SCIPS (2006) defined Physiotherapy as “a science-based health care profession which emphasises the use of physical approaches in the promotion, maintenance and restoration of an individual’s physical, psychological and social well-being through various interventions, supported and influenced by evidence of clinical effectiveness and practitioners may work independently or as members of the health care team.”
Physiotherapy and rehabilitation services in Oman is still in the young phases where most of our practices follows the traditional method, and evidence based approach involves reading international journals, research papers and attendance to seminars, conferences and postgraduate courses. The services have not been accompanied by a comparable increase in systematic evidence. Few practices have been evaluated either for their efficacy in carefully controlled circumstances or for their effectiveness in typical clinical situations, however to keep abreast with our clinical approach and to attain clinical effectiveness in our services, we need to develop strategies and audits to identify areas of improvement and ways of implementing effective and evidence based care.
The essay will demonstrate the action plan by using the quotes of Graham (1996) on clinical effectiveness. The impact of guidelines, auditing and cost- effectiveness will also be discussed within sections of this essay.
NHS Quality Improvement Scotland (NHS QIS 2005) described clinical effectiveness as the extent to which specific clinical interventions do what they are intended to do, i.e. maintain and improve the health of patients securing the greatest possible health gain from the available resources. They further described clinical effectiveness as critical thinking about actions, questioning whether it has the desired result, and about making positive changes to practice. They also continued to describe clinical effectiveness by using the same quotes as Graham 1996.
National Health Service (2009) aimed to achieve clinical effectiveness strategy by developing a culture where clinical effectiveness is seen as being integral to the day-to-day provision of clinical care. Furthermore, through the development of an integrated work programme, setting out the structures, priorities, and implementing and monitoring national guidance, standards and policy.
Evidence -Based Practice.
Evidence-Based Medicine (EBM) is the process of systematically reviewing, appraising and using clinical research findings to aid the delivery of optimum clinical care to patients (Belsey J, Snell T(2009).
Hospital management.net (2005) in their review of rehabilitating physiotherapy stated that evidence-based practice is currently becoming a basic ethical stand in physiotherapy – and other fields of healthcare. The purpose of evidence-based practice is to make any decision-making on diagnosis and treatment proceeds from proven knowledge in the field concerned.
Herbert R et al (2005) in their review of practical evidence-based physiotherapy pointed out that research alone is not enough, it is most effective when patients, health professionals and policy makers bring to their decisions a range of values, preferences, experiences and knowledge.
Clinical effectiveness as quoted by Graham (1996) “the right persons, doing the right thing, the right way, in the right place, at the right time with the right result”
The philosophy in this essay involves team members collecting knowledge of the available service, and then using evidence from a wide range of sources to inform the outcome, linked to the priorities facing the profession. Also develop frameworks to guide ongoing development such as competency framework, and an integrated care pathway, through implementation of patient care knowledge. The process for development will be timely and detailed, and will be actively disseminated using strategic planning to promote implementation and later will be evaluated. Success for the development of clinical effectiveness and evidence-based care would be for the team to experience a constructive and enabling process that contributes to their continuing professional development and progression of research knowledge and skills.
The following sections will apply the parameters of Graham’s quote to the practice of physiotherapy and rehabilitation through clinical effectiveness.
The right persons-(competence)
Epstein and Hundert (2002) defined professional competence as “the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and community being served”
The therapist has to be fully qualified and competent to be able to make decisions for therapeutic interventions, identify and analyse the patients’ condition, a particular clinical problem, should be able to identify and define standards relevant to clinical work, and have the knowledge of the subsequent intervention that might improve outcome.
The right thing (evidence based practice resources)
Graham (1996) quoted that evidence-based practice is about ‘doing the right things right’, and Muir Gray (1997) supported the emphasis on the process rather than on the result.
Evidence can be gathered from a range of resources including published guidelines, journals articles, conferences, books, peer reviews, client feedbacks and other recourses from libraries. In order to attain the evidence based practice resources the social value must be identified and the impact of provider values on access to services and quality of care should be understood.
Rebecca Broughton (2001) stated that clinical guidelines are systematically developed statements designed to help practitioners and patients decide on appropriate healthcare. It stated that guidelines reduce unacceptable or undesirable variations in practice and provide a focus for discussion among health professionals and patients. Furthermore, Van der Wees P and Mead J(2004) in their study on framework for clinical guideline development in physiotherapy concluded that clinical guidelines are a valuable resource for effective clinical practice and are important tools for clinical effectiveness and evidence based practice, and has the potential to improve the quality of patient care.
The right way (skills and competence)
The team will work collaboratively to deliver a new policy as per the needs through an evidence based approach system and evaluate new policy in the context of local and national priorities and critically review the nature of evidence in the context of the working environment.
The right way to develop skills and competence and the necessary step will be observed such as; time to develop the services, required post training for the therapists, duration of training and resources such as current equipment, the evidence based researched journals and the financial implication. Protocols or specification must be developed and updated by ensuring staff development such as participation in Continuing Medical Education (CMEs) and ensuring confidence of current knowledge and skills through evidence based practice. Patient’s dignity and privacy must be equally maintained in all contexts of intervention.
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The right place (location of treatment/services)
This will involve team work to audit and identify the geographical regions that need developing and observe the clinical practice, thus includes identifying priority areas of work to deliver the strategy, The performance will be audited to measure the quality of care the patient experienced including the effectiveness of implementing the best available evidence and then benchmarked against pre-set standards, changes will then be implemented where needed.
The clinical audit process seeks to identify areas for service improvement, develop and carry out action plans to rectify or improve service provision and then to re-audit to ensure that these changes have an effect. (Wikipedia).
The right time (provision of treatment/services)
The team will determine and assess the clinical needs of care and interventions so as to develop the appropriate delivery of services as per the requirements and assess the cost effectiveness of the service delivery. The status of the current services, the type of patients, clinical intervention, time process, duration of treatment and location should be reviewed.
Hurley et al (2009) in their study on effectiveness and clinical applicability of integrated rehabilitation programs for knee osteoarthritis showed that correct integrated rehabilitation programmes involving exercise and self-management are more clinically and cost effective and may be the best way of managing the large and increasing number of people suffering chronic knee pain.
Another example from Santos et al (2004) in their project implementing clinical evidence in the management of coronary care provided a foundation for the development of a management strategy by using a multidisciplinary team approach, involving updating guidelines and resources. A positive outcome of the project was a reduction in hospital admission.
An example in our local services was seen in a study of rehabilitation and management of elderly individuals following stroke which required an integrated approach from a multidisciplinary team. This minimised readmission of chronic cases and proved cost effective.
Cost-effectiveness analysis should be done to address and ensure the efficient use of recourses and compare the financial costs of therapies whose outcomes can be measured purely in terms of health effect. (Alan Haycox 2009). Ceri. P. (2001) stated that one such method for measuring the extent of health gains is the quantity adjustment life year (QALY).
The right result (clinical effectiveness/ maximising health gain)
The results should be identified and reported to assess the benefits and patients’ satisfaction. The appraised research has to have valid and relevant information in the overall results that could be of clinical benefit safe, effective, cost beneficial and when used on the general population will make a difference. Hence health care authorities should develop appropriate use of evidence-based, standardized processes and centers of excellence to support easy reach of health care through a multidisciplinary care team of physiotherapy and rehabilitation.
This essay has discussed the mechanism of clinical effectiveness and evidence based practice in the context of physiotherapy and rehabilitation service. The essay has reflected on the needs and future expectations in the provision of a safe and effective care on a national scale.
It has been found that in the context of providing effective rehabilitation, the implementation of up-to-date guidelines, auditing and cost evaluation are all paramount for the assessment of clinical effectiveness.
In conclusion, clinical effectiveness in physiotherapy and rehabilitation services uses an integrated approach and can be thought of as the sum of the right person; as being the competent skilled therapist, backed with the right evidence, protocols and guidelines (the right way). In addition, an efficient well equipped environment. An ongoing review of such intervention and approach is required to evaluate and further improve the results of the provided service.
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