Quality of care in rehabilitation medicine

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1 International Journal for Quality in Health Care 1999; Volume 11, Number 1: pp Methodology Matters Quality of care in rehabilitation medicine REUBEN ELDAR The Fleishman Unit for the Study of Disability, Loewenstein Hospital Rehabilitation Centre, Raanana, Israel Abstract This paper discusses the generally accepted approaches to the study of the quality of care in medical rehabilitation. It reviews elements of structure, process and outcome of rehabilitation care that are relevant during various phases of rehabilitation and suggests drawing criteria and standards for assessment of quality from these elements of care. Keywords: elements of care, quality of care, rehabilitation care roles in life independent living, participation as family members, socializing, work after disruption because of disabling events. It is possible that the paucity of studies of quality in RM is due to the absence of an integrated, theoretical framework [15]: a framework would help to identify elements of re- habilitation care that could be selected as valid standards to be compared with performance. The purpose of this paper is to describe the main characteristics of RM that may affect its quality, to discuss approaches for studying quality in RM, and to suggest a framework to assess, enhance and improve it. Initiatives to measure and improve the quality of care have emerged in most fields of practice [1] and have already benefited patients and helped practitioners to provide better care [2]. In rehabilitation medicine (RM), the effectiveness of programmes and services has been evaluated and functional outcomes have been studied intensively. However, few studies of quality of rehabilitation care are reported in the literature. Among these accounts is a description of medical practice evaluation in rehabilitation institutions in the Province of Quebec, Canada; these evaluations were performed retrospectively every 2 3 years by two doctors representing a medical, professional body [3]. Outcomes of stroke, with and without rehabilitation, were studied retrospectively and compared to standards [4,5] and the quality of rehabilitation care following hip fracture and stroke was assessed in two types of settings and compared [6]. An activity to improve the care of multiple sclerosis patients is reported [7] and recently the quality of care in a stroke rehabilitation ward was studied using the tracer approach [8]. Patient satisfaction with, and views on, various aspects of rehabilitation care were determined [9 12]. Therapy professions are developing standards and models for auditing these services [13,14]. Quality of rehabilitation care is the degree of conformance between the actual care provided and standards set up for the care. Its study requires an understanding of rehabilitation goals and processes and establishment of valid criteria and standards that specify an adequate, acceptable or optimal level of quality of rehabilitation care. Standards should be derived from the current knowledge base of RM and from its accepted principles and practices as well as from the goals of rehabilitation. These are to return individuals to their usual Characteristics of rehabilitation medicine RM differs from other fields of medicine in that it is not directed at arresting pathology. In focusing on impairment and disability, RM is oriented toward improvement in function and in quality of life [16] and seeks to maximize the functional and psychosocial abilities of the patient. RM involves a very long process consisting of several phases that are not sharply delineated: it requires a multidisciplinary approach in which patients and their families are active participants; its outcome depends to a great extent on the motivation of the individual to initiate rehabilitation and to persist at it. Consequently, in addition to the three components of care the technical care, the interpersonal relationship and the amenities of care [17] quality of rehabilitation care may also be affected by: interaction between multidisciplinary team members, This paper is dedicated with respect, admiration and affection to Avedis Donabedian on the occasion of his 80th birthday. Address correspondence to Dr Reuben Eldar, 278 Achuza Street, P.O. Box 3, Raanana 43100, Israel. Tel: Fax: International Society for Quality in Health Care and Oxford University Press 73

2 R. Eldar effectiveness of interdisciplinary teamwork and re- Process habilitation goal setting [18,19]; Elements of process consist of those activities of rehabilitation the extent to which the attitude, knowledge and skills professionals that result in desired outcomes. to participate actively in rehabilitation, the motivation Although there are few trials in rehabilitation research [28] to engage in it, and the confidence to cope with the and these are often of poor quality, there is evidence to impairment and the disability are communicated to indicate that in most impairments favourable outcomes are patients and families; attributable to early initiation of rehabilitation therapies of appropriateness of the care provided over time, and its adequate intensity [28 33]. Thus the volume of therapy responsiveness to changes in the long-term needs of (physical, occupational, speech, cognitive and other) appatients and families. propriate to the disability, provided as prescribed [34] by a competent therapist, is an indicator of the quality of care. This includes choice of appropriate treatment methods, functional Approaches to studying quality in training and selection of adaptive equipment. Functionally rehabilitation oriented nursing care i.e. a reversal of the traditional caring role into encouragement to patients to do things for There are three kinds of information from which inferences themselves also contributes to a favourable functional can be made about the quality of care: structure, process and outcome [35]. outcome of care [20]; these three approaches apply also to Additional process indicators of the quality of care include RM. rehabilitation activities aimed at: Structure maintaining life and preventing conditions that endanger Elements of structure consist of: it; prevention of secondary disabilities and complications availability and appropriateness of space, facilities and that impede rehabilitation, such as contractures, spasequipment necessary to engage in rehabilitation treatseizures [37]; ticity, atrophy of muscles, pressure sores [36], epileptic ment; human resources (their education, training, experience care of conditions which, if undetected and neglected, and staffing ratio) required to provide the treatment; hinder rehabilitation, such as urinary incontinence [8] the sociodemographic and medical characteristics of and hemiplegic shoulder [38]; patients, their clinical and functional profiles, as well as early detection, control and follow-up of associated their appropriateness to benefit from the treatment in medical conditions that contribute to poor functional general and the given programme in particular. recovery such as congestive heart failure, metabolic disorders, infections, and malnourishment [39]; Structure elements are relatively easy to measure; they rep- early detection and treatment of depression which, if resent the input physical environment, rehabilitation pro- persistent, unfavourably affects recovery [40]; fessionals and patients and reflect the capacity of a service enhancement of motivation and cooperativeness [41 43] to provide rehabilitation of adequate quality. and expansion of social support [43]; Patients are concerned about structure because they wish discharge planning and arrangements for continuing to know whether there is the potential for providing their care [44]. care in a way that maximizes their chances of a favourable outcome. Patients admitted to a rehabilitation facility which An advantage of process indicators is that they are currently has the structure elements appropriate to their specific impairment available and accessible (for example in medical, nursing are reported to achieve better outcomes than those and therapists records) and can be used for prospective, treated in other settings [21 26]. Inadequately staffed facilities concurrent and retrospective assessment and, consequently, are not able to undertake active rehabilitation [27]. The public for prevention or intervention. Also, it is easier to specify at large, and the rehabilitation professional in particular, is criteria and standards for the activities of rehabilitation care also interested in the structural component of quality. than to say precisely what outcome should be achieved at However, it is possible to provide adequate rehabilitation specific points in time following that care. In addition, even care in unfavourable environments, and a fully qualified staff when not fully validated, such indicators may serve as interim does not always provide optimal care. Indeed it has been measures of acceptable rehabilitation practice. reported that functional status at discharge from a setting On the other hand, the appropriate form, intensity and with a poorer structure was no worse than from a setting duration of the rehabilitation therapy for a given impairment with a better structure, although the cost of care in the latter is not always clear. Furthermore, for certain process elements may be almost double that of the former [6]. It is generally of rehabilitation care that are regarded as good practice agreed that there is no direct relationship between structure such as selection criteria of patients, procedures for their elements and the quality of care actually provided. On their admission, the time of contact with a rehabilitation pro- own these elements cannot be used to assess quality of care, fessional, the frequency of follow-up assessments and volume although they may explain some deficiencies. of medical input it is difficult to specify related outcomes. 74

3 Quality of care in rehabilitation medicine Also, adequate and scientifically-based processes of re- mini-outcomes (the immediate and intermediate ones) and habilitation care may not lead to acceptable outcomes when macro-outcomes (the delayed ones) [48]. Thus, it is possible the patient is not sufficiently motivated to participate actively to attribute given outcomes to specific process activities. in the rehabilitation. Finally, a disadvantage of some process Varying time windows of specific outcomes determine the indicators lies in the weakness of their scientific basis. Lack manner and degree of their usefulness in assessments: imof an evidence base may encourage dogmatism, perpetuate mediate outcomes are useful for concurrent monitoring of error and lead to elaborate and costly care. care, allowing adjustments if necessary, whereas delayed outcomes are useful for retrospective assessments that lead to Outcome improvements in the future [20]. Outcomes of care are changes in health status attributable In the earliest phase of inpatient rehabilitation, the focus to antecedent health care interventions. In RM they are of care is on maintaining life and preventing conditions that usually not a change in health status but rather enhanced endanger it. Thus the early forms of care may interfere with functional performance and sense of well-being, enabling functional recovery at a later stage: for example, in persons individuals to function to their optimal physical, emotional after limb amputation during the pre-prosthetic phase, in and social potential in spite of the disablement. Outcome traumatic brain-injured patients who are unconscious, in indicators currently in use are: spinal cord damaged persons with respiratory distress, and in patients with dysphagia following stroke. Immediate out- change in functional status (ability to ambulate, perform comes of this phase would be survival, appearance of comactivities of daily living and self-care, communicate); plications and secondary disabilities, and detection of ability to return to pre-event dwelling and successful associated conditions and their control. work involvement at a level commensurate with capabilities; Standards for outcomes are, in fact, expectations of achieve- involvement in leisure, recreational and other social ment [20]. Thus, evaluating outcomes is closely tied to setting activities. rehabilitation goals [18,19] and to their attainment. In the next phase of inpatient rehabilitation, in which the focus is The influence of many factors, extraneous to health care on training persons with disability in tasks they should be intervention makes it very difficult to attribute a given out- able to perform independently, immediate outcomes would come to a specific intervention or series of interventions [45]. be the accomplishment of rehabilitation goals. These goals This is particularly true in RM in which outcomes depend are expressed in the form of patients activities, such as to a great extent on a number of factors. These factors are mobility, performance of activities of daily living (ADL), patient characteristics (sociodemographic variables, precommunication and cognition. Explicit goals provide a means morbid personality and level of activity [16]), functional status of focusing on desired and achievable outcomes and of at the beginning of rehabilitation, clinical variables (loss of measuring progress toward their attainment [19]. Frequent sensation, agnosia, aphasia, hemineglect, visuospatial deficit, review of patients accomplishment of goals enables conprolonged flaccidity and comorbidities [16]), as well as onsetcurrent assessment of the quality of care, of its planning and rehabilitation delay [42], motivation [42 43], appropriateness of the methods and means used, and allows, if necessary, of patient admission [46] and barriers to recovery (such as their modification. intellectual impairment, incontinence, existence of more than Progress in the activities mentioned leads to functional one disability, availability of family). Furthermore, some derecovery and to the ability of patients to terminate their sirable outcomes are assessed in the community and require inpatient rehabilitation and to continue it on a day-care, long-term follow-up. The longer the time that has elapsed between the rehabilitation care received and the monitoring ambulatory or home-care basis. Thus, towards the completion of outcome, the more opportunity there will be for extraneous of this phase it is possible to assess two intermediate out- factors to affect the causal relationship between process and comes: change in functional status (achievement of potential outcome. improvement, relating the status on discharge to that on On the other hand, rehabilitation is a lengthy process that admission, based on one of the common measurements) and consists of several overlapping phases, each focusing on discharge disposition or destination, i.e. discharge home or different issues. This permits monitoring of the outcomes at to a more supportive environment, different from the pre- a number of points in time. Outcome indicators must be event dwelling. However, as mentioned previously, these selected with reference to points in time ( windows of time ) outcomes may be affected by many factors other than re- when they are sensitive and specific as measures of antecedent habilitation care, so that it is difficult to attribute them to rehabilitation activities focusing on care of a given phase (as this. It is therefore questionable whether these outcomes are suggested by Brooks et al. [47]). In other words, it is possible true indicators of the quality of care. There are clinical factors to concentrate on immediate outcomes of various earlier that serve as predictors of poor functional and placement phases of rehabilitation, almost in conjunction with the outcomes, such as incontinence, visual field deficits, and features of care that are responsible for them, rather than cardiovascular disease [49,50]. The extent to which patients waiting for the more general, delayed outcomes such as are able to return to their homes in spite of these factors changes in functional status at discharge or social reintegration. may indicate the extent to which the competence and the Donabedian differentiates between micro- or confidence to cope with them were imparted to patients and 75

4 R. Eldar families, and thus allow an inference regarding the quality of Approaches drawing consequences care [8]. In September 1996 an invitational conference sponsored by Following discharge from inpatient rehabilitation, relevant the US Institute of Medicine summarized the value of the long-term delayed outcomes would be appropriateness of the three approaches to assessment of quality of care as follows. on-going care, the patient s maintenance of the levels of Structural elements correlate very poorly with other elements improvement and health achieved, ability to cope with the of quality; process elements are valid quality indicators if they demands of the immediate surroundings (i.e. family, comare linked to relevant outcomes; valid outcome indicators munity), psychosocial adjustment and reintegration into somust be directly related to the process of care that can ciety, commensurate with the disability. be manipulated to affect that outcome [52]. According to Patient satisfaction expressed as opinion or inferred from Donabedian s conceptualization, quality of care is represented behaviour [20] is positively related to changes in health by the entire continuum from process to outcome, and not status. Patients satisfied with care and with the information by one or the other element independently [53]. Particularly provided are more likely to comply with treatment re- in RM, it is important to use both process and outcome commendations, thereby increasing the probability that a elements simultaneously. Thus outcomes may be indirect good outcome will occur [51]. In RM, patient satisfaction measures of aspects of process, which are assessed through enhances the cooperation of patients and their motivation to other specific outcomes, because they are easier to measure. participate actively in their rehabilitation. In addition to Outcomes may be supplementary or confirmatory measures satisfaction and related to it, is the setting of goals; this also of aspects of process that provide a second tier to test has a motivating effect [18]. Motivation is essential for whether the elements of the process continue to be properly successful rehabilitation [41 43] and the level of motivation specified and measured. Similarly, measures of process permit achieved is an outcome attributable to the activities of the a check on the corresponding measures of outcome to rehabilitation professionals and should be monitored in all ascertain that the monitoring system is measuring what it is of the phases described above. supposed to measure. It is advantageous to study outcomes when the scientific basis for accepted practice is in doubt. This emphasis discourages dogmatism and helps to maintain a more open and flexible approach to management of care. Use of such The proposed framework practices based on dogma decreases and rehabilitation The proposed framework should enable systematic, conprofessionals then avoid doing more than is necessary; it tinuous review of the quality of rehabilitation care and simplifies rehabilitation care and may help in the deshould it be found to be out of line enable its readjustment. velopment of less costly but no less adequate strategies It should consist of assessment, intervention and verification of care. Furthermore, outcomes are integrative and reflect of the effectiveness of the intervention by repeated assessthe contribution of all those who provide care, including ment. The system should proceed through the various phases the contribution of patients to their own care [20]. This of rehabilitation according to the different settings in which is an important aspect of outcomes in RM, as the it takes place. It should simultaneously monitor activities competence of an individual rehabilitation professional is of rehabilitation professionals (elements of process), that seldom solely responsible for the results of care and constitute the focus of care of the given phase and the because patient satisfaction enhances the patient motivation relevant outcomes of that phase, attributable to process. that is essential for favourable results. In the earliest phase of inpatient rehabilitation, when the A disadvantage of using outcomes is the difficulty of approach is mainly preventative, elements of care from which specifying outcomes of care of optimal magnitude, timing its quality can be inferred would be activities aimed at and duration. Even when relevant outcomes are selected and maintenance of life and prevention of conditions endangering their attribution to prior care is not in doubt, information it (elements of process), and survival, secondary disabilities, regarding some outcomes is not available in time to make it detection and control of associated conditions and comuseful for certain types of assessment. Other disadvantages plications (elements of outcome). These elements of care of using outcome measures alone are that this takes a should be monitored also during the next phase of inpatient utilitarian approach to the problem, examining only the end- rehabilitation. However, during this phase interventions focus product result of care, in its purest sense ignoring the process on training patients in tasks necessary for independent living and structure of care. (mobility, ADL, communication, cognition). The relevant Outcomes do not directly assess the quality of care, but outcomes are attainment of goals set for the training, as they enable an inference about the process of care and its expressed in patient abilities, to be accomplished during a structure. They do not provide information regarding causes planned time-span. of deficiencies that might direct quality improvement [45] Towards the completion of inpatient rehabilitation the but they identify the cases that merit analysis of process and attainment of set rehabilitation goals should continue to be structure in search for causes of poor outcomes [20]. In the focus of quality improvement. Important interventions rehabilitation, outcomes are not necessarily linear and are in this phase that prepare the patient for independent life not easily quantifiable. are those aimed at acquisition of skills in instrumental ADL, 76

5 Quality of care in rehabilitation medicine such as domestic chores and household management, and on which any approach to quality assessment, enhancement psychosocial activities such as writing letters, using the telephone, and improvement rests [48]. shopping, use of transport, keeping accounts, reading, visiting, watching TV [54]. During all phases of inpatient rehabilitation important Acknowledgement process and outcome elements relate to motivation [41 43] control of medical comorbidities [55 57] and prevention of The kind assistance of Benny Steingold with the preparation falling [58]. of this manuscript is gratefully acknowledged. Activities aimed at effective discharge planning [44] should start with admission to inpatient rehabilitation, and they assume particular importance during its last phase [59]. Outcome indicators of these activities would be success in References assessing patient needs and circumstances, extent of in- 1. Harvey G. 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