Person-centred care planning driver diagram 2023

Focus on dementia

 

A visual presentation of the person-centred care planning driver diagram. It contains three columns with text showing what the programme aim on the left, the primary drivers in the centre and the secondary drivers on the right. The text on the page below shows the three primary drivers and the five secondary drivers.

Primary driver: care plans are completed and documented for all people in the ward

Why is it important?

Effective processes are important to ensure that care plans and supporting documents are completed and reviewed appropriately and that the multidisciplinary team can contribute to person-centred care planning. Effective processes such as ward rounds, huddles and family meetings also support good communication between staff, patients, carers and family members.

Secondary drivers

  • There are effective processes for care planning and documentation
  • Recommended guidance and tools are used

Change ideas

  • Include "Getting to know me" in admission packs
  • Coloured stickers on case notes to identify completion and use of person-centred information
  • Personalised activity planner to support person-centred, meaningful activity
  • Use multidisciplinary ward rounds and huddles for communication of key information
  • Face to face meetings or telephone calls with family/carers
  • Coloured binders to identify where information is held
  • Audit process for care plans
  • Use Mental Welfare Commission care planning guidance
  • Process flowchart laying out the steps required for each new admission
  • ‘This is me’ posters at patient bedside
  • Ensure staff have time to complete and review care plans – extend length of review cycle

Primary driver: care plans are co-produced with involvement of the person, their family and carers

Why is it important

The involvement of patients, families and carers is essential for effective person-centred care planning to take place. The views and wishes of the person with dementia form a key part of the care plan through the use of good conversations. Additional information from families and carers is also important, especially if the person with dementia has difficulty communicating their wishes.

Secondary drivers

  • Patients, families and carers are meaningfully involved in the process

Change ideas

  • Choice of timing and approach for families and carers to be involved in care planning processes
  • Information board for families including example completed documents
  • Use person-centred visiting approaches
  • Use digital approaches e.g. emailing documents such as “Getting to know me” to families
  • Include families and carers in review meetings
  • Work with families to develop life story book to support meaningful activities

Primary driver: staff feel competent and supported to use person-centred approaches and are using them to inform practice

Why is it important?

Training and support is necessary to develop a culture of person-centred care. The pace and routine of busy hospital wards can be a barrier to a person-centred approach, so staff require time to develop their knowledge and practical skills in this area. This includes time to have good quality conversations with patients, their families and carers and to use the information they gather in care planning. Ongoing support from managers is required to allow staff to undertake necessary training and to support a person-centred approach in the day to day activities of the ward.

Secondary drivers

  • Workforce capabilities in personalising care and support
  • Workforce capabilities in inclusion and involvement

Change ideas

  • Involve a wider range of staff in care planning such as Health Care Support
  • Workers and Allied Health Professionals
  • Develop ward observation skills and approaches
  • Support a person-centred culture by engaging with local Dementia
  • Champions and Specialist Improvement Leads
  • Train multidisciplinary team in person-centred conversation skills
  • Involve all staff in the use of ‘Getting to Know Me’
  • Use NHS Education for Scotland Promoting Excellence resources
  • Use an education board to support staff with the process of person-centred care planning
  • Develop a weekly multi-disciplinary group to assess and manage patients with differing levels of stress and distress
  • Use Mental Welfare Commission care planning guidance

Resources to support change ideas

Resource Source What it is and what's it for?
Promoting Excellence:
A framework for all health and social services staff working
with people with dementia, their families and carers		 NHS Education for Scotland Web page based knowledge and skills framework. The framework is for all health and
social services staff working with people with dementia, their families and carers.
Person centred care plans: good practice guide Mental Welfare Commission PDF guidance on good practice in the development of person-centred care plans for people using mental health, dementia and learning disability services. 
Assessment, diagnosis, care and support for people with dementia and their carers (SIGN) Healthcare Improvement Scotland (SIGN) SIGN guideline on dementia.
Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews Gwernan-Jones R, Lourida I, Abbott RA, Rogers M, Green C, Ball S, et al. Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews. Health Serv Deliv Res 2020;8(43). Overview of three systematic reviews considering experience of hospital care for people living with dementia.
Can person-centred care for people living with dementia be delivered in the acute care setting? Abbott, R.A., Cheeseman, D., Hemsley, A. & Thompson Coon, J. 2021, "Can person-centred care for people living with dementia be delivered in the acute care setting?", Age and Ageing, vol. 50, no. 4, pp. 1077-1080 A commentary looking at person-centred care for people with dementia in the acute care setting.
Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study Sanatinia R, Crawford MJ, Quirk A, Hood C, Gordon F, Crome P, et al. Identifying features associated with higher-quality hospital care
and shorter length of admission for people with dementia: a mixed-methods study. Health Serv Deliv Res 2020;8(22)		 A study which considers factors associated with reduced hospital stay and improved quality of care for people with dementia.
TURAS learn - Dementia NHS Education for Scotland Dementia online learning site for health and social services staff.
Personal Outcome Network Personal Outcome Network A website to support a personal outcomes approach in children and adult services.
Guide Template for developing Standard Operating Procedures NHS Education for Scotland An online template to support development of
standard operating procedures.
Getting to Know Me Alzheimer Scotland A downloadable PDF to support hospital staff
to gain better understanding of patients with dementia. The document is designed to be completed by a person with dementia, or a carer or relative.
Carers and confidentiality: good practice guide Mental Welfare Commission PDF guidance to support carers and families
who support a person with dementia, mental
illness, learning disability or related conditions
to understand consent, confidentiality and
sharing information.
Care plans: how people with lived experience and their friends and family want to be involved Mental Welfare Commission for Scotland PDF guidance on involving people with lived experience and their carers and families in care plans. The information is written for service users and carers.
Shared decision making in realistic medicine: what works Scottish Government Summary of research considering shared
decision making.
Creating a life story for a person with dementia Dementia UK Resources, including a video, to support people
with dementia to create a life story.
WMTY resources What Matters To You? A series of resources to support the implementation of What Matters to You?

Improvement measure ideas

The following measures are for teams to use for person-centred care planning improvements. You may identify other concepts and changes that require measurement to further understand your progress towards improved care. Our team’s contact details are in the introduction section of the toolkit should you wish to discuss measurement for improvement.

Provision of meaningful activity

Percentage of patients within the ward who have meaningful activities recorded within their care plan daily. Numerator: The number of patients within the ward who have engagement with meaningful* activities documented within their care plan daily (previous three consecutive days). Denominator: Total number of care plans reviewed (10 inpatients, every two weeks). Percentage Calculation: (numerator/denominator) x 100. 

Exclusion Criteria: In the event that a patient was unable to participate in meaningful activity in the preceding 3 days due to factors such as being unwell or not present on the ward (e.g. due to appointments elsewhere), they should be excluded and another patient’s notes selected in their place.

*Activity will be considered ‘meaningful’ if it has been identified as important to that person through the person-centred care planning process.

 

Person-centred care plan in place

Percentage of people in the ward who have:

  • A documented person-centred plan of care which shows patient and / or carer involvement
  • Individualised goals identified, or under development
  • A plan of care related to their assessed needs.

It will be an all-or-nothing measure. Care plans require to have all aspects of the above definition to be compliant. Numerator: The number of patients who have a nursing care plan that meets the above criteria. Denominator: The number of care plans reviewed. Percentage Calculation: (numerator/denominator) x 100.

 

Number of falls

  1. Determine the numerator – the total number of in-patient falls.
  2. Determine the denominator – the total number of acute occupied bed days for the same
    time period.

Calculate the falls rate by dividing the numerator by the denominator and then multiply this figure by 1000 to give the number of falls per 1000 acute occupied bed days (OBDs). Report the numerator and denominator monthly. Provide annotations as appropriate to reflect any interventions you made during the month.

 

Patient / carer experience

Qualitative data regarding the care experience of people with dementia in hospital and their carers / family members.

Teams should have a process in place for capturing the experience of people with dementia and their carers / family members who use their services. This should be used to identify improvements.

Tools and resources to support this include:

 

Staff experience

Teams should have a process in place for capturing the experience of staff working in the service. Tools to support this include: