Integrated quality management in physiotherapy

Health care providers must adhere to the "WZW formula" with their services and products.

For service providers, "WZW" means providing services to patients according to economic, expedient and effective criteria. The Confederation's strategy, "Health2020", provides for the transparency and controllability of the healthcare system to be implemented more efficiently in the future. "Gesundheit2020" calls for quality, patient safety and the appropriate further development of research, education and networking. Defined strategies and approaches require implementation with consistent evaluation and improvement. The latter in particular is very complex.

Contextual factors

Due to the various disciplines involved and the resulting interfaces in basic inpatient and outpatient care, the entire treatment chain of patients must be taken into account. The approach of institutionalising the networking and coordination of all those involved in the treatment process is not new. In addition, pilot projects are needed to demonstrate the effectiveness of measures through networking between physiotherapists, physicians and medical technicians. Finally, the efficiency and effectiveness of surgical procedures can only be assessed after completion of the entire rehabilitation chain.

Framework legislation

According to the Health Insurance Act (KVG Art. 58, Art. 77 KW), the Accident Insurance Act (Art. 48 and 54 UVG) and the Military Insurance Act (Art. 25 MVG), service providers such as physiotherapists are obliged to fulfil the required quality criteria. The quality concept of the professional association physioswiss from 2001 includes:

• Continuous improvement (CIP process)
• Data-based quality management
• Patient-focused approach
• Avoidance of unnecessary services
• Avoidance of unnecessary costs

According to the Q-concept, self-employed physiotherapists commit themselves to institutionalised quality management in practice management, irrespective of the practice model and irrespective of whether the practice management has undergone physiotherapy training in Switzerland or abroad. The following practice models exist in the Swiss healthcare system:

• Private practice as sole proprietorship
• Joint practice with independent physiotherapists
• Practice with employed physiotherapists
• Practice with mixed teams (employed, freelance)
• Joint practice with various service providers

All are required to meet these quality criteria with regard to "Health2020".

Taking the example of field of action 3 "Ensure and increase the quality of care", the statement of intent with objective 3.1 (cf. box) can be seen. The outlined potential for improvement in service provision is much discussed politically, socially and within the individual specialist and professional groups.

Integrated quality management in private physiotherapy practice

Freelance physiotherapists (provided they are members of the physioswiss professional association) are obliged to adhere to the quality concept and the service contract of physioswiss. This is the basis for the invoicing of patients. In accordance with the Health Insurance Act (KVG), the health insurance companies assume the reimbursements on the basis of the tariff system and the cantonal tax point value. Depending on the event, billing is based on SUVA, IV or military insurance rates. Quality management therefore places special demands on the treatment and billing process, irrespective of whether physiotherapy continues to be prescribed via the doctor in future or whether direct access becomes possible as in England, for example. The review of the process efficiency is carried out by means of clinical progress signs and key figures, which document the efficiency and effectiveness of the treatment strategy and the defined achievement of objectives. A target-performance comparison is necessary after each treatment. After 5 treatments at the latest, the situation must be assessed with regard to the maximum of 9 medically prescribed treatment sessions. Based on the result, a further treatment period is decided. The documentation of the diagnostic and therapeutic process is the central tool in quality assurance as well as in the proof of quality.

Within physiotherapy in practice institutions, quality improvement can be achieved by introducing assessments. Quality improvements and the further development of all those involved in the treatment process should therefore take place beyond the professional groups.

health technology

Assessment (HAT) The call is for the targeted and holistic involvement of all stakeholders, actors and interest groups in the patient treatment chain. The discussions regarding monitoring, review and regulation on the basis of a competence centre in the Swiss healthcare system have not been concluded in this regard.

Self-assessment

The resources for self-assessment within the treatment chain with the targeted recording of interfaces are already available today. These would come close to a Health Technology Assessment (HAT). This potential is partially unused today. Several public hospitals, private and rehabilitation clinics are committed to sustainable management in accordance with the EFQM Business Excellence Model 2013.

Practical example of freelance physiotherapists

For outpatient primary care, the practical example of physiotherapy shows the following: The problem in the implementation of the WZW formula arises from the different demands regarding economic, appropriate and effective services within the constellation of service provider, service recipient and service provider. The holistic recording means that all service processes of the services are mapped in the accounting system in a timely manner. This is only given to a limited extent for freelance physical therapists. The commitment to the implementation of "Health2020" brings perspectives and a new starting point in the further development of Health Technology Assessment in Switzerland and already existing recognised management models for quality assurance. Models with the character of holistic assessment, such as the EFQM model 2013, are to be pursued.

Quality

The performance process in terms of quality in successful patient treatment and target achievement is increasingly assessed and determined by various stakeholder interests. In future, the patient as service recipient and end customer should be given greater consideration in terms of appropriateness and effectiveness in operational measures and their achievement of objectives. For the successful achievement of goals and treatment of the functional disorder, the recording within the treatment chain is central. The first contact with the recording of findings in the personal examination interview, the physical examination, the evaluated treatment strategy with defined treatment concept is based on the ICF model of the World Health Organization WHO. This model shows the body structures, body functions, activities and participation as well as interactions including the associated context factors. The clinical thinking, action and decision-making process is taught in Switzerland at a high quality level in physiotherapy education at tertiary level. With the Bologna educational reform, the training has been taking place at the universities of applied sciences since 2006.

Patient Focus

The orientation towards the patient and service recipient with the successful problem solution of the health disorder and restriction distinguishes the following dimensions

• Indication quality
• Structural quality
• Process quality
• Quality of results

The documentation and communication within the quality dimensions are factors that show the appropriateness and effectiveness. These are to be used for the assessment of the economic performance of the practice activity as key performance indicators, so that the quality is controlled in a targeted manner and the management of the business activity is carried out in the sense of the performance mandate according to the KVG. The increase in quality through the application of the continuous improvement process (CIP) is based on the holistic management model EFQM 2013. Thus, the identified gaps and interfaces in the efficient treatment of patients can be eliminated. The cause and effect relationships must be recognised and developed. They cannot be determined within individual disciplines and committees alone. Complex systems and problems require holistic observation and management models that promote understanding between the stakeholders. Holistic management models create transparency and are suitable for all stakeholders and the various service providers in the healthcare system. Holistic means opening the perspective and implies breaking down conventional clinical, technical, cultural and psychological patterns of thinking and acting. In practice, progress requires consistent implementation with concrete action steps that go beyond a declaration of intent. Sustainable quality improvement does not take place on paper and is only sustainable if it is regularly reviewed and consequences follow in the form of action steps.

Assess quality

The quality check in the target-performance comparison is possible with the holistic management model EFQM-2013 and the assessment. Physiotherapy practice institutions can use the holistic management model EFQM-2013 in the self-assessment to assess the maturity of the performance quality, regardless of the selected practice model. It is important to assess quality and to learn from mistakes, be it in the handling of products, processes or systems. This includes careful planning and application of methods and measures, which are improved and deepened as quality techniques within and outside the practice institution. The practice-internal systematic review is not covered without exception. In addition to the basic education of physical therapists, further education is obligatory and involvement in quality circles is foreseen. No figures exist on the implementation in practice.

Self-assessment

The self-assessment for freelance physiotherapists based on the EFQM model 2013 means that the assessment is carried out along the entire treatment process. This requirement can, assuming knowledge of the model, already be applied in all practice institutions. With the assessment according to the EFQM Model 2013, all activities and their results are analysed and assessed with regard to strengths and potential for improvement. The EFQM Model 2013 (EFQM, EFQM Model 2013, 2012) contains 9 sub-criteria, which are composed as follows.

5 "Enabler Criteria

• Leadership
• Strategy
• employees
• Partner & Resources
• Products, Processes & Services

4 "Outcome criteria

• Customer-related results
• Employee-related results
• Society-related results
• Key Findings

Potential integrated quality management model

When physical therapists and their practice institutions question themselves according to this model, they encounter underutilized synergies in managing partners and resources.

If doctors (surgeons, orthopaedists, general practitioners) and medical technology carry out an EFQM assessment, a similar picture emerges. Thus, in order to promote understanding within the various stakeholder groups, which have the patient as their target group as a customer focus, EFQM-2013 can be applied as a motor for sustainable corporate development and for the further development of the healthcare system. For the practical example of physiotherapy, the strategy of the federal government with "Health2020 " is linked to new fields of action.

Quality Circle

• Intra-practice quality circles
• External quality circles
• Interdisciplinary quality circles between different service providers

Quality circles in physiotherapy are not active across the board today. There is a wide range of quality in physiotherapy that can be perceived by the patient. In particular, dialogue between those involved in the treatment pathways, both in inpatient and outpatient primary care, should be ensured for the benefit of patients. Investments in the potential and value of freelance physiotherapists do not cause additional costs. Quality projects and a new form of quality circles are required, which specifically record and further develop the interfaces in patient treatment. Interface management requires a high level of competence of the practice institutions and their management. The coordination of quality and risk management in patient treatment makes sense for the further development of the Swiss health care system and physiotherapy. Quality circles and round tables between physiotherapy, medical technology, surgeons, orthopaedists and general practitioners as well as other interested parties should be promoted:

Pilot project 1

Evaluate interfaces and quality in the health care system and manage them in a targeted manner

Pilot project 2

Manage knowledge in a targeted manner in the clinical thinking, action and decision-making process

• Round Table
• Interdisciplinary quality circles

Pilot project 3

• Assessment according to EFQM-2013 in the physiotherapy practice institution

These measures represent a further step towards comprehensive partner and resource management.