Implementing The Comprehensive Care . - Safety And Quality
Implementing theComprehensive CareStandardIdentifying goals of careApril 2019
Published by the Australian Commission on Safety and Quality in Health CareLevel 5, 255 Elizabeth Street, Sydney NSW 2000Phone: (02) 9126 3600Fax: (02) 9126 3613Email: mail@safetyandquality.gov.auWebsite: www.safetyandquality.gov.auISBN:Print: 978-1-925665-88-8Electronic: 978-1-925665-89-5 Australian Commission on Safety and Quality in Health Care 2019All material and work produced by the Australian Commission on Safety and Quality in Health Care is protectedby copyright. The Commission reserves the right to set out the terms and conditions for the use of such material.As far as practicable, material for which the copyright is owned by a third party will be clearly labelled. TheCommission has made all reasonable efforts to ensure that this material has been reproduced in this publicationwith the full consent of the copyright owners.With the exception of any material protected by a trademark, any content provided by third parties, and whereotherwise noted, all material presented in this publication is licensed under a Creative Commons AttributionNonCommercial-NoDerivatives 4.0 International licence.Enquiries about the licence and any use of this publication are welcome and can be sent tocommunications@safetyandquality.gov.au.The Commission’s preference is that you attribute this publication (and any material sourced from it) using thefollowing citation:Australian Commission on Safety and Quality in Health Care. Implementing the Comprehensive CareStandard: Identifying goals of care. Sydney: ACSQHC; 2019.DisclaimerThe content of this document is published in good faith by the Australian Commission on Safety and Qualityin Health Care for information purposes. The document is not intended to provide guidance on particularhealthcare choices. You should contact your healthcare provider on particular healthcare choices.
ContentsIntroduction 1This paper 2Element 2: Identify goals of care 3Purpose 3Principles 3Consumer actions 3Clinician actions 3Organisational actions 3What are goals of care? 4Goal setting 4Examples of goal setting tools 4Tips for identifying goals of care 10Conclusion 13Glossary 14References 17Identifying goals of care iii
iv Implementing the Comprehensive Care Standard
IntroductionThe National Safety and Quality Health Service (NSQHS) Standards were developed bythe Australian Commission on Safety and Quality in Health Care (the Commission) incollaboration with the Australian Government, states and territories, the private sector,clinical experts, patients and carers. The primary aims of the NSQHS Standards are to protectthe public from harm and to improve the quality of health service provision. They providea quality-assurance mechanism that tests whether relevant systems are in place to ensureexpected standards of safety and quality are met.The second edition of the NSQHS Standardsincludes the following eight standards: Clinical Governance Standard Partnering with Consumers Standard Preventing and Controlling HealthcareAssociated Infection Standard Medication Safety Standard Comprehensive Care Standard Communicating for Safety Standard Blood Management Standard Recognising and Responding to AcuteDeterioration Standard.One of these standards, the Comprehensive CareStandard relates to the delivery of comprehensivecare for patients within a health serviceorganisation. Safety and quality gaps are frequentlyreported as failures to provide adequate carefor specific conditions, or in specific situationsor settings, or to achieve expected outcomes inparticular populations.Having a clear, shared understanding of goals ofcare is crucial for all patients regardless of theirdiagnosis or prognosis, and is particularly importantfor patients with complex healthcare issues, such ascomorbidities or life-limiting illness. Understandingthe clinical situation of the patient is essential tothe establishment of effective goals of care, andidentifying and setting goals of care in collaborationwith the patient ensures care is individualised.The process of identifying goals of care involves anumber of stages including goal negotiation, goalsetting and evaluation. Goal setting tools have beenreported to be useful in tailoring and monitoringtreatment, improving team communication andclarifying team roles.1 There is a range of commonprinciples reflected in goal setting tools whichcan be used by health service organisations as aframework for goal setting.A focus on patient experience is critical to thedelivery of comprehensive care. Developing a sharedunderstanding between clinicians and patientsprovides a foundation for trust, and a basis fordiscussion about healthcare options. Understandinga patient’s values, and their expectations andaspirations for their health and wellbeing helpsto establish their goals of care and contributes toeveryone’s understanding of the actions to be taken.Identifying goals of care 1
This paperThis paper provides practical advice for cliniciansand health service organisations about goal setting,based on the common principles found in manygoal setting tools. It is part of a series of resourcessupporting implementation of comprehensive carethat are based on six essential elements: Element 1: Clinical assessment and diagnosis Element 2: Identify goals of care Element 3: Risk screening and assessment Element 4: Develop a single comprehensive careplan Element 5: Deliver comprehensive care Element 6: Review and improve comprehensivecare delivery.This paper addresses Element 2: Identify goals ofcare. There are also separate short resources thatinclude tips for patients and consumers and tips forclinicians.2 The elements were developed to support practicalimplementation of the Comprehensive CareStandard and more information about all of theessentials elements is available from: Implementingthe Comprehensive Care Standard: Essentialelements for delivering comprehensive care.2This paper has been developed for: Clinicians involved in the delivery of care,providers of clinical education and training,research organisations and other health bodies Managers and executives responsible fordeveloping, implementing and reviewingprocesses to support the identification of goals Planners, program managers and policymakersresponsible for the development of state andterritory governments or other strategicprograms dealing with the processes associatedwith providing comprehensive care.Implementing the Comprehensive Care Standard
Element 2:Identify goals of carePurposeClinician actionsTo develop a shared understanding of: The patient’s goals for their health care in theshort-, medium- and long-term The clinical situation, including diagnosis,treatment options and clinical goals The patient’s values, needs and preferences abouttheir health and care The patient’s expectations about the care episodeand treatment outcomes. Clinicians use person-centred approaches todiscuss the patient’s wishes and expectations Clinicians consider the patient’s level of healthliteracy, and tailor communication stylesaccordingly Clinicians identify who the patient wantsinvolved in discussions about goals and planning Clinicians use the information about thepatient’s goals to inform and drive thecomprehensive care plan and immediate actionthat may be needed Clinicians document and communicate theoutcomes of goal setting discussions.Principles Communication about goals is person-centredand tailored to meet health literacy needs of thepatient Patients, families, carers and other supportpeople as identified by the patient, are involved indiscussions about goals Clinicians have the skills and capacity tocommunicate effectively to discuss patient goalsand preferences A shared understanding of the patient’s clinicaland personal goals drives comprehensive careplanning.Consumer actionsOrganisational actions Health service organisations foster a personcentred culture in delivering comprehensivecare, including supporting the identification ofpersonal and clinical goals of care Health service organisations establish systemsand processes that support eliciting anddocumenting goals of care Health service organisations provide accessto training and education to support effectivecommunication and a person-centred approachto care. Patients engage with clinicians and talk aboutwhat they want to achieve and what is importantto them Families, carers and other support peopleparticipate in discussions, including goal settingconversations, when requested by the patient.Identifying goals of care 3
What are goals of care?Goals of care describe what a patient wants to achieve during an episode of care, withinthe context of their clinical situation. Goals of care are the clinical and personal goals fora patient’s episode of care that are determined in the context of a shared decision-makingprocess. Identifying goals of care helps to organise and prioritise care activities and contributesto improved satisfaction, quality of life and self-efficacy for patients.3–5The purpose of identifying and agreeing to goals ofcare is to develop a shared understanding betweenpatients, family, carers, other support peopleand the clinicians in the multidisciplinary teamabout the clinical expectations, personal needsand preferences of the patient and the likely stepsrequired to attain the agreed goals.Goal settingIdentification of goals is variable in clinical practice.The literature on goal setting and goal attainmentin health describes various frameworks and modelsthat have been tested in small, specific and largelynon-acute populations. This landscape can beconfusing; however, the overarching principles arestraightforward. Clinicians should, at a minimum,regularly ask patients what is important to themin relation to their health care. This enables aconversation that can inform healthcare planning.For some patients with less complex needs, thisapproach may be sufficient to gain an understandingof their goals and prompt discussion and shareddecision making about care. An example of thisapproach has been implemented by the ScottishGovernment and Healthcare Improvement Scotlandwith their adoption of the ‘What matters to you?’campaign to inspire more meaningful conversationsbetween patients and people that provide care.6When using the ‘What matters to you’ approach toestablishing goals, consideration should be givenas to how this informs actions to include in thecomprehensive care plan.4 There are more structured approaches to goalsetting, each with their own strengths andweaknesses. Popular tools available include: SMARTgoals; FAST goals; Think Big, Act Small, MoveQuick (BSQ); and GROW methodology. However,there is no single gold standard tool that has beenagreed for identification of goals in acute caresettings. Despite the absence of a gold standard tool,using some kind of goal setting tool, frameworkor model can provide structure to a goal settingconversation, and serve as a mechanism to buildrapport between the patient and clinician.7Examples of goalsetting toolsThere has been considerable research on goalsetting and negotiation, much of which originatesin organisational psychology. Some of the tools thathave been developed to assist in goal setting aredesigned specifically for determining the goal (suchas SMART), while others span the cycle from goalsetting to review (such as the GROW model).Table 1 outlines tools that could be adapted orhave been adapted to suit collaborative goal settingin health care. Where there has been publishedliterature of use in a particular patient cohort orby specific clinical disciplines, it has been noted.Practical examples of how the tools may be used areincluded below.Implementing the Comprehensive Care Standard
Table 1: Summary of goal setting toolsTime needed touse the toolTarget patient populationClinician groupusing the toolTraining requiredto use the tool‘What mattersto you’campaign65–20 minutesNot studiedNot studiedNilGoalAttainmentScaling (GAS)830–45minutes1Mental healthOccupational therapists Training requiredRehabilitationOutpatients1Substance abuse treatmentChildrenOlder peopleBrain injurySMART/SMARTER5–20 minutesMultiple patientpopulations includingpatients with diabetes9, 10and stroke11FAST15–30 minutes Not studiedNot studiedMinimalBSQ5–20 minutesNot studiedNot studiedMinimalGROW60 minutesNot studiedNursesTraining onal therapists11Speech therapists11Physiotherapists11What matters to you?Goal Attainment ScalingThe Institute for Healthcare Improvementencourages interactions with patients, families,carers and other support people that promotes adeep understanding of what matters to them. Theyrecommend this as a foundation for developinggenuine partnerships and using shared decisionmaking in routine practice.12Goal Attainment Scaling (GAS) is a well-known toolwhich is based on the SMART acronym.14 An exampleof GAS appears in Figure 1. GAS was originallydesigned for mental health settings and has beenadapted for use in other healthcare settings.15, 16‘What matters to you?’ day is a campaign promotedeach year in June by the Scottish Governmentand Healthcare Improvement Scotland. On aspecific day, conversations are encouraged tosupport meaningful listening by clinicians caringfor patients, their families, carers and othersupport people by asking patients what mattersto them. More information can be found on the‘What matters to you’ website: https://www.whatmatterstoyou.scot/Isabella is a 17 year old female with cystic fibrosis(CF). Although she has had multiple lengthy hospitaladmissions, Isabella has kept up with her schoolwork and is focused on completing her final highschool exams alongside her peer group. Maintainingher education is a long-term goal that Isabella hasdiscussed with her CF nurse specialist, generalpractitioner (GP) and respiratory physician. Theyhave developed a comprehensive care plan thatreflects Isabella’s social and clinical goals, whichIsabella brings with her when she is admitted tohospital with a chest infection.Questions framed in this way provide anopportunity for patients to disclose theirinterests, values and preferences, and to promoteunderstanding and empathy. Patients value thequality of interaction with their caregivers, andtheir perception of this correlates with their overallsatisfaction.13Identifying goals of care Case study using goal attainment scaling5
Figure 1: Example of goal setting using GASGoal attainment scaling templateNameIsabellaGoalTo be as well as I can be and to finish my HSC with my classTimeframe12 monthsCategory (select)PsychologicalXMedical ManagementXVocationalOutcomes (list)Most unfavourableoutcomeLess thanexpected outcomeExpectedoutcomeNot completeATAR below 70my HSC with myclass and havemultiple hospitaladmissionsMore thanexpected outcomeATAR of 70ATAR above 80Most favourableoutcomeATAR above 85No moreadmissions tohospital thisyearTo achieve goal (list)Activities needed6 Persons involvedStart dateEnd dateDo school work everydayCompleteassignments frommy regular schoolOn admissionHospital teachersMeMumMy best friend JanineDischargeGet rid of my chestinfectionNursesPhysiosDoctorspharmacistBefore dischargeOn admissionGoal importance to the patient (select)LittleChallenge to the patient in achieving the goal ting the Comprehensive Care Standard
SMART and SMARTER goalstheory (Shared, Monitored, Accessible, Relevant,Transparent, Evolving, Relationship-centred) hasbeen developed which has been used with patientsand families in an aphasia rehabilitation setting,providing an easier way to express the collaborativeaspects of clinical practice. Table 2 outlines thegoals of SMART and SMARTER.18A popular goal setting framework for over 20 yearshas been the SMART theory. The acronym callsfor goals to be Specific, Measurable, Achievable,Realistic and Time-bound.17 More recently SMARTgoals have become SMARTER with the inclusionof Evaluate and Record. An alternative SMARTERTable 2: SMART and SMARTER ateEvolvingR–RecordRelationship-centredCase study using SMART and SMARTERResearch suggests that to be successful in achievinggoals patients need to feel connected to the goaland want to achieve the end point, and there mustbe parts of the goal that translate into actions. Thefollowing case study illustrates how combiningclinical and personal goals can support goalattainment.Rose is a 75 year old patient admitted to hospitalafter a stroke. She is now in a rehabilitation phaseof her admission. She wishes to be able to return toregularly walking to the local RSL club for socialactivities with friends. Rose describes the distanceas approximately 500 metres away from home andwould like to walk there unaided daily. During theassessment Rose is unsteady on her feet and requiresassistance from at least one person to mobilise tothe bathroom. Rose’s prospects for recovery withreturn to previous function are considered to belimited and it is anticipated that she will requiredevices to assist with walking.Also noted is Rose’s desire to mobilise early. Framingthis as a SMART goal could include: Specific: Rose’s goal is being able to walk to thelocal RSL club unaided. Measurable/monitored: Measurement ofprogress towards the goal could focus on vitalsign parameters or other symptoms such asfatigue and shortness of breath to determinetolerance and appropriateness in increases to thedistance walked. Achievable/attainable/accessible: Chunking thegoal into walking the length of the ward withassistance once a day, building up to being ableto walk the length of the ward every two hoursduring the day without assistance. Realistic: Starting with a shorter distance andusing assistance of a person or device untilconfidence and strength is increased. Time-bound: Walking the length of the wardonce a day for three days, three times a day fortwo days, and every two hours within a week.The following is noted in the comprehensivecare plan:1. Refer to Aged Care Assessment Team2. Mobilise when able3. Transfer to rehab bed.Identifying goals of care 7
FAST goalsFAST goals19 were developed for use in corporatesettings as an alternative to SMART goals, but canbe adapted easily for use in health care. The fourprinciples that underpin the FAST frameworkstipulate that goals should be Frequently discussed,Ambitious, Specific and Transparent (FAST). Table 3presents these principles along with definitions anda description of potential benefits.Table 3: FAST goals, definitions and potential benefitsPrinciplesDefinitionPotential benefitsFFrequentlydiscussedGoals should be embedded in ongoing discussions to review progress, allocate resources and provide feedback. Provides guidance for careKeeps the focus on what matters to the patientLinks clinical interventions to concrete goalsAllows for regular evaluation of progress.AAmbitiousObjectives should be difficult,but not impossible, to achieve. Boosts performance of individual and teamEncourages innovative ways to achieve goals.SSpecificGoals are translated intoconcrete metrics or milestonesthat clarify how to achieve eachgoal and measure progress. Boosts performance of individual and teamClarifies what the patient wants to achieveHelps identify what is and is not working. TGoals and current performanceshould be documented onthe comprehensive care planand be readily available to allTransparentthe care team — including thepatient and their family, carerand other support people, asidentified by the patient.Enhances understanding between patient andcare team membersEnables support from the teamIdentifies activities th
Identifying goals of care 3 Element 2: Identify goals of care Purpose To develop a shared understanding of: The patient’s goals for their health care in the short-, medium- and long-term The clinical situation, including diagnosis, treatment options and clinical goals The patient’s values, needs and preferences about
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