Standard Operating Procedures and Clinical Care Plans

Date First Published: January 9, 2015
Date Last Revised: July 15, 2021

“I think one’s feelings waste themselves in words; they ought all to be distilled into actions which bring results.”
—Florence Nightingale

This article hopes to clarify some of the issues regarding the development and use of standardized plans in the delivery of patient care. I have thought about this issue over many years. This article has also taken years to prepare. There were many false starts and yet I have not come to the end of trying to express my understanding the subject fully. It is a complex subject both in breadth and depth. For readers, trying to get through this article may be quite daunting. There are repetitions, and for some content details are spread over a few sections. I have tried to present it as simply as is possible. I have gone to great lengths to explain the work of a clinician because readers are likely to include non-clinicians ranging from managers, administrative staff and people involved in information management. All need to understand each other’s work. However, SOPs are designed to improve consistency. Therefore details are necessary. I hope you will bear with me and persevere in trying to go through reading it.

A. THEORETICAL CONSIDERATIONS

INTRODUCTION

When used in manufacturing industries, the Standard Operating Procedure (SOP) describes the plan for the method of producing a product (operations). It is used to provide instructions on how to perform procedures. A procedure (which can also be called a task) is a group of processes designed to produce an output. The term ‘standard’ refers to the uniform way that workers are expected to carry out the procedures. The product of manufacturing nearly always has specific characteristics (specifications) and rather rigid methods of production. Therefore, the SOP is applicable for the production of particular items at a particular facility.
The product of services can also have fairly uniform characteristics and be called service products. The operations of producing a service is termed as service delivery. In healthcare, services are fashioned according to diseases / illnesses / health problems. Since there are many types of diseases, there is a correspondingly wide variety of service products. While there is a need for uniformity in the way care is delivered (often termed as care), this must be accompanied by efforts to customize it by taking into consideration the many variations in the characteristics of the disease and personalize it according to the needs of the recipient i.e. the patient.

Currently, there is an increasing awareness worldwide of the need to regulate healthcare services, streamline health care funding and ensure uniform quality of care. This has resulted in wider acceptance of the use of standardized documented plans. In many instances, the initiatives are driven by the need to be accountable. For example, organizations who provide funds for health care now determine or at least influence, what goes into the management of different types of cases (e.g. by diagnostic related group – DRG) and allocate funds based on the composition of the recipients (Case mix). Accreditation bodies also expect healthcare facilities to have documented policies and procedures.

Adoption of the Use of Standard Operating Procedures

Obviously, the delivery of patient care is better planned in advance rather than provided in an ad hoc manner. The time has come to relate patient care practices to that of other industries in order to take advantage of innovations in the latter. Within the healthcare community, the design of the service for a typical patient with an episode of a specific illness is often called the ‘Plan for the Management of a Patient’ or “Care Plan”. For all intends and purposes this can be made to be equivalent to the ‘Standard Operating Procedure (SOP)’ and there is no reason not to call it such.

Applicability in Healthcare Setting

Some aspects of healthcare services are not very different from other services in as much as they have fairly uniform output characteristics. Also, the policies and procedures can be followed fairly rigidly. Such areas include:

  1. Administrative services (registration, scheduling appointments, resource allocation)
  2. Non-clinical support services (e.g. laboratory, imaging, sterilization)
  3. Ordering and supply

Applying SOPs in those types of services is not difficult. It has been tried for some time with success. However, problems arise when attempting to apply them for clinical services. This is because clinical patient care has characteristics that pose many challenges to the adoption of the use of SOPs.

Challenges in Using SOPs for Clinical Patient Care

Clinical patient care services are planned according to the needs of patients. For a start, the SOP can be taken to be a detailed plan applicable to the delivery of services to typical patients with a typical disease condition (the service product) in a particular facility or organization. Almost invariably, customization of the SOP would be necessary when the actual care of an individual patient is provided. As in any other service, the design and planning of clinical care involves translating the needs of recipients (patients) into uniform specifications and standards of both the service delivery itself and more importantly the final outcome of the service.

The contention of this article is that the use in health care of the Standard Operating Procedure (SOP) as a term and as a method of standardization of production or service delivery is not only possible but also necessary. The term ‘Care Plan’ which has been used in planning patient care has the same purpose, structure and content. If it is more acceptable, it can used in lieu of the term SOP. Henceforth in this discussion, the SOP and Care Plans are deemed to be synonymous. Both terms will be used together abbreviated as SOP/Care Plans. In practice either term can be used.

PLANNING AS PART OF THE CARE PROCESS

Planning is part of the series of processes in the delivery of patient care (described in another article).

Planning as Part of Patient Care

It is a series of thought processes that are then documented. These consist of:

  1. Identifying the case type (service product)
  2. Determining the objectives of care
  3. Deciding on and choosing the approach and method
  4. Deciding on and scheduling the sequence and layout of actions
  5. Ensuring that resources are available to carry out the plan
  6. Assigning responsibilities
  7. Anticipating issues that may arise
  8. Documenting the plan

The plan is then executed and the results are evaluated. It is redrawn if necessary. The challenge is to standardize and formalize the method.

Planning in Industrial Setting

The way planning is done in patient care as described above, differs significantly from the approach in in industrial setting. In the latter, the scope of planning encompasses all activities from the very beginning of production. Industries use the SOP as a plan that describes the entire methods (operations) of producing a product or delivering a service. Hence instructions are provided for actions to be taken from the very beginning. This is unlike the traditional thinking in clinical medicine (mentioned above) where planning is thought to happen after the diagnosis has been made.

Difference in Approach: Industrial vs Patient Care

Just as the aim of manufacturing industries is to produce useful products, the both the effort and the outcome of delivering services can be can be taken as products as well.

If an SOP/Care Plan is to be developed for patient care the same approach as other industry must be taken. Every action taken to deliver the service must be included in the plan. This way of thinking is better understood if the care of different types of patients are considered as service products.
Thus the initial step of information gathering and obtaining a diagnosis must be included in the SOP/Care Plan. Indeed, as will be shown later, planning clinical patient care will have to be integrated with the planning of the management of patient care as a whole including the administrative, communicational and other related aspects.

PATIENT CARE AS A SERVICE PRODUCT

To apply the concept used in industry to patient care, it has to be assumed that the service to be offered to the patient can be identified as soon as the person seeking care arrives at the facility. If possible, the service to be given is determined at the moment of registration or immediately after it. Patients seek care services for a reason. For follow up cases, this is not a problem as a diagnosis has been made at the previous visit. For new cases the reason for visit take the form of symptoms or complaints. The set of symptoms (symptom complex) supplemented by the discovery of certain signs that are obvious on observation or through simple assessment (at triage) can be taken as a preliminary diagnosis used to infer the needs of the patient and the service that they should be provided. If the preliminary diagnosis is expressed in a standardized way as the reason for visit, symptom complexes and clinical syndromes, then the SOP, even for patient care, can describe the service to be given from the very beginning. The difference (as will be discussed later) is that the service changes as the diagnosis becomes clearer.

It is proposed here that the delivery of a healthcare service product is best described in the form of a Standard Operating Procedure (SOP) which otherwise can be termed as the Care Plan. Both terms refer to the predicted or planned policies and procedures in managing a clinical problem. Although it is common to depict the Care Plan as a table or matrix, this is not the best way to explain it. Tables limit the amount of content and do not show sequence and layout clearly. It is better for the structure and content of patient care plans to be similar to the SOP used in other industries.

A SOP is meant to be used as the guide to production of a particular item or the delivery of a specific service. Services in healthcare are numerous and diverse. The challenge here is to define the service products and then design the SOP/Care Plan for each of them.

SOP/CARE PLAN AS A SERVICE DELIVERY PLAN for a Defined DISEASE

The care of a patient (usually referred to as a case) is based primarily on the identified diagnosis (disease, illness, or health problem). Therefore, the logical approach would be to design the SOP/Care Plans for the provision of services for patient groups (case types) affected by the same disease. That service and its outcome can be called a service product.
Even though diseases are diverse, the medical profession, in general, follows a uniform way of managing them as described in:
https://drdollah.com/clinical-care-processes/

The unique problem in patient care is that, almost always, the diagnosis is not known with certainty at the start, For a particular case, the clinician alters the diagnosis as more information about it is obtained, Therefore, there is a need to work from the general to the specific, from one less accurate to one that is more certain. The diagnosis is rather general at the beginning (identified as reason for visit, symptom complex, clinical syndrome or belonging to a Diagnostic related group (DRG) but later becomes more specific (identified by named diseases and their sub-types). The names of various service products can be based on standardized disease class and names e.g. as in ICD-10 Classification of diseases and SNOMED.

When the illness is diagnosed as a symptom complex, clinical syndrome, or belonging to a diagnostic related group, patients share common problems and be given correspondingly similar care. SOP/Care Plans must be created for the care of patients belonging to these groups.
Subsequently, SOP/Care Plans should be developed for patients with well defined specific diseases. On top of that, variations of the SOP/Care Plans will have to be developed for sub-types of the disease based on

  • pathological grading,
  • urgency,
  • stage at presentation,
  • severity level,
  • presence of complications
  • and etc.

Where there are distinct variations, services for these sub-types can be considered as essentially different service products. A separate sub-set of the SOP/Care Plan should be created for each one of the sub-type.

SOP/Care Plans Matched against Corresponding Service Products

Use of Standard Operating Procedures in Patient Care

The design of SOP/Care Plans in patient care requires knowledge and methods from many areas. Their content and structure should have the following characteristics:

  1. Describe an accepted way of providing care for a case
  2. Clarify the objectives of care (expected outcome, therapeutic end points)
  3. Identify variations in the needs of the patient and provide alternatives (Care pathway, Decision making steps)
  4. Describe the policies and procedures to be followed
  5. Outline the layout and sequence of tasks (Workflow)
  6. Allocate responsibilities (organization of the care team, work schedule, task lists)
  7. Define the control limits of both processes and outcome and incorporate methods to ensure compliance with them (built-in Quality control),

With training, the terms and conventions used in operations management in other industries can be understood and adopted for use by healthcare providers, just as effectively. This would allow people in other fields such as information technology, accounting and management to understand clinical care processes.
The documents and their parts making up the SOP/Care Plan for a specific case type are discussed below.

BENEFITS OF THE USE OF STANDARD OPERATING PROCEDURES / CARE PLANS

The use of a SOP/Care Plan for the care of a patient with a defined disease condition or health problem (a service product) confers benefits for health care providers and health services managers alike. In the end, patients would greatly benefit from care that is made consistent and controlled.

Benefits to the Healthcare Profession

SOP/Care Plans that are developed based on sound theory and experience (research, consensus and best practices) will benefit the healthcare profession as a whole by promoting:

  1. evidence-based practice
  2. uniformity and standardization

Benefits For The Care Provider

For the care provider, formalized planning of care provides many advantages including:

  1. Facilitate care that follows a more structured plan
  2. Include comprehensive content
  3. Encourage proper choice of investigations and treatment (remove redundancy / duplication and wastage)
  4. Encourage better resource utilization
  5. Provide information and decision support (prompts and reminders)
  6. Give a clear picture of future actions
  7. Communicate intentions to the care team (shared objectives and understanding, create task lists)

The SOP/Care Plan acts as the guide for the care provider in the care of his/her patients by providing the essential knowledge on the selection of approaches, paths, methods and standards. It is therefore a good tool for staff orientation and training or as a reference source when in doubt. The degree of detail within it means that it has be to studied conscientiously to be understood. When implementing a SOP/Care Plan, it is assumed that the care provider is conversant with its purpose, content and structure. The theoretical rationale, objectives and methods need not be presented in detail but referred to (through links or appendices) or summarized. In addition when performing specific tasks, instructions that are precise and didactic are required. These are provided as reference documents such as Work instructions and Reference tables.

Benefits From An Operations Management Perspective

From an Operations Management perspective, a documented SOP/Care Plan is useful for the following purposes:

  1. Provide information, guidance and decision support
  2. Clarify objectives and targets
  3. Facilitate conformance to prescribed approaches and methods
  4. Be the standard/specifications for quality measurement and control
  5. Act as a guide for staff orientation and training
  6. Provide predictability in resource planning (staffing, facilities, equipment, technology and information)
  7. Form the basis for the development of information systems

Benefits For The Unit Or Department Manager

From a service or department manager’s perspective, the use of SOP/Care Plans can lead to the following:

  1. Promote uniformity and standardization
  2. Render a degree of predictability in the supply of various resources
  3. Act as a basis for quality measurement and control
  4. Encourage equitable care and remove bias
  5. Improve staff knowledge, skills, attitude and behavior

Benefits From the Business Perspective

From a business perspective, the SOP/Care Plan defines the the package or bundle of tasks and input that make up a service product. Charges or the funds required can be calculated by costing the type and number of tasks to be done, the degree of difficulty, the time taken and the resources (workers, facilities, equipment and raw material) required to deliver the service. Indeed, currently many funders such as insurance companies and government agencies rely on care plans to justify claims or to provide funds to facilities. Reduction in costs by the use of care plans has been shown in one study.

Benefits From The Strategic Management Perspective

From the perspective of strategic management, SOP/Care Plans provide the foundation based on which changes and improvements can be made and benefits evaluated. A clear example would be the re-engineering of processes when computerized information technology is introduced. Without documented SOP/Care Plans, the current and earlier practices cannot be compared and it would not be possible to distinguish any improvement.

Standardization of procedures allow the accumulation of more reliable data that can be used to determine use of resources and outcome (success and failures). The information can be used to predict trends and enable planning.

OVERCOMING DOUBTS ABOUT USE OF SOP/CARE PLANS

Despite these benefits, there are apprehensions, among clinicians and managers alike. Many worry that that use of standardized plans will lead to:

  1. people following them blindly (“cook-book” medicine)
  2. loss of clinical freedom
  3. may be misused in medical negligence litigation.

The first concern is valid and should be addressed by building in variations, exceptions, alternatives and contingency plans into their design.
For the second concern, It must be stressed that the SOP/Care Plan, when first designed, is a reference document to be used as a guide. It has to be converted to actual plans with active input from the healthcare provider in charge of the case him/herself before being applied to actual care.

Medical negligence is defined as “an act or omission (failure to act) by a medical professional that deviates from the accepted medical standard of care”. The worry here is that the SOP/Care Plan can become the de facto medical standard. The argument usually made is that documented the SOP/Care Plan make the standard too certain whereas without it the term negligence lack certainty and provide leeway for defense. Clarity should be welcomed. At the moment the term evidence-based medicine is the by-word for the accepted way. Yet, the term ‘evidence’ itself need to be clearly defined. It should not be construed as only what transpires from research or what is printed in journals. SOP/Care Plans may be a better basis for defining the acceptable standard because it takes into account the practical aspects of practice in a specific work environment taking into consideration the existing limitations. Indeed data, derived from actual practice (best practices) have value that research do not provide.
Most medical practitioners (with the exception of those in lone practice) work in a facility where they are dependent on one another. In fact, the facility is as liable to claims of negligence as the practitioner. There is a need for the facility to advocate common policies and procedures as provided by SOP/Care Plans. Making it available is part of good governance. If it is designed based on scientific knowledge, research findings, best practices, consensus and experience, it acts as a shield for practitioners from unacceptable practice. However, not following the SOP/Care Plan to the letter should not be construed as deviating from the norm. The care provider is allowed to modify elements of the SOP/Care Plan based on his/her own judgment when faced with certain situations. It is advisable to record and explain the reason for the variance from prescribed policies and procedures.

DESIGN OF THE SOP/CARE PLAN

SOP/Care Plans are basically packages of tasks bundled together, arranged and sequenced according to the clinical workflow. The overall plan provides direction to the clinician on tasks to be performed for a patient from the beginning to the end of the care episode. It is then further broken up into sections for various phases, visits, encounters and sessions within the episode.
In current practice and literature, there are many conceptions and formats that are called ‘Care Plans’ discussed in an earlier article. There is a need to develop a more effective alternative approach as proposed here.

GUIDING PHILOSOPHIES AND STRATEGIES IN THE DESIGN OF THE SOP/CARE PLAN

Some of the philosophy, principles and strategies that can guide the development of a SOP/Care Plan for patient care include:

  1. Application of modern management concepts and techniques
  2. Ensuring that the plan is feasible (usable) and acceptable to users
  3. Based on evidence-based medicine
  4. Imbued with the Total Patient Care concept (holistic Care taking into consideration all needs of the patient)
  5. Reflect a team approach (care through interdisciplinary involvement and collaboration)
  6. Incorporation of quality standards and quality control
  7. Cater for an enlightened patient, advocate empowerment and encourage self help
  8. Harness information technology
  9. Follow a two step process i.e. choosing an appropriate plan to be used as a reference and using it to create the plan which will be used in the actual care of the patient.

These principles and strategies are deliberated further below.

APPLICATION OF MODERN MANAGEMENT CONCEPTS AND TECHNIQUES

Strategy Based On “Quality By Design” Concepts

The design of patient care service delivery is similar to the design of other service delivery systems as practised in modern quality management (as advocated by Juran and others). These consist of a systematic sequence of steps i.e.:

  1. Identification of primary needs of the client (the health problem, diagnosis)
  2. Identification of additional / special needs based on characteristics specific to the client
  3. Setting the expected or desired outcome
  4. Clarifying the components of the service delivery system (input and process)
  5. Delineating the sequence and layout of work flow (the Care Pathway)
  6. Clarifying and detailing the processes involved as instructions (the Work Procedure)
  7. Stating the rules that regulate the service (policies)
  8. Choosing the most appropriate technology or modalities to be used
  9. Assignment of responsibilities to various service providers
  10. Identifying the monitoring and control measures (Monitoring, Review and Evaluation, Quality Control)
  11. Providing the means for data documentation (Clinical documentation, Forms, Charts, Information systems)
  12. Catering for variations, exceptions and contingencies by providing alternatives
  13. Anticipating possible errors of omission or commission, their prevention and damage control

The topic of Quality by Design is discussed in a separate article.

USE OF THE “PDCA CYCLE” DURING DEVELOPMENT

To develop a plan that is effective and implementable requires a proper development approach. The Shewhart-Deming-Imai PDCA Cycle is the most dependable method. At the start, the strategy, methods and layout of implementation of the plan are thought out and documented (the Plan stage). Simulations, trial runs or pilot projects are carried out (the Do stage). Various quality measures of input, processes and output are measured (the Check stage). These are used to determine feasibility, productivity, efficiency, costs and most importantly, achievement of an outcome that conforms to the desired standards. Where shortcomings in the design are detected, changes or fine-tuning is done (the Amend stage). The design of the service delivery may be altered to ensure that outcome meets desired specifications. However, it may be necessary to make only minor changes to the service specifications to make the service delivery feasible. The cycle is repeated for every change made until a satisfactory plan is “Adopted”.

The “PDCA” Cycle

Once developed, the plans will act as the standard to be followed by everyone who manages a patient suffering from the disease, syndrome or symptom complex, in the facilities within the organization. This approach to standardization should not, in any way, discourage care providers from altering practices in peculiar situations and for unique demands. Allowance for variations may be written into the plans. Innovations should be introduced through proper research, not through deliberate changes to the existing SOP.
Once adopted and put into practice there is a need for audits to be performed to monitor conformance and to determine its effectiveness. Development of plans is a never ending continuous learning process.

PRACTICE OF EVIDENCE-BASED MEDICINE

The care provider is confronted with multiple possibilities when choosing strategies, methods, approaches, technologies and modalities for investigation and treatment. Their effectiveness, appropriateness, efficiency, cost-effectiveness and safety are difficult to ascertain. Yet, it is essential that the SOPs/Care Plans in healthcare are based on evidence as well as consensus. How policies and procedures can be derived from evidence, by taking advantage of tried and tested practices, is outlined diagrammatically below:

Basis for SOP/Care Plan

The development of clinical practice guidelines is a major step in attempting to identify and promote care approaches with proven efficacy, effectiveness and safety (evidence-based medicine). These guidelines when available, provides the ideal basis for the design of SOP/Care Plans. Currently there are already numerous Practice Guidelines developed by experts in various fields (e.g. professional bodies or collaborative efforts) who have thorough understanding of clinical care processes and the modalities available for investigations, treatment and monitoring. Based on these, more precise plans for disease and patient groups can be deigned as SOP/Care Plans for a specific facility or practice.

TRANSFORMATION OF GUIDELINES INTO SOP/CARE PLAN

Clinical practice guidelines need to be transformed (operationalized) into plans that take into account the resources, environment and objectives of the organizations providing the service. There is a need to show that these plans are feasible, effective, usable and acceptable before being adopted and endorsed by the people in charge (e.g. Clinical Services Committee, Medical Advisory Committee, Clinical Governance Committee and the Hospital Management). As such, the SOP/Care Plan is valid for use within the organization that develops it.

However, currently clinical practice guidelines are not available for all the types of diseases, illnesses or health problems. As such managers need to work with care providers to develop guidelines and from them design SOP/Care Plans suitable for their of facility through consensus. They can use other sources such as recommendations (e.g. by WHO, the Ministry of Health) or the literature as the basis.

Validity of SOP/Care Plan

For the SOP/Care Plan to remain valid it has to be continually updated. The people in charge of producing them need to be constantly aware of recent developments.
Also the hospital need to ensure their dissemination and proper use both in terms of the adherence to them. It must also review their effectiveness in achieving intended objectives. The best way is to audit the SOP/Care Plan. Findings from the audit is then used to improve conformance as well as to rectify the structure and content of SOP/Care Plan itself.

INCORPORATION OF THE TOTAL PATIENT CARE CONCEPT (HOLISTIC CARE)

The SOP/Care Plans need to be comprehensive, cohesive and orderly. A comprehensive patient care plan based on the philosophy of Total Patient Care or holistic care should be adopted. This approach addresses all aspects of the patient’s health issues for both the short-term as well as the long-term. The design of such SOP/Care Plans would require the contribution of all relevant health care professionals involved in the care of each class of patients. This can be achieved through the formation of Interdepartmental or Cross-Functional Teams. The SOP/Care Plan must be based on good evidence (e.g. Clinical Practice Guidelines) supplemented by knowledge and experiences of members of the team. (For details, please refer to the article entitled “The Total Patient Care Concept”).

The involvement of all relevant health care professionals encourages each of them to:

  1. be interested in the overall well-being of the patient,
  2. understand the overall care plan,
  3. be able to respond to a patient’s query regarding every aspect of his/her care
  4. contribute to the success of the overall plan, wherever possible

FUNCTION OF THE SOP/CARE PLAN

Each SOP/Care Plan describes the plan for the realization of a specific service product i.e. the delivery of service for patients with a particular disease or health problem. It should have enough breadth and depth to cater for the following functions:

  1. explain the theoretical basis for content and layout of care
  2. provide the guide to policies, procedures and decision making
  3. provide the essential knowledge and instructions to help the care provider give safe, effective and appropriate care.

Hence, the SOP/Care Plans can act as reference document for:

  1. guide to carrying out work processes
  2. training
  3. use as the standard for comparing actual performance with what is expected

COMPOSITION OF THE SOP/CARE PLAN

SOP/Care Plans are made up of tasks to be performed to produce a product or to offer a service (a service product) and the policies that govern them. For them to be standardized, they need to be documented in a structured way. There should be an SOP/Care Plan for every service product. To that end the clinical processes involved in ensuring successful outcome in patient care must to understood.

When building the SOP/Care Plans to be used by an organization these factors must be take into consideration:

  • goals of the organization in providing the service,
  • environment existing within it,
  • the resources available to it,
  • how service delivery is organized

Plans must match the capability of the organization or it must improve its status to meet the requirements.

There is a need to demonstrate that these plans are feasible and effective through trial or pilot studies. Before being adopted, it should be verified by the persons or committee responsible for Clinical Governance and formally endorsed by the executive body of the organization.

Differences Between Implementing SOP In Clinical Care as Compared to Other Services

In manufacturing industries, the products have well defined specifications and so also are the input and processes used. The production system can be replicated easily at different locations. In service delivery, the service product has specifications that are not so strictly defined and often there is a need for the delivery to be customized and personalized to fit the special needs of the recipient. Some service delivery systems can also be replicated as franchises (e.g. fast food outlets). The need for customization and personalization is more acute in healthcare services.

As such, the core SOP/Care Plan can be a general plan for a typical disease modified to suit the health care facility where it is to be applied. Variations in the disease itself can be anticipated and plans for its care can be written as extensions or appendices to this main SOP/Care Plan. Healthcare is geared towards solving problems both in the methodology used and the anticipated outcome. The nature of problems vary from disease to disease as well as case to case. When the variation is major, a separate SOP/Care Plan need to be written. Therefore, the SOP/Care Plan need to anticipate variations in the disease as well as eventualities in the care of the patient and provide solutions to them. Even so the SOP/Care Plan can only be a guide to performing the procedure. Additionally, another step, i.e. the conversion to the plan to the actual one to be used for the individual case is necessary.

CONVERSION OF SOP/CARE PLANS FOR USE ON AN INDIVIDUAL PATIENT

Varied Nature Of Service Products of Clinical Patient Care

To clinicians, the ‘care’ or ‘the management of a patient’ is the provision of the entire service or care for a certain patient according to his/her needs which are determined largely on the identified diagnosis or health problem. The title of the reference SOP/Care Plan should show that it is designed for the ‘care’ of this particular disease or health problem. As such, the Service product consists of a well-defined set of services to be provided for a typical patient (case) who has an episode of a certain illness. Yet it is, to a certain extent, still generic and would need customization, by additions or omissions, when it is used as the SOP/Care Plan in the actual care of an individual patient.

The needs of each patient varies quite significantly depending on many factors. Thus personalization i.e. variation of the care given to a particular patient must be anticipated not only at the beginning of the service but also throughout the service delivery period because the patient’s condition often vary as the care and the disease progresses. Hence, it is necessary to modify the original SOP/Care Plan, from time to time (throughout the phases of care) during actual implementation.

CONCEPT OF REFERENCE VS ACTUAL SOP/CARE PLAN

In most industries, to produce products that are consistent, the SOP is used directly and strictly by all workers with little or no modification. This approach is not advisable for services in healthcare. Standard SOP/Care Plans cannot satisfy a patient’s needs fully. Besides the attention to the illness and its effects, care plans also give due consideration for the general needs of the patient (i.e. a sick person). These are often unique.

Planning has always been regarded as an essential clinical process. Without a guide, the clinician thinks out the plan spontaneously by applying his/her innate knowledge to the problem at hand. If the problem is common and familiar he/she will repeat the plan that he/she has used before. However, often he/she may find his/her knowledge and experience inadequate to put together a solution for the problem at hand. The SOP/Care Plans fulfil the need for a reliable, comprehensive and easily applicable guides.

Two Step Process In Implementing SOP/Care Plan

As discussed earlier the documented SOP/Care Plan cannot be used directly. Therefore, it is essential that planning of patient care follow a two step process i.e. choosing an appropriate plan as a guide (termed as the Reference plan) and using it to create the plan which will be used in the actual care of the patient (termed as the Actual plan). The Reference Plan is provided as a document for reference. To use it, the relevant part is modified and re-documented in the system presiding over the operations of the service delivery (paper medical record or computerized information systems). The Actual Care Plan is a statement of intent listing out the intended sets of tasks to be performed and their objectives (expected results or outcome). It is derived from the Reference Plan.

When using a SOP/Care plan as a guide, the planning process is done in two major steps i.e.:

  1. Choosing the appropriate Reference (Model) Plan from the library of previously prepared care plans
  2. Converting the chosen reference plan into an Actual (Operations) Plan by customizing it to cater for the special needs of the patient

In practice, the Actual plan is the definite plan and is documented as part of the Medical Record or Clinical Information System. For each case, the primary provider of care (usually the doctor in charge) acts as the leader and is the most suitable person to choose the appropriate Reference plan. However, there are exceptional instances when a practitioner from a different professional group make take the lead. Constructing the Actual plan is the joint responsibility of all the clinicians looking after the patient.

The Reference Plan

At the beginning, the efforts must be made within the healthcare facility to design standardized plans that are generic in nature i.e. applicable to typical patients with a typical disease condition (rather than an individual patient). All such plans should be made available (by whatever means) as a properly indexed comprehensive library of documents. The Reference plan for a particular case is selected from this library.

All aspects of care must be addressed at the time of the development and design of Reference Plans. As far as possible all policies and processes are thought out, eventualities anticipated and variations considered. As care of a patient is a multidisciplinary effort, each professional group should be involved. For example a section for nursing care should be included in the Reference plan. It should address the aspects of nursing required for the disease, illness or health problem for which the plan is written. There should not be a separate Nursing Care Plan standing on its own. The same is true for plans for rehabilitation or the care for psycho-social issues. (This is in contradistinction with current practice).

Reference plans form the basis for the planning of care of an individual patient. They give an overall and comprehensive view of the care expected. The care provider constantly refers to them as the care progresses. He/she needs to be aware of the various alternative plans available because even if he/she starts with a particular plan for a certain problem, he/she may have to change to other plans later.

After choosing a plan that matches the needs of the individual patient, the care provider uses his/her own special knowledge, skills and discretion to modify it. Patient care plans need to be individualized and customized by the care provider by putting together all available information, choosing the most relevant subset of the plans, combining them and adding or omitting certain options. The resultant plan is then the Actual Care Plan to be implemented.

Building Reference Plans For Alternatives, Variations, Options and Contingencies

Care Plans are designed primarily on the basis of diagnosis. At the initial phase of care, the diagnosis is broad or general. Subsequently, as more information is available, a different diagnosis may be made. Hence, it is not good enough to continue using the SOP/Care Plan based on the initial diagnosis.

If the change in diagnosis is minor then the same Reference plan is used but revised accordingly. If the diagnosis differs significantly, another more relevant Reference plan or sub-set of the previous plan must be chosen as a replacement. Hence, in preparing Reference Plans for a disease, besides constructing a plan for a typical presentation of the disease, it is necessary also to build in advance and make available appropriate plans for:

  1. the variant of the disease (pathological grade, clinical variant, acute, chronic)
  2. the stage of its natural history (early, late)
  3. severity grading (mild, moderate, severe)
  4. patient profile / category (age, gender, risk factors, confounding factors)

Reference SOP/Care Plans are constructed, compiled, indexed and kept as a set of reference documents (a properly indexed library of those documents referred to in industry as the Work Procedure Manual) and made accessible to care providers. Each document consists of various components that address various aspects of care (written as sections and paragraphs). The components would be like those in SOPs already in use in other industries as will be outlined below.

If the patient has more than one health problem e.g. a concurrent illness or an active pre-existing illness, then the application of a combination/amalgamation of the generic plans into one actual plan would be necessary (as depicted below). Example: patient with polytrauma. General plus specific. Combinations, inclusion and exclusion, avoidance of repetition.

Amalgamation of Generic Plans into a Single Actual Plan for an Patient with Multiple Problems

TECHNIQUE OF CONVERTING REFERENCE PLANS INTO ACTUAL PLANS

The SOP/Care plan remains as a reference document until it is converted into an actual plan for the individual patient. Once selected, it becomes the basic plan that can be customized by adding or removing certain elements before being accepted and used. Because the patient’s needs change with his/her condition (diagnosis, additional problems), a complete Actual plan cannot be prepared in advance, in one go. The conversion of the plan has to be done in parts in a stepwise fashion (will be discussed later).

Use with Paper Record Systems

If the Reference plan is made available on paper (e.g. a booklet or manual), It is used as a source of reference i.e. as a guide in ensuring that uniform policies and procedures are followed and as a source of knowledge. To construct the Actual plan, the provider need to read the relevant parts, at the point when planning is required, transform it in his mind or jot it on a piece of paper before transcribing (rewriting) it onto the case notes (paper medical record) as instructions. Obviously, this is a laborious method and is the reason why attempts at using care plans (e.g. by nurses) have met with limited success. It works only if the care provider is very familiar with the plan to the extent he/she has it in memory and can construct the actual plan on the go.

If the plan is provided as a document on a stand-alone personal computer, a word processor can be used to copy-paste the relevant part and edited to construct an actual plan. The resulting document can be printed and then incorporated as part of the paper medical record or otherwise transcribed in writing. Printing is more convenient but depends on the availability of a printer.

Use in Computerized Information Systems

The advent of computerized information systems (Hospital Information System, Clinical Information System), provides the most effective mechanism to put SOP/Care Plans to practical use., A complete list of various SOP/Care Plan reference documents can be stored in a file-server and provided as part of the application software. Care providers can look for, select, call for the relevant plan via links through a search mechanism or from a drop down menu and read it. More importantly, it is possible to build into the system the means to actualize the plan. The system can be made to provide the relevant part of the plan at the opportune moment in the care of the patient. The primary trigger of a plan would be the diagnosis. If diagnosis is taken to include reason for visit, symptom complexes and clinical syndromes, then the system can suggest a plan even at an early stage (e.g. at triage). As data indicating diagnosis is entered, the system can present relevant plan to the care provider. Once the diagnosis is established and based on the data that has been collected the Clinical Information System could be made to be aware of which phase of care is being carried out and present the relevant part of the plan. The care provider can then modify the part presented by adding or removing various elements of care. Based on analysis of the current data, the system itself can make changes automatically e.g. perform a reconciliation by omitting redundancies. As changes in the diagnosis is documented by the care provider, the system suggests a different plan accordingly.
There is a wider range of possibilities of manipulating the document when a computerized system is used. For example, if the patient requires the use of multiple plans the combination and permutation can be done based on artificial intelligence. (The use of the SOP/Care Plans in a computerized system will be discussed in another article).

Choosing a Reference Plan From A Library Of Reference Care Plans

CREATION OF ACTUAL PLANS

The Actual Care Plan is a statement of intent listing out the intended sets of tasks to be performed and their objectives (expected results or outcome). It is derived from the Reference Plan but take practical matters into consideration. Conversion of the Reference plan to the Actual plan is performed on demand in batches based on the stages or phases of the care process.
In a paper-based system, the plan takes the form of instructions documented in the medical record regarding tasks to be performed for all aspects of care including investigations, monitoring, and various types of treatment such as nursing care, medication, procedures, rehabilitation, counseling, psycho-social aid etc.
Traditionally, the actual plan is documented as shown below:

Traditional Way of Writing Plans

Planning should be considered as a distinct and separate task. Data concerning it, should be recorded at the time when the plan is generated together with other related tasks in chronological order. Currently, there is a practice of using a separate table to record, in the case notes, the plan together with assessment, tasks performed and outcome achieved. Putting these together in one table is incorrect because those activities occur at different time periods. Instead, the execution of the plan (the treatment given), and the results obtained are documented, as and when the processes are performed, in progress review notes, monitoring charts, procedure records, findings, outcome documentation and etc.

Incorrect Way of Documenting Care Plan

In a completely computerized system, the relevant parts of the the reference plan required at that point of care can be accessed manually or be given automatically (triggered) by the system based on rules, The Clinical Information System software can be designed to make it possible for care providers to modify and transform the relevant parts of the chosen Reference plan into an Actual plan. No transcription is necessary. The plan is then converted into orders (orders list) and tasks to be executed (task lists). When the plan is executed, data regarding task performance and results achieved can be entered as and when they occur and stored in a database. The information can be retrieved, analyzed and displayed as a report on conformance to plans and the outcome of care.

The Reference plans have alternative sections for anticipated variations in the progress of the case. When faced with these variations the care-provider decides on which alternative to take. If the right step to be taken is not available in the Reference plan, then the care provider needs to devise the actions him/herself. Therefore, to minimize this need, it would be helpful if the design of each SOP/Care Plan takes into consideration the possible scenarios that can happen in the care of a patient.

Responsibility and Leadership in Selecting the Appropriate Plan

Although the care of a patient is a multidisciplinary effort, selection of the appropriate plan rests on the care provider deemed to be the leader at that stage of care, The stage may or may not correspond to the phase of care. By convention, the authority to select the plan is given to the primary provider of care. Even though in most instances, this person is usually the doctor in-charge, it is not applicable at all stages of care. The person taking on the role of the primary provider may change depending on the circumstances. The responsibility may or may not be be obvious when preparing the Reference plan but has to be decided in the Actual plan. At the early stage e.g. the triage stage, the attending care provider (not necessarily a doctor) will have to select the appropriate plan and execute it. This is facilitated by the availability of Reference Plans for diagnosis at the level of symptom complexes and clinical syndromes. Subsequently, the responsibility of care is passed on to a care provider who have the necessary expertise to elucidate a more definite diagnosis. Based on the diagnosis he/she decides whether to continue the care or pass on (refer) the case to the appropriate care provider or care team (department of unit) with the necessary capability. From then on the care provider in-charge has the authority and responsibility to change or modify the plan.

When the actual plan has been formulated, it is then communicated to other care providers by documenting it in the medical record/case notes or the Clinical Information System (presented under the section for Plan). Major deviations from to the chosen Reference plan (variance) must be explained and documented.
The details of the plan for the entire care episode is described in the Reference SOP/Care Plan which should be referred to rather than copied onto the case notes/medical record/CIS. Instead, a statement as to which SOP/Care Plan has been chosen is indicated e.g. “to treat patient as case of Acute Coronary Syndrome”. Members of the care team will then become aware of the general approach to the care planned. The actual plan is written in the medical record/case note or entered into the CIS. However, because the entire plan cannot be decided in advance only the parts that is certain i.e. the next set of tasks is documented.

Since the care of a patient is a multidisciplinary effort, each care provider is given the opportunity to create the Actual plan pertaining to his/her area of responsibility by modifying the relevant part of the chosen Reference plan. They should make good use of their expertise to modify the relevant portion of the plan as long as it stays true to what is prescribed in the chosen Reference plan. Yet, there should be consultation with other members of the care team.
If the Clinical Information System (CIS) is used, the finalized plan should be displayed as an integrated plan that can be viewed by all care providers concerned. The patient also should be aware of the plan, be allowed to make queries and be involved in it.

ELEMENTS TO BE CONSIDERED IN DEVELOPING SOP/CARE PLANS

The following elements need to be included in the structure and content of SOP/Care Plans:

  1. Identification of the needs of the patient
  2. Identifying the case type (Primary Diagnosis) Disease complexity (type, pathological grade)
    • Severity Level
    • Stage of the disease
    • Effects and complications of the disease
  3. Other needs arising from the patient’s health profile (preexisting disease, pre-morbid health status, demography)
  4. Care Objectives
    • Cure
    • Containment (by 2O or 3O Prevention)
    • Palliation
  5. Procedures (Clinical Care Processes)
    • Information gathering
    • Deriving conclusions
    • Planning
    • Execution
    • Review/Evaluation (of diagnosis, objectives and plan)
  6. Policies (Legal, professional and ethical considerations)
  7. Breaking the plan into phases of care brought about by:
    • changes in the certainty and comprehensiveness of the diagnosis
    • Progress of the disease along its natural history
    • Stage of the workflow
    • Other emerging issues (e.g. new issues such as complications and ineffectiveness of interventions)
  8. Guide to making decisions
  9. Reference documents providing guide to performing tasks or making decisions
  10. Quality control methods (methods to ensure conformance)
    • Preventive measures
    • Quality Measurement
    • Comparison with Standards
    • Detection of non-Conformance
    • Rectification and Damage control

Identification of Primary Needs of the Patient

Proper planning of care requires an understanding of the needs of the patient (defined as a person who is sick). Patients do not usually present to care-providers with readily identifiable health problems. Patients may or may not know what to expect from the care given. It is important to address their perceived needs but often they have unreasonable expectations or on the other hand have little hope. It is the responsibility of the health care professional to determine their real needs and what outcome can be expected. Therefore, before a service is provided, care providers need to gather information about the patient, analyze it and identify his/her problems. The primary needs relate to the disease, illness or health problem affecting the patient and are identified when an accurate and comprehensive diagnosis is known. Besides the main illness the patient often has secondary needs arising from concurrent illness, preexisting illnesses, unresolved previous illness, disabilities and other health problems. These are not the same for every patient and therefore cannot be anticipated but should be addressed during the actual planning of care. (Secondary and tertiary needs are discussed in another article).

In other industries the product of manufacturing or outcome of service delivery are well defined and so also are the input (human resource, material, machines) and the processes used. This is not so in healthcare. While care can be made uniform based on the patient’s disease, the needs of patient varies quite significantly depending on many factors. Even if it would seem that there as many service products as there are diseases, these would have to be broken further into more specific sub-types.

Design Based on Diagnosis of Present Illness

The present illness is the primary consideration in formulating the service to be given to the patient (the service product). However, the nature of the Present Illness is not immediately apparent at the beginning of patient care. During the course of care, the amount and clarity of information available to the care provider increases and the diagnosis of the present illness becomes clearer or additional problems emerge. If these changes are significant, another more relevant plan is chosen. If the change is minor then the plan is revised or amended accordingly.

The Working Diagnosis As The Basis For Selecting A Plan

Clinicians used the term Working diagnosis to denote the diagnosis based on which the care is planned at the current time. This is the diagnosis that the election of the SOP/Care Plan must be based on at any point during care. It becomes more accurate and changes as the amount and quality of data is available to the clinician. It can be a broad or general diagnosis, a presumptive diagnosis or a definite diagnosis.

This rule also means that appropriate care must be instituted even when the definite diagnosis has not been identified with certainty. For the same reason, plans for care of a particular patient need to change according to the changing levels of accuracy of the diagnosis.

The primary care provider (usually the doctor in charge) is the person responsible for arriving at the diagnosis. Therefore, he/she is also the person to select and initiate the care plan.

Planning when the Diagnosis Is General or Uncertain

At the initial phase when only data gathered through interview, examination and simple tests are available, a broad or general diagnosis may be made. This makes it necessary to build SOP/Care Plans for diagnosis expressed as:

  1. reason for visit
  2. symptom complex,
  3. a clinical syndrome or
  4. a diagnostic related group.

As more investigations and monitoring data are made available a more specific diagnosis is possible. There are instances when not all the criteria for a definite diagnosis are available. The care provider may decide to use the most likely diagnosis as the basis for a SOP/Care Plan. The diagnosis is then called the Presumptive diagnosis. The care provider must be aware constantly that this is the case and be ready to change the plan if further evidence points to a different diagnosis. Even when a diagnosis is deemed to be definite (all the criteria to support it are satisfied), the he/she must identify the variant (sub-type) of the disease and the stage in its natural history. SOP/Care plans must be designed not only for specific diseases but also their variants.

Hence, categorization, staging, pathological grading, severity level and risk stratification are important prerequisites before objectives of care are determined and the right SOP/Care plan is chosen. Interpreting the nature of the health problem inappropriately and therefore choosing an inappropriate plan would lead to dire consequences. Work flows, algorithms or care pathways are tools that can assist health care providers to make the right decisions and provide guidance towards accepted processes of care. A discussion on Diagnosis is available in another article.

Role of the Reason for Visit

For a new case the reason for visit is given by the patient as symptoms or just reasons. It may be apparent based on the referral letter.
In a follow up case, the reason for visit should have been known at the end of the previous visit and indicated in the appointment book or on the follow up card.

The value of symptoms as the reason for visit (in a new case) is weak because it is uninterpreted. The symptoms may be voluntarily given to the receptionist at registration or when seeking for an appointment over the phone. However, it can be used to direct the patient to the right service provider (unit or department). It’s value is better if the patient undergo a triage process by a care provider with clinical experience.
For a follow up case the reason for visit is clearer. It should have been decided before the discharge from the previous visit. Where a CIS is in place, it can be used to trigger a care plan .

Care Plan For Symptom Complexes, Syndromes And Diagnostic Related Groups

The diagnosis in the form of symptom complexes, syndromes and diagnostic related groups are made at the beginning of care, usually at the first visit. The SOP/Care plan then contains activities aimed at:

  1. clarifying the diagnosis through diagnostic investigations,
  2. providing treatment for symptom relief
  3. providing supportive therapy
  4. establishing monitoring and observation routines

At the completion of these activities, a more definite diagnosis is made and the patient profile is known. Then, an appropriate SOP/Care plan for the specific disease can be chosen.

Care Plans for an Identified Disease, Illness or Health Problem (Working Diagnosis)

A SOP/Care Plan is designed and written for a specific service product. While the disease as described in a textbook usually encompass all presentations of it, different categories of the disease will be considered as different service products such that separate SOP/Care Plans will be required for them.

SOP/Care Plan for the Latest Known Diagnosis

The SOP/Care Plan can be written for the main disease if it has very minor variations in its presentation. Otherwise, as a rule, they would be written for a disease sub-type.

For example, Type 1 (Juvenile onset) Diabetes and Type 2 (Adult onset) Diabetes have dissimilar characteristics requiring two separate SOP/Care Plans. It is not appropriate to write one for Diabetes.

Yet, quite often the diagnosis made refers to an entity that is a group of diseases rather than a distinct disease. For example, Pneumonia refers to a group of diseases characterized by infection of the lung consisting of Lobar pneumonia, Bronchopneumonia, Atypical pneumonia and variants related to the causative microorganism. As such Pneumonia is a diagnostic related group (DRG) rather than a specific disease. A SOP/Care plan has to be written for this DRG because it important to provide initial care of Pneumonia even when the cause is uncertain. Then specific SOP/Care Plans are required for its variants (based on causation) when identified later.
Sometimes, despite various efforts, the definite diagnosis cannot be ascertained. Then, either the provisional diagnosis or the closest diagnosis that can be reached (the Working diagnosis or Presumptive diagnosis) is used to select the SOP/Care Plan. Later as care proceeds, further developments in the disease process will lead to a Definite diagnosis warranting a change in the plan. These developments include:

  1. emergence of new symptoms and signs,
  2. physiological changes evident by change in parameters monitored
  3. investigation findings
  4. better exposure e.g. at endoscopy or surgery
  5. response to treatment

Disease Sub-Types and Corresponding Subset of SOP/Care Plans

When the patient’s diagnosis is identified as a specific disease entity or a variant of it, the care that is provided for it would be the service product. For better understanding of the relationship between variants and the SOP/Care Plan associated with it, the following terms are used in this discussion:

  1. the variants of the disease can be called the sub-types of it
  2. the different plans for the care of patients with these variants can be called the subsets of the SOP/Care Plan.
Care Plans for Variants of a Disease

Further Categorization of the Case

Cases can be categorized further according to possible factors that clarifies a diagnosis such as risks, severity of illness, stage of development and therefore prognosis. Categorization in turn allows the clinician to choose the right pathway and start an appropriate care plan. As such, grading and scoring systems for various diseases should be adopted for each disease and the care plan should have variations for different severity levels, stages and grades.

Variants of the disease are determined by:

  1. the pathological grade (virulence of causative organisms, tumour cell type, degree of differentiation of neoplasms)
  2. clinical onset (acute, sub-acute, chronic)
  3. the stage at presentation relative to its natural history (early, late)
  4. severity grading (mild, moderate, severe or extent of involvement)
  5. patient profile / category (age, gender, risk factors, confounding factors)

Designing SOP/Care Plans for a Specific Disease

When the definite diagnosis of a specific disease is made with certainty, the guidance given in the SOP/Care Plan can be more certain, and specific. It will take a more didactic tone and be more regimented.

SOPs are often criticized for being rigid. In fact, by offering different directions and paths, the SOP/Care Plans can offer alternatives in managing a patient based on various valid criteria. SOPs/Care plans are designed to suit different anticipated scenarios (see below). Where there is a choice of methods (e.g. tests) or material (e.g. drug, suture) without major difference in effectiveness or safety, the care provider is given an option to choose one based on being the best suited, available or or according to the patient’s preference. Indeed, the care provider may choose to modify procedures and plans as long as these do not deviate from core policies and the variance (intentional or otherwise) should be noted.

Designing SOP/Care Plans for Variants of the Disease

Creating alternative subsets of a SOP/Care Plan catering for variants or sub-types of the disease is a challenge. They can be designed and documented in two ways depending on the circumstances:

  1. as alternative segments to the main plan (applicable when the variation of the care of the various sub-types is slight)
  2. as a separate SOP/Care Plan, (applicable if there is a distinct difference in the care for the each sub-type of the disease)

Sub-types of the disease and corresponding sub-sets of SOP/Care Plans is depicted below.

SOP/Care Plans for Sub-Types of a Disease

Expressing Variations As Alternative Segments

When the variation in case type and their care is slight there is no necessity to write separate SOP/Care Plans. Instead the difference in the care is expressed as alternatives in identified segments in the document.

Alternative SOP/Care Plans Corresponding to Variations in Patient Profile and Disease Pattern

Expressing Variations as Separate Documents

When the variation in the case type and its care is distinct then separate SOP/Care Plans should be prpared. For example, Bronchial Asthma is categorized based on variation in acuity of onset into Acute and Chronic presentations. The two categories have very different approaches to treatment. As such, there is no value in having a SOP/Care Plan for Bronchial Asthma per se. However, separate SOP/Care Plans have to be designed and written for the two categories with some parts shared. Separate SOP/Care Plans are also needed for care of Bronchial Asthma in children.
Each of the categories (acute or chronic) has further sub-types based on severity. The differences of their care is mainly in the mode of treatment and intensity of monitoring. As such this variation in care of the disease sub-types is written as alternative segments/paragraphs (with headings) as shown below:

Sub-types of Service Product and Corresponding Sub-sets of SOP/Care Plans Plans foe Care of Adult Patients with Bronchial Asthma

Taking the Patient’s Biological Profile into Consideration

For many diseases, the presentation and the management is different for the paediatric vs the adult age group. Separate SOP/Care Plan must be designed for them. The same may be true if there is major variation in the disease and its treatment due to gender (e.g. Urinary Incontinence). Variation in the care when it happens in the elderly would probably require an addendum rather than a separate plan.

Sub-types of Service Product and Corresponding Sub-sets of SOP/Care Plans

Taking The Patients Underlying Health Status (Health Profile) Into Consideration

If complete care is to be given, consideration should be given not only to the present illness but also health status before the illness began (pre-morbid status). It would not be necessary to design separate Reference plans to cater for these factors and circumstances. Instead they need to be considered when the Actual plan is formulated. The Actual Plan should include additional actions in response to needs brought on by the following:

  1. The general health in terms of nutrition, physical ability, physiological functions and psycho-social status
  2. The existence of Concurrent, Preexisting and Unresolved Previous illnesses
  3. The existence of disabilities, handicaps, deformities (congenital or acquired, temporary or permanent)

The plan must therefore incorporate considerations of the Total Patient Care Concept mentioned previously.

INFLUENCE OF CARE OBJECTIVES AND OUTCOME GOALS ON THE DESIGN

The objectives of the service provided (i.e. care of the patient) should be determined and stated at the outset in the SOP/Care Plan if possible or at any point when the prognosis become clear. In fact, interim objectives are also determined for every phase of patient care. Also, the objective for any intervention need to be known.
At the start of the care episode the diagnosis is often uncertain. Yet in the interim, care with appropriate objectives is offered to the patient. As the disease and the care progresses, the diagnosis and prognosis becomes more certain, more definitive treatment is given and the objectives can be stated more clearly.

There are four main categories of treatment goals depending on the potential for altering the progress of the disease (the prognosis) i.e. :

  1. Cure of the disease
  2. Containment (by 2O or 3O Prevention), Support and Relief
  3. Palliation of symptoms and of disturbed function
  4. Provision of comfort

The objectives of care influence the way it is planned. For a given illness, not all of the objectives mentioned can be achieved or are necessary. While many diseases are eminently curable, some can only be contained or their harmful effects reduced/mitigated/delayed. When there is potential for cure or complete resolution of the disease process, the plan is directed towards achieving it. In such illnesses achievement of the objectives is the marker for ending the care episode.
Yet, others are inherently incurable or are too far advanced. However, when there is no possibility for cure, the plan offers other beneficial therapeutic options aimed at restoring functions, symptom relief and providing comfort. Achievement of the objectives mark the point when the care is considered to have been optimized.
Therefore, goals mentioned above can be achieved using the strategies that may contain all or some of the following types of therapeutic (treatment) approaches or modalities i.e.:

  1. Definitive
  2. Symptomatic
  3. Supportive
  4. Preventive
  5. Rehabilitative
  6. Promotive

Depending on the potential for altering the progress of the disease, the main treatment strategies or actions to be taken will include:

  1. Remove or lessen effects of illness (relief symptoms, provide comfort)
  2. Maintain, restore, or improve health status and physiological function (provide support)
  3. Avoid or minimize complications of treatment
  4. Induce remission
  5. Prevent deterioration or recurrence
  6. Cure the disease (if possible)

Each mode of therapy needs to be planned so that the the outcome has the following quality features:

  1. Effectiveness
  2. Safety (including avoidance of unwanted effects)
  3. Appropriateness
  4. Efficiency (especially timeliness)
  5. Sustainability
  6. Acceptability
  7. Cost-effectiveness

Therefore, setting objectives includes specifying standards of the final and also the intermediate outcomes of care based on the desired quality features. Adhering to SOP/Care Plan ensures that materials, methods and the resulting outcome are consistent. By considering patients as clients, due attention is also given to the restoration or amelioration of the disrupted quality of life (ability to work, enjoy leisure, attend school and perform daily life activities) as the objectives of care.

Different treatment modalities pose different requirements. Plans need to take into consideration:

  1. the conditions required to ensure its success
  2. the prevention of adverse effects
  3. the steps to be taken when complications occur

DESIGN BASED ON CLINICAL WORK PROCESSES

Work and Tasks

Work is the expenditure of energy to produce a useful outcome. It is made up of a series of procedures/tasks performed by workers. Similarly clinical care is a service made up of tasks. In industries other than healthcare, it is more common to use the word procedure instead of tasks.

Policies and Procedures

The greater part of the SOP/Care Plan addresses policies and procedures. Hence, the development of effective SOP/Care Plans requires a thorough understanding of the clinical work processes and the design is fashioned according to the sequence and conduct of it.

Policies

Policies provide the limits or constraints whithin which procedures/tasks are performed. Policies are based on legal, professional and ethical considerations as well as rules dictated by the facility/organization where the service is provided.

Procedures

Use of the Term Tasks for Procedures

In healthcare, the word procedure is often used differently to mean some intervention done directly on the patient like a surgical operation, endoscopy, taking blood and so on. In this discussion, the term procedure is taken to mean, just as in other industries, a group of processes performed together to produce a certain output or outcome. To avoid ambiguity, the term task is taken to be equivalent to this meaning of procedure and is preferred in this discussion.

Performance of Tasks

In patient care, tasks are performed by workers delivering services who are called care providers. A service is made up of a series of planned tasks and their delivery. The instructions to perform tasks are called orders. Work can be done in many ways including:

  1. manually by the care provider or a team of care providers
  2. by the care provider with the help of machines.
  3. by a machine based on instructions given by a worker and under his/her supervision
  4. entirely (automatically) by a machine prompted by instructions built in computer applications

As part of the service, items such as drugs, blood products, fluid and nourishment are given or supplied to patients. These tasks must be done in an accepted way. They are often called dispensing or administration.

Processes

Tasks are made up of processes. In caring for a patient, healthcare professionals act as a team. They are dependent on the contributions provided by each another.

Relationship between Input, Processes and Output

A task can be performed only by a worker with the skill and knowledge to perform it. Even then, he/she must do so using the right input and within a suitable environment. Input includes raw material, instruments, assistance and information. In fact, the ability to proceed from one task to the next depends on whether the results of the transformation made by the previous task is immediately available and sufficient. If so, he/she may continue to the next task without pause. Therefore, an essential input is data (results) generated by the previous task.
The environment suitable for a task takes into consideration the adequacy of space, cleanliness, air quality, safety, lighting, noise level, presence of essential equipment and proximity to other facilities.

Transformation of Input by Processes into Output

Description of Tasks in the SOP/Care Plans

Universally in modern healthcare practice, clinical care providers, including doctors, nurses, allied health personnel and other professionals, follow a commonly agreed way of delivering care.

Types of Tasks in Patient Care

Tasks occur in sequential segments termed as phases. The phases of care of both acute and also chronic diseases are categorized into phases for the purposes of:

  1. establishing diagnosis, stabilization and immediate care
  2. initiation and optimization of care
  3. maintenance of care, re-evaluation and modification
  4. discontinuation of care in the event of resolution of illness

Tasks are performed in many ways, using various input. Many are technical i.e. performed manually or with the help of machines. Some take the form thinking (cognitive) processes but most are a mix of both types of processes.

To implement the SOP/Care plan, it is essential that the list of tasks (task lists) are grouped into functional categories i.e.:

  1. Administrative tasks (Admission, Referrals, Transfer and Discharge, visit registration, follow up appointment, referral and discontinuation of visits),
  2. Generation, gathering and collection of data about the patient’s illness and the effect on his/her health through interview, examination, observation, measurement, tests and investigations by various techniques,
  3. Documentation of data regarding tasks done and their results plus reporting incidents that happen and the actions taken (using specific forms and charts).
  4. Analysis and interpretation of data to determine the diagnosis, status, profile and needs of patients,
  5. Planning the case management including response to anticipated side effects,
  6. Therapeutic tasks (treatment, providing support, rehabilitation, preventive actions, damage control) using various modalities.

Because functions are performed by persons with the ability to perform them, tasks are allocated according to professional groups or teams as task lists.

Workflow

Workflow is the predicted or planned sequence and direction and layout of what, when and how work processes are to be done. Usually, the workflow advances in stages as and when all tasks planned for a stage are completed and the objectives are met.
Workflow is the practical way work is done based on algorithms which refers to the flow of thought. Clinical pathway is another term for workflow and when it is used in patient-care activities. The two terms has been used interchangeably. If the term care pathway is to be used at all it should be synonymous with workflow as used in SOPs of other industries. The use of it to mean care plans is incorrect.

In the SOP/Care Plan, the path/flow/sequence/layout of clinical processes is presented in two ways i.e.:

  1. written as a narrative,
  2. depicted graphically as a chart

Description of the Flow Of The Clinical Process

The workflow is first expressed in narrative form. It describes the arrangement of the tasks for the delivery of a service in terms of content, layout, sequence and direction. The operational policies are embedded within it.

A general outline of the workflow is often called the high level workflow or ‘critical’ pathway. It contains only the critical (important, required) steps) with the obvious or mundane steps left out in the documentation (but not in practice). When the processes are complex it is beneficial for better understanding to demonstrate the flow initially in the form of an outline and details are elaborated subsequently. The outline of the generic flow of clinical care is as shown below:

Outline of the Sequence of Work Process

This general workflow is applicable to most cases. However the sequence of the processes does not necessarily follow this strictly but will depend very much on the type, severity, urgency, speed of progress and effects of the illness. In an urgent case, emergency treatment is given first before a full interview, examination and tests are done. Some cases may have obvious diagnosis based on routine tests or chance findings from investigations already done during other instances of care. As such, it would not be necessary to repeat the diagnostic investigations. For some types of cases, it may be more practical to perform certain processes first as a routine for example performing urine tests at a antenatal visit or visual acuity measurements for every case with a problem of vision.

In some instances the following scenarios that affect workflow can occur:

  1. results of tasks are available or become evident only after an interval,
  2. the next transformation must be performed performed by another worker.

For the first scenario, the care provider has to stop, wait for the results and resume his/her work when they are ready. For the second scenario he/she has to pass on the next task to another worker. He/she may resume his/her part of the work when the transformation has occurred or the results are ready.

The workflow has decision making steps i.e. points when care providers have to choose the appropriate path when alternative directions exist. The decision is guided by criteria such as:

  • policies,
  • judgement,
  • patient preference,
  • availability of resources.

Graphical Depiction of the Flow Of The Clinical Process

In the SOP/Care Plan, the understanding of the flow, sequence and layout of clinical processes is much enhanced if depicted graphically as a workflow chart. However, it must always be preceded or followed by a narrative description. The workflow that can be applied generically for patient care is as depicted below:

Clinical Care Workflow
(Click on image-to enlarge it)

Decision Making Steps an Essential Component of the Workflow

Decision making steps is an essential component of the workflow because its determine the direction of the steps of the care process.

In clinical care, the plan is very much dependent on diagnosis. After selecting a plan based on the initial diagnosis, the care provider may decide to alter or revise the plan based on the criteria listed below:

  1. Changes in the understanding of the illness affecting the patient (the certainty and comprehensiveness of the diagnosis )
  2. Evolution of the disease along its natural history,
  3. Advancement of the flow of clinical processes,
  4. Occurrence of other emerging issues (incidents, contingencies)

There are instances when the workflow cannot progress according to the initial plan due to various impediments or circumstances. At times, the processes e.g. information gathering, investigations or tasks have to be repeated or abandoned. In those cases or if the prescribed treatment plan is ineffective, unacceptable or unsafe for the patient, an alternative approach or modality is used. Non-compliance by care providers or patients is also a factor that affects the progress of the workflow as well as the success in achieving the desired outcome.

Decision-Making and the Resultant Change in Plan

Decisions are made when there are choices or options to be selected. In clinical care, decisions are made based on conclusions arrived after appraising the situation based on accumulated information. The conclusion may be determined by appraisal of:

  1. the updated working diagnosis
  2. the latest understanding of the disease/problem,
  3. the evolving objectives of care,
  4. the progress of the disease,
  5. the response to treatment.

The choices or options that a care provider can make are:

  1. to retain the current plan without alteration,
  2. to make modifications to the current plan,
  3. to change the plan completely to a new plan.

Changing To an Alternative Reference Care Plan In Response To Variations, Options and Contingencies

At the start of care (usually at the first session) the primary provider chooses a care plan that matches the diagnosis. At subsequent sessions the same plan may be used if appropriate. There may be a need to follow a sub-set of the plan depending on variations in the pathological grade of the disease, the stage of the disease, the level of severity or the emergence of complications.
Indeed, a Reference Care Plan for a different disease must be chosen in response to a marked change in the diagnosis.

Plans are also modified or revised if various other emerging needs appear. If formally designed plans are not available, then the care provider needs to devise the actual plans him/herself without referring to a Reference plan. Hence, it is better to design and put together a comprehensive library of Reference Care Plans to cater for various scenarios in the care of a patient for each disease, illness or health problem. The primary provider selects the appropriate plan from a library of SOP/Care Plans made available to him/her.

DIVIDING CLINICAL PATIENT CARE INTO SEQUENTIAL SEGMENTS OF ACTIVITIES

In any manufacturing industry, producing the output is achieved through many separate activities, that usually include processing of the raw material, fabrication of parts, assembly, testing and distribution. The activities are usually performed in a logical sequence. For some of the activities, the processes must be strictly continuous e.g. in an assembly line, but in others there can be intervals in between and done at different facilities.

The Care Episode

The entire period during which care is delivered is termed as the Care episode, It mirrors the disease episode. It begins at the time of first contact with a health care practitioner and ends, in most cases, with the resolution of the illness/problem or death of the patient. More than just thinking of it as a period of time it is necessary to view the care episode from separate angles:

  1. the service product
  2. the scope of a particular SOP/Care Plan

Besides what is delivered to the patient, what he/she experiences during the care episode is also the service product. How the service is delivered is described by the SOP/Care Plan designed for it.

Conceptual Division of Care into Phases

In the delivery of patient care work is divided into into sequential stages better termed as ‘phases’. A phase is a portion of the care episode within which certain sets of activities directed towards achieving one or more objectives are carried out. The final outcome of the care episode is achieved through the fulfillment of objectives of each phase achieved through the performance of a complex set of tasks. In the SOP/Care plan document, this complexity can be clarified by dividing the description of care into different sections and paragraphs differentiated by headings.

Iterative Nature of the Workflow

The scope of work and the degree of difficulty in carrying them out varies significantly for different phases and so does the duration. However, even though the objectives of care for each phase are different, the types of activities to achieve them are almost similar. During the care episode and even at every phase of care, the steps of interview, examination, tests, diagnosis, plan and evaluation often forms a cycle that is repeated. This is necessary because clinical patient care mirrors the steps of data management which is made up of:

  • gathering data,
  • putting them together,
  • analyzing them,
  • interpreting them,
  • deriving conclusions based on them, and
  • acting on those conclusions.

Actions will generate more data, the management of which will undergo similar steps. Results of analysis, interpretation, conclusions and actions becomes new data.
Furthermore within the phase itself, some work may have to be repeated until satisfactory outcomes or results are obtained. Repetition is required in circumstances when:

  1. the work is effective only if it is repeated intentionally for a certain number of times
  2. failure to obtained satisfactory result by a single instance
  3. the work has not been carried out properly
  4. the patient’s condition changes as the disease progresses naturally or because of treatment. Repetition of monitoring of parameters, tests, progress review and measurement of outcome will provide data that will show the trend,

The repetition of the clinical care processes makes the work cyclical. Each cycle is termed as an iteration and clinical care is said to be iterative in nature.

Iterative Nature of Clinical Processes

In the Actual plan, if the work needs to be repeated as the care proceeds, without any change in plan, then it is sufficient to document the decision as “repeat as planned” or “continue monitoring” or “continue medication as prescribed”. However, since tasks are performed based on instructions or orders, new ones have to be made if the valid duration of the initial order has lapsed.

Activities within a Phase

Within a phase, the ability to perform each task is dependent on the outcome of the previous task. Therefore as a rule, it is important to perform the set of tasks in sequence.
However, this sequence may not be strictly followed because there are times when:

  • an opportunity to perform the task may not occur again,
  • it is more convenient to perform an activity earlier or later,
  • one activity may be given priority over another because of certain needs.

When designing the SOP/Care Plan, it is necessary to think out and list down the whole series of tasks within the care episode. It may be appropriate to depict them as a single list of tasks in the Reference Plan but as will be discussed later, in the Actual Plan the tasks have to be divided into sets or blocks of tasks so that they can be allocated time slots and assigned to particular care providers. Unlike in manufacturing industries, at the time of designing the Reference SOP/Care Plan, the separation into discrete blocks is not possible because of the the following reasons:

  1. in patient care, an activity need not be carried out at the same location or facility,
  2. alternative equipment may be used to perform certain tasks,
  3. the ability to perform a task is not necessarily confined to a particular care provider category,
  4. often there is a need to repeat the tasks before the desired outcome is achieved, The frequency of this repetition is not predictable.
  5. clinical tasks of data gathering, diagnose, plan, treat, monitor and reevaluate take a variable amount of time to complete.
  6. the advancement of the care process is related to how the disease progresses which is not always the same,
  7. the response to treatment is not uniformly predictable.

Therefore, based on the concept of phases of care clinical care activities in the Reference SOP/Care Plan are divided into varying segments.

Documenting the Reference SOP/Care Plan into Segments Corresponding to Phases of Care

As discussed earlier the SOP/Care Plan is designed to cover the entire episode of care. The primary division of the care episode is into sequential phases of the clinical care process with each phase aimed at achieving defined purposes or objectives. A phase starts with the setting up of one or more objectives and ends when all the objectives have been met. This occurs when all the tasks designed to achieve it are performed. Completing all the segments will then result in the final outcome.

For simplicity, the phases can be divided and sequenced into early, intermediate and later parts. The distinction between phases is in their main objectives. Actions taken at the earliest phase is often concerned with establishing the diagnosis, stabilization of physiological functions and immediate care. In the next phase, attention is given to starting the definitive care and optimizing its outcome. This is followed by efforts at continuation or maintenance of treatment, monitoring and reassessment. Subsequent actions depend on whether the illness resolves such that care can be terminated or remain unresolved hence requiring continued care.

Indeed, phases can be divided in different ways depending on the type of service. They can be given different names but the following division is typical:

  1. Phase of determining the diagnosis
  2. Phase of immediate care / early treatment
  3. Phase of initiation of definitive care
  4. Phase of optimization of care
  5. Phase of maintenance of care
  6. Phase of resolution (continuation or discontinuation of care)

How the clinical care processes are segmented into phases is depicted below:

Grouping Tasks within the Care Episode into Phases

Proceeding from one phase to the next depends on whether the objectives of the former have been achieved. In an emergency case, the initial phases are compressed such that tasks within them such as resuscitation and stabilization are accomplished within a short period. In non-urgent cases the phases are stretched over a longer period.

How the care episode is divided into phases is depicted below:

Division of the Care Episode into Phases

Documenting the Reference SOP/Care Plan into Segments Corresponding to Phase of Care

Each of the categories (acute or chronic) has further sub-types based on severity, grading, stage at presentation, and response to treatment. The differences of their care is mainly in the mode of treatment and intensity of monitoring. As such this variation in care of the disease sub-types is written in the document as alternative segments designated by sections and paragraphs (with headings) as shown below:

As stated earlier, main segments relate to ‘phases’. In the Reference SOP/Care Plan document, phase can be presented as distinct sections and paragraphs with appropriate headings. Each segment is divided further into groups of tasks as will be discussed later.

Content of Each Segment of the SOP/Care Plan

Since moving on from one phase to the next depends on whether all tasks has been performed and the objectives have been met, the content of each phase need to be determined with this consideration in mind. There may be occasions when tasks of one phase is carried over to the next. Some tasks like monitoring persists through out the phases. Adoption of the division into phases is critical in determining the structure and content of the SOP/Care plan.

Phase of Determining the Diagnosis and Early Treatment

This is the phase of initial contact with a health care provider. It is in two parts with both running concurrently.
The disease process itself may be at an early or later stage of its natural history, depending on whether the patient seeks treatment early or late. Early treatment is given based on the working diagnosis even as efforts at determining diagnosis are being made.

Formulation of Diagnosis

The main objective of this phase is to determine the diagnosis as accurately and comprehensively as possible. For a new case where the diagnosis is not known, steps are taken to identify it. This process can be termed as the formulation of the diagnosis. Hence, the initial steps in this phase are:

  • clinical data gathering (interview and examination)
  • performing simple tests
  • initiation of observations and monitoring
  • determining the provisional diagnosis

At the beginning a clinician takes charge of the case and is said to be the primary provider. Usually this person is the doctor to whom the case is assigned. However, depending on the scope of care, he/she can be nurse or therapist or clinical psychologist. The primary provider is responsible for formulating the diagnosis. The data available may allow the clinician to determine the Provisional diagnosis.
At this point the Provisional diagnosis is the Working diagnosis i.e. one that determines the care plan.

Process of Determining the Definitive Diagnosis

The provisional diagnosis will provide a guide to the next step which consists of:

  • taking a more elaborate history
  • finding out more about specific symptoms
  • closer examination of regions or organs involved
  • performing more specific and elaborate diagnostic investigations
  • analysis and interpretation of all data available to formulate the definitive diagnosis

The clinician in charge uses the data from tests, observation and the monitoring to arrive at the definite diagnosis. The diagnosis need to be further refined to clarify the variant of disease, severity grade, stage of illness, risk stratification and prognosis. Investigations are aimed at determining the patient’s general physiological status and functions of various systems besides aiming initially to determine the system or site involved or the likely pathology but in the end to determine the definitive diagnosis. Providers of clinical support services become involved when diagnostic investigations are ordered.

The definite diagnosis is one that is both specific and certain. Often, the effort to determine it takes time. This phase may be completed over a few sessions with intervals between the sessions. This is necessary because the results of pertinent tests and observations are not immediately available but are obtained at different times and have to be accumulated. analyzed and interpreted before the conclusion is made regarding the diagnosis. Depending on results additional tests may have to be done.

However, every effort must be made to obtain a definitive diagnosis becuase it indicates the cause of the disease or at least the pathological processes that are affecting the patient. This information is necessary before the plan for specific treatment can be made. In fact this phase ends only when a reliable working diagnosis is arrived at.

Immediate Care and Early Treatment

Therapy must not wait for want of an accurate diagnosis. Immediate care and early treatment is based on the Working diagnosis which at this point of care is more likely to be:

  • a symptom complex
  • a clinical syndrome
  • a disease identified to belong to a diagnostic related group

The care provider has to obtain guidance from th SOP/Care plans prepared for these diagnoses. Occasionally, the specific diagnosis is obvious from the start.

Generally in both acute and chronic illness, efforts at the immediate phase are directed towards;

  1. nursing care
  2. immediate and continued relief of symptoms
  3. monitoring of relevant parameters
  4. maintaining normal physiology through resuscitation and stabilization
  5. providing nutrition or at least fluids and electrolytes,
  6. giving support (physiological, psychological, social and spiritual)
  7. taking preventive actions
  8. prevention and reducing emergence of disability
  9. treatment of ongoing problem as they arise

The difference in approach between acute and chronic illness is a matter of intensity and priority. In an acute illness resuscitation, stabilization of physiological parameters and support of their functions must be done quickly., In a chronic illness these can be done in a more measured manner.

Phase For Initiation Of Definitive Care

This phase is a direct continuation of the previous phase. Only when the diagnois is definite can the direction of care be set clearly. The care provider chooses the care plan is designed for the specific disease, illness or health problem.. As such, the guidance given in the SOP/Care Plan can be more certain, and specific. It will take a more didactic tone and be more regimented. From this point the care for the rest of episode may be planned, initiated, optimized and maintained clearly.

The definite diagnosis allows the care provider needs to clarify the objectives of care (expected outcome, therapeutic end points). A more definite SOP/Care Plan appropriate to the diagnosis is then chosen and customized. Even so, furtger efforts are made to refine the diagnosis further to clarify the variant of disease, severity grade, stage of illness, risk and expected or desired outcome. In this way more relevant plans can be chosen and implemented as care progresses.

Even when the diagnosis is certain, unexpected developments, eventualities and contingencies can occur. The workflow may take variable paths consequent to decisions made. Because of that, the plan for the latter stages can only be anticipated.

Even though the condition of the patient may have been stabilized, tasks like nursing care, symptom relief, monitoring, support and others initiated earlier must be continued. At the outset, regular observation and monitoring are initiated.

Setting the Objectives of Care

Treatment end points need to be defined and measurements made to determine whether these end-points have been achieved. Depending on the disease, the objective of treatment would be the combination of any of the following:

  1. cure the illness,
  2. contain it or control the progress
  3. mitigate the effects

An appropriate definitive management plan influenced by the care objectives is adopted and implemented. As such, the care provider defines the treatment end points, chooses the plan offering the most suitable treatment approaches or modalities. In this phase and in later phases. measurements are made to determine whether these end-points have been achieved. The progress of the patient is reviewed regularly to detect deterioration or improvement and occurrence of complications of illness or treatment.
Depending on the illness, this phase may spread over a considerable period. In the case of an acute illness, efforts shoukd be made to complete this phase at the initial visit but it may be necessary to have the patient discharged from in-patient care and to complete it in the outpatient setting. For less acute cases this phase may be carried out over a few outpatient visits.

In this phase almost all care providers are involved directly or indirectly in the care and would have their own share of tasks which are listed in their Task lists. These tasks include:

  • review of data
  • ascertain diagnosis
  • choose and execute appropriate plan
  • start definitive treatment
  • initiate rehabilitation
  • provide education and counseling

The tasks involved and their sequence is as shown below:

Phase Of Optimization Of Care

The main aim of this phase is to optimize the benefit of care given. The care provider need to be constantly aware of the desired treatment end points make diligent efforts to achieve them.

Progress is assesed through:

  • review of symptoms and signs,
  • observations,
  • monitoring,
  • repeated investigations

Assessment should address both the progress of the disease and effect of treatment. The outcome of the efforts made will reveal the behaviour of the idisease and improvement or otherwise of the health of the patient. Conformance of the care providers to the plan must be assured through quality control measures. Conformance of patints to instructions must also be assesed and enforced. Optimization is considered achieved when the care regimen produces the best possible level of benefit. To this end, the care provider need to make adjustments and modifications to the care plan.

The phase may extend beyond one session. If the the patient is at first managed as an inpatient he/she may be discharged and the care continues in the outpatient setting. The progress of acute illness is often dramatic and easily discernible. The progress of chronic diseases vary in many ways including:

  1. slower speed of deterioration or improvement
  2. active vs inactive periods (remission, reactivation)
  3. emergence of complications of the disease

Measurement of outcome and comparison with planned targets is an integral activity of care at this stage. Scoring systems and check lists can be used. If the progress is satisfactory, the plan is continued with further improvement if necessary. However, if it appears to be ineffective minor or major modifications must be made. If there is douby regarding the diagnosis further investigations must be done, If the diagnosis is different, a new care plan need to be initiated and optimized.
Optimization is considered achieved when the care regimen produces the best possible level of benefit. The plan is then continued.

Phase of Optimization of Care

Phase of Maintenance of Care

Moving from initiation and stabilization of definitive care to the maintenance phase depends very much on the effectiveness of the care given or improvement in the disease condition. Otherwise, the care persists in that phase. At some point, the care provider has to decide whether the patient requires further care (follow up visits) based on the resolution of the illness or the achievement of the optimal outcome. There is no advantage in putting the patient on regular follow up when it is unnecessary. However, access to the service can still be offered on a needs (prn) basis. It must be noted that a phase may need more than one visit to complete.

The plan of care that led to the optimal level of outcome must be maintained. Depending on the illness, this phase may extend over a considerable period. Usually it is conveniently carried out at outpatient settings (clinics, day, care, home care, teleconsultation. self care).

The care provider is expected to follow the established care regimen as closely as is possible. At the same time, an important aspect of the plan is the continued evaluation of response to and effects of therapy. The following factors are assessed:

  1. conformance to the plan by care providers
  2. patient compliance
  3. detrimental effects of therapy

The progress of the patient is reviewed regularly to detect deterioration or improvement and the occurrence of complications of illness or treatment. An important aspect of this pahse is determining the approprite intervals between reviews.
The effectiveness of the care given may not be maintained for reasons of:

  • poor compliance
  • change in the disease
  • change in the patient’s general health

The care provider may have to revise the SOP/Care Plan and modify the treatment accordingly. Also, he/she should consider reviewing the diagnosis especially in terms of the severity and grading which would then require modification of the objectives and the plan. It is also possible that failure to achieve favourable outcome, even at this stage, may be due to a wrong diagnosis.

For illnesses that has been brought under control, the care provider must be on the look out for recurrence.

Phase of Maintenance of Care

Phase Of Resolution (Continuation Or Discontinuation Of Care)

It is essential that the care provider ensure the continuity of care. There may be opportunities to reduce attendance at the health care facility, One way is to continue care via home care or teleconsultation. The primary provider may delegate the responsibility to care providers at other facilities for the convenience of the patient. The primary care doctor, family doctor or school/factory nurse and voluntary bodies are the most appropriate care providers to take on this responsibility. With regards disability or handicaps, therapists, counselors, optometrists, audiologists or social workers may be more appropriate. Indeed for most cases care is not really discontinued but continued by self-care. Therefore, at discharge patients must be given adequate education on how they can maintain their health. They should be encouraged to come back to the facility or seek the help of any other health care professionals if they are unwell or their health deteriorates.

Depending on the nature of the illness and the response to care, the service may reach a stage where it can be discontinued. This is so with cuarable diseases.

Chronic illnesses are characterized usually by continuous progression or persistence. The duration of care is therefore long term and usually extend throughout the life of the individual. Some diseases may resolve, go into remission and be dormant only to appear again later. Temporary cessation of therapy with planned follow up reviews at longer intervals (quarterly, half yearly, or yearly) may be necessary.
Some diseases may not require care at health care facilities but sufficiently managed by self care. Rarely some chronic diseases runs through its course and dissipates. The care can then be phased out.

If the illness appears to have resolved, discontinuation may be made abruptly or phased out gradually. The plan conveys the manner in which care is to be stopped including how medication or other treatment is to be tapered off and what evaluation criteria need to be met to declare it safe for the care to be terminated.

For illnesses that has been brought under control the care provider must be on the look out for recurrence.

On the other hand, a acute illness/health problem that has dissipated may be a manifestation of an underlying chronic disease justifying further observations, monitoring and investigations. The acute illness may also give rise to permanent or semi-permanent disability, deficiency handicaps or inconvenience. In all these instances, long term care will then be planned and provided.

The circumstances that allow care to advance to the next phase often become evident when actual care is given and the care provider has reviewed whether all efforts planned has been performed and after the outcome of tasks are known. Hence it will be dicussed in the discussion on the Actual Plan.

Documenting Phases as Segments of the Reference SOP/Care Plan

The Reference plan document should be divided into segments consistent with phases with each segment indicating the sets of tasks to be performed. The care provider must be aware of the phase of care that he/she is currently in. If the plan is on paper, each segment need to be marked out clearly as paragraphs with clear headings. In a computerized system, it is possible for the relevant segment to be called for (via a menu) or be automatically presented to the care provider at the appropriate time.

How the structure and content of the SOP/Care Plan is segmented in accordance with phases is shown below:

Content of Various Phases of Care

The decision to progress from one phase to the next is a decision-making process requiring much thought, In a computerizes system moving on can be on the fulfilment of set criteria for based on data regarding progress and outcome. Even then the decision remains the responsibility of the care provider. Completion of a phase may require a variable number of sessions and hence cannot be scheduled in advance.

B. PRACTICAL APPLICATION

As discussed above, the entire care processes within the care episode are divided into segments consistent with phases, This division is conceptual. They are not practical for the purpose of dividing the episode into tangible service entities because phases:

  1. have variable content,
  2. take variable duration to complete,
  3. have no fixed start and end time,
  4. not necessarily completed at a fixed location,
  5. not necessarily allocated to a specific person or team/department/unit.

The Business Model for Patient Care Services

Although the clinical care processes described earlier are conceptual rather than practical, they form the rationale and backdrop for the establishment of a business model for the delivery of patient care. The business model must expanded to include responses catering to the patient’s primary needs as well as the secondary and tertiary needs. Besides emphasizing effectiveness and safety as the main goal, efforts must also be directed towards ensuring accessibility, efficiency, responsiveness, acceptability and cost-effectiveness. Patient care must be organized as a business with the patient considered as a client.

To provide care in a practical way, it must be given as a package consisting of a defined set of service items at defined locations and time periods. Unlike in other industries the items in the package are variable rather than fixed.

DIVIDING CLINICAL PATIENT CARE INTO BLOCKS OF ACTIVITIES

In any manufacturing industry, producing the output is achieved through many separate activities. that usually include processing of the raw material, fabrication of parts, assembly, testing and distribution. The activities are usually in sequence but parts may be built separately before being assembled. For some of the activities, the processes are strictly continuous e.g. in an assembly line, but in others these can performed with intervals in between and done at different facilities.
Services in healthcare are delivered in a similar way. The entire Care Episode is considered as as a package of services. They are offered as sessions consisting of sets or blocks of tasks.

The order by which set of steps are performed or the workflow, from the perspective of both care providers and patients, is very much like those taken by a group of travelers on a journey.

A Typical Journey

A traveler sets own on the journey towards a general destination to discover something. Along the way he or she is joined by other travelers forming a group. They allocate different roles to each traveler.
As they move along they become more sure about their destination and decide where exactly they want to go, Along the way they stop at various stations for various purposes like visiting friends, places of interest, buying things and so on. The journey between stations are of different distances and take different times. They may take a break at the station or press on when the purpose of their stay is achieved. At each station, they then decide what mode of transport to use for the next part of the journey depending on the terrain or the availability (walk, take a taxi, bus, train or ferry) based on maps, time-tables and travel guides. They may decide to take a different route from the usual trail.
Between stations they may cross state or territorial boundaries.
At some point one or more members may leave the group. and new ones join in. They keep a log of their experience. They may at the end reach their destination or somewhere near it. They may decide to stop there but may feel that they must wander on.

The Clinician’s Journey

Similarly, the steps made by a clinician in caring for a patient may be considered as a journey.
A clinician is unlikely to look after only one patient. On any day, he/she will attend to number of patients with different problems. It is beneficial to picture the journey of a clinician in caring for a particular patient in a specific service delivery setting. His or her journey is towards an optimum outcome and he or she often travels in a group.
The path taken by a clinician working in a hospital is different from one working only in an outpatient setting. A hospital doctor may look after patients at inpatient wards, the ICU and the emergency unit besides the clinic. His daily journey is different from that of a doctor working only at an outpatient clinic, Nurses, on the other hand, mostly work at fixed nursing stations.

As an example, the role of SOP/Care plans can be understood, by following the journey of a doctor and the nurse accompanying him/her in an outpatient setting. In the traditional paper based system, the patients would have been registered for the visit, their medical records traced or created and each one is given a queue number. If a Clinical information system is used, a patient list and their queue numbers are created.

The nurse will make a preliminary assessment of the patient . He/she will establish the reason for visit.
On arrival at the clinic, the doctor will call for a patient in turn, The first thing he/she wants to know is the stage of the workflow that the patient is at i.e. what has been done before and what he/she is supposed to do next. He/she is guided by the reason for visit. If it is a follow up case, he reads the previous notes in the medical record and see whether a plan has been suggested,
If the patient is a new case, the doctor identifies the main complaints and gathers data guided by them for visit. He will arrive at a provisional diagnosis and plan more data gathering tasks including investigations. He may start immediate treatment if necessary. Because he/she has to wait for the results of the investigations and the progrees of the disease, he/she ends the consultation and plans for another visit at another date.

At the subsequent visit, he will review the results of the investigation and hopefully will be able to make a more definite diagnosis. He will then plot a more definite care plan. The plan may call for multiple visits to be arranged to optimize care, stabilize the patient’s condition and maintain the care until final resolution is achieved.

During a clinic session the doctor sees patients in his care by turn. For each patient he or she performs tasks required for the type of illness and the stage of the care process. Tasks may include the performance of clinical procedures. He documents what he/she has done and his/her findings in the medical record and plan what is to be done at the following visit.
Patients will make any number of visits required to resolve their problems. The same doctor or another doctor performing the same function will attend to the patients.

The clinician’s journey at an inpatient setting is similar except that the visit is for a longer duration. Instead of calling for the patient in turn, the doctor moves from bed to bed (popularly termed as ‘making a round’. Between his/her consultations, the patient remains in hospital to be attended by other care givers or to rest. If the doctor considers that care can or is better be given at an ambulatory setting (outpatient or daycare) he will discharge the patient and plan for care to be given at that setting.
The scenario described is one of the many scenarios that typifies a clinician’s journey.

The Patient’s Journey

For the most part, the patient’s journey mirrors that of that followed by patient care. The patient begins his/her journey by fulfilling a desire to obtain services at a healthcare facility. Once registered as a patient the choices he or she can make are restricted. Even though the mode of care is discussed with him or her and alternatives are offered, the alternatives are those that the care provider is willing or able to dispense. Otherwise she is likely to be asked to seek services elsewhere. From then on, the patient is obliged to comply with advice and instructions. The patient is of course at liberty to opt out. The journey can be arduous requiring physical, mental, psychological and spiritual resilience. Issues pertaining to access due to physical difficulties and affordability can arise. The destination may or may not be reached.

Structure and Organization of the Business Model

As in other service industries, to be effective patient care must be delivered for a defined purpose, at explicit times and locations i.e. as a service package made up of scheduled units of services. The entire package offered to a patient is is called the Care episode.

Care Episodes

From a business standpoint, a care episode is the entire service offered for an episode of a disease, illness or health problem. While the entire Reference SOP/Care plan for a disease (disease episode) can be designed as a contiguous whole, the same cannot be done for an Actual plan. Even though the content is the same, the actual care episode is made up of sessions that occur at definite time and place. It begins with the first session and ends when sessions are no longer required or voluntarily stopped by the patient. For acute illnesses, the care episode ends when the disease is resolved. For a chronic disease it is meant to be for a lifetime. Services are broken into feasible packages and delivered at facilities that have resources that match the requirements for delivering them.
The care episode distinguishes the service products offered and given to the patient. A person may have a few care episodes running concurrently such that a session may contain elements of more than one care episode. Care is then delivered based on different plans amalgamated into one. This concept is important if funding for different problems comes from different sources.

SESSIONS

The Reference SOP/Care Plan presents to the care provider on the theoretical content and sequence of care as consisting of phases, In a business model, activities need to be performed at designated time slots and locations. The designation ‘session’ is used in this context as a generic term to mean all instances of service delivery within a care episode. While in the Reference SOP/Care Pan the phases of care is divided into segments, in the Actual SOP/Care Plan each phase need to be operationalized into sessions with intervals in between.

  • Care Episode
    • Sessions

Sessions allow work to be scheduled because they have the following characteristics i.e.:

  1. defined purpose (why)
  2. defined content (what)
  3. performed at an allocated time (when)
  4. has an anticipated duration (for how long)
  5. performed at a known location, facility or setting equipped with appropriate resources and a conducive environment (where)
  6. organized in a suitable way (how)
  7. assigned to a specific person or team/department/unit (by whom)

Most of these characteristics are absent in the concept of phases.

Further Division of Sessions

Organizing the care episode into definite sessions enables services to be scheduled i.e. partitioned into blocks of time and services.

Schedules and Queues

Services must be provided in an orderly and predictable manner. These are achieved by allocating sessions according to time, duration, place and person through scheduling. Services can be assigned then to time slots and enable the creation of work lists for various care providers. Patients are assured of access to care by giving them appointments. Sessions are scheduled. Turns to receive service items are allotted using a queue system. These ae done at every level of the hierarchy of sessions.
Converting phases into sessions assures the patient that he/she will receive care in a predictable manner. However, healthcare is not as predictable as in industrial services. The time taken to complete various sessions are not very certain because it depends on many variables. The progress of the workflow for a particular patient varies depending on how his/her disease, illness or health problem behaves. The start and end time of a session depend on the duration taken for:

  • the patient’s previous session,
  • the session of the the previous patient.

Hence, times and periods allocated to sessions cannot be fixed but simply estimated. This uncertainty is mitigated somewhat by the use of queue systems.

VISITS

The care episode is divided into a hierarchy of sessions made up of all instances when patients seek the services from a healthcare facility.

From the perspective of the SOP/Care Plans, even though plans are made on the basis of phases, their actual implementation happens at sessions where there is interaction between the patient and the service delivery facility.

First of all, the care episode is broken down into service-delivery sessions called visits with intervals in between. The visit itself is divided further into smaller time periods and service packages. The top most level of the hierarchy is as shown below:

  • Care episode
    • Sessions
      • Visit 1
      • Visit 2
      • Visit n
      • Last visit
  • Care episode 2

Definition of a Visit

A visit is an instance when the patient comes to the health care facility to receive care. In most instances he/she has to be physically present. The visit is a session that occurs at a specified location and is bounded by time. It contains a set of services. It is formalized by the process of registration and ends with that of discharge. However, the term visit is also applied to instances when the patient is visited by the care provider (as in home care) and also when the interaction is virtual rather than physical e.g. in teleconsultation.

Purpose of Visits

Visits are the sessions during which the care providers executes the activities of the phases of care delineated in the reference SOP/Care plans. The care provider as to decide when a visit should happen and where in the actual SOP/Care plans. A visit is necessary for one of these purposes:

  1. Enrolling and providing services to a new case
  2. Continuation of care of a follow up case

At the beginning of a visit the care provider has to determine the purpose or reason for the visit. The care provider needs to decide the necessity of a visit and its timing. He is then faced with the question of what to do for the visit.
This depends very much on whether the visit is the first visit or a follow up visit. The foremost purpose of the first visit is to gather information for the purposes of making the diagnosis. The actions to be taken for subsequent phases of care are performed if the opportunity is available at that visit. Otherwise, those are pursued at future visits.

The activities to be performed at a follow up visit is significantly different from that for a new visit because information about the patient is already available, from the previous visit. The diagnosis may have been worked out and a plan has been initiated, In this way, at the beginning of a follow up visit, the attending care provider knows the purpose of the visit and the tasks to be done. However, he/she may have to modify it based on any new information.

The sequence and content of visits do not coincide necessarily with the anticipated change-over of one phase to the next. For each case type or sub-type, what can be accomplished during a visit is variable depending on many factors.
The number of visits required to complete a phase are anticipated through experience or derived from lessons learnt from historical data. There are diseases, illnesses and health problems for which the number and frequency of visits can be fixed as part of the Reference SOP/Care plan. However, in most cases these decisions have to be made at the discretion of the care provider in the Actual SOP/Care plan as care progresses.

The extent of each phase, is a variable period. It can span a duration of mere minutes or can span across many encounters and visits. Case managers or the primary provider set the frequency of visits based on the patient’s expected response. The number of visits per episode is by nature variable but may be intentionally fixed in a service delivered as a financial package.

Mode of Visits for New Cases

Patients may make visits in two ways:

  • Planned by prior appointment (scheduled)
  • Unplanned (walk in)

The visit formally begins when the patient is registered. For a new case he has to be enrolled first as a patient and then registered for the visit. A follow up case need only to be registered for the visit.

At the end of a visit, the care plan for the next visit must be made ready by thinking it out and documenting it in the follow up plan.

Planned Visits of New Cases

A planned visit for a new case merely means that the patient has made prior arrangement with the facility. For non-urgent patients (elective cases), visits are scheduled by creating appointment slots in time-tables of appointment books or a computerized scheduling application. On arrival, patients are given queue numbers and served in turn.

Planning Visits for a New Case

The visit of a new case is arranged through an appointment. The scheduling system can be used to:

  • allocate a time slot,
  • determine an appropriate service location (facility, specialty department or unit),
  • assign the case to a care provider.

On the patient’s arrival some information may be available from a referral letter, email, phone call or message from the previous care provider. The patient may volunteer his/her reason for visit. Based on the information available a rough plan can be initiated. Proper plans can be conceived only after some clinical data has been gathered and a preliminary diagnosis is made.

Sessions for the Early Phase of Care

Unplanned New Cases

Unplanned new cases are those where no prior arrangement is made. They are also called walk in cases. New cases with urgent problems can seek services at emergency units without prior appointment. Some facilities e.g. general practitioner clinics may offer services for elective cases for walk in patients.

Planning Visits for Follow up Cases

Follow up cases are those who had prior visit(s) at the facility for the same problem. Follow up visits can also be planned or unplanned.

For the majority of instances, visits are planned and scheduled as a part of the actual SOP/Care Plan at the previous visit. Follow up visits are used mainly for continuity of care and are decided mostly at the end of each visit.

Unplanned Follow-up Visits

Follow up cases requiring urgent attention may avail themselves to services as and when they require them (unplanned). Such patients are also termed as walk in cases. On arrival, they are listed into groups according to priority, placed on a queue and served according to their turns.

Frequency and Intervals of Follow up Visits

The interval between one visit or encounter to the next is dependent on two factors:

  1. the expected behavior of the disease according to its natural history
  2. the expected duration for the treatment or intervention to take effect

There are situations where the transition in the care plan is predictable such that a change-over of the plan can be initiated as and when the visit takes place. A good example is the care plan for the care of a patient with normal pregnancy or a patient undergoing Knee replacement surgery.

Legal and Operational Importance of Visits

There are legal implications applicable to both the patient as well as the care provider when a patient seeks care or is given care. It is assumed that the patient comes willingly and will abide by the rules set by the facility. Hence, for many processes it is assumed that tacit approval from the patient has been received. However for certain procedures, it is necessary for the patient to provide either verbal or written consent. The care provider as an organization and individually is obliged by law to exercise care when providing services. These obligations are often written and displayed as the Patient Charter.

The above reasons make it necessary for patients to be inducted into care through the formalized process of Registration and of Discharge.
It is also a legal requirement for care providers to keep a record of what transpires during the visit as the medical record. A compilation of records of individual visits make up the medical record of the patient. The obligation to exercise care and to record events (planned and unplanned) is applicable to all visits except for self-care where the onus is on the care provider to provide guidance and the patient to follow it.

Composition of the Medical Record

Location of Visits

Services by necessity must be delivered at specific locations. Each location is a service delivery unit with specific settings i.e. the facility design (layout) and the resources made available. Hence, visits can be divided into types based on location that include:

  1. Outpatient visit
  2. Emergency visit
  3. Inpatient visit
  4. Day Care visit
  5. Home Care visit
  6. Teleconsultation visit
  7. Self-care

Each visit must be matched with an appropriate setting. Hence, during the care episode, a case may be managed at some or all these visit types.

Suitability of the Care Delivery Setting for Various Visits

The type of service delivery setting for each visit must be planned. Only in some instances, the most appropriate service delivery setting for a particular visit can can be predicted and decided in advance in the reference SOP/Care Plan but for many the decision has to be made when formulating the Actual plan as the care progresses.
The difference in service delivery settings do not significantly change the clinical content of the SOP/Care Plans but affects mainly the administrative processes, workflow and use of resources. Certain resources available in an inpatient or day care setting may not be available at an outpatient clinic. Of course a decision can be made for an inpatient to receive the following care as an outpatient. Then, the patient will be at home during the interval.

The Emergency Setting

The Emergency setting is designed to provide care for cases requiring urgent attention, resuscitation and stabilization. It receives walk in patients and provides services on a 24 hour basis throughout the year. Patients are triaged and categorized based on urgency and severity. The layout, equipment and staffing is designed to cater for the needs of each category.

The Ambulatory Setting

When the progress of the disease is slow and the effects of treatment take time to manifest, the case is better managed as an outpatient.

An ambulatory visit is restricted to the maximum of one work day. There is a limit to the number of tasks that can be completed. This means that, blocks of processes have to be planned for each visit in a more discreet manner

For cases managed in the ambulatory setting (outpatient or daycare), the patient goes home and comes again for another visit to the facility. At a follow up visit the patient’s progress is reviewed and the decision to move through the phases is usually made then. Between visits, care providers will have to depend on patients to monitor their own symptoms, signs and physiological or biochemical parameters by performing simple tests.
In between the patient may avail himself/herself to teleconsultation, be given home care through home visits by care providers or manage on their own (self-care).
Day care is a setting that is a cross between inpatient and outpatient settings. It allows more complex investigation and treatment procedures to be done. The patient can also be observed for a longer period. It is suitable for care taking a duration of more than a few hours but less than a day.

The Inpatient Setting

In visits at an inpatient setting, the patient stays in the facility allowing the care provider the opportunity to review the plan for the case as often as daily or more frequently and decide on the readiness to advance through the phases. Also, certain resources are available only in the inpatient setting. Hence, it is suitable for the care of either acute illness or the initial care of chronic illness. The patient is managed within the same visit. He/she rests in between activities.

Differences In The Care Of Acute Vs Chronic Illness

In acute illness the disease progresses at a rapid pace. Hence, tasks are also performed rapidly at short intervals or continuously. This means that the appropriate service delivery setting for acute illness at the immediate phase is either the Emergency Unit or the Inpatient facility including the Intensive Care Unit and the Labour room. Efforts are directed towards symptom relief, resuscitation, stabilization and support (physiological, psychological, social and spiritual).

The care of a patient with chronic illness begins with the initial contact with a health care provider. The disease process itself may be at an early or later stage of the natural history of the disease, depending on whether the patient seeks treatment early or late. At the earlier phase, the main objective is to determine the diagnosis as accurately and comprehensively as possible.

The care of a patient with chronic illness can be carried out a slower pace. Chronic diseases are suitably managed as outpatients. The exception is at the start of care of certain diseases where a short stay in an inpatient setting is required for the purpose of stabilization. Care occurs at visits spaced at intervals. The appropriate interval between visits is determined by:

  1. the expected speed of progress of the illness,
  2. the time when of results of tests will be ready,
  3. how fast the effect of treatment will become apparent

The interval gives time for the care provider to obtain a diagnosis with a high degree of certainty and the choice of the most appropriate definitive care plan. Involvement of the patient in care of his/her own self at home is essential. For incapacitated patients, those looking after them (relative or friends ore hired help) will take that role. The same is true for parents in the care of their children.

When the diagnosis is certain, definitive treatment is initiated. Even so, this cannot be accomplished in one sitting. Unless it is the treatment of an emergency case, the effects of treatment will take time to manifest. So, treatment is followed by monitoring of the patient which includes checking on the progress of the illness as well as assessing of beneficial of treatment and the side effects. Rehabilitation would be added to the plan, in earnest. Progress review is done regularly to determine the effectiveness of the therapy. Failure due to non-compliance to the plan by care providers and patients need to be excluded. Once an optimal regime is established, it should be continued until desired outcomes are achieved.
If the success of the plan itself comes into question, the reliability of the diagnosis and the appropriateness in the choice of the plan or the way it is customized need to be reviewed.

Content and Duration of Visits

Visits whether planned or unplanned contain activities that are consistent with those present in phases of patient care discussed earlier i.e.:

  • administration,
  • data collection, review and collation,
  • monitoring,
  • formulation and updating the diagnosis,
  • treatment,
  • review and reassessment..

If possible these activities should be completed preferably in one visit. Otherwise it is carried over to the next visit(s).


For simple cases (e.g. removal of a foreign body in the nostril), the entire phases of care may be completed in one visit. For most cases follow up visits would be necessary.

Planning Visits for Follow up Cases

The next occasion for receiving care after the end of a previous one is called a follow up visit (for the outpatient) . Follow up visits are necessary to complete the remainder of the phases of care. Occasionally, one follow up visit is sufficient but for the majority of cases, multiple visits are necessary. The frequency and regularity of visits are organized based on:

  • the behavior of the disease (its natural history),
  • the type of care to be given, and
  • the predictability of the response to care.

Visits occur at varying intervals at appropriate service delivery settings. These intervals can be planned at the end of each visit. The duration of the interval depends on how the disease, illness or health problem is expected to develop. Unplanned visits may become necessary because of unexpected turn of events and patients should be reminded to do so.

The location of the follow up visit depends on the resources necessary to accomplish its objectives. For example, a patient who is on an outpatient follow-up visit may have to be admitted for inpatient care if certain complications occur.


Sessions in the Intermediate Phase of Care

Criteria for Cessation or Continuation of Visits

Whether services can be terminated or must be continued depends on whether the objectives of the care episode has been achieved. This depends on the desired outcome for the disease, illness or health problem for which the care episode was initiated. This in turn depends on the nature of the disease. Services can be terminated if:

  • cure has been achieved for a curable disease,
  • no further intervention is possible or necessary.
  • the patient decides not to seek further care.

Visits should be continued when:

  1. the disease is chronic is necessitating life-long care
  2. there is a residual complication (disability, handicap, incapacity) requiring continual care despite the disease itself had been cured
  3. the disease has undergone a remission and a recurrence may occur

For the first two types of cases, definite follow up should be arranged so that care is continued at suitable intervals. The care can be continued at the same facility. If it is more convenient, the case can be transferred or referred to another similar facility after arrangements has been made.
For cases in remission, either follow up at longer intervals or given as and when the recurrence occurs. A such the patient need to be educated as to the symptoms of recurrence and the options available for him/her to respond to it. The patient may seek care at the same facility or at the facility convenient to him/her.

Decision on Continuation or Cessation of Care

EVENTS

Having divided the care episode into visits, the next step is to plan what happens during the visit. For this purpose, the visit is further broken down into smaller sessions termed as events.

Definition of Events

Instances when, where and and what services are supposed to take place at a visit are termed as ‘events’. Simply put, events are what the care provider does and the patient experiences during a visit. An event (as much as a birthday party constitute an event) is a happening planned in advance but also refers to any unexpected happening that occur. Planned events are sessions within which services are provided. As noted earlier, it must be emphasized that even as phases do not coincide necessarily with visits, they also do not coincide with events. Events are considered completed when the desired objective is achieved or the result obtained. In complex cases, events belonging to a phase may be completed only after a few visits. In simpler cases, completion of events of more that one phase can be accomplished in one visit.

The use of the term ‘event’ allows for happenings in patient care services to be looked at from the perspective of both the patient as well as the care provider. For care providers, events are sessions for performing work that include:

  • work that has been planned
  • actions in response to unexpected happenings

Events at a Visit

At a visit, not all of these types of tasks will be performed. Review of existing data and collection of new clinical data (symptoms and signs) are always carried out. Review of previous values of parameters used for monitoring and recurrent measurement of them almost always occur at visits. The status of the previously known problems need to be assessed and new problems that emerges are identified. The diagnosis is updated and based on it further investigations are planned. The investigations are planned and ordered at that visit but may be carried out at other visits. The performance of tests and retrieval of results may be spread over different visits. Treatment too may be ordered at one visit, carried out at another visit often at a different setting. The effects of treatment, if not immediately obvious, are appraised at a later visit.
To conform to these requirements it is necessary that at the end of a visit the care provider has to use his/her discretion to plan what is to be done at the next visit or visits.

Therefore, the hierarchy by which visits are broken down further is as shown below:.

  • Care Episode
    • Sessions
      • Visits 1
        • Event 1
        • Event 2
        • Event 3
        • Event n
      • Visit 2
        • Event 1
        • Event 2
        • Event 3
        • Event n
      • Visit 3

Events at the First Visit

  1. proceed to the next phase of the current plan
  2. change the current plan altogether or in part to another plan

Events for a the First Visit of a New Case

For a new case, events at initial first visit or later visits consist of those belonging to the first phase of care i.e.

  • gathering data for the purpose of making a diagnosis,
  • discovering the patient profile and
  • instituting immediate care if required.

The events planned for the first visit is quite different from that for the Follow-up visit because at the very first visit the diagnosis is usually uncertain, while at subsequent visits, the diagnosis is more definite. So, events for the initial phase of care is assigned to the first visit. But it may not be possible to complete all the events for that phase. Some events have to be carried over to the next visit.
The next phase of care is initiated at any point depending on whether all objectives of the first phase has been met. Depending on the whether the objectives for that phase has been attained, the care provider has to make decisions at each visit or encounter on whether to:

  • proceed to the next phase of the current plan
  • change the current plan altogether or in part to another plan

If possible these events should be completed preferably in one visit. Otherwise it is carried over to the next visit(s).

Events at a Visit

Events of Follow up Visits

Follow up visits are the means of ensuring the continuity of care. The care provider plans activities for the visit according to the workflow of the relevant phase of care described in the Reference SOP/Care Plan. Hence, he/she has to be acutely aware which stage of the workflow the patient is currently involved in . As patient care is iterative in nature, it is likely that the cycle of processes will be repeated at each visit.

Sessions for the Entire Episode of are

Types of Events and their Content

An event is an occasion when services are delivered by a care provider, a team of providers working together at the same time or by machines run by workers or automatically.

An event can be

  1. planned or
  2. unplanned.

The events within a visit is dependent on the actions necessary to achieve its objectives which in turn is linked to the phase of care. The decision on events to be organized and carried out depends first of all on whether they are for new cases or follow up cases. There are instances when a care provider would attend to a case more that once during the the visit by repeating an event or adding an extra event.

He/she will perform different block of tasks for each event (e.g. at the ordering of a test and reviewing the results when they become available). In other instances, when results or responses take time to manifest, the patient goes home and comes again for another visit to the facility.

Planned Events

The use of SOP/Care plans will enable almost all events of patient care to be planned. During these events one or more tasks may be performed. Each task is done:

  • for a purpose
  • at a scheduled time
  • at a facility or setting with suitable equipment or resources and a conducive environment.
  • by an assigned care provider or a team of care providers

Planned events may take the following form:

  1. face to face interaction between the patient and care providers (encounters)
  2. performance of actions without the necessity of the presence of the patient (non-encounter events, events sans-encounter)
  3. actions performed on specimens

For each visit, the events that the patient will be involved in are planned. During each event, actions that are to be performed must also be indicated. Unfortunately, not all actions can be planned in advance. There are also activities that are performed in response to unexpected happenings or incidents.

Purpose of Planned Events

Each event has a purpose and desired outcome.

  • administration
  • data collection, review and collation
  • monitoring
  • updating the diagnosis
  • treatment
  • review and reassessment

Examples of Planned Events

Planned events are the discrete activities of patient care carried out by care providers for various purposes. The type of essential events and the tasks within them are listed below:

  1. Clinical information gathering
    • Interview
    • Physical Examination
  2. Deriving the initial diagnosis
    • collating the information
    • postulating a diagnosis
  3. Planning and Carrying out investigations
    • Ordering
    • Performing
  4. Deriving or definite diagnosis
    • collating the information
    • postulating a diagnosis
  5. Planning care
    • Selecting a Reference care plan
    • Creating an actual plan
  6. Putting the plan into practice
    • Carrying out treatment
  7. Monitoring and Observation
  8. Review of plan
    • collating the information
    • assessing progress
    • continue or change or discontinue plan
Sessions for the Early Phase of Care

Unplanned Events

Besides planned events, there are instances when unplanned happenings occur. These include:

  • incidents,
  • side effects,
  • unwanted developments,
  • mistakes.

When these events happen two types of actions must be performed:

  • acknowledgment or notification of the event
  • response to it

The event is observed, noted and recorded. Actions are taken to counteract the effects of the unplanned happening. Both can be considered as one event or separately.
Some of these are not necessarily random events but are known to happen and can be anticipated. In the preparation of the SOP/Care plan, actions in response to them are prepared in advance and documented.

Events Involving Care Providers

Besides being allocate to time and place, most events must be assigned to care providers. Indeed, there are different types of events in this regard.

Encounters

Many tasks can be performed only during face to face meetings between the patient and the care provider. The term ‘encounter’ is used for such an event. The actions performed include those that involve:

  • audio-visual interaction
  • physical examination
  • performance of tests, procedures or interventions on the patient.

Encounters are the most important events of patient care because crucial actions are taken within them.

Non-Encounter Events

An event need not necessarily mean a face to face encounter with patients, Care providers may perform actions on their own without the presence of patients. Such actions include:

  • managing information i.e. reading existing data, data entry, data analysis, data interpretation and deriving conclusions
  • thinking (cognitive) actions: the formulation of diagnosis and plans,
  • preparatory activities performed before procedures

Events of information management can be done, at any time during the visit, without the patient being present. Normally, the first action that a provider does at the beginning of a clinical session is to review the existing data regarding the patient, These can be the case summary, the monitoring chart, results of investigations done previously (pathological or radiological tests) or notes made by other care providers. At the end or in the middle of the session, he/she may formulate and document data regarding the diagnosis, assessments and opinions. He/she may communicate with other care providers directly, by phone or by forwarding referrals or replying to them. In a new case, before attending to the patient, the care provider can read the referral letter and results of tests already performed.
Preparatory activities like the admixture of medication and setting up of equipment or instruments before procedures are also done without the patient being present. It also include communication between tem members.
All these activities take the care provider’s time and effort. They must be taken into consideration when organizing patient care activities.

Tests on Samples

Tests are events that are often performed on the patient (e.g. taking images, EKGs, EEGs, Audiometry, Optometry etc.) during encounters but they are also done on samples from the patient rather than the patient him/herself. A big advantage is that such events can happen concurrently and at different locations.

In healthcare, very often results or outcome of an activity is not immediately available. Hence, for some activities, intervals during which there is inactivity and waiting are necessary before moving on to the next activity. The duration of these intervals depends on the intensity of care, the more intense the shorter the interval. Intervals between visits are managed using the appointment book or a scheduling application software. Intervals between encounters or tasks are managed using a queue system.

Therefore, the events (encounter, non encounter and tests) can be considered as consisting of sets or blocks of tasks to be performed.

Sequencing and Spacing of Events:

At a visit, not all of the above types of events will happen. Planning of events is only possible if the sequence of steps can be anticipated in advance.

At a visit, not all of these types of tasks will be performed. Review of existing data and collection of new clinical data (symptoms and signs) are always carried out. Review of previous values of parameters used for monitoring and recurrent measurement of them almost always occur at visits. The status of the previously known problems need to be assessed and new problems that emerges are identified. The diagnosis is updated and based on it further investigations are planned. The investigations are planned and ordered at that visit but may be carried out at other visits. The performance of tests and retrieval of results may be spread over different visits. Treatment too may be ordered at one visit, carried out at another visit often at a different setting. The effects of treatment, if not immediately obvious, are appraised at a later visit.
To conform to these requirements it is necessary that at the end of a visit the care provider has to use his/her discretion to plan what is to be done at the next visit or visits.

Sequential vs Simultaneous/Concurrent Events

Joint sessions – encounters happening concurrently. A surgical operation is a joint session. Surgeon, anesthetist, Nurse. Team and teamwork.

Encounter and non-encounter events happening at te same or almost the same time

For each visit, the events that the patient will be involved in are planned. During each event, tasks that are to be performed must also be indicated. Unfortunately, not all tasks can be planned in advance. There are also tasks that are performed in response to unexpected happenings or incidents.

Duration of Events

The duration of events cannot be predicted with certainty. For this reason the duration of visits is also uncertain. This is because:

  • events are made up of activities that take a variable time to complete
  • results takes a variable time to be made available
  • resources for certain activities (tests, procedures) are limited and access to them have to be scheduled

Setting for Events

Just like the visit, events also will have special places, time and persons to carry them out. Resources (room, machine or person) are finite and often scarce. Events can take place only if the room, machine or car provider is free. Therefore, even if the patient is present at a visit, the event has to be scheduled or sequenced in queue. Knowing the type of events that will happen allows the care provider to schedule the event in advance (i.e. where the visit take place) to schedule the event.

TASKS

Events are made up of tasks (one or more processes). These tasks can be

  • technical (with or without the use of machines),
  • cognitive (thinking, interpreting, making decisions),
  • communicational (talking, listening, expressing and understanding body language) or
  • documentation (writing down, data entry)

They are the building blocks of patient care and therefore the SOP/Care Plan. Tasks to be performed during an event are grouped. according to their type and purpose as task lists for a person, a work team or a machine.
Policies that govern or limit the way tasks are performed are written in the Reference SOP/Care Plan and must be followed in the Actual SOP/Care Plan. Further division of the hierarchy is as shown below:

  • Care Episode
    • Sessions
      • Visits 1
        • Event 1
          • Tasks 1
          • Tasks 2
          • Tasks n
        • Event 2

Tasks are performed during events occurring during a visit. Hence, first of all events that must happen at a visit are planned. Those block of events are called care-sets. Then, the group of tasks to be performed specifically at each event is identified. This is the basis for enabling tasks to be planned as a set of orders called order-sets (an important method for executing care plans discussed later).

Execution of Tasks and Documentation of Results

Tasks are performed based on instructions made in the Actual plan based on those contained in the Reference Plan. In a computerized Clinical information System, when the Actual plan is generated depends on whether the patient is a new case or a follow up case. For both new cases and follow up cases, the Clinical Provider Order Entry System (CPOE) or otherwise named Order Entry Result Reporting System (OERRS) is used for this purpose. The system must have the capability to group orders into care sets or order sets. Care sets consists of events and order sets list in detail the tasks for each event.

For a new case the plan is triggered by the reason for visit identified at the time of registration and/or triage.
For a follow up visit the instructions can be prepared beforehand at the time of discharge from the previous visit. Since the diagnosis and the stage in the phase of care is known, the tasks to be performed can be listed and assigned right at the start of the visit.

Execution of Tasks through Orders

For new cases the choice of the SOP/Care Plan for the early phase of care is selected by the attending care provider; first by the person conducting the triage and subsequently in a cascade by subsequent care providers as the diagnosis is clarified. Grouping tasks to be performed during an event is the basis for enabling the creation of a set of orders called order-sets and subsequently task lists. Care sets/Order sets are constructed by the care provider based on the Phase of determining the diagnosis and Early treatment as given in the selected Reference SOP/Care Plan.

Continuity of the Workflow

The continuity of the planned workflow must be maintained as the care advances from one phase to the next. A phase is completed when

  • all events and tasks within them has been done,
  • the outcome or results of tasks are are available,
  • those outcome or results show that the objectives of the the phase are met.

For follow up cases the future orders functionality is used. This entails placing Care sets/Order in advance before the patient is discharged and made to be activated when the patient arrives at the follow up date.

Tasks for Various Events

During each event, tasks that are to be performed must be identified and ordered. At a visit, not all of the types of tasks will be performed but some are often repeated. Review of previous values of parameters used for monitoring and recurrent measurement of them almost always occur at follow up visits. This can be done at the time of preparing the Reference SOP/Care Plan. Unfortunately, not all tasks can be planned in advance. There are also tasks that are performed in response to

  • the need to do further tasks to obtain data to clarify an issue,
  • the need to solve a problem, unexpected happenings or incidents,

Each event has its own set of tasks but a task may not appear in more than one event in a care set at that particular point of care. It is important that tasks are not duplicated within a specific time frame. In a computerized system duplication can be resolved automatically. In a paper based system persons ordering tasks or performing them must be alert to the possibility of duplication.
Repetitions becomes necessary for purposes of monitoring and repeated treatment. These tasks have frequency attached to them. For example, to take the B.P and Pulse every 15 minutes. Indeed machines can be made to perform tasks continuously e.g. to measure oxygen saturation or display the EKG..

Tasks for various events are planned as lists in the Reference SOP/Care Plan but any task, if necessary, can be removed or an additional task may be added to the order set of the Actual SOP/Care Plan. The tasks for various events are elaborated below.

Facilities Equipment and Environment for Various Tasks

Tasks can be performed at different physical sites (units, rooms) with amenities, equipment and environment suitable for the event. The patient can be moved and be served by the same care provider or the tasks can be accomplished by another appropriate care provider at the same or different site.

Sequential vs Simultaneous Tasks

Different persons or machines involved in an event may perform different tasks at the same time.

Tasks for the Data Gathering Event

Data gathering as an event occurs at various stages of patient care. This is because data are important input and output of clinical care.

Review of existing data and collection of new clinical data (symptoms and signs) are always carried out. Review of previous values of parameters used for monitoring and recurrent measurement of them almost always occur at visits. The status of the previously known problems need to be assessed and new problems that emerges are identified. The diagnosis is updated and based on it further investigations are planned. The investigations are planned and ordered at that visit but may be carried out at other visits. The performance of tests and retrieval of results may be spread over different visits. Treatment too may be ordered at one visit, carried out at another visit often at a different setting. The effects of treatment, if not immediately obvious, are appraised at a later visit.
To conform to these requirements it is necessary that at the end of a visit the care provider has to use his/her discretion to plan what is to be done at the next visit or visits.

Tasks for a new phase may be initiated at anytime during a visit and event. It may be necessary to leave some tasks to be done at the next visit or next event when circumstances warrants it.

Sessions for Entire Phase of Care


  • Care Episode
    • Sessions
    • Visits
      • Events
        1. Encounters
          • Interventional
          • Non-interventional
        2. Tasks performed on samples
        3. Tasks sans-encounters
          • documentation,
          • data analysis and interpretation,
          • decision making,
          • planning,
          • communications
Sessions for the Entire Episode of are

Start of Events and Tasks Triggers

The events that will happen and the tasks that will be performed subsequently depend on the reason for visit. When a patient is seen at a visit, the choice of care plans is determined mainly by the purpose of the visit (visit type, reason for visit). The visit type indicates whether a new plan need to be activated or a previous plan continued.

Use of Triage as Means of Triggering Events

Triage is the procedure of determining priority of care and distribution of cases. It is usually used in managing mass casualties and emergency situations. As a concept, it can be applied at the beginning of care for all situations including for elective cases. It is most useful for the first visit but can also be applied to follow up cases. Hence, the triage procedure will help in:

  1. directing patients to appropriate care
  2. speeding up the flow of the care process
  3. selecting the appropriate subsequent part of the SOP/Care Plan

Triage for the First Visit

At the first visit, cases can be one of of two types:

  1. Fresh New Case:
    • Purpose: To provide care for a new health care problem (symptom, symptom complex, syndrome)
  2. Referral case: person previously cared for elsewhere
    • Purpose: to continue care provided earlier at another unit/institution

In the case of emergency cases triage is done before or at the same time as registration. For outpatient cases triage is effective when done just after the patient has been registered. It should preferably be performed by a care provider with clinical experience. The triage procedure should follow a standard method. The purpose of triage is the identification of a probable diagnosis which at this point can take the form of a symptom complex, a syndrome or a specific illness (in the case when the patient is a referred case from some other care facility where the diagnosis has already been worked out).
The diagnosis in turn will point to the most appropriate subsequent SOP/Care Plan.

Triage for a Follow-up Case

The concept of triage can also be extended to follow up cases. A follow up visit, at a outpatient or inpatient facility, is the occasion for receiving care following the previous one. There are two main types of follow up visit:

  1. Elective Follow up or Readmission:
    • Purpose: to continue the remainder of care previously planned for a known disease or health problem.
  2. Emergency Follow up or Readmission:
    • Purpose: to provide care in relation to an illness or problem cared for at a previous visit:
      • a complication of illness,
      • complication of treatment,
      • unexpected event (recurrence, exacerbation).

At the end of any visit, a decision can be made for the next plan of action. The type of visit and the location is determined and scheduled. If he/she is to be referred to an external facility, arrangements are made and a referral letter is written.

Similarly, the patient should be aware of what to expect. What is planned for the visit may be:

  • continuation of the current SOP/Care Plan or
  • a change in plan altogether (e.g. relinquishing care to another care provider or unit).

However, the decision to execute the plan is made only after the patient has been reviewed to determine his/her status allows its continuation. This is especially true, for example, in ante-natal care where plans are made for phases coinciding with trimesters of pregnancy. While pregnancy inevitably progresses, certain processes or interventions that have not been successfully completed need to be repeated or certain interventions become necessary.

The circumstances that make it suitable for care to advance to the next phase often become evident during the visit and encounter itself rather than before it. Moving forward is only expedient when the care provider has reviewed what has happened to the patient during the interval, his/her current condition and the investigation/monitoring data that have accumulated .

Activation Trigger of Events

Breakdown of Events into Tasks

During any phase the care provider has to perform many types of tasks including:

  • administration
  • data collection, review and collation
  • monitoring
  • updating the diagnosis
  • treatment
  • review and reassessment

Registration Tasks

  1. Patient Registration Application
  2. Client-Resource Management
  3. Charging, Billing and Receipt of Payment System
  • Capture identification and demographic data
  • Create a new entity with a unique identification number in the Database of Patients
  • Maintain a single Medical Record for the patient
  • Maintain a master list of patients as a permanent register i.e. the Client Register also known as “Patient Register” or the “Master Patient Index” (PMI)

Tasks for Data Gathering

Tasks for the Formulation of Diagnosis

The phase of clarifying the diagnosis, ends when a definite diagnosis is identified with some certainty. If, for example the result of a test is pending, it has to be waited for. If findings are equivocal, more tests may have to be done. In that situation, the phase is delayed.

Monitoring tasks

Occasions When Tasks Are Performed

Tasks of Treatment



Tasks of Review and Reevaluation

  1. during direct interaction with the patient (i.e. encounters)
  2. tests on samples taken from the patient
  3. thinking processes consisting of analysis and interpretation of available data, deriving and conclusions and making plans

At a visit, not all of these types of tasks will be performed. Review of existing data and collection of new clinical data (symptoms and signs) are always carried out. Review of previous values of parameters used for monitoring and recurrent measurement of them almost always occur at visits. The status of the previously known problems need to be assessed and new problems that emerges are identified. The diagnosis is updated and based on it further investigations are planned. The investigations are planned and ordered at that visit but may be carried out at other visits. The performance of tests and retrieval of results may be spread over different visits. Treatment too may be ordered at one visit, carried out at another visit often at a different setting. The effects of treatment, if not immediately obvious, are appraised at a later visit.
To conform to these requirements it is necessary that at the end of a visit the care provider has to use his/her discretion to plan what is to be done at the next visit or visits.

The Reference SOP/Care Plans is used to guide the care provider. For this purpose, it is necessary to identify the set of tasks to be performed at each point of care. This requires the SOP/Care plan to be divided into into blocks of tasks to coincide the event at hand. It is also necessary to assign each task to an identified care provider or anyone from a team of providers.

Therefore, besides breaking down work according to phases, activities within the SOP/Care Plan need to be broken down (scheduled) into sets of tasks to be done at various events (during an encounter and outside of it) in the manner depicted below:

The hierarchy by which sessions are arranged is as depicted below (and will be explained further):

Division of Episode into Sessions, Visits Events and Tasks

Mapping Tasks to Scheduled Events

Using the Reference SOP/Care Plans as a guide, the system need to prompt the care provider what is to be done at scheduled sessions. For this purpose, it is necessary to identify the set of tasks to be performed at each point of care. This requires the SOP/Care plan to be divided into into blocks of tasks to coincide with the session at hand. Further it is also necessary to identify the tasks to be done at events. Each task or set of tasks need to be assigned to an identified care provider or anyone from relevant group of providers on duty.

Prompt and Triggers

  • for a patient relative to a listed group
  • patient’s own sessions

Triggering of each block of of the service

  • automated
  • manual

Activation of Packages/Blocks by Triggers

  • visits
    • Schedules, appointments, arrival, discharge
  • events – completed care-set
    • Queues
  • tasks – completed order-set
  1. trigger by administrative events
  2. triggering by outcome or results
  3. triggering by diagnosis
  4. triggering by completion of an event or task

The set or block of tasks to be performed at a session can be proposed to the care provider at the start of the session through prompts and triggers. These are dependent on

As such the tasks contained in a phase must be distributed according to visits and then according to to events within the visit. This is the major challenge in converting the Reference plan into an Actual plan.. When constructing the Actual plan the care provider groups the tasks into into sets that can be termed as care sets, blocks or packages belonging to sessions. The intervals between the visits is determined by patient’s needs. In this way, a phase may start or end at the beginning of a visit or in the middle of it. However, the application of concept of a phase as a set of processes with a defined objective is still essential in ensuring that care is provided correctly. At a visit the care provider must be aware the phase in the clinical icare process that he/she is at..

Sequential vs Simultaneous Tasks

Whether tasks are performed sequentially or simultaneously need to be addressed in SOP/Care Plans. Tasks need to be sequential if it requires :

  1. active involvement of the patient
  2. the use of the result of another task.

When the tasks requires the patient to cooperate by physical or verbal means, care providers have to take turns to perform them. This is because a patient can only be at one place or interact with one care provider at one time. There are exceptions to this rule like when active input from the patient is not required tasks can be done simultaneously by different care providers. For example, a nurse may observe the patient while the doctor is talking with or examining him/her. There are instances e.g. in emergency situations and in complex procedures (e.g. surgical operations) when more than one care provider may be attending to the patient at the same time. Often, when the patient is unconscious (comatose or under anaesthesia) different interventions are done on him/her.

Tasks that does not require the presence of the patient can be done simultaneously or concurrently. Hence, tasks such as making a diagnosis and planning can be done while another care provider is attending to the patient. These are thinking tasks that uses data from memory or from records. Sometimes, the ability to perform it requires the presence of the medical record. In computerized systems data can be presented as views or displays.

Radiologists, echocardiographers, endoscopists, optometrists and audiologists need the patient to be present when they perform their tests. Pathologists and microbiologists usually work on specimens obtained from the patient and therefore their tasks can be performed concurrently in parallel with that of clinicians.

The involvement of clinicians are often through direct interaction with the patient. Only when the patient is free another clinician may use the opportunity to have direct contact whether to gather information or provide direct care. For example, nurses observe, monitor and chart various parameters after the doctor has done his round.
Indeed they may perform interventions on the patient, Hence their interventions, just like other clinicians, are done during encounters.

Task Lists

SOPs/Care Plans besides listing out the tasks to be done also indicates responsibilities for performing them. In practice, they need to be grouped into list of tasks required for each phase. visit and event. Indeed, the effectiveness of care is dependent on each care provider knowing what is to be done for a particular visit or event.
The set of tasks to be performed in the care of a particular patient (at a particular phase or visit is often called the Care Set,

  1. Information gathering
  2. Monitoring
  3. Investigations
  4. Nursing care
  5. Treatment
  6. Rehabilitation

Each care set is made up of Order sets which in turn consists of individual orders.

Blocks of Tasks as Commercial Packages

When the SOP/Care Plan is used, the care of various types of patients is considered as different service products, From a business standpoint the entire period during which the service product is delivered is a care episode and all the tasks performed and input provided can be considered as a commercial service package. The episode consists of visits and therefore the entire package can be broken down into groups of tasks performed during each visit which can be considered as smaller packages. This provides the basis for clarifying:

  1. the services that the patient is entitled to,
  2. the services that ought to be provided by the healthcare facility,
  3. share of tasks conducted by each department/unit/care provider

Grouping tasks into packages provides the means to arrive at figures for costing, charging and remuneration.

The work of providing services are usually allocated based on expertise such that different care providers or teams of care providers will be responsible to perform sets of tasks as a package.

During the care of the patient, the responsibility of providing care often changes hands. If the diagnosis changes or different problems arise the case can be referred to another care provider or a different clinical team with the appropriate expertise for the purpose of:

  1. co-opting them into the care team
  2. obtaining advice
  3. passing on the responsibility of care to another care provider or team of providers (clinical department or unit)

For the first situation, the reason for referral is to get other care providers involved in the care based on the requirements of the SOP/Care Plan. For the second situation the team leader (the primary care provider) considers the advice and may or may not modify the SOP/Care Plan accordingly. For the third situation, the responsibility of care is transferred to the team that accepts the case. The team leader would then modify the SOP/Care Plan or choose an entirely new one.

The SOP/Care Plan defines the care episode. Therefore, the instance when the episode and so the services for the service product ends need to be defined. At the end of a visit, the doctor in charge must decide whether to continue or discontinue care. The decision to discontinue depends on whether the objectives of care has been achieved or no other benefit can be gained by continuing the service. It can be decided also by the patient if he/she voluntarily opt to not avail himself/herself to further care.

C. DOCUMENTATION OF REFERENCE SOP/Care Plans

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