2: Delivering good quality, safe and effective care

CHAPTER 2
Delivering good quality, safe and effective care


2.1 Introduction


Within the current political and economic climate occupational therapists are increasingly required to work within limited resources and make decisions regarding the most effective interventions to offer people with long-term neurological conditions. This chapter explores the factors that contribute to clinical decision-making and how occupational therapists combine their knowledge of the evidence base, the preferences of people with long-term neurological conditions and an awareness of their own capabilities, in delivering good quality, safe and effective care.


2.2 The strategic context


Strategy or policy offers a political vision which determines the key drivers for change in health and social care. Current policy relating to people with long-term neurological conditions requires the following:



  • Delivery of safe and effective programmes of intervention
  • Person-centred approaches to care
  • Maximising scarce occupational therapy resources to ensure equity of access
  • Involvement of people with long-term neurological conditions in the development and design of co-ordinated and integrated occupational therapy services
  • Preventative measures to reduce demand and lessen inequalities.

Occupational therapists are required to draw on a range of evidence, guidelines and professional standards to inform their practice and to support their ongoing continuing professional development. The evidence relevant to supporting people with long-term neurological conditions will be presented in a hierarchical structure in this chapter for ease of explanation and clarity although it is recognised that they will be applied within a more integrated approach in practice.


2.2.1 National Service Framework for long-term conditions


The National Service Framework (NSF) is a 10-year strategy to transform the way care services support people with long-term neurological conditions to live as independently as possible (Department of Health, 2005). It sets quality standards for supporting people with long-term conditions. The NSF for long-term conditions was developed to:




  • Ensure quick access to specialist neurological expertise for help as close to home as possible
  • Support people to live with long term neurological conditions
  • Improve their quality of life by providing services to support independent living.

At the heart of the NSF are 11 quality requirements based on currently available evidence, including what people with long-term neurological conditions said about their experiences and needs as follows:


Quality requirement 1: A person-centred service


People with long-term neurological conditions are offered integrated assessment and planning of their health and social care needs. They are to have the information they need to make informed decisions about their care and treatment and, where appropriate, to support them to manage their condition themselves.


Quality requirement 2: Early recognition, prompt diagnosis and treatment


People suspected of having a neurological condition are to have prompt access to specialist neurological expertise for an accurate diagnosis and treatment as close to home as possible.


Quality requirement 3: Emergency and acute management


People needing hospital admission for a neurosurgical or neurological emergency are to be assessed and treated in a timely manner by teams with the appropriate neurological and resuscitation skills and facilities.


Quality requirement 4: Early and specialist rehabilitation


People with long-term neurological conditions who would benefit from rehabilitation are to receive timely, ongoing and high-quality rehabilitation services in hospital or other specialist settings to meet their continuing and changing needs. When ready, they are to receive the help they need to return home for ongoing community rehabilitation and support.


Quality requirement 5: Community rehabilitation and support


People with long-term neurological conditions living at home are to have ongoing access to a comprehensive range of rehabilitation, advice and support to meet their continuing and changing needs, increase their independence and autonomy and help them to live as they wish.


Quality requirement 6: Vocational rehabilitation


People with long-term neurological conditions are to have access to appropriate vocational assessment, rehabilitation and ongoing support, to enable them to find, regain or remain in work and access other occupational and educational opportunities.



Quality requirement 7: Providing equipment and accommodation


People with long-term neurological conditions are to receive timely, appropriate assistive technology/equipment and adaptations to accommodation to support them to live independently, help them with their care, maintain their health and improve their quality of life.


Quality requirement 8: Providing personal care and support


Health and social care services work together to provide care and support to enable people with long term neurological conditions to achieve maximum choice about living independently at home.


Quality requirement 9: Palliative care


People in the later stages of long-term neurological conditions are to receive a comprehensive range of palliative care services when they need them to control symptoms, offer pain relief and meet their needs for personal, social, psychological and spiritual support, in line with the principles of palliative care.


Quality requirement 10: Supporting family and carers


Carers of people with long-term neurological conditions are to have access to appropriate support and services that recognise their needs both in their role as carer and in their own right.


Quality requirement 11: Caring for people with neurological conditions in hospital or other health and social care settings


People with long-term neurological conditions are to have their specific neurological needs met while receiving treatment or care for other reasons in any health or social care setting.


2.2.2 Clinical standards: Neurological Health Standards


The overall aim of NHS Quality Improvement Scotland was to produce standards that will address the patient journey from the point of referral into the service and will result in an improvement in care for all of those suffering from neurological conditions (NHS Quality Improvement Scotland, 2009). The standards were intended to support rather than duplicate existing quality initiatives. The Neurological Health Standards include four generic standards:



  • Standard 1: General neurological health services provision
  • Standard 2: Access to neurological health services
  • Standard 3: Patient encounters in neurological health services
  • Standard 4: Management processes in neurological health services

In addition service-specific standards were developed for motor neurone disease (MND), multiple sclerosis (MS) and Parkinson’s services with each including three components of access to specialist disease specific services, diagnosis of specific disease, and ongoing management of specific disease. The future vision for neurological health services in Scotland is that ‘every patient in Scotland referred with a disorder of the nervous system experiences a quality of care that gives confidence to patient, referrer and provider’.



This will be achieved by ensuring the individual:



  • Is assessed by the right person at the right time
  • Has timely access to investigations that promote care
  • Is encouraged to participate in decision-making on a partnership basis when desired
  • Has easy access to information and services that enhance the long-term management of their condition.

2.3 Evidence-based practice


Evidence-based medicine was originally defined as ‘the conscientious and judicious use of current best evidence from clinical care research in the management of individual patients’ (Sackett et al., 1996). For occupational therapists, practising in an evidence-based way means integrating the best available evidence with clinical expertise and client values in making decisions about individual client care (Sackett et al., 2000) as illustrated in Figure 2.1.

Diagram of evidence-based practice applied to occupational therapy depicting the interrelationship of expert clinical knowledge, scientific evidence, practical experience, and person-centeredness.

Figure 2.1 Evidence-based practice applied to occupational therapy.


(Adapted from Hoffman et al., 2010, Figure 1.1, p. 7. Reproduced with permission of Churchill Livingstone Elsevier.)


2.3.1 Why do we need evidence-based practice?



  • To provide the most effective care and improve client outcomes
  • To ensure people with long-term neurological conditions receive the care that fits their needs
  • To minimise risk so that benefits outweigh harm
  • To increase consistency in the delivery of care
  • To ensure interventions are up to date and relevant
  • To ensure scarce resources are used wisely (Hoffman et al., 2010).

2.3.2 Finding the best evidence


There are different forms of evidence which can be used to inform neurological practice. However the main forms of scholarly evidence include the following:



  • Books can vary in quality, so it is important to consider the expertise and reputation of the author; other titles produced by the publisher; the use of references and citations; relevance; and currency to neurological practice (Lou and Durando, 2015).
  • Non-Peer-Reviewed Journals and Professional Magazines (e.g. OTNews) can be a useful source for current developments and discussions. Generally they are not subject to the same scientific scrutiny as peer-reviewed papers which may impact on the application of the findings to neurological practice. It is not recommended to rely solely on this source of evidence to inform your clinical practice (Lou and Durando, 2015).
  • Peer-Reviewed Journals (e.g. British Journal of Occupational Therapy) are generally considered more accurate and relevant as they have been subject to a rigorous scrutiny by neurological experts to ensure higher academic quality, including accuracy of content, methodological design and relevance to neurological practice (Lou and Durando, 2015).
  • Clinical guidelines (e.g. National Institute for Health and Care Excellence (NICE) clinical guidelines) offer a series of systematically developed recommendations on how to care for people with long-term neurological conditions, based on the best available evidence (NICE, 2014). Due to the process of evidence review, however, an absence of occupational therapy evidence in clinical guidelines does not necessarily reflect an absence of effectiveness of interventions (Drummond and Wade, 2014).
  • Practice guidelines are a set of statements or management strategies developed by expert occupational therapists which outline the most prudent approaches to aspects of neurological practice incorporating evidence where this exists (Bennett and Bennett, 2000).
  • Standards of practice include statements of principles to enable occupational therapists to monitor and improve their practice and maintain excellence in the quality care for people with long-term neurological conditions. The standards are underpinned by legislation and regulatory and monitoring bodies (College of Occupational Therapists, 2011).

2.3.3 Using electronic databases to find evidence


Electronic databases are collections of published research, scholarly articles, books, dissertations and reports (Lou and Durando, 2015). Access to electronic databases, for example CINAHL, MEDLINE, PsycINFO and the Cochrane Collaboration, requires a username and password which can be obtained through your librarian depending on your institutional subscription. The range of electronic databases has different functions and may identify different resources. Relevant articles can be retrieved through the use of a well-constructed search strategy using subject headings and/or key words. Articles can be reproduced in the form of abstracts or in full-text PDF format. Copyright restrictions apply to both the storage and use of materials which are subsequently downloaded.


2.3.4 Appraising the evidence


The quality of published research varies due to a number of factors such as the design of the study or the standard of the publication. Occupational therapists must evaluate the reliability of evidence before they decide if the results of the study should inform changes to their clinical practice. A range of tools or critical appraisal checklists are available to support the occupational therapist to determine the validity and clinical usefulness of research (Bennett and Bennett, 2000). The most commonly used checklists include those developed by the Critical Appraisal Skills Programme (CASP, 2014) and the McMaster University Centre for Evidence-Based Medicine (CEBM, 2015). The key aims of critical appraisal are to determine the following:



  • Are the results of the study valid?
  • What are the results?
  • How can the results be applied to clinical practice?

Internal Validity refers to the trustworthiness of the results and is determined by the methodological quality of the study (Hoffman et al., 2010). Different criteria apply for determining the validity of different types of study, that is treatment, diagnosis and prognosis (CASP, 2014). Individual studies are ranked within a scale of levels of evidence to determine the strength and quality of the research design and method and whether the outcomes are unlikely to be caused by extraneous variables (Lin et al., 2010). Randomised controlled trials are rated as high internal validity as a result of their design, randomisation and the existence of a control group (Lin et al., 2010). Studies which are considered to be flawed, for example they have not controlled for bias or the results are misleading will not provide high-quality evidence (Bennett and Bennett, 2000; Hoffman et al., 2010).


Clinical Usefulness determines if there is sufficient evidence to integrate the evidence into practice (Lin et al., 2010). Clinical significance relates to the meaningfulness of that change and whether changing practice would bring about substantial benefit to the client.


Applicability determines whether the results of the study can be applied within your practice context, that is can the results be applied to your client population, is it feasible to introduce the intervention within your practice setting and how do the results of the study fit with other available evidence (Coupar and Edmans, 2010).


2.3.5 Implementing findings into clinical practice


Implementation of evidence in clinical practice is a critical part of evidence-based practice and possibly the most challenging component (Lin et al., 2010). It is frequently stated that it takes an average of 17 years for research evidence to reach clinical practice (Morris et al., 2011). Yet changes in the way health and social care is being delivered, for example increasing costs, reduced staffing levels and shorter hospital admissions, require timely incorporation of sufficiently rigorous evidence (Graham et al., 2007; Lin et al., 2010). Even when the best available evidence is known organisational and economic factors can contribute to the challenges occupational therapists face when trying to change established practice (Ilott, 2003).


The key factors which are believed to impact on the incorporation of evidence at the practice level can be defined within three main categories (Lencucha et al., 2007; Upton et al., 2014):


Knowledge and skills



  • Limited searching skills
  • Limited appraisal skills
  • Difficulties understanding research findings
  • Poor information technology skills and lack of ability to undertake Web-based literature searches

Resources



  • Lack of time to read research and implement findings
  • Large caseload, workload pressures and staffing shortages
  • Difficulty accessing evidence
  • Lack of organisational support

Attitudes



  • Perceived lack of evidence to support occupational therapy intervention
  • Preference for experience over research evidence
  • Reluctance to change practice that has been built up over time
  • Tendency to search for evidence that confirms hunches rather than contradict current practice
  • Perception that research evidence is difficult to apply to individual clients
  • Challenges the competence of individual therapists

2.3.6 Using evidence to inform clinical decisions in occupational therapy


Occupational therapists are required to make complex clinical decisions at all stages of the occupational therapy process (Bennett and Bennett, 2000). This can range from fast, intuitive decisions through to well-reasoned, analytical, evidence-based decisions that drive client care (NHS Education for Scotland, 2015). Occupational therapists apply four strategies when making clinical decisions (Lee and Miller, 2003):



  • Decisions made on intuition or based on what feels right or seems reasonable. Such decisions however can be difficult to justify because of their subjective nature despite the fact that they may reflect extensive clinical experience.
  • Parsimony is a strategy for choosing between alternative interventions. This strategy is based on an assumption that where two interventions are of potentially equal benefit, then the simpler intervention should be selected.
  • Consensual validation reflects the notion that if more than one person concurs with a particular conclusion, then it is more likely to be valid. In clinical practice this often takes the form of peer discussion and consensus of experience.
  • Cross-validation seeks to gather a broad range of evidence incorporating multiple decision strategies to reduce bias or subjective interpretation.

Clinical decisions are therefore informed by a range of different types of evidence which reflect the complexity of clinical practice (Lee and Miller, 2003). Evidence-based practice offers a structured approach to clinical decision-making supporting occupational therapists to resolve clinical questions and make informed treatment decisions (Bennett and Bennett, 2000). The process can be summarised through the following five stages (Bannigan, 2007):



  1. Formulate a clear clinical question.
  2. Find the best evidence.
  3. Critically appraise the evidence.
  4. Implement useful findings in practice.
  5. Evaluate the effectiveness of the new way of working.

2.3.7 Asking clinical questions


Occupational therapists ask clinical questions in relation to many aspects of practice including diagnosis, treatment, prevention, prognosis, client experience and cost-effectiveness (Sackett et al., 1997). Clinicians new to neurological practice are more likely to ask clinical questions that refer to general phenomenon, that is who, what, where, when, how and why, for example ‘what is the occupational therapist’s role with people with Motor Neurone Disease?’ (Lin et al., 2010).


Occupational therapists with greater experience of neurological practice appear more interested in specific questions that relate to interventions and management of neurological conditions (Lin et al., 2010). The most effective way of answering this type of question relies on systematic review or meta-analysis and requires the clinical question to be framed using the PICO format, specifying a Population or problem, Intervention, Comparison intervention (if relevant) and Outcome (Lin et al., 2010).


In the context of neurological practice, if the clinical question asks ‘Is assessment of a functional task more reliable than the Behavioural Assessment of the Dysexecutive Syndrome (BADS) at identifying executive function impairment in people with Huntington’s disease (HD)?’ The PICO framework would be applied as follows:


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Feb 18, 2017 | Posted by in NEUROLOGY | Comments Off on 2: Delivering good quality, safe and effective care

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