The International Committee of the Red Cross (ICRC) works in fragile environments where ensuring quality of services is challenging and resources are often limited. As stated in its current Health Strategy, the ICRC aims to provide ‘the highest possible quality of care in line with appropriate standards that are adapted to the specific contexts’. The ICRC strategy to assure health care for people affected by armed conflict and other situations of violence OP_ASSIST_CHF 14/00012. Our physical therapy practice is aligned with the World Confederation of Physical Therapy (WCPT)’s scope of practice WCPT, Guideline for Standards of Physical Therapy Practice, World Confederation of Physical Therapy, London, 2011, http://www.wcpt.org/sites/wcpt.org/files/files/Guideline_standards_practice_complete.pdf. for direct patient care and other activities, such as supervision, management and teaching. This article outlines the development of ICRC physical therapy standards specific to humanitarian settings.
Physical therapy (PT) is a process, and decisions about therapeutic interventions are negotiated between the therapist and the patient/service user. Each patient’s experience will be unique, so PT can be difficult to measure, and attention is normally focused on clinical outcomes. The ICRC Physical Rehabilitation Programme (PRP) has explored how the quality of physiotherapy interventions themselves might be measured. ICRC physical therapists have been trained in many different countries and healthcare systems and work in the most challenging contexts. This means that PT interventions are likely to be highly variable across different field situations, and outcomes are difficult to measure in a valid and reliable way.
This project aimed to achieve a threshold standard of quality physiotherapeutic input, as the first step in improving PT outcomes for service users in ICRC-supported projects. Phase one ran over two years. The following activities were undertaken:
- A literature review and mapping exercise
- Creation and review of the standards
- A gap analysis
- Development of tools to support implementation of the standards and quality measurement
- Design of an implementation plan
- Standards launch
The literature review was conducted to establish an international context for this work. It found that, while little has been written about PT standards, they are embedded in PT practice in advanced healthcare systems, setting a threshold of quality and standardising interventions and information collection. The review therefore confirmed that the project was appropriate and should be undertaken
A number of different sets of standards have been developed by national physiotherapy professional associations and the WCPT. Rather than adopt internationally accepted standards in their entirety, they were instead used as a basis for an ICRC-derived set adapted to the humanitarian context. A mapping exercise was conducted to identify commonalities across standard sets, the results of which were used as a baseline for the development of a first draft. The draft was produced by consultants working with physiotherapy technical advisors from ICRC headquarters.
The project consultants presented their findings at a workshop in Geneva with expatriate physiotherapists from various field locations, including Iraq, Pakistan, Ethiopia and Tanzania. Proposed standards were discussed at length, and arranged in three layers: those which could be achieved by all ICRC PTs in all circumstances; those which could be achieved by some PTs in some circumstances; and those which were aspirational. The standards were then reworded, revised and some eliminated until 23 remained which were all achievable by all PTs. They were then circulated more widely, sense-checked and revised to ensure that ICRC PT would work for all contexts and teams.
Once a final set of standards had been agreed, a gap analysis was carried out involving 33 physiotherapists in 17 countries. A. Binks, B. Rau and L. Holey, ‘ICRC Gap Analysis of Physiotherapy Standards Special Interest Poster Presentation World Confederation of Physical Therapy Congress’, Physiotherapy 101 (Supl. 1), May 2015, http://www.physiotherapyjournal.com/article/S0031-9406(15)00330-2/fulltext. The standards were explained and the therapists asked to what extent they met each standard. The responses were quantified to produce data in the form of a ‘snap shot’ of the standard of PT in ICRC-supported projects at that time. The results indicated that the standards were appropriate, and provided an initial baseline of compliance against which to benchmark future improvement. They also identified the priorities for training as assessment and treatment of the patient, the relationship with the service user and lifelong learning.
In a subsequent workshop, which included new participants working in Tajikistan and Burundi, the standards were revised again, to ensure that they were worded clearly. A story-board approach was used to sketch the journey of a therapist, from joining the ICRC to completing a field mission. The points on that journey where quality could be measured in a streamlined way were identified, along with the tools needed to support implementation of the standards and measure quality. Where possible, tools already in use were included, rather than adding more bureaucracy. Participants were trained in project planning, implementation planning and stakeholder management.
Phase one of the standards project (development) was completed with the testing of key tools in a physical rehabilitation clinic in rural Cambodia. A pilot launch of the standards was held in Phnom Penh, Cambodia, by staff from ICRC headquarters and consultants, with ICRC national and expatriate participants from across the regions. The Cambodian PT association was enthusiastic and keen to collaborate and, with the approval of the Cambodian Ministries of Social Affairs, Veterans and Youth and Health, has been chosen as the first implementation site. This project is particularly relevant to Cambodia, as it complements a request from a Cambodian university for ICRC support for the development of PT education and training.
There are two key challenges to this type of work in humanitarian settings. The first is ensuring that centrally driven change is fully appropriate to all contexts, and the second is ensuring sustainability. This project is a working example of a transferable process designed with both applicability and sustainability in mind. Successful implementation depends on whether the standards really will work in highly variable field situations, a thorough understanding of the standards and the energy and determination of the workshop participants to drive phase two of the project forward. In-depth contributions from the field foster engagement and ownership to ensure that the work will have a sustained impact.
How was this achieved?
- Organisational cohesiveness
Projects are more likely to be successful when they sit well within the other priorities and policies of the organisation. This process followed the ICRC project management cycle:
This meant that everyone involved in the project could follow it, and understood where their individual involvement fitted into the whole. Each step of the project considered and was clearly related to service users, physiotherapists and physiotherapy services/institutions. This highlights the relevance and potential impact of the initiative for all participants. The project planning cycle and the three-level approach (service user, physiotherapist, service) have also been used to formulate regional implementation plans.
- Situated learning and problem-solving
Learning from the field was used to systematically deconstruct centrally derived ideas and ensure that PT standards could be embedded across all ICRC-supported projects in all contexts. The standards went through a number of changes until consensus was reached. The process by which the outcomes were achieved was seen as a vital element in sustainability and recognising the theoretical models on which our approach was based helps our understanding of why it was effective. The scoping and drafting of the standards was regarded as a very preliminary step. More important was the way in which concepts were tested and deconstructed by workers from the field, who were able to use learning from their own contexts to shape the standards. This situated learning and problem-solving was vital to making sure that the standards and tools for implementation would be appropriate for all PTs in all contexts. This type of applied learning challenges assumptions and is developed through interaction with others.
- Collaborative reasoning and transformative learning
The group experience in the workshops was another central plank in the process. Collaborative reasoning arose naturally when the participants discussed their ideas and experiences and supported and challenged each other, and they made better decisions because of this collaboration. Learning eventually became transformative. Participants’ expectations were raised and their acceptance of the importance and achievability of the project gradually deepened.
These three elements of the process maximised engagement and ownership by using previous learning, and through new ways of learning and collaborative problem-solving. The experience took the workshop participants through a collaborative challenge to previous thinking and ways of working.
The development phase of the ICRC PT standards lasted two years, and involved collaboration between field and headquarters as well as support from academic consultants, all of which was highly valued. The 23 standards, and the related manual and tools, ensure that quality of care is consistent across all levels (patient, physiotherapist and PT service/institution).5 They will also provide ICRC with useful qualitative and quantitative data to assess the services given, as well as providing accountability to donors when requested. At the end of the Cambodian workshop participants tested the tools, and feedback after nine months showed that they were user-friendly for various skilled professionals and transferable to different settings (e.g. hospitals and physical rehabilitation centres). The standards were widely discussed by professionals involved in physiotherapy services (e.g. managers, nurses, orthotist prosthetists). The next stage of the project involves dissemination of the standards across more than 20 contexts, from Afghanistan to Yemen.
The ICRC PT standards are international standards adapted to the humanitarian context. They standards cover all aspects of PT practice: respect for the individual, informed consent, confidentiality, assessment, analysis and treatment planning, implementation, evaluation, transfer/discharge, communication, data management, physical environment and safety of the service user and physiotherapist, lifelong learning, human resources, professional conduct and quality improvement. Each standard is specific and measurable, and an explanation is provided. A strong foundation has been laid for phase two of the project (implementation). Impact evaluation will be necessary to maximise learning from the initiative. The process is both replicable and transferable to other professions and other humanitarian organisations in a context where physiotherapy is often still poorly recognised and valued.
Barbara Rau is physiotherapy advisor at ICRC headquarters, and coordinated the project reported on here. Professor Liz Holey is a consultant, chartered physiotherapist and professor emeritus. The authors would like to acknowledge the contributions of Anne Binks, Associate Dean, Teesside University in the UK, and the ICRC physiotherapists and colleagues who participated in the development phase of the project.