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.

“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?