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President's message: quality is as quality does.

Many years ago a cardiologist contacted me about an inpatient. The patient had complained to her primary care physician about frequent episodes of chest pain and she was admitted to the hospital with unstable angina. Once in the hospital she was referred to the cardiologist. After two days his work-up revealed some cardiovascular disease. However, testing did not reveal a cause for unstable angina, and no angina had occurred while she was in the hospital, so he asked me to determine her capacity for activity. When I examined this woman I learned that she had a history of a trans-tibial amputation and she was proficient functioning with a prosthesis which had allowed her to live independently in the community. She was eager to return to her home.

I recall that while gathering the history she described difficulties with three activities that precipitated her angina-donning her prosthesis, making her bed, and vacuuming. The results of the examination were generally ordinary- she was independent with activities of daily living and functional tasks, including walking at a sufficient distance and rate for safe community ambulation, without exacerbation of angina. However, when donning the prosthesis the task of pulling and leveraging into a tight socket caused angina. I also asked her to make her hospital bed, just as she would at home, and she lifted the mattress to tuck the sheet and blanket tightly at each corner. That also triggered angina. I observed her perform a Valsalva maneuver during these tasks. I instructed this patient in counting out loud when struggling with a physical task, and then had her repeat those tasks while counting, which she did without angina. After questioning I learned that there was also a pattern to her angina while vacuuming- it was only a problem for her when she got down on her knees to vacuum behind and under the couch and some of the other furniture.

I called the cardiologist and explained that this patient did not appear to have unstable angina; rather, she presented with a pattern of Valsalva-related angina that was relieved with techniques that reduced the performance of a Valsalva maneuver. By that afternoon she was pleased to be on her way back home with a plan for outpatient follow-up with the cardiologist.

That story provides an anecdote of a physical therapist adding value to a patient's course of hospital care by informing the diagnosis and facilitating a timely and appropriate discharge. That 'value added' role for physical therapy was a theme I heard frequently during the recent Critical and Inpatient Care Concentrated Education Series at "PTI2: APTA's Annual Conference and Expo." Presenters reminded us that when managing patients within the hospital the physical therapist does not generate revenue, so it is important to distinguish the value we add to the patient's hospital experience.

In a previous president's message I proposed that one way we can add value is by reducing the duration of the inpatient stay. (1) However, we need confirmation of that value, and my anecdote does not rise to the level of evidence of the value of physical therapy. As a physical therapist it has often been difficult for me to articulate the value of my contributions to the quality of health care within a larger system (ie, my role within the team of providers in a large hospital). Fortunately this issue of the Journal of Acute Care Physical Therapy contains a spectrum of types of evidence that describe quality in physical therapy.

For example, in this issue Jackson and Billek-Sawhney provide a case report on physical therapy management accompanying the medical treatment for normal pressure hydrocephalus. (2) That report informs practicing clinicians and is a starting point for future research about physical therapy for patients with normal pressure hydrocephalus. In another article, Palmieri and Orest provide a valuable description of a process for quality improvement across diverse health care providers and systems within a hospital. (3) Improving processes is one component of quality improvement, and this type of evidence is needed by physical therapy managers and leaders to inform strategies for process change.

I was very interested in the work by Ronnebaum, Weir and Hilsabeck as they provide evidence about the value of physical therapy directly on outcomes. Their process changes to improve patient care, and research on the effectiveness of those changes, led them to conclude "This approach led to decreased days spent the ICU and decreased days spent on the ventilator, equating to a savings of $22,000 per patient in the ICU." (4), p. 204 It is important to our profession to generate evidence clarifying the economic value of physical therapy services. (5) It has been gratifying to see this journal, despite its short history, has been a repository of evidence about the impact of physical therapy on length of stay, (6, 7) a central contributor to the expense of hospitalization. I commend those authors and encourage other researchers to use these, and complementary research designs, (8, 9) to contribute to the understanding of the value from physical therapy within a hospital's system of care.

The evidence revealed through these articles, and the methods used by the authors, provide models for the management and quality improvement processes in our physical therapy departments. Data is essential to these types of analyses, and the determination of value, within an organization. The individuals, and the organizations, who are analyzing effectiveness depend on data to measure effect when changes are implemented on a large scale, such as changes is staffing patterns, resource deployment or coordination across services. The better a physical therapy department is at collecting that data, the better it will be prepared to measure the effects of its services and to successfully institute improvements to physical therapy practices within an institution.

As clinicians we are often intimidated by the process of collecting data. However, our institutions are rich repositories of data due to quality measures. According to the National Quality Forum (NQF) "Quality is central to achieving affordable care that knows our needs and keeps us healthy." (10) That may sound like an ephemeral description, but over the last decade the NQF has built an agenda, and made tangible advancements, in evaluating and improving the quality of health care in the United States (11) (as a member of the NQF the American Physical Therapy Association has contributed to that process). The NQF's initiatives include development of measures that generate data used to improve quality, that inform consumers, and that influence reimbursement for services. The breadth of these quality measures, across most practice environments, results in data relevant to physical therapy being collected and reported by hospitals and other health care organizations. Whether your goal is to inform an analysis of a practice within your department, an analysis of outcomes across your institution, or to perform research for publication, you should investigate the quality data collected within your institution. That information will be valuable in revealing variations in processes and/or outcomes that can be analyzed and modified for improving care and managing expenses. Harnessing those resources will inform quality improvement, will clarify value in our institutions, and will improve services for our patients.

References

(1.) Smith J. President's message. Journal of Acute Care Physical Therapy. 20ll;2(3):86-89.

(2.) Jackson NA, Nillek-Sawhney B. Normal pressure hydrocephalus physical therapy assessment before and after cerebrospinal fluid drainage. Journal of Acute Care Physical Therapy. 2012;3(2):189-192.

(3.) Palmieri J, Orest MR. Improving the care of patients who have difficulty weaning from the ventilator in the acute care setting. Journal of Acute Care Physical Therapy. 2012;3(2):193-203.

(4.) Ronnebaum JA, Weir JP, Hilsabeck TA. Earlier mobilization decreases length of stay in the intensive care unit. Journal of Acute Care Physical Therapy.2012;3(2):204-210.

(5.) Goldstein MS, Scalzitti DA, Craik RL, Dunn SL, Irion JM, Irrgang J, Kolobe THA, McDonough CM, Shields RK. The revised research agenda for physical therapy. Physical Therapy. 2011;91:165174.

(6.) Rapp J, Paz JC, McCallum CM, Cole J, Steffey L. The effects of a physical therapy triage system on the outcomes of ICU patients with respiratory failure. Journal of Acute Care Physical Therapy. 2010;1(1):21-29.

(7.) Sharma NK, Arnold PM, McMahon JK, Loyd L, Sabus CH, O'Connor BR. Acute physical therapy and length of hospital stay following lumbar discectomy and lumbar fusion: A retrospective analysis. Journal of Acute Care Physical Therapy. 2012;3(1):157-163

(8.) Morris PE, Goad A, Thompson C, Taylor K, Harry B, Passmore L, Ross A, Anderson L, Baker S, Sanchez M, Penley L, Howard A, Dixon L, Leach S, Small R, Hite RD, Haponik E. Early intensive care unit mobility in the treatment of acute respiratory failure. Critical Care Medicine. 2008;36:2238-2243.

(9.) Smith BA, Fields CJ, Fernandez N. Physical therapists make accurate and appropriate discharge recommendations for patients who are acutely ill. Physical Therapy. 20I0;90(5): 693-703

(10.) National Quality Forum. NQF in the Quality Landscape. http:// www.qualityforum.org/Setting_ Priorities/NQF_in_the_Quality_ Landscape.aspx. Accessed June 18, 2012.

(11.) National Quality Forum. 2012 NQF Report to Congress: Changing Healthcare by the Numbers. http://www.qualityforum.org/Publications/2012/03/2012_ NQF_Report_to_Congress.aspx. Accessed June 18, 2012.

Jim Smith, PT

President, Acute Care Section--APTA

jsmith@utica.edu
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Author:Smith, Jim
Publication:Journal of Acute Care Physical Therapy
Date:Jun 22, 2012
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