Experiences with continuous quality improvement work based on the Occupational Therapy Intervention Process Model

Abstract

Background

Sustainability is an important issue in implementation processes in health care, and more knowledge is needed to facilitate improvement work in occupational therapy practice.

Aim

The aim of this study was to explore how occupational therapists experienced continuous quality improvement work based on the Occupational Therapy Intervention Process Model after 17 years.

Method

Two focus group interviews were conducted with a total of 12 occupational therapists. The data were analysed using qualitative content analysis.

Results

The analysis resulted in three themes with related subthemes describing the occupational therapists’ experiences of their model-based long-term improvement work. The themes were labelled as follows: ‘sharing a safe and well-known professional reasoning’, ‘reaching normality and empowerment’ and ‘questioning and reshaping the too safe and too well-known normality’. The model functioned as a sustainable framework both for ordinary clinical practice and for continuous improvement work.

Conclusion

By using the model, the occupational therapists had established a safe and well-known professional reasoning in which continual quality improvement work had become sustainable.

Keywords:

• Models of practice
• sustainability
• occupational therapy
• professional reasoning

Introduction

According to Batalden [1,2], the aim of quality improvement work in health care settings is to continuously improve processes and systems and promote professional development to optimize the results for the people in need of services. However, new knowledge and working methods can be difficult for organizations to transform into long-lasting daily routines [3,4]. Finding ways to implement quality improvement interventions is therefore an important issue [2,5], and more knowledge about how improvements can be sustained in health care-related settings over time is still needed [6–8]. Various terms have been used for describing aspects of sustainability, such as embedding, integration, stabilization, routinization and normalization [8]. The latter is commonly used when a change has been established and is referred to as ‘the new normal’. According to Normalization Process Theory (NPT), coherence, or sense-making, together with cognitive participation, collective action and reflexive monitoring, are the basis for normalization [9].

In its broader sense, sustainability is described as an ongoing and dynamic process including both a stable, ingrained change and a dynamic, continued change [8,10,11]. An analysis of 240 studies from four systematic or scoping reviews resulted in the following comprehensive definition of sustainability: the continued delivery of improvements and a maintained behaviour change after a stated period of time that also includes possible changes in both the implemented improvements and behaviour to continue to produce benefits [10].

Different models, theories and frameworks can be used for describing, explaining and supporting the implementation of quality improvement changes in health care [9,12,13]. In addition, models supporting professional reasoning in the implementation of intervention processes can guide quality improvement work [14,15]. The Occupational Therapy Intervention Process Model (OTIPM) is an example of a model that can support the expertise of occupational therapists (OTs) in improving their services. The OTIPM guides OTs in implementing occupation-centred reasoning in all steps of the occupational therapy intervention process [14,16]. The model includes three integrated models that contribute to professional reasoning in different ways: a process model, a conceptual model and intervention models. In addition to guiding professional reasoning in practice, the OTIPM can be used to support long-term quality improvements [17].

Our previous study showed how the collective use of the OTIPM can guide improvement processes, promote the integration of evidence-based knowledge and support sustainable improvements, with long-lasting achievements in practice [18]. The long-term improvement work included a redesign of the intervention process in practice, supported by the development of several types of guiding documents. The improvement work included, for example, reviews of evaluation assessments, goals, intervention methods and evidence. These reviews were guided by the OTIPM and helped develop professional reasoning. This improvement work, which started in 2001, is still ongoing, and it is rather unique to have the opportunity to follow improvement work for such a long time. Given the importance of sustainability in implementation processes and the limited empirical research in occupational therapy [19], more knowledge is needed to facilitate improvement work in practice in the long term. There is also a need to increase the understanding of how models such as the OTIPM, in addition to guiding professional reasoning in occupational therapy, can facilitate quality improvement work in the long term. Therefore, the aim of this study was to describe how OTs experienced the continuous quality improvement work based on the OTIPM after 17 years from the onset.

Materials and methods

Design and study context

The study was designed as a qualitative descriptive study focussing on long-term experiences with improvement work. Data were collected by focus-group interviews in 2018 to enable participants to collectively share and describe their experiences with long-term improvement work based on the OTIPM. The context in the current improvement work consisted of an occupational therapy unit at a hospital in Sweden with 17 practising OTs. All of them were invited to participate in the focus-group interviews. The participants consisted of 12 OTs who gave their informed written consent to participate. All participants were women aged from 27 to 64 years (mean age of 51 years) and with a mean professional experience of 20.5 years. Eight of the OTs have participated in the improvement work since 2001, one since 2006 and three since 2011.

Data collection

The data collection included two focus-group interviews with 12 OTs, with 6 OTs in each focus group. A semi structured interview guide with open-ended questions was used to obtain a wide range of experiences from the focus-group discussions. The participants were asked to describe their experiences in working with continuous quality improvements over the years. Additionally, they were asked to describe their experiences of opportunities and challenges in basing the continuous quality improvement work on the OTIPM, and how the model had influenced the quality of their work in practice. The focus-group interviews lasted between 50 and 60 min and were conducted by the last author (KZ). The interviews were sound-recorded and transcribed verbatim.

Data analysis

A qualitative content analysis [20,21] was chosen to analyse the latent content of experiences with the long-term improvement work. The authors began the analyses by reading through the transcribed interviews several times to obtain an overall understanding of the content. The text was then broken down into meaning units and condensed to shorten the text while still maintaining the core meaning. The meaning units were then abstracted and coded close to the data, for example, ‘created an improvement culture in practice’, ‘creating safety’ and ‘there is strength and will in the group striving for change’. The codes were thereafter compared to identify similarities and differences, sorted and transformed into two preliminary themes: ‘feeling safe with the model’ and ‘incorporating the model’. The initial themes were then compared with each other and refined until three themes and six subthemes were formed. The first and last authors (MS, KZ) carried out the analysis of the interviews in steps where the analysis done by one of the authors was reviewed by the other to increase the trustworthiness. The second author (MLL) later took part in the analysis together with the two authors and compared the evolving findings in the data. The study was approved by the Regional Ethical Review Board for Research in Umeå Sweden (Dnr. 2017/45-3).

Results

The findings from the analysis of the interviews are presented in three themes with two subthemes, each describing how sustainability in the work with continuous quality improvements based on the OTIPM was experienced after 17 years. The findings are presented in Table 1, followed by further descriptions.

Table 1. Overview of the themes and subthemes in the content analysis.

Themes	Sharing a safe and well-known professional reasoning	Reaching normality and empowerment	Questioning and reshaping the too safe and too well-known normality.
Subthemes	Having control over ongoing changes	Continuing to integrate improvements as a natural part of work	Searching for new inspiration
	Feeling embedded in a knowledge-based context	Feeling empowered by ongoing professional and personal development	Refining and renewing the working methods

Sharing a safe and well-known professional reasoning

The OTIPM was described by the OTs as a sustainable framework both in the provision of ordinary occupational therapy services and in the long-term quality improvement work to overcome constraints in practice. By using the OTIPM, the OTs had accomplished a safe and well-known professional occupation-centred reasoning that provided a sense of control and a feeling of being embedded in a collective knowledge-based understanding.

Having control over ongoing changes

The long-term use of the OTIPM was described by the OTs as strengthening their professional identity, and they considered their professional roles and expertise to be clear and defined. Through shared reasoning, the OTs retained a sense of control while constantly dealing with changes in the health care system as part of the ongoing improvement work. They described how they continually reflected on constraints in practice and needed changes based on the OTIPM. In this regard, reviews of the degree to which their services were client-centred, ecologically relevant and occupation-based provided support for what needed to be improved and how to make improvements. They had control not only over aspects such as what was a ‘genuine’ occupational therapy intervention process and what truly mattered for their clients but also on what was considered as evidence-based methods. The OTs expressed that they were certain of what authentic occupation-centred reasoning and good quality client-centredness was and how to implement these in intervention processes by focussing on the occupations each client wanted and needed to do in their everyday life. This was expressed as follows: ‘We are clear about what to do and what to ask for, and our assessments are clear… we know what we need to focus on so that they (the clients) can be active at home’. The OTs also described how this clarification of their professional role and reasoning made them feel more recognized for their unique contributions among other professionals. According to the OTs, the clarification of their professional role increased their collaboration with their clients, colleagues, students and other professionals.

Feeling embedded in a knowledge-based context

The embedded collective understanding of occupational therapy created a pleasant workplace and a feeling of being part of a common knowledge-based context. The collective understanding based on anchored common principles and values made thoughts and ideas easily and generously shared. The OTs described how their recurrent reviews of various aspects of practice and their subsequent collective reflections and actions (during their improvement work based on the OTIPM) led to long-lasting achievements. In this, the way the OTIPM approach, e.g. occupations, ecological relevance and client-centredness in practice and the discussion of how it can be evaluated and critiqued, was reflected as being of particular importance for establishing a sustainable collective understanding. This collective understanding was supported by the many types of documents they had developed during the improvement work to guide the implementation of the OTIPM in practice. Operational plans, occupational therapy programs, routine documents, patient information sheets and a guide for documentation in client records are all examples of such guiding documents. Additionally, the review of assessment tools and intervention methods and the subsequent removal of less suitable tools and methods were described as important for the common occupation-centred reasoning.

In the collective understanding, knowledge translation and development were obvious and natural elements, and the OTs expressed having self-confidence in their quality of practice, which can be illustrated with the quote ‘our lowest level is very high’.

Reaching normality and empowerment

The work with continuous quality improvements with support from the OTIPM had normalized routines and integrated them as a natural part of the daily practice. The OTs also emphasized the importance of creating a common culture grounded on the OTIPM based on a desire to improve. The professional reasoning was described as empowering, contributing both to professional and personal development.

Continuing to integrate improvements as a natural part of work

The improved work was described as normalized and a natural part of a systematic sustainable way of working. The OTs described how their created professional foundation, based on the OTIPM, allowed their time to be better used since their professional reasoning continuously solved problems and led to more effective, structured ways of working. One of the OTs expressed this as ‘we do not have to constantly be ready to put out fires’.

With support from the OTIPM's occupation-centred reasoning and the developed guiding documents, they were able to receive support in both their daily client interventions and in their professional role as OTs. During the implementation process, details were sharpened, and routines were refined based on the OTIPM. However, the OTs perceived that it was challenging to implement occupational-centred reasoning in medical wards with short hospital stays. It was difficult to identify clients’ goals in their occupations, and sometimes there was a lack of knowledge of the occupational therapist’s role. Establishing occupation-centred reasoning was described as time-consuming in a medical context, and continuous reviews and changes were required to reach quality improvements and sustainably implement occupation-based services.

Feeling empowered by ongoing professional and personal development

Work with continuous quality improvements based on the OTIPM strengthened the OTs both in their professional roles and on a personal level. This duality was described by the OTs as professional development that took place in the whole group, but the OTs also felt that personal self-development had taken place, expressed as follows: ‘… we have developed working methods and based on these, we have been able to continue, and we have developed both our working methods and our own personal empowerment’. The OTs described that the long-term quality improvement work increased their personal skills, improved their feelings of security and structure in their way of working and improved their professional reasoning. The improvements had grown through the support of facilitators including development-focused leaders, support from the use of the OTIPM and collective collaboration over the years. The model-based reasoning created a special spirit that was expressed as a positive force and sustainable desire to work with improvements.

Questioning and reshaping the too safe and too well-known normality

The long-term work with continuous quality improvements based on the OTIPM was also laborious at times. The OTs described periods when the sustainability of the structure started to shake. Although they were aware of the meaningful structure and the impact of the continuous improvements in the daily client work, the OTs lost the inspiration and motivation to continue the improvement work. They questioned their everyday professional normality that felt too safe and too well-known. The OTs needed new inspiration and refined and renewed working methods.

Searching for new inspiration

The OTs expressed that there were periods when the usual became too common and that they lost the desire and motivation to constantly be ready to review and revise documents and routines. They were also overloaded in patient work, and the continuous changes in the organization contributed to the lost motivation. The normalized and safe methods no longer provided inspiration, and they needed renewal. The improvement work was arranged according to the same structure based on the OTIPM over the years with the constant identification of new areas for improvement. To constantly be up to date with new guidelines and new research and deal with constant changes in the organization related to costs and shorter care times was described as demanding. At the same time, they were expected to continue with their improvement work and adapt the implementation of the OTIPM to these changes, which became overwhelming during periods with a lack of inspiration and work overload.

Although questioning their working methods, the OTs also expressed that they still, in some sense, felt safe and secure in the occupation-centred reasoning based on the OTIPM, but the workload in periods with an increased client flow and organizational change processes began to have a negative impact on the work environment. These feelings were expressed as follows: ‘… there have been periods when we said that we must now stop and calm down…’. ‘Now we just make the most necessary revisions because we felt that we could not reach more… we needed a fresh start, we were tired’. The OTs felt exhausted and had to minimize the level of ambition and only make the most necessary improvements during a period. The OTs also questioned the previously appreciated guidance from the OTIPM and lacked the inspiration and motivation to continue.

Refining and renewing the working methods

The OTs described how the ongoing improvements had been normalized as daily routines in everyday life, but to maintain the improvement work, they had to regain inspiration and reshape the safe and well-known normality. They described how the lost inspiration led to a thirst for new knowledge and a search for renewal. During this period, only minor necessary updates were made, and the OTs switched between visions and necessary improvements. However, after refining and renewing their way of working, the OTs decided to continue their model-based improvement work. It was decided that the rather frequent meetings where routines and documents were revised felt unjustified as the way of working was normalized in practice. Now, fewer common meetings were planned with different content, such as updating assessment tools and routines. The process of questioning and looking for inspiration led not only to increased knowledge about implementation and improvement tools but also to refined working routines with even more structured content to ensure the sustainability of the quality improvement work. This was expressed as follows: ‘… we have had different ways of working (improvement work) … so we do not lose interest… having different ways of working (improvement work) is also important…we noticed that the previous way got slightly tough and switching to a new way provided more inspiration and the work could continue’. The OTs described further that they continued to build their new methods of working with quality improvement work based on the OTIPM, which they described as their main model.

Discussion

This study explored experiences of long-term work with quality improvements based on the OTIPM. Seventeen years after the onset, the OTIPM functioned as a sustainable framework, both for ordinary occupational therapy practice and for continuous improvement work. By the OTIPM, the OTs had accomplished a safe and well-known professional reasoning in which continuous quality improvement work was normalized. They also felt embedded in a collective understanding. Such coherence, or sense-making, where the expected benefits of changed working routines and personal responsibilities are collectively shared, has been described as a condition for normalization [9], which, in turn, is an important aspect of sustainability. Based on this study exploring 17 years of quality improvement work among OTs, it can be argued that the use of a practice model, such as the OTIPM, can be a valuable tool for sustainable intervention processes. Fisher and Martella [14] argue that the OTIPM can support OTs in occupational-centred reasoning and help them maintain their professional identity and be grounded in what they do. According to this study, the model-based improvement work guided the OTs in reviewing and critiquing their services in a way that strengthened both their professional role and their personal development.

The themes and related subthemes identified in this study describe components of sustainability in improvement work overtime. The findings may increase the understanding of how occupational therapy models for practice, such as the OTIPM, can lead to sustainable long-term improvement work in practice. The findings in our previous studies [17,18] both support and contribute to the understanding of OTIPM-based long-term improvement work. Referring to this study, the OTs achieved stability in ingrained reasoning based on the OTIPM. Change processes go through different phases and can require different times for implementation. To avoid crises in successful improvement processes, a motivated group is, among other things, a prerequisite for starting improvement work, but common goals and visions to root the changes in the culture are also important [22]. In the present study, these factors were achieved, but the OTs ended up in crisis anyway, i.e. described as phases of lost motivation and inspiration. Wilding and Whiteford [23] found that OTs working in a medical context found it difficult to be understood and to describe what occupational therapy is, which the OTs in this study also experienced at some times. However, the common vision and the use of the OTIPM in occupational-centred reasoning pushed them further despite the negative phases that arose. According to this study, the OTIPM served as a framework for professional reasoning and sustainability in long-term quality improvement work 17 years after its onset.

Methodological considerations

The current improvement work has been ongoing for over 17 years. The fact that over half of the OTs in the present study have been part of the improvement work since inception strengthened the data. Since OTs were asked to reflect on and describe their experiences with long-term improvement work, there may be a risk that their experiences were influenced by their memory and retrospective interpretations. It may have caused a weakness in the data to include the four OTs who had not participated since inception because they do not have experiences from the whole improvement process. However, all OTs had participated in the work for at least six years, which can be considered a long time. The two focus groups ended when the discussion of the subject was exhausted, indicating saturation [24] in the data. However, it is important to note that the results are based on a limited number of participants in a particular context. It is therefore up to the reader to decide if these findings are also transferable to other contexts. Since the first author was also involved in the improvement work, the focus-group interviews were conducted by the last author (KZ) to avoid inhibiting the participants from speaking freely. The authors, who came from different disciplines and had various experiences with improvement work, took different roles in the analysis process to increase the trustworthiness. Further research is needed to develop a broader understanding of how other models of practice can support long-term improvements in occupational therapy practice. To conclude, this study contributes to more knowledge that the continuous use of an integrated reasoning model such as the OTIPM can support implementation processes and the sustainability and normalization of long-term improvement work. The study can also provide insight into a new way of thinking about improvement work and the importance of OTs being able to complement occupational therapy theories with improvement and implementation theories to clarify and increase the quality of occupational therapy.

Acknowledgements

The authors are grateful to the occupational therapists who shared their experiences.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This research was financially supported by the Region of Norrbotten, Sweden. The authors are responsible for the content of the manuscript.