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Experiencing the Barriers

Authors Alexandra Tobin MCSP is CSP professional adviser for clinical audit and physiotherapy manager, East Wiltshire Health Care NHS Trust. Marlan Judd MSc MCSP is clinical audit co- ordinator at the Camden and Islington Community Health Care NHS Trust, and a physiotherapist. Information about Audit Report Carol Groom, Mid Kent Health Care Trust, Maidstone Hospital and Community Unit, Hermitage Lane, Maidstone, Kent ME16 9QQ.

Tobin, A and Judd, M (1999). ‘Experiencing the barriers’, Physiothmqy, 85, 1,&10.

Introduction This is the second in a series of three articles, which explore some of the barriers to carrying out effective clinical audit. The first, ‘Understanding the barriers’, was published in November 1998 (Tobin and Judd, 1998). In this paper we report on the experiences of physiotherapists in the South Thames area, when they participated in a region-wide low back pain audit last year.

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Background to the South Thames Low Back Pain Audit In 1993 the Mid Kent Health Care Trust ..................................................................................................

(HCT) funded consultant support from the University of Brighton, Department of Occupational Therapy and Physiotherapy (now School of Health Care Professions) to establish a tool to measure the effects of physiotherapy in the general out-patient setting and to gather data on current practice. An outcome measurement tool was developed in liaison with patients and staff and was piloted over a 15-month period in three out-patient physiotherapy departments within Mid Kent HCT. The final outcome measurement tool was published by the University of Brighton in collaboration with the Mid Kent HCT (Moore, 1996), and the measurement tool is now integrated into the day-to-day practice of physiotherapists working in out-patient departments throughout the Mid Kent HCT.

The final outcome measurement tool consisted of a data sheet (discharge summary sheet) consisting of 31 items requiring a response from the physio- therapist together with a codings list.

In the published report (Moore, 1996) low back pain was identified as the most common reason for patient referral to the out-patient departments in the Mid Kent HCT. Low back pain was therefore chosen as a topic for a clinical audit to be carried out across the South Thames Region. The

Key Words Audit , evideiice-base d prac ti ce , low back pain, quality.

by Alexandra Tobin Marian Judd

project was funded by the Clinical Audit Programme Management Group, South West Region, and ten trusts participated.

The aim of the project was to audit the clinical outcomes of physiotherapy management, in out-patient departments, of patients who have low back pain. This would be done using the clinical standards developed in 1995 by the East Kent Health Authority and the Mid Kent and University of Brighton outcome measurement tool.

The trusts who participated in the South Thames Low Back Pain Audit were: w Dartford and Gravesham Hospital w Frimley Park Hospital w Kent and Canterbury Hospital w Mid Kent HCTT w Queen Elizabeth the Queen Mother Hospital w Richmond Rehabilitation Unit

St George’s Hospital w Thameslink

William Harvey Hospital w Worthing Hospital

In December 1996 a small group was formed to manage the audit process. The role of the Audit Management Group was to identify participating audit sites, define the audit topic, agree standards to be audited against, make any necessary modifications to the audit tool following a pilot of the discharge summary sheet, and agree procedures for analysing the audit results. Workshops were held in each participating unit to explain the audit process, the outcome measurement tool and the project as a whole.

The Audit Management Group also established the population size for the audit. It was anticipated that 200 patients from each of the ten units would be included in the audit, giving a proposed total audit population of 2,000 patients.

The audit began, across all the part- icipating sites, in September 1997. By the

Briefing paper

cnd of November 1997, less than 10% of the arilicipatcd number of discharge snmmary shects had been submitted for analysis. By January 1998, 414 completed sheets had been received, and by the end February the final sample size was 564 patients, of whom 33 1 had completed their physiotherapy.

Detailed professional analysis of the data was carried out by the University of Brighton consultant and the final audit report was published early in October 1998 (Moore, 1908).

TheReal World of Clinical Audit ....................................................................................... Conccrns had been expressed, at an early stage in the audit period, about the lack of data coming back from participating units. During an informal discussion between a member of the Audit Management Group and the professional adviser for clinical audit a t the Chartered Society of Physiotherapy (CSP), it was suggested that valuable lessons could be learnt from exploring some of the reasons behind the low voliime of audit data which had been returned from this region-wide pryject.

'I 'here are a number of reasons why physiotherapists may find it difficult to bccome actively involved in clinical audit (Tobin and Judd, 1998). Specific obstacles to implementing evidence-based practice have been identified and these have been grouped as personal, team or organisational barriers (Robertson et d, 1996).

Ar a personal level, health professionals rnay no t be following a clinical practice guidcline. The practitioners may think that Ihtty lack thc relcvant knowledge or ability to follow the guideline. Alternatively, they may be unwilling to consider change, coniiderit that their current. practice is good enough. Some practitioners will deny that there is evidence that their performance is deficient. Others require reassurance that the source of a guideline is credible, before being willing to consider changing their practice.

At a team level, where a multi-site audit nlily have been organised, members of a health care team may fail to change their clinical behaviour. Some team members may think that others will undervake the aiidit and will then implement any changes in clinical practice that have been recommended. In some situations, a powerful minority of the team may think that change is unnecessary and may t.herefore be unwilling to engage in audit activity. Alternatively, team spirit and morale

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may be so high that t.he team believes its performance is good and change is unnecessary.

At an organisational level, there may be failure to implement national recommendations about effective types of treatment. In some organisations, health professionals may reject the role of general managers in discussing clinical issues.

Telephone Survey It was agreed that the CSP Professional .................................................................................................

adviser for clinical audit and the clinical audit co-ordinator from the Camden and Islington Community Health Services NHS Trust would carry out telephone interviews with a lead person from each of the trusts who participated in the South Thames Low Back Pain Audit. The aim of these inter- views would be to provide opportunities for the trusts who had participated in the South Thames Low Back Pain Audit, to explain and discuss any reasons why they had found it difficult to provide completed discharge sumrnary sheets from 200 patients, which was the target population for the audit a t each site. T h e lead person interviewed could either be a physiotherapy manager or a senior clinician.

A semi-structured telephone interview was designed and this was based on the existing evidence about barriers to implementing evidence-based practice. A pilot draft of the interview questionnaire was drawn up. Two senior physiotherapists and one physio- therapy manager agreed to be interviewed as part of the pilot scheme and this led to some minor adjustments to the wording of the questionnaire being made.

A letter was then sent to each of the participating trusts, inviting them to take part in the study.

The telephone interviews were carried out over three days, by the CSP professional adviser for clinical audit and the audit co- ordinator from the Camden and Islington Community Health Care Trust. Ten physiotherapists agreed to be interviewed, two were physiotherapy managers and eight were senior clinicians who had taken part in the audit.

Results Individual Attitudes and Behaviours ..................................................................................................

rn Most services indicated that staff understood the importance of undertaking clinical audit. rn Staff members had expressed a high level of interest in the opportunity to take part in

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a multi-centre region-wide audit of the outcome of physiotherapy for out-patients with low back pain. w The decision to participate in the audit was, on the whole, a management decision. The funding from the South Thames Region was viewed as an incentive by some services. w All the senior therapists and managers interviewed indicated their belief in the importance of delivering clinically and cost- efyective care. The need to provide proof of clinical effectiveness to purchasers and consumers was seen to be important. w Six out of the ten people interviewed said that they had confidence in the audit tool. The reasons givcn for this were that it had been well developed through the original prqject in 1993 and that the consultant leading this work was perceived as having credibility as a researcher. Three sites had expressed reservations at the time about the length of the discharge summary sheet. = Eight of the out-patient sites had previously been involved in audit projects. Two sites had never undertaken any clinical audit of out-patient physiotherapy.

Most staff in the out-patient physiotherapy services appeared willing to consider changing their practice, although departmental cultures differed and personalities influenced the degree of willingness shown. It was felt that people generally saw the need to improve practice. w Staff in all but one of the out-patient departments questioned were involved in some aspect of appraisal of their individual performance. Some departments appeared to be more committed and rigorous in their approach than others. H All but one of the senior therapists and managers interviewed felt that the staff in their out-patient department made the most of the opportunities that were available for personal development. The systems and scope of what was available varied to some extent between services.

Team Attitudes and Behaviours H The response from most of the out-patient physiotherapy teams to participating in the South Thames Low Back Pain Audit was generally positive. Four of the teams were concerned about the length of the discharge summary sheet. One of these teams felt that they needed to allow an extra 15 minutes for each appointment time to fill it in and that 15 x 200 minutes (50 hours) was a huge extra time commitment for the department. One team felt that the audit represented

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a decrease in its paperwork, as the new discharge summary form was shorter than the one currently used. m Four of the teams stated that a feeling of ownership of the audit by the physiothera- pists was crucial to its success. These teams expressed concerns about the workshops that were held at the start of the audit, as failing to sell the benefits to individual departments of participating in a region- wide audit.

Of the ten teams questioned, six had undertaken a literature search relating to low back pain. These had mainly been carried out by individual therapists as part of a degree course or for membership of the Manipulation Association of Chartered Physiotherapists. H Of the teams questioned, 50% reported that at least one physiotherapist had been trained in critical appraisal skills. One physiotherapy service had trained all its staff.

Five teams had developed some standards for the management of patients with low back pain before the start of the audit. One team reported that these were based on the Low Back Pain Guideline (Royal College of General Practitioners 1996) and another team was aware of the standards defined in the Clinical Standards Advisory Group report (CSAG, 1994). One team intended to develop its standards following the results of the audit and another team was involved in the development of a patient pathway.

Four teams had previously audited their standards for the management of patients with low back pain, although two of these indicated that the methodology might have lacked ngour. w Qualified physiotherapists of all grades were involved in carrying out the audit. All the physiotherapy teams excluded their students as it was felt that they were already carrying a heavy work commitment at their clinical placements. w All the physiotherapy teams were unanimous in believing that they delivered a good service to patients. Five teams systematically collected information from their patients about their physiotherapy on a regular basis. This varied from annual individual interviews with patients, which were carried out independently of the department at one site, to the use of patient satisfaction questionnaires which had been designed by the clinical audit department at another site. Two sites had been awarded a Charter Mark in 1996. Five sites had never formally consulted patients to find out their

Briefing paper

levels of satisfaction with the out-patient physiotherapy service.

Organisational Attitudes and Behaviours H Eight out of the ten trusts questioned had ..................................................................................................

a strategy for delivering high quality and effective patient care. Five of these trusts involved the physiotherapy service in the development of the strategy. Five trusts also stated that it was doubtful whether many of the physiotherapists in the out-patient departments had read and fully understood the strategy. Time constraints and lack of motivation were given as the main reasons for this.

All the trusts expected the out-patient physiotherapy services to take part in the South Thames Low Back Pain Audit. H Three trusts had clinical audit departments which were actively able to support physiotherapists to carry out audit projects. Two trusts had withdrawn their clinical audit resources and there was now only minimal support available for physiotherapists. The remaining out-patient departments were unaware of what support was available from their local clinical audit departments. H Only one trust had factored the time needed to carry out clinical audit into the physiotherapy service contract activity levels. w Most physiotherapy service managers were keen to understand the effectiveness of the out-patient physiotherapy service, were interested in the audit, and were supportive towards those who were carrying it out. H The main organisational constraints identified on being able to carry out the audit effectively were lack of time and manpower.

Two trusts felt that the population target for the audit had been set too high. One of trusts commented that the Neck Pain Audit, which is currently being carried out across the same region, is allowing a six-month period for data collection and that the total volume of data required is half that for the Low Back Pain Audit. H Four trusts had seen much lower than expected numbers of patients with low back pain during the period of the audit, which led to fewer data than expected being collected. H One trust reported that because it had a high throughput of students, fewer patients who were suitable for the audit were available for qualified staff to treat. H One trust admitted that there had been some confusion about the audit in one of its

out-patient departments. This had meant that casenotes which had been identified as being suitable for inclusion in the audit had not been set aside, and had been lost in the hospital system.

Discussion The physiotherapy managers and senior ..................................................................................................

physiotherapists from the South Thames area who were interviewed as part of this study were all committed to the principle that physiotherapy services need to be able to demonstrate their clinical- and cost- effectiveness, through clinical audit. Most of the staff in the physiotherapy out-patient departments who took part in the Low Back Pain Audit appeared willing to appraise their individual and team performance critically.

However, knowledge about the tools for achieving clinical effectiveness appears to be generally lacking within the individual services. The systems and processes that are required to support the development of evidence-based practice in a physiotherapy service also appear to vary between the different services. Overall, the amount of clinical audit that staff are able to undertake is lower than might be expected. There is also a notable lack of consultation with patients about their satisfaction with the physiotherapy service.

This situation is perhaps somewhat surprising, given the very positive attitudes expressed by individuals, teams and trusts to the development of clinical audit as part of a wider strategy for clinical effectiveness. It seems that the main reasons why services are finding it difficult to translate these views into audit activity are lack of physiotherapy time and manpower to undertake the work involved, and lack of availability of support from some clinical audit departments.

Given these pressures, physiotherapy teams need to experience the beneficial changes that should result from participating in a large-scale audit such as this, before they will be confident about committing their resources to other clinical audit projects. The need to re-audit the out- patient physiotherapy services which took part in the South Thames Low Back Pain Audit will be an important next stage in the continuous quality improvement cycle.

The lower than expected volume of data that was returned in this project seems to be largely due to practical problems around the availability of suitable patients and the internal organisation of individual out-patient departments. There was a strong

feeling from somc‘ of those who participated in the audit that the population target had been set too high, and this appears to have been addressed in the Neck Pain Audit which is currently being carried out across the Same region.

Conclusion The findings of this small study suggest that, o n the whole, physiotherapists and physiotherapy teams have a very positive attitude towards clinical audit. There is also a good understanding of the reasons why it

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References Moore, A (1998). ‘An audit of the outcome of physiotherapy intervention for out-patients with back pain against set clinical standards’. The South Thames Clinical Audit Programme. Tobin, A and Judd, M (1998). ‘Understanding the barriers’, Physiotherapy, 11, 11,527-529. Robertson, N, Baker, R and Hearnshaw, H (1996). ‘Changing the clinical behaviour of doctors: A psychological framework‘, Quali9 in Health Can?, 5,51-54.

is important. to undertake clinical audit. The physiotherapy out-patient services questioned all reported that they experienced dificulties when trying to find the time, manpower and support for clinical audit. Consequently, the levels of’ audit activity were lower than might be expected.

Anecdotal evidence from elsewhere in the United Kingdom that has been collected hy the authors of this report supports the view that these experiences are not unique to the physiotherapy services which participated in the South Thames Low Back Pain Audit.

The Royal College of General Practitioners (1996). Clinical Guidelines for the Managevnent of Acute Back Pain, RCGP, London. Clinical Standards Advisory Group on Back Pain (1994). RLpmt of CSAG Committee on Back Pain, HMSO.

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