What is Quality in Physical Therapy?

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I have had some interesting interactions in social media over the past few weeks that have had me thinking about the definition of quality in physical therapy. Therapists are paid for our time and the procedures we perform. Because of this (or at least I blame this system) we tend to define quality around ‘actions taken’ and method of work. For example:

  • Quality providers are able to manipulate an acute low back
  • Quality providers avoid modalities
  • Quality providers provide good home exercise programs
  • Quality providers set and track goals
  • Quality providers use evidence based interventions
  • Quality providers spend (however long) with each patient
  • Quality providers do not use PT Assistants or Aides
  • Quality providers have this or that certification
  • Quality providers have/avoid the latest gadgets
  • Quality providers use/have/do whatever is important to you…

We do this in large part because these are the most visible parts of a practice we might judge it by. However, I would argue that while there are a host of factors that the best practices have in common, quality is not defined by actions or our broken reimbursement system. Quality is defined by patient outcome and by patient experience. In this post, I’d like to provide a window into how we measure quality at Texas Physical Therapy Specialists.

In our practice, we measure outcome using a national database called Focus on Therapeutic Outcomes (FOTO). This system uses adaptive surveys to determine a risk adjusted baseline when a patient starts physical therapy, and then tracks their progress. The results can then be used to provide feedback to individual therapists (i.e.”Dr.____, your outcomes with ankle patients aren’t as good as Dr.___’s, lets see what they are doing that you are not) and more importantly can be used to compare outcomes with other participating practices across the nation.

The other component of quality in physical therapy practice is patient experience. We break this into two components: customer service (all staff interactions) and providing quality connection between the therapist and the patient.

We measure customer service with a survey that has multiple components but centers around the ‘net promoter score‘. Often called ‘the most important question in business’ it is simple and captures the desired customer service outcome for most practices.11268773_m

“How likely is it that you would recommend us to a friend or colleague?”

Much harder to measure but equally important to patient experience is the quality of connection between patient and therapist. This is how well a therapist listens and how much empathy they show. These things have a powerful impact on clinical outcome so we measure them separately using a survey specifically for these items (Consultation and Relational Empathy instrument or CARE) at the completion of the first visit. Interestingly, our therapists scored significantly better in this area after receiving training specific to compassion and empathy.

The confluence of these three things is the product our practice produces.

The amount we charge a cash-paying patient, the contract we sign with an insurer or the assignment we accept from the federal government is simply how we receive payment for that product.  Our current payment system bases this on time spent and a host of other items that have no direct relationship to quality.  Paying for time without accounting for outcome is like paying a mechanic for the time spent on your car without accounting for whether the problem is solved.  Regulating work methods is like mandating that a mechanic can’t use helpers and again not accounting for whether the problem is solved.  We have to comply with these external definitions (which vary wildly by state and payer) but we do not have to let them define what Quality is.  In my opinion, quality in physical therapy is a simple equation:

Quality = Outcome + Patient Experience.

There are many ways to get there, and undoubtedly some are better than others.  Having the ability to measure quality gives us the opportunity to find bright spots and emulate best practices.  How do you measure the quality of your service?

Please note: I reserve the right to delete comments that are offensive or off-topic.

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2 thoughts on “What is Quality in Physical Therapy?

  1. Hi David,

    Please allow me to venture off topic slightly. I do use FOTO and I hear what you are saying. Health care is a train wreck and I’d like to reflect on what quality means to me.

    The only thing missing from the equation: quality has to be expanded to be more than just an episode of care. In my opinion, quality also includes the the rippling effect after the episode of care. A short term episodic outcome may be stellar, but what happens within the next 12 months? How does this compare with other episodic outcomes? How does it compare to no intervention? In other words, as health service research grows and learns from claims data, the definition of quality will change and capture the results of quality.

    To me: Quality = the right patient at the right time with the right intervention reaching optimal outcomes in a reasonable amount of time with an end result of maintaining or improving the outcomes without future interventions for same complaint for 12 months or more.
    Outcomes: this term also needs to be defined. Broadly, I think of outcomes as engaged and participatory patients and caregivers who consistently demonstrate self-efficacy in maintaining or improving the highest level of independence, function and health possible for the given situation.

    As a physical therapist, I fail at providing quality on a variety of levels.
    1) I don’t always have patients attending for services at the right time
    2) I have no data as to whether I truly addressed the complaint outside of the episode of care
    3) After the episode of care, I have no idea if patients continue to maintain or improve their situation

    We need extra data to know the impact of our services and there may even be a gap that needs to be filled after an episode of care to help ensure what we thought of quality based on the episode results really was quality.


    • Hi Selena,
      thanks for commenting! I couldn’t agree more – there are alot of aspects inherent in the ‘outcome’ part of the equation (much like the patient experience includes more than just customer service). We do have (some) data that we as a group can impact downstream costs. To some degree we also have the ability to impact patients beyond the disease model and into wellness. Unfortunately, as you know, the ‘medical necessity’ of physical therapy falls short of that next level of impact.
      While patients are sometimes (often) willing to pay for continued services, at the heart of prevention is the patient’s priorities and their own behavior. My personal goal is always to return patients to the ability to exercise and to educate and motivate them to lead a healthy lifestyle as they move back into their normal life. The challenge is that most in need of services beyond the disease model are the least likely to seek it out, pay for it and utilize it to change their lifestyle behaviors. While referral source and patient behavior is (hopefully!) within our sphere of influence, it is not within our sphere of control. It makes sense to keep our focus on outcomes within the sphere where we can have a measure of control and thus confidence that our intervention had the impact we are observing.