Mind the gap. Service evaluation and improvement: The management of children and young people in a private physiotherapy clinic

Abstract

Keywords: Service evaluation; Children and Young People; Scope of practice Purpose: As autonomous practitioners, physiotherapists are responsible for assessing, developing and maintaining their competence in their areas of practice. This needs to be acknowledged by the organisations in which they work, to support and optimise the skillset of their workforce. It was identified that the number of children and young people (CYP) presenting to a large private physiotherapy company (seeing predominantly adult patients) had risen significantly in recent years, and it was unclear what competence and confidence existed among staff to be managing this cohort safely and effectively. Objective: To understand the needs of the CYP attending the clinics, and evaluate this against the competence and confidence of the physiotherapists they presented to. Methods: A multi-methods design was used. A notes audit was conducted across three one month periods: collecting data on patient age, referral source, diagnosis and subsequent pathway (immediate onward referral, discharge, further physiotherapy). This was followed by a series of focus groups involving staff in the physiotherapy clinics, to evaluate their competence and confidence in managing CYP. Physiotherapists were presented five case studies and asked to rate their perceived confidence on a 4-point Likert scale before and after a discussion around diagnosis, differential diagnoses, appropriate management and clinical reasoning. Results: 138 new-patient contacts were included in the notes audit. Over 97% over these were aged between 8 and 17 years. 35% were classified as ‘MSK pain’, 22% apophysitis, 14% sports injury/trauma and 8% orthopaedic/post fracture. ‘Outliers’ to these groups had a much higher rate of being referred onwards, or back to source (deemed an inappropriate referral): 71%, compared to <10% for all other groups. 27 physiotherapists took part in the focus groups. Open questions revealed ambiguity around expectation to accept referrals for CYP, and policies/procedures relating to CYP. The case studies highlighted a trend for confidence scores to be lower where staff were less accurate with diagnosis. Factors such as age <8 years, paediatric-specific red flags, and self-referral led to lower confidence levels. Across all case studies, confidence levels were lower following discussion. This was identified as having a positive impact on physiotherapists engagement with the projects next steps. Conclusion(s): A structured service evaluation demonstrated a disparity between the CYP attending physiotherapy, and the skillset of physiotherapists: potentially jeopardising the safety and quality of service delivered. It was agreed with key stakeholders that developing a minimum competence framework specific to the physiotherapists seeing CYP at the company would be a prudent starting point. Adjustments to policy and procedures/administrative tasks alongside this, would signpost to those referring in to the service and better reflect the capacity of all staff to manage CYP attending the clinics. Impact: The implementation of a minimum competency framework seeks to improve the lowest quality patient-physio interactions, improving safety and staff satisfaction. A secondary effect will be to improve the average interaction and ultimately create a platform from which gold–standard, effective physiotherapy can become the norm for CYP. The process may highlight the merit of a similar approach for other patient groups at risk of being marginalised. Funding acknowledgements: This work was not funded.