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BACKGROUND: The role of patients in healthcare research is slowly evolving, although patient roles in the research process are limited. This paper reports on a patient-led research project aiming to develop a musical hearing training programme for patients with a cochlear implant (CI): the Musi-CI programme. A CI is an inner ear prosthesis that allows people with severe hearing loss to hear. However, while speech can be understood, CI users cannot fully enjoy music or feel aversion to it. The Musi-CI programme aims to reduce this music aversion to ultimately improve music enjoyment and social participation. The development of the Musi-CI programme was supported by a consortium of professionals in CI rehabilitation and research. The aim of this paper is to describe and evaluate the Musi-CI programme development process and its impact on professional CI rehabilitation and research. METHODS: Programme development was described using a 3-layered process model of action research, distinguishing the CI user process, the healthcare professional process and the research process. To evaluate perceptions on the programme development process, consortium partners provided written comments and participated in a reflexive evaluation session that was video-recorded. Reflexive evaluation aims for collective learning and strengthening collaboration among participants. Written comments and video data were analysed using template analysis. RESULTS: The involvement of an expert by experience was perceived as challenging but rewarding for all consortium partners, opening up new perspectives on CI-rehabilitation practice and research. Data analysis revealed two themes on the programme development process, professional space and acknowledgement, and two themes on the outcomes on CI rehabilitation and research: critical reflection and paradigm shift. CONCLUSION: Experts by experience represent a different knowledge domain that may contribute to change in rehabilitation and research. PATIENT OR PUBLIC CONTRIBUTION: The development of the programme was initiated by a professional musician and CI user who organized the funding, had a leading role throughout the research process, including the write-up of the results, and co-authored this paper.

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A cochlear implant (CI) is a prosthesis that allows people with severe to profound hearing loss to understand speech in quiet settings. However, listening to music presents a challenge to most CI users; they often do not enjoy music or avoid it altogether. The Musi-CI training course was developed for CI users with the goal of reducing music aversion and improving music enjoyment. A consortium was established consisting of a professional musician with CI, CI rehabilitation professionals and researchers. Participatory action research (PAR) was applied to develop and evaluate the training experiences, collaborating with 37 CI users during three cycles of eight training sessions, each held over a period of 3 months. Input and feedback were collected after each training session using questionnaires, observations and focus group interviews. Almost all participants (86%) completed the training. After completing the training a large majority of participants reported increased music appreciation, increased social participation in musical settings and a positive impact on general auditory perception. The resulting Musi-CI training programme focuses on music listening skills, self-efficacy, and self-motivation. It consists of exercises intended to strengthen attention and working memory, to improve beat and rhythm perception (with online rhythm exercises) and exercises to distinguish timbre of instruments and emotion in music. A Melody Game was developed to improve pitch and melodic contour discrimination.

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BACKGROUND: A quality framework for hospital-based physiotherapy is lacking. This study aims to design a framework, building on the currently available literature, to improve the quality of hospital-based physiotherapy. METHODS: A multidisciplinary panel of six representatives of hospital-based physiotherapy and their key stakeholders (patients, medical specialists, hospital management and professional association) was set up. We used brainwriting to sample ideas and the 'decision-matrix' to select the best ideas. RESULTS: The first round of brainwriting with an online panel of six experienced participants yielded consensus on seven possible methods for quality improvement of hospital-based physiotherapy [1]: continuing education [2] ,feedback on patient reported experience measures and patient reported outcome measures [3] ,a quality portfolio [4] ,peer observation and feedback [5] ,360 degree feedback [6] ,a management information system, and [7] intervision with intercollegiate evaluation. Placing these methods in a decision matrix against four criteria (measurability, acceptability, impact, accessibility) resulted in a slight preference for a management information system, with almost equal preference for five other methods immediately thereafter. The least preference was given to a 360-degree feedback. CONCLUSIONS: In the design of a framework for improving the quality of hospital-based physiotherapy, all seven suggested methods were perceived as relevant but differed in terms of advantages and disadvantages. This suggests that, within the framework, a mixture of these methods may be desirable to even out respective advantages and disadvantages.

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INTRODUCTION: The tracer method, commonly used for quality assessment, can also be used as a tool for peer observation and formative feedback on professional development. This scoping review describes how, by whom, and with what effect the tracer method is applied as a formative professional development instrument between healthcare professionals of equal status and aims to identify the types of scientific evidence for this use of the tracer method. METHODS: The authors searched four electronic databases for eligible articles, which were screened and assessed for eligibility by two independent researchers. From eligible studies, data were extracted to summarize, collate, and make a narrative account of the findings. RESULTS: The electronic search yielded 1757 unique studies, eight of which were included as valid and relevant to our aim: five qualitative, two mixed methods, and one quantitative study. Seven studies took place in hospitals and one in general practice. The tracer method was used mainly as a form of peer observation and formative feedback. Most studies evaluated the tracer method's feasibility and its impact on professional development. All but one study reported positive effects: participants described the tracer method generally as being valuable and worth continuing. DISCUSSION: Although the body of evidence is small and largely limited to the hospital setting, using the tracer method for peer observation and formative feedback between healthcare professionals of equal status appears sufficiently useful to merit further rigorous evaluation and implementation in continuous professional development in healthcare.

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Purpose: This study evaluated the impact of a quality improvement programme based on self- and peer assessment to justify nationwide implementation. Method: Four professional networks of physiotherapists in The Netherlands (n = 379) participated in the programme, which consisted of two cycles of online self-assessment and peer assessment using video recordings of client communication and clinical records. Assessment was based on performance indicators that could be scored on a 5-point Likert scale, and online assessment was followed by face-to-face feedback discussions. After cycle 1, participants developed personal learning goals. These goals were analyzed thematically, and goal attainment was measured using a questionnaire. Improvement in performance was tested with multilevel regression analyses, comparing the self-assessment and peer-assessment scores in cycles 1 and 2. Results: In total, 364 (96%) of the participants were active in online self-assessment and peer assessment. However, online activities varied between cycle 1 and cycle 2 and between client communication and recordkeeping. Personal goals addressed client-centred communication (54%), recordkeeping (24%), performance and outcome measurement (15%), and other (7%). Goals were completely attained (29%), partly attained (64%), or not attained at all (7%). Self-assessment and peer-assessment scores improved significantly for both client communication (self-assessment = 11%; peer assessment = 8%) and recordkeeping (self-assessment = 7%; peer assessment = 4%). Conclusions: Self-assessment and peer assessment are effective in enhancing commitment to change and improving clinical performance. Nationwide implementation of the programme is justified. Future studies should address the impact on client outcomes.

Objectif : évaluer les répercussions d'un programme d'amélioration de la qualité reposant sur l'autoévaluation et l'évaluation par les pairs pour en justifier la mise en œuvre nationale. Méthodologie : quatre réseaux professionnels de physiothérapeutes des Pays-Bas (n=379) ont participé au programme, composé de deux cycles d'autoévaluation en ligne et d'évaluation par les pairs à l'aide d'enregistrements vidéo des communications des clients et des dossiers cliniques. L'évaluation était fondée sur des indicateurs de la performance qui pouvaient être cotés sur une échelle de Likert de cinq points, et l'évaluation en ligne était suivie de rencontres de rétroaction. Après le cycle 1, les participants se sont donné des objectifs d'apprentissage personnel. Les chercheurs ont évalué ces objectifs par thème et en ont mesuré l'atteinte au moyen d'un questionnaire. Ils ont vérifié l'amélioration de la performance à l'aide d'analyses de régression multiniveaux et ont comparé les cotes d'autoévaluation et d'évaluation par les pairs des cycles 1 et 2. Résultats : au total, 364 des participants (96 %) étaient actifs dans l'autoévaluation en ligne et l'évaluation par les pairs. Cependant, les activités en ligne variaient entre le cycle 1 et le cycle 2 et entre les communications avec le client et la tenue de dossier. Les objectifs personnels portaient sur les communications axées sur le client (54 %), la tenue de dossiers (24 %), les mesures de la performance et des résultats cliniques (15 %) et d'autres points (7 %). Les objectifs étaient complètement atteints (29 %), partiellement atteints (64 %) ou pas du tout atteints (7 %). Les cotes d'autoévaluation et d'évaluation par les pairs s'amélioraient sensiblement dans les secteurs des communications avec le client (autoévaluation = 11 %; évaluation par les pairs = 8 %) et de la tenue de dossiers (autoévaluation = 7 %; évaluation par les pairs = 4 %). Conclusions : l'autoévaluation et l'évaluation par les pairs sont efficaces pour accroître la volonté de changer et améliorer la performance clinique. La mise en œuvre nationale du programme est justifiée. De futures études devraient aborder les répercussions de ce programme sur les résultats cliniques des clients.

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BACKGROUND: In 2013, the Royal Dutch Society for Physical Therapy launched the program "Quality in Motion." This program aims to collect data from electronic health record systems in a registry that is fed back to physical therapists, facilitating quality improvement. PURPOSE: The purpose of this study was to describe the development of an implementation strategy for the program and to evaluate the feasibility of building a registry and implementing patient-reported outcome measures (PROMs) in physical therapist practices. METHODS: A stepwise approach using mixed methods was established in 3 consecutive pilots with 355 physical therapists from 66 practices. Interim results were evaluated using quantitative data from a self-assessment questionnaire and the registry and qualitative data from 21 semistructured interviews with physical therapists. Descriptive statistics and McNemar's symmetry chi-squared test were used to summarize the feasibility of implementing PROMs. RESULTS: PROMs were selected for the 5 most prevalent musculoskeletal conditions in Dutch physical therapist practices. A core component of the implementation strategy was the introduction of knowledge brokers to support physical therapists in establishing the routine use of PROMs in clinical practice and to assist in executing peer assessment workshops. In February 2013, 30.3% of the physical therapist practices delivered 4.4 completed treatment episodes per physical therapist to the registry; this increased to 92.4% in November 2014, delivering 54.1 completed patient episodes per physical therapist. Pre- and posttreatment PROM use increased from 12.2% to 39.5%. LIMITATIONS: It is unclear if the participating physical therapists reflect a representative sample of Dutch therapists. CONCLUSION: Building a registry and implementing PROMs in physical therapist practices are feasible. The routine use of PROMs needs to increase to ensure valid feedback of outcomes. Using knowledge brokers is promising for implementing the program via peer assessment workshops.

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OBJECTIVES: To evaluate the feasibility of a quality improvement programme aimed to enhance the client-centeredness, effectiveness and transparency of physiotherapy services by addressing three feasibility domains: (1) acceptability of the programme design, (2) appropriateness of the implementation strategy and (3) impact on quality improvement. DESIGN: Mixed methods study. PARTICIPANTS AND SETTING: 64 physiotherapists working in primary care, organised in a network of communities of practice in the Netherlands. METHODS: The programme contained: (1) two cycles of online self-assessment and peer assessment (PA) of clinical performance using client records and video-recordings of client communication followed by face-to-face group discussions, and (2) clinical audit assessing organisational performance. Assessment was based on predefined performance indicators which could be scored on a 5-point Likert scale. Discussions addressed performance standards and scoring differences. All feasibility domains were evaluated qualitatively with two focus groups and 10 in-depth interviews. In addition, we evaluated the impact on quality improvement quantitatively by comparing self-assessment and PA scores in cycles 1 and 2. RESULTS: We identified critical success features relevant to programme development and implementation, such as clarifying expectations at baseline, training in PA skills, prolonged engagement with video-assessment and competent group coaches. Self-reported impact on quality improvement included awareness of clinical and organisational performance, improved evidence-based practice and client-centeredness and increased motivation to self-direct quality improvement. Differences between self-scores and peer scores on performance indicators were not significant. Between cycles 1 and 2, scores for record keeping showed significant improvement, however not for client communication. CONCLUSIONS: This study demonstrated that bottom-up initiatives to improve healthcare quality can be effective. The results justify ongoing evaluation to inform nationwide implementation when the critical success features are addressed. Further research is necessary to explore the sustainability of the results and the impact on client outcomes in a full-scale study.

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BACKGROUND: Clinical practice guidelines are intended to improve the process and outcomes of patient care. However, their implementation remains a challenge. We designed an implementation strategy, based on peer assessment (PA) focusing on barriers to change in physical therapy care. A previously published randomized controlled trial showed that PA was more effective than the usual strategy "case discussion" in improving adherence to a low back pain guideline. Peer assessment aims to enhance knowledge, communication, and hands-on clinical skills consistent with guideline recommendations. Participants observed and evaluated clinical performance on the spot in a role-play simulating clinical practice. Participants performed three roles: physical therapist, assessor, and patient. This study explored the critical features of the PA program that contributed to improved guideline adherence in the perception of participants. METHODS: Dutch physical therapists working in primary care (n = 49) organized in communities of practice (n = 6) participated in the PA program. By unpacking the program we identified three main tasks and eleven subtasks. After the program was finished, a questionnaire was administered in which participants were asked to rank the program tasks from high to low learning value and to describe their impact on performance improvement. Overall ranking results were calculated. Additional semi-structured interviews were conducted to elaborate on the questionnaires results and were transcribed verbatim. Questionnaires comments and interview transcripts were analyzed using template analysis. RESULTS: Program tasks related to performance in the therapist role were perceived to have the highest impact on learning, although task perceptions varied from challenging to threatening. Perceptions were affected by the role-play format and the time schedule. Learning outcomes were awareness of performance, improved attitudes towards the guideline, and increased self-efficacy beliefs in managing patients with low back pain. Learning was facilitated by psychological safety and the quality of feedback. CONCLUSION: The effectiveness of PA can be attributed to the structured and performance-based design of the program. Participants showed a strong cognitive and emotional commitment to performing the physical therapist role. That might have contributed to an increased awareness of strength and weakness in clinical performance and a motivation to change routine practice.

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BACKGROUND: Clinical practice guidelines (CPGs) are not readily implemented in clinical practice. One of the impeding factors is that physical therapists do not hold realistic perceptions of their adherence to CPGs. Peer assessment (PA) is an implementation strategy that aims at improving guideline adherence by enhancing reflective practice, awareness of professional performance, and attainment of personal goals. OBJECTIVE: The purpose of this study was to compare the effectiveness of PA with the usual case discussion (CD) strategy on adherence to CPGs for physical therapist management of upper extremity complaints. DESIGN: A single-masked, cluster-randomized controlled trial with pretest-posttest design was conducted. INTERVENTION: Twenty communities of practice (n=149 physical therapists) were randomly assigned to groups receiving PA or CD, with both interventions consisting of 4 sessions over 6 months. Both PA and CD groups worked on identical clinical cases relevant to the guidelines. Peer assessment focused on individual performance observed and evaluated by peers; CD focused on discussion. OUTCOMES: Guideline adherence was measured with clinical vignettes, reflective practice was measured with the Self-Reflection and Insight Scale (SRIS), awareness of performance was measured via the correlation between perceived and assessed improvement, and attainment of personal goals was measured with written commitments to change. RESULTS: The PA groups improved more on guideline adherence compared with the CD groups (effect=22.52; 95% confidence interval [95% CI]=2.38, 42.66; P=.03). The SRIS scores did not differ between PA and CD groups. Awareness of performance was greater for the PA groups (r=.36) than for the CD groups (r=.08) (effect=14.73; 95% CI=2.78, 26.68; P=.01). The PA strategy was more effective than the CD strategy in attaining personal goals (effect=0.50; 95% CI=0.04, 0.96; P=.03). LIMITATIONS: Limited validity of clinical vignettes as a proxy measure of clinical practice was a limitation of the study. CONCLUSIONS: Peer assessment was more effective than CD in improving adherence to CPGs. Personal feedback may have contributed to its effectiveness. Future research should address the role of the group coach.

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BACKGROUND: Peer Assessment (PA) in health professions education encourages students to develop a critical attitude towards their own and their peers' performance. We designed a PA task to assess students' clinical skills (including reasoning, communication, physical examination and treatment skills) in a role-play that simulated physical therapy (PT) practice. Students alternately performed in the role of PT, assessor, and patient. Oral face-to-face feedback was provided as well as written feedback and scores.This study aims to explore the impact of PA on the improvement of clinical performance of undergraduate PT students. METHODS: The PA task was analyzed and decomposed into task elements. A qualitative approach was used to explore students' perceptions of the task and the task elements. Semi-structured interviews with second year students were conducted to explore the perceived impact of these task elements on performance improvement. Students were asked to select the elements perceived valuable, to rank them from highest to lowest learning value, and to motivate their choices. Interviews were transcribed verbatim and analyzed, using a phenomenographical approach and following template analysis guidelines. A quantitative approach was used to describe the ranking results. RESULTS: Quantitative analyses showed that the perceived impact on learning varied widely. Performing the clinical task in the PT role, was assigned to the first place (1), followed by receiving expert feedback (2), and observing peer performance (3). Receiving peer feedback was not perceived the most powerful task element.Qualitative analyses resulted in three emerging themes: pre-performance, true-performance, and post-performance triggers for improvement. Each theme contained three categories: learning activities, outcomes, and conditions for learning.Intended learning activities were reported, such as transferring prior learning to a new application context and unintended learning activities, such as modelling a peer's performance. Outcomes related to increased self-confidence, insight in performance standards and awareness of improvement areas. Conditions for learning referred to the quality of peer feedback. CONCLUSIONS: PA may be a powerful tool to improve clinical performance, although peer feedback is not perceived the most powerful element. Peer assessors in undergraduate PT education use idiosyncratic strategies to assess their peers' performance.

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