Your care plan is flawed and you can’t make it perfect

A comprehensive care plan, bespoken in great detail according to the
service user’s needs, likes and dislikes is something most care homes
perceive to be the ideal. You mainly only hear of the positive effects
of this (something we have also lauded in previous articles) from better
and more meaningful care to an easier introduction for agency staff.

However, as with most other things, there is also a downside to
having immensely detailed written instructions and guidelines. If you
rely too much on these, you risk overlooking the targets they describe.
The fact of the matter is that it is impossible to plan for everything
that happens during a day in a care home environment. Things rarely go
according to plan. Staff get sick, accidents or incidents happen, or
service user’s needs change.

So, how do you plan for the unexpected?

The short answer is that you don’t…

It is impossible to plan for the unexpected, so the best you can do
is to empower your employees with the right information, protocols and
tools to overcome any plan. Or change to these plans. But what does this
mean? How do you deal with imperfect care plans?

When planning we base shifts and resources on multiple care plans for
multiple residents making assumptions whether this will be correct in
the future as well. Always relying on the staff to remain the same as
when planning. No sickness absence and no staff turnover.  In this
sector. Really? Some of these factors are bound to change, and the
initial plan is already flawed.

By providing flexible work structures and a realistic sense of the
environment your plans are adhering to, you are better off. This seems
evident, so the real trick is then to balance between having a
sufficient number of guidelines and instructions and allowing your staff
the autonomy to carry out their professional roles. Something that
“time & task” doesn’t always allow for.

Essentially, care planning and the systems you make use of, do not
tie you down but set you free. After all, the systems are only as good
as the information you put into it. We encourage Sekoia to be used to
guide, streamline, and evidence your immense care and service efforts.

The Nasty Side of Documentation

With the increased focus on improving the richness and frequency of
documentation in the care sector, many also utilise it as a form of
control. To check up on staff. What are they doing now?

And now! The
risk with this approach is the almost obsessive-compulsive focus on time
and task. This takes up an incredible amount of time to adhere to.
Often times, however, the result is not an enhanced quality of care for
the service users, but rather that staff will focus on following the
timetable and not their professional disposition.

Following the increased amount of control comes the fear of losing
this newfound control. The usual solution to this fear? Even more
control. The result is an almost paralysing amount of “cover my ass
procedures”.

You regularly hear of cases of malpractice and even abuse at care
homes. The solution to preventing this? Increased control or even the
installation of CCTV. That way, at least we can say that we are taking
actions to prevent it from happening again. But what if, instead of
treating symptoms of the decease we start to look at the root cause of
it? Is there something wrong with our recruitment process? Is our
onboarding program offering sufficient support for the staff? Maybe the
solution is not just a quick fix.

Electronic care planning is involving, listening, understanding and responding

The key to balancing care planning with real-world challenges is
involvement. Involvement of all stakeholders in the process of providing
care.

Listen to the service users to ensure that you provide care according
to their needs, wishes, and preferences. This is not a one-and-done
activity but rather an evolving practice. These people’s needs
continually evolve and that is why it is nigh on impossible to create a
perfect care plan that mirrors their life for good. Consequently, it
should not be an ideal to work with care plans that way.

Listening to members of staff to empower, motivate, and guide them
towards a shared vision. The antithesis to this is care plans that are
used as micromanagement. If the care plans dictate the care provided to
the letter, then you effectively reduce your caring and engaged staff to
mechanical cogs of a machine. On the other hand, complete autonomy is
not the solution either.

Similarly, it is important to not just sit in the ivory tower and
create guidelines and instructions for your staff. They need to feel
that these guidelines are relevant to the challenges they are facing on a
daily basis. The best way to identify these challenges is by joining
them on the frontlines. When the challenges have been identified and
guidelines have been created it is important to regularly revisit them
to ensure they are still relevant to the care workers’ context.

While some things may change, others will stay the same

It might seem like a tall order to create a care plan that, on one
hand, is flexible and relevant, and on the other personalised to each
service user. Especially if you are a larger operator. While the
technological conditions for delivering care is changing towards smarter
and more efficient ways of collecting, disseminating and sharing data,
some things will never change. The focal point of the work in care
services will always be the user and their needs. No matter how you wrap
up the care delivering with new tools and features, the delivery of
care should always aspire to be personal and empathic.

The former head of the Care Quality Commission, Andrea Sutcliffe, summarises this well in her wishes for social care in 2019.

“Person-centred co-ordinated care
means there isn’t one magic solution that will solve all our ills…
one-size does not fit all, which takes us back to flexibility again.”
Andrea Sutcliffe  
               
                           
       
      

There is no silver bullet that can create
person-centred care, rather it is important to ensure that the service
users are supported by a person and not a machine. In the worst cases,
an overly reliant use of machines and technology can lead to a loss of
control with important decisions being made by data masquerading as
facts in the name of efficiency. To the detriment of human contact and
presence.

The Scientific Answer to Improving Practice

There are ways of minimising the risk of “the machines taking over”.
One of them is the use of the PDSA cycle. The Plan, Do, Study, Act cycle
is based on the idea of trialling a change on a smaller scale and
learning from the experiences from previous cycles before implementing
full-scale. An important aspect of the cycle is the notion of continual
improvement. The four steps are repetitive and are made to create
continuous learnings and improvements.

So how do you get started with the PDSA cycle? You can use the
following questions to kickstart the process (“The Five Ws and an H”):

  1. WHO does this plan impact (specifically, with what presumed or required characteristics or qualifications)?
  2. WHAT is the purpose of the interface/relationship? WHAT are we
    trying to accomplish? WHAT change can we make that will result in
    improvement? (Whichever question is appropriate).
  3. WHY does this support the end purpose of the system (i.e. ‘vision’)?
  4. WHERE will this take place (addressing all characteristics of the
    intended location from parking to power to how many inches from the
    wall, etc.)?
  5. WHEN is it to occur (i.e. earliest start/end, latest start/end, sequence/timing of steps/sub-processes)?
  6. HOW – a step by step procedure to convert any and all system/process
    inputs to all system outputs. HOW will we know that the change is an
    improvement.

An example of the PDSA Cycle that many people find somewhat relatable
would be that of a person doing target practice with a gun or bow: 1.
Plan – Ready/Aim 2. Do – Fire 3. Study – Count the holes and analyse
their positioning on the target 4. Act – Adjust your sights and then
repeat the process.


                   
               

Continuous Process Improvement Methods (CPI)

Read more about the PDSA cycle here.    
       
   
   
       
       

           
              

Striving for real-time organisation

Real-time organisation entails adjusting to the reality frontline
staff face every day. When assessing whether care delivery has been
successful or not oftentimes KPIs are used. How many care tasks has been
performed? How many tasks were missed during the day? How many errors?
These questions are commonplace. Common to all these questions is that
they all measure the process of delivering care, not the actual outcome.

The problem with this approach is that the process is not flawless
due to reasons highlighted earlier in this article. As Lydia Nicholas
points out in her blog post “If care is priceless, why do we treat it as worthless?”
this approach runs the risk of “Hitting the target but missing the
point”. What does this mean? It is all well and good having a flawless
execution of processes but if these do not result in a good outcome then
what is the point? If the care we deliver does not value to the service
users, the processes are simply not the right ones. Factors like
empathy and quality of life are difficult to quantify into metrics so
they are often not an indicator staff are measured on. This priority can
lead to the care outcome being neglected due to busyness and rushing
towards management set targets.

This is why it is imperative to continually align your care delivery
processes to the desired outcomes. Otherwise, there is the risk of
optimising and perfecting processes that provide no real value to the
actual care delivery. This requires an agile way of organising that
allows members of staff to adjust care activities in a complex context
and use their expertise.

Published by Residential Forum

The Residential Forum is to promote the achievement of high standards of care and support for children and adults living in residential care and nursing homes, supported housing, residential schools and colleges, hospices and hostels. It contributes to improving the quality of service to the public. Members of the Forum are people of standing and experience drawn from the public, private and voluntary sectors, as well as some who can speak for service users and carers.

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