The goal of this study was to gain insight in which QI methods could form the design of a QI framework, as a foundation for a system to improve the quality of hospital-based physiotherapy in the Netherlands, by combining the insights of hospital-based physiotherapists and their key stakeholders. Out of the seven proposed QI methods, none stood out in ensuring quality improvement. According to the multidisciplinary panel that we consulted, 360-degree feedback was seen as the least suitable QI method and therefore not further exploited as a QI method in this study. Of the other six proposed QI methods, there was a slight preference for a management information system. The panel’s scores and their comments reflected similar appreciation for continuing education, feedback on PREMs and PROMs, a quality portfolio, peer observation and feedback, and intervision with intercollegiate evaluation. The panellists established that each QI method has its own advantages and disadvantages (Table 3).
Relation to similar studies
The effects and feasibility of each QI method mentioned by the panel have been described previously in the literature. Overall, these studies suggest positive effects and reasonable feasibility, but also make reservations about each method ranging from the degree of effect, reliability, and validity to efforts with and conditions under which application could be successfull [17,18,19,20,21,22,23,24,25,26,27,28]. The results of these studies suggest that, when designing a QI framework for hospital-based physiotherapy, a mixture of these methods may be most appropriate. This allows evening out of advantages and disadvantages of each individual method, because they cover different aspects of professional quality. The result may be a combination of methods that together meet the predefined QI criteria and build a valid and effective framework to improve the quality of hospital-based physiotherapy.
More rigorous research is needed to identify effective and generalizable interventions individually, but also in combination as a multiple method assessment, to improve healthcare quality [29, 30]. This may lead to a more multidimensional approach to quality [31, 32].
The prevailing method of the Individual Quality Register of Physiotherapy of the KNGF in primary care is individually based, where each activity aimed at professional development is rewarded with points [33]. For hospital-based physiotherapy, an integrated approach based on a portfolio of activities would be more appropriate. This is in view of the nature of the work of hospital-based physiotherapists, which can be more short-cycled, more acute, more varied and more multidisciplinary than in primary care. Especially in a healthcare environment that promotes the collaboration of administrators and physicians in ensuring the quality of patient care [34], a multidimensional model also offers advantages in terms of a more flexible applicability to different disciplines pursuing the same quality goal. Also, because hospital-based physiotherapy is bound to other regulations than in primary care, this flexibility of a multidimensional model offers more options for QI. Especially if techniques that are already used in the hospital world, such as the tracer method with peer observation and feedback, are used [25].
Meaning and relevance of the findings
The results of this study, summarised in the design of a framework for quality of hospital-based physiotherapy (fig. 1), provides a foundation to develop a quality system for hospital-based physiotherapy. A quality system comprises a management system and a technical system (methods for IQ). Here, the individual professional manages his own quality efforts in a personal portfolio, which is fed by four types of quality improvement methods. These methods each highlight a different aspect of quality so that a total package is created that fits the described nature of work of hospital-based physiotherapy. The management information system concerns all activities in the field of planning, decision-making, organisation, control, evaluation, motivation, training, and involvement of employees to guarantee and improve quality [35]. Within this management information system, quality indicators found in previous research [6, 7] could be implemented.
Strengths and limitations
The composition of a representative panel for hospital-based physiotherapy enables a balanced answer to our research question. Using the principles of design-based research is another strength, as design-based research studies can play an important role in the advancement of theory and practice in designing or redesigning work-based learning environments and assessment programs [14]. Although exact data on its validity and reliability are still lacking, the method of brainwriting has been presented as a novel and efficient alternative to brainstorming that can rapidly inform program implementation at minimal time and cost [36,37,38].
We acknowledge the following limitations. Although a design-based research panel can produce collective answers, the achieved consensus is not necessarily accurate; bias can occur in the meeting because one individual’s opinion can be overrepresented. Since the panel meeting was not anonymous, respondents may have felt restrained to speak freely, and may have been subject to social desirability bias, especially considering the high scores that were given to the QI methods. Although the panel represented all key stakeholder groups, there was only one representative for each group in the panel, which may have produced selection bias. Also, gender was not considered in the composition of the panel and thus the formation may not have been sufficiently ‘inclusive’, looking at the diversity of interests and perspectives.
A key limitation is the extent to which the results of this design-based research can be generalised or transferred to other contexts. Seen from the perspective of our design and analysis, we think that extrapolation of our results to the Dutch situation of hospital-based physiotherapy is feasible. From an international perspective, this is more complex because the forces within the health care system differ per country, and the positioning of hospital-based physiotherapy can be quite divergent.
Suggestions for further research
In the search for the right mix of the various QI methods, further studies should investigate what this could look like in terms of impact and feasibility. Within the framework of hospital-based physiotherapy, the QI methods discussed can be further explored, either individually or in certain combinations. If a suitable combination seems to have been achieved, which feeds into a management information system on QI of hospital-based physiotherapy, a follow-up study can be conducted to examine its feasibility and total effect on quality. The main question then is how to measure this quality, and with which quality indicators.