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.
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”):
- WHO does this plan impact (specifically, with what presumed or required characteristics or qualifications)?
- 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).
- WHY does this support the end purpose of the system (i.e. 'vision')?
- WHERE will this take place (addressing all characteristics of the intended location from parking to power to how many inches from the wall, etc.)?
- WHEN is it to occur (i.e. earliest start/end, latest start/end, sequence/timing of steps/subprocesses)?
- 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.
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.