A Practical Guide to Developing Successful Clinical Frameworks

Protocols can make your rehab work HARDER and often leads to poor individual treatment outcomes.

Today I'm sharing a step-by-step approach to how you can develop a successful clinical framework, that allows for individualisation & improved outcomes for your injured clients.

Developing frameworks takes time, BUT when you take the time to develop robust systems you actually SAVE TIME & IMPROVE OUTCOMES for your patients in the long run.

In the quest for certainty, definitive answers and time-saving approaches to rehab, we can actually be making our patient's rehabilitation journey harder than it needs to be.

I get it, when it comes to prescribing exercise & movement programs for our injured clients we want to make sure we're doing the right thing.

We want to find the perfect exercise and achieve the best outcome.

BUT, sometimes this search for certainty and dislike of discomfort can actually undermine what we are ultimately trying to achieve.

In the search for certainty and ensuring we're "getting it right", we'll often gravitate towards finding the solution without understanding that the solution develops from the process.

If we take the below example of Achilles tendinopathy, we may have one pathology with hundreds of nuanced clinical presentations, each with their own specific management requirements.

Applying the one-size-fits-all approach to managing a pathology is a trap clinicians can easily fall into.

"When someone presents with _____________ pathology, I do XYZ treatment.

Yes, this may work well for some, but you can guarantee that there will be just as many (if not more) people that this won't work well for.

Frameworks will always deliver better outcomes than protocols.

What is a Protocol?

A protocol is a predefined, step-by-step guide that outlines specific actions to be taken in particular situations. It is designed to ensure uniformity and consistency in the delivery of care.

Protocols are typically rigid and prescriptive, leaving little room for deviation.

What is a Framework?

A framework, on the other hand, provides a broader structure within which clinicians can operate. It sets out general principles, goals, and guidelines but allows for flexibility and adaptation based on individual patient needs and clinical judgment.

Frameworks are more flexible and less prescriptive, encouraging individualised approaches to care.

Why Use Protocols?

There are a number of valid reasons we may use protocols within our clinical practice.

1. Standardisation and Consistency

Protocols provide a standardised approach to treatment, ensuring that all patients receive a consistent level of care. We tend to see this become more important in large healthcare settings where multiple clinicians are involved in patient care.

Standardised protocols help minimise variability in treatment, which can be reassuring for both clinicians and patients.

2. Ease of Use

Protocols are straightforward and easy to follow.

They outline specific steps and timelines, reducing the complexity involved in decision-making.

3. Legal and Regulatory Compliance

Adhering to established protocols can help protect clinicians from legal liability. If a clinician follows a widely accepted protocol and an adverse event occurs, they are more likely to be protected legally compared to if they had deviated from standard practice.

4. Efficiency

Protocols can streamline the treatment process, making it more efficient. By following a set protocol, clinicians can quickly make decisions and initiate treatment without needing to develop a new plan for each patient.

5. Training and Education

They provide a structured approach that can be used to train new clinicians and ensure that all staff are familiar with the standard treatment methods for specific conditions.

6. Insurance and Reimbursement

Insurance companies &/or third party payers often prefer or require treatment to follow established protocols for reimbursement purposes. Adhering to these protocols can simplify the process of obtaining reimbursement for services provided, reducing administrative burdens for clinicians and healthcare facilities.

7. Comfort and Familiarity

Clinicians may feel more comfortable using protocols that they are familiar with and have used successfully in the past. This familiarity can provide a sense of security and confidence in their treatment approach.

Problems with Protocols

While protocols offer several advantages, they also have notable drawbacks:

1. Lack of Individualisation

Protocols are designed to be broadly applicable, which can lead to a one-size-fits-all approach. This often fails to consider the unique needs, conditions, and responses of individual patients.

Person-specific factors such as injury history, age, physical activity levels, anthropometric variables, comorbidities, and personal goals (and many other factors) are often overlooked.

2. Limited Flexibility

Protocols are rigid and do not allow for easy adaptation to unexpected complications or variations in patient progress.

This can lead to suboptimal care when patients do not follow the typical recovery trajectory outlined by the protocol.

3. Inadequate Response to Complex Cases

Patients with multiple or complex conditions may not fit neatly into a predefined protocol. Protocols may not adequately address the nuances of managing such patients, leading to ineffective or incomplete treatment.

4. Potential for Outdated Practices

Protocols can become outdated as new research and clinical practices emerge.

If a protocol is not regularly updated, it may fail to incorporate the latest evidence-based practices, resulting in less effective or even harmful treatments.

5. Reduced Clinical Judgment

Strict adherence to protocols can undermine clinicians' ability to exercise their professional judgment.

This can lead to a reduction in critical thinking and an over-reliance on predefined steps, rather than considering the best course of action for each individual patient.

6. Patient Non-Adherence

Protocols do not always account for patient preferences and circumstances, leading to issues with adherence. If a patient finds a protocol too difficult or irrelevant to their needs, they may be less likely to follow it.

How to Develop a Clinical Framework

For those of you who have completed any of the Progressive Podiatry Project's online courses or attended our workshops, you would be aware of how these help a) develop clinical processes, and b) build skills for the nuanced assessment and management our clients need.

Developing a clinical framework requires a comprehensive approach that combines evidence-based practice with flexibility to accommodate individual patient needs.

If you're a clinician or clinic owner wanting to improve your management of specific pathologies or client groups, here’s a step-by-step guide to develop an effective clinical framework:

1. Identify the Scope and Objectives

• Define the Purpose: Clearly outline the purpose of the framework. Determine the specific condition or patient populations it will address.
• Set Objectives: Establish the primary goals of the framework, such as improving patient outcomes, enhancing treatment efficiency, or increasing patient satisfaction.

2. Review Evidence-Based Guidelines

• Literature Review: Conduct a thorough review of existing research, guidelines, and best practices related to the condition or treatment area. Utilise reputable sources such as peer-reviewed journals, clinical guidelines, and systematic reviews.
• Synthesise Findings: Summarise key findings and recommendations from the literature that can inform the framework.

3. Incorporate Clinical Expertise

• Consult with Experts: Engage with experienced clinicians in the field of interest to gather insights and practical knowledge.
• Consider Practical Experience: Reflect on personal clinical experiences and lessons learned from treating similar client populations.

4. Develop Core Principles and Components

• Core Principles: Establish fundamental principles that will guide clinical decision-making, such as patient-centered care, individualised treatment plans, and continuous evaluation.
• Components of the Framework: Define the key components of the framework, such as assessment methods, treatment modalities, progress tracking, and outcome measures.

5. Create Flexible Guidelines

• Broad Guidelines: Develop broad, flexible guidelines that provide a structure for care while allowing for individualisation.
• Decision Points: Identify critical decision points within the framework where clinicians can adjust the approach based on patient response and evolving needs.

6. Incorporate Patient-Centered Elements

• Patient Goals and Preferences: Integrate mechanisms for incorporating patient goals, preferences, and feedback into the treatment plan.
• Shared Decision-Making: Promote shared decision-making between clinicians and patients to ensure that care is aligned with patient values and expectations.

7. Develop Tools and Resources

• Assessment Tools: Create or adopt tools for comprehensive patient assessment, including questionnaires, physical examinations, and diagnostic tests.
• Treatment Pathways: Develop flexible treatment pathways that provide options based on identified patient-specific factors, patient progress and response to therapy.

8. Pilot and Refine the Framework

• Pilot Testing: Implement the framework on a small scale with a select group of patients to evaluate its effectiveness and feasibility.
• Collect Feedback: Gather feedback from both patients and clinicians on the framework’s usability and impact on care.
• Refinement: Make necessary adjustments based on feedback and outcomes from the pilot phase.

9. Implement and Monitor

• Training and Education: Provide training for clinicians on how to use the framework effectively. Ensure that all team members understand its principles and components.
• Ongoing Monitoring: Continuously monitor the implementation of the framework. Use outcome measures and patient feedback to assess its impact and identify areas for improvement.

10. Continuous Improvement

• Regular Updates: Regularly update the framework to incorporate new evidence and innovations in clinical practice.
• Quality Improvement: Establish a quality improvement process to continually evaluate and enhance the framework based on clinical outcomes and emerging best practices.

Creating a Framework Treatment Pathway

Within my own clinical practice and for other clinics I am working with at present, I develop clinical frameworks that follow the consultation process and allow the gathering information that will influence the next steps in the assessment and management process.

I will share another article in the near future that steps out how I develop treatment intervention frameworks, that serve to outline our management pathways and educate clients during the initial stages of treatment regarding what their treatment journey may look like.

Before then, I have developed a few clinical resources for clinicians to get you started putting these ideas into practice.

Firstly below is the free download I've created - the Plantar Fasciopathy Clinical Decision-Making Framework.

For a exercise prescription-specific framework, there's also the Movement Prescription Blueprint. This free resource is designed to step clinicians through the information gathering process, to develop individualised exercise programs for injured clients.

If you're after guidance on how to apply this specific to your practice, get in touch. There are a number of ways in which I've been working with clinicians and clinic owners develop successful pathology management frameworks that cater to their clinic set-up, their clinician's skill-sets, the specific conditions/client groups they see.