Hospitals are designed to treat illness and stabilise acute conditions, yet for many older patients, hospital admission can mark the start of a different kind of decline. 

Functional deterioration – the loss of mobility, independence and physical capacity – is more prevalent than many well-recognised hospital-acquired complications.

‘Functional decline occurs in approximately 40 per cent of older patients,’ Dr Julie Adsett APAM says. 

‘It’s associated with poor outcomes. These patients are more likely to be in hospital for longer and to be discharged to somewhere other than their usual home, which for older patients can be enormously traumatic. 

'Functional decline is also associated with higher rates of readmission and 12-month mortality.’

For physiotherapists working in hospitals, this is a familiar and persistent challenge, one that sits squarely within the broader remit of public health. 

Preventing functional decline is not just about improving individual patient outcomes; it is about reducing system burden, preserving independence and improving long-term health trajectories. 

At the heart of this issue, Julie says, lies a specific problem: inactivity.

A system-wide problem

In a paper entitled ‘Using quality indicators to improve patient mobility practices in general medical wards’, presented at last year’s APA scientific conference in Adelaide, Julie talked about her project ‘Time to get moving: creating active hospitals to reduce hospital-associated functional decline’, supported by a Metro North Health Clinician Research Fellowship. 

Julie says inactivity needs to be addressed within the hospital setting. 

‘In our hospital system, we know that our patients spend less than 10 per cent of daytime hours standing or walking. 

'This equates to fewer than 450 steps per day, less than half of what you require to prevent functional decline.’

An advanced physiotherapist with the heart failure service at Royal Brisbane and Women’s Hospital, Julie says this level of inactivity is not confined to a particular ward type or patient group. 

It is a systemic feature of the complexity of hospital care, shaped by workflows, resources, environments and cultural norms.

‘Hospitals, by nature, are very bed-centric, meaning that everything we do to care for patients is focused on their bed space.

'This is the opposite of how we would normally function at home.’ 

By necessity, hospitals also prioritise safety, efficiency and acute care delivery.

However, these priorities can inadvertently create conditions where movement is minimised, Julie says. 

Patients are often confined to beds or chairs, mobility is deprioritised in the setting of very busy workloads and staff may be hesitant to encourage activity in risk-averse environments.

Julie describes this as a multilayered problem embedded within complex systems. 

‘As you can appreciate, these mobility barriers exist at multiple levels. 

'It might be that the patient is in pain or fatigued or it might be that the ward is really cluttered and has a limited supply of mobility aids. But there are also higher-level organisational barriers.’ 

These barriers, including leadership and a risk-averse culture, can be particularly influential. 

‘Certainly, our health system is a very risk-averse culture and that filters down from the top.’

A multidisciplinary solution

Addressing inactivity in hospitals requires more than individual effort. 

Julie and her team examined the common components of many national and international evidence-based programs such as the Hospital Elder Life Program and the Johns Hopkins Activity and Mobility Promotion program in the US, the Mobilization of Vulnerable Elders in Ontario program in Canada, the WALK-Copenhagen project in Denmark and the Eat Walk Engage program in Australia. 

‘One thing that’s common to all these programs is that their interventions are multicomponent and they’re multiprofessional – and that’s important. 

'It’s not down to one profession to solve this dilemma.

‘The programs work by identifying and reducing barriers to mobility across the system. 

'If we can reduce those barriers, then that will hopefully make it easier for our patients to be active and for our staff to support patients to be active and in so doing, we should hopefully see a reduction in functional decline.’

While the concept is simple, implementation within public health systems is anything but. 

Measuring whether the interventions are working, and why they are working, requires new approaches, Julie says.

Mapping out indicators

Despite growing recognition of the importance of being active during admission, hospitals have historically lacked practice tools to measure patient activity. 

Julie Adsett.

For example, activity mapping can capture metrics such as the proportion of daytime hours spent upright and research studies can track functional outcomes but these approaches are often resource-intensive and difficult to sustain. 

‘What we haven’t really looked at in any detail is how we monitor the barriers to activity and whether we’re effective at reducing some of them.’

Mobility quality indicators offer a potential solution. 

First proposed in 2019, these indicators provide measurable metrics across structural, process and outcome domains, allowing clinicians and organisations to track changes in practice over time. 

‘Mobility quality indicators may be a useful way of monitoring change in clinical practice,’ Julie suggested to the audience at the conference.

Julie and her team sought to test this in the Australian context, piloting a modified set of indicators across nine medical wards in four hospitals in south-east Queensland.

Applying to our realities

Implementing these indicators required careful adaptation. The original indicators, developed in the Netherlands, were not fully compatible with the Australian healthcare system. 

‘We realised we needed to modify some to be feasible in our health system. 

'At the time of the study, the four hospitals were all paper based, whereas the Dutch hospitals were very familiar with electronic medical records.’ 

Through a stakeholder process that included clinicians and consumers, the team refined indicators to ensure they were both meaningful and practical. 

The final set included 27 indicators: 10 structural, 15 process and two outcome measures.

Data collection was embedded into routine practice through ward audits conducted on a single day. 

Consumers were involved in the auditing process and photographic documentation was used to capture examples of practice. 

‘It was good to take the photos because when we went back a few years later, we took exactly the same photos again and we could see how things had changed.’ 

This approach reflects a key principle in public health: measurement must be feasible within the constraints of real-world clinical environments.

What the data showed

The indicators were used to compare practice before and after an intervention targeting organisational barriers to mobility, implemented over 18 to 24 months. 

Structural indicators, such as ward environment and equipment, showed clear improvement.

‘It looks like our intervention has had a positive effect on the structural indicators.’

Process and outcome indicators provided a more nuanced picture. One key measure was the proportion of patients who sat out of bed at least once during the day. 

‘When we look at 2022 as a whole group, 68 per cent of patients sat out of bed versus 76 per cent in 2025. 

'This certainly seems to be an improvement, which is great overall, but when we look at the individual wards, there is considerable variability. 

'Some wards recorded really impressive improvements, while two of the nine wards actually had fewer people sitting out of bed.’

Julie says that unpicking these results provided valuable insights. 

‘Hospitals are such complex environments and context is everything. In this case, something as seemingly simple as a ward move or change in the ward leadership had significant flow-on effects.’

The team also recognised the importance of realistic targets. Not all patients are able to mobilise due to medical reasons and this had to be reflected in performance benchmarks. 

‘We knew from previous data that up to 20 per cent of patients were unlikely to sit out of bed, which meant that 80 per cent of patients theoretically should sit out of bed during the day.’ 

The team assessed how many wards were meeting this target. 

Interestingly, while overall performance improved, the number of wards meeting the target did not increase as expected. However, more wards are now closer to this mark. 

‘Change takes time, though, and it never takes place in a linear fashion. It’s all about unpicking what’s going on.’

From measurement to change

One of the key strengths of mobility quality indicators is their ability to guide action. Rather than simply reporting outcomes, they help identify where and how to intervene. 

‘I think they are useful, not only for highlighting successes but for guiding what we do next.’ 

The indicators also provided a powerful tool for engaging hospital leadership. 

‘It certainly has helped us to have the data in our hands and that’s been useful when talking to executive and talking to managers.’

This is particularly important in public health settings, where competing priorities and limited resources require strong evidence to support change.

Julie emphasises the role of physiotherapists here. 

‘I believe this needs to be a multiprofessional approach but it does need someone to drive it – and as physiotherapists, we are in an ideal position to lead this sort of work. 

'What is really wonderful is that there are a number of physios around the country who are driving this work.’

Physiotherapists bring expertise in movement, function and rehabilitation and they also have the potential to influence systems and culture. 

By engaging in quality improvement initiatives, advocating for mobility and collaborating across disciplines, they can help embed change within hospital practice. 

This aligns closely with the broader goals of public health: improve outcomes at a population level, reduce inequities and optimise system performance.

As with any quality improvement initiative, sustainability is a key consideration. Auditing 27 indicators is resource-intensive and not feasible in the long term. ‘That’s not realistic.’

The next phase of the work involves refining the indicator set to a smaller number of key measures that can be integrated into routine practice, Julie says. 

This process aims to balance comprehensiveness with feasibility, ensuring that measurement remains meaningful without becoming burdensome. 

At the same time, the team is working to refine strategies based on the insights gained. 

‘We’re rethinking our interventions and aligning them with outcomes.’

Key physiotherapy role

Underlying all of this is the need for a cultural shift within hospitals, Julie says. 

Keeping people active and maintaining function as much as possible must be recognised as a core component of safe, high-quality care and not as an optional extra. 

She acknowledges that in busy hospital environments, this can be challenging. However, says Julie, the risks of inactivity in terms of functional decline and loss of independence are significant and should not be underestimated.

Engaging a broad stakeholder group has already begun to shift awareness. 

As highlighted in the research Julie presented at the conference, the work has led to increased organisational recognition of functional decline as an important issue. 

However, improving mobility in hospitals is more than increasing step counts. 

It is about preserving function, supporting recovery and ensuring that patients leave hospital able to live well. 

Achieving this, Julie says, requires a combination of evidence, measurement, collaboration and leadership, areas in which physiotherapists are well placed to lead the way.