Product Details

Author Information

Corresponding Author
Simon Laprise
Centre de Réadaptation Estrie
300 rue King Est
Bureau 2000
Sherbrooke, QC J1G 1B1
Canada
p: 819-346-8411 ex43094
slaprise.cre@ssss.gouv.qc.ca

Authors (listed in order of authorship):
Chantal Camden
Centre de Réadaptation Estrie

Bonnie Swaine
Université de Montréal

Sylvie Tétreault
Université Laval

Monique Carrière
Université Laval

Carl Chiasson
Centre de Réadaptation Estrie

Chantal Richer
Centre de Réadaptation Estrie

Louise Audet
Centre de Réadaptation Estrie

France Léger
Centre de Réadaptation Estrie

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Allied Health, Management Sciences, Medicine, Public Health

What specific topics does your product address?

Community-based clinical care , Access to health care, Chronic disease, Disabilities, Health care quality, Health services research, Program management , Rehabilitation, Program evaluation, Community-based participatory research

Does your product focus on a specific population(s)?

Adolescents, Children, Disabled

What methodological approaches were used in the development of your product, or are discussed in your product?

Community-based participatory research , Focus group , Qualitative research, Quantitative research, Interview, Participant observation

What resource type(s) best describe(s) your product?

Case study, Documentary

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

Many health care settings around the world are struggling to increase the quality of services they offer to children with disabilities. The product is a video sharing the story of the Children’s and Teenagers’ Program (CTP) that undertook the challenge to reorganize its services to increase service accessibility. A participatory action research (PAR) project documented the 3-year process and evaluated the outcomes following the implementation of the new model of service delivery. Two versions of the video are presented. The shorter version (7m25s, Apollo_short_version) specifically targets children with disabilities, their families and community partners (e.g. School Boards). This video is a tool to share information with them regarding the model of service delivery at the CTP, fostering their empowerment in the rehabilitation process. The longer version of the video (two parts named Apollo Long Version PT1 & PT2, 7m55s & 8m18s) targets health care sector workers & groups of individuals interested in reorganizing rehabilitation services. It provides more information on the facilitators, the barriers and the outcomes related to such a service reorganization, providing tips for future projects. Both versions of the video aim at sharing information to support quality improvement efforts. They can be viewed alone, in a self-standing format, or can be used as a tool during meetings with partners to foster discussions on how to improve service quality in a particular program.

2. What are the goals of the product?

The overall purpose of the product is to build awareness about the need for new models of service delivery for children with disabilities and to share an experience of service reorganization. Three specific goals include:

1. To present the new model of service delivery developed by the Children’s and Teenagers’ Program. The principal components of the new model are described, examples of services are provided and specific outcomes related to each particular component are discussed. Explanations are provided to describe how the new model of services improved some of the problems experienced with the earlier traditional model of service delivery, especially in regards to waiting times.

2. To share the experience of service reorganization within the Children’s and Teenagers’ Program. Information is provided in regards to the change management process (e.g. the development of a committee composed of different representatives), the facilitators (e.g. funds and leadership at the beginning of the project) and barriers to change (e.g. the need to standardize services and the high rate of staff turnover). Examples of ongoing activities to improve the quality of the services in the program are also discussed.

3. To inspire other health care settings to undertake the challenge to reorganize their services. Few examples of service reorganization are available in the paediatric rehabilitation literature. By presenting the model and the experience of the Children’s and Teenagers’ Program, we aim to share, with other settings, our findings and our lessons learned, with the hope of helping them in their continuous quality improvement efforts.

Note that the video can also be used as a tool to inform the public, to influence decision-makers and to train rehabilitation students with regards to the issue of waiting times and the potential solutions regarding services for children with disabilities.

3. Who are the intended audiences or expected users of the product?

The two versions of the video target two different intended audiences. The shorter version specifically targets youths with disabilities, their families and community partners (e.g. School Boards, kindergartens, Parents’ associations, sports groups, etc.). The video is a tool to share information with them regarding the model of service delivery, fostering their empowerment and their collaboration in the rehabilitation process. The longer version of the video specifically targets health care sector workers (e.g. service providers and administrators) as well as groups of individuals interested in undertaking the challenge to reorganize rehabilitation services in their health care setting. It provides more information on the facilitators, the barriers and the outcomes related to such a service reorganization, providing tips for future projects.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

The video is appropriate for multiple types of contexts. It can be viewed alone, in a self-standing format, or can be used as a tool during meetings with families, community or health care partners. For example, the video has been shown to families and community partners during a meeting of the Children’s and Teenagers’ program, to present results of the service reorganization, to share ideas and to discuss the next steps to guide quality improvement efforts in the program.

Originally, both versions of the videos were in French, but they have been subtitled in English to be accessible to the English-speaking clientele of the rehabilitation centre and to other potentially-interested persons around the world. The English versions are submitted as part of the current product. For access to all versions of the video, follow the provided link to the YouTune site and click on the “6 videos” button near the top of the page.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

This work builds principally upon the field of children's rehabilitation. Waiting times, and the related negative consequences, are issues well documented in the literature (1-8) but few concrete solutions are proposed. Some authors suggest reorganizing services or increasing the use of group interventions (4,9), but no model of service delivery is proposed to address these issues nor are service reorganization projects described in the literature. The Life Needs Model (10) has however inspired the development of the model of the Children’s and Teenagers’ Program, since it clearly states the children's, families' and community partners' needs to address in order to foster social participation for children. We however adapted this model to incorporate different types of services and processes of care thought to increase a program's efficiency: service monitoring, community or group interventions and mechanisms of service coordination (11-13).

Other models and theories also guided the service reorganization process. Tandon's steps (14) were used to guide the development of the participatory action research project accompanying the reorganization process. For example, the use of these steps resulted in the creation of a committee of representatives. The EGIPSS (Évaluation Globale et Intégrée de la Performance des Systèmes de services de Santé - Global and Integrated Evaluation of the Performance of Health Services Systems) model (15) was also used to guide our reflections on service quality. Its components of service quality also helped define the project's objectives. The different research tools used in this project were also chosen based on the scientific literature. For instance, questionnaires to document the strengths, weaknesses, opportunities and threats (SWOT) in the program were based on SWOT analysis, a technique used to foster empowerment, support change management efforts and facilitate service reorganization (16-21). Likewise, the two versions of the Measure of Processes of Care (22,23) were used to evaluate families and service providers' perceptions of service quality during and following the service reorganization process, as they are two of the most commonly used tools to assess quality in pediatric rehabilitation.

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1. Boucher N, Fougeyrollas P, Levesque P, Roy K. Les délais d'attente et leur impact en matière de réadaptation spécialisée. Les résultats de la recension des écrits. Québec: Institut de réadaptation en déficience physique de Québec et Centre. interdisciplinaire de recherche en réadaptation et intégration sociale; 2005.
2. Ehrmann Feldman D, Couture M, Grilli L, Simard MN, Azoulay L, Gosselin J. When and by whom is concern first expressed for children with neuromotor problems. Arch Pediat Adol Med 2005;159(9):882-6.
3. Feldman DE, Swaine B, Gosselin J, Meshefedjian G, Grilli L. Is waiting for rehabilitation services associated with changes in function and quality of life in children with physical disabilities? Phys Occup Ther Pedi 2008;28(4):291-304.
4. Grilli L, Feldman DE, Swaine B, Gosselin J, Champagne F, Pineault R. Wait times for paediatric rehabilitation. Health Policy 2007;2(3):e171-187.
5. Majnemer A, Shevell M, Rosenbaum P, Abrahamowicz M. Early rehabilitation service utilization patterns in young children with developmental delays. Child Care Hlth Dev 2002;28(1):29-37.
6. Mazer B, Feldman D, Majnemer A, Gosselin J, Kehayia E. Rehabilitation services for children: therapists' perceptions. Dev Neurorehabil 2006;9(4):340-50.
7. Sorel L, Bouchard J-M, Kalubi J-C, Maltais. Programme d’intervention pour les familles en attente de services (pifas). In: Éditeurs I, editor. Innovations, apprentissages et réadaptation en déficience physique. St-Jérôme: Kalubi, Michallet, Korner-Bitenski et Tétreault; 1998.
8. Tétreault S. Handicap et rôles parentaux: perceptions des parents. In: CRP Éd, editor. Famille et situation de handicap : Comprendre pour mieux intervenir. Sherbrooke; 2002. p 51-74.
9. Miller AR, Armstrong RW, Mâsse LC, Klassen AF, Shen J, O’Donnell ME. Waiting for child developmental and rehabilitation services: an overview of issues and needs. Dev Med Child Neurol 2008;50(11):815-821.
10. King G, Tucker MA, Baldwin P, Lowry K, LaPorta J, Martens L. A life needs model of pediatric service delivery: services to support community participation and quality of life for children and youth with disabilities. Phys Occup Ther Pedi 2002;22(2):53-77.
11. Bayona CL, McDougall J, Tucker MA, Nichols M, Mandich A. School-Based Occupational Therapy for Children with Fine Motor Difficulties. Phys Occup Ther Pedi 2006;26(3):89-110.
12. King G, Meyer K. Service integration and co-ordination: A framework of approaches for the delivery of co-ordinated care to children with disabilities and their families. Child Care Hlth Dev 2006;32(4):477-92.
13. Palisano RJ, Murr S. Intensity of Therapy Services: What are the Considerations? Phys Occup Ther Pedi 2009;29(2):107-112.
14. Tandon R. Participatory research: main concepts and issues. In: Tandon R, editor. Participatory research: revisiting the roots. New Delhi: Mosaic books; 2002. p 22-39.
15. Champagne F, Contandriopoulos A-P, Picot-Touché J, Béland F, Nguyen H. Un cadre d’évaluation globale de la performance des systèmes de services de santé : Le modèle EGIPSS. Québec: Gouvernement du Québec; 2005.
16. Gordon J, Hazlett C, Ten Cate O, Mann K, Kilminster S, Prince K, O'Driscoll E, Snell L, Newble D. Strategic planning in medical education: enhancing the learning environment for students in clinical settings. Med Educ 2000;34(10):841-50.
17. Pollack CD. Planning for success: the first steps in new program development. J Sch Nurs 1994;10(3):11-5.
18. Sackett KM, Erdley WS, Jones J. The Western New York regional electronic health record initiative: Healthcare informatics use from the registered nurse perspective. St Heal T 2006;122:248-52.
19. Srivastava PK, Kulshreshtha K, Mohanty CS, Pushpangadan P, Singh A. Stakeholder-based SWOT analysis for successful municipal solid waste management in Lucknow, India. Waste Manage 2005;25(5):531-7.
20. Tomasovi N. Geriatric-palliative care units model for improvement of elderly care. Collegium Antropol 2005;29(1):277-82.
21. Williams CM, Petrelli J, Murphy M. Development and implementation of a geriatric care/case management program in a military community-based family medicine residency. Mil Med 2000;165(11):809-15.
22. King SM, Rosenbaum PL, King GA. Parents' perceptions of caregiving: development and validation of a measure of processes. Dev Med Child Neurol 1996;38(9):757-772.
23. Woodside JM, Rosenbaum PL, King SM, King GA. Family-Centered Service: Developing and Validating a Self-Assessment Tool for Pedicatric Service Providers. J Child Health Care 2001;30(3):237-252.
24. Camden C, Swaine B, Tétreault S. Increasing the use of group interventions in a pediatric rehabilitation program: Perceptions of administrators, therapists and parents. Phys Occup Ther Pedi (In press).
25. Camden C, Swaine B, Tétreault S, Bergeron S. SWOT analysis on a pediatric rehabilitation programme: A participatory evaluation fostering quality improvement. Disabil Rehab 2009;31(16):13-73-1381.
26. Camden C, Swaine B, Tétreault S, Brodeur M-M. Reorganizing pediatric rehabilitation services to improve accessibility: do we sacrifice quality? BMC Health Serv Res 2010;10:227.
27. Camden C, Swaine B, Tétreault S, Carrière M. Going beyond the identification of change facilitators to effectively implement a new model of services: Lessons learned from a case example in pediatric rehabilitation. Dev Neurorehabil 2011;14(4):247-260.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

In 2005, CTP therapists provided services to over 1000 children yearly but hundreds of children remained on the waiting list. Most of the interventions provided were on a one-on-one basis. Service providers and managers of the CTP decided then to completely reorganize their service delivery model to: 1) review admission procedures; 2) improve the follow-up; 3) develop more structured community interventions; 4) develop an annual calendar of recurring group activities; and 5) develop criteria and guidelines for individual therapies.

Participatory action research was initiated following a request from the CTP. The research was used to bring together clinicians, administrators and researchers to collaborate in the experimentation of a new model of service delivery aimed at increasing the accessibility and quality of rehabilitation services offered to children with physical disabilities. A committee composed of clinical, administrative and research representatives was formed. During the weekly meetings of the committee of administrative and clinical representatives, research literature, research design and preliminary results were systematically discussed.

With regards to the research protocol, it was developed to respect everyone’s interests and any modifications were discussed with all stakeholders. The research project aimed to facilitate the implementation of the new model into the program and its transfer to other settings dealing with similar issues. Specifically, the objectives were to : 1) evaluate outcomes of the service reorganization, and 2) critically analyze the change process. Quantitative and qualitative methodologies were used. Researchers proposed different data collection tools to administrators and to the committee of representatives. Tools and the data collection procedures were negotiated together to ensure they responded to clinical and administrative concerns, while guaranteeing scientific validity.

First, the two Measures of processes of care (MPOC) were used to document quality-related perceptions before (2007), during (2008) and after (2009) the implementation of the new service delivery model. In total, these tools were used with 222 families and 129 clinicians. On four occasions, clinicians and administrators also responded to a questionnaire about the program’s strengths, weaknesses, opportunities and threats. In 2008 and 2009, focus groups and phone interviews were conducted with families (n=5), clinicians (n=19) and administrators (n=13) to document their perceptions of the change process and of the service reorganization outcomes. Participatory observation allowed collecting data during the whole process of service reorganization. Finally, all the data collected are analyzed using different approaches, such as statistical tests and content analysis using an emerging coding grid inspired from the organized action systems theories. A minimum of two persons from the research team were always involved in the analysis to validate the procedures and the coding.

Clinical and administrative representatives were also involved in different activities to validate the accuracy of the data. Preliminary results were always discussed with them to validate the interpretation of the findings. Clinical and administrative representatives on the committee made sense of the data and helped diffuse the results to their peers within the program and the centre, but also to colleagues from other centers.

The impact of the service reorganization included the following changes in the services offered in the program: groups increased from 20 in 2007 to 47 in 2009, structured community interventions increased from 3 to 11, new admission procedures were created and contributed to reducing the waiting times and the number of children waiting for services by about 50%. All these changes were achieved with a smaller staff to child ratio (1/24 in 2007 and 1/32 in 2009), suggesting greater efficiency in the way services were provided.

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

At the end of the study, the research coordinator and one of the directors of the center met to brainstorm on the possible activities that could be used to disseminate the clinical experience and the research results. Beside traditional congress and scientific articles focusing on specific results, they wanted to develop a product describing the model and the service reorganization experience. They wanted a user-friendly format to reach the broad community and to foster discussion about the issues and potential solutions related to pediatric rehabilitation service delivery. They thus suggested producing a video resuming their experiences. The Executive Board of the centre accepted the project and also provided logistic support for the product’s development. The project was also proposed to the committee of representatives, who also supported the idea and accepted to participate in this initiative. Different meetings were held to discuss the goals, content and intended audiences of the video(s).

Based on her knowledge of the administrative and clinical project (because she was part of the committee of representatives), and on the research results, the research coordinator drafted the first version of the proposed scenario for the videos. She sent it to the different partners in the video project: three research team members, two directors of the centers, the current program head and the other one who initiated the project, four clinical coordinators of the program and six clinicians on the committee of representatives. Content modification of the videos was made based on their comments from a meeting and through email communications, allowing each participant to express freely their views and opinions about the most important aspects of the reorganization process.

A person from the centre’s communication and technology department worked with the clinical coordinator to review the video scenarios and to ensure a high quality product. This person hired a specialized company and coordinated the shooting of the different scenes. He also edited the video and reviewed the pre final product with the research coordinator. The pre final versions were sent for comments to all those who had participated in the shooting of the video. The research coordinator and one of the researchers created the English subtitles so the program’s Anglophone clientele can understand the video contents.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

The shorter version of the video was shown for the first time during a meeting with families and community partners. Comments were very positive and many persons agreed the reorganization experience should be shared with others. The video was perceived as a good tool to share the information about the Children’s and Teenagers’ Program service delivery model, the reorganization process and its outcomes. The two versions of the video are available on the centre’s website (i.e. also available to the general public). Families from the program will be invited to view the video (computers are available in the centre for those who may not have access to a computer or the internet). Families will thus be made more aware of the program's services and should be empowered to participate in the rehabilitation process. Likewise, community partners will be invited to view the video to have a better idea of the program's services. As suggested at the meeting by a participant from a parents' association, community partners do not always know what kind of support they can ask for from the centers, as they do not know all the services offered by the program. By providing information on the new service delivery model and its goals, the video has the potential to foster collaboration and thus ultimately, the development of a more inclusive society.

The video adds to existing knowledge in an original way. Indeed, financial constraints and the quest for quality improvements are pushing for changes, but few models of service delivery are available to guide service reorganization in pediatric rehabilitation. Still, families, clinicians and administrators need some guidance to support their efforts. In that sense, the video provides lessons learnt that are likely to be very useful to others.

The research coordinator and the centre's administrators have been invited on numerous occasions in different settings to present the service reorganization process and the new model of service delivery. The video products will enable reaching more people all across Québec and outside the province. Benefits are thus not only for the local community, that now has access to a better service delivery model and information on the centre's services, but also for similar settings in other regions. The videos can also be used as a political tool, to explain how it's possible to improve the rehabilitation services for children with disabilities. For such changes to happen, the video highlights that funds and administrative support are needed. The potential significance of the videos is thus huge, as they can ultimately make a big difference in the lives of many families.

10. Please describe why you chose the presentation format you did.

The video was perceived to be very user-friendly. The specific study's results have also been reported in other formats including published papers in renowned pediatric scientific journals (24-27). However, to report the overall «experience» and the lessons learned over the reorganization process, we believe a video format is the most appropriate. Indeed, busy family, clinicians and administrators rarely have time to read a lengthy and technical report. Even short reports do not allow one to visualize the kind of services to which we are referring.

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

Several strengths can be identified for the product. First, it’s user-friendly, format is portable and thus can be widely disseminated. The language images used make it appropriate for a variety of audiences. Moreover, having two different versions of the video allows having a more accessible version for the general public, and a longer version providing more scientific information, for individuals interested in detailed information.

The product is the result of a multidisciplinary and multisectorial collaborative project. Indeed, the service reorganization process was rooted in participation action research principles. Likewise, several steps were planned in the development of the video to insure the participation of all those who were concerned with the dissemination of the results. The research coordinator drafted the first version of the proposed scenario but different partners reviewed the script (three members of the research team, two directors of the centers, the current head of the program and the one who initiated the project, the four clinical coordinators of the program and the six clinicians on the committee of representatives). Modifications on the content were made based on their comments from a meeting and through email communications, to allow each participant to express freely their opinions on the reorganization process. For instance, the original descriptions of the first step within the new model sounded too much like a report of the different activities. Based on a social worker’s comment, discussions on values and approaches were also included in the final version. In fact, although a script was drafted for the video, each participant was free to modify, during the shooting, the way they chose how to exactly to share the predetermined message.

The product is not perfect. For instance, despite the efforts to include everyone's point of view, we acknowledge that we were not able to include representatives from community partners or families in the videos. Many of them were not available when the video was being made and we also felt we needed to keep the video relatively short and to the point. Some important information thus may have been omitted; however, persons interested in more detailed information may access our other publications listed in the bibliography (24-27).

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

The PAR was approved by the ethics board of the Center of Interdisciplinary Rehabilitation Research of Montreal. Following PAR principles, a committee of representatives was formed at the beginning of the service reorganization process. Clinicians on this committee were selected by their peers. This committee met regularly during the three-year reorganization process and became a forum for information sharing about clinical, administrative and research issues. Work and responsibilities were shared between everyone, and most of the time, decisions were made by consensus. Disagreements were rare and always managed with respect among the different committee members and the research team members.

Mutual respect is also illustrated via the different mechanisms for consultations that were put into place during the course of the project. For instance, clinicians on the committee of representatives met with their peers once a month to share with them information regarding the service reorganization project. They also brought back to the committee comments from their peers. Moreover, formal data collection process allowed gathering the points of view of families and service providers. More importantly, this information was fed back to the committee for discussion and to guide future actions accordingly.

Shared credit to all representatives who contributed to this project is acknowledged with each dissemination activity. When administrators or clinicians presented the service delivery model and its outcomes, they also referred to the study's results and recognized the researchers' work. When the researchers presented the research results, the work of the clinical team was acknowledged.

Participation of the families in the study was also acknowledged in our publications, especially with regards to data collection. We however recognized the limited involvement of the families and the community partners in the decision-making process during the service reorganization project. Originally, at the same time that the committee of representatives of the CTP was formed, two other committees of representatives were also formed, one composed of family members and the other of community partner representatives. A meeting was organized with each of these groups to present the project and identify their perceptions about children’s needs and potential services. The information collected was used to develop the model. The original plan was to meet with the representatives of the families and the community partners at different points of time during the course of the project to keep them abreast of the project development. However, time constraints prevented us from organizing further meetings with them. One meeting had been planned but had to be cancelled due to the small number of participants who could attend. Fortunately, information on the project advancement was shared informally (during School Board meetings or Parents' association meetings) with the families and the community partners over the course of the project by clinicians and administrators.

One of the lessons learnt during this project was that collaboration needs mutual respect, shared work and shared credit - but it also takes time. Various partnerships existed in the program, but they were oriented towards providing traditional services. To implement the new service model, new types of collaborations were needed. For instance, to implement the community interventions, it took time to identify exactly when formal agreements were needed with the directors of the community partners (e.g. directors' involvement were needed for long term partnership with School Boards but not for organizing a one-time activity with a sports group). When such agreements were needed, the lack of already existing structures for meeting and the busy schedules of the program heads and the directors of the community partners made the implementation of community interventions a lengthy process.