tra ining centre in subacute care tracs wa speaker notes v1 march 2014.pdf · tra ining centre in...

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Training Centre in Subacute Care TRACS WA

SCIPE (Subacute Care InterProfessional Education)

This project was possible due to funding made available by Health Workforce Australia as an Australian Government Initiative.

All material generated by TRACS WA remains the intellectual property of WA Health. In keeping with TRACS WA’s guiding principles to support the availability, dissemination and exchange of information (and subject to the operation of the Copyright Act), you are welcome to reproduce the material for personal, in-house or non-commercial use, without formal permission or charge and with full acknowledgement of the provenance of the materialIn the event that you wish to reproduce, alter, store or transmit the material for a purpose other than personal, in-house or non-commercial use you can apply to TRACS WA for formal permission: [email protected]

SCIPE stands for Subacute Care InterProfessional Education. Although it shouldn’t be confused with the Internet communication program, it is very much about communication.

The project has been funded by Health Workforce Australia.

The first 7 slides/pages are common to all modules. Below is the index for each module -

Module 1 Patient Assessment – go to slide/page 7

Module 2 Goal Setting – go to slide/page 25

Module 3 Discharge Planning – go to slide/page 42

Module 4 Caring for Yourself – go to slide/page 59

Module 5 Adding Value – go to slide/page 71

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© TRACS WA and Health Workforce Australia 2014

Welcome to SCIPE – come in

Program of 5 modules

� Patient Assessment

� Goal Setting

� Discharge Planning

� Caring for Yourself

� Adding Value

This package consists of 5 modules, each designed to run for approximately an hour. You can see the modules detailed on the slide.

The modules can be followed in any order, so don’t worry if you are not starting at module one, or if you are unable to complete all the modules.

Provide information to the students regarding the timetable for the presentations.

Following each presentation, you will have some learning activities to complete to demonstrate that you have met the learning objectives. You are encouraged to work together if possible to complete these activities.

Before we start, anybody who is new to the program should have completed the e-learning package “Introduction to SubAcute Care”.

There is also a self-assessment tool – which each student needs to complete at the beginning and end of the program. RIPLS stands for Readiness for Interprofessional Learning Scale. Students who are joining the program at this point should complete the RIPLS tool, if they haven’t already done so, whilst other students are discussing the learning activities from the last module (slide 6). Any student who is on their last module should complete another RIPLS tool as part of their learning activities for this module.

Advise the students to provide you with copies of their completed RIPLS tools at the end of each set of student placements. The students should also keep a copy in their portfolios.

Each student should also have a copy of the SCIPE Reflections on IPL tool. You should be completing this as you go along whenever you have had an experience related to one of the IPL learning outcomes.

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Introductions

� Name?

� Course?

� Year?

� Previous placements?

� Expectations

Skip this slide if all the students have already introduced themselves to eachotherpreviously.

If this is the first module for the group of students, or if there are any new members, ask them in turn to briefly introduce themselves.

Also remember to introduce yourself to the students if they don’t already know you.

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Self-Directed Activities

� Each module has a selection of activities for you to undertake in the workplace

� Where possible, try to work as a team with the other students to complete the activities but keep your own records and reflective diary

� If you need assistance from staff, think carefully about which team member to ask

� The activities can be discussed at the beginning of the next module presentation

Each week we will start by reviewing the tasks that were undertaken in the previous week. This will take the form of general discussion and while it is not assessed it will add value to everyone’s understanding of the SAC working environment.

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Review of Previous Learning Activities

� How did you get on?

� Share your experiences

This conversation should take no more than 10-15 minutes. During this time any new members of the group need to complete the RIPLS self-assessment tool and can also talk about the learning activities from the e-learning module which they should have completed prior to the placement.

Refer to the learning activities students were given from the previous module. Invite conversation on the degree of difficulty or ease that was experienced on finding the information required.

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Select Module

1. Patient Assessment

2. Goal Setting

3. Discharge Planning

4. Caring for Yourself

5. Adding Value

Click on the relevant button to go automatically to the required module.

1 Patient Assessment – go to slide 7

2 Goal Setting – go to slide 25

3 Discharge Planning – go to slide 42

4 Caring for Yourself – go to slide 59

5 Adding Value – go to slide 71

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Learning Objectives – Module 1Patient Assessment

� Understand the referral pathways into SAC

� Recognise the need to identify and discuss the patients’ expectations

� Understand the need for a full team review on admission to Subacute Care

� Understand issues around consent and guardianship

To achieve these objectives you will need to attend this session and complete the self-directed learning activities that follow it.

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Where do our patients come from?

� Acute wards

� Other Subacute services

� Community services

� GP referrals

� Allied health referrals

� Their own home

� Other places?…………………………

Ask students to think of other ways and other reasons why people may access SAC services

People requiring the support of sub acute care can come from anywhere in the community. There are common pathways, eg. following a stroke, but a dramatic health event such as this is not the only reasons someone may need assistance.

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A patient may move between acute care services and subacute care services

Rehab inthe Home

CommunitySettings

RehabUnit

Day Hospital

PsychoGeriatric

GeriatricEvaluation

& Mgt

HighDependency

Unit

SpecialtyWard

Outpatientservices

EmergencyIntensiveCare Unit

OperatingTheatre

Patient’shome

PalliativeCare

Patient

Subacutecare

Acute Care

This is a very generic overview of health agencies.

Notice the light green areas. These are recognised as places that work within a subacute care framework. However it is possible that SAC may overlap onto the acute wards, or acute care may overlap into SAC. So you can see the division between the two is somewhat artificial and we should always be working towards finding the patients optimum level of function.

SAC may be accessed from the community, or it may be part of a longer complex patient journey.

Ask students if they have any questions about any of the areas and if they understand how a patient’s journey through the health care system is influenced by their clinical condition. They will be mapping patient journeys as part of their learning activities.

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What would it take for a person to go from extreme sport to extreme care and back

again?

“A picture paints a thousand words” someone wise said this. What story does this tell?

Ask the students if they can think of the different pathways a patient may take to go from one photo to the other……….how long do you think this process would take? Can everyone achieve this? What kind of specialist clinicians may be involved.

Ask them if it is possible to start Rehab in ICU How would they map a patients journey?

Ask them if they think all patients will make such a full recovery?

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How do we know how people feel and what they want?

http://thornesquest.com/blog/?p=253

Communication is the key to working with all patients. It helps us understand their point of view. Avoid making assumptions based on somebody’s appearance or age.

If we listen to their needs not only do we understand more of their story but we reduce the level of anxiety they may feel.

To initiate this kind of conversation with a patient it is best to start with an assessment of their current position and their future needs.

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HOLISTIC ASSESSMENT

� What should the assessment include?

� When should the assessment be done?

� Who should lead the assessment?

� Why should the assessment be done?

� How should the assessment be done?

Discuss these questions with the students to start them thinking.

The answers will come up over the next few slides.

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WHAT is being assessed?The whole patient

Don’t just think of the disease or condition

Consider how the condition affects, and is affected by:

� The person’s family and social environment

� Vocational responsibilities and financial situation

� Hobbies, interests, hopes and dreams(Frontera, 2010)

The assessment of a patient for subacute care involves understanding the person as a whole, including:

•patients physical condition and past medical history

•their current medical status

•functional status

•Mood and motivation

•Pain

•Cognition and perception

•their psychosocial situation

•What the patient wants and what is important to them

The assessment process will differ for each patient depending on their condition, aspirations, enablers and barriers. Flexibility is the key to providing patient-centred care.

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WHAT makes a good assessment?Every team member contributes

� History of current illness or presenting condition� Functional history� Communication (speaking, listening, reading, writing)� Self care� Mobility (ambulation, transfers, bed mobility and walking

aids)� Eating/nutrition/swallowing� Previous medical history (it may impact on any, or all of the

above)� Prescribed medications� Vocational history� Family structure / where they live / financial impact� Hobbies, sports, changes in sexual function� Alcohol and recreational drug intake

Every team member contributes to the assessment process. It does not need to be led by one specific discipline.

As you can see there are many things about the patient that need to be assessed and documented.

Although all members of the team are involved, they will not all be assessing the same things. Each discipline’s assessment should build on the assessments that have already taken place.

It is very important to read the notes of the team members who have gone before you. This way you can prevent the patient having to repeat themselves.

Imagine if you had been in hospital or had a chronic health problem and everyone you saw started off with the same questions.

Patients can be very disenchanted with this happens and they can question the organisation with comments like “Don’t you people ever talk to each other”

Give an example of how the professions can build on each other’s assesmentsfor example the OT might say, “I see you told the physiotherapist that you would have steps to climb when you get home. Could you tell me more about them –where are they? How many steps? Is there a handrail?” The dietitian might say “You told the nurse you hadn’t been eating well lately. Can we talk more about that?”

With this in mind remember to document your findings well, as soon as possible after seeing the patient and communicate important matters with the rest of the team as part of a verbal handover and during the interdisciplinary team meetings.

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When should the patient be assessed?

� On admission to the service

� On discharge from the service

� AND regularly in between to measure improvement, identify goals and assess efficacy of treatment

Interdisciplinary team meetings, documentation and regular communication

Ask the participants if they have seen or undertaken any assessments yet. How did they find the experience? Have they seen any assessments being done by other professions and were they surprised by the questions that were asked?

In the discussion bring out the points on the slide and these other points.

Assessment isn’t a one-off process. Although there needs to be formal assessments on admission and discharge we need to be constantly assessing to see how the patient has changed. It is important that changes are documented and communicated so that all members of the team know how the patient is progressing for example, they can now use the toilet unaided, they are using a walking stick instead of a frame.

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WHY should a patient be assessed?

� To understand the patient’s story

� To set goals

� To measure progress

� To identify needs

� …………………

Ask students why patients should be assessed. Can they come up with any other reasons for assessment?

Help them bring out these points in the discussion.

Without an understanding of the patients story we are unable to understand their needs.

We are unable to help them to set their goals.

We have nothing to measure progress by.

We won’t know when they are ready to be discharged.

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HOW should the patient be assessed?Interview and Observation

� Observe physical appearance/presentation and ask the

question - can this person care for themselves?

� Conversation - can you understand what they are saying,

can they hear you, can they read and sign the consent to

treatment form?

� Can they walk across the room or up the hallway - do

they limp, use a stick, frame, wheelchair? Did they need

help getting up or sitting down?

� Do they look well nourished? – have they lost or gained

weight, are they eating well?

Is assessment just about asking questions and writing down the answers on a form? Ask the students to discuss ways of assessing patients which are used in their own profession.

Assessment tools will vary from site to site and between different disciplines but a few tips to remember are:

Assessment is not just about asking the questions on a form – anybody can do that. As health professionals we need to be doing more than that.

Use your eyes – it is quite difficult when you are starting out and you are concentrating on the specific information which you need to gather. Try to familiarise yourself with any paperwork before you see the patient so that you can spend more time looking at them and less time looking at your piece of paper. Observe what they are doing from the time you first set eyes on them (you might meet them in the waiting room or they might walk into your room or you walk into theirs depending on the setting.)

Use your ears – what are they saying? how are they saying it? Does it make sense? Are they understanding your questions? Do they repeat themselves?

Some professions will also use their hands to feel the patient or they might get the patient to undergo some tests. It is important to explain to the patient what you are doing and why you are doing it.

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Who should be assessing the patients?

IT TAKES A TEAM

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The Principles of Person Centred Care

� Getting to know the person beyond the diagnosis

� Sharing of power and responsibility

� Accessible environment

Goals

Abilities Values

FamilyInterests

Home environment

Roles

Motivation

When assessing a patient remember person centred care is the focus of good rehabilitation.

Imagine you were injured in a car accident and couldn’t walk. What would be most important for you? Would you all want to be treated the same?

Talk through the points on the slide and ask the students if they can give examples of each point.

We need their story in their words.

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The patient who cannot consent

� Guardianship and Administration Act 1990

� Guardianship

� Enduring Power of Attorney

� Advanced Health Directives

www.publicadvocate.wa.gov.au

Ask students if they have been in a situation yet when a patient has been unable to give consent. What happened?

Some patients may not be able to make informed decisions about their lifestyle, finances or care needs.

The Guardianship and Administration Act (1990) promotes and protects the rights of adults with decision-making disabilities to reduce their risk of neglect, exploitation and abuse.

Guardianship may be considered as an option when there is a need for somebody with legal authority to make personal, lifestyle and treatment decisions in the best interests of a person with a decision-making disability. This might be due to conflict between family members about the person's best interests. A guardian may be a close friend or family member of the represented person. Alternatively a guardian from the Office of the Public Advocate can be appointed. An enduring power of guardianship enables a guardian to be appointed in advance should you ever become incapable of making such decisions yourself.

An enduring power of attorney is a legal agreement that enables a person to appoint a trusted person - or people - to make financial and property decisions on their behalf. An EPA can be operational while the person still has capacity but may be physically unable to attend to financial matters. It does not permit an attorney to make personal and lifestyle decisions, including decisions about treatment but is limited to decisions about the donor's property and financial affairs.

An Advance Health Directive (AHD) is a legal document that enables you to make decisions now about the treatment you would want - or not want - to receive if you ever became sick or injured and were incapable of communicating your wishes. In such circumstances, your AHD would effectively become your voice and it takes precedence over a guardianship arrangement.

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Think of everything it takes to get you to University in the morning

If you had a physical or cognitive impairment how would you manage to get yourself to Uni?

How would you enjoy the things you do in your spare time?

Stand in someone else’s shoes

By DAVID BARBOZAPublished: April 17, 2009 NY Times

Liu Yan, is a classical dancer who was paralyzed at a rehearsal for the Beijing Olympics opening ceremony and has adjusted to life in a wheelchair.

It is very hard to think about the complexity of life and how we take many day to day activities for granted. Think about everything you need to get out of bed in the morning and get to Uni or Work.

Get the students to think beyond the physical activities and include the cognitive and psychological issues such as remembering, planning, motivation etc

•Remember to set the alarm

•Be motivated to get out of bed

•Remember where the bathroom is and walk to it

•Go to the toilet

•Have breakfast….

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References

� Duff, Jane. "Team Assessment in Stroke Rehabilitation." Topics in Stroke Rehabilitation16, no. 6 (2009): 411-419.

� Frontera, Walter R., ed. Delisa's Physical Medicine and Rehabilitation: Principles and Practice. Edited by Joel A. DeLisa. Philadelphia, PA: LIPPINCOTT WILLIAMS & WILKINS, 2010.

� Office of the Public Advocate, "Guardianship", Department of the Attorney General http://www.publicadvocate.wa.gov.au (accessed 20th May 2013).

These references will also be included in the handouts for the student learning activities.

Provide each student with a handout for the learning activities associated with this module.

If any student is at the end of the program remind them that they need to complete their second RIPLS tool and provide you with a copy.

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End of Module One

� Click button or press “Esc” to exit

End

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Learning Objectives – Module 2Goal Setting

� Be able to set SMART Goals

� Understand the benefits of involving patients and carers in goal-planning.

� Understand how goals are set, documented and reviewed in this setting

� Understand the use of outcome measures.


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What is a Goal?� Hope� Ambition� Expectation� Dream� Purpose� Finish line� An observable and measurable end result having

one or more objectives to be achieved within a more or less fixed timeframe

BusinessDictionary.com (2013)

� The object to which effort or ambition is directed; the destination of a (more or less laborious) journey. Oxford English Dictionary cited in Wade (2009)

Ask the students to identify their own goals. This could be their professional goals or something in their personal life.

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Why Do We Need to Set Goals?

� Motivate the patient

� Ensure that individual team members work

towards the same goals

� Ensure that important actions are not

overlooked

� Allow monitoring of change to abort

ineffective activities quicklyWade, 2009

Motivating the patient has been shown to increase behavioural change (Wade, 2009)

Health professionals will have their own roles and duties but it is important that they all work to reinforce the patient’s goals such as all using the same transfer techniques, encouraging purposeful activity and so on.

If we don’t have goals we have no purpose or direction and we won’t know when to stop.

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Sometimes different words may be used for SMART goals but generally the meaning is the same or very similar.

SMART goals provide us with a framework so that we can easily see whether the goal has been met and we are less likely to set an unrealistic goal.

Most students will already know about SMART goals but they might not have used them for patients before.

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Creating SMART Goals

� “I want to be able to walk”� How far?

� By when?� With help?

� “Before I am discharged home in three weeks, I will be able to walk safely and independently, using a stick, a distance of ten metres.”

When first talking to a patient about their goals they might be very simplistic and sometimes they will be completely unrealistic. It is important to be sensitive and to help the patient select goals that are within their reach. In some cases a patient might have no idea what is achievable, for example, if they have just had a stroke, they may not have any understanding of how much they are likely to improve and possible timeframes. If a patient suggests an unrealistic goal you can use phrases like “why don’t we aim for something that you might achieve in the next week or so”. Your supervisor will be able to guide you about what is a realistic goal for a particular patient. If you are working in an in-patient setting you should be concentrating on goals that the patient needs to achieve in order to go home but there might also be longer term goals which the patient will continue to work towards after they have been discharged such as returning to work.

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Four Parts to Creating a Goal

1. Specify the target activity or behaviour

2. Specify the support needed

3. Quantify the performance

4. Specify the time period

Bovend-Eerdt et al (2009)

Support can be people (hands-on assistance, reassurance or prompting), physical aids (equipment, adapted environment) and/or cognitive/language aids (check-lists, signs, physical prompts or barriers).

Performance can be quantified as the time taken to do something or the amount of activity such as the distance travelled or the frequency of an activity. It might be a reduced quantity e.g. less falls, less swearing, less prompting required or less dropping items.

The time period is the timeframe in which the goal will be reached.

These parts of the goal can then be built into a SMART goal.

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Some Questions about Setting Goals

� Does the patient (and family) need to be present?

� How many goals?

� What is an appropriate time-frame?

� How do you deal with patient’s unrealistic goals?

These are some suggestions for getting the students to talk about goal-setting. There is no definitive answer. They may have already had some experience of goal-setting which they can share with other students.

Is it OK just to talk to the patient and/or family first and then set the goals in a team meeting without the patient being present?

Too many goals can be overwhelming, too few may not provide sufficient motivation.

Some goals may span the entire rehabilitation process from in-patient to community and beyond e.g. returning to driving or going back to work, others will be shorter. Shorter time-frames provide more “wins” and therefore more motivation. It may be helpful to set goals which will allow the patient to move on to the next stage in the rehabilitation process, for example from in-patient to community or from specialist rehab to a regional hospital closer to their home.

You can substitute the example below with any other example of an unsuitable goal.

Setting goals can be unpredictable and risky. For example, a patient stated that her goal was to be able to get on the internet. The staff member asked the patient if she had a computer at home and she replied “No, I haven’t. That’s the point. They’re expensive” (Levack et al. 2011)

If a patient suggests a totally unrealistic or irrelevant goal, they will need to be redirected and may need you to suggest something so that they get the right idea.

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A Goal Setting Framework 1. Goal Negotiation

Discuss problems& potential goals Self-efficacy

4. Action

5. Appraisal Feedback

2. GoalSetting

For time limitedRehab stage3. Plan

•Action•Coping•Confidence

rating Scobbie et al, 2011

1 Goal Negotiation – Get to know your patient and develop rapport.

Self-efficacy refers to the patient’s confidence in their ability to achieve a desired goal.

Motivational Interviewing techniques can be used. (Motivational Interviewing focuses on exploring and resolving ambivalence and centres on motivational processes within the individual that facilitate change) Some undergraduate students are being trained in MI. Ask the students if they have learnt anything about MI or whether they know if it is on the curriculum.

2 Goal Setting – Set SMART goals. If goals are assigned by the health professional, ensure that the patient understands and agrees.

3 Planning – How is this going to be achieved? What action is required? How often? When and where? Consider coping plans – what might get in the way of achieving the goal and how can this be avoided? Get the patient to rate their confidence in achieving the goal e.g. on a scale of 1 – 10 where 1 is no confidence and 10 is fully confident.

4 Action – “Just do it”

5 Appraisal and feedback. Evaluate performance in relation to the action plan and progress in relation to the goal.

If the goal has been achieved, do you want to set further goals?

If the goal has not been achieved you may need to go back to goal negotiation or keep the same goal and make further plans (step 3)

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Collaborative Goal Setting

� What does the client want to do?� What can they do at the moment?� What are they likely to be able to do?� How much support/time/effort is available?� How motivated is the client?� What other goals do they have?� Which goals are more important:

� to the client? � to the team?

� Who “owns” the goal and who will monitor progress?� “A collection of individuals working within their own discipline

and setting their own goals does not count as a rehabilitation team”

Barnes (2003)

Encourage the students to discuss goal-setting using these questions. Maybe use an example of a patient they are all familiar with.

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There is more to SAC than meets the eye

Remember

You might think one person’s goal is small and incredibly simple

BUT:

to that person it may be a complex achievement that will change their paradigm

With Quality improvement issues, financial considerations it is important never to lose sight of the people at the heart of the care.

Subacute care has not always been seen an exciting option for some disciplines but working in this area can hold rewards not experienced else where. You can be making real changes to the way a person is able to continue to live their life.

The Oxford English Dictionary defines the basic meaning of the term paradigm as "a pattern or model, an exemplar".

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Work with your patients to meet that new paradigm

Think about this:� You enable someone

who needs to be fed to learn to use a cup again

� How does their life and the life of those around them change?

The improvements made by people in sub acute care not only effect themselves but their carers and family too.

They have a greater sense of self and require less support from the community.

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Outcome Measures

� An outcome measure is the “determination and evaluation of the results of an activity, plan, process or program, and their comparison with the intended or projected results”.

businessdictionary.com (2013)

Outcome measures in this context are a measure of the progress made by a patient. Some things are reasonably easy to measure, others are more difficult. Essentially we need a score or value at the beginning and another one at the end so that we can compare the two.

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Functional Independence Measure

� This may be used both as a funding tool and an outcome measure.

� It measures a person’s disability and the amount of assistance required for basic activities of daily living.

� Compare the FIM scores “before” and “after” intervention to determine the amount of improvement.

The Functional Independence Measure is being used in inpatient subacute care (except mental health) as part of the Activity Based Funding program but it is a useful outcome measure for many healthcare settings.

It consists of 18 items which are each scored from one (total assistance required) to 7 (completely independent). Therefore the minimum score is 18 and the maximum is 126. The 18 items include dressing, toiletting, mobility and memory. Often several members of the interprofessional team will work together to complete the scoring for each patient.

If we compare their FIM score at the start with their FIM score now, we have an indication of the progress they have made.

If your service doesn’t use the FIM at all you may want to discuss one of the outcome measures you use. For mental health these may be from the National Outcome and Casemix Collection e.g. HoNOS.

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Goal Attainment Scaling� Developed in the 1960’s.� Individual goals are set with the patient.� Outcomes are measured against the original

goal as follows:+2 – much better than expected+1 – better than expected0 – expected outcome-1 – worse than expected-2 – much worse than expected

� Goals may be weighted according to importance and difficulty

Turner-Stokes, 2009

There are many different goal setting tools. This particular tool measures the outcome based on initial expectations. This may or may not be used in your unit.

Think of a goal for a typical patient on this unit and try to come up with examples for each of the five outcomes.

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It takes a team!

Team Goal……………….

“to empower the individual to attain the fullest possible physical, mental, social and

economic independence by maximising activity and participation” (Frontera 2010)

You can do this!

This is the motivational message for this module.

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References

� Barnes, M P. "Principles of Neurological Rehalitation." J Neurol Neurosurg Psychiatry 74, no. Suppl IV (2003): 3-7.

� Bovend'Eerdt, T. J., R. E. Botell and D. T. Wade. "Writing Smart Rehabilitation Goals and Achieving Goal Attainment Scaling: A Practical Guide." Clin Rehabil 23, no. 4 (2009): 352-61.


� Scobbie, L., D. Dixon and S. Wyke. "Goal Setting and Action Planning in the Rehabilitation Setting: Development of a Theoretically Informed Practice Framework." Clin Rehabil25, no. 5 (2011): 468-82.

� Turner-Stokes, L. "Goal Attainment Scaling (Gas) in Rehabilitation: A Practical Guide." Clin Rehabil 23, no. 4 (2009): 362-70.

� Wade, D. T. "Goal Setting in Rehabilitation: An Overview of What, Why and How." Clin Rehabil 23, no. 4 (2009): 291-5.




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End of Module Two


End

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Learning Objectives – Module 3Discharge Planning

� Understand that discharge planning commences at admission.

� Understand the medical, physical, social and environmental factors that may impact discharge planning

� Know a range of discharge options/services that can be utilised for patient’s in this setting

� Be able to handover patient information using the iSoBAR tool

� Understand the concept of self-management


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When do we start to consider discharge?

When the patient is admitted!The initial assessment of the patient should familiarise the team to a patient’s lifestyle

and what they require to return home.

All our lives are complex and we are all different.

The complexity increases when we are admitted to hospital or have to undergo out-patient treatment.

For the purpose of this presentation we will focus mainly on hospital discharge as this is often the most complex but the same information applies for patient’s using community services.

It is important to remember that an admission to hospital can be one of the most stressful times in a person’s life and your patient may not be performing at their best because of their changing situation.

Preparing patients for discharge is every team member’s responsibility. Be sure you know what needs to happen for each patient before they can discharged, and how this information is shared amongst the interprofessional team.

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What will impact on a patient’s ability to thrive in the community?

� The environment as a contextual factor in the International

Classification of Functioning, Disability, and Health. Fontera 2010 p476

The subacute care patient may not have the same level of physical or cognitive function they had previously. When discharging a patient it takes a team of health professionals to ensure the patient will be safe at home and able to access any support they need.

Many hospitals have discharge check lists to ensure nothing is missed. The things required for the patient may be –

Mobility aids

Rails, toilet surrounds

Home modifications

Emergency alarms

Follow up nursing care

Outpatient allied health

Medications

X-rays

Doctors appointments

Transport assistance

Home exercise program

This list is not exhaustive. All patients are individuals and will have individual needs.

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How do we know what a patient will need?

� Confirm what support is available from family, partner, friends

� Family meetings – ensure everyone has the same level of expectation

� Interprofessional meetings – everyone has the same expectation of date of discharge and needs of family

In order to know what a patient needs after discharge, we need to understand how the patient was managing before they were admitted and what resources are available to them. We also need to know what is important to them.

We find this out through the assessment process and the information should be documented in the patient’s notes.

Where the patient is going to need support, we cannot automatically assume that the partner, family or friends will be able or willing to provide this and that is why we may have family meetings. If a level of support cannot be sustained we need to investigate alternatives before something goes wrong.

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Who should be involved in the patient’s discharge?

� The patient

� The family

� Carers

� All clinicians who treat the patient must consider� Will this patient need to continue with some

form of therapy/treatment on discharge?� Who will provide this?

Talk through this slide with the students.

Ask the students what patients they have worked with have required on discharge and who organised it?

Often there is too much information for a patient to take in and they need the information to be shared with others to assist them. Patients in SAC will have had many interventions and we cannot expect them or their family to remember everything.

Some information will need to written down, such as medication regimes, home exercise programs. Some information will need to be sent through to other facilities such as GP letters (the patient should also have a copy), referrals to community services and pharmacies if the patients require Webster packs for their medications.

Describe Webster Pack. See picture.

Webster-pak sets out all tablets and capsules that need taking at each particular time of the day, for each day of the week - making it easy to manage medication. The pharmacist takes the doctor's prescriptions and dispenses the medication into a securely sealed blister pack, protecting the medication - leaving no chance of spills or mix-ups. The pack lists all contents plus other medications taken, providing vital information for hospital or ambulance staff in the case of emergency. At medication time, the person or carer simply pushes out the blister's contents through the foil backing, for the correct time on the correct day. Webster-pakprovides a visual cue, so you always know where you are up to.

47


Possible Discharge Pathways

� Community Nursing

� Outreach allied health

� Day hospitals/therapy units

� General Practitioners

� Other medical specialists

� Community programs/groups

� Nursing homes…….

Don’t forget the patient may feel bewildered and needs to be involved in the decision-making.

The discharge pathways are complex and often require the skill and local knowledge of experienced health professionals to navigate. There are many issues of eligibility for referrals to particular services such as age, funding and geography.

New staff to sub acute care often comment on how long it takes to organise a discharge and how much paperwork is involved.

Both these things are true but time and paperwork are necessary to ensure each organisation communicates effectively with each other and the patient.

Consider a current patient who will soon be discharged. Where are they going? Who will be involved in their continuing health-care?

48


Be aware of what is available in the community

� Commonwealth Respite and Carelink

� Transitional Care Packages

� Transitional Care Units

� Carers Support groups

� Rehab in the Home (RITH)

� Charitable OrganisationsClear written and verbal information is essential when liaising with other agencies

Ask the students what they know about available services in the community. Which services have they heard about? What are the referral criteria?

Ask the students who in their team organises ongoing support such as those mentioned on the slide.

It is difficult to keep up to date with all the community options available and the eligibility criteria. If there is nobody in your organisation available to discuss support options with patients Commonwealth Carelink is a good place to start. In addition to this – don’t forget your patient may have some financial difficulties due to loss of income. In these cases it is often the social worker who will assist the patient and their family to access financial support through Centrelink.

49


Handover of Patient Information

Confirm shared understandingPorteous et al (2009)

READ BACKR

Given the situation, what needs to happen

AGREE A PLANA

Pertinent patient informationBACKGROUNDB

Include vital signs and assessment results

OBSERVATIONSO

Describe the reason for handing over

SITUATIONS

Introduce yourself and your patient

IDENTITYI

Clinical handover has always been the cornerstone of good communication in health care. If it is insufficient patient safety is at risk because information may be missed.

The acronym ISOBAR is used to promote a full and comprehensive handover.

Get the students to practice. They can either hand over information about a patient they are familiar with or work in pairs and handover information about eachother.

50


Aged Care Assessment Teams (ACAT)

� Aged Care Assessment Teams are teams of health professionals who help older people and their carers determine the level of care needed to remain at home or what other pathways are available if the older person is unable to remain at home

� An ACAT assessment is required to be eligible for certain services

An ACAT assessment is needed before somebody can be approved to go into an aged care home, receive a Home Care Package or to access transitional care.

51


Care Packages in the Community

� Home and Community Care (HACC)

� Home Care Packages (HCP)

� Levels 1 to 4� Supplements e.g. dementia, oxygen

� Transition Care Programme (TCP)

Ask the students if they know what each of these services do.

The Home and Community Care (HACC) program provides basic support services to some older people, people with a disability and their carers to assist them to continue living independently at home. This includes support to participate in social activities, assistance with everyday household tasks, assistance to support independence in personal care, assistance with activities such as shopping, banking and maintaining social contacts.

Home Care Packages have replaced the previous CACP (Community Aged Care Packages) and EACH (Extended Aged Care at Home).

Level 1 is for basic care needs, level 4 is for high-level needs.

Supplements to HCP’s are available for Dementia and Cognition, Veterans’ with service related mental health conditions, Oxygen Supplement for people with an ongoing medical need for oxygen and Enteral Feeding Supplement for people who need enteral feeding on an ongoing basis.

TCP helps older people at the end of their hospital stay. It gives them more time and care in a non-hospital environment to improve or maintain their level of independence, whilst assisting them and their family to make longer term care arrangements. This service takes place in either a residential or a community setting, including the person’s home. A number of care options are available, designed to be flexible in helping meet each patient's needs.

An ACAT assessment is required to access HCP’s and TCP.

52


Residential Care

� Low Level Care

� High Level Care

Residential care is generally for older people, but can be accessed by younger people with appropriate needs. There are also other options such as long-term rehabilitation and group homes.

LLC facilities are for people who need some help but usually they can walk or move about on their own. It focuses on personal care services (help with dressing, eating, bathing etc.), accommodation, support services (cleaning, laundry and meals) and some allied health services such as physiotherapy. Nursing care can be given when required.

HLC is for people who need 24-hour nursing care. This may be because they are physically unable to move around and care for themselves, or because they have a severe dementia-type illness or other behavioural problems. Residents in high care must receive additional care and services as required.

53


Chronic Conditions� Unlike acute care medicine, rehabilitation does not centre on

a sick patient whom treatment is expected to cure. Rather, rehabilitation practitioners treat dysfunctions that are chronic,often irreversible, and rarely curable. Residual disability maywell persist throughout a person's life. (Frontera, 2010)

� The average 75-year-old suffers from 3.5 chronic diseases (Strauss & Tinetti, 2009)

� 50% of over 30’s suffer from at least one chronic condition.(Bamm et al., 2013)

“When patient needs are minimal and family members poised to sacrifice relatively little, the patient's best interests may well entail encouraging relatives to fulfil family obligations. In circumstances of severe disability in which significant sacrifice will be required, however, strong persuasion does not appear justified.”(Delisa 2010)

Ask the students to reflect on how their family might cope if a member of the family was severely disabled and requires full-time care. Are they willing to share their thoughts or experiences?

Unfortunately the options for long term care are not always easy for any of us to accept. Elderly patients may be admitted to nursing homes. Younger patients with profound disability may live in supported accommodation rather than with their families but this is reality. If a family says they are unable to care for their loved one who has a severe disability this decision must be respected.

REMEMBER – put yourself in the families shoes. It is better that families admit they are unable to cope at the outset than to struggle and fail to provide the support a patient needs.

54


Chronic Condition Self-Management

Active participation by people in their own health care

� Collaborative and active partnership between the patient and service provider

� Patient-centred care

� Shared responsibility for outcomes

� Empowerment and enhanced capacity as goals of care

� Care is lifelong

Expertise is shared between the patient who is the expert on their life, and the provider who is an expert on chronic illness care.

Care is planned around the patient’s individualised circumstances, needs and preferences.

Responsibility for outcomes is shared between the patient and often multiple service providers

The goal is to empower the patient and enhance their capacity to engage in activities that will improve their health and care.

This is a very different model to the “Doctor knows best” where people rely on health professionals to tell them what they should be doing each step of the way

55


Some chronic disabilities are invisible

� Brain Injury

� Psychiatric disorders

� Chronic Pain

� Anxiety and Depression

� Epilepsy

� Diabetes

� Heart disease

� …………..

Ask the students if they can think of and how these invisible disabilities might impact on their life. Why is it different to a disability that is obvious?

When we start out in sub acute care we meet more people with invisible disabilities than we realise. Some of these diseases may be well managed with support and medication but as clinicians we need to be aware of them as they may impact on a persons ability to participate in therapy.

If you suspect a patient is not reaching their potential because of an invisible disability that has not been identified talk to the health professional working with you.

56


Consider the Carers

� Our society neither rewards nor honours people who transcend their own needs to care for others.

� Carers are vulnerable to social isolation and financial difficulty. (Frontera, 2010)

This module’s take home message is – Consider the Carers. Without them the community would cease to exist!

57


References� Bamm, E. L., P. Rosenbaum and S. Wilkins. "Is Health Related Quality of

Life of People Living with Chronic Conditions Related to Patient Satisfaction with Care?" Disabil Rehabil 35, no. 9 (2013): 766-74.

� Community Programs Branch Ageing and Aged Care Division, "Commonwealth Respite and Carelink Centres", Commonwealth Department of Health and Ageing http://www9.health.gov.au/ccsd/index.cfm (accessed 20th May 2013).


� Glasper, Alan. "Planning Optimum Hospital Discharge for Older People." British Journal of Nursing 21, no. 22 (2012): 1352-1353.

� Health, Department of, "Aged Care Assessment Team (Acat)", Department of Health Government of Western Australia http://www.agedcare.health.wa.gov.au/home/acat.cfm (accessed 20 May 2013 2013).

� Porteous, Jill M, Edward G Stewart-Wynne, Madeleine Connolly and Pauline F Crommelin. "Isobar — a Concept and Handover Checklist: The National Clinical Handover Initiative." Medical Journal of Australia 190, no. 11 (2009): S152-156.

� SE, Strauss and Tinetti ME. "Evaluation, Management, and Decision Making with the Older Patient." In Hazzard's Geriatric Medicine and Gerontology, edited by JB Halter, JG Ouslander, ME Tinetti, i S Studensk, KP High and S Asthana. New York: McGraw-Hill, 2009.




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End of Module Three


End

59


Learning Objectives – Module 4Caring for Yourself

� Identify causes of stress for health professionals in sub-acute settings

� Identify strategies for managing issues that may lead to physical or emotional injury or stress

� Understand professional boundaries and know your profession’s code of ethics

� Be aware of grief and loss issues


60


Caring for yourself The organisation cares for you

The organisation you work with will provide services to support your well-being and prevent injury

Physically� Occupational Health and Safety� Manual handling training� Immunisation programsEmotionally� Psychological and

counselling services

Caring for yourself is important. You are a valued member of a team and need to be able to perform at 100% every day

Find out what is available in your organisation to assist and support you when you need it.

Know which programs are mandatory, such as manual handling. These programs are aimed to protect you from injury and allow you to maintain your job and lifestyle.

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Your University or TAFE cares for you Sometimes we over stretch ourselves

� All educational institutions have services to assist

students with many issues

� Personal

� Study problems

� Medical

� Disability

Everybody experiences difficulty juggling study and work. Universities and TAFE are aware of this and will support you if you reach out. They want you to achieve your best. Placement can be particularly challenging as you are away from your usual support networks at your educational establishment, you will probably be working longer and there is a lot to learn. If you are also trying to keep up with a paid job elsewhere and a busy social life you may have some problems.

Do the students know who they should contact at their university or TAFE if they are having difficulty during their placement?

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Your professional association cares for youand enables you to care for yourself

� Maintaining your professional integrity

� Maintaining your professional code of ethics

� Professional boundaries protect both patients and clinicians

� Work within the organisational policies and procedures

Ask the students if they know where to find the code of ethics for their professional organisations.

Part of caring for yourself is to maintain your professional integrity. This means approaching your job in a framework that is supported by your profession’s code of ethics or code of conduct.

We all need to consider professional boundaries when working so closely with people. These boundaries help protect us as well as the patients.

Working within the rules and policies of the organisation also help protect you especially if problems arise such as conflict with patients or other staff and staying within our own scope of practice.

As a newcomer to the organisation it can take time to understand all the workplace issues around you.

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Tuckman’s Stages of Group Development

www.mindtools.com

Many students will already be familiar with this. Ask if they are able to describe the stages themselves.The Forming – Storming – Norming – Performing model of group development was first proposed by Bruce

Tuckman in 1965, who maintained that these phases are all necessary and inevitable in order for the team to grow, to face up to challenges, to tackle problems, to find solutions, to plan work, and to deliver results.

Teams initially go through a "forming" stage in which members are positive and polite. Some members are anxious, others are excited about the task ahead. This stage is usually fairly short, and may only last for a single meeting at which people are introduced to one-another.

When reality sets in your team moves into a "storming" phase. The ways of working start to be defined and some members may feel overwhelmed by how much there is to do, or uncomfortable with the approach being used. Some may react by questioning how worthwhile the goal of the team is, and by resisting taking on tasks. This is the stage when many teams fail, and even those that stick with the task may feel that they are on an emotional roller coaster, as they try to focus on the job in hand without the support of established processes or relationships with their colleagues.

Gradually, the team moves into a "norming" stage, as a hierarchy is established. Team members come to respect the authority of the leader, and others show leadership in specific areas.

Now that the team members know each other better, they may be socializing together, and they are able to ask each other for help and provide constructive criticism. The team develops a stronger commitment to the team goal, and you start to see good progress towards it.

There is often an overlap between storming and norming behaviour: As new tasks come up, the team may lapse back into typical storming stage behaviour, but this eventually dies out.

When the team reaches the "performing" stage, hard work leads directly to progress towards the shared vision of their goal, supported by the structures and processes that have been set up. Individual team members may join or leave the team without affecting the performing culture.

As students and then as new grads, you will often be coming into a team which is already in the “norming” or “performing” stage. Established teams can normally adopt a new (temporary) member without too many problems. You should be aware of the group processes that are going on around you and understand that, as a student, you will only be part of the team for a short time.

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� Conflict is normal when teams are in the “storming” phase and it can be positive.

� Healthy discussion can sometimes appear as conflict

� Separate the people from the problems

� Conflict between student and supervisor

� Conflict between students

Conflict within Teams

www.mindtools.com

Conflict can arise due to role ambiguity, power differentials, poor communication and differences in goals.

Conflict can potentially be positive.

It can be unsettling as a student if you perceive that there is conflict within the team – consider whether the conflict is personally directed or whether it is disagreement over a specific problem.

If you feel there is conflict between yourself and your supervisor, follow your university guidelines for addressing this.

If there is conflict between yourself and another student, take steps to resolve it as soon as possible. If you cannot resolve it quickly between yourselves, speak to your supervisor or a university tutor. Remember that the placement is time-limited and you need to get the most out of it.

65


Challenges to professional integrity

� Maintaining patient confidentiality

� Discussion of other health care professionals

� Personal relationships with patients

It is easy to become personally involved withpatients especially if they are vulnerable and

experiencing issues of grief and loss

Conflict is just one of the challenges to our professional integrity.

Relationships with patients are often deeper in subacute care than in other areas of healthcare. Ask the students why relationships with patients are different to those in acute care…..do they agree with this statement.

This is due to the length of time we work with the same patients and the intimate nature of the care they require. Because of this we do build up deeper relationships with patients and we need to earn their trust and confidence to enable them to reach their optimum.

We all understand the requirement to preserve the confidentiality and dignity of our patients. Ask the students…….. has anyone’s patient ever asked them about another patient or another clinician……….How do you handle this as a student?

Disclosing information about other patients, forming personal relationships with patients while they are undergoing treatment, and commenting on other health care professionals are just some of the ways we make ourselves vulnerable to scrutiny from other staff and patients.

In addition to this, some of the patients in SAC may be experiencing grief for lost levels of function, lost opportunities or even lost loved ones. These responses may also affect families as they may need to adjust to a different future.

As a student or a new health professional you are also vulnerable because you may be facing new experiences. It is normal for us to want to help with everything but we all need to understand that we cannot solve all the patients problems.

66


Grief and Loss in Sub Acute Care

� “Grief is the normal emotional response to loss.

� Loss can be through changes in function or the

loss of a loved one

� Finding a way through loss and grief can be quite

confusing.

� Grief can lead to surprising reactions

� Grief changes us and with adequate support, can

help us grow as human beings”http://www.anglicare-sa.org.au/loss-and-grief-service/

Your patients, their friends and relatives may be suffering from grief and loss. You are also likely to have emotional responses to the clinical situations you experience.

IT is important to understand that patients in SAC are not functioning under “normal” circumstances. They are outside their own field of experience and they may react in ways they would never have predicted. Sometimes this shocks them and those around them.

Someone who is normally calm and organised may seem stressed and irrational. Think about what could be driving these reactions and how it affects the way you might respond to the patient and their family.

Ask the students if they are aware of the vulnerability of people in this situation and ask them how they may respond.

Ask them which members of the team may be able to help the patient and who the students can turn to for help.

67


We are all capable of over empathising with patients

Our emotions sometime take us by surprise when we meet patients who:

� Are a similar age to ourselves

� Remind us of people we know who may have a challenging diagnosis

http://www.shivawndavis.com/index.html

It is not unusual to over empathise with patients and their families. While empathy is an important feature of health care it can become paralysing for staff members who become deeply involved with patients.

It is important to recognise this if it happens and realise, it is not anyone’s fault but it does need to be managed. If you become distressed by someone’s condition you can either find a colleague you trust to talk to or talk to any of the services mentioned previously.

If you feel a patient is getting too attached or reliant upon you, discuss this with your supervisor or colleagues so you are able to swap patients. This will avoid any awkwardness you may feel.

Ask students to discuss or reflect on what diagnoses or patients they will find most challenging.

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We need to find time for ourselves and find activities that restore us.

As health care clinicians we need to care for ourselves and support each other.

Ask students to think about the activities they normally use to restore themselves? Are they managing to continue these while they are on placement? How do they think they will continue with outside activities once they are working?

69


References� Anglicare, "Loss and Grief Service", Anglicare SA

http://www.anglicare-sa.org.au/loss-and-grief-service/ (accessed 27th May 2013).

� Kelly, Kerrie. "Avoiding Burn-out in Remote Areas. Surviving the Day-to-Day Hassles: A Guide for Remote Health Practitioners." edited by Council of Remote Area Nurses of Australia Incorporated (CRANA). Alice Springs NT: CRANA, 2000.

� Mind Tools Ltd, "Conflict Resolution: Resolving Conflict Rationally and Effectively", Mind Tools Ltd http://www.mindtools.com/pages/article/newLDR_81.htm (accessed 27th May 2013).

� Mind Tools Ltd. "Forming, Storming, Norming, and Performing: Helping New Teams Perform Effectively, Quickly." Swindon, UK: Mind Tools Ltd, 2013.

� SARRAH, "Education and Training for Rural and Remote Allied Health Professionals", Services for Australian Rural and Remote Allied Health www.sarrahtraining.com.au (accessed 27th May 2013).




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End of Module Four


End

71


Learning Objectives – Module 5Adding Value

� Understand how information about this

service is communicated to other health

staff and the public

� Learn how to use quality improvement

tools to improve the service

� Understand how data/statistics can be

used to improve care and service delivery


72


Promoting your Subacute service

� As members of the team we are responsible for how the image of our service is projected to the outside world

� What is the core business of our service?

� Who do we provide services to?� How do people get to know

about us?� How do we maintain our

service?

Promotion and image of a service in the health environment is often overlooked. We can be so busy doing the job that we don’t consider how we link with other services and to the “outside” world.

Ask the students to consider the questions related to this particular service.

To be able to project a positive image of our unit we need to be able to demonstrate we have credibility and meet the levels of service set down by our appropriate governing/professional body. This means monitoring the processes that occur within the unit, reflecting on them and being able to adapt and change them when necessary.

We should always ask ourselves “how can we be better at this”.

73


Quality Improvement Cycle

Ask the students if they have been involved in any quality activities or if they have had any part of their studies focused on this area

The quality improvement cycle 'plan, do, study, act‘, often referred to as PDSA, uses simple measurements to monitor the effects of change over time. It encourages starting with small changes, which can be built into larger improvements quickly, through successive cycles of change. It emphasises starting unambitiously, reflecting and building on learning. It can be used to test suggestions for improvement quickly and easily based on existing ideas and research, or through practical ideas that have been proven to work

74


Plan the change (P)What do you want to achieve, what actions need to happen and in what order? Who will be responsible for each step and when will it be completed? What resources are required? Who else needs to be kept informed or consulted? How will you measure changes to practice? What would we expect to see as a result of this change? What data do we need to collect to check the outcome of the change? How will we know whether the change has worked or not?

Do the change (D)Put the plan into practice and test the change by collecting the data. It is important that the ‘do’ stage is kept as short as possible, although there may be some changes that can only be measured over longer periods. Record any unexpected events, problems and other observations.

Study (S)Has there been an improvement? Did your expectations match what really happened? What could be done differently?

Act on the results (A)Make any necessary adaptations or improvements, acknowledge and celebrate successes. Collect data again after considering what worked and what did not. Carry out an amended version of what happened during the ‘do’ stage and measure any differences.

Cycles of improvement may occur at different levels and new actions may be planned as a result of previous cycles. Alternatively, new skills may be learned, barriers to change overcome and new areas targeted for improvement. Testing small changes sequentially means design problems may be detected and amended earlier rather than later.

75


Activity Based Funding and Management

� Activity Based Funding and Management relates to how we fund and manage the WA Health system.

� Historically health services have been “block funded”, where as under ABF health services are funded on the basis of their expected activity.

� ABF is designed to drive improvements in the safety, quality and accessibility of the care we deliver as cost effectively as possible.

Activity Based Funding means that health services are funded on the basis of their expected activity.

Activity is everything that WA Health does for, with and to patients, residents, patients and their families and carers and the community. Previously, the funding that a health service received was decided by looking at the funds they received in the previous year, and adding a certain level of additional funding to cover growth in costs.

During your placement have the students come across situations where provision of service is questioned because of the funding required to support them? Has this impacted on the type of care given? Eg. Patients seen in groups is more cost effective than seeing patients individually for some disciplines.

76


Three elements to ABF/ABM…

� Improving Care

� Managing Resources

� Delivering Quality

Activity Based Funding and Management is about:

• improving care - using accurate and timely information to identify and deliver improvements in services we provide to patients and their families

•managing resources - making best use of the public funds we receive. Ensuring we get maximum value from each dollar we spend, as well as ensuring we allocate resources in ways which will deliver health services where and how they are needed

• delivering quality - continuing to focus on delivering safe high quality care

Activity Based Funding and Management is not a technical financial reform. It impacts on every aspect of the services we provide across WA Health.

77


Using Data to Improve Care

� Data can be used for clinical decision making and improving patient care

� Identify the key problems or areas for improvement

� Set goals/targets for improvement

� Evaluate the impact of interventions

Data

Information

Knowledge

Decision

Action

Although data for Activity Based Funding is primarily collected for financial reasons, it can also be used as the basis for improving services.

By comparing the data for your own service with benchmark data or other similar services, you can identify problem areas or areas of poor performance.

The PDSA cycle which we discussed earlier can be used to implement the changes.

This also puts a new perspective on the importance of accurate documentation. Not only is accurate documentation a legal requirement it contributes to the overall evaluation of the service.

Ask students if they can think of examples of this. (FIM would be one)

78


Clinical AuditChoose a

topic

Identify EBP /

Standards

Audit current practice

Identify required changes

Implement changes

Repeat the audit

cycle

www.health.qld.gov.au

The clinical audit cycle involves defining or identifying evidence based standards, collecting data to measure current practice against those standards, and implementing any changes deemed necessary followed by a repeat audit to evaluate the improvement. Selecting an audit projectThe clinical team has an important role in prioritising clinical topics, and the following questions may be a useful guide to place topics in priority order. Is the topic related to high cost, high volume or high risk to staff or users? Is there any evidence of a serious quality problem; for example, patient complaints or high complication rates etc? Is good evidence available to inform standards; for example, systematic reviews or national clinical guidelines? Is sustainable improvement possible? Is there any potential for involvement in a statewide network or national audit project? Is the topic pertinent to national policy initiatives? Is the topic a priority for the organisation?

Selecting criteria/standardsIn clinical audit, criteria or standards are used to assess the quality of care provided by an individual, team or organisation. These criteria are explicit statements that define what is being measured and represent elements of care that can be measured objectively. The criteria or standards may be taken from a set of guidelines or from evidence such as a systematic review.

Measuring performanceTo ensure that the data collected are precise, and that only essential data are collected, certain details of what is to be audited must be established from the outset. These are: The user group to be included, with any exceptions noted The healthcare professionals involved in the users' care The period over which the criteria apply.

It is necessary first to define the population to which the audit applies; for example, all patients presenting with a specific diagnosis over a specific period of time. However, it might be impractical to collect data on every patient in the population, so a representative sample can be used instead. A time frame is often used to define the sample: for example, all new patients in a one-month period. Alternatively, a consecutive sample of patients might be used; for example, the last 100 referrals. It is important that all those likely to be affected by the audit results agree on the sample sizes and agree that they will act on the results. Where data is not routinely collected, or is held only in paper records, it may be necessary to devise a data collection form on which to record information .The data collected should relate only to the objectives of the audit.

Making improvements

Once the results of the audit have been published and discussed, agreement must be reached about the recommendations for change. Use an action plan to record these actions required to make improvements. Answer the question “Are we achieving it? Have we made things better?”

Sustaining improvements

79


Lean Thinking

� An approach to service improvement which begins with driving out waste

� Identify the individual steps in each process

� Lean approaches can be used to reorganise the way a particular task is done or a particular department works

� Lean thinking is based on a system used by the car manufacturer Toyota

NHS Confederation

Although lean thinking developed in the world of car manufacturing, it has now been applied to all types of businesses all over the world.

There are 5 main principles in Lean Thinking. These are:

Patient perspective

Under Lean, value is defined solely from the customer’s perspective – in our case, this will generally be the patient. Anything that helps treat the patient is value-adding. Everything else is waste. Lean eliminates waste and reinvests released resources in value creation.

Pull

To create value we need to provide services in line with demand. No less. And no more. Delivering services in line with demand also means all work, materials and information should be pulled towards the task as and when needed. Not before. Not after. Any time spent waiting or queuing is another form of waste: resources are being used up but are idle.

Flow

Pull leads to flow where each patient is worked with, one unit at a time, and passed on for the next step of the process without any delay. A preoccupation of Lean is to identify blockages and obstacles that cause delay, and to remove them.

Value streams

For flow to happen we need to design and manage each value stream – each sequence of steps that adds value for the patient from the start of the journey to the finish – as a single integrated whole. Each step in the process needs tobe designed with an eye to the effects it has on the steps that precede it and follow it – so that they all link together seamlessly.

Perfection

80


There is more to SAC than meets the eye

� Did you expect to learn so much about business models and management when you chose your career?

� Health in the 21st century has a business model whether we like it or not.

� Imagine that you were dependent on a poorly functioning system

� We need to promote a healthy model of care to maintain the health of our patients

Ask the students if they have been subject to poor organisation in a service or hospitality industry and get them to reflect on how they felt about being the recipient of poorly planned services

81


Just some of the skills it takes towork in SAC

� Team work� Understanding

complex physical and psychological impairments

� Understanding the changes on the whole of the patient’s life

� Compassion� Business

management

� Enthusiasm� Innovation� Empathy� Life Skills� Flexibility� Persistence� Strength of character� Respect for the patient

and other team members

In the e-learning module that you completed before the placement, you learnt about the skills needed for subacute care. Now we can add “business management”.

82


Subacute Care

Do YOU have what it takes

to make a difference !

83


References� Department of Health, "Activity Based Funding and Management",

Government of Western Australia, Department of Health http://www.health.wa.gov.au/activity/home/ (accessed 27th May 2013).

� Jones, Daniel and Alan Mitchell. Lean Thinking for the Nhs, edited by Lean Enterprise Academy UK. London, UK: NHS Confederation, 2006. http://www.nhsconfed.org/Publications/Documents/Lean%20thinking%20for%20the%20NHS.pdf (accessed 27th May 2013).

� National Institute for Clinical Excellence. Principles for Best Practice in Clinical Audit. Abingdon, UK: Radcliffe Medical Press, 2002. http://www.nice.org.uk/media/796/23/BestPracticeClinicalAudit.pdf (accessed 27th May 2013).

� Queensland Health. "“How to” Guide for Clinical Audit and Review." edited by Queensland Health. QLD: Queensland Health, 2013.

� The Royal Australian College of General Practitioners, "Putting Prevention into Practice (Green Book): Plan, Do, Study, Act Cycle", RACGP http://www.racgp.org.au/your-practice/guidelines/greenbook/prevention-in-general-practice/planning-for-prevention/plan,-do,-study,-act-cycle/(accessed 27th May 2013).




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End