Full Terms & Conditions of access and use can be found athttp://www.tandfonline.com/action/journalInformation?journalCode=yotb20

World Federation of Occupational Therapists Bulletin

ISSN: 1447-3828 (Print) 2056-6077 (Online) Journal homepage: http://www.tandfonline.com/loi/yotb20

Development of a Quality Indicator Framework foroccupational therapy

World Federation of Occupational Therapists, Claudia von Zweck, CarolinaAlchouron, Susan Brandis, Sandra Bressler, Helen Buchanan, TeenaClouston, Camilla Cox, Lucila Moreno, Tim Reistetter & Ariela Zur

To cite this article: World Federation of Occupational Therapists, Claudia von Zweck, CarolinaAlchouron, Susan Brandis, Sandra Bressler, Helen Buchanan, Teena Clouston, CamillaCox, Lucila Moreno, Tim Reistetter & Ariela Zur (2018): Development of a Quality IndicatorFramework for occupational therapy, World Federation of Occupational Therapists Bulletin, DOI:10.1080/14473828.2018.1556962

To link to this article: https://doi.org/10.1080/14473828.2018.1556962

Published online: 27 Dec 2018.

Submit your article to this journal

Article views: 2

View Crossmark data

Development of a Quality Indicator Framework for occupational therapyWorld Federation of Occupational Therapistsa, Claudia von Zweckb, Carolina Alchouronb, Susan Brandisb,Sandra Bresslerb, Helen Buchananb, Teena Clouston b, Camilla Coxb, Lucila Morenob, Tim Reistetter b andAriela Zur b

aWorld Federation of Occupational Therapists (WFOT), Geneva, Switzerland; bWFOT Quality Indicators Project Expert Working Group,Geneva, Switzerland

ABSTRACTOccupational therapists are increasingly expected to implement and monitor indicators ofoccupational therapy quality performance. Goals of quality measurement and improvementinclude enhancing satisfaction of the end-user, optimising the efficient use of resources andimproving health outcomes. A Quality Indicator (QI) Framework with 56 generic indicatorswas developed for occupational therapy by the World Federation of Occupational Therapistsfor selecting, organising and reporting on quality indicators in a structured and meaningfulway. A consultation involving 46 occupational therapists from 21 countries indicated the QIFramework shows promise to help occupational therapists select relevant and usefulmeasures to evaluate their occupational therapy services. Work will, therefore, continue tofurther evaluate and refine the QI Framework, as well as develop resources to support theimplementation and use of the tool.

KEYWORDSEvaluation; performancemeasurement; qualityimprovement; professionalissues

Introduction

The importance of quality measurement is paramountas health and social systems experience significantshifts and transformations, driven by factors such asrising costs, changing demographics, service inequities,increasing litigation and inadequate accountability(Arah, Westert, Hurst, & Klazinga, 2006; Kotter, Blo-zik, & Scherer, 2012). Monitoring of quality indicatorsis central to a system’s sustainability, responsivenessand capacity to drive improvements to attain tangibleresults (Truchon, 2017). Goals of quality measurementand improvement include enhancing satisfaction of theend-user, optimising the efficient use of resources andimproving health outcomes (Berwick, Nolan, & Whit-tington, 2008).

The use of accurate and appropriate measures toevaluate the quality of service provided by occupationaltherapists is essential to promote the implementationof evidence-based decisions that lead to desired healthoutcomes. Effective evidence-based decision-making inoccupational therapy is dependent upon critical think-ing and problem solving, awareness of end-user needsand priorities, as well as consideration of data gatheredthrough objective measurement (Kröger et al., 2007).Opportunity exists for advancing the profession byusing quality measurement to demonstrate how occu-pational therapy contributes to desired population out-comes within our changing environment. Conversely,if efforts are not taken to demonstrate value, occu-pational therapy is at risk of becoming marginalised

(Leland, Crum, Phipps, Roberts, & Gage, 2015; Olinet al., 2014; Sandhu, Furniss, & Metzler, 2018).

Quality performance in occupational therapy relatesto the degree to which services increase the likelihoodof desired outcomes and are consistent with pro-fessional knowledge and evidence-based practice(Hanefeld, Powell-Jackson, & Balabanova, 2017;Mainz, 2003). Occupational therapists are increasinglyexpected, as part of their professional obligations, toimplement and monitor indicators of occupationaltherapy service to improve quality performance(Leland et al., 2015; Roberts & Robinson, 2014; Sandhuet al., 2018; Swedish Association of OccupationalTherapists, 2011). Indicators provide a quantitativemeasure of quality service at a specific point in time.Reviewing performance measurements over time pro-motes transparency and accountability by allowingthe impact of changes to improve quality of occu-pational therapy services to be evaluated (Laverdure,McCann, McLoone, Moore, & Reed, 2018).

As quality is a broad and subjective term, many fac-tors may potentially be measured when using indi-cators to evaluate occupational therapy services.However, no gold standard exists for quality indicatorselection and development (Kotter et al., 2012). The useof a conceptual framework is recommended in theresearch literature as a useful device for selecting,organising and reporting on quality indicators in astructured and meaningful way (Arah, Arah et al.,2006; Arah, Klazinga, Delnoij, Ten Asbroek, & Custers,

© World Federation of Occupational Therapists 2018

CONTACT Claudia von Zweck cvonzweck@gmail.com

WORLD FEDERATION OF OCCUPATIONAL THERAPISTS BULLETINhttps://doi.org/10.1080/14473828.2018.1556962

2003; Brown, 2009; Grimmer et al., 2014). The absenceof such a framework may result in the inconsistent andpotentially inappropriate use of an eclectic mix of indi-cators, with no clear rationale for their selection(Brown, 2009).

An occupational therapy Quality Indicator (QI) Fra-mework was developed as an initiative of the WorldFederation of Occupational Therapists (WFOT), witha purpose of providing a guide for occupational thera-pists practicing in countries around the world to selecta coherent, relevant and balanced set of quality indi-cators to monitor and improve the quality of servicesthey provide. This paper describes the developmentand design of the QI Framework, discusses the resultsof an initial consultation regarding the utility of thetool and outlines next steps for further developmentof the Framework.

Development of the QI Framework

The development of the QI Framework was initiatedfollowing a WFOT review of the use of quality indi-cators in health care. This review identified several rec-ommendations for future work on the topic for theoccupational therapy profession, including a projectto define an international set of indicators that describequality occupational therapy in an interdisciplinarypractice context. An international working groupwith eleven members was assembled to work on theproject in early 2017 with representation of occu-pational therapists with experience with quality

measurement from diverse geographic and practiceareas. Meetings of the group were held by Skype on amonthly basis to complete the work of the project.The efforts of the working group culminated in thedevelopment of the draft QI Framework described inthis paper.

Design of the WFOT QI Framework

The WFOT QI Framework provides a basket of indi-cators from which occupational therapists may chooseto evaluate quality. A systematic process is used withthe QI Framework to ensure consideration of elementsof quality most relevant to an occupational therapypractice setting for selecting and monitoring indicators.By providing a comprehensive range of indicators forquality issues of importance to the occupationaltherapy profession, the QI Framework provides choicefor measuring service quality using indicators that rep-resent areas of greatest priority to occupational thera-pists and the end recipients of their services.

The QI Framework is outlined using a matrix modeldesign, with quality dimensions described along thehorizontal plane and quality perspectives defined onthe vertical axis (Table 1). The QI Framework, there-fore, outlines what aspects or dimensions of qualityof an occupational therapy service require measure-ment, as well as defines different perspectives for deter-mining how quality is measured (Arah et al., 2003,2006). Generic indicators for measuring quality ofoccupational therapy services are identified for each

Table 1. Quality indicators framework.

2 C. VON ZWECK ET AL.

cell of the Framework. Indicators review quality at anaggregate level and are explicitly defined, usuallyexpressed as a number or percentage relating to a per-formance standard.

To ensure that QI Framework measures are consist-ent with the basic tenets of occupational therapy, thefollowing assumptions are made regarding the servicesmonitored by the indicators:

. Occupational therapy promotes health and well-being through occupation (WFOT, 2010a);

. Occupational therapy promotes an inclusive societyin which all persons benefit from equitable opportu-nities for participation (adapted from WFOT,2010b); and

. Occupational therapy operates within a systemsapproach to influence the interaction of person,environment and occupation for the enhancementof occupational participation (WFOT, 2010a).

Quality dimensions

Quality dimensions are definable and measurableaspects of health services that are related to restoring,improving or maintaining health (Arah et al., 2006).Quality dimensions identified in the research literaturewere reviewed by the WFOT Expert Working Group toselect those most relevant to occupational therapy ser-vices to include in the QI Framework. The selecteddimensions are listed in Table 2.

For the purposes of the QI Framework, the qualitydimension of accessibility refers to the ease of obtainingoccupational therapy services from a physical, financialor social perspective (Kelley & Hurst, 2006). Appropri-ateness requires that the right occupational therapy ser-vices are delivered by the right person, at the right time,to the right person in the right place (De Schreye,Houttekier, Deliens, & Cohen, 2017; Kelley & Hurst,2006). The optimal use of resources in occupationaltherapy to yield maximum benefits is needed for the

quality of efficiency (Arah et al., 2006). Effectiveness isthe degree of achieving desired outcomes that is depen-dent on the provision of evidence-based services con-sistent with occupation-focused and strength-basedenablement principles of occupational therapy practiceto those who could benefit (Arah et al., 2003; Kelley &Hurst, 2006).

The ability to meet legitimate expectations of theend recipient for occupational therapy services is con-sidered under the quality dimension of person-centred-ness. Person-centredness requires that the experienceof receiving occupational therapy services is consideredfrom the standpoint of the end recipient of the service(Arah et al., 2006). This perspective is congruent withthe humanist philosophy that guides occupationaltherapy practice to establish a person-centred relation-ship with the individuals, families, groups, commu-nities, organisations and populations served by theprofession (WFOT, 2010a). A wide variety of termsare used in occupational therapy practice to describethe end recipients of occupational therapy services; innaming the quality dimension as person-centred, it isacknowledged that personmay be used interchangeablywith patient, client, consumer, service user or any otherterm that is best suited for the occupational therapyservice.

The quality dimension of safety considers the degreeto which risk enablement and avoidance of harm isconsidered in the provision of occupational therapyservices (Arah et al., 2006; Kelley & Hurst, 2006).Lastly, inclusion of sustainability as a quality dimen-sion reflects the increasing importance of qualityinitiatives that maximise continued improvement andextend quality occupational therapy services into thefuture, by using resources to deliver health care todaywithout compromising the health of current or futuregenerations (WFOT, 2018). Sustainable practicesaddress economic, social, as well as environmentalagendas and reflect core occupational therapy valuesand beliefs regarding client-centredness, empower-ment and preventative intervention (WFOT, 2012).

Quality perspectives

Consistent with the Donabedian model of health qual-ity (1966), it is expected that occupational therapy indi-cators measure quality by evaluating structure, processor outcome. Each type of indicator evaluates qualityfrom a different perspective (Ayanian & Markel,2016; Donabedian, 1966; Schiff & Rucker, 2001). Struc-ture indicators assess environmental factors andresources required to deliver quality occupationaltherapy services; process indicators evaluate how occu-pational therapy is delivered to ensure quality service;and outcome indicators measure changes occurring asthe result of occupational therapy intervention(adapted from Donabedian, 1966).

Table 2. Quality dimensions.Accessibility The ease in obtaining occupational therapy services

from a physical, financial or social perspective.Appropriateness The degree to which right occupational therapy

services are delivered by the right person, at theright time, to the right person in the right place.

Effectiveness The degree of achieving desirable outcomes, given thecorrect provision of evidence-based andoccupation-focused health care services to all whocould benefit.

Efficiency The optimal use of resources in occupational therapyto yield maximum benefits.

Person-centredness

The experience of receiving occupational therapyservices from the perspective of the end recipient ofthe service.

Safety The degree of reduction of risk and avoidance of harmin the provision of occupational therapy services.

Sustainability The use of resources for occupational therapy serviceswithout compromising the health of current orfuture generations.

WORLD FEDERATION OF OCCUPATIONAL THERAPISTS BULLETIN 3

Each type of indicator has inherent advantages anddisadvantages for effective quality measurement. Forexample, structural indicators such as the presence ofrequired resources for quality service may be easier tomeasure in some contexts, but do not ensure use ofappropriate process to attain quality outcomes. Indi-cators that measure process are useful only to thedegree that the processes measured are known to beneeded and appropriate for the outcomes desired.Measurement of outcomes may be complicated bydifficulties in isolating the variable under investigationfrom other potential influencing factors (Hanefeldet al., 2017; Kelley & Hurst, 2006). A perceived lackof control over the results of outcome indicators, there-fore, may result in limited efforts towards qualityimprovement (Gort, Broekhuis, & Regts, 2013).

Generic indicators

The development of a QI Framework for occupationaltherapy by theWFOT international working group waschallenged by the wide array of practice areas andpopulations served by occupational therapists, as wellas the differences in the way occupational therapy isprovided around the world as result of factors suchas government policy and resource allocation. The QIFramework, therefore, identifies high level, genericindicators that may be applicable to the services pro-vided by all occupational therapists, regardless oflocation, settings and populations served. The genericindicators are appropriate for practice in areas of differ-ing levels of economic development, from low-incomecountries to highly resourced nations. The indicatorsreflect the profession’s beliefs in the value of occu-pation and the importance of occupational perform-ance and engagement (WFOT, 2010a). The indicatorsare also relevant from a population, organisation,team and/or individual perspective regarding the qual-ity of services provided.

The QI Framework includes 56 generic indicators.The indicators are outlined for each of the seven qualitydimensions from the perspective of structure, processand outcome, Given the challenges of measuring qualityand the diversity of occupational therapy practice, a var-iety of structure, process and outcome indicators areprovided to offer choices for how quality of occupationaltherapy services may be measured for each dimension.As an example, an indicator evaluating structure toassess person-centredness of occupational therapy ser-vices may determine the availability of staff andresources to enable shared decision-making, informedchoice and enabling participation in occupational inter-ventions. Process indicators for the same quality dimen-sion may examine audit findings regarding complianceof occupational therapists with approaching all personsreceiving their services with respect. Outcomes assessedmay include the percentage of service recipients that

report occupational therapists treat them with respect,kindness, compassion, understanding and honesty.Additional examples of generic indicators for differentquality dimensions are outlined in Table 3.

Implementation of quality indicators

A multi-step process is recommended to use the QIFramework to identify and implement the use of qual-ity indicators in an occupational therapy practice set-ting, as outlined in Figure 1. The process involvesconsideration of priority issues within a practice inorder to identify indicators that have greatest relevancefor promoting quality performance. Essential elementsof the process include: specifying a clear purpose andgoals for the quality indicators; incorporating evidence,expertise and end user perspectives while consideringcontext and variation; and identifying data collectionand management processes (Gort et al., 2013).

Step 1: describe the practice

The first step of the quality indicator implementationprocess involves explicitly defining an occupationaltherapy practice. This step is critical to ensure a commonand consistent understanding of the services to be mon-itored by the quality indicators. The practice is describedby considering factors such as themission of the organis-ation, population(s) served, type of service(s) offered,practice location(s), setting(s) and practitioners involvedin service delivery. High risk, high volume and highimpact activities are identified because of their potentialsignificant influence on quality of service.

Step 2: understand the context

A SWOT analysis examines Strengths (favourable attri-butes contributing to the mission); Weaknesses(internal factors impeding quality and service); Oppor-tunities (beneficial external factors and trends); andThreats (external conditions that could cause harmor weaken chances to be successful). A SWOT analysisundertaken in step two is critical to understanding thecontext in which the practice operates and examiningthe internal and external factors that impact the qualityof occupational therapy services provided.

Step 3: identify quality goals

The results of the SWOT analysis are used in step threeto determine the goals and priorities of the occu-pational therapy practice for quality monitoring andimprovement. The priorities may address how risksand threats to service quality can be avoided. Prioritiescan also build on strengths to develop opportunitiesidentified in the SWOT analysis to improve service.

4 C. VON ZWECK ET AL.

Step 4: select generic indicators

Step 4 involves identifying the generic indicators mostappropriate for monitoring the identified priority qualitygoals. Each of the quality dimensions in the quality frame-work is reviewed during this step for relevance and impor-tance in monitoring quality goals and priorities. Genericindicators may be selected relating to structure, processandoutcome to evaluate different perspectives of the issue.

Step 5: define practice-specific SMART indicators

In Step 5, selected generic indicators are explicitlydefined as practice specific indicators. Practice specificindicators meet the unique needs of the occupationaltherapy practice and reflect factors such as the qualitypriorities of the setting, perspectives of end-users,research evidence, consensus opinion, requirementsand expectations of the national or regional health

Table 3. Sample generic indicators.

Figure 1. Quality indicator implementation process.

WORLD FEDERATION OF OCCUPATIONAL THERAPISTS BULLETIN 5

system, as well as the data and data measurementresources available to monitor quality issues.

To be effective in driving change for qualityimprovement, practice specific indicators must includea number of key characteristics. For example, the indi-cator must be a valid measure that provides usefulinformation regarding an important factor that influ-ences the quality of occupational therapy service(Laverdure et al., 2018). The indicator must be clearlystated to allow reliability over time and among differentevaluators and settings (Kotter et al., 2012). Actionabil-ity and controllability are also important consider-ations to ensure opportunity for change in the factorsthat influence quality performance (Gort et al., 2013;Mainz, 2003). Desirable elements of practice specificindicators to promote quality occupational therapy ser-vices are summarised using the SMART acronym inTable 4. The concept of SMART is well recognisedinternationally (Macleod, 2012) and is used to promoteunderstanding and use of the criteria.

Step 6: implement indicators and trend data

The sixth and final step involves implementing themeasurement of the SMART practice specific indi-cators to monitor the quality of service provided byan occupational therapy practice. The indicators arefirst trialled and refined as necessary to ensure data col-lection is feasible and the information obtained is validand reliable. The development of an implementationstrategy is recommended for the successful real-lifeapplication of quality indicators (Kotter et al., 2012).Monitoring of the indicator data can then assess thescope of the priority quality issues and identify trendsthat may be shaped by different factors. Through regu-lar review of indicator results, the impact of imple-menting quality improvement initiatives can bemeasured.

Consultation study

To obtain feedback regarding the potential utility of thedraft QI Framework, a consultation was undertaken bymembers of the international working group at the2018 WFOT Congress held in Cape Town, SouthAfrica. During the two-hour workshop, volunteer par-ticipants were given the opportunity to work in smallgroups to use the draft QI Framework to develop prac-tice-specific indicators for a quality priority in theirpractice. A written feedback form completed after theworkshop was used to collect information from partici-pants regarding the potential use of the tool. The formrequested demographic information regarding the role,practice setting and home country of each participant.A five-point Likert scale was used to rate the potentialutility of the QI Framework, with higher scores repre-senting greater usefulness. Participants were also givenopportunity to provide comments regarding the QIFramework.

Completed feedback forms were received from all 46delegates that participated in the consultation. The datacollected indicated participants attended from a cross-section of 21 low, medium- and high-income countries.Many participants had multiple roles in their occu-pational therapy practice. Fifty-seven percent of par-ticipants worked in clinical practice, with 24%identifying as managers or administrators. Forty per-cent of participants were educators and 13% hadresearch roles. The primary practice setting of the par-ticipants was most frequently an educational facility(33%), followed by community practice (26%), acutecare (22%), rehabilitation facility (15%), private prac-tice (11%) and other settings (13%).

While participants were noted to vary significantlyin their knowledge and background regarding qualitymeasurement, all small groups were successful in com-pleting the exercise to identify practice-specific indi-cators using the QI Framework for their identifiedquality issue. When asked to rate the potential useful-ness of the QI Framework, an average rating of 4/5was provided by participants. Positive commentsrelated to the potential for use of the framework to pro-mote quality practice; allow comparison of practiceacross jurisdictions; collect culturally responsive andsensitive data; and provide evidence to support thevalue of occupational therapy when speaking with fun-ders and administrators. Concerns that may limit theuse of the tool included: difficulties understanding con-cepts associated with quality measurement; and theneed for time and money to implement the use of qual-ity indicators. Some participants stated that additionaleducation and support was needed for them to be com-fortable with using the QI Framework.

Feedback from this initial consultation did notnecessitate substantive revision of the design and con-tent of the draft QI Framework, although it was

Table 4. Quality indicator SMART criteria.SMARTcriterion Description

Specific • The indicator is well defined and clear;• ‘What’, ‘why’, ‘who’, ‘where’ and ‘when’ are explained.

Measurable • The chosen measure is valid, reliable and discriminateswell, with high specificity and sensitivity;

• The cost or burden of measurement is acceptable;• Comparable data is available regionally, nationally and/or internationally.

Agreed upon • The indicator is based on a standard of care;• Strong evidence exists that what is measured affectsimportant outcomes as measured by high-qualityresearch;

• When scientific evidence is lacking, the standard isdetermined by an expert panel in a consensus processbased on experience.

Relevant • The indicator provides useful information;• Variability exists in the performance of the measure.

Timely • The indicator addresses issues of current and futureimportance;

• Opportunity currently exists to influence change ormaintenance of a current standard of service is critical.

6 C. VON ZWECK ET AL.

recognised by the Expert Working Group thatadditional pilot testing of the Framework was necessaryto receive additional input. Suggestions of the partici-pants were utilised for the design of educationalresources for use during the pilot testing, includingthe development of a QI Framework Manual.

Next steps

More intensive pilot testing of the QI Framework isplanned by the international project working group.Objectives for the pilot testing include trialling theuse of the QI Framework in diverse locations aroundthe world with occupational therapists from differenttypes of practice settings. Feedback provided by theparticipants will be used to further refine the QI Frame-work and the supporting resources to assist occu-pational therapists with design and implementationof quality indicators for their practice.

Summary and conclusions

Occupational therapists want and need to evaluate thequality of services they provide. In a climate of changewithin the health and social systems that occupationaltherapists operate, the provision of objective data isintegral to position the profession to provide valuedand required services. The QI Framework provides atool and process to ensure a comprehensive review ofissues that may impact the provision of quality occu-pational therapy services.

The results of an initial consultation regarding theQI Framework indicates that the tool shows promisein helping occupational therapists select relevant anduseful measures to evaluate occupational therapy ser-vices. The work of the WFOT Expert WorkingGroup, therefore, will continue to further evaluateand refine this tool. Next steps in the evaluation ofthe QI Framework include pilot testing of the tool invaried occupational therapy practice settings aroundthe world, plus development of resources to supportits implementation and use. Through continued workon the QI Framework, it is hoped that occupationaltherapists will be enabled to meet their obligations toimprove service provision and demonstrate account-ability for the quality of occupational therapy theyprovide.

Disclosure statement

No potential conflict of interest was reported by the authors.

ORCID

Teena Clouston http://orcid.org/0000-0003-0032-5473Tim Reistetter http://orcid.org/0000-0003-1732-5533Ariela Zur http://orcid.org/0000-0002-3028-8098

References

Arah, O., Klazinga, N., Delnoij, D., Ten Asbroek, A., &Custers, T. (2003). Conceptual frameworks for health sys-tems performance: A quest for effectiveness, quality andimprovement. International Journal for Quality inHealth Care, 15(5), 377–398.

Arah, O., Westert, G., Hurst, J., & Klazinga, N. (2006). Aconceptual framework for the OECD health care qualityindicators project. International Journal for Quality inHealth Care, 18(1), 5–13.

Ayanian, J. Z., & Markel, H. (2016). Donabedian’s lastingframework for health care quality. New England Journalof Medicine, 375(3), 205–207.

Berwick, D., Nolan, T., & Whittington, J. (2008). The tripleaim: Care, health, and cost.Health Affairs, 27(3), 759–769.

Brown, D. (2009). Good practice guidelines for indicatordevelopment and reporting. Retrieved from https://www.oecd.org/site/progresskorea/43586563.pdf

De Schreye, R., Houttekier, D., Deliens, L., & Cohen, J.(2017). Developing indicators of appropriate and inap-propriate end-of-life care in people with Alzheimer’s dis-ease, cancer or chronic obstructive pulmonary disease forpopulation-level administrative databases: A RAND/UCLA appropriateness study. Palliative Medicine, 31(10), 932–945.

Donabedian, A. (1966). Evaluating the quality ofmedical care. The Milbank Memorial Fund Quarterly,44, 166–206.

Gort, M., Broekhuis, M., & Regts, G. (2013). How teams useindicators for quality improvement – a multiple-casestudy on the use of multiple indicators in multidisciplin-ary breast cancer teams. Social Science & Medicine, 96,69–77.

Grimmer, K., Lizarondo, L., Kumar, S., Bell, E., Buist, M., &Weinstein, P. (2014). An evidence-based framework tomeasure quality of allied health care. Health ResearchPolicy and Systems, 12, 1–10. doi:10.1186/1478-4505-12-10

Hanefeld, J., Powell-Jackson, T., & Balabanova, D. (2017).Understanding and measuring quality of care: Dealingwith complexity. Bulletin of the World HealthOrganization, 95, 368–374.

Kelley, E. & Hurst, J. (2006). Health care quality indicatorsproject: Conceptual framework paper (OECD HealthWorking Papers, No. 23). doi:10.1787/440134737301

Kotter, T., Blozik, E., & Scherer, M. (2012). Methods for theguideline-based development of quality indicators – a sys-tematic review. Implementation Science, 7(21), 1–22.

Kröger, E., Tourigny, A., Morin, D., Côté, L., Kergoat, M. J.,Lebel, P.,… Benounissa, Z. (2007). Selecting process qual-ity indicators for the integrated care of vulnerable olderadults affected by cognitive impairment or dementia.BMC Health Services Research, 7, 1–9.

Laverdure, P., McCann, M., McLoone, H., Moore, L., & Reed,L. (2018). Developing quality indicators for school prac-tice. Journal of Occupational Therapy, Schools, & EarlyIntervention, 11, 1–13.

Leland, N., Crum, K., Phipps, S., Roberts, P., & Gage, B.(2015). Advancing the value and quality of occupationaltherapy in health service delivery. American Journal ofOccupational Therapy, 69(1), 1–7.

Macleod, L. (2012). Making SMART goals smarter. PhysicianExecutive, 38(2), 68.

Mainz, J. (2003). Defining and classifying clinical indicatorsfor quality improvement. International Journal forQuality in Health Care, 15(6), 523–530.

WORLD FEDERATION OF OCCUPATIONAL THERAPISTS BULLETIN 7

Olin, S., Kutash, K., Pollock, M., Burns, B., Kuppinger, A.,Craig, N.,…Hoagwood, K. (2014). Developing quality indi-cators for family support services in community team-basedmental health care. Administration and Policy in MentalHealth and Mental Health Services Research, 41, 7–20.

Roberts, P., & Robinson, M. (2014). Occupational therapy’srole in preventing acute readmissions. American Journalof Occupational Therapy, 68, 254–259.

Sandhu, S., Furniss, J., & Metzler, C. (2018). Using the newpostacute care quality measures to demonstrate thevalue of occupational therapy. American Journal ofOccupational Therapy, 72, 1–6. doi:10.5014/ajot.2018.722002

Schiff, G. D., & Rucker, T. D. (2001). Beyond structure-pro-cess-outcome: Donabedian’s seven pillars and eleven but-tresses of quality. The Joint Commission Journal onQuality Improvement, 27(3), 169–174.

Swedish Association of Occupational Therapy. (2011).Quality policy. Nacka: Author.

Truchon, C. (2017). Shaping quality through vision, struc-ture, and monitoring Oof performance and quality indi-cators: Impact story from the Quebec Trauma Network.International Journal of Technology Assessment inHealth Care, 33(4), 415–419.

World Federation of Occupational Therapists. (2010a).Position statement: Client centeredness in occupationaltherapy. Retrieved from http://www.wfot.org

World Federation of Occupational Therapists. (2010b).Position statement: Diversity and culture. Retrieved fromhttp://www.wfot.org

World Federation of Occupational Therapists. (2012).Position statement: Environment sustainability, sustain-able practice with occupational therapy. Retrieved fromhttp://www.wfot.org

World Federation of Occupational Therapists. (2018).Sustainability matters: Guiding principles for sustainabilityin occupational therapy practice, education and scholar-ship. Retrieved from http://www.wfot.org

8 C. VON ZWECK ET AL.