Table 3 Facilitators (F) and barriers (B) expressed by care-providers and patients regarding the implementation of the TTCM, related to structure, culture and practice. Quotes are from trauma patients (P), trauma surgeons (T), hospital-based physiotherapists (HBP), and network physiotherapists (NP)
Level | Theme | Subtheme | Facilitator | Barrier | Stakeholders | Illustrative quote |
|---|---|---|---|---|---|---|
Structure | Communication structure | Secured email system | Use of a secured email system between hospitals and network practices | Electronic patient records in hospitals and network practices are often incompatible | • Trauma surgeons • Hospital‐based physiotherapists • Network physiotherapists | B: ‘The problem is the Electronic Public Records. They aren’t communicating with each other. That’s where the problem lies.’ (R17, NP) |
B: ‘I’m not sure why exactly, but I think my emails from ZorgDomein are not being received.’ (R24, NP) | ||||||
F: ‘It’s of course ideal for the network that you can simply send it digitally and securely.’ (R13, HBP) | ||||||
Use of a standardized template for the secured email | Standardized template is not implemented in the appropriate software | • Hospital‐based physiotherapists • Network physiotherapists | B: ‘There are still some difficulties. Initially, communication was supposed to be via e-mail, but there still seem to be some issues. I believe it’s being run by the hospital, but the system isn’t fully functional yet.’ (R19, NP) | |||
F: ‘It’s a standardized list that we fill in, which is very nice because it’s faster and easier. We don't have to rush through things. In principle, you can send it in straight away. The process costs you very little time.’ (R12,HBP) | ||||||
(Changes in) dates and times of the patients’ outpatient appointments are not automatically communicated to the NP/HBP | • Network physiotherapists | B: ‘It does cause some stress or [extra] work because we have to keep track of the patients’ outpatient arrangements or when they need to go for a checkup. And then you still have to write a transfer report.’ (R23, NP) | ||||
Financial structure | Reimbursement | Reimbursement for the HBP at the outpatient clinic for trauma patients has been arranged | Reimbursement for the HBP at the outpatient clinic for trauma patients has not been arranged | • Trauma surgeons • Hospital‐based physiotherapists | B: ‘Look, one has to pay. It’s all about budgeting and whether the department says it won’t reimburse or pay for it. It has nothing to do with a lack of space. I think it's really a matter of finances.’ (R5, T) | |
F: ‘… things started in November [2021][start implementation phase February 2021], when all the financing had been arranged. That’s when we launched the outpatient clinic.’ (R12, HBP) | ||||||
Physical structures and resources | Availability of rooms and/or computers | Sufficient consultation rooms available | Insufficient consultation rooms available | • Trauma surgeons • Hospital‐based physiotherapists | F: ‘Well, the clinic is so big and has so many rooms available that’s not a problem.’ (R13, HBP) | |
B: ‘It would be more helpful if they [HBP] were there with us. Only, in terms of actual rooms, there’s no physical space available. So that’s, of course, a pity. Yes, that’s a problem at our hospital, in my opinion. This must improve if you want to get the most out of it.’ (R4, T) | ||||||
Too few computers available | • Hospital‐based physiotherapists | B: ‘We can't type at the same time as the doctor because they’re often behind the computer. So, we often have to do that on the side (after the consultation). This can be quite time-consuming.’ (R14, HBP) | ||||
Rules and regulations | Patients are free to choose their care providers | The lack of guarantee on a high number of referrals for the network physiotherapists | • Trauma surgeons • Network physiotherapists • Patients | B: ‘But we ended up training so many therapists in [name of city]. But if you compare the number of patients per trained therapist in [name of city], I think it's [referrals] very little.’ (R21, NP) | ||
F: ‘No, just unrestrained. I didn't at all feel controlled or anything.’ (R32, P) | ||||||
F: ‘… the patient can choose a physiotherapist himself.’ (R4, T) | ||||||
Benchmark (a regulatory tool) limits the number of treatments | Network physiotherapists | B: ‘Yes, in some cases I’d prefer to see certain people three times a week. But I don't because my treatment index limits what I can offer.’ (R18, NP) | ||||
Reimbursement through the basic insurance package is limited | • Network physiotherapists | B: ‘One thing that’s sometimes inconvenient is that the health insurance policy only covers treatment lasting half a year when there are cases when you really do need more time.’ (R24, NP) | ||||
B: ‘If you don’t have supplementary insurance, you’ll have to pay for the first twenty treatments. And if the initial phase includes treatments at home, then this can run up to around 40 euros per treatment. So, after the €285 deductible excess, you’d have to pay an additional €800, more or less. For some people, that’s a lot of money. Occasionally people say, well, I'll use my supplementary insurance, and I'll see what happens. That also happens. And of course this, well… sometimes this, unfortunately, has an impact on the initial goal or the recovery process.’ (R18, NP) | ||||||
Organization of the network | Accreditation | Accreditation of the network activities has not been arranged | • Network physiotherapists | B: ‘The meetings have yet to be accredited, so at the moment, it’s completely voluntarily.’ (R21, NP) | ||
Training and education | Being part of the network is free of charge | Training for the NPs is a prerequisite for joining the network and costs money (e.g. because they had to close the practice) | • Network physiotherapists | B: ‘The only investment we had to make is to take a course… [I] watched some presentations by trauma surgeons. I think it cost more than six hundred euros. And the annoying thing was, this wasn’t possible during the weekend, so I also had to take three days off. So I also lost three days’ revenue because I had to close [my practice] for three days.’ (R17, NP) | ||
F: ‘No, no, the only investment we had to make is that we had to take a course.’ (R17, NP) | ||||||
The fact that the training was online due to the Covid-19 pandemic made participating more feasible from a logistical perspective | The fact that the training was online due to the Covid-19 pandemic resulted in fewer possibilities for personal interaction | • Network physiotherapists | F/B: ‘Everything took place online, so it was all a bit detached and impersonal during this Corona time. I think this was a plus, especially considering the travel time to the north of the country. But if you want more interaction, I think one should arrange live or face-to-face meetings.’ (R18, NP) | |||
The duration of the training was good | The training could have been shorter | • Network physiotherapists | B: ‘As far as I am concerned, the training could easily have been completed in two days.’ (R17, NP) | |||
F: ‘Yes, I thought the duration [of the course] was okay. I think three days was in itself good as a basis.’ (R18, NP) | ||||||
Content of the training was of added value for the treatment of patients with trauma | Training lacked some topics/content relevant to the treatment of trauma patients | • Network physiotherapists | B: ‘Maybe the psychological aspect of the trauma process could also be looked at a little more. This doesn’t always receive the same amount of attention.’ (R20, NP) | |||
B: ‘My biggest problem was that I found the second training quite bad, to be honest. This was because there was a lot of overlap between what the various doctors said.’ (R22, NP) | ||||||
F: ‘Yes, to some degree. You learn to look more critically at things, especially at the burden you may be placing on your patients. So in this sense, certainly.’ (R17, NP) | ||||||
Website | Having an appropriate and up-to-date website | More information about the NPs (e.g. expertise) on the website would be useful | • Patients | B: ‘It would be useful to provide a description of the specialties of the physiotherapists on the list that’s handed out.’(R25, P) | ||
Culture | Commitment | Commitment at the hospital | High intrinsic motivation of TTCM teams and colleagues of other relevant departments (e.g.: trauma surgery, rehabilitation medicine) | Low intrinsic motivation of TTCM teams and colleagues of other relevant departments (eg: traumasurgery, rehabilitation medicine) | • Hospital‐based physiotherapists | B: ‘If they can tackle it at the front-end, so to speak so that also my colleagues [could be involved] and not just me. This way, it will also ‘come to life’ more, also in the department. I think this is one area where we could improve.’ (R10, HBP) |
B: ‘We have a surgeon who is very enthusiastic about it. But he communicated very little about it with other surgeons [from other departments].’ (R9, HBP) | ||||||
B: ‘… it’s a logistical issue involving your work, so to speak. You have to take, well, your colleagues have to grant you the space to take the time you need to be there.’ (R11, HBP) | ||||||
F: ‘I’ve noticed that if you build something together from scratch [network], you’re inclined to make sure it’s a success; maybe just take those extra steps, call again, or send an e-mail or describe things in more detail...’ (R10, HBP) | ||||||
Commitment at the network | High intrinsic motivation of the participating network physiotherapists to be part of a network | Low intrinsic motivation of the participating network physiotherapists to be part of a network | • Network physiotherapists | B: ‘Honestly, I feel I need to say that… well, many people currently involved in the trauma network didn’t join because they are interested in trauma patients. They seem more interested in just being part of a network.’ (R22, NP) | ||
F: ‘You have a group of therapists who are motivated to do something with it. Otherwise, you wouldn’t follow the training.’ (R21, NP) | ||||||
Acting as a team | Contact trauma surgeons and hospital‐based physiotherapists | Care-providers at the outpatient clinic act as a team during the joint consultations | Care-providers work separately from each other during the outpatient consultations | • Trauma surgeons • Hospital‐based physiotherapists • Patients | B: ‘So, three times people [the trauma surgeon and the HBP] came by, and I just sat there alone in that room, and that felt strange... […] they each came by and sent the other over, but they never visited me at the same time. Well, I just sat in that chair and wondered: ‘What now?’’ (R26, P) | |
B: ‘We don't have fixed days when we’re present at the trauma clinic because the surgeons don't want us in the room with them. So yes, we have a separate room.’ (R9, HBP) | ||||||
F: ‘It was a shared effort. The surgeon explained what had taken place and what he had done [during the surgery], and the physiotherapist indicated what I can do. Of course, there was also the treatment by another physiotherapist affiliated with the trauma [network].’ (R29, P) | ||||||
F: ‘… Yeah, as colleagues among colleagues, it all ran very smoothly. There just didn’t seem to be any [professional] borders getting in the way.’ (R12, HBP) | ||||||
F: ‘And I also like is that you immediately have more eyes, and they looked at them [the trauma patients] with a slightly different view. Look, we do a trick during the operation, then our work is done for the most important part. So in that…. we are also very often dependent on the physiotherapist’s work.’ (R4, T) | ||||||
Awareness of responsibilities, leadership, and professional boundaries: care-providers at the outpatient clinic (trauma surgeon and HBP) take pro- fessional boundaries into account | • Trauma surgeons | F: ‘So, there’s this patient where I still have to look at the wound to see if the fracture isn’t healing properly yet, and the physiotherapist then takes a bit of a step back. So it’s clear to us what our responsibilities are.’ (R2, T) | ||||
Contact between network and hospital team | The possibility of low-threshold contact between network and hospital team | Inconsistent feedback loop between network and hospital team | • Trauma surgeons • Hospital‐based physiotherapists • Network physiotherapists • Patients | B: ‘Sometimes, the feedback sent from primary care to us is a bit lacking. And, of course, we [only] see what takes place at the outpatient clinic. So, I don't know how people perform their exercises at home, and I don't always know if what people tell me in the doctor's office is the actual truth. This is why I think feedback is so important. This is where we should establish a smoother or better feedback loop.’ (R3, T) | ||
F: ‘The advantage of having a physiotherapist is that you can just contact them, and they can then easily contact the trauma surgeon.’ (R20, NP) | ||||||
F: ‘It’s easier when the physiotherapist [HBP] is there because they can then take over that task, thus bridging the gap in communication.’ (R1, T) | ||||||
B: ‘Only what I understood from my physiotherapist. He had questions regarding certain pains I have at the moment. But these haven’t been answered yet. It’s been two weeks now, and I have no explanation for this yet.’ (R29, P) | ||||||
F: ‘The times I was in contact with them were very pleasant. We could just talk to each other, as colleagues. So, I think the cooperation is very balanced.’ (R23, NP) | ||||||
F: ‘I think it’s a big plus for patient satisfaction or patient-friendliness.’ (R4, T) | ||||||
Quality and efficiency of care | Contact between care providers and patients | Care-providers think that the TTCM, which amongst others, improved the level of contact between different care provides, enhances the quality and efficiency of care | • Trauma surgeons • Hospital‐based physiotherapists • Network physiotherapists | F: ‘I think that good collaboration between primary and secondary care can reduce that kind of risk, improve cooperation, and also improve the speed and agility of care.’ (R21, NP) | ||
F: ‘You are able to provide more efficient outpatient services.’ (R2, T) | ||||||
F: ‘[Yes, excellent, very nice.] I think good cooperation between primary and second care [the TTCM] is greatly lacking within the Dutch healthcare system.’(R21, NP) | ||||||
Workload | Lower administrative workload for trauma surgeon | • Trauma surgeons | F: ‘I think the administrative workload has decreased, even for surgeons.’ (R2, T) | |||
Applicability of the TTCM | Presence of a hospital-based physiotherapist at the joint consultations is particularly useful – and of added value - for complex injuries | The HBP does not have an added value at the joint consultations for every patient | • Trauma surgeons • Hospital‐based physiotherapists | B: ‘No, [multidisciplinary collaboration] is not always an equally useful contribution for [trauma patients].’ (R4, T) | ||
F: ‘For certain patient categories, yes, especially regarding more complex cases, such as patients receiving multidisciplinary treatment or patients with multiple injuries. I think that's the most important thing.’ (R8, T) | ||||||
F: ‘Yes, I just think it [the TTCM] should happen nationwide, especially in large trauma centers with patients dealing with multiple trauma.’ (R5, T) | ||||||
Patients experience | Patients receive a clear treatment plan | Patient is not aware of what has been communicated between hospital‐based physiotherapists and network physiotherapists | • Patients | F: ‘I do know that my physiotherapist [network physiotherapist] sent feedback to the hospital's physiotherapist before the final interview with the doctor.’ (R30, P) | ||
Patients feel heard | Care providers sometimes contradict each other | • Hospital‐based physiotherapists • Patients | B: ‘Doctors and physiotherapists don't go well together. That’s often the old practice, especially in the Netherlands. While it's precisely the combination of recovery and [a focus on] the body – actually moving and building things up again – that can help.’ (R30, P) | |||
B: ‘So, the physiotherapist who released me from the hospital gave me a schedule with exercises. But when I eventually had a consultation with the hand physiotherapist, they never referred to those exercises at all. They gave me completely different exercises, from which I benefitted much more.’ (R26, P) | ||||||
F: ‘No, no, they certainly heard me, and it was an empathetic conversation. I wasn’t sent away by anyone, and I was given the time I needed. So I didn't get kicked out, no.’ (R25, P) | ||||||
F: ‘Now that I've been through this whole process, I have to say that my confidence in the Dutch healthcare system has increased. Not that I had little faith in it, but I eventually felt supported by the fact that all this [collaboration between care providers] is possible. Yeah, so it gave me courage.’ (R26, P) | ||||||
Patients are satisfied with the care that they received | Patients feel like the care process was somewhat rushed | • Patients | B: ‘I had the feeling that things were being rushed, that it was just hectic. I understand that, I'm busy too sometimes. But, well…’ (R26, P) | |||
F: ‘I do have the feeling that going to the physiotherapist at a relatively early stage ensured that my shoulder soon regained freedom [of movement], and I suffered less in the long term.’ (R30, P) | ||||||
F: ‘Yes, I liked the joint consultation with the physiotherapist and doctor, trauma doctor, or surgeon. Also because they could respond to each other, which they did. So when one of them said something, another immediately gave an answer, which gave clarity to what, why, and how. So yes, it was very clear.’ (R27, P) | ||||||
Job satisfaction | Care providers indicated that they were more satisfied with their job after the implementation of the TTCM | • Trauma surgeons • Hospital‐based physiotherapists • Network physiotherapists | F: ‘Well, at [hospital], I'm just super happy with how things are going. And I’m also very satisfied with the meetings.’ (R24, NP) | |||
F: ‘So yes, they are just two different specializations present in one place at the same time. And I’m personally very excited about this.’ (R3, T) | ||||||
F: ‘So it's, well, actually, I'd rather spend my full twenty-six hour working week just working with TTCM.’ (R11, HBP) | ||||||
F: ‘So that just makes it a really fun group. Let me put it this way: it makes it all just a little more satisfying.’ (R20, NP) | ||||||
Practice | Practical issues at the outpatient clinic | Sufficient consultation rooms available | Insufficient consultation rooms available | • Trauma surgeons • Hospital‐based physiotherapists | B: ‘It would be more helpful if they [HBP] were there with us. Only, in terms of actual rooms, there’s no physical space available. So that’s of course, a pity. Yes, that’s a problem at our hospital, in my opinion. This must improve if you want to get the most out of it.’ (R4, T) | |
B: ‘...if there are any additional questions, or if I think, well, I’d actually like to spend some more time with them, I don't currently have the time or space for that as things are.’ (R16, HBP) | ||||||
F: ‘Well, the outpatient clinic is so big and has so many rooms available that’s not really a problem.’ (R13, HBP) | ||||||
Too few computers available | • Hospital‐based physiotherapists | B: ‘We can't type at the same time as the doctor because they’re often behind the computer. So, we often have to do that on the side (after the consultation). This can be quite time-consuming.’ (R14, HBP) | ||||
Knowledge gained | Knowledge exchange between care providers | Trauma surgeons and hospital-based physiotherapists at outpatient clinic learn from each other’s field/profession | • Network physiotherapists • Trauma surgeons • Hospital‐based physiotherapists | F: ‘Of course, we bring along the know-how of the injury and exactly what kind of surgery we’ve performed (if we operated). So that is our know-how. But they really take care of the movement issues and really know how the physiotherapist works in the network practice. [So, they can do that, yes, they can do that too, they may be talking at that level]. I think that's an advantage.’ (R6, T) | ||
Network physiotherapists gain knowledge and expertise in trauma rehabilitation | • Trauma surgeons | F: ‘Insight into the various fracture treatments has improved, and this knowledge actually expands via the network.’ (R2, T) | ||||
Network physiotherapists gain knowledge and expertise in trauma rehabilitation | • Trauma surgeons | F: ‘Well, through the trauma network, you can refer more directly to physiotherapists who are involved with trauma patients. So it’s no longer enough to send a patient with an ankle fracture to go to the nearest general physiotherapist, who may have never or only incidentally dealt with trauma patients and doesn’t know what to do.’ (R1, T) |