oa Effectiveness of a Cost Effective Competency Workshop in Disseminating Knowledge of ‘Clinical Practice Guideline’ among Physical Therapist in a Tertiary Level Hospital in Qatar

Background

Clinical guidelines are systematically developed statements designed to help practitioners and patients to make decisions about appropriate health care (Field and Lohr 1992). Higher quality of care and improved cost effectiveness are important goals in guideline development, optimally resulting in improved health (Woolf et al., 1999). Moreover, the process of guideline development addresses the need to decrease variability in professional practice, and practitioners' desire to legitimize their profession in the eyes of external stakeholders (Grimshaw et al., 1995a, Grimshaw et al., 1995b, Grol and Grimshaw 2003, Grol et al., 2004). The concept of evidence-based practice, supported by clinical guidelines, is a common aspect of health care today. Currently there is no formal training or education sessions to unify the Physical therapy practice in the department, which in turn resulting in greater practice variations and results. Grater variability in professional practice directly influences the outcome of patient care. To counteract this, Physical therapy unit, Rumailah hospital, Qatar has developed Physical therapy specific clinical practice guideline called ‘PAAS Guideline’ (Physical Therapy After Acute Stroke) to enhance the effectiveness and efficiency of post acute stroke Physical therapy care. Evidence argues that guideline-adherent care results in better health outcomes, quality of care, shorter treatment period and reduced cost of care. The phase I of the PAAS G adherence trail focuses on the knowledge dissemination phase of the clinical practice guideline through a structured competency workshop and its effectiveness. ‘Physical Therapy After Acute Stroke’ (PAAS) guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care ‘exclusively’ developed by the Physical therapists of Rumailah hospital. The goal of the PAAS guideline is to improve the quality, transparency, and uniformity of the physical therapy provided to patients whose main diagnosis is a stroke (cerebrovascular accident), throughout the chain of integrated care, by explicitly describing the Physical therapist's management of these patients on the basis of scientific research, adjusted where necessary on the basis of consensus among Physical therapy experts in primary, secondary and tertiary care, as well as associated professions in the field.

Objective

To find out the effectiveness of a cost effective competency workshop in disseminating knowledge of ‘Physical Therapy After Acute Stroke (PAAS) guideline’ among physical therapist of Rumailah Hospital, Qatar Method Participants and procedure: Through the intranet system of the Hamad Medical Corporation the competency workshop was announced well in advance of the date. The workshop and the competency training were made mandatory for all the Physical therapists practicing the neurological Physical therapy of Rumailah hospital. The supervisors of other Physical therapy department were informed to select physical therapists practicing stroke physical therapy in their unit in order to coalesce the practice across the corporation.

Workshop Structure

The program offered Physical therapists free one day eight hour PAAS guideline training. Upon successful completion of the workshop (60% marks in the post competency examination), participants will receive a ‘PAAS guideline competency certificate’ of one year validity. One full day was prepared as a competency training day by cancelling all the clinical related works of that day. The essential clinical duties of the day were rescheduled to one public holiday with 2 physical therapists on overtime coverage. The cost of the program was strictly controlled with an intention to create a cost effective workshop model which can be employed even in other units. We used our gym hall as the lecture room with all the furniture and audio-visual medias of the department. A two time simple snack was provided by using unit and hospital petty cash facility. All the printing and the publication works were done using the unit internal resources. Medical corporation media was informed to cover the event. The pre and post workshop competency exam were conducted at the beginning and very end of the program with 30 minutes given to answer 20 guideline related questions. A feedback recording was taken concerning the workshop and the arrangement in a structured course feedback form.

The training

Program agenda of the workshop was announced well in advance of the date (Table 1). All the topics were the direct reflections of the PAAS guideline converted to power point presentations. The 1-day, 8 hour training was organized in a ‘constructivist didactics’ way followed by clinically relevant examples as a way to maximize active participation by the attendees. A course and session objectives and lesson plan were given before every presentation. For every five slides of the powerpoint presentation, one review question was given inorder to refresh and refocus the attendees back to the session. The conclusion was made interactive by highlighting all the key points discussed on the session and by randomly asking the attendees to expand the key words into ideas that has learned. A five minute break was given for every presentation which was used as a question and answer session. The specialists of the department of the physical therapy, conducted the training. All the training presentations were unified in there structure and content and verified for errors well in advance of the course. The PAAS guideline was made available to all the participants before the workshop. Participating Physical therapists received author-developed handouts adapted from the workshop. The guideline was presented as seven sessions covering the seven topics of the PAAS guideline. The trainers did not target training with special conclusion nor were attendees told what would be learned and evaluated at the end of the training. However, participants were encouraged to increase the number and diversity of reflections used, diminish the frequency of questions and increase the use of open questions. PAAS guideline knowledge building was the clear goal of the training, but the emphasis was on the participants understanding and amalgamation of the given evidences with the current practices and experiences they have.

Competency examination

The participants of the PAAS guideline training were required to complete a guideline competency exam at the beginning and at the end of the training. The objectives of the competency exam was to evaluate and document the percentage of knowledge acquisition by the attendees. We believed that a respectable launch of the PASS guideline implementation should begin from an effective and equally distributed knowledge dissemination process. Twenty questions were created from the eight sessions of the guideline based on the Bloom's taxonomy. PAAS competency examination was designed with 10% questions to test the knowledge domain, 20% with comprehension, 25% with application, 20% analysis, 15% with synthesis and 10% to test the evaluation skills (Fig. 1). A total 30 minutes were provided to complete the examination. Test validation As a part of test validation 3 Physical therapy specialists with stroke rehabilitation experience from different hospital background were given the designed questionnaire and were asked to mark any questions that were unclear to them when they were taking the test. After the test, a discussion session was organized to ensure their understanding of the test questions was the same as what was intended. Two questions were adjusted based on this ‘internal pre-testing’ measure.

Results

The candidates were given the pre and post examination with the same question set. No information or clues were given to the participants regarding the posttest examination during the pretest or workshop. The same question set was used inorder to quantify the transfer of knowledge from the workshop. The maximum possible mark in the question set was 20. The average mark scored by the candidates in the pretest was six (6) out of 20 with standard deviation of (SD) 1.9. The average mark scored by the candidates in the post test was 14.5 out of 20 with standard deviation of (SD) 3.0 indicating difference of 8.5 marks with standard deviation of (SD) 1.6 between the two examinations. This has proven that the cost effective competency workshop succeeded in improving PAAS guideline knowledge to 141.7% compared to the pre workshop. Figure 2 represents the PAAS G examination mark analysis. A paired t test was executed to analyze the pre and post workshop test results. The t statistics was observed as, t = 21.496, and p = 0.001; ie, 0.001 probability of this result occurring by chance, under the null hypothesis of no difference. The null hypothesis was rejected, since p <  0.05 (Table 2).

Conclusion

There is strong evidence (p <  0.05) that the cost effective competency workshop improved PAAS G knowledge. In this data set, it improved marks, on average, by approximately 8.5 points or 141.7% with a 95% Confidence Interval (7.7–9.3). The feedback evaluation revealed an overall very good to excellent rating for the competency workshop (Fig. 3).

Implication

PAAS guidelines is a professional Physical therapy guideline for patients with stroke; based on scientific evidence, intended to optimize patient care, developed by the guideline task force of Physical therapy unit, Rumailah Hospital. PAAS Guideline offers recommendations for appropriate care. An evaluation of the guideline adherence and practice variations helps to fine tune the Physical therapy care to a highest possible standard of practice. A proper assessment of the relationship between the process of Physical therapy care and outcomes with a comprehensive set of process indicators will be implemented during the year 2016. We strongly believe that by means of systematic approach and implementation we can change the culture of practice so that it can suit and align with the international quality care in evidence based manner there by uplifting the corporation and its vision of becoming an internationally recognized center of excellence in health care. We believe that this ‘small changes will make a big difference in our health care system in the coming years’.

Physical Therapy, Practice behavior, Clinical practice guideline, Adherence

References

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Grimshaw, Jeremy, Martin Eccles, and Ian Russell. “Developing clinically valid practice guidelines.” Journal of evaluation in clinical practice 1.1 (1995): 37–48.

Grol, Richard. “Successes and failures in the implementation of evidence-based guidelines for clinical practice.” Medical care 39.8 (2001): II–46.

Grol, Richard, and Jeremy Grimshaw. “From best evidence to best practice: effective implementation of change in patients' care.” The lancet 362.9391 (2003): 1225–1230.

Woolf, Steven H., et al. “Clinical guidelines: potential benefits, limitations, and harms of clinical guidelines.” BMJ: British Medical Journal 318.7182 (1999): 527.