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Original Article

Using Quality Improvement for Refining Program Materials for Exercise Promotion in Comprehensive Multiple Sclerosis Care

Fifolt, Matthew; Richardson, Emma V.; Barstow, Elizabeth A.; Motl, Robert W.

Author Information
doi: 10.1097/JHQ.0000000000000279

Abstract

Introduction

Multiple sclerosis (MS) is a chronic, neurodegenerative condition whereby an immune-mediated response within genetically susceptible persons causes demyelination and transection of axons in the brain, brain stem, spinal cord, and optic nerves.1 The resulting damage, depending on its location, causes a multitude of physical, cognitive, and psychological symptoms.2 Currently, there is no cure for MS. Disease-modifying therapies only slow the rate of eventual progression of the disease3 and might not influence physical, cognitive, and psychological symptoms. This supports the importance of secondary, complementary treatment options for managing the residual effects of MS.

Exercise is a safe and efficacious approach for managing many of the physical, cognitive, and psychological symptoms of MS.4-6 Nevertheless, fewer than 20% of persons with MS engage in sufficient amounts of exercise necessary for accrual of the benefits.7 One reason for this lack of engagement involves the gap between evidence-based knowledge of exercise benefits and the translation of these benefits among persons with MS within clinical practice.8 Indeed, persons with MS often receive conflicting information about exercise, its safety, and benefits from healthcare providers (HCPs).9 Health care providers have further discussed not having sufficient time, training, resources, or expertise for promoting and discussing exercise with patients.10 This presents a significant gap regarding effectively managing MS through exercise promotion in a systematic, rigorous process within the patient–provider interactions. This article describes a healthcare quality improvement initiative using a Plan-Do-Study-Act (PDSA) cycle, and specifically represents the second cycle of a PDSA ramp to assess and improve previously developed program materials11 based on feedback from a more diverse group of HCPs. The empirical grounding for the program materials under investigation is outlined below.

Background of Program Material Development

Researchers initiated a process of inquiry through two qualitative research studies that explored needs and wants of persons with MS and HCPs (i.e., neurologists, nurses, physical therapists [PTs], and occupational therapists [OTs]) regarding exercise promotion in comprehensive MS care.10,12 Persons with MS expressed a need for (1) information and knowledge on the benefits of exercise and exercise prescription, (2) materials that facilitated home and community exercise, and (3) tools for initiating and maintaining exercise behavior.12 Healthcare providers expressed a need for (1) opportunities for exercise promotion through the healthcare system, (2) education on exercise for persons with MS, and (3) tools and strategies that would help promote exercise among persons with MS.12 This formative, qualitative research informed the design of a conceptual model13 that underwent multiple degrees of evaluation through the lens of patients14 and providers.15 Authors crafted a final conceptual model that patients and providers perceived was a strong representation of exercise promotion through the patient–provider interaction in comprehensive MS care, namely, the “Exercise Promotion Conceptual Model in MS.”15

The Exercise Promotion Conceptual Model in MS involves three hierarchically organized, interactive layers representing (1) the necessary exercise promotion training HCPs require; (2) the interactive, dynamic exercise consultation between the patient and provider that prepares the patient for exercise; and (3) ongoing support patients receive from HCPs regarding the initiation and long-term maintenance of exercise behavior. These three layers support the ultimate goal of shifting the distribution of exercise participation among people with MS.

The next stage of development in this line of research involved the design and improvement of tools that translate the conceptual model into practice (i.e., practice models and a quick screening tool) through the adoption of a quality improvement (QI) approach. One of the most commonly used tools in QI is the PDSA methodology.16,17 A PDSA cycle represents an approach to generate knowledge and gain support for changes by testing them before implementation.18 This iterative, four-step model allows program planners to predict outcomes (Plan), test change ideas (Do), analyze results (Study), and determine appropriate next steps (Act).19 A PDSA ramp occurs when multiple, related PDSA cycles are conducted to test a common change strategy. The goal of a PDSA ramp is to learn quickly and make adjustments to increase the chances of delivering and sustaining the desired improvement.20 Plan-Do-Study-Act cycles rely on rapid testing among a small number of specific individuals relative to the context of the implementation setting to collect just enough data to select one of three outcomes as follows: adopt, adapt, or abandon the change idea.21,22

Researchers evaluated the first set of practice models and a quick screening tool using a PDSA ramp.11 The first cycle of the PDSA ramp involved 20 HCPs (five neurologists, five nurses, five PTs, and five OTs) who completed an online survey containing a Likert (0–5) scale, percentage, and short answer questions about the models.11 Collectively, HCPs perceived the practice models and quick screening tool as useful resources for promoting exercise within comprehensive MS care but recommended further improvement and refinement. Healthcare providers posited ideas for improving and modifying the materials, namely, direct referrals to PT/OT rather than the nurse; contextualizing the models within the Exercise Promotion Conceptual Model in MS; providing information regarding training and resources for neurologists, nurses, PTs, and OTs; and providing information regarding community support. These recommendations resulted in the current, revised practice models and quick screening tool (i.e., the first outcome of the PDSA ramp was to adapt the change idea). This article describes the second cycle (Cycle 2) of the PDSA ramp through evaluation of these adapted practices models and quick screening tool.

Methods

Study Design

We used Qualtrics, an online survey platform, to collect QI data from HCPs for revising practice models and the quick screening tool necessary for promoting exercise in comprehensive MS care. This research was approved by the University of Alabama at Birmingham institutional review board: IRB-300002674.

Recruitment and Data Collection

The online survey link was made available to HCPs through multiple channels, including an announcement within a National MS Society (NMSS) newsletter; an email blast among HCPs registered with the NMSS (approximately 1,386 recipients); and printed announcement cards (100) distributed by the second author at the 2019 Consortium of MS Centers Conference in Seattle, Washington. Survey responses were received between May 31, 2019 and September 10, 2019.

The online survey comprised seven blocks of questions, including an informed consent page. Demographic questions ascertained participant age, sex, profession, years of experience, and location. These questions were followed by scenario-based questions containing a Likert scale (0–5), percentage, and open-ended questions regarding (1) HCP's perceptions of program materials, (2) how program materials could be implemented, (3) resources/trainings needed to implement program materials, and (4) ideas for improving program materials. Questions specifically focused on clarity, reliability, and appropriateness of tasks based on professional roles. The online survey with program logic is provided as Supplemental Digital Content, http://links.lww.com/JHQ/A120.

Participants

The sample included the following 11 HCPs: three neurologists, two nurses, three PTs, and three OTs, who represented eight states in the United States (1 North; four West; four South; and two East). Neurologists included one man and two women, with ages ranging between 44 and 61 years (mean age = 54.7 years). Neurologists' years of experience ranged between 14 and 32 years (mean years = 26). Nurses included two women. Nurses did not report ages but reported years of experience that ranged between 12 and 20 years (mean years = 16). Physical therapists included one man and two women. Physical therapists' ages ranged between 34 and 62 years (mean age = 50.7) with years of experience ranging between 10 and 40 years (mean years = 25.7). Occupational therapists included three men. Occupational therapists' ages ranged between 32 and 55 years (mean age = 41.7) with years of experience ranging between 7 and 15 years (mean years = 11.7).

Data Analysis

The original study design for this research was based on analytical eclecticism23; that is, approaches that consciously address substantive elements of scholarship from different research traditions. Because of a low response rate, however, we focused our efforts on applied content analysis to convert participant feedback into refined, improved versions of the practices models and quick screening tool. Copies of program materials are presented in Figures 1–4.

Figure 1.
Figure 1.:
Quick screen process for exercise promotion.
Figure 2.
Figure 2.:
Exercise in Medicine: Model 1.
Figure 3.
Figure 3.:
Exercise in Medicine: Model 2.
Figure 4.
Figure 4.:
Exercise in Medicine: Model 3.

Results

Participation in this study was lower than anticipated; 22 individuals accessed the survey and provided consent but only 11 completed the survey in full. The research team agreed that partial completions did not meet the necessary threshold for inclusion as data. Nevertheless, responses represented an even distribution of HCPs across disciplines and yielded insights from individuals who could meaningfully evaluate the practice models and quick screening tool. As discussed in the QI literature, the number of respondents in a PDSA cycle is not as important as the quality of responses.24

Quick Screening Tool

The quick screening tool (Figure 1) depicts a decision tree for HCPs to follow in making recommendations for patients regarding an appropriate exercise promotion model. The vertical column on the left hand side presents a series of questions regarding patient readiness and ability to engage in exercise. Based on patient data, HCPs have the option to check-in with patients at a subsequent visit or make recommendations to Model 1 (minimal HCP intervention), Model 2 (moderate HCP intervention), or Model 3 (significant HCP intervention).

Healthcare providers answered questions about clarity, relatability, and roles and responsibilities in comprehensive MS care and offered five suggestions for improvement to the quick screening tool. Recommendations focused on conciseness and navigation of the tool, previous and current patient history with exercise, and appropriateness of roles and responsibilities. For example, regarding patient history with exercise, PT 1 observed, “One addition which may be helpful would be add a question about history with exercise…and current exercise.” In terms of roles and responsibilities, PT 2 stated, “In an office where a nurse is available, it may make more sense for the nurse to conduct the screen, but if the neurologist would do it, it would signify a priority.” A full list of HCPs suggestions for the quick screening tool and Models 1–3 is available in Table 1.

Table 1. - Healthcare Providers Suggestions for Improvement to Program Materials
Material Healthcare provider improvement suggestion
Quick screener Too wordy. I had to read the boxes on the left several times to fully understand the difference in them. Small bullets are better (Neuro 1)
“It would help if you put within the ‘follow Model 3’ box where the information is located” (Neuro 3)
“If we treat the whole person, then it fits into comprehensive care time if a factor could be this is delegated to the RN’ (Nurse 2)
One addition which may be helpful would be add a question about history with exercise…and current exercise (PT 1)
In an office where a nurse is available, it may make more sense for the nurse to conduct the screen, but if the neurologist would do it, it would signify a priority (PT 2)
Model 1 “Similar to prior answers, relying on neurologists to actually do an evaluation and referral is the main weakness” (Neuro 2)
‘For referral, delegate this strategy to the RN’ (Nurse 1)
Model 2 “This is too complex for a routine MS follow-up of new patient visit. We have just a couple minutes to discuss therapies as we also have 10+ other symptomatic and disease-modifying therapy issues to address per visit. If someone other than the neurologist has time to do this then it may work.” (Neurologist 1)
“We have a comprehensive MS center but PT etc is not on site (separate building) and I can only see this working if we saw patients in parts of the same visit.” (Neuro 3)
“As before it is a little busy. If someone is interested in implementing then it is clear and straightforward, but those for whom it is not a priority it may be too busy. Would prefer checklist format” (Nurse 1)
Model 3 “I feel this scenario is more in line with how neurologists refer for exercise/rehab so there would not be as much of a barrier.” (PT 1)
“Better clarity of OT/PT roles and how to determine exercise intensity based upon MS phenotype.” (PT 2)
“Why does the nurse refer to the local PT and not OT (OT 1)”

Practice Model 1

Model 1 (Figure 2) depicts a course of exercise promotion for patients with MS who require minimal HCP intervention. In this scenario, the neurologist takes the lead by discussing with the patient the concept of exercise as a form of therapy for managing MS, and “hands off” the patient to a nurse for a more in-depth consultation. In addition, nurses provide patients with an exercise toolkit (to be provided by the Exercise Neuroscience Research Laboratory [ENRL], the University of Alabama at Birmingham). Healthcare providers offered two suggestions for improvement to Model 1, both related to roles. Nurse 1 stated, “For referral, delegate this strategy to the RN”. Neurologist 2 stated, “…relying on neurologists to actually do an evaluation and referral is the main weakness (of Model 1).”

Practice Model 2

Model 2 (Figure 3) depicts a course of exercise promotion for patients that require moderate HCP intervention before engaging in exercise independently. In Model 2, a patient expresses an interest in exercise and has insurance for HCP intervention but also has mild physical/cognitive/sensory deficits that require short-term HCP intervention. Once again, the neurologist initiates a discussion with the patient about the concept of exercise as a form of therapy for MS and “hands off” the patient to the nurse. The nurse, however, plays a more active role by deciding if the patient needs PT/OT intervention before engaging in independent exercise. In this scenario, the neurologist orders the referral but the nurse manages it. The role of PT/OT is to assess physical deficits and work with the patient until they are able to safely engage in exercise. Physical therapists/OTs provide the exercise promotion toolkit when the patient is ready and then refer the patient to the ENRL for ongoing support.

Healthcare providers proposed three suggestions to improve Model 2. All three recommendations highlighted relatability issues in terms of implementation; one of the three recommendations included a comment about HCP roles and responsibilities. Specifically, Neurologist 1 stated,

“This is too complex for a routine MS follow-up of new patient visit. We have just a couple minutes to discuss therapies as we also have 10+ other symptomatic and disease modifying-therapy issues to address per visit. If someone other than the neurologist has time to do this then it may work”.

Practice Model 3

Model 3 (Figure 4) depicts the course of exercise promotion for patients that require significant HCP intervention before engaging in exercise independently. In Model 3, a patient expresses an interest in exercise and has insurance for HCP intervention but has moderate physical/cognitive/sensory deficits that require longer, intensive HCP intervention. Healthcare providers roles and responsibilities in Model 3are the same as Model 2, but HCPs expect that patient deficits will be more severe and require a longer intervention plan. The role of PTs and OTs is to ensure that patients are ready to engage in exercise safely. Throughout the process, patients are supported by regular email check-ins with the nurse and through follow-up appointments with the neurologist.

Healthcare providers provided the following three suggestions for improvement of Model 3: one affirmation of the referral process (relatability), one affirmation of roles, and one question seeking clarification of referrals to OTs. Regarding the referral process, PT 1 said, “I feel this scenario is more in line with how neurologists refer for exercise/rehab so there would not be as much of a barrier.” Likewise, PT 2 stated, “Better clarity of OT/PT roles and how to determine exercise intensity based upon MS phenotype.” Occupational therapist 1 posed the following question, “Why does the nurse refer to the local PT and not OT?”

These suggested improvements were applied to new evolutions of the practice models and quick screening process. Therefore, the research team chose to once again adapt the materials under investigation.

Limitations

This study was limited by the total number of participants who completed the online survey. As previously noted, the total number of participants in the study (Cycle 2; n = 11) was lower than the first cycle (Cycle 1; n = 20). The timing of the survey during the summer may have influenced this response rate due to heavy HCP patient loads and/or vacations. Respondents represented an even distribution across health professions but were geographically underrepresented in the North and East. In addition, 11 respondents (50%) did not complete the survey in full resulting in incomplete data and therefore exclusion from the study. Incomplete responses may have been due to the overall length of the survey (maximum of 55 questions) or the program logic, which required users to click on embedded links to view program materials on separate screens. The online nature of the survey might have further created difficulties in completing the evaluation, accounting for the 50% completion rate. Finally, the low response rate (n = 11) rendered the quantitative data moot thereby undermining the research team's ability to report descriptive statistics and draw strong conclusions.

Discussion

Healthcare providers submitted 13 suggestions to improve the quick screening tool and Models 1–3 regarding clarity, relatability, and roles and responsibilities. Approximately half of these comments (7/13; 54%) focused on appropriateness of roles and responsibilities. Based on HCP recommendations, we made four specific changes. The research team revised the process by assigning the tasks of patient screening and community referrals to the nurse rather than the neurologist. This was a fundamental shift in the structure of the models. We further inserted a screening question within the quick screening tool for determining current exercise behavior based on the MS exercise guidelines (2 times a week, moderate aerobic exercise, or 2 times a week moderate strength exercise).25 We revised Models 2 and 3 with a detailed section regarding referrals to PTs/OTs. We finally translated HCP program tools into provider checklists based on the training tools depicted in Models 1–3. As a research team, we have seen a progression of these materials from theory into practice. Feedback from HCPs and the low response rate, however, suggest that a third cycle of the PDSA ramp is warranted.

Next Steps

To address limitations in Cycle 2 (i.e., response rate, incomplete responses, and digital format of program materials), the research team will conduct a third cycle of QI on this PDSA ramp by distributing hard copy packets among comprehensive MS centers throughout the United States through postal mail. Beyond instructions and consent documents, the packets will include paper copies of the quick screening tool, Models 1–3, and HCP checklists. Potential respondents will be incentivized with a drawing for one of four, $250 gift cards. Once these program materials are finalized, the research team intends a clinical trial of this systems-based process from feasibility through efficacy and effectiveness in a comprehensive MS care center.

Conclusions

This article describes a QI approach for refining program materials designed for promoting exercise in comprehensive MS care.26,27 Moreover, it demonstrates the importance of iterating a change idea through a PDSA ramp before implementing a fully vetted change package to scale.28 The individuals who participated in Cycle 2 added valuable insights to program materials based on discipline-specific knowledge and experience in supporting individuals with MS. These contributions have been used to further refine program materials, which address previously articulated needs by HCPs for promoting and discussing exercise with patients and, ultimately, improve the lives of persons with MS.10

Implications

This article provides a step forward in a line of research focused on developing a systems-based process for integrating exercise promotion as part of comprehensive MS care. In particular, it moves the research closer toward implementing this system into practice. Healthcare providers evaluated the content of the models, providing essential insights and improvements regarding the applicability of such an approach in a real-world context. Furthermore, HCPs directed a new evolution of these models regarding how to implement them in practice by discussing strategies to simplify the system in such a way that it can become embedded within each patient's appointment. The ultimate goal of this research is to revolutionize exercise promotion in comprehensive MS care by implementing this approach within comprehensive MS care centers across the United States.

Authors' Biographies

Matthew Fifolt, PhD, is an Assistant Professor in the Department of Health Care Organization and Policy at the University of Alabama at Birmingham, Birmingham, Alabama. Dr. Fifolt's scholarship emphasizes the areas of quality improvement and innovative pedagogy across a wide range of public health topics. Dr. Fifolt specializes in program and outcome evaluation; he currently serves as a Senior Evaluator on multiple state and national grants and cooperative agreements.

Emma V. Richardson, PhD, is a Postdoctoral Fellow at the University of Alabama at Birmingham, Birmingham, Alabama. Dr. Richardson is currently part of the Exercise Neuroscience Research Laboratory at UAB, which promotes health and wellness among persons with MS through exercise. She specializes in qualitative research and uses a broad range of data collection and analytical techniques in her work.

Elizabeth A. Barstow, PhD, OTR/L, SCLV, FAOTA, is an Associate Professor and Director of the Graduate Certificate in Low Vision Rehabilitation program at the University of Alabama at Birmingham, Birmingham, Alabama. Dr. Barstow's research efforts focus on understanding the occupational limitations and needs of persons with vision impairment and related conditions, especially as it relates to health and wellness.

Robert W. Motl, PhD, is a Professor of Physical Therapy at the University of Alabama at Birmingham, Birmingham, Alabama. Dr. Motl has systematically developed a research agenda that focuses on physical activity and its measurement, predictors, and consequences in persons with neurological diseases, particularly MS. Dr. Motl has generated a body of research on the validity of common physical activity measures in persons with MS. This has resulted in foundational research on quantifying differences in physical activity, particularly rates of moderate to vigorous physical activity in persons with MS.

References

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3. Dendrou CA, Fugger L, Friese MA. Immunopathology of multiple sclerosis. Nat Rev Immunol. 2015;15:545-558.
4. Pilutti LA, Platta ME, Motl RW, Latimer-Cheung AE. The safety of exercise training in multiple sclerosis: A systematic review. J Neurol Sci. 2014;343(1-2):3-7.
5. Motl RW, Pilutti LA. The benefits of exercise training in multiple sclerosis. Nat Rev Neurol. 2012;8(9):487-497.
6. Motl RW, Sandroff BM, Kwakkel G, et al. Exercise in patients with multiple sclerosis. Lancet Neurol. 2017;16(10):848-856.
7. Klaren RE, Motl RW, Dlugonski D, Sandroff BM, Pilutti LA. Objectively quantified physical activity in persons with multiple sclerosis. Arch Phys Med Rehab. 2013;94(12):2342-2348.
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12. Learmonth YC, Adamson BC, Balto JM, et al. Multiple sclerosis patients need and want information on exercise promotion from healthcare providers: A qualitative study. Health Expect. 2017;20(4):574-583.
13. Motl RW, Barstow EA, Blaylock S, Richardson EV, Learmonth YC, Fifolt M. Promotion of exercise in multiple sclerosis through HCPs. Exerc Sport Sci Rev. 2018;46(2):105-111.
14. Richardson EV, Blaylock S, Barstow E, Fifolt M, Motl RW. Evaluation of a conceptual model to guide HCPs in promoting exercise among persons with multiple sclerosis. APAQ. 2019;36(1):109-131.
15. Richardson EV, Barstow E, Fifolt M, Motl RW. Evaluation of a conceptual model regarding exercise promotion through the patient–provider interaction in multiple sclerosis: Health care provider perspectives. Qual Health Res. 2020;30(8):1262-1274.
16. Christoff P. Running PDSA cycles. Curr Prob Ped Ad. 2018;48(8):198-201.
17. Libbon JV, Austin CM, Gill-Scott LC, Burke RE. Improving the transition of care process for veterans hospitalized at non-VHA facilities. J Healthc Qual. 2019;41(2):68-74.
18. Agency for Healthcare Research and Quality (AHRQ). Plan-Do-Study-Act (PDSA) cycle. 2008. https://www.ahrq.gov/health-literacy/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool2b.html. Accessed October 3, 2019.
19. Stepanovich PL. Using system dynamics to illustrate Deming's system of profound knowledge. Total Qual Manag Bus. 2004;15(3):379-389.
20. Taylor MJ, McNicholas C, Nicolay C, Darzi A, Bell D, Reed JE. Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Qual Saf. 2014;23:290-298.
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22. Rutman L, Hariharan S. QI methods and implementation science. In: Dandoy CE, Hilden JM, Billett AL, Mueller BU, eds. Patient Safety and Quality in Pediatric Hematology/oncology and Stem Cell Transplantation. New York, NY: Springer; 2017:67-80.
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24. Etchellis E, Woodcock T. Value of small sample sizes in rapid-cycle quality improvement projects 2: Assessing fidelity of implementation for improvement interventions. BMJ Qual Saf. 2018;27:61-68.
25. Latimer-Cheung AE, Pilutti LA, Hicks AL, et al. Effects of exercise training on fitness, mobility, fatigue, and health-related quality of life among adults with multiple sclerosis: A systematic review to inform guideline development. Arch Phys Med Rehabil. 2013;94(3):1800-1828.
26. Asadoorian J, Hearson B, Satyanarayana S, Ursel J. Evidence-based practice in healthcare: An exploratory cross-discipline comparison of enhancers and barriers. J Healthc Qual. 2010;32(3):15-22.
27. Nolan TW. Execution of strategic improvement initiatives to produce system-level results. In: IHI Innovation Series White Paper. Cambridge, MA: Institute for Healthcare Improvement, 2007.
28. Kurowski EM, Schondelmeyer AC, Brown C, Dandoy CE, Hanke SJ, Cooley HLT. A practical guide to conducting quality improvement in the health care setting. Curr Treat Options Pediatr. 2015;1(4):380-392.

Journal for Healthcare Quality is pleased to offer the opportunity to earn continuing education (CE) credit to those who read this article and take the online posttest at www.nahq.org/journal/ce. This continuing education offering, JHQ 291 (July/August 2021), will provide 1 hour to those who complete it appropriately.

Core CPHQ Examination Content Area

III. [Domain – Performance Measurement and Improvement]

CE Objectives and Posttest Questions: Using Quality Improvement for Refining Program Materials for Exercise Promotion in Comprehensive Multiple Sclerosis Care

Learning Objectives:

  1. Identify the three potential outcomes for testing a change idea through PDSA.
  2. Describe how a healthcare provider (HCP) would use the quick screening tool to recommend Model 1, Model 2, or Model 3.
  3. Describe the purpose of a PDSA ramp for testing change ideas
  4. Describe the use of PDSA in this study.

Questions

  1. What percentage of persons with multiple sclerosis (MS) engage in sufficient amounts of exercise necessary for accrual of the benefits.
    1. Approximately 10%
    2. Fewer than 20%
    3. More than 50%
    4. Exactly 70%
  2. The “S” in PDSA stands for:
    1. Scan
    2. Screen
    3. Solve
    4. Study
  3. Based on the quick screening tool, a patient who is ready/interested in exercise; does not screen as a high risk of an adverse event if they exercise; has moderate to severe physical/cognitive/sensory deficits that require longer, intensive healthcare provider intervention, but does not have insurance for healthcare intervention, should be directed to:
    1. Check-in next visit
    2. Model 1
    3. Model 2
    4. Model 3
  4. Analytical eclecticism represent:
    1. Approaches to scholarship that solely focus on qualitative data
    2. Approaches to scholarship that solely focus on quantitative data
    3. Approaches that consciously address substantive elements of scholarship from different research traditions
    4. Approaches that consciously disregard all rules of scholarship
  5. Based on the quality improvement literature, the number of respondents in a PDSA cycle is not as important as the:
    1. Length of responses
    2. Tone of responses
    3. Consistency of responses
    4. Quality of responses
  6. Based on Model 2, what occurs first in the clinic:
    1. Neurologist–patient interaction
    2. Patient provided with toolkit
    3. PT/OT–patient interaction
    4. Nurse–patient interaction
  7. To address potential limitations of the study, authors are planning to:
    1. Distribute hard copy packets to comprehensive MS centers across the United States
    2. Offer an incentive of a drawing for one of four, $250 gift cards
    3. Implement a third round of quality improvement on this PDSA ramp
    4. All of the above
  8. In this study, healthcare providers included:
    1. Neurologists, nurses, dentists, and social workers
    2. Nurses, PTs, OTs, and audiologists
    3. Neurologists, nurses, PTs, and OTs
    4. Nurses, OTs, pharmacists, and optometrists
  9. The following is a safe and efficacious approach for managing many of the physical, cognitive, and psychological symptoms of MS:
    1. Exercise
    2. Sitting
    3. Medical marijuana
    4. Psychotherapy
  10. Identify the order in which the authors developed this systems-based process for integrating exercise promotion as part of comprehensive MS care:
    1. Feasibility study, conceptual model, practice models, full-scale implementation
    2. Full-scale implementation, practice models, conceptual model, feasibility study
    3. Conceptual model, practice models, feasibility study, full-scale implementation
    4. Practice models, feasibility study, conceptual model, full-scale implementation

Keywords:

exercise promotion; quality improvement; multiple sclerosis; comprehensive care

Supplemental Digital Content

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