Does quality matter?
If you ask any physiotherapist about the outcomes of their care, they will undoubtedly tell you that most of their treatments are effective and patients are satisfied. The question is: how do we know? We pride ourselves on being a scientific profession, but do we fully utilise the scientific method in evaluating the efficacy of our physiotherapy interventions?
Sure, we use clinical reasoning to establish a diagnosis (the hypothesis), and implement a treatment regime based on the particular presentation, our knowledge of the literature, our experience with similar conditions and the patient’s preferences (the experiment). But do we spend as much time measuring results as we do honing our diagnostic and interventional skills? Do we focus on sustainable outcomes that are meaningful to our patients? Do we really know, six months after treatment ceases, how they are doing? Whether they’ve gone on to other providers, or if they were actually ‘cured’?
Building a culture of continual quality improvement and professional excellence has several facets. At an individual level, reflective practice, peer discussion, ongoing PD, education and keeping up to date with current evidence all play important roles. At a practice or department level, there need to be systems in place to ensure that we know the true outcomes of our practice, and benchmark against similar services. An industry-wide view can also add value.
In his book Better; A surgeon’s notes on performance, Atul Gawande discusses the role of data collection, outcome measurement and benchmarking in several medical settings, and the innovative changes to clinical practice that have resulted. One example is that of a Cincinnati hospital managing patients with cystic fibrosis. The facility was staffed by national leaders in the field; clinicians who contributed to the development of national guidelines for the management of this condition. The staff were committed, caring, diligent, scored highly on patient satisfaction measures and developed innovative programs—sounds like a recipe for success, right?
Unfortunately, the available benchmarking data revealed that there was a variance of greater than 15 years in average life expectancy of patients managed in this clinic compared to the best performing centres in the country. The data was not available in a way that allowed high performing clinics to be identified, and learning to be gained.
Over several years, a culture of more open reporting developed, and the staff were able to identify, visit and learn from the best performing centres. The difference in outcomes was identified to be in large part based on some ‘intangibles’ in clinical care: the coaching skills of staff to maximise adherence with recommendations, developing a culture of intolerance for clinical variation in care plans, and several other features.
Sometimes, we need to take on board information that may confront our assumptions. We need to embrace direct patient feedback and monitor longer term outcomes of our care. Otherwise, we will always be at the mercy of the results of others, through published research or surveys from funders, to interpret what the impact of our interventions really is.
When we advocate for access to physiotherapy, we need information on which to base our efforts. Much of this is not currently available. It is up to us to get it.
I encourage all clinics and departments to start the conversation on how they measure longer term outcomes and patient satisfaction. Get together with your peers and agree on a methodology so data can be comparable.
MARCUS DRIPPS, APAM
APA National President
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