GUIDANCE AND TEMPLATE

Transcription

1 GUIDANCE AND TEMPLATE The care pathway mapping tool is designed to be used as part of the map the care pathway stage of the eight stage workforce planning approach. The output of the tool will be the creation of maps which identify the key activities of the care pathway under examination. This document will guide the user through the creation of the care pathway maps. The tool follows a very simple process mapping methodology and can be used in alignment with other tools you may have in your area to conduct pathway mapping. If you do not have access to Microsoft Visio, you can follow this guidance to create the map in Microsoft PowerPoint or a similar programme. Information collected within stage 2 and steps 3.1 and 3.2 will provide you with sufficient information to draft a first version of your pathway map. You will require the input of others along the pathway to revise the draft version. The purpose of this tool is to allow you to map out the key activities of the care pathway across different settings. This will allow for the team who delivers the service to gain a common understanding of how each role in the pathway contributes to delivering an integrated service. The first step to using this tool is to identify the key settings that the care pathway goes through. For example, if the care pathway requires input from the acute and community setting, you may decide to use a 2 lane background. Once you have determined the team settings, you can now begin to map on activities. It is recommended that the activities be mapped on by gaining input from those involved in delivering the service and also by consulting existing pathway mapping documentation. The NHS Institute for Innovation and Improvement and other organisations have produced guidance about how to conduct pathway mapping: NHS Institute for Innovation and Improvement: European Pathway Association: Scottish Government: Icons are used to represent each stage of the process. The process maps created by this tool are intended to be high-level. Therefore only a basic selection of icons have been included. Activity Represents where a task or process is as part of the care pathway. Such as Assessment Undertaken Signifies the beginning of the process Signifies the completion of the process Arrows used to link together activities and decisions We suggest that you divide your pathway into high-level segments so it is easier to link workforce to your pathway. An example of this can be seen on the website in the Integrated Discharge Care Pathway map from Cambridgeshire. Annotation Where explanatory comments are required to explain an element of the process an annotation can be added 1 Indicates where there is a workforce implication as part of the process

2 1. Using the standard toolbar select Insert, and then New Page On the dialog box that appears (as shown below in figure), choose Foreground and enter an appropriate name for the new page. It might be helpful to choose the name to match the process that will be displayed on the page. 5. To add a title, logo and swimlane headings to the new page, navigate to the Template Materials page using the tabs at the bottom of the window. Follow the instructions that appear on that page. The finished page should look similar to the below figure. Insert organisation logo here Insert version control, status and date of page Select Foreground Name field Align swimlane titles to left of the diagram Background drop down menu 3. In the Background drop down menu select an appropriate background template. The background template chosen must align to the number of swimlanes required for the process. The number of swimlanes is dictated by the number of organisations involved in the process. For instance, if there are four organisations, choose 4 Lane Background. 6. The process map can now be created. Either drag and drop shapes from the stencil window to the diagram area (as shown in the below figure), or copy and paste the shapes from the Template Material page. 4. A new blank page will be created with the background selected in step 3. Stencil opened by selecting File, then Shapes, and choosing Care Pathway Stencil To drag an icon, select it on the stencil, hold down the left mouse button and drag to the desired place on the page

3 Insert your logo here [Name of Program here] High-level process [Name here] Status: [DRAFT/FINAL] Version: [X.X] Date: [Date last updated] Using template title and logo: 1. Draw a box around the titles in red at the top of this page by holding down the left mouse button and dragging 2. Copy the contents of the box by clicking the right mouse button and selecting copy 3. Navigate to the relevant page, right click the mouse, then select paste Using template icons: 1. Copy from the below table of icons by right click with the mouse on the image and select copy 2. Navigate to the relevant page, right click the mouse, then select paste Using swim lane titles: 1. Hold down the shift key ( ) and left click with the mouse on the desired number of swim lane title fields (shown in red to the right of the page) 2. Navigate to the relevant page, right click the mouse, then select paste 3. While still selected, drag the boxes to the correct position at the far left hand side of the swimlane, as shown on the example pathway page. Activity box Start of pathway End of pathway Sequence Flow Annotation Workforce implication Activity Annotation 1

4 Cambridgeshire - Integrated Discharge Process High-level process Pre-admission and Upon admission Pre-admission Upon admission In the future state Person seen by community team Section 2 received Received by community team in the future state (Up to 8 days before) Patient planned for elective admission Length of stay set (ELECTIVE Section 2 sent (ELECTIVE) Patient admitted Expected Date of Discharge (EDD) set Via RealTime system Section 2 received Section 2 sent 1 2 Discharge risk produced 3 EAU Clerk Ward Nurse Admission checklist completed Admission booked 4 Discharge plan created 5 Medication review conducted Via RealTime system Advance notification received Advance notification sent To Ongoing Care page Pre admission (ELECTIVE) Patient presents to A&E Set within 24 hours GP Liaison, START informed (Ref from GP) Ward nurses (Ref from outpatient/ self) START (ref from ambulance) Only if required For very complex patients only

5 Cambridge - Integrated Discharge Process High-level process Ongoing Care Roles: DPSN, SW, etc Community hospital ward staff? In the future this function could be performed in the community Could potentially fulfil an inreach role and s in the community in future Reablement team undertakes inreach Community s 10 MDT decide plan for discharge Options include: special needs funding, health equipment needed, fast track, funded nursing care, continuing health care, community rehabilitation/ intermediate care Draft discharge letter started 1 Updates to draft discharge letter 6 Patients reviewed in depth MDT meeting Decisions on patient treatment made Daily EDD review Daily board meetings Discharge plan review Investigation/ intervention made Discharge plan updated 3 Special needs funding Liaison psych service nurse from acute hospital comes to acute hospital 8 Funded nursing care Continuing health care fast track Acute s Psych Acute Continuing health care 9 Community rehab. Referral/ intermediate care Patient & carer updated To 48 hours discharge to EDD page Discharge letter updated Junior doctors carry out this task Nurses to complete in future state CHC checklist which can trigger health needs Others relate to section 2/ discharge Mental capacity Best practice Performed by social worker

6 Cambridge - Integrated Discharge Process High-level process 48 hours to EDD Capacity monitoring tool used Section 2 received 11 Taking into account: Equipment needs Funding model Geographical location Person/ carer wishes Via RealTime system List compiled Community rehabilitation form Intermediate care referral form Assessments completed Discharge letter finalised District nurse letter created Forms populated Care package/ placement arranged Confirmed route out of acute setting 48 hours to EDD Transport booked or carer notified Prescribe and dispense lag time Pharmacy informed District nurse letter created Confirmed date of discharge Completed on RealTime by DPT Persons made ready for discharge To Discharge page Section 2 sent Patient and family made aware Discharge letter finalised

7 Cambridge - Integrated Discharge Process High-level process Upon discharge Person received To 6 weeks post discharge page Undertaken by junior doctors Could be done by nurses in future state Final discharge letter signed Person moved to discharge lounge OR Carer picks up OR Patient removed from HISS Person discharged Medication received (traditional bottleneck here) Transport required Information shared with transport team

8 Cambridge - Integrated Discharge Process High-level process 6 weeks post discharge Community organisations/ options Person dies Care package/ placement arranged 19 Interim beds Residential home Reablement Domiciliary care Mental Health Trust Extra care/ sheltered housing Intermediate care Hospice ISPs Voluntary organisations Nursing home Community hospital Other Person no longer needs care E.g. Welcome home from hospital team Inpatient rehabilitation I.e. Homeless shelter Person discharged Person readmitted; Go to Pre-admission & upon admission page