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Quality indicators can help to ensure our patients don’t fall through the health care cracks (and chasms)

Marie Westby, PT, PhD

As part of my teaching supervisor position in an outpatient arthritis clinic, I still treat patients (and love it!) one day a week. During one of these days, I noted on my paper-based schedule that I had a new patient booked at 10 a.m.

Since the patient had been seen in our clinic a year ago, the scheduling clerk pulled his paper chart for me to review prior to his visit.

I noted that he (I’ll call him Mr. H) had been treated for chronic hip pain due to osteoarthritis, and at that time was hoping to avoid joint replacement surgery. The referral and admission papers were dropped on my desk while reviewing his chart and I read that Mr. H had a total hip replacement (THR) five weeks previously.

The state-of-the-art surgical facility and teaching hospital where the procedure was performed uses a physiotherapy voucher system where patients are eligible for three funded, private physiotherapy visits after THR. After that it is their responsibility to pay out-of-pocket for ongoing rehabilitation, or use their extended health insurance, if they have it.

I was immediately curious as to how this patient came to be referred to our publicly-funded program. 

 

He didn’t return and had now gone more than one month without a physiotherapy consultation or treatment. The private practice therapist had not followed-up with him to ask why he hadn’t returned.

The crack

I went out to the waiting room to greet Mr. H. He shakily rose to his feet and grabbed his two crutches; it’s not common to see patients still requiring two crutches for walking, five weeks post-op.

He slowly walked to the treatment area using a step-to gait pattern, putting very little weight on his surgical leg. After a couple of pauses to catch his breath, he tentatively sat on the raised plinth asking me to check that he wasn’t bending his hip past 90 degrees – standard precaution after THR to avoid dislocation while the capsule heals.

Mr. H admitted that he had barely left his apartment since the surgery; he hadn’t walked outside more than one block. His family physician referred him to our program for rehabilitation after he had complained about a very short initial appointment and lack of individual attention at the private practice clinic.

He didn’t return and had now gone more than one month without a physiotherapy consultation or treatment. The private practice therapist had not followed-up with him to ask why he hadn’t returned.

 

The chasm

After further inquiry, I found that:

  • I was not able to access a shared electronic health record that might have told me what Mr. H’s discharge status was from the hospital. While the patient was provided with a copy of a discharge report, he had given this to his private physiotherapist and did not keep a copy.
  • I had to call the acute care hospital to request a copy of the physiotherapy discharge report which indicated that he had a routine hybrid THR with no surgical complications, was weight-bearing as tolerated (WBAT), and had no additional precautions precluding him from following a standard progressive rehabilitation program.
  • He was not provided written instructions on weight bearing and use of walking aids; he thought he was told to not put his full weight on the surgical leg for six weeks. He hadn’t put more than about 25 per cent of his weight on his leg since the surgery.
  • He did not know when his follow-up appointment with his surgeon was.
  • He was advised to continue with three of the same exercises prescribed during his acute care stay by the private physiotherapist. The patient did not recall being told, shown how, or when to progress these exercises. At five weeks post-op, Mr. H was still doing the same three exercises: ankle pumps, active hip/knee flexion and extension in supine position, and bridging.
  • When assessed in the clinic, his self-paced walking speed over 10 metres was 0.34 m/sec – not sufficient for ambulating safely in the community or walking across roads with a “walk” light.

 

Not quite high-quality care

Practitioners who see clients after elective hip surgery know that this is not optimal, coordinated, and efficient care for a patient who has undergone a straightforward THR.

This was not “high quality” care. The result of this experience was that this 65-year old man, determined to get back to work, was:

  • Weeks behind in his functional recovery;
  • Confused by the conflicting advice on weight bearing through the surgical leg; and
  • Unclear about exercises to do at home, and what muscle groups to focus on.

The Institute of Medicine in the US defines quality health care as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”(1). The IOM goes on to identify six aims of quality care: safe, effective, patient-centred, efficient, timely and equitable (2).

 

Quality indicators can help your practice (and your patient)

One way to assess and monitor the quality of care provided to patients is through the development and use of quality indicators (QIs). These specific, measurable aspects of health care delivery specify the minimum standard of care a patient should receive for a given health condition or procedure. Quality indicators can reflect the structure (e.g., equipment and facilities), process (e.g., delivery of rehab interventions) or outcomes (e.g., self-reported function, quality of life) of care (3).

Physiotherapists can use QIs to guide clinical decision making, assess treatment effectiveness, report achievement of benchmarks to key stakeholders (including patients) and inform quality improvement efforts. Patients can use QIs to become more engaged in their own care, make informed decisions about their treatment options, select providers, and monitor the quality of care received (4).

Evidence-based, and often consensus-generated, QIs are available for a variety of acute and chronic health conditions and health promotion, medical, surgical and rehabilitation interventions that are relevant to physiotherapy practice (4). Selecting ones that are most important and appropriate for your patient population, treatment setting and practice model is critical.

 

How to select a QI to use in your practice

Features to look for in an appropriate QI:

  • Is the process or outcome QI within your control or your clinic’s control? Is it relevant or specific to PT practice? (e.g., are there factors outside of your treatment intervention that could influence whether a patient received a specified QI?)
  • Is the QI feasible to collect in your practice? (QI data readily available, minimal time/burden/cost to collect and analyze, integrated into patient flow/care path)
  • Will this QI guide clinical decision making? (help you to provide better care, monitor treatment effectiveness, compare outcomes across providers or clinics)
  • Is the QI important in your practice/patient population? (patient centred, large patient volume, area with significant practice variation or less than optimal outcomes)
  • Does the QI statement represent high-quality care that is supported by a strong evidence base?

 

Sources of QIs

Places to look for established QIs relevant to physiotherapy practice:

 

What QIs could have helped Mr. H?

So many QIs were not met in Mr. H’s case that I’m not sure where to start. I’ll focus on one generic QI that applies across health conditions and health care settings – care coordination. The Agency for Healthcare Research and Quality (AHRQ) endorsed a QI reflecting transfer of care and care coordination.

“IF a vulnerable elder is discharged from a hospital to home (or nursing home), THEN there should be a discharge summary in the outpatient (or nursing home) medical record; BECAUSE treatment of patients after transfer from a hospital requires communication of clinical information (5).” (Vulnerable elders are community-dwelling individuals aged 65 and older at risk of functional decline or death over a two-year period).

Care coordination involves “organizing patient care activities and sharing information among all healthcare providers concerned with a patient’s care to achieve safe and effective care” (6). The Institute for Healthcare Improvement in the US recommends use of standardized care transition and “handoff” communication between hospital providers, discharge care providers and care settings for up to a year post-surgery including communication checklist and template, transfer of rehabilitation and medical notes, and notice of discharge (7).

Had this coordinated care and communication taken place, Mr. H’s rehabilitation and physical recovery very likely would have been further along.

 

Over to you

  1. What QIs do you use in your practice?
  2. What “chasm” experiences have you had with a patient?
  3. How would you structure this system to lessen or close-up cracks like these?

 

References:

  1. Lohr K. Committee to Design a Strategy for Quality Review and Assurance. In: Medicare, editor. Medicare: a strategy for quality assurance. Vol. 1. Washington, DC: National Academy Press; 1990.
  2. Institute of Medicine (IOM). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, D.C: National Academy Press; 2001.
  3. Straus S, Tetroe J, et al. eds. Knowledge Translation in Health Care: Moving from Evidence to Practice. 2nd ed. West Sussex, UK: Wiley-Blackwell; 2013.
  4. Westby MD, Klemm A, et al. Emerging role of quality indicators in physical therapist practice and health service delivery. Phys Ther. 2015;96(1):90-100. PMID: 26089040
  5. Wenger NA, Young RT. Quality indicators for continuity and coordination of care in vulnerable elders. J Am Geriatr Soc. 2007;55 Suppl 2:S285-92.
  6. Agency for Healthcare Research and Quality (AHRQ) Available at:  http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html
  7. Premier, Inc. and Institute for Healthcare Improvement. Integrated Care Pathway for Total Joint Arthroplasty. Charlotte, NC:Premier, Inc and Cambridge, MA: Institute for Healthcare Improvement; 2013.