







































Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the provision 
of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, No 4, 2018. DOI: 
https://doi.org/10.33137/cpoj.v1i2.31326 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 
 
 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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https://doi.org/10.33137/cpoj.v1i2.31326
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Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

1 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 RESEARCH ARTICLE 

 
DEVELOPMENT OF A GOVERNMENT CONTINUOUS QUALITY IMPROVEMENT 
PROCEDURE FOR ASSESSING THE PROVISION OF BONE ANCHORED LIMB 
PROSTHESIS: A PROCESS RE-DESIGN DESCRIPTIVE STUDY 
 
Frossard L1,2,3*, Ferrada L4, Quincey T4, Burkett B3, Berg D4 
 
1Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia. 
2School of Nursing, Midwifery and Paramedicine, Faculty of Science, Health, Education and Engineering, University of the Sunshine 

Coast, Maroochydore, Australia. 
3School of Allied Health Sciences, Griffith University, Gold Coast, Australia. 
4Queensland Health, Queensland Artificial Limb Service, Brisbane, Australia. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

*CORRESPONDING AUTHOR  
Adj / Professor Laurent Frossard (PhD), ORCID: 0000-0002-0248-9589 
PO Box 143, Red Hill, 4059, QLD, Australia. 
Phone: +61 (0)413795086;  
E-mail: LaurentFrossard@outlook.com 
DOI: https://doi.org/10.33137/cpoj.v1i2.31326 

CITATION 

Frossard L, Ferrada L, Quincey 

T, Burkett B, and Berg D. 

Development of a government 

continuous quality improvement 

procedure for assessing the 

provision of bone anchored limb 

prosthesis: a process re-design 

descriptive study. Canadian 

Prosthetics & Orthotics Journal, 

Volume 1, Issue 2, No 4, 2018. 

DOI:https://doi.org/10.33137/cpo

j.v1i2.31326 

ABSTRACT 

BACKGROUND: Evidences of sustainable clinical benefits of bone-anchored 

prosthesis (BAP) using osseointegrated fixation over typical socket-suspended 

prostheses are becoming more probing. This influx of individuals to be fitted with 

BAP has pressed government organisations to adjust their policies. However, the 

appraisal of consumer’s experience for the provision of BAP founded by 

government organisation is yet to be developed. This descriptive study shares the 

experience gained by a government organisation, namely the Queensland Artificial 

Limb Service (QALS), while developing a specific BAP-inclusive continuous quality 

improvement (CQI) procedure. 

OBJECTIVE(S): The primary objective was to present the methods and outcomes 

of key steps required to plan and create this CQI procedure. The secondary 

objective was to highlight key barriers and facilitators of the transition from a 

socket-focused to the proposed BAP-inclusive CQI procedure.   

METHODOLOGY: The re-design process of the CQI procedure for 65 current 

QALS’s consumers with BAP involved a two-step process for the planning (e.g., 

case-mix, stakeholder) and creation (e.g., diagnosis, technical options, cost). 

FINDINGS: Prosthetists labour toward CQI procedure represented 1.3 hrs out of 22 

hrs and AUD$213 out of AUD$3,300 or 6% of the whole procedure for the provision 

of BAP. The time spent by a prosthetist, consumer and QALS staff represented 

24%, 24% and 53% of the time of the CQI procedure, respectively. The cost of 

prosthetist and QALS staff labour represented 70% and 30% of the CQI procedure, 

respectively. 

CONCLUSIONS: This descriptive study shares the workings and methodology that 

government organisations, such as QALS, can use to re-design a CQI procedure 

for comprehensive appraisal of the provision of prosthesis that could be inclusive of 

BAP and affordable while minimally time-consuming for prosthetists. The transition 

from a socket-focused to the proposed minimally disruptive BAP-inclusive CQI 

procedure was facilitated by prior knowledge of BAP treatment, early identification 

of the stakeholders and adaptation of current CQI procedure. 

 

 

ARTICLE INFO 

Received: October   25, 2018 

Accepted: December 11, 2018 

Published: December 12, 2018 

 

KEYWORDS 

Amputation; Artificial limb; Bone-

anchored prosthesis; Quality 

improvement; Osseointegrated 

implants; Osseointegration; 

Procedure; Prosthesis; 

Reimbursement. 

https://doi.org/10.33137/cpoj.v1i2.31326
mailto:LaurentFrossard@outlook.com
https://doi.org/10.33137/cpoj.v1i2.31326
https://doi.org/10.33137/cpoj.v1i2.31326
https://doi.org/10.33137/cpoj.v1i2.31326


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

2 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 LIST OF ABBREVIATIONS 

 
BAP: Bone-anchored prosthesis 
SSP: Socket-suspended prostheses 
QALS: Queensland Artificial Limb Service 
CQI: Continuous quality improvement 
PSP: Prosthetic Service Provider  
CMS: content management system 
PID: Prosthetic Issue Document 
VOS: Validation of Services 
PSE: Prosthetic Service Evaluation 
SF12: Short Form 12V2 Health Survey  
PLUS-M™: Prosthetic Limb Users Survey of Mobility 
DVA: Rehabilitation Appliance Program of the Department of 
Veteran Affairs  
NDIS: National Disability Insurance Scheme 

 
INTRODUCTION 

Strong demand for bone-anchored prostheses 

Evidences of sustainable clinical benefits of bone-

anchored prosthesis (BAP) using osseointegrated 

fixation over typical socket-suspended prostheses 

(SSP) are becoming more probing, particularly for 

young and active individuals with non-vascular 

transfemoral amputation.(1-4) Clinical risks with BAP 

particularly infection and breakage of components 

are currently deemed acceptable although yet to be 

resolved satisfactorily.(5-8) Significant improvement 

in health-related quality of life has driven a steady 

demand from wide range of individuals with lower 

limb amputation.(1-4,7-26) Indeed, surgical procedures 

are growing at an unprecedented pace 

worldwide.(18, 27, 28)  

Health services delivery of bone-anchored 

prosthesis  

This influx of individuals fitted with osseointegrated 

fixation has pressed government organisations, like 

the Queensland Artificial Limb Service (QALS), to 

adjust their policies for fair and equitable provision 

of BAP.(18, 29) 

Indeed, QALS established such procedure allowing 

financial assistance for consumers choosing BAP 

that involves seven processes costing AUD$3,300 

for 22 hrs of labour per patient during the 

treatment.(29) Furthermore, cost cross-comparing 

and cost-effectiveness demonstrated health 

economic benefits of BAP over SSP from 

government perspective.(30-32) For instance, 

provision of BAP costed 21±41% more but 

increased quality-adjusted life-year by 17±5% 

compared to SSP leading to an indicative 

incremental cost effectiveness ratio of 

approximately AUD $17,000 per quality-adjusted 

life-year. Despite a partial compensation of the cost 

by quality-adjusted life-year, the provision of BAP 

was deemed cost-effective since the incremental 

cost effectiveness ratio was noticeably below 

willingness to pay threshold.(33) 

Need for government continuous quality 

improvement procedure 

Appraisal of consumer’s experience for the 

provision of BAP by government organisation is yet 

to be developed. A series of standardised surveys 

could assess delivery of particular prosthetic care 

and/or experience with prosthetic components (e.g., 

SERVQAL, OPUS, QUEST).(34-41) However, their 

relevance to provision of specific BAP care by 

government organisations is limited.    

QALS has carried out a SSP-focused continuous 

quality improvement (CQI) procedure detailed 

below that has emerged through regular revisions 

over the last decade in response to best practice 

and legal obligations imposed by government as 

well as expectations from consumer advisory 

groups. Whilst some aspects of this CQI procedure 

are relevant to the provision of BAP, there is a need 

to further investigate developments of CQI 

procedure capable of appraising consumer’s 

experience for the provision of BAP by government 

organisation.  

Objectives 

The aim of this work was to improve government 

health service delivery of prosthetic care specific to 

individuals fitted with BAP. The purpose of this 

process re-design descriptive study was to share 

the experience gained by a government 

organisation while developing a specific BAP-

inclusive CQI.    

The primary objective was to present the methods 

of model re-design with particular emphasis on 

outcomes of key steps required to plan (e.g., case-

mix profiling, stakeholder analysis) and create (e.g., 

diagnosis, pros-cons analysis of technical options, 

cost) this specific CQI procedure. The secondary 

objective was to highlight key barriers and 

facilitators of the transition from a pre-existing 

SSP-focused to the proposed BAP-inclusive CQI 

procedure. 

 

 

https://doi.org/10.33137/cpoj.v1i2.31326


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

3 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 METHODS  

Setting 

The study followed ethical guidelines from the 

Queensland Health’s Health Innovation, Investment 

and Research Office (HIIRO) responsible for 

consultation, development and review of State-wide 

research ethics and research governance policies. 

This study was undertaken by QALS in the 

jurisdiction of the Queensland State Government 

Minister of Health, Australia. With a yearly budget of 

AUD$5.4 million, QALS provides equitable funding 

for prosthetic services to 3,600 active consumers 

annually through a network of up to 10 individual 

prosthetists referred to as Prosthetic Service 

Provider (PSP).(29, 30, 33)   

Participants 

The development of the CQI procedure was led by 

a  QALS steering committee including QALS 

management team, two researchers in health 

services, three PSPs and the five first consumers 

representing 8% of the QALS’s population fitted 

with BAP.(42, 43)  

Study design  

The descriptive study started in July 2015, shortly 

after the whole QALS’s procedure for provision of 

BAP was completed.(29) As detailed in Table 1, the 

development of the specific CQI procedure was 

achieved using the following two-step re-design 

process: 

• Step 1 to plan the procedure, including: 

o Step 1A identifying problems to solve using root 

cause analysis that involved case-mix profiling 

achieved by looking at typical demographics, 

amputation, as well as access to prosthetic care 

and funders data extracted from QALS client 

information system.  

o Step 1B identifying deliverables of the CQI 

procedure that involved stakeholder analysis 

using typical matrix ranking selected 

organisations in relation to their power and 

interest in CQI depending on capacity to 

influence allocation of resources and to provide 

prosthetic and medical care, respectively. 

Stakeholders were classified as controllers (high 

power, low interest), promoters (high power, high 

interest), providers (low power, high interest) or 

advocates (low power, low interests).(44)   

• Step 2 to create procedure including: 

o Step 2A diagnosing quantitatively the suitability 

of the current SSP-focused CQI procedure by 

counting the number of sections, questions and 

possible answers in each evaluation form and 

by categorising the focus of each question as 

administration (e.g., consumer’s identification, 

processing status, quality control), service (e.g., 

labour associated with provision of prosthetic 

services and/or components), prosthesis (e.g., 

provision of repair, fitting, replacement of 

prosthetic components and/or cosmetic cover), 

socket (e.g., light, definitive) or BAP (e.g., 

provision of all interventions to fit a BAP). 

Questions focusing on administration, service 

and BAP were considered relevant while those 

focusing on prosthesis and socket were 

deemed partially suitable and irrelevant to 

appraisal of provision of BAP, respectively. 

o Step 2B exploring options for new specific CQI 

procedure that relied on pros-cons analysis of 

pathways and products investigated for 

administration and analysis of surveys and 

content management system (CMS).  

o Step 2C adapting the existing CQI procedure to 

each phasis of BAP treatment, adjusting forms 

and estimating participants’ typical time 

commitment.(29) Cost for PSPs’ contribution and 

internal labour (e.g., QALS staff time) allocated 

to CQI procedure (e.g., data collection, entry 

and reporting) was set at hourly fee of 

AUD$160 and AUD$30, respectively. All costs 

are reported in Australian dollars (1 Australian 

dollar ≈ 0.63 Euro ≈ 0.56 British pound ≈ 0.74 

US dollar) according to 2017-18 prices. 

In all steps, the steering committee considered 

critical qualitative and quantitative information and 

applied a typical standards for interactive inquiry 

process and data-driven collaboration leading to 

consensus.(45) 

 

RESULTS 

Definition of specific procedure 

Case mix profile 

The characterisation of case-mix presented in 

Table 2  involved the 65 QALS consumers fitted 

with lower limb BAP since 2011, representing 16% 

and 7% of existing BAP population estimated at 400 

in Australia and 950 worldwide, respectively.  

 

 

https://doi.org/10.33137/cpoj.v1i2.31326


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

4 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 
Table 1. Timeline and actions of the two-step process 

taken by the Queensland Artificial Limb Services (QALS) 

to develop specific Continuous Quality Improvement 

(CQI) procedure to appraise consumer’s experience for 

provision bone-anchored prostheses (BAP). 

 

 
 

 

Table 2. Case-mix profile including demographics, 

amputation, access to care and funder information for the 

65 Queensland Artificial Limb Services (QALS) 

consumers with lower limb amputation treated with bone-

anchored prosthesis (BAP) between 01/2011 and 

01/2017 (PSP: Prosthetic Service Provider , DVA: 

Rehabilitation Appliance Program of the Department of 

Veteran Affairs, NDIS: National Disability Insurance 

Scheme). 

 

Stakeholders analysis 

Twenty key stakeholders were identified with half 

operating at state or national levels as presented in 

Figure 1C and further detailed in Figure 2 

(Supplement). No stakeholder was identified as 

controllers. As expected, the six (30%) promoters 

involved the decisional entities around QALS 

including consumer advisory group, in particular, as 

well as national government funding agencies. The 

seven (35%) providers involved all health 

professionals in the clinical teams responsible for 

osseointegration treatments in state and interstate, 

including essentially prosthetists. The seven (35%) 

advocates included mainly consumer support 

groups and professional associations as well as 

other artificial limbs services across Australia. 

Creation of specific procedure 

Diagnosis of initial CQI procedure 

The appraisal of QALS’ provision of prosthetic 

services involved a series of evaluations supported 

by three paper-based forms including a total of 73 

items allowing 240 possible answers. As detailed in 

Table 3, the review this CQI showed that:   

• Evaluation A, involving seven steps, relied on 

Prosthetic Issue Document (PID) to acknowledge 

PSP’s service that triggers QALS’ reimbursement. 

Circulated by mail, the PID included 18 (25%) of 

all the questions that were completed by PSPs 

and consumers after each service. A total of 61% 

of the questions focused on the whole prosthesis.    

• Evaluation B, involving four steps, relied on a 

Validation of Services (VOS) form designed to 

assess a consumer’s satisfaction with quality of 

the prosthetic service delivered by PSP. The VOS 

included 25 (34%) of all the questions that were 

completed by QALS staff while talking to 

consumers over the phone after each service.    

• Evaluation C, involving four steps, relied on 

Prosthetic Service Evaluation (PSE) form 

designed to assess overall consumer’s 

experience with service provided by QALS. The 

PSE included 30 (41%) of all the questions that 

were completed by consumers yearly.  

 

Overall, 51%, 40% and 9% of the questions were 

relevant, partially suitable and irrelevant to the 

development of CQI for BAP, respectively. The 

content of the paper version of each form was 

manually tabulated by QALS staff into a purposely-

designed CMS, easily adjustable in-house in 

response to stakeholders’ regular changes in 

reporting expectations, including a series of 

spreadsheets organising entries, analysis and 

reporting of consumer experience information.  

 

 

A B C

Define project Determine deliverables Review literature

•      Identify problems to solve
•      Review regulatory 

obligations
•      Delivery of health care 

•      Define aim, purpose and 

objectives

•      Conduct stakeholders 

analysis

•      Provision of prosthesis 

services 

•      Profile case-mix 
•      Determine reporting 

expectations 

•      Consumer satisfaction 

survey

A B C

Assess SSP-focused CQI Explore options Create BAP-inclusive CQI 

•      Review current process •      Simulate new workflow 
•      Adapt CQI procedure to 

BAP treatment

•      Review current forms
•      Determine cost-benefits 

analysis
•      Adjust forms 

•      Review current Content 

Management System

•      Choose most cost-effective 

procedure

•      Determine participants 

involvements 

Step 1. Plan BAP CQI procedure (06/2016 - 12/2016)

Step 2. Redisign BAP CQI procedure (01/2017 - 07/2017)

Number Percentage Min Max

Demographics

Male 50 77 - - - -

Female 15 23 - - - -

Age (years) 65 100 52 13 26 74

Height (m) 58 89 1.75 0.10 1.50 1.94

Mass (kg) 62 95 82.86 17.29 45.00 128.00

Amputation

Timeline

Time since first amputation (years) 65 100 20 15 1 66

Time since first surgery for BAP (years) 64 98 3 1 0 6

Cause

Trauma  44 68 - - - -

Vascular insufficiency 9 14 - - - -

Malignant neoplasma 6 9 - - - -

Level of amputation

Transfemoral 53 82 - - - -

Transtibial 9 14 - - - -

Through Knee 3 5 - - - -

Hip disarticulation 1 2 - - - -

Number of amputations

Unilateral 58 89 - - - -

Bilateral 5 8 - - - -

Quadrilateral 2 3 - - - -

Access to prosthetic care

Distance-Residence to PSP (km) 60 92 145 212 5 1,345

Distance-Residence to QALS (km) 62 95 364 499 5 1,771

Funder

QALS 38 58 - - - -

DVA 8 12 - - - -

NDIS 12 18 - - - -

Mean SD
RangeParticipants

https://doi.org/10.33137/cpoj.v1i2.31326


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

5 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 

Figure 1. Overview of initial and newly developed specific 

Continuous Quality Improvement (CQI) procedure to 

appraise consumer’s experience for socket-suspended 

(SSP) and bone-anchored (BAP) prostheses that involved 

(A) collection of data with clients and Prosthetic Service 

Providers (PSP),  (B) analysis of the data relying on 

Content Management System (CMS) and (C) reporting to 

stakeholders, respectively. 

 

Table 3. Overview of structure with number of sections, 

questions and possible answers and percentage of 

questions focusing on administration, service, prosthesis, 

socket or bone-anchored prosthesis (BAP) for each initial 

form of the continuous quality improvement (CQI) 

procedure used by Queensland Artificial Limb Services 

(QALS). PID: Prosthetic Issue Document, VOS: 

Validation of Services, PSE: Prosthetic Service 

Evaluation.  

 

 

Explore options for specific CQI  

Opportunity for redesigning a specific CQI 

procedure relying on new pathways, forms and 

cloud-based technological platform was initially 

investigated.(37, 46, 47) Quote from external 

professional provider with relevant programming 

skills indicated that such project will require 

approximately 200 hrs of labour at the cost of 

AUD$33,000.   

Alternatively, keeping the current delivery pathway 

and adjusting forms and CMS was considered. We 

made the assumption that these adjustments could 

be achieved in approximately 120 hrs for in-house 

knowledgeable staff labour at an internal cost of 

AUD$3,600. The latter option was deemed the most 

sensible and cost-effective.  

 

Creation of BAP-inclusive CQI procedure 

A dynamic overview of the proposed BAP-inclusive 

CQI procedure in Figure 1 detailed the 

intersections between phases of the treatment and 

each of the three sequential evaluations with 

emphasis on contribution of participants, documents 

and forms used, the tasks achieved, CMS used to 

collect, analysis and report consumer experiences 

outcomes.  

Evaluations A and B were required to be completed 

after each service that occurred typically at least 

four times during the first year of the BAP treatment 

between pre-operative consultation and fitting of 

definitive prosthesis. Evaluation C occurs usually at 

least once a year after delivery of definitive 

prosthesis.       

The adaptation and reorganisation of all forms was 

achieved by implementing basic principles of so-

called computerized adaptive testing.(48) The first 

part of all forms involving administration items, 

mainly focusing on identification of consumer and 

processing information, remained unchanged. 

However, a two-answer routing question was added 

at the end of administration section asking 

consumers what type of attachment they use. The 

SSP users were directed to the second part 

including essential questions in current forms 

related to socket and prosthesis cleaned of any 

BAP related items. Those using BAP were directed 

to the third part including newly developed 

questions. Practically, this third part in PID and VOS 

forms required consumers to indicate at which of 

  Evaluation A Evaluation B Evaluation C 
CQI 

  PID VOS PSE 

Structure (Number) 

    Sections 4 6 7 17 

Questions 18 25 30 73 

Answers 51 79 110 240 

Focus (Percentage of questions) 

   Administration 24 57 7 28 

Service 0 0 53 22 

Prosthesis 61 37 30 40 

Socket 13 5 10 9 

BAP  2 1 0 1 

 1 

https://doi.org/10.33137/cpoj.v1i2.31326


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

6 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 the five stages of the treatment they were at. 

Developments of the third section in the PSE form 

was more involved and lead to design of custom-

made survey including 32 questions as outlined in 

Table 4 to assess clinical outcomes in six 

domains.(49) Benefits were assessed into two 

domains including the health-related quality of life 

and mobility outcome using the standardized self-

report Short Form 12V2 Health Survey (SF12) and 

Prosthetic Limb Users Survey of Mobility (PLUS-

M™) 12-item short forms, respectively.(39, 48) Safety 

was assessed by self-reporting selected adverse 

events into four domains including fixation stability, 

fixation integrity, injuries as infections.(5) 

As presented in Table 5, resources provided to 

PSP’s efforts toward CQI procedure represented 

1.3 hrs out of 22 hrs and AUD$213 out of 

AUD$3,300 or 6% of the whole procedure for the 

provision of the BAP detailed previously.(29) The 

time spend by PSP, consumer and QALS staff 

represented approximately, 24%, 24% and 53% of 

the time of the whole procedure, respectively. The 

cost for reimbursement of PSP’s and QALS staff 

labour represented 70% and 30% of the total costs 

of the CQI administration per consumer, 

respectively. Altogether, the typical total cost per 

consumer for the first year of treatment with BAP 

was approximately AUD$416.  

 

Table 4. Overview of 32 questions asked in third part of 

the Prosthetic Service Evaluation (PSE) form extracted 

from two standards surveys and eight specifically-

designed questions to assess six evaluation domains 

related to benefits and safety experienced by consumers 

fitted with bone-anchored prosthesis provided by QALS. 

DISCUSSION 

Outcomes 

This study revealed that a government organisation, 

such as QALS, can redesign a CQI procedure for 

comprehensive appraisal of the provision of 

prosthesis that could be inclusive of BAP while 

been minimally time-consuming for PSPs and 

affordable. 

 

The transition from a SSP-focused to the proposed 

minimally disruptive BAP-inclusive CQI procedure 

was facilitated by the following redesign inputs: 

• Capitalising on prior knowledge. Initial 

understanding of specific rehabilitation program 

following BAP treatment was gained during 

development of the QALS overall procedure to 

support provision of BAP. This elucidated 

involvements of PSP in the delivery of services 

and components during treatment that was 

essential to determine workload and cost.(29) 

 

• Identification of the stakeholders. Early 

selection, organisation of key stakeholders 

helped to ascertain common and separate 

expectations and subsequently prioritise 

reporting requirements. 

• Adapting current CQI procedure. 

Redesigning a BAP-specific CQI might lead to 

increased delivery efficiency and, more 

importantly, suitability of tailored forms 

providing distinctive results for this group of 

consumers. However, such parallel CQI 

procedure has several shortcomings including, 

but not limited to, confusion of consumers used 

to initial CQI, significant cost required to build 

dedicated CMS, lack of consistency in reporting 

limiting benchmarking with other consumers.(49) 

Alternatively, keeping the initial procedure 

relying on three evaluations but adapting the 

forms and CMS was deemed the most sensible 

and cost-effective option. 

 

The main obstacles to the development of BAP-

inclusive CQI procedure were associated with 

adjustments of PSE form, particularly the selection 

of relevant outcomes to consider. Only confounders 

of customer’s experience responsible for potential 

cross-correlation with provision of particular 

components and clinical outcomes were selected 

from classification of benefits and safety of BAP 

Standard Customized

1. Benefits

1.1. Health-related quality of life

● Short Form 12V2 Health Survey (SF12) 12 x

1.2. Mobility outcome

● Prosthetic Limb Users Survey of Mobility (PLUS-M™) 12-item 

short form
12 x

2. Safety

2.1. Fixation stability

● Has the osseointegrated fixation been formally diagnosed as loose by 

treating clinicians (e.g., surgeon) during the last 12 months?
1 x

2.2. Fixation integrity 

● Have you experienced one or more bone fractures around the 

fixation including fracture of proximal joint (e.g., Greater Trochanter) 

during the last 12 months?

1 x

● How many times the internal part of the fixation in contact with the 

bone has been broken or replaced during the last 12 months?
1 x

● How many times the external part of the fixation connecting to the 

prosthesis (e.g., taper sleeve, abutment) has been repaired or replaced 

during the last 12 months?

1 x

2.3. Injuries

● How many falls have you experienced in the last 12 months? 1 x

2.4. Infection

● How many episodes of infections requiring a course of oral 

antibiotics for a week of less have you experienced in the last 12 

months?

1 x

● How many episodes of infections requiring a course of oral or intra-

venous antibiotics for more than a week have you experienced in the 

last 12 months?

1 x

● Have you been taking antibiotics continuously for more than four 

weeks during the last 12 months?
1 x

Number 

of 

questions

Domains and Questions

Validation

https://doi.org/10.33137/cpoj.v1i2.31326


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

7 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 treatment presented by Frossard (2015) further 

detailed in Figure 3 (Supplement).(49) Also 

challenging was to balance the selection of 

outcomes (inclusion vs exclusion), the choice of 

instrument to measure selected outcomes (e.g., 

preference on validated over  in-house design self-

reported surveys) and the overall length of the 

survey (e.g., preference on short over long forms of 

surveys). Generic health-related quality of life 

measures were achieved using validated and widely 

used SF12 because the outcome could be readily 

benchmarked and converted in quality-adjusted life-

year required for subsequent cost-utility 

analyses.(31, 33) Mobility outcomes associated with 

actual usage of the prosthesis using T-score from 

PLUS-M™ could be supplemented by physical 

tasks such as Time Up and Go and 6-Minute Walk 

accessible from consumer’s passport completed by 

PSP after fitting of definitive components as 

described in Frossard et al (2017), if needed.(29)  

 

Table 5. Breakdown of typical time commitment and 

costs associated with administration of the QALS’s 

Continuous Quality Improvement (CQI) procedure for 

Evaluations A and B that repeated four times during the 

course of BAP treatment and Evaluation C that is 

conducted once and repeated yearly (Prosthetic Service 

Provider (PSP) labour = AUD$160 per hour accordingly to 

the schedule of allowable fixed expenses in QALS’ 

procedure, QALS’ staff time = AUD$30 per hour). 

 

For the safety outcomes, a decision was made to 

discard issues of soft tissues management, skin at 

stoma interface and phantom pain as they have no 

established links with prosthetic components. 

Adverse events associated with fixation stability and 

integrity as well as injuries and infections were 

applicable since they might be inherent with the 

load generated by prosthetic components and, 

therefore, might have potential legal bearings. 

Another hurdle to overcome was the lack of 

validated instruments to report advert  events and 

complications. Alternatively, a custom-made survey 

involving a short series of eight questions was 

collectively elaborated, pilot tested with selected 

consumers and implemented.  

Limitations 

The PSE form might be deemed onerous by some 

consumers because of redundancy of SF12 and 

PLUS-M with regular follow ups conducted by 

treating clinical teams. Purposely designed survey 

lacked typical statistical validation. Other limitations 

derived from typical intrinsic shortcomings of 

prospective study presenting the initial steps of 

action research cycle. Beyond the scope of this 

study, the lack of actual long-term consumer’s 

experience data limited the validation of this 

proposed CQI procedure.  

The generalization of the outcomes must be 

considered carefully. The proposed CQI was 

purposely designed to fulfil specific needs for an 

Australian State organisation providing funding for 

prosthetic care only. However, stakeholders and 

treatment pathways for provision of BAP could differ 

between jurisdictions, particularly in European and 

North American countries.(33) Indeed, the scalability 

of this CQI procedure within and between 

jurisdictions is yet to be established, particularly its 

capacity to integrate requests from broader 

stakeholders, the geographical spread of 

consumers extending to rural areas with limited 

access to a PSP, the increasing number of 

treatment sites in Australia and abroad as surgeries 

are more routinely performed. Nonetheless, a 

series of valuable insights provided could be readily 

integrated by other organisations while customizing 

their own BAP-inclusive CQI procedure, including 

the importance of understanding rehabilitation 

programs, identification and organisation of the 

stakeholders (e.g., local, regional, national), 

benefits and ways to adapt existing procedures 

(e.g., pathways, forms and CMS), methods to 

determine involvement of participants (e.g., 

consumers, PSPs, funder) as well as consideration 

for confounders of customer’s experience with 

provision of BAP (e.g., clinical benefits and safety). 

 

Future studies 

Future developments of the proposed CQI 

procedure will be facilitated by additional 

(Hrs) ($) (Hrs) ($) (Hrs) ($) (Hrs) ($)

Repeated at each phase of BAP treatment (-2 to 9 months)

Evaluation A

1 PSP Send invoice for a service to QALS 0.17 $27 0.17 $27

2 PSP Send PID to client 0.17 $27 0.17 $27

3 Consumer Acknowledge PSP service using PID 0.25 $0 0.25 $0

4 Consumer Sent PID to QALS 0.08 $0 0.08 $0

5 QALS Review invoice sent by PSP 0.25 $8 0.25 $8

6 QALS Review PID sent by client 0.25 $8 0.25 $8

7 QALS Reimbourse PSP for service 0.25 $8 0.25 $8

Evaluation B

1 Consumer Evaluate PSP and QALS service using VOS 0.25 $0 0.25 $0

2 Consumer Sent VOS to QALS 0.08 $0 0.08 $0

3 QALS Review VOS sent by client 0.50 $15 0.50 $15

4 QALS Tabulate information into registry 0.25 $8 0.25 $8

0.33 $53 0.67 $0 1.50 $45 2.50 $98

1.33 $213 2.67 $0 6.00 $180 10.00 $393

One-off yearly upon completion of BAP treatment (12 months)

Evaluation C

1 Client Evaluate PSP and QALS service using PSE 0.25 $0

2 Client Sent PSE to QALS 0.08 $0

3 QALS Review PSE sent by client 0.50 $15 0.50 $15

4 QALS Tabulate information into registry 0.25 $8 0.25 $8

0.00 $0 0.00 $0 0.75 $23 1.08 $23

1.33 $213 2.67 $0 6.75 $203 11.08 $416

Total for yearly assessment

Total for each phase of treatment

Total for all phases of treatment

Total for year of treatment

ConsumerPSP QALS Overall
Step Participant Task

https://doi.org/10.33137/cpoj.v1i2.31326


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

8 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 longitudinal studies providing experience outcomes 

for a large cohort of BAP users over an extended 

period of time that could be benchmarked against 

other BAP or SSP users.  

Possibilities for additional cross-sectional studies 

are endless, particularly for the ones correlating 

experience with provision of BAP accordingly to 

technological platform supporting CQI procedure 

(e.g., online forms, cloud-based CMS), provision 

standards of components (e.g., microprocessor 

prosthetic knees) and clinical outcomes (e.g., 

Health-related quality of life,  mobility, fixation 

stability and integrity, injuries, infections) with 

different type of fixations (e.g., screw-type, press-

fit).(2, 50-54)    

 

CONCLUSIONS 

The early development of a CQI procedure, 

including the management of barriers and 

transferable facilitators, to appraise the provision of 

BAP by a governmental organization was shared for 

the first time. This work was an initial effort toward 

the assessment of fair and equitable governmental 

financial assistance programs for individuals 

choosing BAP. Altogether, this study should be 

considered as a stepping-stone providing a working 

approach for BAP-inclusive CQI to other 

organizations worldwide. 
 

SOURCE OF SUPPORT 

This study has been funded by Queensland Artificial 

Limb Service.  
 

ACKNOWLEDGEMENT 

The authors wish to express their gratitude to John 

Vasil for his contribution to the development of this 

project as well as Fiona Barnett, Stephan Laux, 

Barry Leech and Luke Lorenzin for their insight into 

prosthetic care.  

DECLARATION OF CONFLICTING 
INTERESTS 

The authors have no conflict of interest. 

AUTHOR CONTRIBUTION  

• Laurent Frossard has developed the study 

design including collection, analysis, 

presentation the data as well as writing this 

manuscript.  

• Luciann Ferrada has contributed to the 

collection and analysis of the data as well as 

the writing of the manuscript.  

• Tanya Quincey has contributed to the collection 

and analysis of the data as well as the writing 

of the manuscript.  

• Brendan Burkett has contributed to the writing 

and reviewing of the manuscript. 

• Debra Berg has lead the whole project including 

the study design, collection, analysis, 

presentation the data as well as writing this 

manuscript. 

 

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Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

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Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
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https://doi.org/10.1177/0309364617728118


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

11 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 
International Conference Advances in Orthopaedic 

Osseointegration; Las Vegas, Nevada, USA2015. p. 20. 

50. Pitkin M. Design features of implants for direct 
skeletal attachment of limb prostheses. J Biomed Mater 
Res A. 2013 Nov;101(11):3339-48. DOI: 
10.1002/jbm.a.34606 
 
51. Pitkin M. One lesson from arthroplasty to 

osseointegrationin search for better fixation of in-bone 

implanted prosthesis. J Rehabil Res Dev. 2008;45(4):6-

14. 

52. Orendurff MS. Literature Review of Published 

Research Investigating Microprocessor-Controlled 

Prosthetic Knees: 2010 – 2012. JPO: Journal of 

Prosthetics and Orthotics. 2013;25(4S). doi: 

10.1097/JPO.0b013e3182a8a922 

53. Van der Linde H, Hofstad CJ, Geurts AC, Postema K, 

Geertzen JH, van Limbeek J. A systematic literature 

review of the effect of different prosthetic components on 

human functioning with a lower-limb prosthesis. J Rehabil 

Res Dev. 2004 Jul;41(4):555-70. PubMed PMID: 

15558384. Epub 2004/11/24. eng. 

54. Collins DM, Karmarkar A, Relich R, Pasquina PF, 

Cooper RA. Review of research on prosthetic devices for 

lower extremity amputation. Crit Rev Biomed Eng. 

2006;34(5):379-438. DOI: 

10.1615/CritRevBiomedEng.v34.i5.20 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v1i2.31326
https://doi.org/10.1002/jbm.a.34606


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

12 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 
SUPPLEMENTS 
 
Development of a Government Continuous Quality Improvement Procedure for the Provision of 
Bone-Anchored Prosthesis Using Osseointegration Fixation 
 
 
Figure 2. Stakeholder matrix included the groups of controllers, promoters, providers and advocates of the Continuous 
Quality Improvement (CQI) procedure depending on power (capacity to influence allocation of resources) and interest 
(capacity to provide prosthetic and medical care). 

 

P
o

w
e

r 

 C
a
p

a
c

it
y

 t
o

 i
n

fl
u

e
n

c
e

 r
e

s
o

u
rc

e
s

 

L
o

w
  

  
  

  
  
  

  
  
  

  
  
  

  
  
  

  
  
  

  
  
  
  

  
  

  
  

  
  
  

  
  
  

  
  
  

  
  

  
  

  
  
  

  
  
  
  

  
  

  
  
  

  
  
  

  
  

H
ig

h
 Controllers Promoters 

 • State governmental funding agencies:  
o Consumer advisory group (CAG) 
o QALS’s Executive Committee 
o Medical Aids Subsidy Scheme (MASS)  
o Queensland Health  

• National governmental funding agencies: 
o Department of Veteran Affairs (DVA)  
o National Disability Insurance Scheme 

(NDIS)    

• State consumer support group: 
o Amputees and Families Support Group 

QLD Inc  

• National consumer support group: 
o Limb4life 

• National professional associations: 
o Australian National Membership 

Society of the International Society of 
Prosthetic and Orthotics (ANMS-ISPO) 

o Australian Orthotic and Prosthetic 
Association (AOPA) 

• Artificial Limbs Services in other States: 
o Orthotics and Prosthetics South 

Australia (OPSA) 
o EnableNSW 
o Victorian Artificial Limb Program 

(VALP) 

• State service providers: 
o Prosthetic Service Providers (PSP) 
o Physiotherapists 
o Occupation therapists 
o General practitioners  
o Clinical teams  

• National service providers: 
o Prosthetic Service Providers (PSP) 
o Surgeons  

 

  Advocates Providers 

Low                                                                                                                                         High 

Capacity of provide medical and prosthetic care 
Interest 

 

 

 

 

https://doi.org/10.33137/cpoj.v1i2.31326


 

 

 

 

Frossard L, Ferrada L, Quincey T, Burkett B, Berg D. Development of a government continuous quality improvement procedure for assessing the 
provision of bone anchored limb prosthesis: a process re-design descriptive study. Canadian Prosthetics & Orthotics Journal, Volume 1, Issue 2, 
No 4, 2018. DOI: https://doi.org/10.33137/cpoj.v1i2.31326    

13 

 
OPEN  ACCESS 

ASSESSING THE PROVISION OF BONE 

 ANCHORED LIMB PROSTHESIS 

 

Volume 1, Issue 2, Article No.4, December 2018 

 

 
Figure 3. Overview of evaluation framework to extract clinical benefits (top) and harms (bottom) as presented in 
“Frossard L. Evaluation framework to assess benefits and harms of bone-anchored prosthesis. 6th International 
Conference Advances in Orthopaedic Osseointegration. 2015. Las Vegas, Nevada, USA. p 20” available from: 
https://eprints.qut.edu.au/82763/  

https://doi.org/10.33137/cpoj.v1i2.31326
http://eprints.qut.edu.au/82763/1/2015-OSOS-Conf-Abs%2001-Evaluation_framework-ePrint-All_01.pdf
https://eprints.qut.edu.au/82763/

