Capability 2: planning

This page sets out what behviours someone with capability two would show, and the knowledge and skills needed. The capability is: “Able to develop a rehabilitation plan for a patient, both when the professional is the first to see a patient and when in a team planning meeting, and ensuring that the plan covers all aspects of a patient’s need both from the team and from other services and agencies.” The capability is written as if the professional may plan in isolation. While this will, in practice, not be the usual situation, every rehabilitation expert needs to be able to form an outline plan when they are the first team member seeing the patient. The capability also needs to recognise that most planning occurs at a team level, in meetings, and so it includes behaviours, knowledge and skills more focussed on that aspect of planning. A MindMap illustrating key points is available here.

Context – ‘solitary planning’

This capability is specifically aimed the skill of making an initial plan, to see what rehabilitation might be possible, because the skill is necessary in many settings, and the knowledge and skills required are also important in all aspects and types of planning. However the capability also includes participating actively in rehabilitation planning meeting which requires skill also covered in capability three.

It is commonly held that decisions on admission to a rehabilitation unit, or on being taken on by a rehabilitation service, should be ‘a team decision’ for each individual patient. I am contrasting this against the team discussing and deciding in general what patients fall within their area of expertise. Some services enact ‘team decision-making’ by arranging for joint, multi-professional initial assessment clinics or for joint visits to see a patient on a ward. These joint assessment are usually restricted to two people.

Although, at first sight, this may appear both in keeping with team ethos and better, because more expertise is available, there are disadvantages. It at least doubles the resources involved; it may add delay because organisation of the assessment is more difficult; it may be wasteful if one profession has nothing to add; and it may not be any more effective. There is no evidence known to me on the relative value of multi-disciplinary or uni-disciplinary initial assessment in deciding on rehabilitation.

In any team, members should have some insight into the contributions other team members are able to make to team care so that, given reasonable information, a single team member should be able to predict which team professions are needed and, in outline, what they might achieve. This knowledge is also helpful in team meetings, because it will often avoid need or prolonged debate and discussion.

The skill needed to develop an overall rehabilitation plan is also vital for any healthcare professional who offers some aspects of rehabilitation but is not part of a multi-professional team. This situation is obviously not satisfactory, but equally obviously it occurs, and these professionals need to be able to identify when a fuller team’s input is needed.

Context – ‘team planning’

The eventual full formulation of a patient’s problems will, in more complex cases, depend upon a team meeting as discussed here. And, although the process is separate (see here), formulation meetings usually progress to undertake planning as well. Moreover, one important aspect of any plan is for coordinated and complementary actions to be arranged as team members collaborate in working towards a goal. Indeed, meetings to discuss patients and to plan actions are a central team activity. All team members need to be able to participate effectively and efficiently.

Team members at a meeting may be required to take on additional roles: chair or leader; organiser of the meeting or a future meeting; person with responsibility for documentation; and key person reporting on the beliefs and wishes of the patient and responsible for feeding back to the patient. An expert needs to be be competent at all these roles.

Meetings are very resource-intense, and it is vital that all those attending are trained to contribute both effectively, adding the particular information or suggestions that they have, and efficiently, being concise, staying focused, and not repeating anything. While is is the chair of the meeting who should ensure a meeting runs well, every team member present carries some responsibility for the efficiency and effectiveness of the meeting.

Behaviours

This capability covers several important behaviours that characterise good team-working, especially a high awareness of the expertise of all other team members. It also draws on behaviours associated with using the biopsychosocial model of illness, particularly the ability to consider the patient holistically. In planning, there are two aspects to a holistic approach: the first is obvious, being aware of all aspects of the current situation; the second is less obvious, and it si appreciating that the patient’s life extends far beyong their brief involvement with the rehabilitation service. The ability to shift attention from a focus on precise details to a focus on very broad aspects of a case is an important part of all rehabilitation, but especially applies when planning.

The list of behaviours indicative of this capability in practice therefore covers aspects of a professional’s approach to clinical matters, aspects of their ability to behave a member of a team, and aspects of inter-personal communication.

The first set of behaviours concern the ability to generate a plan when first seeing a patient, especially but not only when the decision made is that the professional and the team will not be taking further direct responsibility for the patient. Under those circumstances there is a requirement to provide a plan for the team who is responsible for the patient, so that the patient’s rehabilitation carries on. The behaviours are that the professional:

  • provides a rehabilitation plan for the patient, fully documented, that:
    • makes explicit the formulation upon which the plan is based;
    • takes into account the perspectives and expectations of the patient, the referrer, and all other interested parties
    • considers involvement of any other potentially appropriate complementary or alternative services;
    • justifies the particular plan outlined and, if necessary, explains why other plans are less satisfactory;
    • considers and sets out goals in the long-, medium-, and short-term;
    • provides a more detailed plan when the professional and the team are not going to be involved.

The second set of behaviours concern the capability of participating in team rehabilitation planning meetings. They are that the professional:

  • when involved in a rehabilitation planning meeting with others:
    • acts as chair (leader) when necessary, and always supports the chair when not in that role;
    • draws on the expertise of other team members appropriately;
    • contributes actively, but also ensure that everyone contributes, and helps others to do so if necessary;
    • avoids repetition, and curtails repetition by others;
    • maintains a focus on the purpose of the meeting, and avoids discussion or comments not focused on the purpose;
    • ensures that the patient’s perspectives, priorities and goals are considered at all times;
    • summarises matters when appropriate, to check that all understand and agree;
    • when disagreeing with an opinion or proposal, is always respectful and, if appropriate, uses the opportunity to educate,

Knowledge,
and skills

I suspect that few professional healthcare workers are taught much about planning, yet there is probably a considerable literature written about planning complex building projects, centred on things like to Gantt chart. While a rehabilitation plan is not on the same scale as building a nuclear reactor or a new high-speed railway, it is in it own way complex with many people with different expertise contributing. There is probably a gap in research in relation to planning in rehabilitation.

Therefore much of the knowledge needed is not easily available, and it will require searching the literature. Fortunately some of the knowledge is available. For example, there is a considerable literature on goal setting (see here). It is interesting and notable that much of this literature arises from management studies. The process of goal setting was transferred from business to healthcare, and research in healthcare started long after it started in management. Other areas of knowledge concern publications in other areas, such as law, ethics, and policy documents from other organisations.

The knowledge needed in support of this capability includes knowledge of:

  • the evidence relating to and the theories underlying the setting of goals within rehabilitation;
  • the specific expertise of all other team members (or their professions);
  • relevant legal and ethical guidance, especially relating to patients who lack the mental capacity to participate;
  • the priorities, practices, policies and expertise of other services and organisations involved in supporting disabled patients;
  • principles of teamwork, team coordination, and project management
  • how to act as an effective chair of a meeting.

Many of the skills needed are generic, applying to all meetings in any context. Nevertheless, they may not be taught explicitly and so may need specific learning. Just as with the knowledge, much of the research and training of the skills need occurs within management courses and these may not be known to or attended by healthcare professionals. Furthermore, because they are largely set in a commercial, business context, their cost is likely to be exorbitant. There is probably little research into this area of healthcare.

The specific skills needed to acquire this capability include being able to:

  • prepare effectively before the meeting;
  • present information clearly and concisely, while also distinguishing fact or evidence-based opinion from personal opinion;
  • provide evidence clearly, with explanation if needed
  • identify or recognise priorities, justifying them if needed,
  • understand and accept decisions and conclusions differing from your own, provided they are reasonable and justified;
  • lead when needed, and to be led when necessary.

This capability, summarised here, covers much that will stand the rehabilitation expert in good stead when involved in management meetings and many other meetings. Much of the knowledge may be found in management literature, and the skills learned from management training courses. Although some rehabilitation professional consider meetings a waste of time – and a poorly planned and prepared meeting, badly chaired will indeed be a waste of time – successful rehabilitation depends crucially on meetings to reach a proper formulation, and to ensure an efficient and effective coordination of the team’s activities both internally, and with people from outside the team. Hence this is an important capability.

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