Category Archives: outcome measure

Articles of interest – initiating change in the clinic, BESTest in subacute stroke

I’m catching up on journals (part of a New Years resolution to reduce/ eliminate the collection I have) and came across two good articles, so I thought I would share briefly.

The first is “Use of the Theoretical Domains Framework to Develop and Intervention to Improve Physical Therapist Management of the Risk of Falls After Discharge” in the November 2014 issue of PTJ.  If you have input into programs at your facility, or you have initiated a program but then had limited change in therapist behaviors, you may want to read this.  I found it interesting as I’m currently reading through “Better” (see previous posts).

The second is “Reliability and Validity of the Balance Evaluation Systems Test (BESTest) in People with Subacute Stroke” in the same issue of PTJ.  If you see patients with subacute stroke (or Parkinsons) and you haven’t checked out this test, you can read more about it here.

Components of Being “Better” – Diligence

8947350623_2bcbb0538b_qThanks to a recent blog post on PT Think Tank by Kyle Ridgeway, I became aware of Better: A Surgeon’s Notes on Performance by Atul Gawande, MD, MPH.  I checked it out from the library and read it in just a few days, but am going back and digesting it more.  While he is a surgeon writing about the practice of medicine, I believe there is much in here we can apply as physical therapists.

In the book he writes that the practice of medicine is more than diagnosis, technical skills, or empathy, but you also have to wrestle with “systems, resources, people and ourselves.”  Still, we “must advance… refine… improve.” How much does that describe PT?  We may do differential diagnosis, be masters at manual therapy, stroke recovery, etc, and really connect with our patients, but we work within a system.  Most of us are within a corporation or organization, but we are all within a larger system as we face rules, regulations, and reimbursement issues.  Next, we may have difficult families, or coworkers having bad days.  And finally there is us – our virtues and our vices, the things that warm our hearts or set us off.  Our professional life is so much more than the basics of Netter to the mastery of motor control or manual therapy.

Why should we care about being better?  “Betterment is a perpetual labor.  The world is chaotic, disorganized and vexing, and medicine is nowhere spared that reality.  To complicate matters, we in medicine are also only human ourselves.  We are distractible, weak, and given to our own concerns. Yet still, to live as a doctor is to live so that one’s life is bound up in others and in science and in the messy, complicated connection between the two.  It is to live a life of responsibility.  The question, then, is not whether one accepts the responsibility. Just by doing this work, one has.  The question is, having accepted the responsibility, how one does such work well.” Substitute the word “medicine” with “physical therapy” and it may need a few tweaks but overall I think it describes well why we should work at betterment.

He believes there are three core requirements in any endeavor that involves risks and responsibility – the first of these is diligence. He defines diligence as the “necessity of giving sufficient attention to detail to avoid error and prevail against obstacles” and believes it is “central to performance and fiendishly hard.” He then goes on to tell three stories to demonstrate this: hand washing, eradication of polio, and the story of decreasing combat mortality.

In the chapter on hand washing, several things jumped out at me.  It is the approach to others with the lack of performance or knowledge that matters.  Don’t ask “why don’t you wash your hands” but “why can’t you wash your hands” – you will get two different responses and answers.  Here is where he presents the idea of positive deviance that Kyle mentions in his blog post (“the idea of building on capabilities people already had than telling them how they had to change”) – have others identify the ideal, then have them visit the ideal to see exactly what they are doing.  They involved everyone in this – from food service staff to MD’s to patients, having them identify ways of solving the problem.  In the groups, even if it was the 30th time they had heard the suggestion the facilitators treated them like group #1 “because it was the first time those people had been heard, the first time they had a chance to innovate for themselves.”  What a great way to solve a system problem.  In this case it impacted infection rates (as PT’s, how are we at washing hands?), but can we use the idea of positive deviance to help others follow clinical guidelines, or patients be more adherent or participate more fully?

The story of the work on the eradication of polio is inspiring.  One quote stuck out – “if the eradication of polio is our monument, it is a monument to the perfection of performance – to showing what can be achieved by diligent attention to detail coupled with great ambition.”  As PT’s we won’t have that type of public health impact.  But what can we achieve in our profession or in the systems we work in if we have diligence and great ambition?

The last story for diligence is about how military surgeons have dramatically reduced mortality rates in the wars in Iraq and Afghanistan.  By being observant and keeping statistics, 90% of those wounded in battle are saved.  Simple things like requiring the wearing of Kevlar vests and changing where and how the wounded are treated have made a great impact.  “Military doctors continued to transform their strategies for the treatment of war casualties.  They did so through  a commitment to making a science of performance, rather than waiting for new discoveries.” (the science of performance – “to investigate and improve how well they use the knowledge and technologies they already have on hand.”  Do you track data on your patients, taking into account who treated them, comorbidities, activities performed, codes and units used during the plan of care, etc?  Do you use everything at your disposal in your clinic, maybe being creative and changing how you do something to improve your patient outcomes?

Next up: Components of being “Better” – “Do Right”

Photo: NE130044.  LicenseAttributionNoncommercialShare Alike Some rights reserved by FlarePhot (When I searched for “diligence” on Creative Commons, this picture came up.  It reminded me that if you join the Naval Nuclear Power Program and don’t have a concept of diligence, they will drill it into you)

Speaking of EDGE task forces (Neuro recommendations)

In the previous post I mentioned the GeriEDGE task force.  In the same October 2013 issue of PTJ, there is an article Outcome Measures for Individuals with Stroke: Process and Recommendations From the American Physical Therapy Association Neurology Section Task Force.  I like how they broke it down into the ICF model (body structure/ function, activity, participation) and then made recommendations for patient acuity, practice setting, and educational exposure.  I will be sure to consult these recommendations when I evaluate a patient with a CVA either in the SNF/TCU setting or in the OP clinic.

Of note, the Neuro section also has posted these and other recommendation summaries on their website: