BackgroundLean as a management system has been increasingly adopted in health care settings in an effort to enhance quality, capacity and safety, while simultaneously containing or reducing costs. The Ministry of Health in the province of Saskatchewan, Canada has made a multi-million dollar investment in Lean initiatives to create “better health, better value, better care, and better teams”, affording a unique opportunity to advance our understanding of the way in which Lean philosophy, principles and tools work in health care.MethodsIn order to address the questions, “What changes in leadership practices are associated with the implementation of Lean?” and “When leadership practices change, how do the changed practices contribute to subsequent outcomes?”, we used a qualitative, multi-stage approach to work towards developing an initial realist program theory. We describe the implications of realist assumptions for evaluation of this Lean initiative. Formal theories including Normalization Process Theory, Theories of Double Loop and Organization Leaning and the Theory of Cognitive Dissonance help understand this initial rough program theory. Data collection included: key informant consultation; a stakeholder workshop; documentary review; 26 audiotaped and transcribed interviews with health region personnel; and team discussions.ResultsA set of seven initial hypotheses regarding the manner in which Lean changes leadership practices were developed from our data. We hypothesized that Lean, as implemented in this particular setting, changes leadership practices in the following ways. Lean: a) aligns the aims and objectives of health regions; b) authorizes attention and resources to quality improvement and change management c) provides an integrated set of tools for particular tasks; d) changes leaders’ attitudes or beliefs about appropriate leadership and management styles and behaviors; e) demands increased levels of expertise, accountability and commitment from leaders; f) measures and uses data effectively to identify actual and relevant local problems and the root causes of those problems; and g) creates or supports a ‘learning organization’ culture.ConclusionsThis study has generated initial hypotheses and realist program theory that can form the basis for future evaluation of Lean initiatives. Developing leadership capacity and culture is theorized to be a necessary precursor to other systemic and observable changes arising from Lean initiatives.

Background Physical therapists are key players in the management of musculoskeletal conditions, which are common in rural and remote communities. There are few physical therapists in rural regions compared to potential need, so care is either not provided or must be sought in urban centers, requiring travel and time away from work and family to access services. Telerehabilitation strategies, such as real-time videoconferencing, are emerging as possible solutions to address shortages in rural physical therapy services. Objectives This review will: (1) determine the validity and the reliability of secure videoconferencing for physical therapy management of musculoskeletal conditions; (2) determine the health, system, and process outcomes when using secure videoconferencing for physical therapy management of musculoskeletal conditions. Methods A protocol-driven systematic review of four databases was carried out by two independent reviewers. Study criteria included English language articles from January 2003 to December 2016, on physical therapy management using secure videoconferencing, pertaining to adults 18-80 years with chronic musculoskeletal disorders. Randomized controlled trials, pre-experimental studies, and case-control studies were included. Quality analysis was performed utilizing standardized tools specific for the study designs. Results and conclusions Validity and reliability studies were identified as having high risk of bias. Intervention studies were of moderate quality, and found positive impact on health outcomes and satisfaction. Two studies evaluated costs, with evidence of cost savings in one study. More robust research is required to evaluate long-term effects of telerehabilitation for physical therapy management of musculoskeletal disorders, including cost-benefit analyses.

We found no evidence of a difference in effectiveness between inter-professional video-conferencing and traditional rheumatology clinic for both the provision of effective follow-up care and patient satisfaction for established RA patients. High dropout rates reinforce the need for consultation with patients' needs and preferences in developing models of care. While use of video-conferencing/telehealth technologies may be a distinct advantage for some patients, there may be loss of travel-related auxiliary benefits for others.

The objective of this umbrella systematic review was to identify, evaluate, and synthesize systematic reviews of physical activity interventions for adults with fibromyalgia (FM) focussing on four outcomes: pain, multidimensional function (wellness or quality of life), physical function (self-reported physical function or measured physical fitness) and adverse effects. A further objective was to link these outcomes with details of the interventions so as to guide and shape future practice and research. Electronic databases including Medline, EMBASE, CINAHL, AMED, the Cochrane Library, and DARE, were searched for the January 1(st) 2007 to March 31(st) 2013 period. Nine systematic reviews (60 RCTs with 3816 participants) were included. Meta-analysis was not conducted due to the heterogeneity of the sample. We found positive results of diverse exercise interventions on pain, multidimensional function, and self-reported physical function, and no supporting evidence for new (to FM) interventions (i.e., qigong, tai chi). There were no serious adverse effects reported. The variability of the interventions in the reviews prevented us from answering important clinical questions to guide practical decisions about optimal modes or dosages (i.e., frequency, intensity, duration). Finally, the number of review articles is proliferating, leading researchers and reviewers to consider the rigor and quality of the information being reviewed. As well, consumers of these reviews (i.e., clinicians, individuals with FM) should not rely on them without careful consideration.

PurposeTo evaluate participant and referring care provider satisfaction associated with a spinal triage assessment service delivered by physiotherapists in collaboration with orthopedic surgeons.MethodsPeople with low back-related complaints were recruited from those referred to a spinal triage assessment program delivered by physiotherapists. Measures of patient and provider satisfaction were completed at approximately 4 weeks after the assessment. The satisfaction surveys were analyzed quantitatively with descriptive statistics and qualitatively with an inductive thematic approach of open and axial coding.ResultsA total of 108/115 participants completed the posttest satisfaction survey. Sixty-six percent of participants were “very satisfied” with the service and 55% were “very satisfied” with the recommendations that were made. Only 18% of referring care providers completed the satisfaction survey and 90.5% of those were “very satisfied” with the recommendations. Sixty-one participants and 14 care providers provided comments which revealed a diverse range of themes which were coded into positive (ie, understanding the problem, communication, customer service, efficiency, and management direction), negative (ie, lack of detail, time to follow-up, cost) and neutral related to the triage service, and an “other” category unrelated to the service (ie, chronic symptoms, comorbidities, and limited access to health care.)ConclusionThe quantitative results of the participant survey demonstrated very high levels of satisfaction with the service and slightly less satisfaction with the recommendations that were made. Satisfaction of referring care providers with the recommendations and report was also high, but given the low response rate, these results should be interpreted with caution. Qualitative analysis of participant and provider comments revealed a diverse range of themes. These other issues may be important contextual factors that have the potential to impact patient relevant outcomes.

Purpose: People living in rural and remote regions need support to overcome difficulties in accessing health care. The objectives of the study were (1) to compare demographic characteristics, professional engagement indicators, and clinical characteristics between physiotherapists practising in rural settings and those practising in urban settings and (2) to map the distribution of physiotherapists in Saskatchewan. Method: This cross-sectional study used de-identified data collected from the 2013 Saskatchewan College of Physical Therapists membership renewal (n ¼ 643), linked with the Saskatchewan Physiotherapy Association's (SPA) 2012 membership list and a list of physiotherapists who had served as clinical instructors. Employment location (rural vs. urban) was determined by postal code. Results: Only 11.2% of Saskatchewan physiotherapists listed a rural primary employment location, and a higher density of physiotherapists per 10,000 people work in health regions with large urban centres. Compared with urban physiotherapists, rural physiotherapists are more likely to provide direct patient care, to provide care to people of all ages, and to have a mixed client level, and they are less likely to be SPA members. Conclusions: Rural and urban physiotherapists in Saskatchewan have different practice and professional characteristics. This information may have implications for health human resource recruitment and retention policies as well as advocacy for equitable access to physiotherapy care in rural and remote regions.

Purpose: To describe the characteristics of participants in a physiotherapist spinal triage programme, compare the profiles of patients for whom surgery was and was not recommended by a surgeon, and determine the surgical yield among those referred to surgeons. Methods: Data were collected retrospectively by reviewing charts of people who used the service over a 3-year period (2003)(2004)(2005)(2006). Data from up to1,096 people were used in the analysis; complete data were available for 299 people. Descriptive statistics were used to summarize demographics, clinical features, and management recommendations. Characteristics of those who were and were not recommended for surgery were examined using Pearson's chi-square or Fisher's Exact tests. Results: The majority of 746 participants were classified as ''mechanical spine'' (92.5%), 2.9% were ''other body part,'' 2.5% were ''medical/other,'' and only 2% were classified as ''surgical spine.'' Recommendations for surgery (by a surgeon) were independent of patients' age, sex, duration of symptoms, residence (urban/rural), source of health care funding, and diagnosis. The surgical yield was 80%. Conclusions: Most people were not considered candidates for surgery. Triage assessment by physiotherapists can increase the efficiency of an orthopaedic surgeon's caseload by reducing the number of non-surgical referrals and can thus help to ensure more timely access to appropriate health care.Key Words: collaborative practice; diagnosis; advanced practice; low back pain; spinal triage programme. RÉ SUMÉObjectif : Dé crire les caracté ristiques des participants à un programme de triage en fonction de leurs problè mes à la colonne verté brale, comparer les profils des patients pour qui une chirurgie é tait ou non recommandé e et dé terminer l'é tendue de la chirurgie parmi les personnes dirigé es vers un professionnel de la chirurgie. Mé thode : Les donné es ont é té recueillies ré trospectivement en procé dant à un examen des dossiers de personnes qui ont utilisé le service pendant trois ans (de 2003 à 2006). Des donné es relatives à 1 096 personnes é taient disponibles et des donné es complè tes é taient disponibles pour 299 personnes. Des statistiques descriptives ont é té utilisé es pour ré sumer les donné es dé mographiques, les caracté ristiques cliniques et les recommandations de gestion. Les caracté ristiques des personnes ayant ou non fait l'objet d'une recommandation pour une chirurgie ont é té examiné es à l'aide du test du Khi-carré de Pearson et du test de Fisher. Ré sultats : La majorité des 746 participants ont é té classé s comme « mé canique verté brale » (92,5 %); 2,9 % comme « autres parties du corps »; 2,5 % l'ont é té dans « mé dical/autres » et 2 % ont é té classé s comme « verté bral chirurgical ». Les recommandations pour une intervention (par un chirurgien) é taient formulé es indé pendamment de l'â ge des patients, de leur sexe, de la duré e des symptô mes, de leur milieu (urbain ou rural), de la source de financement des soins de santé dans l...

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