Professional Development and Research Issues 71

Measuring and learning in clinical practice

The Collaborative Action Learning Project progress report, October 1995

MAGGIE JOHNSON Gap House School MICHAEL FAULKNER Vice-president, RCSLT

ABSTRACT Within healthcare there is an increasing need to demonstrate the effec- tiueness and cost-effectiveness of clinical interuen tion. This paper describes a model developed for speech and language therapy which takes as its starting point the proposition that finding o u t about clinical effectiveness is a continuous learning cycle. The model uses a database to enable therapists to record their goals, inter- uentions and outcomes in a form which allows sophisticated analysis and learning to take place as a by-product of clinical practice. The database enables therapists to create assessment and care protocols by use of dictionaries of standard terms. Protocols are then used to create indiuidual care plans. Interventions carried o u t are recorded against the indiuidual care plan and outcomes achieved recorded against targets set during the assessment process. Through a process of audit, therapists seek causal explanations for uariances between actual and expected outcomes and use such explanations to refine the protocols. To couer the unusually wide range and complexity of speech and language therapy, the authors have developed the concept of ‘health benefits’ which particular programmes of care set o u t to deliuer. The authors believe that health benefit is a clearer and wider construct than ‘out- come’ or ‘health gain’. Health benefits may be associated with named clients or with populations. The paper reports on the creation of a collaboratiue action re- search program within speech and language therapy as an efficient and effective way of developing robust research-led practice models. The collaborative programme inuolues therapists at a number of sites joininga network or ‘clearing house‘. Through their membership, therapists are able to propose new protocols and dictionary entries for the database and to share research data. Network members are also able to access support and training in the use of the model and to propose deuelop- ments to the software. The creation of such a research community promotes a much faster developmen t of research-led practice than would be possible through individual efforts. The authors also belieue that i t creates a strong sense of a pro- fessional community which is of great importance when seruices are being frag- mented and therapists isolated within their management units. The model is being extended to other professions and to multidisciplinary settings. I t has attracted strong interest and support from purchasers and from providers. The paper ad- dresses the relationship between this model and other initiatives, such as the devel-

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opment of Read Coding and integrated information systems for hospitals and com- munity units. Therapists haue found the model sufficiently flexible to ac, rommo- date the individuality of clients and the application of professional judgement in determining appropriate interuentions. Therapists haue found that the model en- hances clinical effectiveness by offering a clear focus on outcomes and by enabling systematic eualuation of practice as a by-product of their work. The collaboratiue research model is a potentially powerful tool in building the confidence of the profession in its own effectiveness and in creating a knowledge base for the prac- tice of speech and language therapy.

INTRODUCTION

This paper gives an account of an experiment in collaborative learning within speech and language therapy. The project is known as the Collaboratiue Action Learning Project (CALP) and is led by Maggie Johnson, speech and language therapist, and Michael Faulkner, an independent adviser and researcher.

BACKGROUND

The project was instigated in 1993 following a seminar on marketing for speech and language therapy service managers in the (then) South East Thames Region. At the seminar, the authors were advocating the need for the profession to be able to offer programmes of care for particular types of client. Each programme would have to offer a known probability of specific benefits being delivered at a known cost.

At the seminar, the concept of ‘health benefits’ was introduced as a way of placing value on the work which therapists do. The importance of health benefits was in intro- ducing a form of description which seemed to encompass all of the work of the profes- sion rather than focusing purely on a curative (quasi-medical) model. The set of health benefits proposed at the original workshop has been extended through discussion with colleagues in our own profession and in other disciplines. The current set is shown as Appendix 1.

In subsequent discussions with therapists, it became very apparent that the data is not often available to enable therapists to provide reasonable forecasts of the benefits which they should be able to deliver for particular client groups. There can be resist- ance to forecasting what may be achieved. Many therapists tend, instead, to proceed on a heuristic problem-solving approach to see what outcomes are achieved.

The conclusion drawn at this stage was that therapists needed to learn much more about their own practice if they were to be able to provide commissioners and other clinicians with reliable predictions of what should be achieveable.

It was also acknowledged that the issue being addressed was common to all therapy services and that there could be significant benefits in developing a network of collabo- rators to tackle the task.

At the time of writing, 15 speech and language therapy services have agreed to participate in the Collaborative Action Learning Project (CALP) and it is our intention to recruit additional members from other clinical disciplines.

KEY PROPOSITIONS

CALP rests on a number of key propositions. Some of these were apparent at the start of the project, others have become clear through the development process.

Professional Deoelopment and Research Issues

In all of these propositions, the term client is used to refer to the people who are closely involved in and affected by the communicative problems of an individual. It includes, as appropriate, parents, partners and other close family members. The propo- sitions are:

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For therapy to be judged effective, it must bring about a change which is per- ceived by the client as beneficial. Change does not always entail making things better in absolute terms. Change may simply involve making things better than they would otherwise have been. The judgement of the client is a necessary but not sufficient criterion of effective- ness. The validity of the aims of a programme should also be tested against the clinical judgements of peers to safeguard against the client having unduly low or high expectations of what can be achieved. Although it is often not possible to provide accurate predictions of outcomes in individual cases, it should be possible to make accurate predictions of the probability of particular outcomes being achieved for a group of similar clients. The effectiveness of therapy is strongly influenced by the extent to which the client is involved as an equal partner in all stages of the therapeutic process.

THE AIMS OF C A W

The aims of the project are as follows:

To enable clinicians to learn about the efficacy and efficiency of their practice as an integral part of their clinical work. To enable clinicians to share knowledge with their colleagues within the profes- sion and in other clinical disciplines. To enable clinicians to demonstrate the value of what they do to commissioning agencies, other clinicians and the general public.

A LEARNING MODEL

CAW is based on the proposition that it is possible to learn about clinical practice by:

Predicting the difference which a programme of therapy should be able to make and expressing this in terms of specific aims. Defining how achievement of the aims will be assessed or measured. Developing a plan of action to achieve the defined aims. Recording the actions which occur in reality. Measuring what has been achieved against the goals set before the start of therapy. Seeking to explain differences between the predicted goals and the actual goals by identifying sources of variance. Changing practice and/or categorisation of clients to enable better predictions to be made in the future.

ENABLING LEARNING

In principle, case records maintained in accordance with the precepts of Communicating Quality (RCSLT, 1991) contain all the information which is required to enable the

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outcomes

n Evaluation

/

I UNDERSTANDING I planning

delivery

FIGURE 1: Learning from practice.

learning cycle (Figure 1) to take place. In practice, a number of problems had to be solved:

Records are often not kept in a sufficiently consistent or detailed way to facilitate learning. Individual therapists record different kinds of information in quite different ways and do not use any standard terminology or format for their records. Goal setting is often very imprecise, partly because of our lack of confidence in making predictions. Therapists feel unable to ‘commit’ themselves too early in the therapeutic process. Furthermore, there is a tendency to plan in terms of interventions rather than gains for the client. Paper records are difficult to analyse without a significant commitment of time and effort.

CAW sought to address these issues by developing:

A relational database which will enable participating therapists to keep their records in a format which facilitates analysis, learning and sharing. Standardised formats for assessment, care planning, recording care delivery, and outcome measurement. Agreed methods of assessment for particular groups of client. These take the form of ‘assessment protocols’ which identify the items of information which should be collected during assessment, with a choice of appropriate information- gathering techniques. ‘Clinical templates’ which capture the essential ingredients of programmes of care which will be appropriate for particular client categories. Therapists can then draw upon clinical templates when constructing their own individual care plans. A client category is defined as a cluster of clients for whom the same aims are appropriate and who are likely to respond in the same or similar ways to particular programmes of therapy. Factors likely to influence client category in- clude the needs, aspirations and motivation of clients and those around them.

Professional Development and Research Issues

ENABLING COLLABORATION

Participants in CALP undertake the following:

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To use the CALP database and structures in their clinical practice for assess- ment, care planning and recording of care. To design new assessment protocols and clinical templates which will then be made available to all CALP participants. To provide anonymous data on the outcomes achieved to the CALP clearing house which will then consolidate the data and make it available to all CALP participants. To participate in the CALP training programmes. To contribute to the funding of the CALP project.

The CALP database will provide automated facilities for downloading data to the clearing house and for uploading new protocols, new templates and consolidated evalu- ation data.

CURRENT DEVELOPMENT OF CALP

As indicated above, 15 speech and language therapy services are involved in CALP and are at various stages of implementation. A pilot project in occupational therapy is just about to start and parallel work is under discussion in health visiting and commu- nity nursing.

The assessment process and supporting software is currently well-defined and un- der evaluation by participants. The process for designing clinical templates is also well defined and the software is currently being developed. It is anticipated the the first phase of software development will be completed by the end of March 1996.

SOME PRELIMINARY CONCLUSIONS

CALP is very much an action learning project. It is something which is owned by its members and which is constantly developing in the light of discussions amongst mem- bers and their clinical experience in the field. However, at this stage, it is possible to draw some tentative conclusions:

Commissioners are very supportive of the CALP concepts of health benefits and probability estimates of outcome. The CALP model seems very acceptable to members of our profession. The CALP membership is, of course, a self-selecting sample. Having said that, nearly 500 therapists have been exposed in some detail to the methodology and have felt that it meets their needs. The concept of collaboration within our profession and across professions has been very warmly welcomed, in particular in a climate in which collaboration is not always encouraged. The project has been seen as very empowering of our profession - enabling us to support our clinical opinions with robust data and to argue coherently for the resources needed to deliver particular health gains reliably. It is also highlighting the areas in which we need to focus fundamental research to better understand the theoretical basis of our practice.

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The process of having to re-think and to dissect our practice is very informative. During the CALP training events, nearly everyone had to ask themselves quite challenging questions about their own practice and the rationale behind it, and we have become aware of deficiencies in our undergraduate and continuing professional education. Participation in the CALP project requires and enables record keeping and care planning in accordance with the standards of Communicating Quality (RCSLT, 1991). It therefore reinforces that extremely valuable initiative. The process of developing the CALP model has highlighted the need for our practice to be one which exists in partnership with clients and the people around them. One of the authors has introduced significant changes in her service to emphasise the need for establishing a collaborative relationship with clients, which has led to a significant reduction in complaints. Participation in CALP requires proper investment of time and resources in the initial states. Members have expressed the irony of a situation where the de- mands to reduce waiting lists and increase contact levels are counter-productive to developing initiatives which will ultimately streamline and improve service de- livery.

SUMMARY

CALP supports current initiatives within the National Health Service reflecting an in- creasing emphasis on evidence-based practice, the application of information technol- ogy and the development of a ‘language of health’ - a consistent way of using lan- guage about healthcare which will enable information to be shared amongst profes- sionals in a meaningful way.

CALP project provides a methodology and set of tools which enables clinicians to learn about their practice in the course of delivering care. It appears to meet the needs of commissioners to move towards commissioning for outcomes rather than activity.

The CALP methodology appears to reflect adequately the complexity and range of speech and language therapy practice.

The learning approach which is reflected in CALP appears to be an effective and appropriate way of complementing the clinical research undertaken in academic de- partments.

The CALP methodology and supporting training programmes promote the idea of therapy as an active partnership between client and therapist.

Finally, the CALP methodology lends itself well to multidisciplinary working.

Professional Development and Research Issues 77

APPENDIX I

Health benefits - what good are we doing

Benefits for named clients

Benefit

1 Reassuring that no intervention is needed

2 Resolving or partially resolving a clinical condition

3 Accelerating a normal developmental process

4 Preserving function or slowing down loss of function

5 Alternative function to compensate for loss of normal function

6 Adaptation to loss of or reduction in normal function

7 Maintenance of health

8 Auoiding risk of harm

9 Informing another clinician’s or professional’s decisions about a client

Definition

Determining that a clinical intervention is not required and reassuring the client and family that no intervention is needed Resolving or partially resolving a clinical condition at either a symptomatic or causative level Accelerating a normal developmental process to overcome or mitigate the effects of a developmental delay Preventing or slowing down the loss of normal function

Providing an alternative method of functioning to compensate for the absence or reduction of normal function Enabling a client and his or her family to adapt psychologically and environmentally to absence or reduction in normal function Enabling a client and and family to maintain their own health Reducing the risk of a client harming himself or causing harm to others Providing a specialist opinion or assessment as a contribution to the work of another clinician or professional

Example

Assessing a child and reassuring the parents that the child’s difficulties will resolve spontaneously

Eradicating vocal nodules by teaching a client how to avoid vocal strain

Providing a language programme for a Down’s syndrome child

Passive and active physiotherapy to maintain muscle tone in a client with Motor neurone disease (MND) Providing a wheelchair

Providing adaptations, aids and counselling to minimise the handicapping effects of muscular sclerosis (MS)

Educating at-risk families about diet, hygiene or language stimulation Providing a safe environment for a client with suicidal intentions Providing a specialist opinion on language function to inform educational target-setting

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Benefits for populations

Benefit

10 Teaching other clinicians or professionals

11 Preventing health problems

12 Reducing handicap by raising awareness

13 Service development

Defi n it ion

Transferring specialist skills and knowledge to another professional group to increase their ability to provide care Carrying out screening and/or educational activities designed to prevent ill-health in a particular population Reducing the handicapping effects of a particular disease or abnormality by changing the attitude and behaviour of members of the public towards that disease or abnormality Investing time and resources to improve the quality and/or efficiency of a clinical service and/or the competence of the clinicians delivering that service

Example

Teaching nurses feeding techniques for clients with dysphagia

Teaching members of the public how to reduce the risks of high blood pressure

Organising a sensory deprivation experience to change attitudes towards deafness and blindness

Undertaking a research programme to learn about the efficacy and efficiency of particular models of care

REFERENCE

Royal College of Speech and Language Therapists (1991). Communicating Quality. London: RCSLT.