AUDITREPORT

1st April 2009 - 31st March 2010

Virginia KnoxConsultant Physiotherapist

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CONTENTS Page

1. Introduction 3

2. Summary of findings 5

3. Serve a wide variety of children with cerebral 7palsy

4. Referrals and Appointmentsa. Referral management 10b. Management of Appointment system 12c. Therapy provision 14

5. Therapy indicatorsd. Goals and Outcome measures 16e. Contact with local therapists 18f. Patient progress notes and reports 20

6. Feedback from service usersg. Parent 22h. Visiting Therapist 29

7. Continuing professional development 31

8. Conclusion 32

9. Summary of recommendations 33

10. Appendix i. Recommendations from 2009 Audit 35ii. Clinical Mix – report of individual patients 39iii. MPOC: occasional & service provider 41

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1.IntroductionThe Bobath Centre is a specialist treatment centre providing individually tailored therapy for children who have cerebral palsy. Our aim is to improve the quality of life for children so that they are healthy and active, and can participate in everyday life to the best of their ability.

Treatment and management services are delivered in different patterns the allocation of which is dependent on the patients clinical needs, geographic location, and funding arrangements:

Single Consultation appointments to address a specific issue. Some of these patients will then progress to occasional or regular therapy.

‘Occasional’ therapy delivered in two week intensive therapy blocks (90 minute daily appointments). Children typically attend once or twice per year. All patients have a key therapist and may have one or two additional therapists of other professions to ensure all their needs are addressed.

‘Regular’ therapy for children who live with in reasonable travelling distance of the Centre, and attend the Centre either weekly, fortnightly or at a different frequency but on a regular basis throughout the year. Appointments are either 45 or 90 minutes.

Purpose of audit of clinical activities This is to provide a tool that can inform changes in clinical practice and provision of service, evaluate the effectiveness of any changes, provide a detailed transparent account of our clinical service, and serve as a record of our activities.

We need transparency for:

Key scope of AuditEight key areas of the service are highlighted as important to evaluate during audit:

1. Services to a wide variety of children with cerebral palsy (of different ages and with different types of cerebral palsy)

2. Efficiency of referral and appointment service3. Bobath treatment for children 4. Reports and home programmes5. Education and training for parents and carers

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TRANSPARENCY

STAKEHOLDERS

CHARITY COMMISSION

TRUSTEES

NHSFUNDERS

SERVICE USERS

CHARITIES

INDIVIDUALS

6. Liaison with local therapists7. Therapeutic skills of therapists8. Services which are client and family friendly

The audit plan has been revised and the timetable updated following analysis of last year’s data. Audit activities took place throughout the year to fit in with the clinical activities of the Centre. This is the second full year audit report from 1st April 2009 to 31st March 2010.

Presentation of reportThe report starts with a summary of the main findings, followed by a detailed report on each key area, stating the objectives of the audit, audit activities, performance indicators and main findings with any resulting specific recommendations. An appendix follows including more detail from the data analysis.

Recommendations from 2008-9 auditThese were discussed with management and followed through as appropriate (see appendix). These included providing further training to clinical therapists on specific outcome measures, training the therapy assistant in how to support therapists using outcome measures, providing specific guidance to therapists to further improve the standard of record keeping, and some fine tuning of the process for allocating the clinical mix of therapy for returning occasional patients.

2008-9 report This is available as a separate document on request from Christine Barber Director of Clinical Services or Jayne Pearce Director of administrative services at the Bobath Centre.

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2.Summary of Findings

I. Serve a wide variety of children with cerebral palsy

Type of cerebral palsy & degree of disability: There were slight changes in the ratios compared to last year. More children were seen with athetosis (35%, previously 31%) and less children with spastic diplegia (26% to 23%). Slightly more children were therefore seen with a greater degree of disability

II. Management of Referrals & Appointments

Number of new referrals. This decreased slightly from 96 new referrals in 2008/9, to 83 new referrals into the year ending March 2010.

Referrals leading to Appointments: Although the rate of referrals decreased, the rate of new referrals having appointments has slightly increased from 68 to 72%.

Waiting times for therapy blocks: Ddecreases in waiting times occurred this year when compared to the same three months periods last year.

Attendance for 2 week therapy blocks: there was a small increase from 161 to 167.

III. Therapy provision

Clinical mix of physiotherapy, occupational therapy & speech and language therapy: In 92% of cases this was appropriate to the child’s needs. In only 2 of the remaining 12 cases, would it have been possible to predict in advance more accurately the child’s specific needs.

IV.Therapy

Goals More GAS goals are being set in preference to SMART goals. This is a progression as GAS goals are more complex and can provide more detailed information.

Frequency of using Outcome measures This has remained largely unchanged: a small increase with more able children (51% to 58%) but a reduction with more severely impaired children (35% to 22%).

Visits by local therapists Numbers of local therapists visiting the Centre increased from 138 last year to 153 this year.

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Reports The number of reports sent out within 3 weeks has improved (89%), along with number of draft home programmes being provided on the last day of a visit (93%).

Audit of Regular and Occasional notes Therapist’s average score for inclusion of all items in Occasional notes was 89 % (91% in 2008-9) and for Regular notes was 83% (75% in 2008-9).

V. Feedback from service users

Parents satisfaction survey o Ninety-seven percent of parents stated they are satisfied or very

satisfied with the therapy their child received. o All parents stated that they saw improvements in their areas of

concern for their child.o All parents had opportunity to practice home therapy activities and

97% of parents felt these would fit in with home life.

Measure of Processes of Care (MPOC) rates the degree to which a service is family friendly. Scores slightly improved demonstrating that we continue to provide an effective family friendly service.

Local Therapists Eighty percent of visiting therapists heard of the Bobath appointment at least four weeks prior to the appointment date, and all therapists recorded that they were satisfied with their visit (similar results to last year).

VI.Continuing professional development (CPD)

Attendance for continuing professional development: Attendance increased at external clinical training and clinical workshops, decreased slightly for other tutorials and statutory training (due to snow disruption).

Year on year comparisons are not very meaningful due to staffing changes and differing work patterns (teaching versus clinical, part versus full time staff, etc.) and in addition the numbers of tutorials and clinical workshops has changed since last year.

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European populations

7%

61%

32%

Dyskinetic (Athetosis)Bilateral Spasticity Unilateral Spasticity

Bobath 2009

38%

50%

12%

3.Serve a wide variety of children with cerebral palsy

Objective: to provide services to a wide variety of patients with cerebral palsy. Audit procedure: data collected on indicator forms for each patient by therapists

Performance Indicator 2009 2010The variety of the caseload remains the same or complex cases increaseChildren with athetosis (more complex cases)Children with GMFCS level IV & V (more complex cases)

31%48%

35%50%

One hundred and sixty two occasional children attended and were analysed according to diagnosis, classification, GMFCS level and age band.

Table 1: Diagnoses of occasional patients2008 2009

DIAGNOSIS No. % No. %Cerebral palsy 144 91.0% 153 94.5%Traumatic brain injury 2 1.0% 1 0.5%Other 12 8.0% 8 5.0%

Table 2: Classification of occasional patients2008 2009

CLASSIFICATION No. % No. %Spastic quadriplegia 35 22.0% 37 23.0%Spastic diplegia 41 26.0% 37 23.0%Spastic hemiplegia 17 11.0% 18 11.0%Dystonic quadriplegia 36 23.0% 45 28.0%Choreoathetosis 13 8.0% 11 7.0%Ataxia 1 0.5% 3 1.5%Hypotonia 1 0.5% 1 0.5%Other 14 9.0% 10 6.0%

Diagnoses and classifications remained largely unchanged, but the classification of children attending the Bobath Centre differs from that of typical European populations, with a greater proportion of children being seen with athetosis and a lower proportion with unilateral spasticity (hemiplegia).

Charts 3 & 4: Comparison of Typical European(SCPE 2002) & Bobath 2009 CP populations

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European population: GMFCS levels

48%

18%

12%

9%

13%

IIIIIIIVV

Bobath 2009: GMFCS levels

10%

11%

26%

21%

32%

The numbers of children seen of different levels of gross motor ability (Gross Motor Function Classification System – GMFCS) and manual dexterity (Manual Ability Classification System – MACS) remained at similar levels.

Table 1: GMFCS & MACS levels2008 2009

GMFCS LEVEL No. % No. %I 15 9% 15 9%II 16 10% 17 11%III 43 27% 39 24%IV 31 20% 32 20%V 44 28% 49 30%Not applicable 9 6.% 10 6%MACS LEVEL No. % No. %I 2 1% 8 5%II 33 21% 25 15.5%III 19 12% 24 15%IV 17 11% 14 8.5%V 20 13% 20 12%Too young to classify 56 7% 61 38%Not applicable 11 35% 10 6%

The population of children seen at the Bobath Centre differs from typical European populations as a higher proportion of children are seen with a greater level of disability (GMFCS levels IV and V).

Charts 5 & 6: Comparison of rates of GMFCS levels in European population (Westbon, Hagglund et al. 2007) and Bobath Centre 2009

The ages of children seen at the Bobath Centre are varied, but fewer children are seen under 2 years of age and over 12 years of age.

Table 2: Age band data2008 2009

AGE BAND No. % No. % < 2yr 19 12% 10 6%

2 – 4yr 47 30% 59 36% 4 – 6yr 35 22% 38 24%

6 – 12 yr 50 32% 42 26%

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12 - 18yr 7 4% 13 8%

Findings: The Bobath Centre continues to provide therapy to a wide variety of children

with cerebral palsy, in terms of motor disorder, level of disability and age. However, in children seen with cerebral palsy, some types are under or over represented as follows:

o Athetosis is seen more often (35%, previously 31%) than found in typical populations of children with cerebral palsy (~6.5%), so the Bobath Centre provides more services for children with more complex presentations.

o GMFCS Levels I and II (milder impairment) are under represented (21% versus 66% in typical European populations) and children in the other levels (moderate to severe impairments) are over represented (79% versus 34% in typical European populations)

o Bilateral spastic cerebral palsy is seen somewhat less often (Bobath =46%; typical populations = 57%)

o Unilateral spastic cerebral palsy (11% percent – same as last year) is seen less than in typical populations of children with cerebral palsy (32%), so the Bobath Centre treats fewer children who have a milder impairment.

o The Bobath Centre sees fewer children under 2 years and fewer children over 12 years, compared to other age groups.

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4. Referrals and Appointments

a. Referral management

Objectives: 1. Follow recommended procedure from receipt of referral to provision of

appointment2. Improve quality of referral process demonstrated by

a. minimising waiting time for occasional appointments b. where it is possible decreasing cancellations

3. Monitor trends in referrals and appointments to better be able to address parents and clients needs, and the needs of the Bobath Centre

4. Provide consistent number of therapy interventions each year

Audit Procedures:Appointments and Funding staff collected the following data on referrals: Referrals: Number of new referrals

Number of returning occasionalsNumber of 2 week blocks, consultations & regular appointments Number of regular patients attending within year (omit patients who came <4 times within the year)

No appointment: If a new referral did not result in an offer of an appointment within 8 months, the reasons are clearly stated in notes

Waiting list recorded new referrals and returners waiting less than / more than 3 months. Checked waiting list report twice yearly (June and December)

Cancellations: Recorded number of blocks which were cancelled after confirmation of appointments and the reason(data analysed from Jan-Mar 10)

Performance Indicators for referral management 2008 2009If referral did not result in provision of appointment within 8 months, the reasons are clearly recorded in 100% of cases

100% 100%

Provision of therapy blocks, consultation & regular appointments remains consistent ((+10) or increases more

- Within +10

Maintain or decrease number of blocks which were cancelled after confirmation of appointment giving reason

1 1

85% of new referrals wait less than 3 months for an appointment (checked twice yearly for period of one month)

82% 82.5%

Referrals: April 09 – March 10A total of 83 new referrals were received, 32 (39%) of which were seen for 2 week blocks, 28 (34%) for consults. The remaining 23 are either on the waiting list, in process of receiving their funding and appointment, or were inappropriate referrals. This compares with 96 new referrals in 2008/9, of which 36 (37.5%) were seen for 2 week blocks and 29 (30%) for consults. Therefore although the rate of referrals has decreased, the rate of new referrals having appointments has increased (from 67.5% to 73%). There were 120 occasionals as of 31st

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March 2010 waiting to return for subsequent appointments, compared with 130 at the same time last year.

Attendance for therapy 2008-9 2009-10Two week blocks 161 167Consultations 56 54Other 18 13This shows a slight increase in number of 2 week blocks.

Waiting List: The waiting list was checked in June 2009 and December 2009 for waiting times for appointments. For the majority of patients, decreases in waiting times occurred in comparison to the same periods last year.

June 08 June 09Less than 3 m More than 3 m Less than 3 m More than 3 m

New referrals 30 (81%) 7 (19%) 16 (84%) 3 (16%)Returning patients 21 (68%) 10 (31%) 105 (90.5%) 10 (9.5%)

Dec 08 December 09Less than 3 m More than 3 m Less than 3 m More than 3 m

New referrals 122 (83%) 25 (17%) 13 (81%) 3 (19%)Returning patients 145 (80%) 37 (20%) 152 (89%) 18 (11%)

A sample of 12 patients from throughout the audit year were checked, to determine the number of patients offered an appointment within 2 weeks of funding having been agreed: n=10 (n=10, 2008/9). One patient had funding agreed early, and one family wished to defer. Between January and March 2009, only 1 block was cancelled after confirmation of appointment (due to illness).

Funded versus self funded patients: There were 124 (58.5%) funded and 88 (41.5%) self funded patients (via insurance, trusts, compensation awards, family, etc.) seen during the audit year (from waiting list data). In addition, twenty two patients were supported through the treatment fund (previous year n=11). This compares with 117 (56%) funded and 91 (44%) self funded patients last year.

Regular patients: A total of 21 paediatric and 5 adult patients with cerebral palsy were being seen on a regular basis by paediatric therapy staff as at 31st March 2010. (Previously 19 paediatric and 4 adult patients).

Regular appointment sessions:2008-9 2009-10

May 08 47 May 09 33Oct 08 37 Oct 09 32Dec 08 33 Dec 09 32Mar 09 35 Mar 10 32

Conclusion: The number of new referrals has decreased but the rate of ‘converting’ these to appointments has increased. Waiting times have slightly decreased. The number of funded patients has increased from 54% to 62%. There is a continued need to monitor data for trends.

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b. Management of Appointment system

Objectives:1. Provide accurate information on appointments for clients, families and visiting

therapists2. Maintain a high level of satisfaction by service users by providing the facility to

change appointments to fit in with client/family needs whenever possible 3. Achieve a high level of consultation patients becoming occasional or regular

attenders

Audit Procedures: Information to be collected on a parent/patient feedback form, sampling parents of children attending over a 2 month period and keeping a record of appointment errors at reception fro 3 months. Record number of consultations that become blocks or regular attendees (i.e. had a minimum of 4 regular appointments)

Performance Indicators for appointments 2008 200990% of requests for change of appointments by parents to be met

85% (6 out of 7)

78%(yes=14; no=3; no response = 1)

<5 errors in appointments reported per month 3/month 0.3/monthMinimal waiting time for appointments: <5% parents waiting 10 min+

0% 0%

Maintain (+1) or increase number of consultations that then return for therapy blocks or regular treatment

- +1

Consultations resulting in subsequent treatment episodes: A total of 5 consultations subsequently came for 2 week blocks (previously 6) and 3 consultations became regular attendees (previously 2).

Appointment errors data: A record of appointment errors was kept from April until June in reception. Centre errors: NilParent errors: One – parent came at 11.30 but appt. was documented on schedule and on their letter as 1.45. Parent happy to wait until 1.45.Also parents of regular attendees were asked on their feedback form whether there had ever been confusion over appointment times – of the 8 forms returned, none reported any problems.

Parent satisfaction with appointments: Process between referral to the Bobath Centre and receiving the first appointment All but two parents responded they could think of no improvements or made comments such as: ‘always excellent’, ‘very smoothly administrated’, ‘very good communication’, ‘very well organized’, ‘the system works very well’, ‘very impressed with the appointment dates and helpfulness of staff’. One parent wished to have come sooner and one parent commented that ‘direct contact would speed up the process’.

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Date and time of appointments: Thirty one parents stated they were happy with all appointments, three parents were happy with some appointments and two were not happy. No parents waited for the therapist to attend at their appointment time, except for once when this was pre-arranged.

Changes to appointments: Eighteen parents requested changes to their appointment times. Fourteen requests were fully met, three were not and one parent did not respond. Parents commented staff listened to their requests and were very helpful in accommodating changes to suit their needs. Many also commented on specific times that suited their child better, generally mornings after 10am and early afternoons.

Administration: Parents rated administration surrounding their visit on a scale of 1 = not at all satisfied to 5= very satisfied. Parents of occasional and consultation patients rated this as follows: 5 (n=33); 4 (n=8); 2 (n=1), No response (n=2).

Recommendation: The question regarding confusion over appointments will be added to the Occasional feedback form in 2010. The record at reception for documenting errors will be discontinued, as it is not possible to be certain that all people working in reception remember to complete it.

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c. Therapy provision

Objective: Provide an appropriate clinical mix of therapies for occasional patients

Audit ProceduresTherapists collect data on an indicator form about every occasional patient that attends.

Performance Indicator: therapy provision 2008 2009Clinical mix of physiotherapy, occupational therapy and speech and language therapy should be appropriate to child’s needs in 85% of cases

89% 92%

Report on appropriate clinical mix of therapies – April 2009 - March 2010Out of a total of 162 occasional patients, therapists stated clinical mix was not optimal in 5.5% (n=9) cases (previously 9%, n=15, 2008-9 audit), and minor issues were raised in a further 2.5% (n=4) cases (previously 3%, n=5, 2008-9 audit). One of the minor comments was irrelevant as the clinical mix was appropriate, but the therapist was referring to future visits. All of the other 12 cases were reviewed by a consultant therapist.

o Inappropriate clinical mix highlighted by treating therapist prior to block, and therapy mix able to be changed appropriately n=2

o Single session of a therapy was provided but proved unnecessary n=1o Best available clinical mix provided in the circumstances n=3 o Reasonable clinical mix provided considering previous information available

from the parent questionnaire and referral letter, i.e. optimal mix was not predictable from available information n=2

o More appropriate clinical mix was predictable from available information, but not provided, n=4

o One case due to staff member on compassionate leaveo One case due to staff members teaching so not available to treato One case was not reviewed at senior’s meeting where differing

clinical needs might have been noted, but by another member of clinical staff. There is no record of why this occurred.

o One case had no parent questionnaire. If this had been received, this might have helped with decision making.

Therefore, in two of the twelve cases, carrying out a review of the returner parent questionnaire if it had been available, and ensuring the cases were discussed at the seniors’ meeting, could have ensured a more optimal clinical mix.

Therefore in 17% (n=2) of these 12 cases, different actions may have led to a more optimal clinical mix. This is 1.25% of the occasional patients who visited during this period. This is an improvement from the 2008-9 audit (n=8%).

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Clinical Mix: analysis of the 12 cases considered inappropriate by therapists

0

1

2

3

4

5

6

7

8

Appropriate mixconsidering prior

information

Inappropriate mixconsidering prior

information

Parent questionnairenot reviewed/received

Clinical mix changedby appointments

department

Inappriate singlesession

Mix changedappropriately prior to

block by treatingtherapist

2008-092009-10

For details of individual patients – see Appendix, Section 2

Recommendations Continue with current policy of ensuring where possible a parent questionnaire

is received from every new and returning occasional, and clinical mix for referrals is decided by senior staff, ideally at the senior staff meeting.

Senior staff decided independently of the clinical audit, to change from using a shorter questionnaire to the full parent questionnaire with returning occasionals. The content of this questionnaire is also to be reviewed this autumn, to gain more specific information to assist with determining clinical mix appropriately.

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5. Therapy indicatorsd. Goals and Outcome measures

Objectives:1. Provide an expert and effective therapy service to a wide variety of children

with cerebral palsy, including consultation, occasional and regular patients. 2. Increase frequency of improvement shown in individual treatment goals, and

scores of outcome measures year on year. 3. Increase frequency of use of GAS goals and Outcome measures by

therapists

SMART Goals: specific measurable goals set for individual patients. Outcome is achieved or not achieved. Goal Attainment Scaling (GAS) Goals: goals set for individual patients on a scale with 5 possible outcomes: zero is the desired outcome and there are two levels below this and two levels above this (-2 to +2).

Audit ProceduresTherapists to collect data on every occasional patient on an indicator form

Performance Indicators for SMART & GAS goals 2008 2009Set >2 SMART goals for >80% occasional patients 82%

>1 goal = 92%64%

>1 goal = 82%Achieve 80% of SMART therapy goals 89% 91%Set 1 GAS goal for >50% of occasional patients (2008 indicator) 69% 64%Set 2 GAS goals for >60% of occasional patients 36% 46%Achieve a GAS goal score of 0 or higher in 80% of patients 95% 81%

2008-9 2009-10SMART GoalsNumber set 375 341Achieved 334 309GAS GoalsNumber set 188 243Achieved 188 239GAS >0 score 147 194 0=desired level of improvement or greaterGAS -1 & -2 scores 41 45 -1 & -2 smaller degrees of improvement

There is a trend towards setting more GAS goals, and GAS rather than SMART goals, with less SMART goals being set. GAS goals have an ordinal scale and are thus a more sophisticated measure of progress, so this is a positive change. Only two children last year and this year had no goals set.

Recommendation: Review performance indicators as current indicators would suggest that less SMART goals is a negative change.

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Outcome measures

Performance Indicators for outcome measures 2008 2009Use outcome measures in 70% of Gross Motor Function Classification System (GMFCS) level I-III children (more able)

51% 58%

Use outcome measures in 40% of GMFCS level IV-V children (more severe)

35% 22%

Improve scores on outcome measures in 80% of cases 84% 96%

The use of outcome measures has improved among Level I-III children with more showing improved scores. Fewer outcome measures (n=20 compared with n=13 last year) fail to be repeated at the end of the block of treatment. Where outcome measures did not result in an improvement, the reason was stated in all cases. There has been a reduction in Level IV and V children having outcome measures performed (22%; n=18 compared to 35%; n=26 last year). Overall a very similar number of outcome measures were performed by therapy staff (2009-10; n = 65 compared to 2008-9; n = 61).

Recommendations:Some of the strategies recommended from the 2008-9 audit to improve use of outcome measures are starting to be implemented:

a training half day on outcome measures was undertaken on 9th June the therapy assistant has received training to enable her to assist

therapists administering outcome measures a volunteer profile has been developed which would include assisting with

outcome measures, but no volunteer has been identified as yet additional therapists are being scheduled earlier in therapy blocks so they

are more likely to be able to use outcome measures. These strategies need to be continued throughout this year.

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e. Contact with local therapists

Objectives: Improve frequency of contact with local therapists by

o The child’s local therapists being invited to attend every occasional block by letter

o Therapists making telephone contact with local therapists preceding or during the visit if possible and recording if they attempted to do so but failed to speak to the therapist.

Audit procedures:Three strategies were used to collect data: A questionnaire was given to all visiting therapists over a 2 month period A count of all local therapists who visited was made from the appointment

schedule Bobath Centre therapists record information on an indicator form as to their

contact with local therapists, for every occasional patient throughout the year

Performance Indicators for liaison 2008 200980% of visiting therapists to hear of Bobath appointment >4wk before appointment date (questionnaire)

80% 80%

<5% of visiting therapists not informed of any changes in appointments (questionnaire)

11% n=3

4% n=1

A local therapist attends during an occasional patient’s therapy block in >60% of cases (appointment schedule)

54% 54.4%

Bobath Centre therapists achieve telephone contact with a local therapist involved with an occasional patient in 75% of cases

56%n=89

57%n=93

Bobath Centre therapists attempt but fail to make telephone contact with a local therapist involved with an occasional patient, in 25% of cases

32%n=50

28%n=45

Visits: 153 local therapists visited patients, of which, there were 93 physiotherapists,

43 occupational therapists and 17 speech and language therapists. Eighty-seven (54.4%) out of 160 occasional patients received visits, of these,

31 patients receiving visits by more than one therapist. Seventeen (38%) of 45 consultation patients received visits (compared to

25% of consultations last year) Five regular patients were visited by therapists. Nine other people involved with occasional patients visited, including case

managers, teachers, classroom assistants, etc. Five patients had no local therapist.

Although the number of occasional patients receiving a visit from a therapist(s) remains at 54%, 153 therapists visited the Centre this audit year compared with 138 in the previous year. If the same period is compared, year on year, there also appears to have been an increase in numbers of visits. This suggests the strategy of contacting therapists directly by letter is proving effective.

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Jan-March comparison 2008 2009 2010No. of occasionals 41 39 29Percentage of occasionals visited by therapist 41.5%

(n=17)41.0% (n=16)

72.4% (n=36)

No. of therapists visiting occasional & consult patients 26 40 45

Appointment information: Thirteen therapists (53%) heard of the appointment from the Bobath Centre by letter or telephone (previously 41%), and twelve (48%) directly from parents (previously 51%). Therapists heard of the appointment 2-3 months beforehand (n=11); 4-7 weeks before (n=9); <3 weeks (n=5) (similar to last year’s figures). The majority of therapists (84%) visited on a day a Bobath therapist of the same profession was treating or did not mind which therapist they saw (slightly less than last year). Fourteen therapists (56%) had provided written information about the child they were visiting prior to their appointment.

Telephone contact as recorded by the therapists at the Bobath Centre (on all patients throughout the year) remains at a similar high level to the previous year. Successful and attempted telephone calls numbered 138 in total this year compared to 139 calls last year. Of visiting therapists completing a questionnaire, 36% had received a phone call or spoken to the Bobath therapist on the telephone prior to their visit, both slightly lower rates than last year.

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f. Patient progress notes and reports

Objectives: Reports and home programmes adhere to guidelines of Bobath Centre Improve quality of reports, home programmes and clinical progress notes Occasional patients: Doctor’s letter, report and home programme provided

within a reasonable time frame and to a high standard Consultation patients: Report and home programme provided within a

reasonable time frame and to a high standard Regular patients: Provision of an annual report and updated home activities Ensure reports meet the needs of parents and local therapists, improving their

satisfaction with reports Ongoing training on report writing/home programmes provided for clinical staff

Audit procedures Collect data via parent, patient and local therapist feedback forms

(questionnaires were given over a 2 month period), and collect data from Bobath Centre therapists on indicator form on every occasional patient.

Perform notes audit. This consists of therapists assessing three sets of regular notes and three sets of occasional/consultation notes against set criteria, of children they have not treated.

Performance Indicators: provision of reports 2008 200990% of occasional patients receive the doctor’s letter, therapy report and home programme within 3 weeks

83%11% >3wk6% unknown

89%9% > 3 wk2% unknown

Provide a draft home programme to 95% of parents of occasional patients on the last day of visit: reported by * Therapists on indicator forms for 12 months* Parents on questionnaire (given out over 2 month period) (12.5% (n=2) –No; 12.5% (n=2) - No comment)

94%75% (n=16)

97%93%

80% of annual reports for regular patients to be received from therapists by 31.01.09. (Remaining report in by 23.02.09.)

92%12 out of 13

80%8 out of 10

Notes audit: achieve average therapist score of 80%: Regular Occasional

75%91%

83%89%

95% of regulars to have annual update of home activities 61.5% 86%

Occasional, Consultation and Regular notes auditTwenty one sets of occasional notes, three sets of consultation notes and thirteen sets of regular notes were selected randomly to represent all therapists, i.e. they had either been a key or additional therapist for the child. Eight therapists were requested to audit the notes of children they had not treated Scores are allocated against set criteria. These are similar to those recommended by the Chartered Society of Physiotherapy.

Overall, a high standard of record keeping was maintained and/or improved. The average raw score for all therapists for occasional reports was 97 (last year 99);

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and the average percentage score was 89%. This is similar to last year 91%. Average raw score for regular notes was 52/62 or 83%. This is an increase of 8% compared to the results of the audit from last year.

Recommendations were then made to clinical therapists to further improve the quality of records. These included:

Ensuring every child has a Risk Assessment form completed for manual handling, and that all sections on the assessment form are complete or if information is unknown, this is stated.

Reducing the length of some sections within doctor’s letters, therapy reports and home programmes.

Recommending using an outcome measure(s) with every regular attender and checking if and when parents would like a written update of home activities.

In addition, consultation notes need to be audited separately with a different scoring system, as there are different priorities in recording information.

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6. Feedback from service users

g. Parent

Objectives: Parents will have a high level of satisfaction with therapy Hands on training in therapy activities will be provided for all parents/carers Improve satisfaction of parents regarding quality of home programmes Parents and carers will have a continuing high opinion that the service they

receive is family friendly On going training to therapists in working with parents as necessary

Activities: In addition, every occasional patient will have a named key therapist, goals will be set jointly with families and clients and the last 15 minutes of occasional appointments will be designated for discussion with the family regarding the child’s therapy.

Audit procedures:1. A parent feedback form was given to all parents of occasional children over 2

months (June – July 2009) and to all parents of consultation children over a 6 month period (May to October) requesting information about their visit including provision of appointments, therapy, facilities and reports.

2. The Measure of Processes of Care (MPOC) is a standardised measure which aims to identify parents’ and service providers perceptions of the extent to which a service is family-centred. This was used with parents of occasional patients attending over a one month period (August 2009).

3. The MPOC and a parent feedback form was used with parents of regular patients attending over a one month period (November 2009).

4. Bobath Centre therapists were also surveyed using the MPOC for service providers to determine their views of the service during August 2009.

Performance indicators and results: Performance Indicators 2008 2009>90% state they are satisfied or very satisfied with the therapy their child received (4 or 5, on 5 pt scale) on feedback form

88% (n=15) 97% (n=35)

>90% of parents/carers state on their feedback form that they had opportunity to practise home therapy activities

100% 100%

>90% of parents report that home activities are practical and will fit into home life

94% 96%

Scaled scores for the same categories in MPOC and MPOC-SP will be within 1.0

- Yes

>60% of occasional parents complete an MPOC form in specified time period

65% 68%

100% of therapists complete an MPOC-SP form (excepting author or report & staff who are in their induction period)

100% 100%

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OCCASIONAL PARENT FEEDBACK REPORT – September 2009Questionnaires were given to all parents attending with children during June and July 2009, for 2 week therapy blocks (occasional patients).

RESPONSE TO QUESTIONNAIRESForty one forms were given out. Thirty-six were returned and five were not returned. Two families did not receive forms (one stopped treatment early for personal reasons) and the other form was not placed in the patient’s file.

OVERALL VISIT TO THE BOBATH CENTREComments fell into the following themes: Excellent, worthwhile, interesting, enlightening, useful, enjoyable, productive,

beneficial for child and family, extremely happy with therapy sessions Appreciation to fitting the block and/or appointments around the family’s /

child’s needs, and in relation to interventions such as Botulinum toxin therapy Bobath Centre staff were described as professional, friendly, approachable,

helpful, very kind, very welcoming and nothing was too much trouble. Therapists were excellent, had real enthusiasm and dedication. Continuity of

care in keeping same therapists throughout visit appreciated Learned more about their child and their condition, understood their child

more, appreciated daily feedback from therapists, clarified focus and goals, motivating, and a problem solving experience

Child’s needs clearly addressed and therapists worked effectively towards goals set at the start of the treatment. Children made good progress.

Child very engaged, relaxed, interested, happy and had fun in sessions, therapists helped child to achieve the best of their abilities

Useful ideas, activities, guidance, helpful to practise activities, video useful.

THERAPYParents rated therapy on a scale of 1 = not at all satisfied to 5= very satisfied. Ratings were as follows: 5 (n=31); 4 (n=4); No response (n=1). All parents stated concerns they wanted addressing in therapy and all reported specific improvements in relation to these concerns. Some examples are:

Arms and hands looser, able to reach out more, more willing to use arm(s) Legs more flexible and looser, improved posture, balance, strength and

stamina for standing/walking, straighter hips and knees; able to cruise around furniture with confidence, able to use sticks

Head control and posture improved, more upright and relaxed posture in sitting, stronger trunk muscles, able to move from wheelchair to bed

Vocalisation and interaction increased, more consistent choice making, eye pointing and responses to yes/no cards, starting to use switches

Easier positions for dressing and playing; more willing and able to dress self, self feeding improved

HOME PROGRAMME OF ACTIVITIES: Twenty five out of 27 parents, who were asked on the last day of their visit, said they had received a draft home programme. All parents had been given opportunities to practice home activities. All but one parent stated that they felt

23

these were practical and would fit in with home life, the remaining parent stated that they were mostly practical ideas. All parents felt they would have time to carry out home activities. Nineteen parents thought they would carry out the activities daily, seven stated between 2-3 times/week, five occasionally and others were unsure or did not respond. Twenty-nine parents stated they already had the necessary equipment for the home activities, four had some equipment, two did not have the equipment and one did not respond.

FACILITIES & ACCESSParents rated access to the Bobath Centre on a scale of 1 = not at all satisfied to 5= very satisfied. Ratings were as follows: 5 (n=28); 4 (n=6); no response (n=2) and also facilities at the Bobath Centre as 5 (n=27); 4 (n=7); no response (n=2).Comments: Having the tumbler drier in the kitchen makes very noisy and makes it hard to

chat to other parents and the intercom makes a sharp beep when announcing arrivals which is quite distracting – our child jumped a mile! (In response, the tumbler drier is now situated in the changing area).

The kitchen was very warm in the Summer

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Consultation feedback September 2009

Eight forms were definitely placed in the files of consultation patients, given to parents at time of appointment and returned complete, in the period June to mid August 2009. A further six patients attended, where it was unclear if a form had been put in the notes and as none were returned, new forms were sent out in the post, but none of these were returned.

OVERALL VISIT TO THE BOBATH CENTREComments included: “Good, excellent, fantastic visit, encouraging, positive, realistic, very helpful in focussing on certain issues, a nice environment, friendly people and lots of information to take in. Hope we are able to come back as very informed therapist and learnt a lot”

THERAPYAll parents expressed some specific main concerns and stated that these had been addressed. Concerns included:Head control, weight bearing, lack of extension, use of right hand, balance, posture, stiffness and muscle tone, facilitating stepping and walking, feet rolling inwards, hips turning out, new treatment ideas, confirmation that current therapy was sufficient and appropriate. Therapy was rated on a scale from 1= not at all satisfied to 5= very satisfied. All parents were satisfied with the therapy: 4 (n=1); 5 (n=6), no response (n=1).

HOME ACTIVITIES: All parents said they were shown how to do home activities and that they were practical and would fit into daily life. The parents’ perception of their understanding of the activities was rated on a scale from 1= not at all satisfied to 5= very satisfied. All parents felt they understood the activities, 4 (n=1); 5 (n=6) no response (n=1).

OTHER COMMENTS One parent commented that on the first appointment the therapist was sick,

the appointment was re-arranged and was fine, but no compensation was offered for travel costs

Open a centre in Yorkshire! Thank you for another successful visit, it is always good to come away feeling

so positive about how to move our child’s therapy forwards. Therapist was excellent: positive, realistic, and friendly. A true professional

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Measure of Processes of CareThe Measure of Processes of care aims to identify parents’ perceptions of the extent to which certain health professionals’ behavior occur within childhood rehabilitation services, which are considered to represent important aspects of delivering a family-centred service. Twenty items are scored on a seven point scale from 1= does not happen at all to 7= happens to a very great extent. Participants can also score 0 for not applicable. Items are arranged in five scales:

o Respect and supporto Coordinated and comprehensiveo General informationo Specific informationo Enabling and partnership

Raw scores for each scale are converted to scale scores by calculating a mean score from all participants’ data (omitting ‘not applicable’ scores). The range and standard deviation of these scores can be calculated. Individual item scores are also converted to mean scores so these can be analysed.

Occasional Paediatric patients August 2009:This was distributed to all occasional paediatric patients attending in August 2009 and the first week of September 2009. Twenty two forms were distributed and fifteen returned (68%). Verbal and telephone reminders for the non-responders, did not result in any more returns.

Table 1: Category Scaled scores and Descriptive statistics (excluding not applicable scores)

Scaled Scores SD

Scores within Mean + 1SD Min Max Range Median

Not Applicable

scores

2009 Scaled scores

Respectful & Supportive care 6.13 1.03 5.10-7.16 3 7 4 6 0 5.96Coordinated & comprehensive care 5.95 1.06 4.89-7.01 3 7 4 6 1 5.98Enabling & partnership 5.97 1.06 4.91-7.03 3 7 4 6 2 5.79Specific information 6.02 1.14 4.88-7.16 3 7 4 6 2 6.01General Information 4.65 1.80 2.85-6.45 1 7 6 5 7 4.37

Scale scores either improved slightly but not to a significant level, (respectful & supportive care; enabling & partnership; providing general information) or they remained largely unchanged (Specific information; Coordinated & comprehensive care). This demonstrates the Bobath Centre continues to provide a high level of family centred care.

Most individual items were either largely unchanged or showed some improvement (14 improved by an average of 0.47 points -see Appendix). Data can be analysed to look for those behaviors occurring between ‘never’ and ‘sometimes’ (scores 1-4). The only item where >50% of responders reported the item as occurring between ‘never’ and ‘sometimes’ was the same as last year: Provide advice on how to get information or contact other parents, e.g. organization's parent resource library which is not surprising as this is not a resource which the Bobath attempts to provide excepting some information present in the parents’ kitchen.

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Measure of Processes of Care: Regular Paediatric patients Dec09 – Jan10This was distributed to all regular attending patients during December and January 2010. The response rate was very poor, with only 6 out of 15 questionnaires being returned, despite reminders. Analysis can not therefore give an overall representation of views of parents of regular patients.

Parents gave fairly high scores for the different categories (4.0 - 5.0) excepting providing General Information which received a mean scaled score of 3.7. The scaled scores are lower than last year, but still within one standard deviation, so there is probably little significant change. One parent gave high scores for activities the Bobath Centre does not provide and low scores activities which are within our remit, so may have misinterpreted the scoring system. It is possible, that parents found completing these questionnaires rather cumbersome, in addition to an audit parent feedback form and survey from the Appointments & Funding department.

Table 1: Category Scaled scores and Descriptive statistics (excluding not applicable scores)

Scaled Scores SD

Scores within Mean + 1SD Min Max Range Median

Not Applicable

scores

2009 Scaled scores

Respectful & Supportive care 5.03 1.85 3.18-6.86 1 7 6 5.5 0 6.48Coordinated & comprehensive care 4.44 1.98 2.46-6.42 1 7 6 4 0 6.24Enabling & partnership 4.20 2.55 1.65-6.75 1 7 6 3.5 4 6.00Specific information 5.52 0.46 5.06-5.98 1 7 6 6 0 5.52General Information 3.70 0.41 3.29-4.11 1 7 6 4 9 4.10

Recommendations: Cease using the MPOC with parents of regular attendees, as the response

rate is very low, and has not improved despite personally giving the form to parents, verbal, telephone and written follow up, additional forms sent to parents if the original one was not completed within one month, and individual follow up by the therapy assistant.

Response rate for completion of a more general questionnaire regarding services was higher, so will be continued.

Consider with management, if any other strategy such as interview or a focus group would yield better feedback of services

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Measure of Processes of Care for Service providers (MPOC-SP) – Dec 2009The Measure of Processes of care for Service Providers aims to identify service providers perceptions of the extent to which behaviors occur within their delivery of childhood rehabilitation services, which are considered to represent important aspects of delivering a family-centred service.

Summary of ResultsThe MPOC-SP was distributed to 7 out of 9 paediatric therapists during a 4 week period during July and August 2008. The author of this report did not complete a form due to the risk of being a potential source of bias, and a member of staff did not complete a form due to being within their induction period.

Mean Scale ScoresThe highest scores were for providing respectful care, communicating specific information and showing interpersonal sensitivity. Providing general information received a lower score, similar to the parent MPOC results.

Table 5: Category Scaled scores and Descriptive statistics

CategoriesScaled Scores SD Min Max Range Median

2008 Scaled scores

Showing interpersonal sensitivity 5.67 1.56 1 7 6 6 5.18Providing General Information 3.37 1.52 1 6 5 4 2.98 Communicating specific information 6.43 0.75 5 7 2 7 5.96Providing respectful care 6.62 0.73 3 7 4 7 5.86

Item Scaled Scores: Highest item scaled scores were mainly within ‘providing respectful care’ and ‘showing interpersonal sensitivity’. Again providing general information received the lowest scores.

Conclusion: Therapists appear to have a fairly realistic view of the service they provide in terms of the degree to which it is family-centred and this largely correlates with the views of parents and carers.

Recommendation from MPOC-SP results: Feedback information to therapists.

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h. Visiting Therapist

Objectives:1. Local therapists will be satisfied with their visit to the Bobath Centre2. Reports and home programmes will be sent to all local therapists (see section

on therapy)3. At the end of all courses for therapists, the course leader will encourage visits

by local therapists when any of the children on their caseload attend the Bobath Centre

Audit procedures:Questionnaire to all visiting therapists over a 2 month period (April-May2008)

Performance Indicators 2008 2009>60% of local therapists attending complete a feedback form in specified time period

59% 55.5%

>90% positive responses of local therapists to reports

100% 100%

>90% of therapists record they are satisfied with their visit

96% 100%

VISITING THERAPIST QUESTIONNAIRES: APRIL – JULY 2009Only 12 therapists visited with only 5 questionnaires returned during April – May 2009. It was therefore decided to extend the period until the end of July. A further 21 questionnaires were received out of a possible 33 visitors. So from a total of 45 visiting therapists, 25 questionnaires were returned. Forms were received from: 18 physiotherapists, four occupational therapists and four speech & language therapists.

All staff were reminded to give out forms, but it was difficult to ensure people covering for reception always distributed these, and visiting therapists do not always introduce themselves, so some can be missed. It is not clear what proportion of the19 non-responders did not receive questionnaires and what proportion did not return them.

Therapy All visiting therapists found the visit beneficial and were given the opportunity to ask questions, raise issues and/or discuss management. Fifteen therapists (60%) were given opportunities to try out therapy activities during the session (72% last year). Of the ten who did not try out activities, 5 would have liked to, but 4 preferred to observe and one did not comment.

Report Of those therapists visiting children who had attended previously, 11 (44%) had received reports, 2 did not know if one had been received and 4 stated they had not received a report. This could be for a variety of reasons such as a child moving area, change of therapist, change of venue of therapy etc. Comments about the report included ‘received punctually’, ‘clear & informative’, ‘interesting, and very clear and easily understood with photographs’.

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Comments Other comments about the visit included ‘very helpful discussion about specific issues, e.g. positions, handling techniques, plastering, splints, botulinum toxin, etc.’ ‘excellent interaction throughout the session’, ‘informative and friendly’, ‘it was useful to have another opinion and share ideas and local recommendations were reinforced’, ‘it was useful to observe and try out handling techniques and see the therapy in action’.

They also appreciated gaining a greater understanding of current therapy aims and objectives, the child’s tone and patterns and how to influence them, therapy techniques, new treatment ideas, how to develop the child’s skills apply ideas in the school setting use equipment.

Other suggestions were to have a summary of priorities of treatment to take away, suggestions on further progressions to therapy once improvements made and feedback on any outcome measures which are done at Centre.

Recommendations: Remind Bobath therapists to invite local therapists to try therapy activities Suggest a draft home programme is supplied to visiting therapists if available Remind Bobath therapists to supply copies of outcome measures with the

report to local therapists.

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7. Continuing Professional Development

Activities: Provide time for continuing professional development for all therapists Provide appropriate level of clinical supervision per therapist (appropriate to

standards agreed for different bands) Provide variety of tutorials, clinical workshops, and statutory training To ensure a high standard of satisfaction by service users and that report

writing guidelines are followed, provide ongoing training as necessary, on report writing, home programmes and collaborative working with parents

Audit Procedures: Collect monthly data on CPD via an Excel data sheet from each therapist and analyse data at year end.

Performance Indicators and ResultsPerformance Indicators 2008 (6m

of data only)2009

100% of clinical therapists attend >20 other tutorials (>10 in 6m) not relevant as only had 11 tutorials this year

50% Ave attendance 5.75 tutorials

100% of clinical therapists attend >5 clinical workshops (>3 in 6m) (15 workshops took place)

60% 75%

100% of therapists involved in teaching attend >8 other tutorials not relevant as only had 11 tutorials this year

- Ave attendance 5.75 tutorials

100% of therapists involved in teaching attend >3 clinical workshops (15 workshops took place)

- 80%

90% of therapists attend 3 days external clinical training 91% 100%90% of therapists attend statutory training sessions (3 days) during which there was disruption due to snow

75% 62% all 3 days38% 2 days

Findings: It is difficult to make any comparisons, as several staff changes occurred

through the year, and the number of clinical workshops/tutorials changed. Attendance at workshops and external clinical training has probably improved.

Completeness of recording of CPD activities by staff was very varied, with one member failing to complete the necessary forms.

The frequency of clinical supervision given by a senior member of staff or peer within treatment sessions (i.e. advice on analysis and treatment), varied widely. It did not always reach expected levels, but was higher for new staff

Performance indicators need to change to relate to number of tutorials and clinical workshops which took place.

Due to staff changes, it may be better for staff to be compared against themselves to see if improvements are taking place.

Percentage data are not very meaningful due to the small numbers of staff and differing working patterns, i.e. part time, full time, teaching, clinical, etc.

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Recommendations: Review whole process of collection and recording of CPD data to allow for more meaningful comparison of year on year data

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8. ConclusionThe evidence of the clinical audit demonstrates that the Bobath Centre continues to provide parents, patients and visiting therapists with a high quality service.

Some specific conclusions are as follows:

The appointment system continues to be reliable and flexible. Overall the occasional clinical notes have been maintained at a high standard

and notes for regular attendees have improved. Therapists are setting more GAS goals The use of outcome measures has remained largely unchanged. The current system for deciding clinical mix of therapies for child patients is

proving effective. There was a high satisfaction reported from service users (parents of children,

patients and visiting therapists). The process of collection and recording of CPD data needs reviewing, to

allow for more meaningful comparison of year on year data

Virginia KnoxResearch Physiotherapist

November 2010

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9. Summary of recommendations

Appointments & Referrals Monitor trends: of number of new referrals, ratio of funded to self funded

referrals, and rate of ‘conversion’ of new referrals to appointments. Appointment errors recording: A question regarding any perceived confusion

over appointment times/dates will be added to the Occasional feedback form. The document recording errors at reception will be discontinued.

Therapy provision Continue policy of ensuring a parent questionnaire is received from every new

and returning occasional, and clinical mix for referrals is decided by senior staff at the senior staff meeting.

Review the content of the parent questionnaire in autumn 2010, to gain more specific information to assist with determining clinical mix.

Outcome measures & Goals Ensure therapy assistant continues training in outcome measures Encourage therapists to utilise therapy assistant Endeavour to recruit a volunteer to assist with undertaking outcome measures Check twice yearly that additional therapists are being scheduled earlier in

treatment blocks to facilitate their involvement in utilising outcome measures Review performance indicators as current indicators would suggest in

correctly, that setting less SMART goals is a negative change.

Notes Audit Feedback to clinical therapists has already taken place regarding sections with

more frequent omissions in occasional and regular notes (see appendix) Audit consultations separately. Virginia Knox to meet with Lynzi Crisp to

implement this.

Parent Feedback Cease MPOC with regular patients as response rate is consistently low Continue General feedback form with regular patients as response rate higher. Other strategies: Consider with management, if an interview or focus group

would yield better feedback of services Feedback to therapists results of the MPOC

Local therapist feedback Remind therapists to Invite local therapists to try therapy activities if they wish Supply a draft home programme to visiting therapists if available Supply copies of outcome measures to local therapists with the report.

Continuing Professional Development: Review process of recording of CPD data to allow for more meaningful comparison of year on year data.

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10. APPENDIX

APPENDIX SECTION i:

OUTCOME OF RECOMMENDATIONS FROM 2008-9 AUDIT REPORTThis document summarises the outcome of reviewing the recommendations from the last audit report in a joint meeting with Jayne Pearce, Director of Administrative Services, Christine Barber, Director of Therapy Services and Virginia Knox Research Physiotherapist. Recommendations which have not been implemented (under CPD) are highlighted.

Referrals and Appointments

a. Referral management Set new performance indicator for management of referrals following 2008-9

audit: ‘85% of new referrals wait less than 3 months for an appointment’ Check whether the ratio of funded to self funded patients is changing with

more being self funded - There were with 91 (44%) self funded and 117 (56%) funded patients seen during the 2008-9 audit year. Eleven patients were supported through the treatment fund. Continued monitoring of funded versus self funded patients to take place, so any trends can be identified.

b. Appointments Instead of requesting reception staff to keep a record of any errors in

appointments, a question to be added regarding this to the parent questionnaire. As the appointment record and parent questionnaire had already taken place within 2009 when this was decided, the parent questionnaire has subsequently been amended and this will take place in the audit year from April 2010 to11

c. Therapy provision Appointments and Funding department to continue to ensure that returning

occasional patients receive a new parent questionnaire and complete this prior to assigning clinical mix for their block. Currently this is sent out with the appointment letter i.e. after funding has been agreed and the appointment confirmed.  However, the appointment still goes ahead, even if the form is not returned. Further Action: Discussion took place with management as to the policy when funding is in place for a patient, but despite requests, the parent questionnaire has not been returned – this should be documented in patient notes as this may affect choice of clinical mix adversely, but has happened only rarely in the last year.

Returner questionnaires will continue to be reviewed by a senior therapist along with information from local therapists if available, to determine appropriate clinical mix. If the Appointments and Funding department are suggesting a change to previously recommended therapy mix or balance of appointments, this will be discussed with a senior therapist in advance. In

35

each case, the therapist must document their recommendations, with reasons as appropriate.

Continue with policy of suggesting a maximum of 2 therapies for a 1st visit unless very specific clinical reasons to suggest that 3 therapies are required. Continue with the policy of discouraging a single double appointment unless very specific reasons for this, with these stated on the returner form.

Therapy indicatorsd. Goals and Outcome measures Low use of outcome measures (especially with Level I-III children) needs to be

analysed as to why measures are not used more frequently. An anonymous questionnaire will be given to therapists to complete to determine the reasons and therefore how this may be addressed – this took place along with a discussion at a staff meeting. (See 2009-10 recommendations)

Smart goals Clinical indicators discussed and amended to include ‘To set 2 GAS goals for >60% of patients’.

e. Contact with local therapists of child patients Remind clinical therapists to endeavour to achieve telephone contact with

local therapists prior to/at the beginning of a therapy block, even if they are planning a visit (planned visit often given as reason not to telephone therapist)

Keep encouraging local therapists to visit through everyday contact with local therapists and through courses.

Compare a 3 month period in next financial year with a 3 month year period in previous year to investigate whether letters sent directly to therapists inviting them to attend (rather than given out by parents) is proving more successful: overall numbers of therapists visiting the Centre are rising year on year, and when a three month period is compared – there has been an increase in numbers visiting.

f. Children’s patient progress notes and reportsRecommendations from occasional notes audit:Feedback was given to clinical therapists on the following: Ensure completion of main problems, functional implications and general aim

sections on re/assessment forms Sign re/assessment form on front, particularly if not present on first day (also

additional therapists to check they sign forms) Only highlight <4 key parental concerns in Doctor’s letter (there may be more

in the therapy report) Remind therapists to ‘suggest’ equipment, using general principles, rather

than prescribing particular equipment Instruct therapy assistant and volunteers who send out reports, that treatment

forms that invite re-referral should be attached to the hard copy of the doctor’s letter (these were often not in the file, so it was difficult to be certain that they had been sent). Numbering pages of reports by therapists, may also help to ensure reports are sent our complete.

36

Changes for next year’s audit: Include risk assessment form in audit for next year to determine rates of

completing risk assessment documentation. Associated impairments – not all children have associated impairments, so to

add the choice of ‘none’ to the assessment forms on ThankQ. There was a query as to whether consent forms for photographs/videos should

be audited. If so, this would need to be done separate to the clinical notes audit, as they are no longer filed in children’s therapy notes. The Appointments and Funding department state that this aspect is going well with no significant number of missing or incomplete forms, so this will not be audited.

Modify notes audit forms, with shading in sections to clarify which parts need completion.

Recommendations from regular notes audit:Feedback given to clinical therapists regarding: Include interpretation of outcome measures Number pages Include goals for regular clients. Check goals are SMART (possibly with a

colleague) Encourage all therapists to use “SOAP” format for notes Ensure correct details for the data sheet are obtained from regular clients or

their carers, at the time of annual report, so these can be updated by the appointments and funding department, or if nothing needs changing, sign and date at top of data sheet.

Omit the next appointment in the P section of SOAP notes as impractical. Continue to use Home Activity Record Sheet and at time of annual report,

check whether family want any further update of home activities if none have been given or requested during the year.

Next year’s audit: Omit ‘planned intervention frequency’ and ‘next appointment’ from audit as not necessary

During the free days in the week of the 3 centre training days, suggest therapists check ongoing goals and whether treatment activities need updating, with parents of regular patients as this is a less busy time for therapists, than when they are producing the annual reports for regular clients (previously usually only done at this time).

Schedule of Audit Activities 2009-2010TIME TASKSApril Visiting Therapist QuestionnaireMay Visiting Therapist QuestionnaireJune Parent Satisfaction QuestionnaireJuly Parent Satisfaction QuestionnaireAugust Measure of Processes of Care (Occasional Patients & Staff)September  October  November Measure of Processes of Care (Regular Patients)December Occasional notes audit

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January  February Regular notes auditMarch  Quarterly Collate 'Continuing Professional Development' (CPD) dataThroughout year Collect data on Occasional patients on Indicator formsThroughout year Referral & appointment data; numbers of visiting therapistsYear end Collate data, analyse and write report

Feedback from service usersg. Parent Feedback forms: To determine strategies to increase return rate: a list of all consults kept and checked. If forms not returned, a further form will be sent by post. Also collection of forms will take place over a longer period so there is more possibility of a larger number of consultation patients attending. The return rate for occasional parent feedback forms stayed at 89% but more forms were completed (36, previously 17). The return rate for consultation parent feedback forms remained at 57% but slightly less were completed partly due to less consultations occurring despite collecting over a longer time period (8 out of 14 completed compared with 11 out of 20 for the previous year).

Overall Recommendations from MPOC results: Feedback information to therapists. Improve response rates for parents of regular clients completing the MPOC -

therapy assistant to distribute and collect forms from parents

h. Visiting Therapist feedback- No current recommendations

Continuing Professional DevelopmentRecommendations: Re-evaluate way in which data is recorded, set realistic attendance targets for formal CPD events by tutors and trainee tutors not done as yetAttend >8 (tutorials & journal clubs combined) Attend > 3 workshops per yearRevise levels of clinical supervision for all bands – not done as yetDivide the data into teaching and clinical staff, for analysis. Include number of sessions where therapists observed other therapists treating as well as supervision sessions – not done as yetOmit annual tutorials on report writing, home programmes and collaborative working as current staff working at a high standard. Ensure these areas continue to be covered within induction of new staff.

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APPENDIX SECTION ii: CLINICAL MIX: REPORTS ON INDIVIDUAL PATIENTSPatients where clinical mix highlighted as inappropriate by therapists

Planned Actual Explanation

No OT concerns PT X 10OT X 1

PT x10OT x2

Mentioned difficulty with fastenings in PQ, but no concerns on visit so OT pulled out.

SLT & PT originally assigned, but had OT needs.

Pt X 10SLT X 4

PT x10OT x 4

Unsure why SLT selected originally – some coughing on drinking. Bobath PT requested OT on seeing file, so changed prior to visit.

Put down for OT, PT but had SLT needs.

PT x 10OT x 4

PT x10SLT x3

Needs were OT not SLT on PQ. Local OT & PT Qs received supported this. Changed before block due to unidentified new information (no written record as to why).

Therapist felt clinical mix satisfactory, but families only concerns were SLT

PT X 10SLT X 4

PT x 9SLT x 4

No PQ. Parent highlighted SLT issues with appointments department. OT & SLT highlighted communication; PT highlighted mobility. Senior SLT suggested 4 SLT.

Needed more PT, but clashed with teaching

PT x 10OT x 4

PT x 8OT x 5SLT x2

PQ requested SLT as well, so changed to PT 7, OT 3, SLT 2. then changed to PT 8, OT 5, SLT 2 due to PT having teaching commitments.

SLT sessions reduced due to staff absence, but needs SLT key next time

PT X 6 SLT X 8, Changed to PT & SLTX7 each

PT x 10SLT x 4

Due to compassionate leave, SLT sessions reduced.

Self funded. Parent wanted 10 PT only despite recommendation for 4 OT.

PT x 10 or 8OT x 4 or 6

PTx10;OTx4PT x7 OT x 3 if self fund

Organised 2 OT sessions at no charge during visit. Recommendations for next visit give ideal if funded and alternative including OT within 10 sessions if self funding

Better to have OT key next time

PT x 8OT x 3SLT x 2

PT x 8OT x 3SLTx2

PT mentioned OT concerns. No PQ. Could have been predicted and changed. Next visit planned PT 4, OT 8, SLT 2.

Perceptual concerns – had to ask OT to come in

PT X 10 PT x10 Not obvious from PQ or therapists information. OT able to come in for 2 sessions, so dealt with during visit.

Needed more OT PT X 10OT X 4

PT x10OT x2SLT x2

1st visit. PQ mentioned SLT along with mobility and OT needs. Senior reviewing therapist went for only 2 therapists as 1st visit. Changed some sessions during visit to SLT due to parental concerns, but still needed more OT (but not keying by OT).

OK but recommended OT & PT for next visit

PT X 10 PT x 10 Therapist letter mentioned OT & PQ mentioned using R hand. Clinical therapists (not senior) reviewed returner PQ. prior to visit and agreed to PT x 10. Different needs could have been foreseen if discussed at seniors meeting.

Needed some SLT PT x 10 PT x10 PQ – head & trunk control. Treatment fund used so only one therapist funded. Not predictable

PQ = Parent questionnaire

39

Increase in omissions in Assessment report items

0

2

4

6

8

10

12

14

16

Diagno

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Items

Num

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20082009

Improvements in Assessment form

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Age

Inves

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Treatm

ent a

ims

Notes i

ncon

cise

Dated

Errors

cross

ed by

>sing

le lin

e

Errors

initia

lled

Treatm

ent u

nclea

r

Items

Num

ber o

f om

issi

ons

or u

nsas

tifac

tory

sec

tions

20082009

Occasional Notes Audit – December 2009Twenty one sets of occasional notes and three sets of consultation notes were selected randomly to represent all therapists, i.e. they had either been a key or additional therapist for the child, from the previous four months. Eight therapists were requested to audit three sets of notes of children they had not treated (1 set was not found). Scores are allocated for

Data Sheet – all details were complete except for those of one paediatrician and one physiotherapist (5 omissions in 2008). The Risk assessment form was audited for the first time. Seventeen out of twenty-three were complete. Re/Assessment form – There were significant improvements including a reduction in omissions of additional therapist details, age of child, past medical history, range of movement (ROM), main problems, functional implications, associated problems, and treatment aims. Errors were being crossed out by a single line, initialled and dated, and treatment was more clearly described in progress notes. There were small increases (maximum of 3) in omissions of local therapists’ details, frequency of intervention, postural tone, inabilities, patterns of movement and an increase in the use of abbreviations. There were omissions of the GMFCS (2009=8;2008=5) and MACS (2009=8;2008= 0).

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Doctor’s Letter – this had improved significantly. Hard copies of the form requesting agreement for future treatment were only omitted from 3 sets of notes (previously 19); no addresses were omitted (previously 4) and the section on main changes was too long in only 5 cases (compared to 9 previously). The age of the child was not on any of the reports which had used templates from the new ThankQ database, as this is not included on that template.

Therapy Report – Overall this had showed continued improvements: there were no longer any omissions of diagnosis, associated impairments, GMFCS, or investigations. Only two sets of goals were not SMART (previously 4).The reports were overall more concise with fewer occurences of sections being too long, e.g. general impression, functional implications, and aims. One exception was that the number of reports with a longer section on main problems than recommended increased (2009=9 ; 2008=3)

Home Programme – this showed continuing small improvements, such as including more precise information on suppliers of equipment; jargon was no longer being used, but many therapists are continuing to include more home activities than are recommended in the guidelines (2009=10; 2008=9). The age of the child was not on any of the reports which had used templates from the new ThankQ database as this is not included on that template.

Table 5: Individual Therapist results for occasional patientsTherapist 1 2 3 4 5 6 7 8Mean raw scores (Total = 109) 104 101 101 96.7 96.5 93.7 93.7 89Mean percentage scores 95 93 93 89 89 89 86 82

If the three audits of consultations (different total raw score) were included, average percentage score was 86%. Although one report received a high score (60/64), two consultations had lower scores (30 and 34 out of a total of 64). These had largely comprehensive reports but most information was missing from the assessments. This has been observed to occur previously due to the shortage of time for completing the report and all accompanying paperwork – therapists would choose to ensure the report was complete typing assessment information into the report, before completing the hand written assessment form. The average raw score for all therapists for occasional reports was 97 (last year 99); and the average percentage score was 89%. This is similar to last year 91%.

Recommendations: Feedback to clinical therapists: Alert therapists to improvements and also main omissions,

which included. Incomplete Risk assessment formsRe/Assessment form GMFC, MACS, local therapists’ details and frequency of intervention, postural tone, inabilities, patterns of movement. There was also an increase in the use of abbreviations.Doctor’s Letter –section on main changes sometimes too long Therapy Report Main problems too long. Home Programme many therapists are continuing to include more home activities than are recommended in the guidelines – this needs review: to discuss optimal length with staff.

Changes for next year’s audit:

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o Omit age from audit of doctor’s letter and home programme as the ThankQ templates do not include this, the date of birth is included on these documents, and it is not considered necessary to include current age as it appears in the report.

o Consider auditing consultations separately as there are different priorities in recording information, and the scores differ between occasional and consultation audit forms.

Regular Notes Audit – March 2010Thirteen sets of regular notes were audited by an uninvolved therapist. Notes were selected randomly to represent all therapists. Longstanding regular client notes were audited for the previous year and more recent regulars were audited from the date of therapy commencing. The audit was divided in to the following sections: Data Sheet, Order of notes, Annual Report, Progress notes and Home Activity Record Form.

Data Sheet – All but one of the thirteen data sheets had been updated, a significant improvement since the audit in February 2009. Order of notes – All but one set of notes was in the correct order. Annual report – Areas of frequent omissions in the previous audit year (child’s age, PCT and local therapy details) had reduced in frequency. Almost half the reports audited had more than 5 future goals and/or these were not considered to be SMART goals and some lacked goals. Outcome measures where used, sometimes lacked interpretation.

Table 1: Frequency of omissions from Annual report

Annual Report

0 1 2 3 4 5 6 7

No recommendationsInconcise

not SMART>5 goalsno goals

too many aimsno aims

no current equipmentno interpretation

no resultsnot dated

no explanationno reasons

no outcome measuresno tone or patterns

>6 functional>5 main problems

no resultsno dated investigations

no changescurrent therapy

local therapist detailsconsultant paediatrician

PCTNo MACS

No GMFCSnot dated

No associatedDiagnosis

AddressAge

no DOBchild's name

Req

uire

men

t

Number of omissions

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Progress Notes Overall these were of a high standard, with notes showing evidence of ongoing assessment and recording changes. The “SOAP” format is used by most therapists (SOAP – notes arranged under following headings: S-subjective; O-objective; A-analysis; P-progress). All notes audited presented clear treatment aims with record of ongoing assessment and change. However four sets of notes lacked page numbers and three had incomplete headers. Notes were occasionally not concise and some errors were not initialed.

Table 2: Frequency of omissions in Progress notes Progress notes

0 1 2 3 4 5

Incomplete header

SOAP not used

Notes not concise

Illegible notes

Illogical flow of notes

No abbreviations

Entry not dated

Entries not signed

correction fluid used

Not written in permanent ink

>Single line to cross error

Error not initialled

No ongoing assessment

No record of change

Treatment not clear

Planned visit lacks entry

Pages not numbered

most recent entry at back

Req

uire

men

t

Number of omissions

Home Activity Record form Nine out of the thirteen notes had a completed record of home activities, a significant increase. Two clients did not receive updated activities over the last year.

Table 3: Individual therapist resultsTherapists 1 2 3 4 5 6 7 8 9 10 11 12 13Total scores(out of 62)

35 46 50 52 52 54 55 56 56 57 57 58 58

Average score is 52/62 or 83%, an increase of 8% compared to the results of last year’s audit.

Recommendations from notes audit: Feedback to clinical therapists:

o Update contact details of client and professionals involvedo Number pages and complete header on each pageo Include maximum 5 future goals for regular clients. Check goals are SMART

(possibly with a colleague)o Ensure that GMFCS level is documentedo Complete section listing any recent investigations/ interventions o Increase use of outcome measures to support clinical findingso Continue to use Home Activity Record Sheet and at time of annual report, check

whether family want any further update of home activities if none have been given or requested during the year.

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APPENDIX SECTION iii: Measure of Processes of Care (MPOC)

MPOC: Occasional Patients – additional informationItem Category  

2009 Scaled scores

2008 Scaled scores

15 SI Tell you about the results from assessments 6.36 5.7711 RS Treat you as an equal, rather than just the parent of a patient 6.27 5.85

1 RS Help you feel competent as a parent 6.20 5.85

13 RS Treat you as an individual rather than as a typical parent of a child with a disability 6.07 6.153 RS Provide a caring atmosphere rather than just give you information 6.07 6.08

12 CC Give you information about your child that is consistent from person to person 6.07 5.6910 CC Plan together so they are all working in the same direction 6.07 5.62

9 RS Provide enough time to talk so you don't feel rushed 6.00 5.927 EP Fully explain treatment choices to you 5.93 5.855 CC Look at the needs of your whole child, e.g. mental, emotional, social, not just physical 5.87 5.922 SI Provide you with written information about what your child is doing in therapy 5.87 5.92

14 SI Provide you with written information about your child's progress 5.86 5.698 EP Provide opportunities for you to make decisions about treatment 5.80 6.006 CC Make sure that at least one team member is someone who works with you & your family over a long period of time 5.79 4.384 EP Let you choose when to receive information & the type of information you want 5.62 5.08

16 GI Give you information about the types of services offered by your organization/your community 5.00 4.1517 GI Have information available about your child's disability (e.g. its causes, how it progresses, future outlook) 4.93 4.3119 GI Have information available to you in various forms, such as a booklet, kit, video 4.43 4.3118 GI Provide opportunities for the entire family to obtain information 4.92 4.9220 GI Provide advice on how to get information or contact other parents, e.g. organization's parent resource library 4.00 3.46

Fourteen items showed improved scores (average of 0.47), one item remained the same and five items showed slight decreases in score (average of 0.078)

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MPOC for Service providers – additional information

Table: MPOC for Service providers: Item scaled scores

Item Category  MPOC items for Service providers

Scaled scores

2009

Scaled scores

200815 CSI Provide parents with written information about their child’s condition, progress or treatment 6.86 6.673 SIS Take the time to establish a rapport with parents and children 6.86 6.56

22 PRCTreat children and their families as people rather than as ‘cases’ e.g. by not referring to the child & family by diagnosis such as the ‘spastic diplegia’ 6.86 6.00

10 PRC Make sure parents had a chance to say what was important to them 6.86 6.006 PRC Accept parents and their family in a non judgmental way 6.71 6.22

19 PRC Make sure parents has opportunities to explain their treatment goals and needs e.g. for services or equipment 6.71 6.1120 PRC Help parents feel like a partner in their child’s care 6.71 6.117 PRC Trust parents as the ‘experts’ on their child 6.71 5.89

17 PRC Treat each parent as an individual rather than as a ‘typical’ parent of a child with a ‘problem’ 6.71 5.6721 SIS Help parents feel competent in their roles as parents 6.71 5.442 SIS Offer parents and children positive feedback or encouragement, e.g. in carrying out a home programme 6.57 6.111 SIS Suggest treatment/management activities that fit with each family’s needs & lifestyle 6.57 5.89

14 CSI Tell parents about the results of tests and assessments 6.57 6.5018 PRC Treat parents as equals rather than just as the parent of a patient (e.g. by not referring to them as ‘Mum’ or ‘Dad’ 6.14 5.1113 PRC Answer parents’ questions completely 6.00 5.6716 CSI Tell parents details about their child’s services, such as the types, reason for, and durations of treatment/management 5.86 5.444 SIS Discuss expectations for each child with other service providers, to ensure consistency of thought and action 5.71 5.335 SIS Tell parents about options for services or treatments for their child, e.g. equipment, school or therapy 5.71 5.338 SIS Discuss/explore each family’s feelings about having a child with special needs e.g. their worries about their child’s health or function 4.86 4.67

11 SIS Let parents choose when to receive information and the type of information they wanted 4.71 4.6712 SIS Help each family to secure a stable relationship with at least one service provider who works with the child and parents over a long period of time 4.71 3.5023 PGI Promote family to family connections for social informational or shared experiences 4.29 3.119 SIS Anticipate parents’ concerns by offering information even before they ask 4.29 4.67

25 PGI Provide advice on how to get information or to contact other parents e.g. through a community’s resource library support groups or the internet 3.43 3.44

24 PGIProvide support to help families cope with the impact of their child’s chronic condition e.g. information of parents of assistance programmes or counseling how to work with other service providers 3.29 3.33

26 PGI Provide opportunities for the entire family, including siblings to obtain information 3.29 3.11

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MPOC for service providers: Least commonly reported behavioursData can also be analysed to look for those behaviours occurring between ‘never’ and ‘sometimes’ (scores 1-4) and ‘more than sometimes’ to ‘a very great extent’. Behaviours were analysed to determine whether >50% of responders ever reported any items to be occurring between ‘never’ and ‘sometimes’. The only items in this category were those within providing general information, which is an area the Bobath Centre acknowledges is not within it’s remit or provision.

The items in the service providers MPOC do not always exactly correlate with items on the parent and carer MPOC, but for those items which are the same or related, therapists were about the service they provide than parents. For a few items, therapists rated themselves slightly more highly:

Table : MPOC-SP – item score comparison with MPOC for parents

Item  MPOC items for Service providersScaled scores

MPOC for parents

15 Provide parents with written information about their child’s condition, progress or treatment 6.86 5.873 Take the time to establish a rapport with parents and children 6.86 6.00

14 Tell parents about the results of tests and assessments 6.57 6.3620 Help parents feel like a partner in their child’s care 6.71 6.2710 Make sure parents had a chance to say what was important to them 6.86 6.00

7 Trust parents as the ‘experts’ on their child 6.71 5.58

References:SCPE (2002). "Prevalence and characteristics of children with cerebral palsy in Europe." Developmental Medicine and Child Neurology 44: 633-640.

Westbon, L., G. Hagglund, et al. (2007). "Cerebral palsy in a total population of 4-11 year olds in southern Sweden. Prevalence and distribution according to different CP classification systems." BMC Pediatrics 7(41).

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