planning of care on practitioners

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Unit 20: Care Planning
Processes in Healthcare Practice
Session 9
L04 Reflect upon the impact of the planning of care on practitioners,
individuals, family and carers in relation to own practice

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Effective Team working STEPPS
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Partnering With the Resident
Embrace residents as valuable and contributing partners in
their care
Learn to listen to residents and their families
Assess the resident’s preferences regarding involvement
Ask residents about their concerns
Speak to them in lay terms
Ask for their feedback
Give them access to relevant information
Encourage residents and their families to proactively
participate in resident care

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5
Partnering With the Resident
Embrace residents as valuable and contributing partners in
their care
Learn to listen to residents and their families
Assess the resident’s preferences regarding involvement
Ask residents about their concerns
Speak to them in lay terms
Ask for their feedback
Give them access to relevant information
Encourage residents and their families to proactively
participate in resident care
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Paradigm Shift to Team System
Approach
Dual focus (clinical and team skills)
Team performance
Informed decisionmaking
Clear understanding of teamwork
Managed workload
Sharing information
Mutual support
Team improvement
Team efficiency
Single focus (clinical skills)
Individual performance
Underinformed decisionmaking
Loose concept of teamwork
Unbalanced workload
Having information
Self-advocacy
Self-improvement
Individual efficiency

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Why Teamwork?
Reduce clinical errors
Improve resident outcomes
Improve process outcomes
Increase resident satisfaction
Increase family satisfaction
Increase staff satisfaction
Reduce staff turnover
Reduce resident and family grievances
and complaints
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High-Performing Teams
Teams that perform well:
Hold shared mental models
Have clear roles and responsibilities
Have clear, valued, and shared vision
Optimize resources
Have strong team leadership
Engage in a regular discipline of feedback
Develop a strong sense of collective trust and confidence
Create mechanisms to cooperate and coordinate
Manage and optimize performance outcomes
(Salas, et al., 2004)
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Barriers to Team Performance
Inconsistency in team
membership
Lack of time
Lack of information sharing
Hierarchy
Defensiveness
Conventional thinking
Varying communication styles
Conflict
Lack of coordination
and follow up
Distractions
Fatigue
Workload
Misinterpretation of cues
Lack of role clarity
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Multi-Team System (MTS) for Resident Care
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Core Team
members have
the closest
contact with
the resident!
A Core Team is…
A group of care providers
who work interdependently
to manage a set of
assigned residents
from point of
assessment to
discharge
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A team comprising those
work area members who are
responsible for managing
the operational
environment that
supports the
Core Team
A Coordinating Team is…
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A time-limited team formed
for emergent or specific
events and composed
of members from
various teams
A Contingency Team is…
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Ancillary Services provide direct,
task-specific, time-limited care to
residents
Support Services provide indirect
service-focused tasks that help to
facilitate the optimal health care
experience for residents and their
families.
Ancillary and Support Services provide…
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Establish and communicate
vision
Develop policies and set
expectations for staff
related to teamwork
Support and encourage
staff during implementation
and culture change
Hold teams accountable
for team performance
Define the culture of
the nursing home
The Role of Administration is to…
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Example: A Multi-Team System
in a Nursing Home

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Exercise: Your Multi-Team System
?
?
Integration, cooperation and partnership
working
NHS Reorganisation Act 1973
The New NHS: Modern, Dependable 1997
Health Act 1999
Independence Wellbeing and Choice 2005
National Health Service Act 2006
Health and Social Care Act 2012
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Importance of involving service users in
assessment and care planning
Access to services
Local provision
Prevent and delay care needs
Integration, cooperation, partnerships
Silo working Organisational
barriers
Different operational practices
Duplication
Vision and outcomes of Integration,
cooperation and partnership working
“The vision is for integrated care
and support that is personcentred, tailored to the needs
and preferences of those
needing care and support, carers
and families.”
Improve service user experience
Eliminate duplication
Streamline care pathways
Collaborate on early intervention
and prevention
Improve safeguarding
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Why integration, cooperation and
partnerships?
Improves the service user experience
Eliminates duplication
Streamlines care pathways
Early intervention and prevention
Improves safeguarding
Teamwork and leadership
processes and impact:
Leading the care process
Working in partnership Supporting care teams
multidisciplinary approaches
Promoting best practice in the best interests of the individual
Reflective review, identifying gaps in service to improve
Collecting and interpreting data and drawing conclusions
Reviewing measures and terminating ineffective processes
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Why integration, cooperation and
partnerships?
Improves the service user experience
Eliminates duplication
Streamlines care pathways
Early intervention and prevention
Improves safeguarding
What do we mean by integration,
cooperation and partnerships?
Integration: The combined set of methods, processes and models that
seek to bring about improved coordination of care
Cooperation: Public organisations working in partnership to ensure a
focus on the care and support and health and health-related needs of
their local population
Partnership: A joint working arrangement where the partners: are
otherwise independent bodies; agree to co-operate to achieve a
common goal; create a new organisational structure or process to
achieve this goal; plan and implement a joint programme; share
information, risks and rewards

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Involving and working with families
The vision is for integrated care and support that is person-centred,
tailored to the needs and preferences of those needing care and
support, carers and families.”
Care and Support Statutory Guidance October 2014
Other legislation and policies
This duty applies where the local authority considers that the integration of
services will:
“promote the wellbeing of adults with care and support needs or of carers in its
area;”
“contribute to the prevention or delay of the development by adults in its area of
needs for care and support or the development by carers in its area of needs for
support, or;”
“improve the quality of care and support for adults, and of support for carers,
provided in its area (including the outcomes that are achieved from such
provision).”
The Health and Social Care Act 2012 (Sections 13N and 14Z1) also states that the
NHS also has a duty to promote and secure integrated care where it will improve
the quality of services, and reduce inequalities in accessing services or improve
outcomes.

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The five aims of cooperation
Promoting wellbeing
Improving the quality of care (including the outcomes from such
provision)
Smoothing the transition from children’s to adults’ services
Ensuring agencies work effectively together to safeguard adults at risk
of abuse or neglect
Reviewing and learning lessons from cases where adults have
experienced abuse or neglect
Integration, cooperation and partnership in
practice
Partnership, cooperation and integration need to be key components
of a local authority’s strategic approach. This may be with a range of
organisations (including other local authority functions, public sector
organisations and the independent and private sector) and occur in a
number of ways:
Planning and commissioning
Assessment and information
Care delivery
Quality assurance
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Strategic planning by building better commissioning arrangements or
joint commissioning teams
Commissioning integrated services, or jointly commissioning specific
services such as advice and advocacy services
Assessments, information and advice such as integrated health, care
and housing assessments
Delivery or provision of care via integrated community teams, or
working with housing providers to ensure that adaptations support
independence, reablement or recovery
Working together: examples of integration, cooperation and
partnerships
Joint information and advice service – based around the needs of the
end user rather than around individual services or structures
Integrated assessment processes
“Care co-ordinators”
Integrating assessment and care planning for carers
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Supervision and management:
Review of practice, review of policies Measuring outcomes, data
analysis Quality assurance, meeting regulatory standards,
benchmarking.