THE ISSUE IS . . .

Creating Evidence for Practice Using Data-Driven

Decision Making

Roseann C. Schaaf

MeSH TERMS To realize the American Occupational Therapy Association’s Centennial Vision, occupational therapy

data collection practitioners must embrace practices that are not only evidence based but also systematic, theoretically grounded,
and driven by data related to outcomes. This article presents a framework, the Data-Driven Decision Making

decision making
(DDDM) process, to guide clinicians’ occupational therapy practice using systematic clinical reasoning with

evidence-based practice a focus on data. Examples are provided of DDDM in pediatrics and adult rehabilitation to guide practitioners

occupational therapy in using data-driven practices to create evidence for occupational therapy.

outcome and process assessment
(health care) Schaaf, R. C. (2015). The Issue Is—Creating evidence for practice using Data-Driven Decision Making. American Journal
of Occupational Therapy, 69, 6902360010. http://dx.doi.org/10.5014/ajot.2015.010561

Roseann C. Schaaf, PhD, OTR/L, FAOTA, is

Professor and Chair, Department of Occupational
Therapy, Jefferson School of Health Professions,
T he Patient Protection and Affordable
Care Act of 2010 (Pub. L. 111–148) has
created an environment in which health
therapy research can make toward evidence-
based practice” (p. 700), and Frolek Clark
(2010) provided specific strategies for us-
and Faculty, Farber Institute for Neurosciences,
Thomas Jefferson University, Philadelphia, PA; care professionals must redefine their skills ing data to guide practice decisions. How-
roseann.schaaf@jefferson.edu and expertise to ensure optimal outcomes ever, despite this widespread emphasis on
using evidence-based practices. Fortu- evidence-based practice and the use of
nately, the American Occupational Ther- outcome measures to document interven-
apy Association (AOTA) promotes these tion effects, the literature has consistently
practices in occupational therapy through shown that rehabilitation professionals are
its Centennial Vision (AOTA, 2007) by not using evidence and data to guide and
envisioning the profession as “powerful, measure their interventions. Barriers include
widely recognized, science-driven, and clinicians’ perceived lack of time, knowl-
evidence-based” (p. 614). To realize this edge, and skill and the belief that a reliance
vision, Burke and Gitlin (2012) and Schaaf on evidence may limit their ability to pro-
and Blanche (2012) urged the adoption of vide client-centered or family-centered care
evidence-based strategies by the field of (King, Wright, & Russell, 2011).
occupational therapy to sustain and validate To realize the Centennial Vision, occu-
clinical practice. Moreover, Gutman (2009) pational therapy practitioners must embrace
warned that for occupational therapy to sur- practices that are not only evidence based but
vive in today’s health care environment, we also systematic, theoretically grounded, and
must “generate evidence for practice” (p. 670). driven by data (Gutman, 2010). Fleming-
Many occupational therapy leaders Castaldy and Gillen (2013) called for a culture
have supported this vision. For example, shift whereby practitioners move away from
Law, Baum, and Dunn (2005) advocated practices based on tradition alone and move to
that outcome measurement must be the a profession informed by evidence. To ac-
standard for occupational therapy practice, complish this objective, Jette (2012) suggested
and Kielhofner (2008) emphasized the use that “therapists become interested in data”
of assessment data to guide intervention (p. 1221) and skilled in solving problems based
and evaluate outcomes. Sudsawad (2006) on data. By doing so, occupational therapy
noted that “creating outcome research practitioners can create evidence through their
that is usable for practice is one of the everyday practice. The purpose of this article
most important contributions occupational is to present the Data-Driven Decision

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 Making (DDDM) Process (Schaaf, 2011)
and its application to occupational therapy
practice. This framework is drawn from the
extensive literature on evidence-based prac-
tices, including the works of Sugari and
Hagan-Burke (2001) and McEwen (2009)
and personal conversation with T. Benevides,
E. I. Blanche, D. Kelly, J. Hunt, E. van
Hooydonk, P. Faller, Z. Mailloux, and
R. Freeman (January 15, 2010). A unique
feature of DDDM is its use of systematic
clinical reasoning with a focus on data.
One important aspect of creating a
profession that embraces evidence-based
practices and utilizes measurement of
outcomes as part of everyday practice is to
clearly articulate the unique contribution
of the profession and set interventions
within it. Occupational therapy practi-
tioners have expertise in the facilitation of
successful participation in daily life across
the lifespan (Law, 2002). We accomplish
this facilitation by appreciating the client
Figure 1. Data-Driven Decision Making process.
within his or her life context and creating
bridges to health and participation (World
Health Organization, 2002). Practitioners 2. Describe the current level of function- tivities and strategies so they can be
also have unique skills for crafting in- ing in each area. replicated. Document the frequency,
dividually tailored interventions based on 3. Identify factors that may interfere intensity, and time course of these
personal and environmental factors to fa- with participation for each identified activities and strategies.
cilitate health and participation. We must goal by making observations; taking 8. Identify the proximal and distal out-
continue to clearly articulate this unique the client’s history; and having dis- comes that will be used to monitor prog-
expertise, use it systematically, and eval- cussions with the client, family mem- ress toward goals. These outcomes are
uate the impact of occupational therapy bers, teachers, and others. directly related to the hypothesized
interventions on participation, health, 4. Conduct standardized and systematic factors affecting participation and in-
and quality of life by collecting data on assessments. Use specific assessments to clude individual and environmental
these outcomes. As Law (2002) stated, “Oc- evaluate the potential factors that affect strengths and barriers. Proximal out-
cupational therapy, at its best, measures each occupational challenge. The choice comes are the identified factors that
outcomes of participation” (p. 646). Thus, of assessment tools is based on informa- affect participation (e.g., poor praxis,
important components of occupational ther- tion gleaned from Steps 1 and 2 and is decreased cognition or motivation, pov-
apy practice and research include identifying guided by the practitioner’s clinical rea- erty of movement, spasticity, difficulty
factors that may affect successful participa- soning and theoretical perspective. As- processing and integrating sensation;
tion and health, designing interventions to sessment data are summarized and guide Melnyk & Morrison-Beedy, 2012).
enhance participation and health, and the development of the hypotheses. Distal outcomes are the skills, abilities,
providing data to evaluate outcomes. 5. Identify strengths and barriers to par- and behaviors that are expected to
ticipation. Ascertain the individual and change in response to the intervention
environmental (social, physical, and (Melnyk & Morrison-Beedy, 2012).
Data-Driven Decision Making cultural) strengths that can be used to These outcomes are directly related to
DDDM provides a framework for reasoning support participation in meeting goals the participation challenges and goals
through the occupational therapy process and the environmental factors that may identified in Step 1.
with a focus on utilization of data to guide be barriers to successful participation. 9. Conduct the intervention.
and measure outcomes. The DDDM pro- 6. Generate specific hypotheses regarding 10. Collect, display, and analyze data with
cess comprises a series of steps designed to the factors that affect successful partic- a chart, bar graph, line graph, or table
organize and guide reasoning (Figure 1): ipation by using assessment findings. for analysis.
1. Identify participation challenges and 7. Design the intervention. Develop and 11. Monitor progress. Modify hypotheses
goals. explicate specific evidence-based ac- and intervention as needed on the

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 basis of outcome data. Additional as- ized trial of occupational therapy using The occupational therapy inter-
sessments may be performed to further Ayres Sensory Integration® for children ventionists then used an evidence-based,
the development of the hypothesis. with autism (Schaaf et al., 2014), we used manualized intervention based on sensory
Generating hypotheses that are the- DDDM to guide the occupational therapy integration theory to craft sensorimotor
oretically driven and that use assessment intervention and to measure outcomes. activities and environmental adaptations
data to identify the factors affecting par- Assessment data were translated into to facilitate participation and goal attain-
ticipation and identifying and measur- individually tailored interventions, ensur- ment. The intervention was systematically
ing outcomes that are both proximal ing that the occupational therapists created described and replicable and individually
and distal to participation goals are key interventions that were theory and evi- tailored to each child’s needs. Importantly,
to this process because they provide dence based and that addressed the outcomes were identified and measured,
a link between function and occupation. sensorimotor factors hypothesized to be and findings were organized graphically
Using this process, occupational therapy affecting each child’s participation in for analysis and used to tailor, adjust, or
practitioners can articulate a clear ra- identified goals. The independent eval- refocus the intervention plan. (Table 1
tionale for the intervention and objec- uators in this study used the DDDM table details an example of this process for
tive outcome markers. Hypotheses can be (illustrated in Table 1) to (1) guide the use one child in the study.) Thus, the inter-
tested and confirmed or revised on the of standardized assessment data in combi- vention was rigorously tested, providing
basis of solid data. The review, display, nation with history taking and observational data on outcomes. Participants who re-
and analysis of outcome data provide data to identify participation-focused goals ceived the intervention (n 5 17) scored
objective evaluation of outcomes that af- (identified by the parent) for each child; (2) significantly higher on goal attainment
fect function and participation in valued analyze, synthesize, and interpret the data in scaling (p 5 .003, d 5 1.2) and signifi-
occupations. Clinicians can use the light of the proposed contribution to the cantly decreased their need for caregiver
DDDM process to systematically identify child’s participation goals; (3) create hy- assistance for self-care (p 5 .008, d 5 0.9)
and test their reasoning process by ac- potheses that clearly articulated the pro- and socialization (p 5 .04, d 5 0.7) as
quiring outcome data about the occupa- posed supports and barriers to the identified measured by the Pediatric Evaluation of
tional therapy intervention. areas of need; (4) identify outcomes and Disability Inventory (Haley, Coster, Ludlow,
methods to measure these outcomes; and Haltiwanger, & Andrellos, 1992) com-
Application to Practice: Sensory (5) provide this information to the occupa- pared with the control group (n 5 15).
Integration
tional therapy interventionist in a way that Qualitative data obtained from parent and
We have begun to systematically test created a seamless link between assessment teacher interviews supported these quanti-
DDDM in practice. In a recent random- data and intervention approach. tative findings.

Table 1. Data-Driven Decision Making: Example of Steps 1–9 Using Ayres Sensory Integration® Theory
Identify
Participation Describe Current Level Proximal and
Challenge and and Factors Affecting Identify Strengths Hypothesis Design and Conduct Distal Outcome
Goal Participation Conduct Assessment and Barriers Generation Intervention Measures
To play with Child prefers to play Sensory Processing Strength Overresponsivity to tactile Discuss the impact Proximal
others during alone, and when Measure (SPM; Child enjoys playing and auditory sensations of the environment Child’s tactile and
preschool others approach, Parham, Ecker, with trucks. makes it difficult for the on sensory processing auditory reactivity
he moves away; Kuhaneck, Henry, & child to tolerate others and behavior with as measured by
he may become Glennon, 2007) Challenge in the environment. classroom staff, and SPM and charting
physically shows overreactivity Environment is noisy identify strategies for of behaviors
aggressive. to tactile and and cluttered, Decreased body reducing noise and (improvement in
auditory sensations, which affects play. awareness related clutter in the play body awareness
He is overly focused decreased body to underresponsivity environment. as measured
on objects. awareness, and and seeking of by SPM).
underreactivity proprioceptive Implement supervised,
He tends to and vestibular active sensory–motor Distal
play roughly, to proprioceptive
and vestibular sensations result activities using sensory Number of minutes
including in overly rough play integration theory to spent in parallel
pushing or sensations with
active seeking of with others. decrease sensory play during free
shoving. seeking, underresponsivity play time, as
these sensations.
of vestibular and measured
Delayed play skills proprioceptive sensations, by daily charting.
based on Revised and overresponsivity
Knox Preschool to tactile and auditory
Play Scale stimuli (e.g., climbing
(Knox, 2008) up slide on playground,
riding toys with peers,
rolling down grassy hill,
playing on climbing
structures).

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 for occupational therapy practitioners in-
terested in implementing similar strategies.

Strategies for Action

To remain a leader in health care, the oc-
cupational therapy profession must generate
practice-based evidence. Several strategies
are recommended to realize this goal. First,
practitioners can use DDDM as part of their
routine practice. This framework provides
Figure 2. Proximal outcomes: Change in active range of motion of right upper extremity. a strategy for clearly articulating the occu-
Note. ABD/ADD 5 abduction/adduction; Admit 5 at admission; ER 5 external rotation; pational therapy reasoning process. By fol-
ext 5 extension; flex 5 flexion; IR 5 internal rotation.
lowing the steps outlined in DDDM, the
practitioner systematically tests occupational
Application to Practice: Rehabilitation did self-care skills, including the ability
therapy intervention and provides evidence
of the client to feed himself and drink
DDDM was used in rehabilitation prac- for practice. As Forsyth, Summerfield
independently as measured by the FIM ™ Mann, and Kielhofner (2005) and Ohtake,
tice for a client with an incomplete C5–C6
spinal cord injury whose goal was to be- (Deutsch, Braun, & Granger, 1997; Kidd Strasser, and Needham (2013) suggested,
come independent in drinking from a cup et al., 1995; Figure 3). Further, perceived knowledge for practice is generated when
and self-feeding so that he could resume the use of the upper extremity improved as clinicians link theory to practice, thereby
occupations of dining with his significant measured by increase in scores on the Ca- engaging in practice scholarship. DDDM
other and hanging out with his friends pabilities of Upper Extremity instrument adds to this concept, providing a strategy to
while watching sporting events (Sledziewski, (Marino, Shea, & Stineman, 1998), and the identify, collect, display, and analyze out-
Schaaf, & Mount, 2012). Using assess- client’s perceived quality of life improved as come data.
ment data, the occupational therapist (first he was better able to participate in desired Second, publication of these data
author) determined that decreased strength occupations. informs practice, allowing the profession
and range of motion were the primary fac- The efficacy of the intervention for to build its repertoire of evidence. AJOT
tors limiting the client’s ability to bring this client was demonstrated by system- supports this effort by providing an outlet
a cup and fork to his mouth, and they then atically implementing an occupational to disseminate practice-based research,
developed an evidence-based intervention. therapy intervention based on solid as- adding to the profession’s knowledge base
Data on strength and range of motion sessment data and measuring, document- (Gutman, 2008). Third, on a professional
(proximal outcomes) and self-feeding and ing, and charting outcomes. Publication of association level, AOTA and the American
drinking (distal outcomes) were collected. this case report in the American Journal of Occupational Therapy Foundation can
After 4 wk of intervention, data analysis Occupational Therapy (AJOT; Sledziewski further support these efforts by providing
showed that strength and range of motion et al., 2012) provided evidence-based data training opportunities in outcome-driven
in elbow flexion improved (Figure 2), as for occupational therapy and an example approaches and continuing to support the

Figure 3. Distal outcomes: Change in FIM scores.

Note. Admit 5 at admission; D/C 5 at discharge; LE 5 lower extremity; UE 5 upper extremity.

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 development of research capacity in the of outcome data can scientifically vali- in a 3-year-old boy. American Journal of Oc-
field. Finally, education programs must date occupational therapy practice. cupational Therapy, 67, 601–606. http://dx.
train students with the skills and knowl- • DDDM provides a mechanism to cre- doi.org/10.5014/ajot.2013.008086
edge to participate in practice-based re- ate evidence through practice by utiliz- Burke, J. P., & Gitlin, L. N. (2012). The Issue
search, ensuring that their occupational Is—How do we change practice when we
ing data to guide and measure practice.
have the evidence? American Journal of Oc-
therapy skills not only are theory and • Occupational therapy practitioners’ ex-
cupational Therapy, 66, e85–e88. http://
evidence based but also designed to pro- pertise in facilitating participation and
dx.doi.org/10.5014/ajot.2012.004432
duce evidence through measurement and measurement of participation-based out- Deutsch, A., Braun, S., & Granger, C. V.
analysis of outcomes. comes is essential to validate practice. (1997). The Functional Independence
To address this need, our team Measure (FIM Instrument). Journal of Re-
designed and implemented a series of habilitation Outcomes Measurement, 1, 67–71.
Conclusion
advanced-practice certificates with the goal Fleming-Castaldy, R. P., & Gillen, G. (2013).
of enhancing content expertise through DDDM can be a useful strategy to help Ensuring that education, certification,
evidence-based, data-driven methods (see realize the Centennial Vision by providing and practice are evidence based. American
http://www.jefferson.edu/health_professions/ practitioners with a systematic process for Journal of Occupational Therapy, 67,
occupational_therapy/programs/certificates. explicating reasoning, using assessment 364–369. http://dx.doi.org/10.5014/ajot.
cfm). Participants reported that these data to develop and tailor client-centered 2013.006973
advanced-practice certificates helped guide intervention, and measuring and reporting Forsyth, K., Summerfield Mann, L., & Kielhofner,
G. (2005). Scholarship of practice: Making
their clinical reasoning and assisted them in on outcomes. By providing a clear link
occupation-focused, theory-driven, evidence-
being more systematic and critical of the from impairment to function to participa-
based practice a reality. British Journal of Oc-
assessments and interventions used in daily tion, DDDM affords occupational therapy
cupational Therapy, 68, 260–268.
practice. practitioners a vehicle for creating evidence Frolek Clark, G. (2010). Using data to guide
Three student case reports have pro- and demonstrating their unique skills and your decisions. In H. Miller Kuhaneck &
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Sledziewski et al., 2012), emphasizing that data-driven approach; and allows practi- Gutman, S. A. (2008). From the Desk of the
evidence-based methods must also become tioners to document evidence in their daily Editor—State of the journal. American
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Gutman, S. A. (2009). From the Desk of the
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Editor—State of the journal 2009. Amer-
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Acknowledgments ajot.63.6.667
interventions with specific measurement Gutman, S. A. (2010). From the Desk of the
strategies. Fieldwork supervisors and stu- I thank Alison Bell and Carol Just for their
Editor—State of the journal, 2010. Amer-
dents reported that these practices helped contributions to the projects that are de- ican Journal of Occupational Therapy, 64,
with utilization and understanding of scribed in this article and Joanne Hunt and 832–840. http://dx.doi.org/10.5014/ajot.
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