Standard Operating Procedures and Clinical Care Plans

Date First Published: January 9, 2015
Date Last Revised: December 23, 2020

“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 taken months to prepare. There were many false starts and 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 and 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. II have gone to great lenghts to explain the work of a clinician because readers are likely to include non-clinicians. hope you will bear with me and persevere in trying to go through reading it. The outline below may help in its understanding.

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). The method consists of strictly following a sequence of procedures strictly. A procedures (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 particular facilities.
The product of services can also have fairly uniform characteristics and be called service products. In healthcare, services are fashioned according to diseases / illnesses / health problems. Since there are many types of diseases, there are a wide variety of products. While there is a need for uniformity in the way care is delivered, this must be accompanied by efforts to customize it by taking into consideration the 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).

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 is as much as they have fairly uniform output characteristics and 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. Order and supply

Applying SOPs in these areas are not difficult and has been successful. However, problems arise when attempting to apply them for clinical services. However, clinical patient care has characteristics that pose many challenges to the adoption of the use of SOPs.

Challenge of 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 in 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, it would differ 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 method (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 happens 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 effort and 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 including data gathering and formulating a diagnosis 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.
Indeed, as will be shown later, planning clinical patient care will have to be integrated with the planning 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 patient seeking care arrives. If possible at the time of registration or immediately after it, the service to be given is determined, 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 symptom complex supplemented by the discovery of certain signs that are obvious on observation or through simple assessment (at triage) can be used to infer the needs of the patient and therefore the service that they need. If reason for visit, symptom complexes and clinical syndromes are taken to be a diagnosis then the SOP. even for patient care, can describe the service 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 product and then design the SOP/Care Plan for each of them.

SOP/CARE PLAN AS A SERVICE DELIVERY PLAN for a SPECIFIC 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 ubique problem in patient care is that, almost always, the diagnosis is not known with certainty at the start, For a particular case, the clinician changes 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 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.
If the patient has more than one health problem, then the combination of various plans would be required.

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 the use of many tools. 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. Enable the design of 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 using a SOP/Care Plan, it is assumed that the care provider is conversant with its purpose, content and structure. The theoretical rationale and detailed objectives and methods need not be presented in detail but referred to 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)

Benefits For The Unit Or Department Manager

From a service or departmental managerial 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. Encourage uniformity and standardization
  4. Act as a basis for quality measurement and control
  5. Encourage equitable care and remove bias
  6. Improve staff knowledge, skills, attitude and behaviour

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.

OVERCOMING DOUBTS ABOUT USE OF SOP/CARE PLANS

Despite these benefits, there are apprehensions, among clinicians and managers alike, 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 could be that it makes the standard clearer whereas without it the term has less certainty and provide leeway for defense. Clarity should be welcomed. At he 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. 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 therefore for common policies and procedures as provided by SOP/Care Plans and making it available is part of good governance. If it is designed based on scientific knowledge, research findings, good practice, 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 good if the reason for the variance from prescribed policies and procedures are noted and explained.

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 and encounters 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 (the Work Procedure)
  7. Stating the rules that regulate the service (policies)
  8. Choosing the most appropriate technology/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)
  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 make plan that is effective and implementable require a proper development approach . The Shewhart-Deming 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.
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 be assured their proper use both in terms of the adherence to them and also 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 providing 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.

Plans must take into consideration the resources, environment and goals of the organization providing the service. 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/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 main 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. 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 constructing the In addition, another step, i.e. the conversion to the plan is actually 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 specific 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 specific 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 needs 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 need to have 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. 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 governing 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 clinician(s 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. Nursing care should consist of what is required for the disease, illness or health problem that shape the service product 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.

Reference plans form the base that guides the planning of care of a 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 at the beginning, 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 mainly 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 revised accordingly at the time of implementation. 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
  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).

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 one go in advance. The conversion of the plan has to bedone done in parts in a staggered 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 most useful when used for reference i.e. as a guide in ensuring that uniform policies and procedures are adhered to 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. While this method makes the effort of modifying easier, it depends on the availability of a printer. Also while it removes the extra work of rewriting/transcribing, it adds the extra task of printing.

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. Care providers can select, call for it via links and read the relevant plan through a search mechanism or from a drop down menu. 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 relevant 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 would be aware of which phase of care is being carried out 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. 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

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 I). It is derived from the Reference Plan
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

The data concerning planning, being a distinct and separate task, should be recorded at the time when it is performed in between 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 reached. Putting these together is incorrect because because these occur at different times. 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 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 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 phase of care, By convention leadership 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. Leaderhip changes accordding to the stages of the care episode. 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, When the responsibility of care is passed on to another care provider who can make a more definite diagnosis, he/she assumes the responsibility to select the reference plan to be used. If the care is passed over {referred) for more specialized care the specialist has the 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 (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”. The actual plan documented in the medical record/case note or CIS should only be that for the next set of tasks.

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 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.

FACTORS TO BE CONSIDERED IN DEVELOPING SOP/CARE PLANS

The following factors need to be considered in the development of SOP/Care Plans:

The structure and content of the SOP/Care Plan document is written in accordance with the factors listed below.

  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 other Health problems (preexisting disease, pre-morbid health status)
  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 Client

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. 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 is identified through an accurate and comprehensive diagnosis. 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 and therefore cannot be anticipated for for every patient but should be addressed during the actual planning of care.

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 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 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 making 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 needs to 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.

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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 Specific Disease (Definite 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, the service product must have clear specifications and limits as to its application. 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 wit 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.

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 VARIANTS OF THE DISEASE

SOPs are often criticized for being rigid and didactic. 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 or available. 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.

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 circumstsnces:

  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.

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.

Sub-Types of SOP/Care Plan 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 need 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 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 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 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. 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 STANDARDS 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.

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.

Use of the Term Tasks for Procedures

In healthcare, the word procedure is often used differently to mean something 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 outcome. To avoid ambiguity, the term task is taken to be equivalent to procedure and is preferred in this discussion.

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

  1. manually by the care provider
  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, fluid and nourishment are given to patients but giving hem are also considered as tasks of dispensing or administration. This is because they have to be given in an accepted way.

Processes

Tasks are made up of processes. In a healthcare information system instructions or requests to perform tasks are called orders, by preference. In caring for a patient, healthcare professionals act as a team. They are dependent on the contributions provided by one 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 requires the right input and environment. Input includes the raw material, instruments, assistance and information. In fact. to proceed from one task to the next depends on whether the results of the transformation of the previous task is immediately available and sufficient. If so, he/she may continue to the next task without pause. An essential input is data (results) generated by the previous task.

Transformation of Input by Processes into Output

Description of Tasks in the SOP/Care Plans

All clinical care providers, including doctors, nurses, allied health personnel and other professionals, follow a commonly agreed way of providing care in terms of content, layout, sequence and direction. In the SOP/Care Plan, tasks for the delivery of a service is presented in two ways i.e.:

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

Sequence Of Processes (Workflow)

The path/flow/sequence/layout of clinical processes is best depicted as a workflow chart. The generic chart for clinical care processes is as outlined below:

Clinical Care Workflow

This workflow is applicable to most cases. The priority in sequencing the processes does not necessarily follow strictly this generic clinical work flow. These will depend very much on the type, severity, urgency, 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.

More often than not, the following scenarios 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.

Types of Tasks

Tasks are performed in many ways, using various input. Many are technical, 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. Data documentation 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 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),

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

Concept Of Triage

Triage is the procedure of determining priority of care and dispersion of cases 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.

Triage is done just after the patient has been registered. It should preferably be performed by a care provider with clinical experience. A SOP/Care Plan should be available even at this stage. The purpose of triage will be the identification of a diagnosis which in turn will point to the most appropriate subsequent SOP/Care Plan. The diagnosis can take the form of a reason for visit, symptom complex or 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). 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 SOP/Care Plan

Triage is quite unnecessary for a follow up case because the plan shoud have been decided at the time of dischrge from the previous visit. The exception is for an old case that has developed an unexpected complication.

Concept of Follow-up

In patient care the entire service cannot be given through a continuous process. Instead, it is necessary to have intervals between activities because:

  1. Often the results of a task is not immediately available and has to be waited for
  2. it is more convenient or appropriate to provide the care at a different service delivery setting (e.g. from inpatient to outpatient and vice versa)
  3. some tasks need to be repeated at a different time later
  4. the patient have to go to a dedicated facility to get the service (e.g. for rehabilitation)

These intervals can be between encounters or visits. In an inpatient setting, the patient stays in the facility. He/she rest in between encounters. In the outpatient setting the patient goes home and comes again for another visit to the facility. The next occasion for receiving care after the end of a previous one is called a follow up visit (for the outpatient) or encounter (in the case of the inpatient). Of course a decison can be made for an inpatient to receive the following care as an outpatient. Then, the patie nt will be at home during the interval.

The tasks performed at a follow up visit or encounter is significantly different from that for a new visit because some information about the patient is already available, the diagnosis may have been worked out and a plan has been initiated, At the end of any encounter or visit, the care plan for the future need to be made ready. In this way, at the beginning of a follow up encounter or 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.

Iterative Nature Of the Clinical Workflow

Clinical processes are iterative (cyclical, repetitive) in nature. By this, it is meant that The steps of interview, examination, tests, diagnosis, plan and evaluation are repeated at every phase of care. In fact they represent the data mangement steps of gathering data, accumulation of the data, analysis of the data, interpreting them, deriving conclusions and acting on it. Actions will generate more data which will undergo the same steps of the data management process.
Many tasks are also repeated in circumstances when:

  1. the task is effective only if it is repeated intentionally for a certain number of times
  2. the objectives are not met or desired results are not obtained by a single instance
  3. the results of processes (such as monitoring, review and measurement of outcome) are expected to vary (improve or worsen) as the care progresses
  4. the task has not been carried out properly
Iterative Nature of Clinical Processes

If tasks are 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 done based on instructions/orders, new ones have to be made if the duration of the initial order has ended.

Variation of the Plan Based On Changes in the Characteristics and Behaviour of the Illness

The characteristics and behaviour of a disease varies with each occurrence. Its progress may be typical or atypical and may become better or worse. Complications of treatment may occur. The care provider modifies the existing plan or if necessary selects a different Reference plan in response to these variations. Usually, the work flow advances as and when all tasks planned for the phase are completed and the objectives are met. The phases of care of both acute and also chronic diseases are categorized into phases for :

  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

The Flow Of The Clinical Process

Clinical pathway is another term for work flow and algorithms when it is used in patient-care activities. These terms can be used interchangeably. They are the predicted or planned sequence and direction of what, when and how work processes are to be done. They also provide guides for care providers to switch to alternative plans based on certain criteria.
A ‘critical’ pathway contains only the critical (important, required) steps or processes with the obvious (mundane) steps left out in the documentation (but not in practice). The term pathway has been incorrectly used to describe care plans. If the term care pathway is to be used at all it should be synonymous with workflow as used in SOPs. The workflow/care pathway is an essential component of the Reference SOP/Ca re Plan.

Hence, the SOP/Care Plans is designed as segments with phases of care in mind.

After selecting a plan based on the initial diagnosis, the care provider may decide to alter or revise the plan based on:

  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 clinical process workflow
  4. 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 process 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 changes in:

  1. the understanding of the disease/problem affecting the patient
  2. the objectives of care
  3. status of progress of the disease
  4. status of response to treatment

In terms of the SOP/care plan the decision to choose an option or lternative leads to the necessity to select a different plan. The care provider may select the appropriate plan according to the following choices:

  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 visit) the primary provider chooses a care plan that matches the diagnosis. At subsequent visits 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 Refernce plan.. Hence, it is necessary 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 illness or health problem. The primary provider selects the appropriate plan from a library of SOP/Care Plans made available to him/her.

Scheduling Care Activities

Health care provider delivers care at events (mainly at encounters / consultations with the patient), usually during a visit i.e. when the patient comes to the health care facility or are visited by health care provider or via Teleconsultation. For practical reasons and convenience, service managers try to schedule visits to coincide with the anticipated change-over of the clinical care process from one phase to the next. If the workflow for the care of the case type or sub-type is studied the number of visits or encounters to complete a phase can be anticipated and scheduled as a feature of the SOP/Care Plan. For example, a patient who is on an outpatient follow-up may have to be admitted for in-patient care if certain complications occur. Inpatients should be discharged as early as possible so that nosocomial side effects can be minimized.
At the visit or encounter, tasks to be performed and other events that the patient will experience or incidents that is likely to happen to them can be anticipated by the care providers. 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. However, the decision to execute the plan is made only if the patient’s status when reviewed allows for or warrants the change-over. 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 continued.

The circumstances that allow care to advance to the next phase often become evident during the visit and encounter itself rather than before it. It is only possible then because the care provider has reviewed the progress of the patient’s symptoms during the interval, his/her current condition and the investigation/monitoring data that have accumulated .

Suitability of the Care Delivery Setting for Various Tasks

In some instances, the most appropriate service delivery setting for a particular visit can can be predicted and decided in advance. 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. When the progress of the disease is slow and the effects of treatment take time, the case is better managed as an outpatient.

When the patient is managed in an in-patient setting the care provider has 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 only available in the inpatien setting. Hence, the inpatient setting is suitable for the care of either acute illness or the initial care of chronic illness,
For cases managed in the outpatient or daycare setting, the patient is reviewed at a follow up visit such that the decision to move on to the next phase is usually made then. Care providers will have to depend on patients to monitor their own symptoms, signs and physiological or biochemical parameters by performing simple tests.

Planning at Every Visit

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 encounters at short intervals or continuously. This means that the appropriate service delivery setting for acute illness at the immediate phase is ether the Emergency Unit or the Inpatient facility including the Intensive Care Unit. 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. In this 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 by 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. when 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. Except at the very beginning of care for some diseases, most chronic diseases are suitably managed as outpatients. Phases of care move along visits rather then encounters. Involvement of the patient in care of his/her own self at home is essential. For incapacitated patients, their wards 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 monitoring of side effects of treatment. 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 objectives 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.

DIVIDING CLINICAL PATIENT CARE INTO A SEQUECE 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 must be in 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 delivery of patient care can also be grouped into separate activities, each aimed at achieving certain objectives. It is also important to perform these activities in sequence because each activity is dependent on the outcome of the previous activities. But this is not strictly so because sometimes there is:

  1. an opportunity that may not occur again presents itself
  2. it is more convenient to perform an activity earlier or later
  3. one activity may be given priority over another because of certain needs

The separate activities can be considered as blocks or packages consisting of a series of tasks. However, the separation between the activities are not as distinct and predictable as that in manufacturing industries. There are many reasons why this is not so:

  1. in patient care, unlike in industry, each activity need not be carried out at fixed locations (facility),
  2. alternative equipment may be used to perform certain tasks
  3. the ability to perform a task is not necessarily confined to a certain care provider category.
  4. there is a need to repeat the tasks before the desired outcome is achieved,
  5. the progress of the tasks of diagnose, plan, treat, monitor and reevaluate takes a variable amount of time.
  6. the progress of the care is related to how the disease progresses
  7. the response to treatment is not uniformly predictable

because of the iterative (cyclical) way procedures are performed in healthcare,The term ‘care’ is preferred rather than treatment or therapy because many other elements/aspects contribute to improving the patient’s status.This time depends on when its objectives are met, This length of time is variable. Hence, it is more applicable to divide the entire care activities into periods

Because of the aboye consderations bringd about the concept of pahses of care.

For some of these activities a set of process must be completed in continuous steps, Other activities may be done with intervals in between. Similarly, while the SOP/Care Plan describesit does not mean that it is performed continuously. The whole procedure cannot be listed down as a long list of processes but have to be segmented into packages or blocks.

Dividing the SOP/CARE PLAN Into Sections Containing Corresponding Blocks of Tasks

A Typical Journey

The journey of clinicians in performing their work is very much like a group of travelers on a journey.

A traveler sets own on the journey towards a general destination. Along the way he/she is joined by other travelers. 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 porposes 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 visit 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 last reach their destination or somewhere near it. They may decide to stop there but may feel that they must wander on.

Routes and Destinations

The Clinician’s 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. However, to look at the work of clinical care it is beneficial to picture the journey of a clinician in caring for a particular patient in a specific service delivery setting.
The job of 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 the emergency unit besides the clinic. His daily journey is different from that of a doctor working only at an inpatient clinic, Nurses on the other hand mostly work at fixed nursing stations.
The role of 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 setting thr 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 plan a more definite care plan. The plan may call for multiple visits to be arranged to optimize care, stabilise the patients 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 performs tasks required for the type of illness and the stage of the care process. Tasks may include tje 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 outpatient setting he will discharge the patient and plan for care to be given at an outpatient setting.
The scenario described is one of the many scenarios that typifies a clinician/s journey.

The Care Episode

The entire period during which care is delivered is termed as the Care episode, It begins at the time of first contact with a health care practitioner and ends with the resolution of the illness/problem or death of the patient. More than just thinking of this as a period of time it is necessary to consider it as:

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

What is delivered to the patient and what he/she experiences is the care episode is also the service product. How the service is delivered is described by the SOP/Care Plan dedigned for it. This period is divided further into into sequential stages or phases,

Dividing The Care Episode Into Phases

The clinical care workflow progresses in phases. Each phase have its own objective or purpose. A phase starts with the setting up of one or more objectives and ends when all the objectives have been met. Each objective is met by performing tasks contained in it successfully. Completing all the phases will result in the final outcome.
The Reference plan is divided into segments corresponding to phases. The tasks planned for each phase phase are grouped according to their purpose and the persons responsible for performing them. These tasks may be distributed over as many sessions as is necessary. The scheduling of tasks for each session is done in the Actual plan. .

For simplicity, the division sequence can be into early, intermediate and later segments. Indeed, phases can be divided in different ways depending on the type of service and 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 definitive care
  5. Phase of maintenance of care
  6. Phase of resolution (continuation or discontinuation of care)
Grouping Tasks/Processes into Blocks

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 periods.

Division of the Care Episode into Phases

Because phases have different objectives/purposes, 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 it. This is followed by continuation / 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 long term care.

Content of the SOP/Care Plan for Each Phase of Care

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 analyzed and clarified. There may be occasions when tasks of one phase is carried over to the next Adoption of this method 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. 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 even as efforts at determining diagnosis are being made.

Determination of Dignosis

The main objective of this phase is to determine the diagnosis as accurately and comprehensively as possible. This is done in two steps. The first plan consists of:

The primary care provider, depending on the scope of care, is the clinician in charge (doctor, nurse or therapist). At the beginning of this phase, the diagnosis is usually uncertain. The data available may allow the clinician to determine the Provisional diagnosis i.e. diagnosis in terms of symptom complexes, clinical syndromes or as a disease belonging to a diagnostic related group.

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

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

  • taking a more elaborate history
  • finding out 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 a definitive 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 patients 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.

As diagnosis is deduced by interpreting of data, the necessary data must be made available. Proceeding from one tasks to the next depends very much on whether results of tasks (assessment, tests and treatment) are immediately available or takes some time to be ready. Many results would only be ready after a time interval, To complete a phase, it is often necessary to do so at more than one encounter or visit with a break between. Therefore, for practical purposes the entire array of tasks need to be broken up into segments or blocks.

However, every effort must be made to obtain a definitive diagnosis so that the plan for specific treatment can be started as early as possible. In fact this phase ends only when a reliable working diagnosis is arrived at.

Once a definitive diagnosis is made and the appropriate treatment regimen is known, then the definitive care for the rest of episode may be planned, initiated, optimized and maintained. 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.

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.

Immediate Care and Early Treatment

Therapy must not wait for want of an accurate diagnosis. In both acute and illness at the immediate phase, efforts are directed towards;

  1. nursing care
  2. continued relief of symptoms
  3. monitoring of relevant parameters
  4. maintaining normal physiology through resuscitation and stabilization
  5. providing nutrition,
  6. giving support (physiological, psychological, social and spiritual)
  7. taking preventive actions
  8. 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.

At the outset, regular observation and monitoring are initiated.

Phase For Initiation Of Definitive Care

This phase is a direct continuation of the previous phase. The separation is necessary only because the results of pertinent tests and observations are not immediately available. It. has two parts

  • determining the definite diagnosis
  • planning definitive care.

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

Formulating the Definite Diagnosis

The definite diagnosis is one that is both specific and certain. It indicates the cause of the disease or at least the pathological process that is affecting the patient. The definitive care plan is designed or selected based on it.
Results of data gathering done in the previous phase are retrieved, interpreted to arrive at a definitive diagnosis. Once the diagnosis is ascertained, 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, futyer 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.

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. 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 visit. 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. The plan is then continued with minimal change. Optimization is considered achieved when the treatment regimen produces the best possible level of benefit. The plan is then continued with minimal change.

Phase of Optimization of Care

Phase of Maintenance of Care

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).

The care provider is expected to follow the established care regimen closely. At the same time, an important aspect of the plan is the 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. 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. Also he/she should consider reviewing the diagnosis because the 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 Continuation Or Discontinuation Of Care

It is essential that the care provider ensure the continuity of care. If it is necessary to reduce visits to the health care facility, one way is to continue care via home care or teleconsultation. He/she 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 bodie are the most appropriate care providers to take on this responsibility. With regards disability or handicap, 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 usually characterized 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.

Presenting Phases as Segments of the Reference Plan

The Reference plan should be divided into segments consistent with phases with eaqch segment indicating the sets of tasks to be performed.. The care provider must be aware of the phase that the care is currently on. 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 can be called for 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

Moving on from Conceptual Segments to More Concrete Blocks of Tasks

Depending on the disease or health problem, the completion of a phase takea a variable amount of time. As discussed earlier, tasks conatined in a phase may make many sessions to be successfully finished. At the beginning of a phase all the tasks to be performed are laid out in the Reference plan. Then, the care provider has to plan when they are to be carried out in the Actual plan. He/she has the freedom to . The beginning and end of a phase is not definite. Each phase is not necessarily done at a fixed time or a known duration. Also, the location is not fixed because clinical care can be given at different service delivery settings (clinics, ward, operation rooms, ICUs etc.).

To be effective the plans must be made for every step where the care is given. This is a major challenge.

Division of the Care Episode into Sessions, Visits Events and Tasks

Dividing the Reference plan is into segments consistent with phases give rhe overall scope of the tasks to be done, This division is essential. As such, tasks to be performed in each phase are listed out in the Reference plan. To implement the care plan in a practical manner, the tasks must be grouped into portions to be performed at scheduled sessions. Therefore, the sessions must have the following characteristics:

  1. defined purpose
  2. defined content
  3. for an anticipated duration
  4. performed at an allocated time
  5. at a known location
  6. assigned to a specific person or team/department/unit

In healthcare, such sessions are termed as visits, events and tasks. A mechanism has to be provided to enable the care provider to transfer the relevant contents of the Reference plan to the Actual plan.

The care provider has to determine what exactly is to be done when he/she arrives at the point of care. As such the tasks contained in a phase has to be distributed according to visits and then according to to events within the visit. Therefore when constructing the Actual plan the care provider tasks need to group the tasks into into sets of tasks that can be termed as care sets, blocks or packages. to be carried out during scheduled sessions and grouped into blocks or packages of tasks that can be scheduled (on specific date and time).

Types of Tasks Based on Purpose

.At any phase the care provider has to perform many types of tasks.

  • administration
  • data collection and data collation
  • monitoring
  • treatment
  • review and reassessment

In a care episode, the care provider team plans various visits. For each visit, the events that the patient will be involved in is planned. During each event tasks that are to be performed must also be known. Unfortunately, not all tasks can be planned in advanced. There are also tasks that are performed in response to unexpected happenings or incidents.

Visits in Realtion to Phases in Chronic Illness

Tasks can be performed during during face to face meetings between the patient or the care provider termed as encounters or be performed by care providers on their own. During encounters, the patient may be subjected to planned procedures or interventions.
Care providers may perform tasks of data analysis, data interpretation, deriving conclusions and planning without the presence of the patient. Tests are often performed on the patient but they also can be done on samples from the patient rather than the patient him/herself.
Besides those actions, the patient may experience incidents, for which care providers will respond by by performing various interventions .

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.

Division of Episode into Sessions, Visits Events and Tasks

The care episode can be considered as consisting of blocks or packages of tasks corresponding to various periods in the care of the patient as depicted below. Each of them will be explained subsequently,

Activation of Packages/Blocks by Triggers

Division of the Care Episode

Dividing The Care Episode Into Phases

The care provider must be aware of the phase that the care is currently on. The division of care into phases is conceptual rather than practical/concretes because for different diseases the phases have:

  1. variable content
  2. variable duration
  3. no fixed start and end time
  4. no fixed location
  5. not allocated to a specific person or team/department/unit

Initiation And Continuation Of Phases Of Care To Coincide With Visits And Encounters

The division of care into phases is conceptual rather than practical. .For practical reasons, tasks have to be scheduled at known time and location. To cater for its peculiar requirements, the delivery of patient care services are broken down into sequential periods termed as visits with intervals in between. On top of this, various approaches and mechanisms need to be introduced to ensure that there is continuity of care so that the objectives of care are achieved.

In an inpatient setting, processes are performed during encounters or during the intervals in between. The exception is for the processes of monitoring or observation (manually or by machine) which are often continuous .
In an outpatient setting, more often than not, each visit will have discrete blocks of processes. There are instances when a care provider would perform more that one block of processes by attending to a case more that once during the the visit (e.g. at the ordering of a test and after the results are available).
The the service setting (i.e. where the visit take place) deemed suitable for the process depends on the part of the workflow to be accomplished.

Difference in Approach for New vs Follow up Cases

When a patient is first seen, 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. The purpose of various types of visits is as below:

  1. New Case:
    • To obtain care for a new health care problem (symptom, symptom complex, syndrome)
  2. Referral:
    • to continue care provided earlier at another unit/institution
  3. Elective Follow up or Readmission:
    • to continue the remainder of care previously planned
  4. Emergency Follow up or Readmission:
    • to seek care for:
      • a complication of illness or
      • complication of treatment or
      • unexpected event (recurrence, exacerbation)

Events

Types of Visits and Service Delivery Settings

Service delivery may be provided in various settings including:

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

Matching Care With The Appropriate Service Delivery Setting

Different types of disease and different phases of care has to be matched with the appropriate health care service delivery setting. Diseases that are sudden in onset with severe symptoms and physiological derangement need to be cared for in the Emergency Unit or an Inpatient facility. The care of a patient with certain chronic illness at the initial phase (e.g. Thyrotoxicosis) requires frequent monitoring of parameters that give an idea regarding the response to treatment . Therefore, it is better carried out in an outpatient setting. Otherwise the care of patients with most diseases can be cared for on an outpatient or daycare basis. Telehealth as a service delivery system augments inpatient and outpatient services. It is better to start the earlier encounter(s) with direct interaction where the care provider can use all his senses and instruments directly to examine and observe the patient. Also, this will help in developing the provider-patient relationship. Later, when the care regimen is firmly established, interaction via remote audio-visual mechanisms and telemetry is more convenient for patients in lieu of visits to clinics. Self care works well only after stabilization through initial encounters with care providers at a facility. Home care can be offered when patients are unable to visit the facility.

Grouping Tasks Into Blocks To Coincide With Phases and Visits

It is obvious that in the entire list of tasks/procedures in any SOP/Care Plan must be grouped together, taking into consideration when and where they are supposed to take place i.e. within visits/encounters at the appropriate service delivery setting. However, it must be emphasized that phases do not coincide necessarily with visits or encounters. A phase may may be completed only after a few visits but sometimes the objectives of more that one phase can be achieved in one visit.

The tasks 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 becomes more definite. So, processes for the initial phase of care is assigned to the first visit. The later phase of care is initiated at the next visit depending on whether all objectives of the first phase has been met. If they are not met, some of the the processes of the initial phase has to be repeated over more than one visit or encounter. 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:

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

Events Happening on the Occasion of a Visit

Having planned the care episode into phases and visits, the next step is to plan what happens during the visit. The occasions when care is given by various care providers may be called events, These events may take the form of:

  1. planned face to face encounters between the patient and care providers
  2. planned tasks outside of encounters encounters
  3. tasks performed on specimens
  4. incidents and the tasks performed in response to them

The term event does not denote something happening in the past but an occasion that planned as part of the SOP/Care Plan (very much like a birthday party is an event). As much as work can be planned, there are instances when efforts have to be made to counteract the effects of unplanned happenings such as incidents, side effects and mistakes. It is better to be prepared, especially when their occurrence can be anticipated.

Occasions When Tasks Are Performed

An event is an occasion when tasks are performed by one care provider or a team of providers working together at the same time. Tasks are not necessarily done during face to face encounters with patients, The occasions when tasks are performed include:


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. 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.

  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

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:

  • Care Episode
    • Visits
      • Events
        • Tasks at encounters
          • Interventional
          • Non-interventional
        • Tasks performed on samples
        • Tasks outside of encounters
          • documentation,
          • data analysis and interpretation,
          • decision making,
          • planning,
          • communications

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 Service 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 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 should be provided by healthcare facility.
  3. tasks performed 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.

Activation of Packages/Blocks by Triggers

Blocks of Tasks for Phase of Determining the Diagnosis and Immediate Care / Early Treatment

The clinician in charge uses the data from tests, observation and the monitoring to arrive at a definitive 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 patients 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.

Phase For Initiation Of Definitive Care

Phase of Initiation of Care

Phase Of Optimization Of Care

In this phase, the care provider need to be constantly aware of the desired treatment end points and evaluate them through feedback from patients, observations, monitoring and repeated investigations to determine whether these have been arrived at. 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.

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. . The plan is then continued with minimal change.

Phase of Optimization of Care

Phase Of Maintenance Of Care

The progress of the patient is reviewed regularly to detect deterioration or improvement, occurrence of complications of illness or treatment. For illnesses that has been brought under control the care provider must be on the look out for recurrence. Also he/she should consider reviewing the diagnosis because, the failure to achieve favourable outcome, even at this stage, may be due to a wrong diagnosis. The effectiveness of the care given may be due to poor compliance or an inappropriate plan. He/she then, may have to revise the SOP/Care Plan and modify the treatment.
Depending on the illness, this phase may spread over a considerable period. The patient may be discharged from in-patient care and the care continues in the outpatient setting or at home.

The main aim of this phase is to optimize the benefit of care given. The main tasks in this phase is monitoring, reassessment and progress review addressing both the disease and also the treatment. The results will reveal the behaviour of the illness and various developments. The progress of chronic diseases vary in many ways including:

  1. speed of deterioration
  2. active vs inactive periods
  3. emergence of complications
  4. Another important aspect is the evaluation of response to and effects of therapy.

The following factors are assessed:

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

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. Optimization is considered achieved when the treatment regimen produces the best possible level of benefit. The plan is then continued with minimal change.

Once the condition of patient has been stabilized, attention is paid to:

  1. relief of symptoms
  2. monitoring various parameters
  3. maintaining normal physiology,
  4. providing nutrition,
  5. giving psychological support
  6. taking preventive actions
  7. treatment of ongoing problem

Phase of Maintenance of Care

It is essential that the care provider plans for the continuity of care well and ensure that it happens. He/she may delegate the responsibility to others for the convenience of the patient. The primary care doctor, family doctor or school/factory nurse are the most appropriate care providers to take on this responsibility. If it is a disability or handicap, depending on the type, then therapists, counselors, optometrists, audiologists or social workers may be more appropriate. Self-care, home care and care by voluntary bodies may be adequate or may supplement those given by health care professionals.
Periodic review by the provider who initiated the plan may be necessary.

Phase Of Continuation Or Discontinuation Of Care

Depending on the nature of the illness and the response to care, the service may reach a stage where it can be discontinued.

Chronic illnesses are usually characterized by continuous progression or persistence. The care is therefore long term and usually extend throughout the life of the individual. Some may resolve, go into remission and be dormant only to appear again later. Temporary cessation of therapy with planned follow up reviews may be necessary.
Rarely some diseases runs through its course and dissipates. The care can then be phased out.

If the illness appears to have resolved, discontinuation may be abrupt 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 and what evaluation criteria need to be met to declare it safe for the care to be terminated.

On the other hand, the acute illness/health problem 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 or handicap. In both instances, long term care will then be planned and provided.

Phase of Continuation and Discontinuation of care

REVISION OR COMPLETE CHANGE OF THE SOP/CARE PLAN

For every case, the actual SOP/Care Plans are revised frequently based on the ever-changing changing needs (brought about by changes in diagnosis or condition of the patient or occurrence of events). The revision is documented as part of the plan in Progress Notes.

Decisions to start, continue or abandon plans are dependent on the data available. In inpatient care, the data available are results of clinical reassessment, monitoring data and routine investigations. For outpatient care, these data can be made available by asking patients to come for a preliminary visit when investigations and other assessment are performed. As part of self-care, patients may also submit records of symptom characteristics and measurements they make themselves (Body weight, Blood pressure, Temperature, Blood sugar level, etc.).

Planning The Frequency, Interval And Duration Of Visits

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 encounters and 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 package.

However, there are situations where the transition in the 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. The interval between one visit or encounter to the next is dependent on two factors:

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

A visit requires one or more identified physical resources such as room/bed within a clinic complex or ward. During the visit, the patient may have one or more encounters with different care providers using the same or different resource. The duration of each encounter is defined as time slots. All these need to be planned. In a computerized HIS, this planning is done using the scheduling and resource allocation application.

B. PRACTICAL APPLICATION

STRUCTURE AND CONTENT OF THE REFERENCE SOP/CARE PLAN

Standard Operating Procedures are descriptions of how work is to be carried out for a specific category of patients defined mainly by the diagnosis. Each comprises many specific components. Reference SOP/Care Plans should contain the following components:

  1. A title defining the service product that the plan is designed for.
  2. Description of the Service product.
  3. Care objectives including the quality features of the service and outcome standards (equivalent to quality objectives in ISO quality management system)
  4. Description of the policies and processes involved
  5. Textual (narrative) description of the various work processes detailing layout, the input, technology to be used, assignment of responsibility and expected intermediate outcome
    • Tasks for each phase of care
      • Tasks for each aspect of care.
  6. Operational policies defining constraints within which procedures are to be carried out
  7. Work Flow Charts or Care Pathways (the ‘flow’ of the procedure depicted graphically)
  8. Specific Work Instructions or Protocols
  9. The Work schedule and Task lists
  10. Guide to use of charts or forms to be used as part of the work process
  11. Reference tables or lists (normal values, regimens, drug dosages etc)
  12. Quality Control Methods (Standards, Check-lists etc. i.e. equivalent to quality procedures in quality a management system)

Care Plan 4

Content of SOP
– SECTION CONTENT

  1. Title Name of the Service Product for which the SOP/Care Plan is Applied
  2. 2Service Product Description of the Service Product i.e. the services to be given
    1. A. The typical patient group for whom the SOP/Care Plan is applicable
    2. B. The Needs of the Patient to be served
      • a. Primary Diagnosis
      • b. Disease Complexity (type, grade)
      • c. Severity Level
      • d. Stage of the Diseas
      • e. Effects and complications of the disease
    3. C. The location where and the care providers who provides the service
  3. 3 Objectives The Desired Outcome of the care given with regards to:
    1. A. Productivity and Efficiency
    2. B. Effectiveness (Cure / Containment / Support / Relief / Comfort)
    3. C Safety (Risk assessment, Prevention)
    4. D. Quality
  4. 4 Policies and Procedures
    1. Description of Policies and Procedures to be followed including:
      1. A. Operational policies (rules and regulations)
      2. B. Methods, modalities and Processes
      3. C. Input required (expertise, material, machines, equipment)
    2. D. Workflow, and links to related SOP/Care Plans
    3. E. Phases of Care (Episode, Visits, Encounters, Tasks and Events)
    4. F. Work Schedule (Orders, Tasks, Task , Time table)
    5. G. Guide to decision making
    6. I. Guide to documentation
  5. F. Reference documents
    1. i. Work instructions
    2. ii. Specifications and Standards
    3. iii. Forms and Charts
  6. 5 Quality Control Quality Control Methods
    1. a. Methods to Ensure Conformance
    2. b. Preventive measures
    3. c. Quality Measurement
    4. d. Comparison with Standards
    5. (Detection of non-Conformance)
    6. d. Rectification and Damage control

Structure and Content of an SOP/Care Plan

Headings and Sub-Headings

Multilevel Headings

TITLE: THE SERVICE PRODUCT

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 specific 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 specific illness. Yet it is, to a certain extent, still generic and would need customization, by additions or omissions, when it is used as the Actual SOP/Care Plan in the actual care of an individual patient.

The title is a very concise statement indicating the patient type, the diagnosis or indication and the context such as the phase of care, the service delivery setting where the service is to be given (inpatient, outpatient and day care) and the type visit or encounter.

The title of the Care Plan indicates that it is designed for the specific disease or health problem and for a particular phase. The model plan is generic in application. Conversion of such plans is done when the actual care of an individual patient is provided.

DESCRIPTION OF THE SERVICE PRODUCT

Following the title, what the service is for and what is contains is described briefly.

The examples below, illustrates two main service products Care of a Patient with Bronchial Asthma and Care of a Patient with Intertrochanteric Fracture of the Femur. How the service is further refined is as shown below:

Types of Service Products

In the case of Bronchial Asthma, the service can be differentiated into more refined products based on acuity of onset/urgency and then further into types based on severity levels. The care for Acute vs Chronic Asthma follow quite different approaches. Some of drugs are used for all types but a few will be used only in certain types.
In the case of Intertrochanteric Fracture of the Femur, variations the service products being offered will have different characteristics to suit the different requirements necessitated by degree of fragmentation and displacement. While the main service will contain the service elements of managing a fracture the main difference for the various types will be in the surgical treatment.

OBJECTIVES OF CARE

The intended objective and expected outcome is precisely indicated. These may be the expected outcome, treatment end points, the degree of restoration or amelioration of the disrupted quality of life (ability to work, enjoy leisure, attend school and perform daily life activities) and avoidance of side effects. Details such as targets, limits and standards are understood by reference to the SOP.

A statement defining the objectives of care is essential for every SOP. These may include:

  1. expected outcome,
  2. treatment end points
  3. the intended degree of restoration or amelioration of the disrupted quality of life (ability to: work, enjoy leisure, attend school and do daily life activities)
  4. avoidance of side effects or complications of treatment

It should declare the quality policy about the service being offered i.e. a statement of targets, limits and standards with regard to quality.

DESCRIPTION OF POLICIES AND PROCESSES

In an SOP, the policies and processes are presented in two forms i.e.

  1. A textual description (narrative)
  2. A work-flow chart

When designing the SOP/Care Plan, starting with the narrative description is the bet way to go. However, when presenting it as the final document it may be better to show the graphical workflow first.

Detailed Textual Description Of The Policies And Processes

The whole work procedure needs to be described in text format. In general, the description takes the form of a sequential list of instructions on how to perform processes and the policies that guide it. At the same time the direction, input, technology to be used, persons assigned to perform the task and the expected intermediate outcome are specified. The operational policies that guide and constraint these processes, such as indications and contra-indications, alternatives, allowable variations and contingency plans, rules and criteria, are embedded in the description of the processes.

The sequence, direction and layout of processes or tasks that makes up a procedure must be described clearly and in detail. It is best written before or at the same time as the flow chart is being drawn. In a general sense, the textual description explains each workflow symbol (boxes, arrows etc.) but more importantly, it states the specifications and standards of the care process as well as the operational policies that govern them. Therefore, it is the principal component of the SOP/Care Plan.

The main tasks listed below need to be elaborated.

  1. Acquisition and documentation of clinical data (Initial Assessment, Progress Notes)
  2. Acquisition and documentation of data obtained from various investigations
  3. Analysis and interpretation of available clinical data
  4. Deriving conclusions regarding the patient’s health problems (the diagnosis) and documenting it (including severity grading, staging)
  5. Monitoring and charting of clinical parameters (Observations, serial measurements )
  6. Planning the management and documenting it (with decision support)
  7. Implementation of plans: Placing orders and carrying out tasks (Performing Investigations, treatment, administering drugs)
  8. Documentation of results, procedures performed, findings, and outcome
  9. Review of (monitoring and test) results and interpretation
  10. Quality Control Procedures (e.g. check lists)
  11. Progress review, assessment of outcomes
  12. Communications (Referral Notes, Replies), requests and orders
  13. Writing Summaries

Operational Policies

At the operations level (i.e. when work is performed), the general policies of the institution or service unit are translated into operational policies which define goals or objectives as well as the limits within which tasks or processes are performed. These limits (rules, regulations, targets and standards) may relate to efficiency, quality, costs, responsibilities, preferences and exceptions. Operational policies are embedded within the work procedure (see above).

Example of Textual Description of the Work Processes and Operational Policies

  1. Take history of frequency of exacerbation, limitation of activity & night-time symptoms
  2. Examine patient
  3. Perform PEFR
  4. Assess response according to these criteria:
  5. frequency of exacerbation,
  6. limitation of activity,
  7. night-time symptoms and
  8. PEFR
  9. If response is not satisfactory; review patient’s compliance to medication & advice. If the poor response is due to poor compliance then, continue the previous treatment and more effort is made to educate patient on the disease, treatment methods and need for compliance.
  10. If compliance is not deemed as a problem then, consider the possibility of the need to re-assign patient to a higher severity class. The medication need to be stepped up accordingly (refer treatment chart)
  11. Give explanation regarding the new added medication and further education on use of bronchodilator, use of PEFR meter and self-monitoring chart
  12. End the visit and give the patient an appointment date for a follow-up visit in one month.

Work Flow/Clinical Care Pathway

Besides describing the path/flow of how the service is given as a narrative, it is also depicted graphically. It may be better to present the workflow before the text description but the idea is for the user to switch from one view to the other regularly. An example is shown below:

Clinical Care Pathway for Care of a Polytraumatized Patient

The work flow (care pathway) illustrates:

  1. the sequence of the processes
  2. the process layout (simultaneous, contingent on completion of the previous step or iterative)
  3. the decision-making steps that lead to alternative paths or variations

It is good to draw an outline of the processes (the critical pathway) to show the entire scope of the service. It is not necessary to depict the entire pathway completely on one page as it maybe quite long. Instead, it can be truncated and shown as a continuation on another page, Deviations and variations can be written separately and links/references to them made to the main document.

Depicting the Work Schedule

Work is the expenditure of energy to produce a useful outcome. It is made up of a series of tasks performed by workers which in patient care are called care providers. The work can be done manually or with the help of machines. There are instances when the work is done by machines initiated by instructions given by a worker or automatically based on instructions built into applications. These instructions are called orders.

The activities (processes, tasks) within the SOP/Care Plan is broken down into sets relevant for particular scheduled periods (visits or encounters) or phases of care. This is the schedule of implementation of the SOP/Care Plan and it contains:

  1. a heading indicating the purpose for which it is used i.e. the health problem, the phase of care and any other indication
  2. objectives and expected outcome
  3. a list of all tasks grouped according to the method or technique or the professional competency

Care plans/SOP remains as a reference document until it is converted into an actual plan by customizing it for the individual patient.

It is helpful to present the overall schedule of the plan for the care episode as an outline in the form of a table. Details are not presented in this overall plan but would be written in the discrete plans for different phases or context of care.

Care Schedule or Care Matrix for the Whole Care Episode

Relationship between Diagnosis, Phases of Care and Care Plans
Criteria for Dividing the Care Episode into Different Phases of Care

Care Episode fora Specific Health Problem
Example of Series of Care Plans for Different Phases of Care (Plan for Acute Myocardial Infarct)

Modules by Phases
Plans at Different Levels of Diagnostic Certainty
The development and design of Care Plans are described in detail below.

Task Lists

SOPs/Care Plans besides listing out the tasks to be done also indicates responsibilities for performing them. The tasks to be performed in the care of a particular patient (often called the Care Set) will consist of all or some of patient care processes. Different categories of care providers are allocated responsibilities based on their role.

Task List for One Patient

From the SOP/Care Plan the tasks assigned to a particular care provider (the same person or another person from the same professional team) can be listed. This list called the Task List guides the care provider on his/her contribution to the care of the patient and when it is to be performed.
In a paper based system, the list is created manually (e.g. on a piece of paper or written into the medical record) at the time of initial assessment or progress review. The list acts as a reminder. The care provider must at all times be aware of the progress of the work process and also of any changes made to the plan by the team leader or any other care provider..
In a computerized environment, what is to be done according to plan is listed as a set orders called the Order Set. These list of orders are generated automatically but can still be amended to vary the urgency, frequency, duration, location and assignment. Depending on who is responsible for performing the task, Task lists are ten generated for each named care provider or for a care team belonging to a professional category.
Thus, Task lists are the means for executing the SOP/Care Plan. Care providers must be aware of the tasks that have been completed and those that are still pending. When a computerized system is used, the system is able to indicate the status of performance and provide reminders through prompts and alerts.

Multi Patient Task List View

Care providers usually provide care for more than one patient. The care set for a particular patient will consist of all or some of patient care processes. It may also include clinical administration tasks. For inpatients, these can be admission, referrals, transfer and discharge. For outpatients, these can be visit registration, follow up appointment, referral and discontinuation of visits.

ORDER SETS (CARE PACKAGE, CARE-SET, CARE-BUNDLE)

Quality Control Methods

This section addresses quality control and quality improvement activities. The quality procedure describes the steps to be taken to evaluate conformance to process specifications and outcome standards. Major parts of it are:

measurement of a quality characteristic
comparing with a set standard
determining conformance
improvement methods
It may be incorporated in the work procedure or written as a separate document (as per ISO 9002:2000 QMS standards).

GUIDE ON DOCUMENTATION (USE OF FORMS OR CHARTS)

Relationship between Plan, Performance and Documentation

Pertinent data that is generated as results of tasks or processes must be recorded in standardized forms. In the SOP, guides are given on the use of various data documentation forms or charts used by the organization. Documentation forms should anticipate the data generated by the tasks within the SOP/Care Plan. In addition, the forms/charts also provide prompts/reminders for the care provider to perform certain tasks to obtain the data. Thus, the form itself acts as a decision support instrument

PROVISION OF CLINICAL DECISION SUPPORT

Clinical care is a knowledge driven and information dependent activity. Modern clinical practice must be re-engineered to take advantage of the advancement in knowledge and practice of clinical sciences, management science, and information and communications technology. Clinical Decision Support is the provision of guidance and knowledge at the point of care. It is an integral part of the SOP/Care Plan.

Clinical decision support is envisaged not as something separate but as built-in functions within the whole patient care. It is applied through several mechanisms:

Guide to the data that must be gathered and captured
Guide to making a diagnosis (diagnostic criteria)
Provision and matching of care plans for various categories of patients
Manual / Computerized analysis and interpretation of results (normal, abnormal, scoring, stratification, grading, staging, comparison with standards for quality control)
Provision of guides, instructions, alerts, prompts, reminders and suggestions,
before or during the performance of certain procedures
In response to certain situations, occurrences, incidents, non-conformance and abnormalities
indications and contraindications in use of a modality

SUPPORTIVE REFERENCE DOCUMENTS
REFERENCE DOCUMENTS

The SOP should contain reference documents that care providers can refer to when performing their tasks. The information provided should be endorsed officially by the organization . Examples of these include

work instructions or protocols
table of normal values,
percentile charts,
dosage regimens, food menu,
expected / control limits, standards, specifications,
regimens, recommended drug dosages and charges.
lists of drugs (official drug formulary)
glossary of terms ,
diagnoses terminology,
charge codes.

Care Plan 7

Care Process with Decision Support through Reference Documents
Work Instructions Or Protocols
Work Instructions or Protocols provide further details on how certain processes are to be carried out. They are predetermined didactic reusable instructions for performing a certain specific task or process as prescribed or endorsed by the organization. They are usually instructions describing how to:

Reference tables or lists may become part of this work instruction.
Since processes depicted by a work instruction would be performed in a similar manner at any time, location or for any indication, they may be compiled separately as an addendum to the SOP or kept in separate manuals/folders and only referred to if required. In a computerized system they can be reached through hyperlinks.

perform of-repeated routine tasks (insert a CV line, catheterize a patient, take a blood specimen, take consent etc.)
document (use of standard forms or charts, ),
operate machines (user manual),
use instruments,
use chemicals (safely and effectively),
order items (food, drugs, blood etc.)
serve or administer drugs,
transfuse blood or other infusions
other specific tasks

DIAGNOSTIC CRITERIA

A diagnosis is made by interpreting certain variables including signs, symptoms, the results of clinical tests, investigation findings (laboratory, imaging, and endoscopy), monitoring parameters, clinical progress and response to treatment. Through research and experience, the medical profession has identified sets of variables that predict a diagnosis i.e. the ‘diagnostic criteria’. This knowledge can be presented (as decision support) to care providers to aid them in making a diagnosis. In certain instances, especially when a scoring system is used, these predictions have a high level of accuracy. However, a rough guide can be also of use to the clinician.

CATEGORIZATION, RISK STRATIFICATION / SEVERITY GRADING/ STAGING

Having made the diagnosis the clinician needs to clarify further:

which variant of the illness is affecting the patient
which stage of the natural history of the illness has been reached
what complications has accompanied the disease
how the patient has responded to the disease
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.

INDICATIONS AND CONTRAINDICATIONS FOR USE OF A MODALITY

Investigation and treatment modalities, however efficacious, have limitations such as unwanted side effects and interactions. They may not be effective in certain situations or when prerequisites are not met. Care providers need to be reminded of these indications and contraindications as part of the decision-making process.

ALTERNATIVES, VARIATIONS, OPTIONS AND CONTINGENCIES

The Reference Care Plan is a guide that contains the following :

The Objectives And Expected Outcome
The intended objective and expected outcome is precisely indicated. These may be the expected outcome, treatment end points, the degree of restoration or amelioration of the disrupted quality of life (ability to work, enjoy leisure, attend school and perform daily life activities) and avoidance of side effects. Details such as targets, limits and standards are understood by reference to the SOP.

Lists Of Tasks

Administrative tasks (Admission, Referrals, Transfer and Discharge, visit registration, follow up appointment, referral and discontinuation of visits.)
Clinical Data Gathering Tasks (Clerking or Assessment, Progress reviews)
Investigations
Monitoring tasks

Treatment divided further based on modalities such as therapeutic procedures, medication to be supplied or administered, blood product supply and transfusion
SOPtoPlan
From SOP to Care Plan
Relationship Between SOP, Reference Care Plan and Actual Care Plan

Specific disease entity which give rise to further stages or phases

PlanPhaseDiagnosis
Plan According to Diagnosis and Phases of Care
Two Main Phases of the Care Episode Based on Clarity of Diagnosis

Even when the definitive diagnosis is known and a specific care plan is applied, modifications need to be made constantly based on variables such as:

changes in the patient’s condition in accordance with the stages of the disease process
the workflow or the treatment regimen
demands arising from the patient’s response and other effects of therapy
Phase of Care
Phase of Care
Outline Of The Care Episode
Care plans also need to vary with other changes including:

The Reference Care Plan is in three parts:

Example: Reference Care Plan for Initial Phase of Acute Coronary Syndrome

Care Plan Table
Reference Care Plan Table
Customization Of Case Management Plan For An Individual Patient With Multiple Needs
The Actual Care Plan is basically a work schedule made up of tasks grouped according to functions. In a paper-based information system, the care provider responsible for a particular function may write their own schedule with their own notes in the medical record. For example doctors may write their planned tasks in the medical notes. Nurses my write the Nursing Care Plan together with other entries in the Nursing Notes part while rehabilitation therapists, optometrists and audiologists and other allied health professionals may write their own plan in their respective sections in the medical record. Whatever is recorded is the actual plan and becomes part of the medical record.

EXECUTING PLANS VIA ORDERS

In a fully computerized Hospital Information System, a plan can be chosen by the doctor in charge (or any other health professional assigned as the primary provider). It will then trigger Care Sets (Order sets, care bundle) for various other the designated care providers of the functional group who will then modify these sets of planned tasks (orders). These allow the care provider categories freedom to customize their own respective plans. Once confirmed these planned tasks would be recorded as the actual task list. Later when the tasks are performed this fact together with the results emanating from it would be recorded as part of the Medical Record.

Plans are realized by executing orders (planned tasks). While in the Reference plan, tasks are grouped according to purpose or function, for purposes of execution they are assigned to identified members of the care team. For example rehabilitation tasks are allocated to the Physiotherapist or Occupational therapist. The dietitian takes on the provision of appropriate diet. The social worker will address the social support issues. These care providers will have to be alerted regarding their involvement in the care of the patient through e-mail (in-box), by phone or other methods of referral.

Actual Care Plan for Acute Coronary Syndrome

Order Set for “Acute Coronary Syndrome”

Care Set for Management of Acute Myocardial Infarct

The use of the Care Plan in a computerized Hospital Information System is discussed in the article on Clinical Information System.

The Relationship Between Stages in the Work Flow and Content of Care Plans

Relationship between Care Process, Documentation and Reference Information
The use of Care Plans in a fully integrated Hospital Information System is discussed in another article.

ORDER SETS (CARE PACKAGE, CARE-SET, CARE-BUNDLE)

The tasks that addresses all aspects of the patient’s health problems for the short term, make up the content of the Actual Plan. It is often called the Care Set, Order Set or Care Bundle.

Each Care Plan is executed using pre-constituted but modifiable order sets. In a system based on paper the orders are transcribed (copied) manually from a printed copy of the Reference Plan or from a stand-alone computer. In a computerized Clinical Information System, the care provider may use the order set suggested by the system or choose one from a given list. Depending on the context or scenario, order sets can be didactic or flexible in content. In any case, the set can then be modified by exclusion or inclusion of orders. The tasks are then assigned to the relevant provider group as a task list. Tasks are performed according to the orders.

The care provider retains control of decisions and choices. The plan is a recommendation. Quality control mechanisms such as detection of deviations or variance from the plan, unexpected results and tasks not completed via check lists are put in place.

TASKS: THE MAIN CONTENT OF CARE PLAN

The essential content of Care Plans are tasks for all or some of the patient care processes that addresses all aspects of the patient’s health problems for both the short-term as well as the long-term. These pre-determined tasks take the form of sets of orders often called Order sets otherwise also called Care package, Care-set and Care-bundle. Although care is necessarily continuous and often simultaneous, the content is different for different periods or phases. These periods may or may not coincide with definite moments in time such as a certain day (e.g. day of admission, the morning before surgery, first day post-surgery or day of discharge. The care provider should be given the choice of modifying the care set by activating or inactivating the orders that it contains.

An order-set is made up of a combination and permutation of orders predetermined for each category of illness. Tasks are performed according to the orders. The care sets will consist of all patient care processes necessary for a defined period. It may also include clinical administration tasks.

The type of orders within an order set would include any or all that is necessary to carry out the patient care processes including:

Administrative tasks (Admission, Referrals, Transfer and Discharge, visit registration, follow up appointment, referral and discontinuation of visits.)
Generation, gathering and collection of data about the patient’s illness and the effect on his/her health.
Data collection tasks e.g. Clerking or Assessment using a specific clerking form and Progress reviews guided by various note types.
investigations by various techniques,
Analysis and interpretation of data to determine the diagnosis and needs of patients
Planning the case management
Preventive actions,

Treatment using various modalities including therapeutic procedures, medication to be supplied or administered, blood product supply and transfusion
Monitoring and Review of progress of disease status of the patient’s health, effects of treatment
Evaluation of outcome)
Review of diagnosis and management
Rehabilitation
Patient education
Provision of or advise on nutrition
provider-patient communications (briefing, advice)
Any other therapeutic tasks
Continuation of care or Final disposal of the case
For inpatients, these can be admission, referrals, transfer and discharge. For outpatients, these can be visit registration, follow up appointment, referral and discontinuation of visits.

PROCESSES AND TASKS
Traditionally, the plan for the overall care of a patient is done by the doctor in charge (or any primary care provider). By choosing a Care Plan he/she communicates the to members of the care team on what needs to be done for the patient.

Administrative tasks (Admission, Referrals, Transfer and Discharge, visit registration, follow up appointment, referral and discontinuation of visits.)
Generation, gathering and collection of data about the patient’s illness and the effect on his/her health. Data collection tasks e.g. Clerking or Assessment using a specific clerking form and Progress reviews guided by various note types.
Analysis and interpretation of data to determine the diagnosis and needs of patients
Investigation tasks, Diagnostic tests
Planning the case management
Treatment using various modalities including therapeutic procedures, medication to be supplied or administered, blood product supply and transfusion
Review of progress of disease (including assessment of outcome)
Monitoring of the progress of the illness, status of the patient’s health, effects of treatment
Review of diagnosis and management
Rehabilitation
Patient education
Nutrition provision
Any other therapeutic tasks
Continuation of care or Final disposal of the case
Multi Patient Task List View
In a computerized Clinical Information System, planned tasks take the form sets of orders. The computerized provider Order Entry application (CPOE) is used to create task lists for various functions. The type of tasks within a care-set would include any or all that is necessary to carry out the patient care processes i.e.:

DECOMPOSITION OF ORDER SETS INTO TASK LISTS

Traditionally, the plan for the overall care of a patient is done by the doctor in charge (or any other primary care provider). In a computerized environment, the care plan is predetermined by consensus and executed through Order/Care Sets and can be manually or automatically triggered. From this overall plan, the care providers responsible for each aspect of care may select and activate care plans applicable for the patient. The care provider should be given the choice of modifying the care set by deselecting some of the orders or placing additional orders. All or some of the items listed in a plan/order set can be made mandatory or pre-selected while others can be actively selected or deselected by users.

EXAMPLE Order Set For “Acute Coronary Syndrome”
The care provider retains control of decisions and choices. The plan is a recommendation. Quality control mechanisms such as detection of deviations or variance from the plan, unexpected results and tasks not completed via check lists should be put in place and documented.

Chest trauma
DIVISION OF DURATION OF CARE INTO PERIODS
For a particular health problem, the care delivery may be divided into:

Episode
Phases
Visits
Encounters
Tasks or Events
Entire Care Episode
A particular Phase
A particular service
A care episode refers to the whole duration of service provided from beginning to end. It contains the sum of all visits.The division into Phases is conceptual rather than real. The differentiating factor is whether the illness is acute, sub-acute or chronic.Visits are instances when the patient comes to the health care facility. They can be categorized further according to service delivery systems i.e.

Outpatient visit
Emergency visit
Inpatient visit
Day Care visit
Home Care visit
Teleconsultation visit
Visits can also be categorized according to sequence

First
Follow up (FU 1, FU 2, FU 3 etc.)
Final
The number of visits per episode is by nature variable but may be intentionally fixed in a service package. A visit requires one or more identified physical resources such as room/bed within a clinic complex or ward. During the visit, the patient may have one or more encounters with different care providers at the same or different resource. The duration of each encounter is defined as time slots.

Tier 2: Visits and Encounters for each Phase

The progression from one phase to the next need to be decided by the care provider based on the amount and quality of data available, the certainty of diagnosis, the appropriateness of a chosen care plan and the response to therapy. Since the Case Management Plan is an interdisciplinary effort, each care provider has the opportunity to operationalise the part of the plan in their area of expertise. Yet, there should be consultation with other members of the care team. The patient also needs to be aware of the plan, be allowed to make queries and be involved in it.

Care Schedule 2
Division of a Care Episode into Phases
Care Schedule 3
Care Schedule
PRACTICAL CONSIDERATIONS IN EXECUTING PLANS
For a chosen plan, the transition from one phase of care to the next depends on:

completion of planned tasks
achievement of objectives for the phase
Failure to complete tasks can be due to non-conformance by care providers or non-compliance by patients. Failure to achieve objectives may be due to the two aforementioned issues or due to an inappropriate hence ineffective plan. The latter is likely to be due to inaccurate or wrong diagnosis, in which case further efforts need to be made to clarify the diagnosis. A change in plan may then become necessary.

Phases of Care
Framework for Patient Care Plan
Phases of Care in a Patient with Blunt Chest Trauma

⇒ [Back To The Top]
CARE PLAN FOR ACUTE ILLNESS
quick action by defining the process sequence
readiness of equipment,
defining care-provider roles
preparedness for any eventuality

Example of Care Plan for Patient With Multiple Needs

PRACTICAL CONSIDERATIONS IN EXECUTING PLANS
Care of a patient with an acute illness is characterized by varying levels of urgency and uncertainty. Setting priorities is of overriding importance. Most tasks need to be performed simultaneously. The Care plan is an indispensable aid in ensuring:

Customization Of Case Management Plan For An Individual Patient With Multiple Needs
CARE PLAN FOR CHRONIC ILLNES
preventive, education An example of the model care plan for this phase is shown below. (yet to be written)

In this phase because of the above factors, modification and revision of the plan is often necessary.

VARIATION BASED ON EMERGENCE OF SPECIAL NEEDS
In managing a patient, an integrated plan that will cater for all of his/her needs is necessary. For a particular disease, there are individual variations in how the disease or health problem affects a patient. How the patient responds to them also varies. The continuation of a care regimen to the next phase is contingent on the completion or success of the previous phase.

To some extent the difference in response is contributed by the patient’s pre-morbid health status (pre-existing problems including chronic illness), physiological condition and psychological make up.

After making a diagnosis, the clinician categorizes his/her patient according to possible risks, severity of illness, stage of development and therefore prognosis. Categorization in turn allows the clinician to choose the right pathway and initiate an appropriate care plan. It is also a determinant of applicability, availability, timeliness and cost effectiveness. Grading and scoring systems for various diseases have been developed and tested.

CESSATION AND INTRODUCTION OF NEW PLANS
Plans need to change with variations in progress of the disease, severity, complications, different phases of care and outcomes. Changes can be made manually or be suggested based on a trigger. Planned tasks may end or continue as the phases evolved.

Tasks can continue or retained in new plan. Tasks no longer necessary are not included in next plan any task can be cancelled from the task list at any time

Whether the changes are slight or major, in a computerized system, it is best that the old plan is terminated and replaced by a new plan. Previous orders that are to retained are cancelled and the orders are remade. The new order set will then contain previous and new orders. Hence, the task list is also renewed. This will prevent confusion as to which order is to be retained and which to be continued.

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