Physiotherapy target measure for hip fracture
'Advancing Quality' (AQ) was launched in 2008 across all hospitals in the north west of England with the aim of improving patient outcomes and reducing costs (Advancing Quality Alliance 2016). In 2015 the management of hip fracture was added as a key clinical area for evaluation/improvement, and included the measure: 'HFR-07 - Physiotherapy assessment within 24 hours of surgery'. Our Trust audit department therefore started producing monthly data for AQ hip fracture targets, which initially revealed our compliance with the above physiotherapy measure to be at 78% (target set at 100%). The purpose of this project was therefore to improve the achievement of this measure. A Plan-Do-Study-Act (PDSA) service improvement approach was chosen - as initially described by Deming (1986), and then later adapted specifically for use in healthcare by Langley et. al. (1996).
In the first PDSA cycle the initial results produced by the Trust audit department were studied, and included a thorough case note review of all incidences of 'fails' of HFR-07 over a six month period. This subsequently informed discussions within our orthopaedic physiotherapy team, and led to the formation of a clear action plan for improvement. The second cycle included study of any variances in compliance with the measure across a seven day period. Although the department provides a full seven day service for this patient group it was felt that creation of individual action plans for weekday and weekend service provision could help to further improve performance. In both cycles the action plan was implemented through a thorough training programme inclusive of all physiotherapy staff working with hip fracture patients.
Following the implementation of the action plan identified during the first PDSA cycle the compliance with HFR-07 rose from 78% to 88%. This subsequently rose again to achieving three monthly results of 100% compliance with the measure following the second PDSA cycle.
Cost and savings
There were no cost implications to this project. Although the project clearly demonstrates an improvement in clinical performance, no cost savings can be directly attributed at this stage.
The three key questions identified by Langley et. al. when linking the PDSA cycle to healthcare provide a useful synopsis of this project:
- What were we trying to accomplish: Achievement of full compliance with the physiotherapy AQ measure for hip fracture
- How do we know that a change is an improvement: Through study of monthly audit results
- What changes have been made that have resulted in an improvement: Relevant action plans have been identified and implemented
In this instance we can conclude that a PDSA approach has been successful in achieving the desired service improvement. Future work will centre on maintenance of full compliance with the target measure.
Results of this project have been shared with all physiotherapists who work with this patient group.
The action plans have become embedded in to standard practice through ongoing tuition, including sessions for any new therapists to this clinical area. Finally, any ongoing 'fails' of the target will continue to be studied with individual case reviews.
Top three learning points
PDSA is a simple but highly effective method of conducting service improvement project work
That whole team engagement in a service review/improvement/change process is crucial to its success
Clinical performance measures/Key performance indictors can be used positively to help drive improvements in clinical practice
There were no funding implications to this project.
The AQ Measure for ‘Physiotherapy assessment within 24 hours of surgery' has more recently become superseded for our practice by the Physiotherapy measures that are set out in The National Hip Fracture Database (NHFD) and Hip Fracture Best Practice Tariff (BPT) measures – which both record performance for ‘Assessed by a physiotherapist on the day of or the day after surgery’.
We have found it extremely useful to reference/translate the work completed in this project to new work now aimed at achieving the NHFD and BPT measures above.
The authors of this work may be contact at: Peter.Eckersley@pat.nhs.uk
This work was presented at Physiotherapy UK 2017.