Quality practice is a main driver and objective of physiotherapy care. As students we learn many ways to assess, diagnose and treat patients and we are encouraged to improve those skills as we progress through our training. Upon graduation physiotherapists continue their life-long learning due to the desire to improve their craft and the quality of their services, but also because it is a registration requirement to engage in activities to support their continuing competence.
When applied to patient care there are several important questions about quality that need to be addressed:
- What does quality physiotherapy practice look like at the patient-practitioner level?
- How can a clinician do better today than they did yesterday?
- How can they know that they are improving and use that knowledge to advocate for themselves and their patients?
The Client Assessment, Diagnosis, Interventions Standard of Practice speaks directly to clinical practice and the process of completing an assessment, forming a physiotherapy diagnosis and developing a treatment plan. The Standard clearly outlines what was once assumed to be a given. It also provides clarification of what constitutes quality clinical practice from the College of Physiotherapists of Alberta’s perspective. A few key requirements are covered in the Standard, including that the physiotherapist:
- Applies appropriate assessment procedures to evaluate clients’ health status using standardized measures appropriate and available for the population they serve.
- Uses critical thinking and their professional judgment to determine a physiotherapy diagnosis and plan interventions to address the client’s needs.
- Regularly re-evaluates the client and their response to treatment, making adjustments and discontinuing services that are no longer required or effective.
The Standard includes several additional performance expectations. I encourage you to read the Standard in full.
I highlight these specific expectations as they go to the heart of what constitutes quality practice:
- The use of objective indicators to assess and quantify a problem.
Thorough assessment appropriate to the patient’s condition and objective measurement of a problem and of progress towards a solution to that problem is foundational to the ability of physiotherapists to demonstrate that they are implementing quality care. Measurement is key when demonstrating change, you really cannot objectively define patient improvements without it.
2. Determining a physiotherapy diagnosis.
Physiotherapists possess unique knowledge and skills that enable them to effectively complete an assessment, review their findings, and develop a diagnosis and a plan of care for the patient in front of them.
Physiotherapy Alberta often hears from physiotherapists and others who are uncertain if a physiotherapist can form a diagnosis. The answer, from the College of Physiotherapists of Alberta’s perspective, is that a physiotherapist can and should formulate a diagnosis within the scope of practice of the profession and the physiotherapist’s personal competence.
While it would be inappropriate for a physiotherapist to diagnose a condition such as leukemia, when it comes to the musculoskeletal system, there is considerable evidence to suggest that physiotherapists are highly competent to formulate an accurate diagnosis,2,3 provide effective treatment and deliver desired patient outcomes.3,4 In many cases physiotherapists can do so as accurately as other health-care providers.3,4
The College of Physiotherapists of Alberta endorses that physiotherapists should work to the full limit of their legislated scope of practice and individual competence. Doing so is good for patients and the entire health system.
3. Regularly re-evaluating and discontinuing ineffective treatment.
This is an indicator of accountability, one of the cornerstones and requirements of being a member of a regulated health profession.
It is simply unacceptable for a physiotherapist to continue to provide the same treatment for weeks or months without re-evaluating their impact and altering their approach depending on the patient’s response to treatment. Stated another way: “subjective, objective, or treatment - at least one must change at each treatment. As above is not appropriate.”
It is equally inappropriate for a physiotherapist to “soldier on” attempting to provide a treatment that they are not truly skilled and competent to provide. If a service is beyond the skill of the treating therapist, they have a duty to refer the patient to a colleague who can provide the service.
While this may seem self-evident, if not insulting to the many members who routinely hold themselves to this standard, reports from third party payers and from patients alike indicate that this is not a universal practice. Such a failure of accountability, even by a minority of physiotherapists, diminishes the public’s trust and confidence in the physiotherapy profession.
The expectations outlined in the Standard provide clear direction for how clinicians can raise the bar within their own practice by thinking critically, measuring objectively, and reflecting on patient progress at each interaction.
Some will argue that they know they have delivered quality care based on their interaction with their patient and the strength of the therapeutic alliance they have with the patient. To some extent, they are right. The strength of the therapeutic alliance is a demonstrated predictor for positive patient outcomes.5,6 The problem is that this outcome can be vague and is often not viewed as credible when presented to unsatisfied patients, third party payers, or hospital managers.
Collecting objective outcome measures helps to demonstrate the effectiveness of the treatments physiotherapists employ and builds the evidence base regarding specific treatments, contributes important clinical evidence, and supports the clinical and program decisions you make each day. Objective outcomes recorded clearly and consistently in the clinical record are also essential when responding to patient complaints.
Demonstrating quality care to the patient at the bedside is critical. It’s imperative that physiotherapists look at their practice patterns and strive to improve the quality of the care they provide every day.
- Physiotherapy Alberta. Standard of Practice – Client Assessment, Diagnosis, Interventions. Available at: https://www.physiotherapyalberta.ca/physiotherapists/what_you_need_to_know_to_practice_in_alberta/standards_of_practice/client_assessment_diagnosis_interventions. Accessed June 16, 2017.
- MacKay C, Davis AM, Mahomed N & Bradley EM. Expanding roles in orthopaedic care: A comparison of physiotherapist and orthopaedic surgeon recommendations for triage. Journal of Evaluation in Clinical Practice 2009; 15:178-183.
- Foster NE, Hartvigsen J, & Croft PR. Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: A review and critical analysis. Arthritis Research & Therapy 2012; 14:205.
- Ojha HA, Snyder RS, Davenport TE. Direct access compared with referred physical therapy episodes of care: A systematic review. Physical Therapy 2014; 94(1):14-30.
- Ferreira PH, Ferreira ML, Maher CG, Refshauge KM, Latimer J & Adams RD. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical Therapy 2013; 93(4):470-478.
- Hall AM, Ferreira PH, Maher CG, Latimer J, & Ferreira ML. The influence of the therapist-patient relationship on treatment outcome in physical rehabilitation: A systematic review. Physical Therapy 2010; 90(8):1099-1110.
