Q U A L I T Y A S S U R A N C E Q u a l i t y A s s u r a n c e i n a R e h a b il it a t io n S e r v ic e A B ST R A C T : A im : The aim o f this study was to develop, implement and evaluate a Quality Assurance (QA) program m e f o r use by nine rehabili­ tation departm ents in the M idlands province o f Zimbabwe. M ethodology: A participatory methodology was im plem ented to: 1. Define and im plem ent the param eters o f quality f o r a rehabilitation service. 2. Design standardised assessment fo rm s fo r the different conditions managed. 3. Develop, p ilo t an d evaluate a QA measuring instrum ent to use in defining the QA profile o f a rehabilitation service, and 4. D eterm ine patient satisfaction with the rehabilitation service. Adm inistering a sim ple questionnaire, whose design was based on the Zim babw e Patients Charter, accom plished this. Results: The process o f developing, implementing and evaluation o f the QA program m e took six years. One yea r after implem entation o f the QA, all (J00% ) patients coming into contact with the service had a rehabilitation record. The QA profile f o r the M idlands province rose fro m 55% in 1994 to a record high o f 92.1% in 1998, a nd 89.4% in 1999. The patient satisfaction profile f o r each indicator also dem onstrated a linear increase with areas such as satisfaction with service rising fro m 86% in 1997 to 100% in 2000, a nd satisfaction with benefit fro m the service rising fro m 76.6% in 1997 to 100% in 2000. O ther qualitative benefits not depicted by the QA m easuring instrument o r the patient satisfaction instrument, but which were observed an d expressed by rehabilitation s ta ff as measures o f success o f the QA program m e are discussed. Conclusion: This p a p e r concludes that significant improvem ents in clinical docum entation arising fro m the QA programme, translated to an overall increase in the service providers ’ professional skills an d know ledge base, and ultimately rehabilitation outcomes. The success o f this process is attributed to its participatory an d empowering nature. MYEZWA H, MCSP'; M'KUMBUZI VRP, BSc(Hons)2; MHURI F, BSc(Hons)2 1 Regional Co-ordinator, GTZ-Health Systems Research Faculty of Medicine, University of Zimbabwe K E Y WORDS: Q U ALITY ASSU RANCE, REH ABILITATIO N SERVICE. INTRODUCTION The M idlands province is one o f eight provinces in Zim babw e and has a popu­ lation o f 1.3 m illion (Central Statistics O ffice, 1998). Gweru is the provincial capital o f the M idlands province and is situated 300km southw est o f Harare, the capital city o f Zim babw e. The M idlands province is m ade up o f eight adm ini­ strative districts. O f these, Gweru and K w ekw e are two o f the five large cities found in Z im babw e and are largely urban. T he rem ain in g d istricts are G okw e North, Gokwe South, M vum a, M berengw a, Zvishavane and Shurugwi have largely rural p o p u la tio n s ., The rehabilitation service described here is set principally in the Gweru d istrict in the M idlands province of Z im b ab w e, b u t w as sub seq u en tly extended to the rem aining eight districts in the M idlands p ro v in ce. G w eru Provincial H ospital is a 300-bed, referral hospital with a bed occupancy rate of 94.5% (M idlands Annual Profile, 1997). T he M idlands annual pro file (1997) established the daily attendance rate as 224.7. A ncillary departm ents servicing the hospital include radiology, occupa­ tional therapy, physiotherapy, rehabili­ tation, dentistry and ophthalmology. Rehabilitation Service Delivery Development In 1980 the rehabilitation departm ent w as one o f the new est departm ents in the hospital, staffed by one therapist, w ho was subsequently jo in ed by three re h ab ilitatio n tech n ic ian s. B etw een 1980 and 1987 initiatives w ere taken to establish and develop the rehabilita­ tion service. By 1990 the departm ent was running the follow ing services: • In and out patient services • O utreach services • C om m unity b ased re h a b ilita tio n services R eh ab ilitatio n here in clu d e s the provision o f occupational therapy, p hy­ siotherapy, speech therapy and rehabi­ litation services. In all these areas, the rehabilitation departm ent in Gweru H ospital was the nucleus for activity. It functioned as a referral and facilitation centre for the M idlands province, and as such had to be exem plary in all its functions. Eight new departm ents situated in districts w ithin the M id lan d s p ro v in ce w ere opened under the guidance o f the Gweru P ro vincial R e h a b ilitatio n d ep artm en t and the provincial therapist. In addition to developing reh abilitation services, C O RR E SP O N D E N C E TO: H M yezw a PO Box 2406, H arare, Zim babw e Tel: +263-4-733696, Fax: +263-4-733695 Email: gtz-hsr@ internet.co.zw SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 7 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:gtz-hsr@internet.co.zw the core function o f the Gweru depart­ m ent rem ained that o f supporting the clinical work. Quality Assurance (QA) Quality assurance is “ .. ..all the processes and su b -p ro c esses o f p lan n in g for quality, the developm ent o f objectives for quality, setting standards (in clu d ­ ing guidelines, policies, protocols etc), a ctiv ely co m m u n icatin g standards, d e v elo p in g in d icato rs, setting th re s­ holds, collecting data to m onitor com pli­ ance to standards and applying solutions to im prove healthcare” (Paeger, 1997). Q uality assurance in the health field is a “process w here the ultim ate objective is to improve the outcome of all healthcares, functional ability, patient w ell-being and consum er satisfaction” (Reerink, 1999). Q uality assurance is driven by “cus­ tom er dem ands, financial burdens and p ro fe ssio n a l d em an d fo r q u a lity ” (Blum enthal, 1997). H ealth services in general, and rehabilitation services in particular are no exception to the gro w ­ ing need and recognition o f QA. Statement of the Problem A n annual performance review conducted in the M idlands province for all eight districts, in 1993 revealed that one o f the m ajor problem s was the varied quality o f clinical work. T his w as attributed to: a) The different cadres providing the service - physiotherapists, occupa­ tional therapists, rehabilitation tech­ nicians and orthopaedic technologists; b) T h eir varied training backgrounds and c) A lack o f standardisation o f clinical procedures. To resolve this anom aly a quality assurance program m e fo r im proving and ensuring high quality patient m anage­ m ent was com m enced. Quality Assurance Development A three-step process com m encing in 1993 was undertaken in order to form u­ late the objectives o f the QA program me. T hese w ere as follows: 1. Introduction o f the quality assurance approach to all staff m embers. 2. Identification o f problem s in patient m an ag em en t using the pro b lem analysis m ethod - O bjective P ro ­ g ram m e P lannin g (Z O PP - G TZ, 1992). The ZO PP analysis elicited the follow ing problem s: • N on-standardised approach to clients • Poor recording o f assessm ent, treat­ ment, results and outcom es • Poor treatm ent outcom es • Poor perception o f services by clients • H igh non return rate o f clients • H igh turnover o f staff resulting in a lack o f consistency. 3. Once staff understood the methodology in im plem enting QA, they form ulated the follow ing objectives for the QA program m e: • To design standardised assessm ent form s for the different conditions m anaged • To ensure that every client undergoes an assessm ent • To ensure consistent recording o f inform ation in agreed categories • To ensure that all clients visits are recorded and follow ed up. • To obtain the clients views on the quality o f service METHODOLOGY Participants: T he ZO PP was conducted during the M id lan d s annual p lan n in g m eeting. Each district in the province is rep re­ sented at this m eeting. Participants were therefore drawn from each rehabilitation departm ent in the province and consti­ tuted 5 therapists and 16 rehabilitation technicians. Participants engaged in brainstorm ­ ing sessions and gro up d iscussio ns. B ased on their professional opinions and experiences on areas o f breakdow n in patient m anagem ent, participants agreed on the areas for QA as: • The need to m ake a record for each client attending rehabilitation • The need to ensure a high degree o f com pletion o f each patient record • The need to ensure a high level of patient satisfaction w ith the service provided by the rehabilitation depart­ ment. Further, it was agreed that the patient record should contain the follo w ing categories: - D em ographic data - A ssessm ent findings - Problem list - T reatm ent plan - Progress notes - R eassessm ent w here needed. T he procedure for carrying out the p ro ­ gram m e was as follows: A p eer review group was convened every three m onths and a review sche­ dule set up. Each m em ber o f staff was in v o lv ed . T he p e e r rev iew gro up assessed each record for new patients seen during the quarter under review. T he assessm ent involved allocating a percentage to the degree o f com pletion on an agreed rating schedule. A mean for the d ep artm en t p er q u arter and per annum was then calculated to obtain a QA status. A report was com piled, and each m em ber o f staff received feedback on the strengths and w eaknesses o f their recordings. Only one or tw o rehabilitation staff m anned all districts. In such instances support was m ade available by borrow ­ ing staff from other districts around the province to conduct the peer review. One such district - M berengw a benefited from this arrangem ent, but on the whole it enabled the Q A program m e to develop at a relatively equal pace in all districts and subsequently to define a provincial QA status. Finally, a stan d ard q u estio n n aire was developed to provide feedback on c lien ts’ perception o f the quality o f the reh abilitation service. T his q u estio n ­ naire w as adm inistered to all new clients for a period o f three months. Process of Developing the QA Instrument Two m ajor sources o f expertise were used to establish a rating scale for the com pletion o f the physiotherapy record. A review o f the literature (M cRae, 1983; Cash, 1984) facilitated a defini­ tion o f the sections that w ere considered an essential part o f the physiotherapy record and needed to be included. It also becam e evident that the objective and p h y sical ex am in atio n w as the m ost im p o rtan t p art o f the p hysiotherap y record in term s o f determ ining progress and outcom e, as well as assisting in the monitoring. 8 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) T he second source was based on particip an ts’ professional opinions. A Delphi approach was used to define sec­ tions o f the record m ost com m only rated highly. Such factors as; w here staff felt the greatest proportion o f their tim e in assessm ent lay, as well as aspects o f the record that m ight im prove the w ider application o f their w ork w ere put for­ w ard as justification for rating o f the sections. For instance, initially partici­ pants ju stified a high rating for dem o­ graphic data because o f the problem s they experienced in following up patients. It was noted that the high w eighting given by the staff for the different areas recorded such as dem ographic data and assessm en t fin d in g s w ere co n sisten t with the literature. For exam ple, the assessm ent findings and problem list w ere im portant for the clinical outcom e, hence these were rated highest. The ca te g o rie s o f a ssessm en t w ere thus defined and rated as follows: - D em ographic data: 25% - A ssessm ent findings & problem list: 35% - Treatm ent plan & progress notes: 30% - R eassessm ent and discharge notes (w here applicable): 10% To form ulate standardised assessm ent form s, participants engaged in a consen­ sus building process for all categories o f patients m anaged, w ithin the depart­ m ent. T hus, standardised assessm ent form s w ere developed for orthopaedic, adult neurology, paediatric neurology, general paediatric, general adult and psychiatry conditions. Pilot of the QA Instrument Prior to the introduction o f the QA pro gram m e, not all p atients had an assessm ent record filled out. The prac­ tice in the departm ent at the time was to com plete rehabilitation records for patients with chronic conditions such as cerebral palsy and cerebrovascular acci­ dent. All other patient categories had no specific rehabilitation record, or had a rehabilitation progress sum m ary written in the m edical record. A fte r im p lem e n tatio n o f the QA program m e all (100% ) patients had a rehabilitation record. This first draft o f the QA instrum ent was piloted in G weru. The QA results obtained are shown in Table 1. TABLE 1. Gweru Rehabilitation Department - Q A Status 1994 - 1996. Number of Patient Records Reviewed QAStatus 1994 2159 55% 1995 2680 75% 1996 2723 75.2% A linear increase in the degree o f com pletion was observed from inception o f the QA program m e to 1996. D uring this tim e the num ber o f records with a higher degree of com pletion and m ore categories (such as dem ographics, assessm ent findings etc.) filled in, increased. T he problem o f follow up dim inished w ith the im provem ent in recording o f patient dem ographics. Review of the QA Instrument A fter three years o f use o f the QA instrum ent, rehabilitation staff expressed the need to review the QA instrum ent. This need was m ainly borne out o f a realisation that the initial problem s in quality assurance w ithin the province had been dealt with i.e. a) Each client now had an assessm ent and treatm ent record and b) the problem o f follow ing up patients had im proved significantly. Staff felt that the program m e should now focus on a new set o f quality problem s. Hence during brainstorm ing and problem solving sessions, staff indicated that in the process o f im proving the degree o f com pletion o f the patient record, they had identified their areas o f clinical weakness. This enabled the planning and execution o f relevant and specific in-service training. Subsequently, the effort and quality of clinical assessm ent and recording im proved and staff mem bers found the current QA ratings now inappropriate. They expressed the need thus to: 1. Increase the assessm ent findings and problem list allocation and rating and 2. To further desegregate the categories so as to improve the sensitivity o f the instrument. S taff m em bers found they w ere spending more tim e on the physical assessm ent and said they could see the direct benefit o f this process to clinical outcom es and patient satisfactio n . This new shift in focus reflected a m ove from concern with clerical type recording to clinical data recording and staff could m ore easily translate the im portance o f the rehabilitation record to clinical outcom es. As a result the review cam e up with new ratings outlined in Table 2. TABLE 2. Post - Review Q A Ratings Per Assessment Category ■•Demographic data 15% Past and present medical and social history 15% Assessment Findings and problem list 50% Treatment aims and plan 10% Progress, notes 10% After the review the new instrum ent was used first in Gweru district alone, and then in the other eight districts in the M idlands province to obtain a provincial Q A profile. TABLE 3. Gweru Q A Status after the Q A Instrument Review 1997 - 1999. Number of Patient Records Reviewed QAStatus 1994 2688 90% 1998 2876 91.2% 1999 2064 89.4% SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 9 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) The QA status rose by over a 15% margin between 1996 and 1998. It becam e evident that a sense o f ow nership o f the program m e had taken root. T he value o f QA was now m ore readily accepted and appreciated, as one m em ber o f staff com m ented, “I now see that it is not a w itch hunt.” The decrease in patient records in 1999 is attributed to the introduction o f user fees. This saw a fall in the num ber o f patients attending rehabilitation. The m arginal drop in the QA status also evident in 1999 is attributed to a loss and change o f rehabilitation staff including the substantive provincial therapist through whose office m ost QA m onitoring was planned and directed. (See Table 3.) FIGURE 1. Midlands Q.A. Status 1995-1998 The average Q uality A ssurance status for the province was calculated at the end of each year as part o f the annual report. All eight districts with operational rehabilita­ tion departm ents w ere included and the total num ber o f records review ed in 1994 was 6381 w hile the average for 1995-1999 was 8565. (See Figure 1.) Patient Satisfaction Patient satisfaction was considered an im portant co m p o n en t o f the quality assurance program m e. The clien t’s per­ ception and view o f the service and its delivery were sought. Methodology For 3 m onths o f the year (first quarter = January to M arch), each new patient attending rehabilitation was asked to fill in a questionnaire or interview ed to determ ine the satisfaction w ith the reh a­ bilitation service. The sim ple question­ TABLE 4. Patient Satisfaction naire was m ade available in English, Shona and N debele, and was based on the Z im babw e Patients Charter. This charter describes the rights o f patients and the obligations o f health service providers to patients. Thus indicators o f satisfaction were defined as: - W aiting time - Availability o f inform ation e.g. Expla­ nation o f diagnosis, treatm ent etc.. - R eception - Friendliness o f staff - G eneral satisfaction with service - Areas that clients felt need improvement Two Q A areas w hich clients constantly id en tified as n eed in g im p ro v em en t included: 1. An increase in the num ber o f attend­ ing staff 2. A decrease in user fees T he patient satisfaction results dem on­ strate a linear increase in the degree o f satisfaction, w hich is consistent w ith the developm ent o f the QA program m e. Secondly it attests that clients are an im portant force in QA. (See Table 4.) It is w orth n o tin g that the Q.A. process continues to develop. In the first quarter o f the year 2000, refining o f the patient satisfaction instrum ent is already underway as 100% targets are being met. F or instance the section on benefiting from the service has been broken down to specify the type o f benefit e.g. physical or inform ation on condition. Qualitative Results of QA Review: Rehabilitation Staff A lthough tangible and objective results had been obtained to define the QA status for the M idlands province from the service record and client satisfaction points o f view, staff often expressed other benefits that had not been dem on­ strated w ithin the defined param eters o f the QA instrum ent or patient satisfaction questionnaire. G roup discussions during QA review s w ere convened to identify these benefits. F our them es em erged from the reha­ bilitation service providers as areas, w hich dem onstrated the success o f the QA program m e. • S taffs’ clinical skills and know ledge im proved com pared to 1995 • S taff could easily detect problem s that had not been apparent previously • S taff felt that the QA program m e m ade it easy for them to plan for clinical w ork • S ta ff accep ted and v alu ed peer review sessions as a tool to facilitate their own professional developm ent. As a result o f these positive outcom es the QA outline was adapted and included in the standard procedures m anual for the M idlands rehabilitation departm ents. Number of clients N =60 N =76 N =26 W aiting time <5 minutes 41.3% 46.8% 65.4% Satisfaction with availability o f information 75.2% 92% 92.1% Satisfaction with reception 86.7% 89.5% 100% Satisfaction with rehabilitation service 86% 90.7% 96.2% Satisfaction with staff politeness 88.3% 89.5% 96.2% Satisfaction with benefit from rehabilitation service 76.7% 83% 100% 10 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) DISCUSSION OF RESULTS The sim ple QA m ethodology outlined above solved problem s that had been identified through the Z O PP analysis m ethod. It m ust be noted that the QA status for G w eru was higher than the QA status for the w hole province. This difference was a result of: 1. G w eru ’s proxim ity to better-qualified rehabilitation and medical staff. 2. L arger num bers o f rehabilitation staff m em bers 3. As a result o f the above two factors G w eru had closer m onitoring systems 4. A ccess to m ore frequent and timely in-service training. Further, in spite o f the heterogeneity o f the rehabilitation service providers, the variations in training levels and back­ grounds, and differences in w orking experience the QA status achieved was extrem ely high. It is thus the subm ission o f the authors o f this paper that QA is im plem entable in a variety o f situations even when the professionals involved have different backgrounds. T he unify­ ing factor to providing a quality service cam e through a com m on understanding and insight into the program m e objec­ tives. This was best achieved by partici­ pation o f the different professionals in the process o f problem identification, analysis and in working out solutions. T he QA program m e once developed w as used as a tool and becam e instru­ m ental in the w hole process o f m oni­ toring quality. T h e sta ff th em selv e s ex p ressed greater confidence in m anaging condi­ tions they previously felt unsure o f and lacked in confidence. The effect o f the p ro g ram m e th erefo re did n o t ju s t im prove the quality o f patient records but had the added benefit o f raising the stan d ard o f a ssessm en t and clinical skills o f those involved. Furtherm ore, the staff said they found it easy to iden­ tify problem s and outcom es required in the planning process at an individual, departm ental and program m e level. D em ing (no date) outlines five factors in the process o f QA program m e devel­ opm ent - D efining the desired output (through analysis); - Identifying the value creation process in the organisation; - M odifying the existing system to get desired change; - C o m m ittin g top m an ag em en t to change process; - D eveloping change concept. Further one m ust acknow ledge the com ponents necessary fo r successful rehabilitation. These include, “a problem ­ solving interaction between client and therapist, based on system atic assess­ m ent, realistic goal setting, appropriate use o f resources, and intelligent evalua­ tion o f o u tc o m e s...’’(Bauer, 1989). T he process that led to the develop­ m ent o f the M idlands Q.A. instrum ent and QA program m e, dem onstrates all o f D em m ing’s and B a u e r’s factors as o u t­ lined above. It also highlights the im por­ tance o f understanding and com m itting to this change process by all stakeholders at every stage. CONCLUSION The success o f the M idlands QA instru­ m ent developm ent and the QA p ro ­ gram m e im plem entation is attributed to the participatory nature o f the w hole p ro cess. A lthough m em bers initially viewed the process as a threat and only conform ed in response to coercion, they developed a better understanding by participating in the program m e. This resulted in a sense o f ow nership and professional gain. Finally, it is im portant to realise that QA is one o f the essential ingredients involved in the philosophy o f a total approach to reh abilitation. As B auer (1989) sum m arizes, “The focus is on the accountable delivery o f a holistic ser­ v ice to p e o p le w ith p ro b lem s; the em phasis is on the process rather than on the technical practice.” Clearly, rehabilitation service p ro ­ viders, rehabilitation patients and rehabi­ litation funding agencies stand to benefit from im plem enting QA program m es within rehabilitation services. ACKNOWLEDGEMENTS: T he authors would like to thank the re h a b ilita tio n sta ff in the M idlands p ro v in ce , the M id lan d s P ro v in cial M edical D irectorate, and rehabilitation clients in the M idlands province for their work, support and cooperation in the ongoing process o f QA instrum ent and program m e developm ent. REFERENCES B a u e r D. 1989. F o u n d a tio n s o f P h y sical R e h abilitation - A M an a g em en t A pproach. 1st E dition. C hurchill Livingstone. B lum enthal. 1997. T he futu re o f quality m ea­ surem ent and m anagem ent in transform ing health care system . Journal o f the A m erican M edical A ssociation (19) 1622-5. C a sh ’s T extbook o f O rth o p aed ics & R h e um a­ tology fo r Physiotherapists. E d ited by P.A. D ow nie. 1984. F ab er & F aber C a s h ’s T extbook fo r som e Surgical C o n d i­ tions. 1979. E dited by P.A. D ow nie. F a b er & Faber. C entral Statistics O ffice - Z im babw e. 1997 D em in g W E . (N o d ate ). P rin c ip le s for Q uality: D e m in g ’s 14 points http.V /dem in g .c e s .c le m s o n .e d u /p u b tq m b b s / prin -p ract/1 4pts.txt G esellsch a ft fur T echnische Z u sam m en arb eit (G T Z ). 1992. O b je c tiv e s -o rie n te d P ro je c t P lanning, (ZO PP) M cR ae R. 1983. C linical O rth o p aed ic A ssess­ m ent. 2nd edition. C hurchill L ivingstone M id la n d s P ro v in c e H e a lth In fo rm a tio n D epartm ent. M idlands A nnual P rofile 1997 P aeger A. 1997. Q uality Im provem ent in G erm any. Journal o f Q uality Im provem ent 1(23) R eerink E. 1999. Intro d u ctio n, Im p lem e n ­ ta tio n an d S u p p o rt o f Q u a lity A ssu ra n c e and Im provem ent P rogram m es. L eadership S e m in ar fo r Q uality M an a g em en t in H ealth. N o v e m b er 1999, G erm any. SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) http://http.V/dem O P P O R T U N I T I E S I N T H E U.K. We'll organise everything for you. 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BumJL Health Care Recruitment Physiotherapis • Widest choice of Locum, Permanent and Fixed-Term Contracts • Advice on: State Registration UK Visas and Work Permits Accommodation Bank Accounts • Top rates of pay • UK CPSM Registration Fees reimbursed • FREE Holiday Pay Contact Bridget O ’Farrell BScOT in South Africa on (0 2 1 ) 4 2 3 -3 853 Fax: (021) 423-3855 E-mail: corinth@mweb.co.za Corinth London Office Toll Free 0800-99-3055 Fax: 09 44 20 8207 6894 E-Mail: pt@corinth.co.uk 12 SA J o u r n a l o f P h y s io th e ra p y 2001 V o l 57 No 1 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:bupa.hc.recruitment@lineone.net mailto:corinth@mweb.co.za mailto:pt@corinth.co.uk