Explain outcome based practice In 1990 health care providers had just began to discover what appeared to be a very powerful tool for reducing variation in patient care practices – clinical paths. A clinical path includes descriptions of key events that, if performed by caregivers as described, are expected to produce the most desirable outcomes for patients with specific conditions or procedures. By the late 1990s, caregivers started to question the benefits of clinical paths. Organizations reported problems integrating the pathway document into patient records, thus dampening caregiver enthusiasm for using the pathway.
Physicians, nurse, and other clinicians found the pathways difficult to apply to all patient populations. A variety of factors may be causing clinical paths to look like yesterday’s failed solution, when in fact the lessons learned during years of pathway development are being put to good use in many organizations. Today caregivers are adopting outcomes-based practice methods to achieve desired patient care goals. Outcomes-based practice (sometimes called outcomes management) involves a combination of teamwork, continuous quality improvement, and process and outcome measurement.
These collaborative multidisciplinary efforts build on the pathway development work of the 1990s. It’s quite likely that outcomes-based practice would not have been possible if caregivers hadn’t learned how to work together while designing clinical paths. All of those multidisciplinary meetings to develop paths were not a waste of time! Paths and Outcomes-Based Practice Caregivers have discovered that an “as needed” pathway philosophy seems to work best. Clinical paths were never intended to solve every documentation challenge, eliminate every unnecessary cost, or be used for every patient.
Instead of trying to develop an unlimited number of clinical paths, organizations are now adopting outcomes-based practice as the goal. Paths are viewed as one of the many different tools caregivers can use to achieve that goal. An outcomes management initiative starts with the decision to improve clinical care for a particular group of patients. All involved caregivers must agree that it is important to study and improve the process. Improving a clinical process is hard work and unless the physicians, nurses, and other team members are rooting for project success, their interest in the initiative will be short-lived.
Administrative and medical staff leaders should jointly define the goals for the project. Once the patient population for the project is chosen a multidisciplinary team of people involved in caring for these patients is formed. After studying current patient care practices, the outcomes management team selects the actions necessary for achieving the project goals. What people have learned from their clinical pathway experiences is that the process improvement actions should be chosen after everyone knows what needs fixing.
Otherwise organizations end up with “solutions in search of a problem” rather than measurable improvements. Any number of actions can be taken to achieve the goals of an outcomes management project. For example, if data show that physician practices vary widely for no particular reason and reducing variation is a goal, then physician-friendly tools are developed. It’s unlikely that physicians will use a clinical path located in the nursing section of the patient’s hospital record. That’s why hospitals are designing physician-friendly point-of-care reminder tools such as pre-printed order forms.
As order entry becomes computerized, written order sets can easily be converted to an electronic format. Computerized decision support systems are another effective tool for changing physician practices. These automated systems offer physicians point-of-care treatment advice for a variety of conditions and diseases. Protocols are also an effective strategy for reducing undesirable variation in patient care practices. Unlike clinical paths that cover all aspects of care for a particular group of patients, protocols are designed for specific clinical situations, e.g. administration of heparin, management of postoperative nausea, treatment of pressure sores, etc.
Protocols can be used by themselves or in combination with clinical paths. In the latter situation, the protocol serves as an expanded definition of the ideal plan of care found on the pathway. For example, a clinical path for oncology patients undergoing chemotherapy might state, “Initiate anti-emetic protocol. ” The path helps to remind physicians and nurses that the anti-emetic protocol should be implemented at a particular time.
The protocol contains all the treatment details that would be impossible to completely spell out in a less detailed clinical path. Good Data is Essential The outcomes management project team focuses on fundamental changes in systems and practices that are most likely to produce positive long-term gains. The team does this by determining the barriers to goal attainment and then incrementally investing in strategies to achieve these goals. The project team must learn how to analyse practice pattern data to determine the best interventions and then monitor the success of various strategies.
Each initiative requires timely feedback of process and outcome measures to the clinicians. Clinical paths are not close to extinction. These patient management tools will continue to be key components of the outcomes management initiatives in many organizations. However, unlike the situation in the 1990s, a clinical path will not be the primary tool used to control costs and improve patient outcomes. Clinical paths have been joined by a variety of different tools and techniques which are all intended to improve patient outcomes and reduce unwarranted practice variation.
Regardless of how health care organizations implement outcomes-based practice, there’s one certainty – caregivers will always need valid, reliable and timely information about important clinical processes and patient outcomes. Copyright 2003 by Brown-Spath & Associates Critically review approaches to outcome based practice Outcome based care is about putting the person at the centre of the care service, and not prescribing a standard service to everyone. It is about delivering meaningful outcomes to every individual and helping people to lead more fulfilling lives.
Outcome based care requires careful planning, which involves working with the people who use our services to help them identify and achieve the things they want to do. Delivered well, outcome based care increases interest and motivation and creates the enthusiasm needed to support people to lead a more fulfilling life. Analyse the effect of legislation and policy on outcome based practice Analyse the data. Depending on the types of data you collect and the nature of your evaluation, analysis may involve qualitative, quantitative or a combination of both methods.
When describing program activities or experiences, qualitative analysis is appropriate. Quantitative analysis is used when trying to assess policy outcomes and impacts. Explain how outcome based practice can result in positive change in individuals lives An outcomes-based approach encourages us all to focus on the difference that we make and not just the inputs or processes over which we have control. Success for the Government and its Public Bodies is about impact and it is right that we should be judged by tangible improvements in the things that matter to the people of Scotland.
Government is therefore committed to an outcomes based approach and will work with Public Bodies to: Align activity to connect explicitly to the Government’s over-arching purpose of sustainable economic growth through the National Performance Framework Scotland Performs. Better integrate activities with local government, with other Public Bodies, and in partnership with the third sector and private sector, to deliver the Government’s Purpose Targets and National Outcomes.
The current development of Single Outcome Agreements (SOAs) with community planning partnerships, under the leadership of local authorities, offers a significant opportunity for Public Bodies which are delivering local services to help achieve this locally. Focus activity and spend on achieving real and lasting benefits for people and as such minimise the time and expense on associated tasks which do not support this purpose. Create the conditions to release innovation and creativity to deliver better outcomes.
2. Able to lead practice that promotes social, emotional, cultural, spiritual and intellectual well being Explain the psychological basis for well being Key points: The psychological well-being of young people (a) Psychological models of mental health, quintessentially, emphasise the key role of a Healthy, loving, supportive, connected childhood in producing well-adjusted adults. (b) It must clearly be a key policy aim to protect children from abuse, to identify children at risk from abuse, and to help address any problems resulting from abuse at the earliest possible stage.
(c) We therefore fully and unequivocally support the emphasis in ‘New Horizons’ and elsewhere on the importance of a healthy start in life. As elsewhere, investment in positive policies to support parents, families and communities will pay dividends in terms of a healthy adult population. (d) When specialised care in needed, a well-being focused approach should be used within services to address a child’s or young person’s physical and psychological needs. Promote a culture among the workforce of considering all aspects of individuals’ well-being in day to day practice.
The implementation of The Wellbeing and Performance Strategy requires an Agenda for Action. The purpose of this agenda is to embed into the organisation a culture, attitudes and daily behaviours that result in high levels of wellbeing amongst all staff (managers and employees) and will produce the high level performance dividend that can be measured as lower sickness absence, staff turnover, presenteeism and HR/Manager time on conflicts, disputes, tribunals and other features of presenteeism.
The agenda items also improve involvement, innovation, energy, motivation, engagement, commitment, trust, all of which lead to greater profit/flexible budget, market share, innovation and improved reputation and resilience. The Agenda items are: * 1. Engage top management in the Wellbeing and Performance Agenda * 2. Undertake an analysis of the current levels of wellbeing and performance * 3. Establish a steering group * 4. Develop a strategic framework for action * 5. Build a culture for wellbeing and performance * 6. Develop the ethics and behaviours that produce wellbeing and performance * 7.
Take the actions that produce wellbeing and effective performance * 8. Strengthen personal resilience * 9. Implement change management utilising the Managers Code of Conduct 1. Engage top management in the Wellbeing and Performance Agenda Senior management influences the behaviours of those below them, and senior management set the tone for the organisation. The culture of the organisation is heavily determined by the personalities and characteristics of senior managers, and their own determination in promulgating a wellbeing and performance culture.
This will normally necessitate the champions of wellbeing and performance to raise awareness of the arguments, and issues relating to wellbeing. 2. Undertake an analysis of the current levels of wellbeing and performance A survey of staff provides the benchmark against which the effect of various wellbeing initiatives can be measured. A year on year assessment of progress can be made, and those initiatives which show least impact can be dropped in favour of those with greatest impact. Various surveys exist with different purposes.
At the least, all organisations that employ 5 or more people are obliged to demonstrate they comply with the Health and Safety Management Standards. More comprehensive surveys examine the health and wellbeing of staff, the quality of working lives of staff, the intention to leave or stay amongst staff, and the assessment of the organisation in relation to commitment, trust and engagement. The results of a survey provide the information to focus attention of specific actions that are needed to build and sustain a culture of Wellbeing and Performance. 3. Establish a steering group
Many organisations are made up of different divisions and departments, with different purposes. They will have different managers and perform differently. In order to promote a wellbeing and performance culture, it may be necessary to establish a steering group to oversee and take responsibility for this project. A steering group needs to have decision makers on it, as there will be decisions about resource allocation that will be necessary. 4. Develop a strategic framework for action A strategic framework provides the focus for action, and a map against which progress can be routinely measured.
A suggested framework embraces * a) promoting wellbeing and performance and the prevention of risks of psychological distress and other forms of ill health and accidents; * b) preventing deterioration amongst those who suffer distress; * c) restoring those with psychological distress back to their normal level of performance and beyond; * d) supporting those with chronic conditions and * e) sustaining wellbeing and performance. In addition, a strategy will need to consider the services and training required to implement a wellbeing and performance programme.
Suggested topics are Behaviour, Wellbeing programmes and services, Structure, Culture, Resilience and tolerance. 5. Build a culture for wellbeing and performance The culture of the organisation embraces the features that influence how people behave. In building a culture of wellbeing and performance the features need to be those that promote commitment, trust, engagement and a strong psychological contract – the idiosyncratic unwritten contract that individuals have between themselves and their organisation based on personal notions of fairness.
Most psychological contracts are based on the behaviour that managers and employees exhibit towards each other that denote trust, value, and reliance, where each party engages fully with each other and builds trust between them. For this to happen, the context in which behaviour takes place needs to promote values that accord with the values of the employee. The steps to be taken in building a culture of wellbeing and performance are: Clarity of purpose – The clarification of the purpose of the organisation and its sub divisions in ways that are simply expressed, and that staff and the public can understand and relate to.
The structures – The design of structures that enable staff to be engaged in decisions about themselves and their work. The ‘rules’ – The rules are the policies and procedures that are expressed (often in writing) that describe how the organisation is meant to work. Among the topics that are known to influence trust and commitment are: * Recruitment – The recruitment of managers and staff based on the convergence of clear and unambiguous expectations of the skills, knowledge and experience needed for the job and those of the applicant.
* Training and development – The training and development (the acquisition of skills, knowledge and experience) of all staff based on meeting the needs of the organisation and those of the trainee; the training is based on sound learning principles, and applied in practice. * Challenge – The provision of challenges and stimulation in the work employees and managers are expected to perform. * Teams – The building of teams with people who are sufficiently trusting of each other that they can critique each other’s work without fear of humiliation or retribution, and in the knowledge that lessons can be learnt and applied.
* Communication – The provision of excellent communication – the process of engaging people in communication, interpreting messages, conveying them intelligibly, seeking responses, and reacting to them positively. * Involvement – The involvement of staff, organisations and customers/clients in the processes and decisions that affect them. * Performance appraisal – The provision of regular and routine performance appraisal of staff as part of the bloodstream of management, together with providing appropriate supporting resources to raise performance where needed.
* Career development – The provision of career development opportunities through nurturing and developing staff to use wider skills, knowledge and experience in practice. * Security – The protection of tasks, projects and assignments from termination in advance of their completion. * Encouragement – The encouragement of staff in their work, and in taking calculated risks intended to contribute to the performance of the organisation. * Worklife balance – The motivation to respond positively to domestic crisis. * Openness – The maintenance of transparency in all aspects of management.
These ‘rules’ need to be formulated in consultation with managers and staff, and implemented into the bloodstream of management through a range of devices that reinforce the ‘messages’ of trust, commitment and engagement. 6. Develop the ethics and behaviours that produce wellbeing and performance The behaviours that managers need to demonstrate are those that build and sustain trust, commitment and staff engagement.
These behaviours are the building blocks for a Wellbeing and Performance culture. The headlines are in the diagram. Attentiveness * Politeness * Courtesy * Personal communication * The Use of Body language.
* Addressing needs * Empathy Intellectual flexibility * Emotional intelligence * Negotiation * Sharing Reliability * Honesty * Clarity * Fairness * Humility Resolving conflicts Encouraging contribution These behaviours can be developed in every manager and staff member using Corporate Cognitive Behaviour Therapy (CCBT) approaches, in a coaching or group workshop setting. This involves replacing ambivalent attitudes about people at work with positive thoughts that promote the benefits of positive interaction, and the benefits that accrue from gaining commitment, trust and engagement between staff and managers.
7. Take the actions that produce wellbeing and effective performance The actions required from managers who wish to implement the Wellbeing and Performance Agenda are divided into the classical purposes of management. They are: Decision making * Justification for decisions based on appropriateness, evidence, experience, timeliness and feasibility. Direction * Providing direction based on analysis and with committed ambition. Co-ordination * Integration of the mosaic of available resources to achieve a declared aim.
* Reaching an agreed goal within agreed boundaries of time and resources. * Keeping resources at his/her disposal within agreed boundaries. These classical purposes of management normally form the basic training for managers. There are technical and psychological aspects in their application to practice. The psychological aspect embraces the ability to follow the ‘Just a Minute Model’ of performance, that seeks to ensure that actions are taken without hesitation, deviation or repetition, and that the decisions are appropriate, efficacious, effective and efficient.
This requires intense concentration by managers, and is the principal benefit arising from a Wellbeing and Performance strategy, and a Positive Work Culture. 8. Strengthen personal resilience Resilience is the capacity to tolerate excessive demands and stresses without experiencing personal stress. Resilience is about the maintenance of person control in adverse situations, combined with the capacity to control the responses of others to oneself in these situations. Resilience is based on individual attitudes towards an adverse event.
Attitudes are developed from conditioning throughout life, combined with personal experiences that have either built or reduced self esteem (depending on one’s capacity to cope with the situation), combined with a decision to be motivated to overcome and tolerate an adverse event or not. Most people have built a degree of resilience, simply through the process of experiencing challenges and rising to them successfully. However, there are some established adverse events that pose a risk to individuals. Many of these arise in the workplace.
A substantial number of people are not prepared for these challenges and find them difficult to tolerate, causing a lowering in performance, reduction in motivation, and the possibility of significant distress. Training in building the capacity for resilience is an important aspect of the Wellbeing and Performance Agenda. 9. Implement change management – the Manager’s Code This is a method of change that uses a Manager’s Code that all managers are expected to follow. The Code is based on the principles of a Positive Work Culture and the link between wellbeing and performance. The Manager’s Code focuses on:
* Managing my Organisation * Managing my Enterprise * Managing my Workforce * Managing Myself. All organisations have the capacity to develop a Positive Work Culture with managers promoting wellbeing and performance. Introducing this approach is made easier with a Code that has been drawn up based on sound principles and supportive of manager behaviours that promote commitment and trust. Implementing the Code needs to follow the enabling as opposed to policing principle. Managers should be encouraged to follow the Code rather than feeling threatened if they don’t follow the Code.
Manager’s need to be convinced a Code is helpful in forming their attitudes towards their staff which encourages high level performance from the workforce by ensuring high levels of wellbeing. Review the extent to which systems and processes promote individual well being In this day and age of individualised, person-centred service provision, effectively promoting and maintaining well-being and choice for people who use services, presents many-headed challenges for service providers, especially frontline staff.
From their waking moments to bedtime as well as throughout the night, providers of adult social care, especially frontline staff, have a social and legal responsibility to ensure that the needs of individuals who use services are being continually met. It is important to note that a key challenge for staff to effectively promote and enhance the well-being of service-users, is in understanding and accepting that it is both a process and outcome involving service-users and frontline staff.
Thus it requires presence of mind, careful consideration and monitoring and evaluation by service providers in order to maximise the quality of life of the vulnerable people who they care for and support. The importance of well-being and the availability of choices is unsurprisingly a common thread which runs throughout the Essential Standards of Quality and Safety outlined by the Care Quality Commission, and involves meeting the needs and aspirations of service-users. Let us consider well-being and choice touching on a few examples during a hypothetical day in the life of a service-user.
The timing, approach and manner in which a service-user is supported to get out of bed impacts on their well-being. Knocking, waiting to be invited in and offering the person choices such as whether or not they are ready to get out of bed and if they are, how they would like to proceed, may make the person feel respected. This may even be the case when the service-user has an established routine. A key challenge for service providers is to ensure continuity of care, so that staff who are familiar with the needs of the service-user are also those who care for and support them.
Effective communication is also important in promoting well-being and choice, as it fosters mutual understanding, which is at the core of the process to facilitate desired outcomes. Achieving this is however fraught with pitfalls, including limited or non-existent knowledge of the best way or means to communicate with individuals. Inappropriate or poor communication also manifests itself in various ways such as making critical comments about service-users who are within ear shot or chatting with colleagues and excluding the service-user from conversations.
This becomes more obvious when temporary staff such as different agency workers who are not properly inducted are called upon on a regular basis to care for and support people they have not met before. Respecting the privacy of service-users is also key in maintaining the well-being of the individual. Thus, invading personal spaces such as barging into bathrooms, bedrooms or quiet areas especially when there is a perceived ‘emergency’ does little to foster well-being. Staff may also unconsciously speak loudly in the presence of others when talking to individuals about things the service-user may wish to keep private.
Issues of confidentiality in all its forms must also be maintained in order to facilitate the well-being of individual service-users. Personal care such as bathing, toileting and managing continence presents its own challenges for frontline staff in their bid to promote, the well-being of service-users who require this level of support. Privacy and dignity is always linked to the well-being of individuals. Another aspect of the service-user’s day which is often taken for granted by staff is nutritional care. It is generally accepted and a well documented fact that mealtime is among the highlights of a service-user’s day.
It is therefore an activity, when managed properly, which improves the quality of the day for the individual. The challenge is for staff to ensure that meals are provided to individuals when and where they want it, and not only at set times when it is convenient for the service-provider. Furthermore, offering a wide range of food choices becomes a logistical nightmare for providers, especially when catering for more than a handful of individuals. Offering the appropriate cutlery and crockery for the individual service-user is also very important to promoting well-being.
Service-users may wish to feed themselves, rather than be fed by staff in what may sometimes be undignified ways. The only inhibiting factors may be the lack of non-slip table mats, especially modified cutlery and the use of ‘pseudo-bowls’ instead of flat plates to reduce spillage, promote independent eating and make mealtimes an enjoyable experience. Regular input from a dietician may also help to ensure that meals are of nutritional value. Another area worthy of note is that of healthcare and a particular ‘typical’ scenario which springs to mind. A service-user has an appointment with the GP and is supported by staff to attend.
The doctor completely ignores the patient and talks to the staff about the patient’s symptoms as though the service-user is not present. No physical examination of the person is made even though required. This attitude of some healthcare professionals seems to be just like this when dealing with patients with learning disabilities. In such cases GPs need to be reminded that they too are subject to the requirements of the Health and Social Care Act 2008, and are expected to follow the Essential Standards of Quality and Safety when dealing with service-users.
It appears that due to the limited or scanty knowledge that some General Practitioner’s (especially locums) may have about certain conditions that fall within the broad spectrum of learning disabilities, there is consequently a perceived reluctance to engage with such patients even when no communication difficulties exist. It is the writer’s view that this attitude is another subtle dimension of health inequality which needs to be addressed whenever it arises. Such attitudes can diminish the feeling of well-being, which a service-user may have developed over a period of time.
The challenge faced by care and support staff is to be confident enough to politely challenge GP’s and other health professionals who display a distinct lack of decorum based on such assumptions. It is also important for staff to encourage self advocacy in service-users. Good health also has a direct impact on our well-being and more so for someone who is vulnerable or who has a disability. Thus it becomes even more disorienting when people who use services do not understand why they may be feeling a particular way. This is frequently the case when it comes to prescribed medication, its known side-effects and the management thereof.
Often staff who have been trained to administer medication to those in their care are not always fully aware of the possible side effects of some prescribed medication. To promote the well-being of service-users, staff need to learn about the medication their clients take in order to facilitate this. What is also relevant is the need to be acutely aware of pain management strategies and how communication difficulties may affect the ability of some individuals, such as those with dementia or learning disabilities, to express themselves.
It is good practice for staff to routinely enquire about well-being and to know the service-users well enough in order to spot signs of pain and discomfort and to then take steps to alleviate this. Assisting service-users to participate in the wider community, such as attending social/ cultural and religious activities, is another method of maintaining the well-being of individuals (facilitating personal shopping trips also falls within this description). The challenge for staff is to understand the need for this, and to positively encourage the service-user, thereby making it a worthwhile activity for the individual to undertake.
Just as vital is the facilitation of contact with family and friends. Celebrating birthdays in the way the individual chooses is also a great boost to self confidence. This helps in no small measure to foster well-being and choice. Effective person-centred-planning is therefore key to achieving this endeavour. Promoting the well-being and choice of the service-user may also be achieved in the development of everyday living skills. This may involve staff offering practical assistance to carry out household tasks.
It is key however, to use simple tools such as an Everyday Living Skills Inventory (ELSI) form to accurately chart progress. (This may be found in the QCS Management System). Choice is always inextricably linked to the making of decisions and suggests that at least two options/a range of options/limited alternatives exist, and that the choice is made independently. However in practice this is hardly ever the case. Thus the use of independent advocates is of crucial significance in the quest to promote and maintain well-being and choice for service-users in different care settings.
Source: David E Kingsley-Nyinah Be able to lead practice that promotes individuals’ health Demonstrate the effective use of resources to promote good health and healthy choices in all aspects of the provision It is estimated that illness at work costs UK employers ? 12. 2 billion a year, as a result of sick days taken. Whatever the cause of ill health, it is in the interests of the organisation to support an employee’s return to work wherever possible. Health issues can not only affect the individuals concerned but can also have a detrimental effect on the wider workforce and the organisation’s performance.
Organisations should be aware of possible problems and be confident that they have the background knowledge and policies in place to deal with them. According to research recently conducted by the Institute: “The Quality of Working Life 2007”, 42 per cent of managers reported that sickness rates in their organisation had increased over the last year. 67 per cent of managers who suffered ill health reported that it had affected their productivity levels.
There appears to be an emerging trend that absence and sickness rates are on the increase and there is a high degree of ill health that does not necessarily translate into days off but appears to be affecting motivation levels. This guide seeks to raise awareness of health and well-being issues, the effects on organisations, strategies for dealing with ill health and suggests how a policy may be implemented. Ill health in the workplace It is recognised that many factors from genetics to the external environment can cause or trigg