B-5 rehabilitation planning meetings
Some doctors say, “I did not train to be a specialist just to go to meetings.” Rehabilitation is, above all else, a team activity, and the team, not any individual, collects, collates, and uses the information to arrive at a formulation and develop a plan. Every person contributes knowledge and, crucially, different ideas and perspectives so that the team arrives at the best understanding possible. Then, when planning what to do, each person also contributes ideas and questions the assumptions of others. The doctor is a vital team member and can contribute information and ideas. A rehabilitation expert from any profession needs knowledge and skills about how to contribute and how to run a meeting effectively. Meetings are resource-intense; a good session, well run, is productive and can justify the resources but bad meetings undoubtedly waste resources. Training in meetings, especially rehabilitation planning meetings, could hugely improve effectiveness.
Table of Contents
The competency is ....
The rehabilitation expert should be “Able to participate actively in a rehabilitation meeting about a patient involving different professions and organisations, including leading it.” This expertise is invaluable because it will generalise to most other professional meetings attended, such as quality improvement projects, service management, research, best interest meetings, and even review of a group of patients, such as all out-patients. Some aspects of this competency are covered elsewhere on this site. A document giving the indicative behaviours, knowledge and skills with a few references to assist you can be downloaded.
Background
Complex problems are much better solved by multi-disciplinary teams, whether fighting a battle, building a hospital, or organising a national conference. Rehabilitation problems are usually complex, defined by the many interacting factors involved and the non-linear relationships between the variables involved.
A group of people with different areas of knowledge and skill is superior because each person will contribute information and ideas that others will not have. However, the main superiority of a team arises from the discussions and debates between team members as they question and clarify statements made by other people. Respectful, challenging conversations often advance understanding and generate new ideas, leading to a better formulation and plan.
Therefore, rehabilitation planning meetings can lead to efficient and effective management of a patient’s problems but requires team members to know what is expected and have the skill to participate. It also requires an attitude that welcomes challenge as an opportunity to reconsider ideas and assumptions, not as an attack on one’s competence or integrity.
Types of rehabilitation planning meetings.
This competency is relevant to all clinical meetings by the team, with other people at times, whether about a named patient or a defined group of patients. Rehabilitation teams have many different types of meeting about patients and use many names such as goal-planning meetings, review meetings, case conferences, discharge meetings, best interests meetings, family meetings, outpatient reviews, sit-down ward rounds, and so on.
The archetypical meeting is the rehabilitation goal-setting (or goal-planning) meeting usually held on inpatients with the patient and family members present with the team. However, there are many variations on this, and all are rehabilitation meetings:
- Best interests meetings about unconscious patients when the patient is not present
- A forum to discuss challenges posed by family members; they will not be present, but the patient might be
- A meeting to plan a behavioural approach to a patient’s socially inappropriate behaviours when the patient will not be present; the family might be
- A meeting with other teams or agencies to discuss options on future placement when the patient and family may not be present
- A meeting to review all active inpatients or outpatients when only the team is present
These meetings all plan the patient’s rehabilitation.
Skills needed by participants.
The more each participant in a meeting is aware of the mechanics of meetings and how a participant should contribute, the more efficient and effective the conference will be. Most people in healthcare attend several meetings a week, yet formal teaching about meetings is uncommon. I will discuss the knowledge and skills needed.
This page is structured around the roles of a chairman as articulated in 1969 in the Harvard Business Review by George Prince, who wrote about “How to be a better meeting chairman.” with additional ideas from another business site, CEO worldwide. Many roles are concerned with running an efficient meeting, and this is more likely if people attending already know how a meeting should be run. Further, in rehabilitation teams, it is appropriate for most members to be the chair from time to time.
Constructive conversation.
The key to effective meetings is excellent communication skills. This requires all those present to:
- Listen to the person speaking, be interested, and do not interrupt them
- Be constructive and develop ideas from others rather than ask for justification
- Avoid direct early critical comments in response to any new idea
- Encourage anyone who is not participating to speak
At the same time, everyone must avoid repetition or saying more than necessary, and when something has been agreed upon, no further comments are needed.
Maintain focus.
Every meeting must have an agreed purpose, and all participants should only contribute to the goal. Anyone raising matters seemingly unrelated to the topic should be asked politely to stop unless they can show their contribution to be relevant. Participants should refrain from adding information or ideas that are interesting but irrelevant to the meeting.
Place discussions in context.
A common failure is focusing on manageable or resolvable matters to avoid confronting significant, more considerable difficulties. Everyone needs to remind themselves and others of the critical issues requiring discussion and consider how their contribution relates to the essential points.
In rehabilitation planning, complex issues often relate to the long-term, what will happen after the episode in question, and they concern accommodation, social activities, and social relationships. Two other issues commonly avoided are whether treatments should be stopped and when to tell someone their expectations will not be met.
Summarising and concluding.
Certainty is rare, and further information can always be identified so that discussions can be endless and ultimately inconclusive. A vital skill in rehabilitation is to know when debate should be stopped so that you can summarise the position and suggest a conclusion or decision. Part of this skill is being able to identify the crucial issues and the matters that are unimportant and to say so,
Conversely, an essential attribute of all participants is accepting that it is time to stop a discussion and resisting the desire to add one more small point.
Know the meeting's structure
In 1999, I proposed a detailed agenda for stroke rehabilitation goal-planning meetings. The detail is only relevant to a small proportion of sessions, but the general structure is appropriate and will be used here. Rehabilitation planning meetings are too frequent to allow patient-specific agendas to be prepared and circulated; moreover, discussions are likely to have a predictable structure within any service.
All rehabilitation meetings should have a similar general structure, although they will differ in the time devoted to each component. Moreover, additional parts may be added, or, rarely, portions may be left out. I will suggest a generic structure here. Most case conferences will have a similar design, and this will be close enough to enable anyone to prepare for any rehabilitation meeting.
Introduction
This is essential. It is polite, allows new people to explain who they are and why they are attending, and reminds family members and the patient who each person is. People should give their information clearly, in sufficient but not excessive detail.
Purpose - the goal
The purpose of a meeting should be given to everyone invited and should be restated at the meeting. If it is not given, it is appropriate for anyone attending to ask for the purpose to be explained. Everyone attending should remain focused on the reason for the meeting, which can be referred to as the goals of the meeting.
Patient's perspective
For any meeting about an individual patient, their perspective should be given first. The detail will depend on the reason for the meeting. The information may be provided by the patient, their family, or the team, but it is essential always to remind everyone that the patient’s interests are central. If the patient is not present, then the reason should be recorded with a discussion on how their views will be considered and how any conclusion will be fed back.
The formulation
Every meeting must have, at a minimum, a formulation of the situation. In some discussions, the formulation will be derived within the conference.
Active discussion of the meeting’s goals.
This is the meat of a meeting. Each attendee needs to prepare concerning its purpose. Usually, this involves giving information that is not already known and documented, with an explanation of how it may impact the understanding of the situation or what interventions could be considered. If there is more than one goal for the meeting, consider each separately.
Summary and recording
The chair should summarise topics discussed during the meeting, and the session must end with someone summarising what has been concluded, what has been decided, what actions are to be undertaken, by whom, and when.
The final vital step is for the meeting to be fully documented, especially the agreed actions, with the document being prepared quickly and circulated to all participants.
Participant role.
Just as most rehabilitation patient meetings will have a similar structure, the role of participants will be similar across almost all services. All team members attending a rehabilitation meeting should know the vital features of their position; preferably, all should also know and understand how to take on the part of the chair.
Be well prepared
The crucial duty of everyone attending is to prepare for the meeting. This depends on the organiser of the conference informing you about the following:
- the time and location, leaving you sufficient time to prepare
- the reason for the meeting.
- anything specific required of you that you might need to be made aware of.
Behaviours in the meeting.
Although the chair may lead on some parts of the meeting, success depends upon all participants considering all aspects of the meeting. Thus you should:
- be attentive and always engaged, not only when you are asked to speak
- avoid repetition, even if someone from a different profession has covered matters you would expect to cover. You should confirm that you agree with the information given.
- Seek clarification, sometimes on behalf of other members who look puzzled. This is especially important when someone uses jargon or abbreviations, even if you know what they mean.
- Support the chair in stopping others who are off the topic, repeating things, or in other ways disrupting the meeting
- Give your information succinctly and with an appropriate structure.
- Be open to new suggestions about what you may do or how your information could be interpreted.
Information for formulation
A planning meeting may give little time for formulation if one exists, but every forum should consider the existing formulation and whether it needs improving. Each participant must review the current formulation if available and, if not, consider their formulation. You should bring any information relevant to the formulation to the meeting, and if the information alters the understanding of the patient’s situation, it should be given.
This information is not restricted to direct clinical details. It might include essential information about the family, accommodation, recent events, work, and other matters.
Information on prognosis and potential treatments
Many people attending will have expertise in an area where they may be able to give a more certain prognosis. Further, they will have interventions that they know most about. Therefore you should come prepared to talk about prognosis where you have that information and to explain the options for intervention, those that might help and any that other people might consider helpful but are unlikely to help.
It would be best if you were prepared to suggest what you think would be most helpful, why, and how it might relate to other proposed interventions.
Information on patient priorities.
Even if the patient or family are present, it is vital that you give any information about the patient’s wishes, priorities, and expectations that might affect the choice of goals and interventions. You should ensure that everyone considers the “bigger picture”, the patient in their broader life now and in the future.
Learning
The easiest way to start is to spend five or ten minutes after any meeting reflecting on what went well, what needed improvement, what you learned about conferences and how to participate in them (and what not to do!).
This can be extended to discussing the meeting with some or all the participants within an hour or so, with an agreed short time to prevent over-analysis. The agenda should be simple – what went well, what could have been better, and what we learned.
A Case Conference Assessment Tool, often abbreviated to cCAT, may be used by individual participants to gain feedback on their performance. It was developed for doctors in training but can be used by any profession. It was also designed for an archetypal meeting with the patient and family present, but it can be adapted. Due to its shortcomings, a new tool, the Meeting Assessment Tool, is currently being developed by some UK trainees in Rehabilitation Medicine.
A second tool can be used to study the planning meeting itself; it is a 20-item questionnaire covering four aspects of a session. One of them asks the respondent to rate their contribution, which would also provide headings for a more detailed reflection on a meeting. It has been used to study planning meetings in the UK by Siva Nair and me. If anyone wishes to obtain more information about the conferences held in their service, a 36-item questionnaire for staff about meetings is available.
Conclusion
Rehabilitation planning meetings have been observed and evaluated, though not very extensively. I am still looking for much written about how to structure and run them, what participants need to know, and the skills required. Most of the ideas here come from experience and studies of meetings in business. However, there are tools for assessing and giving feedback on the performance of individuals and also for evaluating and providing feedback on single sessions. Suppose one adds feedback from reflection, alone or with others, on what went well, what could have been better, and what was learned. In that case, most people will soon be much better at participating in and chairing rehabilitation meetings.
