Working Together - Plan - Identifying and Preparing
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Plan – Identifying and Preparing

The “Plan” module focuses on:

  • Analysing your organisation’s current performance in palliative care and advance care planning processes and identify areas for improvement
  • Deciding if there is an imperative to partner with other palliative care providers
  • Identifying potential partners to aid your palliative care and advance care planning improvement goals
  • Planning your partnership with these key stakeholders
  • Developing a co-designed plan to achieve your palliative care and advance care planning goals

After working through this module, you will be able to:

  • Conduct a gap analysis
  • Identify potential palliative care partners utilising service mapping, exploratory meetings, resource mapping
  • Reach a partnering decision utilising a SWOT analysis
  • Develop a partnering agreement and related governance structures
  • Utilise relationship building strategies
  • Develop a palliative care/advance care improvement and communication plan

How do you currently assess your palliative care and advance care planning processes and outcomes?

How do you identify areas for improvement in the delivery of this care?

A gap analysis will help you identify areas for improvement in your delivery of quality palliative care and advance care planning. A gap analysis asks you to compare your current level of performance with a desired level of performance. Your desired level of performance may be to meet accreditation guidelines, national palliative care standards, or an internal continuous improvement target.

Desired outcomes in delivering quality palliative care include: 1) improved quality of care for aged care recipients; 2) reduction of unnecessary hospital admissions from residential aged and home care providers; and 3) reduction in length of hospital stays for palliative care admissions from residential aged care facilities and home care providers.

ELDAC has developed a palliative care framework identifying key processes facilitating quality palliative care. These processes include:

  • Discussing advance care planning
  • Recognising end of life
  • Assessing end of life needs
  • Developing an end of life care plan
  • Working together across services and professional groups
  • Responding to deterioration
  • Managing dying
  • Supporting bereavement

Investigate your current level of performance, including palliative care outcomes and processes – as identified above. You may elect to use a simple measure or a tool to provide a baseline.

A simple measure may include:

  • a count or tally (e.g. the number of palliative care educational sessions for staff in a year)
  • a proportion (e.g. the percentage of residents/clients/patients with an advance care directive or plan)
  • a rating (e.g. family satisfaction rated on a scale from 1-10).

Data collected from multiple individuals can be averaged (e.g. the average family satisfaction score).

You may also elect to utilise a tool. ELDAC recommends two tools to assist you to identify areas for improvement:

The ELDAC After Death Audit (Residential version) or After Death or Discharge Audit (Community version) are tools to measure the quality of care provided to an individual at the end of life. Outcomes measured in the after death audit include hospitalisations in the last week of life, place of death, and compliance with the individual’s end of life wishes. The After Death Audit can also be used to assess your use of key palliative care processes, including advance care planning and the development of end of life care plans. For access to the After Death Audit tools that can be used in either residential or community care settings, click download link below.

(This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

>> Download the ELDAC After Death Audit for Residential Aged Care (744kb pdf) 

>>Download the ELDAC After Death Audit for Home Care (722kb pdf)

The ELDAC Organisational Audit provides a snapshot of your organisations’ structural commitment to quality palliative care and advance care planning. It allows you to measure your organisations’ performance in the following areas: clinical care, education and workforce development, policies and procedures, information systems, and quality improvement. This analysis will help you to identify how working together with other aged, primary and palliative care services can improve palliative care and advance care planning in your service. For a sample Organisational Audit template, click download link below.

(This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

>> Download the ELDAC Palliative Care and Advance Care Planning Organisational Audit for Residential Aged Care (576kb pdf) 

>>Download the ELDAC Palliative Care and Advance Care Planning Organisational Audit for Home Care (599kb pdf) 

The following advance care planning audit tool and supporting resources will assist with identifying current practices and areas for improvement.

Advance Care Planning Continuous Quality Improvement Audit Tool
The Start2Talk website has a more detailed advance care planning audit and supporting resources: 

Personal Learning Assessment

To assist in identifying your staff's learning and development needs and to give an indication of the priority learning areas for your organisation, please utilise the ELDAC Personal Leaning Assessment and ELDAC Personal Learning Plan.

There are two sections to the assessment:

  • Section 1: Knowledge of palliative care and advance care planning
  • Section 2: Skills and confidence in providing palliative care and advance care planning

It is recommended that your staff complete this process annually as their learning and development needs may change.

>>Download ELDAC Personal Learning Assessment Form (356kb pdf)

>>Download ELDAC Personal Learning Plan Form (1096kb pdf)

More detailed information regarding these tools are provided in the ELDAC Home Care and ELDAC Residential Aged Care toolkits.
Browse the links provided in the “What can I learn” section of both ELDAC Home Care and ELDAC Residential Aged Care toolkits for various types of education and resources that are recommended by the ELDAC team.

Comparison of your palliative care and advance care planning performance to national standards and frameworks can also inform your Gap Analysis (see below).

FURTHER READING: Standards and frameworks

Identify the opportunities and gaps in provision of best possible palliative care for older persons in your care by reflecting on the extent to which your service meets the following relevant standards:

Using a partnership and collaborative approach leads to positive outcomes for organisations collectively with an increase in capacity, resources, and systems. The outcomes from working together will bring opportunities and a greater impact on the care we provide. 1

Identifying areas for improvement in your provision of palliative care and advance care planning will assist you to determine the advantages of potential partnerships.

What could partnerships bring to your organisation’s palliative care delivery?

Activities:

Conducting a SWOT analysis can assist you in identifying the advantages and disadvantages in partnering. It asks you to identify:

  • Strengths: What does our service do well in terms of palliative care and advance care planning?
  • Weaknesses: What aspects do not work so well?
  • Opportunities: Would partnering with other providers help our service overcome our weaknesses and build on our strengths?
  • Threats: Are there any constraints or threats we need to consider in a potential partnership?

View a SWOT analysis template. (This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

An alternative to the SWOT is an SBAR analysis:

  • Situation: What is happening at the present time, within our service, in relation to palliative care and advance care planning?
  • Background: What are the circumstances leading up to this situation?
  • Assessment: What do I think the problem is?
  • Recommendation: What should we do to improve the provision of palliative care and advance care planning for older people under our care?

View SBAR template.(This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

 

Now that you have decided to investigate partnering, it is time to give further consideration to who these partners might be. Give serious consideration to potential palliative care partners from the aged care, primary care, acute care, and specialist palliative care sectors. These steps will guide you through this decision making.

Service mapping

A Service Mapping exercise can assist you in:

  • identifying all the providers, resources and treatment options in the delivery of palliative care and advance care planning to older persons in your service and local area
  • identifying the contributions that various service providers make to providing palliative care and advance care planning
  • increasing your knowledge of existing referral and treatment options
  • identifying gaps, overlaps and barriers in accessing existing services

View sample service mapping template (This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

Potential partners could include:

  • specialist palliative care services
  • aged care services (residential and community)
  • acute health services (hospitals)
  • ambulance service
  • primary care providers (General Practitioners)
  • pharmacists
  • allied health professionals (e.g. social workers, occupational therapists, speech pathologists, physiotherapists)
  • the local Primary Health Network (PHN).

Consider connecting with service providers that can bring additional expertise to meet your client’s needs in palliative care and advance care planning.

Consider connecting with service providers that can bring additional expertise to meet your client’s needs in palliative care and advance care planning.

The following service directories can assist you to complete a comprehensive service mapping exercise:

Remember, your local PHN may be able to assist you with service mapping in your area!

Conduct an exploratory meeting with potential partners

Conduct preliminary discussions with potential partners about opportunities and gaps for improving palliative care and advance care planning for older people. Focus on identifying mutual benefits of working together.

An exploratory meeting with potential partners allows you to investigate opportunities for working together with a range of aged and palliative care service providers, setting the stage for a new collaborative approach to palliative care delivery.

Key aims of an exploratory meeting include:

  • Defining the advance care planning and/or palliative care issues the partnership will address;
  • Discuss the individual interests of each partner;
  • Determining if partnerships will add value; and
  • Identifying how the partnership would work in order to provide coordinated palliative care.2

Tips for a successful exploratory meeting 3 4 5

Use effective communication (both written and verbal) to give clarity and promote understanding between service organisations about their various roles in providing palliative care to older people:

  1. Set the tone for the meeting in your invitation. Be clear about the purpose of the meeting.
  2. Ensure the key people are ‘at the table’ from the beginning.
  3. Do attendees have decision making authority for their organisation?
  4. Determine if smaller group meetings are necessary prior to the main meeting, particularly with the lead stakeholders/organisations.

Once the meeting has been scheduled, it’s important to:

  1. Provide an agenda, with background information and clear goals for the meeting.
  2. Explain which organisations are present and introduce the representatives.
  3. Identify the opportunity for developing a partnership to achieve better palliative care and advance care planning for older people.

Prepare well:

  1. Ensure the meeting is properly facilitated, either by a Chair or an appointed Facilitator. Careful facilitation will help to harmonise everyone’s interests.
Consider what template documents you might need to record the meeting’s discussion and agreed actions.

Conduct a resource mapping activity

This step enables each partner to consider what they can contribute to your palliative care and advance care planning action plan.

  • Think about “resources” in its broadest context (e.g., staff time, knowledge and expertise, competencies, equipment, products, networks, influence, and cash are all considered valuable commodities in a partnership).6
  • Undertake a Resource Mapping exercise in a workshop format to generate discussion. 6 7
  • Document resource commitments in a written document signed by each partner.

Developing a resource plan assists in clarifying roles and potential contributions from each of the partners.

View sample resource map template. (This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

Decide whether or not to partner

At this stage, you have collected information on each potential partner, including a partner’s individual interests in palliative care and resource availability. Your goal now is to align your interests and objectives for the partnership in relation to providing palliative care. You need to identify the “why” – “why should we partner?” Consider any mutual benefits in partnering.

Activity:

Ask partners to write individual interests and objectives in separate circles. Merge the circles and look for areas of overlap.

Develop a shared vision for the partnership. Such a statement is a powerful beacon guiding the partnership team in improving palliative care and advance care planning for older people.

A vision statement “is a vivid mental image of what you want your [service] to be at some point in the future, based on your goals and aspirations. Having a vision will give your [service] a clear focus, and can stop you heading in the wrong direction…A vision statement captures, in writing, the essence of where you want to take your [partnership] and can inspire…your [partnership] to reach [mutual] goals.” (Adapted from:https://www.business.qld.gov.au/starting-business/planning/business-planning/vision)

Utilise a Systems Mapping process to plan how you might work together.

Activity:

View an example of how to facilitate a Systems Mapping process. The activity is outlined on p.31 of the document.

For an example of a process to follow to make your decision

Build the partnership relationship

Enable participants to see the possibilities through partnership as “stronger together”.

Activity: Share examples of successful partnerships in delivering palliative care for older people, learnings and outcomes. For examples of successful partnerships between aged and palliative care service providers (1402kb pdf).

If you didn’t get to the videos earlier in this module, they will show you real life examples of successful partnerships between aged and palliative care service providers.

Establish communication guidelines and effective communication strategies.
More information about building relationships to create partnerships is available online.

Develop a partnering agreement

A partnering agreement formalises the decisions reached in the exploratory meeting. Formalising your partnering agreement in a written document facilitates shared understanding and steps partners through a list of essential project decisions. As alternatives to a formalised partnering agreement, you may prefer utilising a letter of intent, terms of reference, or a memorandum of understanding (MOU) if these approaches are more acceptable to you.

For guidance on developing a partnering agreement (592kb pdf)terms of reference (156kb pdf), or a MOU (296kb pdf)

Establish governance structures and roles

Partnerships have two arms of responsibility:

  1. A strategic or governance arm; and
  2. An operational arm. 5

The governance arm is responsible for effective decision-making, planning and management, 7

and:

  • provides guidance and support to the operational arm 5
  • responds to partner grievances and project obstacles
  • includes service managers, senior clinical staff, and key stakeholders (such as aged care peak body representatives and service users).

From: www.goodgovernance.org.au

The operational arm is responsible for delivering project outputs and outcomes 5.

TIP: Ensure the governance and operational groups include representatives from each partner organisation.

If your partnership team is small, members can take on both governance and operational roles.

Developing a mutually agreeable action plan, risk plan and communication plan can increase the success of your palliative care and advance care planning initiatives.

Develop an action plan

An action plan transforms your palliative care and advance care planning objectives into concrete steps or actions. It is the “who, what, how and when” document. To develop your actions:

  • Undertake a brainstorming activity with your partners 6
  • Remind the group of your shared objectives in relation to palliative care 9
  • Break objectives into activities (What will you do to achieve the objective? e.g. conduct a palliative care case conference) 9
  • Break activities into actions (What tasks are required to implement the activity? e.g. develop a policy document, develop a case conference template, contact GPs regarding possible involvement) 9
  • Utilise results from your resource mapping activity to allocate resources to each activity/action. 9
  • Consider the order of the activities and actions (In which order should activities/actions be performed? Are some activities/actions dependent on the completion of other activities/actions? Are some activities/actions quite lengthy requiring an earlier start date?)9

For each action, record:

  • A start and end date 9
  • Resources required (Are any capacity building initiatives required?) 9
  • Person responsible for completing the action 9
  • An evaluation strategy for your palliative care initiative (How will you know your work has been effective?) Earlier we discussed options to use a simple measure or tool. You may wish to revisit this section to consider your evaluation options 9.

Remember to obtain management approval for the plan. 9 Widely distribute the action plan for comment. 9

Encourage creativity and group ownership through joint brainstorming activities.

Activities:

Mind Map. Work out as many ideas for achieving your palliative care and advance care planning goals as you can in a hierarchical tree and cluster format. Start off with your objective in the centre, branch out into the major structures or systems required, and continue to branch out into as many tasks as needed.

Gap Filling. Identify how you are currently performing in palliative care and advance care planning? – this is Point A – and your desired palliative care and advance care planning outcome/s – this is Point B. What is the gap between these two points? What are the things you could do to address this gap? List these things down and think about what it takes to implement your ideas.

These activities are available online.

IMPORTANT QUESTIONS: Are there any legislative requirements, clinical best practice guidelines, or standards to be considered in running your palliative care and advance care planning improvement activity? What internal policies and procedures are effected? 9

View sample action plan template (446kb pdf). (This interacti​ve pdf can be completed online, downloaded and printed for your organisation’s records.)

Develop a risk plan

Think about the possible risks or consequences associated with making your palliative care or advance care planning changes. The aged care sector has many recognised challenges (e.g. high staff turnover, lack of resources, frequently changing policies).

Also consider:

  • Workplace health and safety issues 9
  • The likelihood of the risk
  • What impact it would have on the project if it does occur? Give particular attention to risks that have both a high likelihood and impact.
  • What actions you can take to reduce or address the risk 10.

View sample risk plan (446kb pdf). (This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

Develop a communication plan

Think about what information needs to be shared and with whom. Consider the best medium for communicating with a particular target group. Consider appropriate methods for internal (between the partnership team members) and external communications 5.

The communication checklist (136kb pdf) ,(This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

TIP: Communication responsibilities can be shared across partners to encourage project ownership and increase promotional opportunities. 6

View sample Communication Plan (445kb pdf). (This interactive pdf can be completed online, downloaded and printed for your organisation’s records.)

Page updated 18 January 2019