“The experience of people using our health services is that care is often excellent, but excellence is not reliably and consistently guaranteed.”1
Quality is often on our minds at the College of Physiotherapists of Alberta, leading to questions about how this organization can facilitate high-quality physiotherapy services across the province. Clinicians also face quality questions daily: How do you know you are doing a good job? How does your practice of physiotherapy compare with that of your peers? How can you do a better job today than you did yesterday?
These are the very questions that are at the heart of quality improvement. First, we must define what quality is. While most of us believe we can spot quality when we see it, defining quality proves more difficult. Is it efficiency, cost effectiveness, eliminating process variation, adherence to clinical guidelines or avoiding negative outcomes? For some, the most expensive option is the highest quality one, for others it’s the most cost-effective option. For most of us, myself included, safety is a key measure of quality. While quality and safety are closely linked in the literature, let’s set aside issues of adverse events and patient safety for a future article to focus of quality care.
It’s not surprising that quality, ultimately, is in the eye of the beholder. Quality of care is demonstrated by our ability to provide patient-centered care that is safe, effective equitable and timely.1 In other words, the patient defines quality care in clinical practice. There are, however, other stakeholders that also have a voice in the quality conversation.2 In fact, it seems that one clinical episode could have multiple customers, all of whom are interested in different indicators of quality. Patients care about the outcomes that matter in their lives: can they work, play and live without pain? Payers care that what they are purchasing is of good value, effective, and achieves the patient outcomes in the most cost effective and efficient way possible. The health-care system cares that the limited resource known as “physiotherapists” is used in the best, most effective way possible, ensuring that treatments applied create benefit to the health of the patient and the population as a whole.
Over the years many models of change and quality improvement have been presented to solve the issue of quality in healthcare such as CQI, TQI, Lean, Six Sigma, and PSDA. Rather than discussing the merits of different quality improvement programs, let’s consider the practice changes that lead to improved quality of care to the patient, realizing that when true quality in direct patient care occurs the concerns of insurance companies and the health system at large are also met. There is lots of evidence that quality care is cheaper care and results in greater satisfaction for the patient and the provider. Some key ingredients must be in place in order to achieve quality improvement, regardless of the framework applied, such as leadership, collaboration, small measurable changes and time.1,2,3,4
The first step is to decide that change is needed and commit to improving. This is leadership and it happens at all levels of an organization, from bottom up and top down. As physiotherapists we must first be accountable for the outcomes that our work generates. We must each lead our organizations on a mission of quality in the name of performing our work with integrity. Everyone has a role to play in the pursuit of quality, however the exact role and approach will vary depending on the role you play in your organization. Will you innovate change, create opportunities for others to improve, or adopt and embed a quality improvement attitude into everything that you do? In reality, “Leaders at all levels need to encourage and spread ideas about alternative ways of doing things.”1
Although those at the front line often complain of their lack of ability to influence the system, new ideas from front line are especially important as the combination of efforts of many will lead to improvement.1 By collaborating with others in the same practice environment to improve care processes and clinical practice, or joining with those from other organizations through online discussion forums and communities of practice, the evidence informed innovations of a single clinician can spread and start a movement of improved quality of care.3
In order to innovate and improve you need data, and one thing all quality improvement programs have in common is a commitment to data. If you’ve ever heard the saying “you measure what you treasure,” in the context of physiotherapy practice it may be more correctly phrased as “measure what your patients treasure.” To achieve improvement, one needs to gather data, consider the outcomes achieved and then look for ways to improve those outcomes through intentional process improvement strategies.4
Sometimes creating the case for change takes more than data, it takes a compelling story of someone who didn’t get the care they needed to remind us of why we are here and why we need to do better.
The gap between what is achieved and what we wish to achieve creates the space for innovation and improvement. Improvement efforts can include:
- A review of best practices and education to ensure appropriate, effective treatments are employed.
- The development of clinical guidelines and decision tools to ensure that the normal route through therapy for a particular condition is known and followed where possible.
- The creation of checklists to ensure that the ‘best practice’ care is consistently delivered, regardless of who is providing it.
While it is unwise to mindlessly follow care pathways and clinical guidelines, process variability decreases and both quality and safety improve when clinicians are more consistent in providing evidence-informed, best practice care such as that set out by these tools. While process variability may indicate that patient centered care is happening, it may equally reflect a failure on our part to be consistent in our approach to providing care.
So how can a physiotherapist working on their own, a busy manager or practice owner, or a large institution improve the quality of the service they offer? The reality is quality improvement is a process, one that takes time and effort. The key is small, measurable change sustained over time.1 As a clinician these efforts will lead to consistent improvement at the point of care. As a manager or business owner this will signify that your business is serious about quality improvement. This is an important step in developing a culture of quality improvement and fostering these behaviours in those you employ. By choosing small things to change, you increase the likelihood of success in making a change, and as we are often told “success begets success." The College of Physiotherapists of Alberta encourages all registrants to reflect on how to increase the quality of their individual practice through a process of small, measurable changes.
- NHS Wales. The quality improvement guide: The improving quality together edition. Cardiff: 1000 Lives Improvement, 2014. Available from: http://www.1000livesplus.wales.nhs.uk/sitesplus/documents/1011/Quality%20Improvement%20Guide%20-%203rd%20edition%20%28IQT%29%20WEB.pdf
- Berkowitz B. Collaboration for health improvement: Models for state, community, and academic partnerships. Journal of Public Health Management Practice 2000; 6(1): 67-72.
- Gabbay J, le May A. Introducing evidence-based innovations into healthcare systems: Lessons from a series of UK studies. Presentation at: The Health Policy Speaker Series; 2014 Oct 21; Edmonton, AB.
- Smith J. President’s message: Quality is as quality does. The Journal of Acute Care Physical Therapy 2012; 3(2): 180-181