How To Be A Person Centred Doctor

Transcription

1 Person Centred Practice Guide to implementing person-centred practice in your health service Photo: 2008 ABC

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3 Table of contents Section 1: Concept of person centred practice 1 Philosophy of care 2 - What is person centred practice? 2 - Why is person centred practice important? 2 - Principles of person centred practice 3 - How and when to apply these tools 4 Section 2: Improving person-centred practices 5 How can I become more person centred in my practice? 6 STEP 1 and 2: Assess - How person centred am I? 7 STEP 3 and 4: Objectives On which area of person centred practice should I work? 8 STEP 5: Action plan - How do I become more person centred in my practice? 10 STEP 6: Evaluation 11 Page Section 3: Resource Section 12 Where can I find out more on person centred practice? 13 - How to find relevant resources 14 - Some resources that have been found for you 15 Barriers and enablers 16 Section 4: Supplements Supplement 1: Person centred Practice Assessment Instruments Supplement 2: Other Person-centred Practice Resources Bibliography ii

4 Section 1: The concept of person centred practice

5 Major concepts: Definition for person centred care We are human beings; our patients or clients are human beings; and it is shared humanity that should be the basis of the relationship between us (Curtin, 1979). The assessment and delivery of person centred practice will be different for each individual, team and organisation. Philosophy of care The philosophy that underpins the information presented in this toolkit is that of person centred care. The National Health and Hospitals Reform Commission (2008) has recommended people and family centred care as the first principle for guiding the delivery of health care. It describes this as health care that is responsive to the individual differences, cultural diversity and the preferences of people receiving care, and is achieved partly through providing choice in health care. In addition, it is recommended that pathways of care should be easy to navigate and care should be provided in the most favourable environment (National Health and Hospitals Reform Commission, 2008). What is person centred practice? Person centred practice for older persons is treatment and care provided by health services [that] places the person at the centre of their own care and considers the needs of the older person s carers (Victorian Government Department of Human Services, 2003). It is also known as person centred care, patient-centred care and client-centred care. Person centred practice is treating patients/clients, as they want to. be treated. This might include considering concepts such as dignity and respect. Curtin encapsulated this when he wrote we are human beings, our patients or clients are human beings, and it is shared humanity that should be the basis of the relationship between us (Curtin, 1979). Individuality of person centred practice. Culture change is a long-term effort. It starts with analysing individual, team or organisation practice to identify areas requiring development. For this reason, this document does not contain recipes, but rather tools to allow each individual, team and organisation to take the journey improve in the areas that are important to them. By the end of reading this document, you will have identified unique needs to work on, and designed unique action plans just as when you are working with patients and clients you will assess their unique needs and deliver unique treatment plans. 1

6 Why is person centred practice important? It makes sense that when you get to know the patient or client well, you can provide care more specific to their needs and therefore better care. by promoting and facilitating greater patient and client responsibility, patients and clients are more likely to engage in treatment decisions, feel supported to make behavioural changes and empowered to self manage. A recent literature review found that person centred practice could make a positive difference to health outcomes, patient and client satisfaction and can improve one s sense of professional worth (Department of Human Services, 2006). Major concept: Principles of person centred practice 1. Getting to know the patient or client as a person 2. Sharing of power and responsibility 3. Accessibility and flexibility 4. Coordination and integration of care by the service provider 5. Having an environment that is conducive to person centred care both for the service providers and service users (Victorian Department of Human Services, 2006) Principles of person centred care 1.Getting to know the patient or client as a person: This focuses on building a relationship between the clinician and the patient/client and carers. Health professionals need to get to know the person beyond their diagnosis. 2. Sharing of power and responsibility: This focuses on respecting preferences. It includes treating patients / clients as partners when setting goals, planning care and making decisions about care, treatment or outcomes. 3. Accessibility and flexibility: This focuses on meeting patients and clients individual needs by being sensitive to values, preference and expressed needs. It also focuses on giving the patient / client choice by giving timely, complete and accurate information in a manner they can understand so they can make choices about their care. 4. Coordination and integration: This is about teamwork. It includes working together to minimise duplication and providing each patient / client with a key contact at the health agency. It also involves service providers and systems working seamlessly behind the scenes to maximise patient outcomes and provide them with a positive experience. 5. Environments: The environment refers to both the physical and the organisational / cultural environment. This is focused on having an environment that enables staff to be person centred in the way they work. 2

7 How and when to apply these tools The information in this chapter can be used to assist individuals, teams or organisations to make changes to their practice. Listed are some suggestions on how you may approach this for different intended outcomes. Also listed are some key considerations to achieve a successful outcome. Possible approaches to reviewing person centred practice Approach Outcome Actions During team planning As a team building exercise To review / assess current practice Teams or organisation make changes in their practice Individual clinicians complete an assessment instrument on their own. A team member or facilitator collates the results for the entire team OR Complete an assessment instrument in a group, as a team Discuss the results of the assessment as a team and develop objectives and an action plan together Key factors for success Receiving active executive support Planning is important and should be ongoing via critical reflection and evaluation and refinement of action plans Appoint a project champion Draw attention to the need for change Create a sense of urgency Work across teams; involve staff from multiple disciplines & levels Make dedicated time initially to assess practice and develop some objectives, to avoid the increasing work loads for clinicians Use every team meeting to reinforce the principles and importance of person centred care Use person centred practice principles when measuring performance within the organisation During performance appraisals To assist performance management Education / information sharing Individual to make changes in their own practice Individual to make changes in their own practice Culture change Individual clinicians complete an assessment instrument on their own Individual clinicians develop a personal action plan and shares this with supervisor Individual and supervisor complete assessment instrument together OR Individual and supervisor complete the assessment instrument separately Discuss the results of the assessment together and compare to previous times Using principles of person-centred practice placed as screen savers or s Place emotive posters of older people and caring health professionals on walls Conduct workshops for example the Enhancing Practice Program (see supplement 2) Embed this culture by highlighting it at all staff orientation programs 3

8 Section 2: Improving person centred practice in practice ABC

9 How can I become more person centred? First you need to decide who will participate in a review on person centred practice. This is important, as the assessment you choose will need to suit the individuals, teams or organisation chosen. Then, follow the steps below to help you, your team or your organisation, become more person centred in practice. Step 1 and 2 Assess Step 3 and 4 Objectives Step 5 Action Plan Step 6 Evaluation What is the problem? How person centred am I? What area should I address to become more person centred in my practice? How do I become more person centred in practice? How will I know if my practice is more person centred? 1. Select an assessment instrument that best fits your role. 2. Complete the assessment to determine your current strengths and weaknesses in terms of person centred practice. Reflect on the findings from your assessment. Consider the impact you would like to make in relation to person centred care and how achievable it will be to make that impact. Now: 3: Write objectives and 4: Prioritise them 5: Develop an action plan for your high priority objectives. This involves identifying the steps you might need to take to become more person centred in your chosen area of practice. One of your actions might be to find resources on a particular subject. The resource section will help you with this. 6: Evaluate. This might involve using the assessment instrument you used in step 2. Some other ideas for evaluation are discussed in this section. 5

10 Step 1 and 2: Assess How person centred am I? Actions STEP1: Select an assessment instrument - Organisations and teams: consider using the Strategies for Leadership instrument - Individuals and teams: consider using the Person Centred Care Benchmarking Survey - For additional assessment instruments, see supplement 1 STEP2: Complete the assessment instrument Tools to assess the strengths and weaknesses of you and/or your team in relation to person centred practice can have three main purposes: 1) To help identify particular areas in which you and/or your team might like to improve, and to direct you to resources that might help; 2) For comparison purposes to evaluate how far you may have come once you have changed your practice; and 3) To allow for benchmarking with like services. Note: The more reflective and honest you are when completing these assessment instruments, the more useful your results will be. There are a few approaches that can be taken to assess how person centred your practices are: - Self assessment - Observation - Client feedback - Other approaches such as evaluating practice process, health behaviours and health status. When deciding which assessment instrument to use, consider: - The target: are the participants at an clinical, team or the organisation level? - Time: how much time would you like participants to spend on the assessment? - Purpose: For some ideas see page four. If you plan to complete an assessment of person centred practices at an organisation or team level, then use of the Strategies for Leadership: A hospital Self- Assessment Inventory is recommended. If you plan complete an assessment of person centred practices at an individual or team level, then use of the Person Centred Practice: Benchmarking Survey is recommended. Other self-assessment including ones that focus on the environment, nurse practices and attitudes are summarised in Supplement 1. Measurement instruments that use an observation, client feedback or other approach are also summarised in Supplement 1. Many of these are identified in the Cochrane review on interventions that promote a patientcentred approach (Lewin, Skea, Entwistle, Zwarenstein, & Dick, 2001). 6

11 Step 3 and 4: Objectives On which area should I work? Actions STEP 3: Determine your objectives STEP 4: Determine priority of objectives Highest priority will be given to objectives that: - currently have poor performance, - will have a large impact on patient care, and - can be realistically achieved. Not everyone will have the same strengths and weaknesses when it comes to person centred practice. Reflecting on the results or themes that arose from the assessment instrument you have just completed may help you to define some objectives. What is an objective? An objective is essentially what you hope to achieve, or what you would like to be different as a result of your actions. It is generally the longer-term result or outcome you would like to obtain. SMART objectives Specific: To be specific, include detail on exactly what you are hoping to achieve Measurable: Consider how you will know if you have achieved the objective Achievable: To determine if an objective is achievable, you should consider what is within your sphere of influence. This means selecting an objective that you really can achieve. You should also identify who has the authority to make / endorse a change in your area of interest. You might like to talk over your idea with your supervisor / manager or other team members, as this will increase your power or influence to make the change. You also need to consider what is feasible to tackle with available resources. Relevant: The objective needs to be relevant to your patient / client group, your team and your health service. In this case it should also be relevant to the principles of person centred practice Timeframe: These will help keep the project on track It can be helpful to state your objectives in SMART terms, that is, an objective should be Specific, Measurable, Achievable, Relevant and have a Timeframe. 7

12 On which objectives should I work first? It is recommended you prioritise highly those objectives that: - will have a large impact on patient care, and - you are able to achieve (sits within you sphere of influence). To help you prioritise, you may choose to use the matrix provided. Using a matrix may help you combine information on the feasibility of an objective and the impact achieving it will have on patient care, to determine what priority level to assign each objective. Impact on patient Minor Impact Moderate Impact High Impact Difficult to achieve Feasibility Somewhere in between Easily achieved Leave it for later Leave it for later Plan for it soon Leave it for later Plan for it soon Plan for it soon Plan for it soon Act on it now Act on it now 8

13 Step 5: Action plan - How do I become more person centred in my practice? Action STEP 5: Develop an action plan Action Plan Template Problem On which area do you want to work? Difficulty getting patients to name a goal Objective What do you hope to learn / achieve? Set collaborative goals with each patient at the first assessment & review them weekly Action plans are used to help you think through and document the steps you might need to take to achieve a change in practice. An action plan provides a timetable of events that sets out exactly how an objective will be achieved. Once you have identified the area of person centered practice upon which you would like to work, you need to establish some manageable tasks that will help you achieve an improvement in this area. Each task should be small enough to be completed in one sitting. Fill in the template below. An example of an action plan is also provided. If the problem is at a team or organisational level, the action plan should be completed with your team. Actions What are the steps you need to take? What are the time frames to achieve these steps? 11 th Jan: Speak with supervisor for advice 20 th Jan: Research collaborative goal setting 30 th Jan: Share knowledge of collaborative goal setting with my team 14 th Feb: Meet with team to discuss new format for case conference that supports collaborative goal setting Resources Who are the people and what are the resources you need? (Consider information, time and cost.) Information: NARI website has work place examples People: Manager Time: Two hours to look at goal setting information. Meet with supervisor fortnightly to review progress Cost: nil Evaluation How will you know that you have achieved your goal? I set collaborative goals with all of my clients and can report on them at each patient s first case conference I score better on this section of the assessment instrument 9

14 Step 6: Evaluation - How will I know if my practice is more person centred? Action STEP 6: Evaluate Evaluation will be built into each action plan. While you are planning how you will makes changes to practice, you will also be planning how you will evaluate the impact of those changes. The evaluation for each objective will be specific to each objective. Evaluating the broader picture of person centred care as a philosophy of care, takes additional planning. Changes to philosophy of care, or organisational culture, take a long time to achieve. Therefore the evaluation you choose will need to be sensitive to small changes, as the full effect of your actions may not be witnessed until some time in the future. Generally evaluation involves repeating the assessment you initially competed to see if there are different results. The two assessments recommended, the Strategies for Leadership assessment and the Person Centred Care Benchmarking Survey, both use 5-point scales, which are more sensitive than assessment instruments that only use yes/no answers. However these assessment instruments might only show significant change following a significant amount of time (perhaps a year). Some additional question you may ask to evaluate the changes you have made in the short term could include: What actions have taken place in comparison to the objectives and action plans set? What observations and results (planned and unexpected) have been achieved? What lessons have been learned that can be applied elsewhere? How can these lessons be communicated? What can be done to further improve practice? If your objective has been achieved, then share the success with your team and start the cycle again by defining a new objective. If you have not completely achieved your objective you may wish assess what has been accomplished and define new objectives to meet remaining needs. 10

15 Section 3: Resource Section ABC

16 Where can I find out more on person centred practice? Major concepts: Learn how to search for resources using database and web search engines, Or use the resources provided for you. The PICO model: P Patient / Problem What are the important characteristics of your patients / clients? I C O Intervention or Indicator E.g. aged care How to find relevant resources If you have access to a library, the librarian may be able to assist you with finding relevant resources. If not, then below is some information on how to find resources. To find the most useful resources or information when using a search engine, you need to be clear about what information it is you are seeking to find. Asking the right question will help you to determine the keywords you will enter to direct your search. One way of formulating the right question is by using the PICO model. Not all of the resources available on person centred practice are published. For this reason you may need to perform a web based search as well as a database search Which main intervention, E.g. You can find more information on searching for the right resources using prognostic factor, or exposure collaborative databases and an evidence based practice approach at are you considering? goal setting Comparison (Centre for What is the main alternative E.g. Clinical Effectiveness, 2006). to compare with the therapist intervention? goal setting You can find more information on searching for the right resources using a Outcome web browser, by reading your preferred web browsers search guide. What can you hope to E.g. patient Some general tips are: accomplish, measure, satisfaction improve or affect? Choose descriptive and specific keywords. The more keywords, the more specific and relevant your search will be. Use quotes for an exact match. For example, if you enter the words person centred practice (with quotation marks) your search should result in web pages in which these three words appear in that order. Most web browsers will automatically search for stem variations (for example, using the word practice will also search the word practices ), synonyms, abbreviations and words that might be combined or split. 12

17 Some resources have been found for you Tabled below are some resources that provide information on one or more areas of person centred practice. The table is arranged by person centred practice principle and key element. You can find more information on these resources in supplement 2 including: - A table arranged by target (ie organisation, team or individual focus) - Reviews of each resource can be found in the Person-centred Practice Section of the Resource Reviews folder Person centred practice principles 1 Getting to know the person 2 Sharing power and Responsibility 3 Service flexibility and accessibility 4 Coordination and integration Person Centred Practice Terms Key elements Patient and family support Using a holistic assessment Goal setting Care planning / decision making Case conference Patients and families as advisors Patient rights and responsibilities Information / education for patients and families Language and different cultures Resource availability to patients and families Triage so patient is seen by the best person Charting and documentation / minimising duplication Making sense of services including key person and single access point Discharge planning and post discharge follow up 5 Environment Leadership, mission statement and definition of quality, recruitment / orientation, use of volunteers Attitudes and organisation culture The physical environment Transport 13

18 Person centred practice principles Key elements Top 3 Resources (resource number and name) 1 Getting to know the person Patient and family support Using a holistic assessment 8 Client Centred Care: Nursing Best Practice Guideline. 16 Planetree organisation website 9 Essence of Care. Patient-focused benchmarks for clinical governance. 2 Sharing Goal setting 6 Person-Centred Health Care Good Practice website. power and Responsibility Care planning / decision making 3 Consumer, Carer and Community Participation Information. (website) 13 Respecting Patient Choices: An Advanced Care Planning Initiative 17 Ottawa Health and Research Unit 3 Service flexibility and accessibility 4 Coordination and integration 5 Environment Case conference Patients and families as advisors and in quality improvement Patients rights & responsibilities Information / education for patients and families Language and different cultures Resource availability to patients and families Triage Charting and documentation / minimising duplication Making sense of services including key person and single access point Discharge planning and post discharge follow up Leadership, mission statements, recruitment, use of volunteers, orientation, quality Attitudes and organisation culture The physical environment Transport 6 Person-Centred Health Care Good Practice website. 3 Consumer, Carer and Community Participation Information. (website) 4 Institute for Family Centered Care (website) 2 Developing A New Approach To Koori Hospital Liaison Services Final Report. 15 Rehabilitation Charter 3 Consumer, Carer and Community Participation Information. (website) 14 Victorian Charter of Human Rights and Responsibilities 8 Client Centred Care: Nursing Best Practice Guideline. 10 Centre for Culture, Ethnicity and Health 11 The Picker Institute website 6 Person-Centred Health Care Good Practice website 8 Client Centred Care: Nursing Best Practice Guideline. 16 Planetree organisation website 6 Person-Centred Health Care Good Practice website. 8 Client Centred Care: Nursing Best Practice Guideline. 9 Essence of Care. Patient-focused benchmarks for clinical governance. 11 The Picker Institute website 6 Person-Centred Health Care Good Practice website. 8 Client Centred Care: Nursing Best Practice Guideline. 18 Incorporating patient and care concerns in discharge plans: Patient centred checklist. 7 Improving Care for Older People. 6 Person-Centred Health Care Good Practice website. 16 Planetree organisation website 3 Consumer, Carer and Community Participation Information (website) 1 American Hospital Association website. 12 Enhancing Practice Program 14 Department of Jusitce. Victorian Charter of Human Rights and Responsibilities 5 Improving the Environment for Older People in Health Services: An Audit Tool. 16 Planetree organisation website 3 Institute for Family Centered Care (website) 6 Person-Centred Health Care Good Practice website. 14

19 Barriers and enablers to person centred practice When introducing anything new, or trying to make change in practice, it is useful to consider some of the principles that contribute to successful change. One of the principles of culture change is having organizational support. Major change is most likely to be successful when leaders in an organisation are active supporters (Kotter, 1996). You can make a difference to the kind of care your patient / client will get today. The changes you make to your practice will impact on their experience in the health care system immediately. Barriers and enablers to person centred practice are discussed below. They are taken from the literature review What is Person Centred Care? (Victorian Department of Human Services, 2006). This literature review also discusses barriers specific to caring people with chronic disease, mental health, dementia, palliative care and neurological disorders. These are important to know about so that you can consider them when you are action planning. Barriers Time Dissolution of professional power, or staff experiencing a loss of professional status and decision making power Staff lacking the autonomy to practice in this way The lack of clarity about what constitutes person-centered care, making it more difficult to practice and to explain to clients Clients with communication difficulties The constraining nature of institutions, including physically or spiritually impoverished environments of care Enablers Having skilled, knowledgeable and enthusiastic staff, especially with good communication skills Opportunities for involving the service user, their carers, family and community [for example, volunteers] in health care Providing the opportunity for staff to reflect on their own values and beliefs and express their concerns Opportunities for staff training and education, including feedback from service users Organisational support for this approach to practice Working in an environment of mutual respect and trust Physically and emotionally enriched care environments Being in the client s home 15

20 Person centred practice Supplements

21 Abbreviations Where the The Its meaning abbreviation abbreviation will be found Target O Organisation T Team I Individual Principles 1 Getting know the person 2 Sharing power and Responsibility 3 Service flexibility and accessibility 4 Coordination and integration 5 Environment Resource Resource available in toolkit availability 2

22 Supplement 1: Supplement 1 Photo: 2008 ABC Person centred practice assessment instruments 3

23 Index: Assessment Instruments No. Target Person centred practice Name principle 1 O 1, 2, 3, 4, 5 Advancing practise of patients and family centred care: How to get started 2 O, T 1, 2, 3, 4, 5 Strategies for Leadership. Patient and Family Centred Care. A Hospital Self-Assessment Inventory 3 O, T 5 Improving the environment for older people in Health Services: An audit tool. 4 O, T 1, 2, 3, 4, 5 Patient Care - Elderly Persons 5 O, T, I 1, 2, 3, 4, 5 Essence of Care: Benchmarking person-centred care 6 T, I 1, 2, 3, 4, 5 Person-Centred Care Benchmarking Survey NOTE: An excel spread sheet for collation of data using this assessment tool is also available in the Toolkit 7 I Attitudes Kogan s old people scale 8 I Knowledge and environment Geriatric Institutional Assessment Profile (GIAP For further information on the above resources, please see the Resource Review Folder for Person-centred Care 4

24 Supplement 2: Photo: 2008 ABC Other Person-centred Practice Resources Supplement 2 5

25 Index: Person-centred Practice Resources No. Target Person centred practice Name 1 O principle Bold indicates strong focus 1, 2, 3, 4, 5 American Hospital Association website. Patients as advisors Organisation culture 2 O 2, 3, 4 Australian Institute of Primary Care Latrobe Organisation culture University (2004). Developing A New Approach To Koori Hospital Liaison Services Final Report. 3 O, T 1, 2, 3, 4, 5 Consumer, carer and community participation 4 O, T Patient information Decision-making Patients as advisors 1, 2, 3, 4, 5 website. Institute for Family Centered Care website. Physical environment Patients as advisors Organisational attitudes 5 O, T 5 Improving the environment for older people in Physical environment Health Services: An audit tool. 6 O, T, I 1, 2, 3, 4, 5 Person-Centred Health Care Good Practice cover most areas well website. 7 O, T, I 2, 3, 4, 5 DHS. Improving Care for Older People website 8 O, T, I Organisation culture Physical environment Discharge planning 1, 2, 3, 4, 5 Registered Nurses Association of Ontario Covers most areas well (2006). Client Centred Care: Nursing Best Practice Guideline. 9 O, T, I 1, 2, 3, 4 NHS (2003). Essence of Care. Patient-focused Covers most areas well benchmarks for clinical governance. Guidance and Benchmarks. 10 O, T, I 2, 3, 4 Centre for culture, ethnicity and health website. Language and different cultures 11 O, T, I 1, 2, 3, 4,5 The Picker Institute Organisation culture Different cultures Coordination of care 12 O, T, I 1, 2, 3, 4, 5 The Enhancing Practice Program 13 O, T, I Attitudes and organisation culture 1, 2, 3 Respecting Patients Choices: An advanced care Decision making planning initiative website. 14 O, T, I 2, 3, 4 Department of Justice. Victorian Charter of 6