentre audits. As healthcare environments are complex sociocultural organisational environments, implementing multicentre audits within them is likely to be highly context dependent.

OBJECTIVE

We aimed to examine factors that were influential in the implementation process of multicentre comparative audits within healthcare contexts-what worked, why, how and for whom?

METHODS

A realist review was conducted in accordance with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards reporting standards. A preliminary programme theory informed two systematic literature searches of peer-reviewed and grey literature. The main context-mechanism-outcome (CMO) configurations underlying the implementation processes of multicentre audits were identified and formed a final programme theory.

RESULTS

69 original articles were included in the realist synthesis. Four discrete CMO configurations were deduced from this synthesis, which together made up the final programme theory. These were: (1) generating trustworthy data; (2) encouraging audit participation; (3) ensuring audit sustainability; and (4) facilitating audit cycle completion.

CONCLUSIONS

This study elucidated contexts, mechanisms and outcomes influential to the implementation processes of multicentre or national comparative audits in healthcare. The relevance of these contextual factors and generative mechanisms were supported by established theories of behaviour and findings from previous empirical research. These findings highlight the importance of balancing reliability with pragmatism within complex adaptive systems, generating and protecting human capital, ensuring fair and credible leadership and prioritising change facilitation.

Priorities of Hybrid Clinician-Managers: A Qualitative Study of How Managers Balance Clinical Quality Among Competing Responsibilities

OBJECTIVE

Oversight of clinical quality is only one of physical therapy managers' multiple responsibilities. With the move to value-based care, organizations need sound management to navigate this evolving reimbursement landscape. Previous research has not explored how competing priorities affect physical therapy managers' oversight of clinical quality. The purpose of this study was to create a preliminary model of the competing priorities, motivations, and responsibilities of managers while overseeing clinical quality.

METHODS

This qualitative study used the Rapid Qualitative Inquiry method. A purposive sample of 40 physical therapy managers and corporate leaders was recruited. A research team performed semi-structured interviews and observations in outpatient practices. The team used a grounded theory-based immersion/crystallization analysis approach. Identified themes delineated the competing priorities and workflows these managers use in their administrative duties.

RESULTS

Six primary themes were identified that illustrate how managers: (1) balance managerial and professional priorities; (2) are susceptible to stakeholder influences; (3) experience internal conflict; (4) struggle to measure and define quality objectively; (5) are influenced by the culture and structure of their respective organizations; and (6) have professional needs apart from the needs of their clinics.

CONCLUSION

Generally, managers' focus on clinical quality is notably less comprehensive than their focus on clinical operations. Additionally, the complex role of hybrid clinician-manager leaves limited time beyond direct patient care for administrative duties. Managers in organizations that hold them accountable to quality-based metrics have more systematic clinical quality oversight processes.

IMPACT

This study gives physical therapy organizations a framework of factors that can be influenced to better facilitate managers' effective oversight of clinical quality. Organizations offering support for those managerial responsibilities will be well positioned to thrive in the new fee-for-value care structure.

Development of a Standard Set of Outcome Domains and Proposed Measures for Chronic Obstructive Pulmonary Disease in Primary Care Physical Therapy Practice in the Netherlands: a Modified RAND/UCLA Appropriateness Method

Background

Standardization of measures in a common set opens the opportunity to learn from differences in treatment outcomes which can be used for improving the quality of care. Furthermore, a standard set can provide the basis for development of quality indicators and is therefore useful for quality improvement and public reporting purposes. The aim of this study was to develop a standard set of outcome domains and proposed measures for patients with COPD in Dutch primary care physical therapy practice, including a proposal to stratify patients in subgroups.

Material and methods

A consensus-driven modified RAND-UCLA appropriateness method was conducted with relevant stakeholders (patients, physical therapists, researchers, policy makers and health insurers) in Dutch primary physical therapy care in eight steps: (1) literature search, (2) first online survey, (3) patient interviews, (4) expert meeting, resulting in a concept standard set and methods to identify subgroups' (5) consensus meeting, (6) expert meeting (7) second online survey and (8) final approval of an advisory board resulting of the approved standard set.

Results

Five outcome domains were selected for COPD: physical capacity, muscle strength, physical activity, dyspnea and quality of life. A total of 21 measures were rated and discussed. Finally, eight measures were included, of which four mandatory measures: Characteristics of practices and physical therapists, Clinical COPD Questionnaire (CCQ) for quality of life, Global Perceived Effect (GPE) for experience, 6-mins Walk Test (6-MWT) for physical capacity; two conditional measures: Hand-Held Dynamometer (HHD) (with Microfet™) for Quadriceps strength, Medical Research Council Dyspnea (MRC) for monitoring dyspnea; and two exploratory measures: Accelerometry for physical activity, and the Assessment of Burden of COPD tool (ABC). To identify subgroups, a method described in the Dutch standard of care from the Lung Alliance was included.

Conclusion

This study described the development of a standard set of outcome domains and proposed measures for patients with COPD in primary care physical therapy. Each measure was accepted for relevance and feasibility by the involved stakeholders. The set is currently used in daily practice and tested on validity and reliability in a pilot for the development of quality indicators.

Development of a standard set of outcome measures for non-specific low back pain in Dutch primary care physiotherapy practices: a Delphi study

PURPOSE

To develop a clinical standard set of outcome measures that are accepted for relevance and feasibility by stakeholders and useful for (a) interaction between patient and the professional, e.g. shared decision-making in goal-setting, monitoring and feedback based on outcomes, (b) internal quality improvement, and (c) external transparency in patients with non-specific low back pain (NSLBP) in primary care physical therapy.

METHODS

We used a consensus-driven modified RAND-UCLA Delphi method in seven steps with panellists (patients, representatives of patient and physiotherapy associations, researchers, policy makers, health insurers): (1) literature search, (2) first online survey, (3) patient interviews, (4) an experts meeting, (5) a consensus meeting, (6) second online survey, and (7) final approval of an advisory board. Steps 1-4 resulted in potential outcome measures. In the consensus meeting after discussion panellists voted for inclusion per measure. In the second online survey the final standard set was rated on relevance and feasibility on a 9-point Likert scale; when the median score was ≥ 7, the standard set was accepted and finally approved.

RESULTS

Thirteen draft outcome measures were rated and discussed, and finally, six outcome measures were accepted. The standard set includes the Quebec Back Pain Disability Scale, Oswestry Disability Index, Patient-Specific Functional Scale, Numeric Pain Rating Scale, Global Perceived Effect (GPE-DV), and the STarT Back Screening Tool (SBT).

CONCLUSION

This study presents a standard set of outcome measures for patients with NSLBP in primary care physiotherapy accepted for relevance and feasibility by stakeholders. The standard set is currently used in daily practice and tested on validity and reliability in a pilot study. These slides can be retrieved under Electronic Supplementary Material.

Impact of Self- and Peer Assessment on the Clinical Performance of Physiotherapists in Primary Care: A Cohort Study

Purpose: This study evaluated the impact of a quality improvement programme based on self- and peer assessment to justify nationwide implementation. Method: Four professional networks of physiotherapists in The Netherlands (n = 379) participated in the programme, which consisted of two cycles of online self-assessment and peer assessment using video recordings of client communication and clinical records. Assessment was based on performance indicators that could be scored on a 5-point Likert scale, and online assessment was followed by face-to-face feedback discussions. After cycle 1, participants developed personal learning goals. These goals were analyzed thematically, and goal attainment was measured using a questionnaire. Improvement in performance was tested with multilevel regression analyses, comparing the self-assessment and peer-assessment scores in cycles 1 and 2. Results: In total, 364 (96%) of the participants were active in online self-assessment and peer assessment. However, online activities varied between cycle 1 and cycle 2 and between client communication and recordkeeping. Personal goals addressed client-centred communication (54%), recordkeeping (24%), performance and outcome measurement (15%), and other (7%). Goals were completely attained (29%), partly attained (64%), or not attained at all (7%). Self-assessment and peer-assessment scores improved significantly for both client communication (self-assessment = 11%; peer assessment = 8%) and recordkeeping (self-assessment = 7%; peer assessment = 4%). Conclusions: Self-assessment and peer assessment are effective in enhancing commitment to change and improving clinical performance. Nationwide implementation of the programme is justified. Future studies should address the impact on client outcomes.