External Facilitation Could Aid Clinics’ Quality Improvement Measures

Activities that could improve quality of life for lower limb amputees require a high degree of organizational commitment and support, according to data published recently in Prosthetics and Orthotics International. External facilitation could support clinics in implementation of these activities.

Objective measures

Researchers at the Northwestern University Feinberg School of Medicine conducted a study of seven prosthetics clinics to determine whether externally facilitated patient-reported outcome measures could be a cost-effective method of quantifying the effectiveness of a treatment plan. They also wanted to determine whether outcome measures could provide insight into the quality of clinical interventions and allow clinicians the knowledge to improve overall outcomes.

“I think there has been an increasing interest during the [past] 15 years in outcome measures and how outcome measures can be used in clinical practice,” Stefania Fatone, PhD, BPO(Hons), associate professor at the Northwestern University-Prosthetics Orthotics Center, told O&P News. “This was one example of an approach to using outcome measures as part of quality improvement of practice.”

External facilitation

As part of external facilitation, researchers provided clinicians and administrative staff with an extensive orientation covering quality improvement concepts and project procedures. They also maintained weekly contact to monitor data collection and provide additional support.

Stefania Fatone, PhD, BPO(Hons)
Stefania Fatone

Each clinic determined procedures suited to their patient needs, such as identifying eligible patients, tracking appointments and submitting de-identified data.

Eligible patients included those ages 18 years and older who were receiving a new prosthesis or socket replacement. Patients who received socket adjustments were ineligible. Participating patients were provided quality improvement activities.

Clinic staff were responsible for all aspects of patient-related data collection, and researchers planned to share aggregate results plotted across time by level of amputation and primary etiology after the clinic collected data from 100 patients.

Using a qualitative, ethnographic design, researchers implemented the Orthotics Prosthetics Users’ Survey (OPUS), a patient-reported outcome tool that measures lower limb functional status, quality of life and satisfaction with device and services. Clinics incorporated OPUS into routine care.

Patients were asked to complete the survey at three time points, while prosthetists completed a document to report Medicare’s Functional Classification Level, as well as the patient’s demographic characteristics.

Researchers assisted clinic staff in identifying areas of concern that were considered “amenable to change, feasible to address and measurable over time,” according to the report. When clinicians defined a quality measure to address issues they deemed important, researchers facilitated planning of a quality improvement project by completing a root cause analysis and developing an action plan.

External facilitation was concluded approximately 1 year later, at which time researchers shared a report based on data collected through the course of the project and clinic staff reported their progress in implementing quality improvement programs into routine operations.


Allen W. Heinemann, PhD, ABPP (RP), FACRM
Allen W. Heinemann

While there were limitations in the study design, Allen W. Heinemann, PhD, ABPP (RP), FACRM, professor of physical medicine and rehabilitation at the university and director of the Center for Rehabilitation Outcomes Research at the Rehabilitation Institute of Chicago, said it led to greater findings.

“When you are using a qualitative, ethnographic design, having things go wrong is a good thing because we want to survey the universe of potential barriers to implementation and then try to facilitate solutions to them,” he said. “The ways in which we may not have reached saturation on those barriers reflects the sampling. [For example,] these are facilities willing to do it, these are not facilities that had to do it [or] that were being coerced into it.”

Of the seven clinics in the study, three were able to sustain data collection. Feedback from those clinics suggested the clinicians understood the importance of monitoring patient progress and found the combination of function, quality of life and satisfaction with the device and services to be unique and valuable information.


Clinicians also offered suggestions to facilitate interpretation of the patient-reported outcomes data. They requested help calculating minimal clinically important differences in order to evaluate the magnitude of functional status, quality of life and satisfaction changes. They also suggested documenting clinician opinions on changes in functional level.

In addition, several suggested eliminating the number of items to reduce patient burden. They suggested that risk-adjusted outcomes would be helpful to account for variations across clinics in terms of patients’ age, amputation level and etiology.

According to the researchers, a large comparative data set would provide a useful management tool by allowing clinicians to benchmark their performance, both with their facility and across clinics.

Future initiatives

Researchers said outcomes monitoring and quality improvement initiatives require a high level of leadership support, organizational commitment and sophisticated planning to sustain patient-reported outcomes data collection and quality improvement activities as part of routine clinic operations. Multiple opportunities exist to develop greater sophistication in quality in prosthetic and orthotic care.

According to Heinemann, the team has submitted a proposal to the U.S. Department of Defense’s Congressionally Directed Medical Research Program to evaluate potential quality measures for orthotic practice. – by Shawn M. Carter

Disclosure: The researchers report the project was supported by the National Institute on Disability, Independent Living, and Rehabilitation Research through the Rehabilitation Engineering Research Center on Prosthetics and Orthotics [H133E080009] awarded to Northwestern University.

Leave a Reply

Your email address will not be published.