WP2 (PCSP) Standard Implementation Toolkit

PCSP Standard Implementation Toolkit

This toolkit is for the implementation of the Personalised Care and Support Planning Standard in health and social care organisations.

The Personalised Care and Support Planning standard provides a framework for standardising the content and sharing of personalised care and support plans between individuals, professionals and systems.

Introduction

This digitised implementation toolkit has been developed in collaboration with  two mental health trusts who provided insight and specialist knowledge to support the collection and curation of the resources and support materials to help create personalised care and support plans that included mental health.  The materials will support the adoption and implementation of the PCSP information standard across the Integrated Care Systems (ICS). Creating a digital toolkit makes care planning implementation more accessible to all health and care professionals, senior leaders and transformation managers.  In addition to the PCSP toolkit there is also a dedicated section that covers Community Mental Health Care Planning as an integral part of the PCSP information standard, available here.

Information standards exist to improve the safety and quality of health and social care, specifically to ensure that the right information is recorded correctly, in the right place, and can be accessed easily, by any authorised person who needs it, wherever they are.

Using the right-hand navigation menu work through the 4 stages – getting ready, getting started, getting going and getting people onboard (also outlined by the iterative process shown in the diagram below). To view the PCSP standard, click the button in the right hand navigation toolbar.

Adoption of the PCSP standard will help you capture the ‘patient’s view’ of their condition/s and enable the sharing of this information between services supporting those providing care, enabling individuals to exercise their choices and  decisions about their own care.  

The materials and resources are intended to support you with your local implementation of the PCSP Information Standard, including managing the associated change and transformation processes required to embed care and support planning within your organisation.

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Personalised Care and Support Planning Toolkit:

Getting Ready

Who is the PCSP Implementation Toolkit for?

These toolkits will help health and care professionals engage and embed the PCSP information standard to support the sharing of a person’s  needs, goals and wishes to provide a personalised care and support to individuals.

It will also help: 

• Transformational Leads

• Project/Programme managers

• Commissioners 

• Clinicians 

 

What does successful transformation look like?

The implementation of the Personalised Care and Support Planning (PCSP) standard potentially requires four types of change to occur, systemically throughout the organisation:

High level statements of intent to guide future practice which provides necessary strategic steer and commitment to adopting the PCSP standard

Practitioner-focused protocols for care planning underpinned by the PCSP standard to enable information sharing

Enacted principles of continual enhancement in care planning such that all those involved in providing care and support are committed to adopting standardised approaches so that information can be shared

Infrastructure and data architecture are designed and configured to support the PCSP standard, and are adequate to meet practical needs and expectations at the point of care

PRSB vision for PCSP

Our vision is for the standard to support safe, person-centred care across the system and for our work to be aligned to the changing needs of people receiving care, their families and carers to:

  • Improve the quality and safety of care
  • Empower and enable people to own their own health and social care strategies​
  • Improve people's experience of health and social care
  • Reduce unplanned hospital admissions
  • Improve collaboration between professionals

This can be achieved through:

• Care planning –  an iterative process based on relationships and connections between those relying on health/social care services and those who support them – users, carers, professionals, community agencies.

• Care plans – co-created summaries of information which describe how, where and why particular strategies will be most useful to people.

• Shared care plans – accessible to a range of stakeholders with a legitimate and agreed interest in a person’s care, wherever and whenever that will be useful.

How to use this toolkit and the approach

The toolkit provides direct links to various policy documents and websites from PRSB and the NHS. The materials and resources are intended to support you in your own PCSP standard implementation project. 

This toolkit draws on two models used to define major projects and system change; The roadmap model and the convoy model (see right).

You can work towards improved personalised care and support planning which better meets people’s needs and enables information sharing by working through a structured approach suggested in the getting started section of the community mental health care planning toolkit.

How was the toolkit developed?

The Roadmap Model Approach

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The Roadmap Model Aproach

Ensures that the widespread transformation required for systematic change on multiple fronts is moving in the same direction with a common destination in sight. This change process has: 1. a starting point 2. an intended destination and a clear purpose 3. clearly defined parameters and roles and responsibilities This change process is iterative and rarely a simple linear progression.

The Convoy Model Approach

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The Convoy Model Aproach

Divides major projects into elements or workstreams for a successful conclusion. We might envision these elements as part of a "convoy" of vehicles for change. The journey will not be complete until all parts of the convoy have arrived, but realities and constraints might mean each element may move at a slightly different speed from the other and may follow different specialist routes along the way. The journey is complete only when the slowest moving part of the convoy has arrived at the destination.

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CHAT theory also explicitly addresses five areas which if addressed systematically will help overcome stakeholder differences in pursuit of the common goal:

1. Understanding the artefacts that characterise the group and its activity.
• The artefacts might be clinical settings or the forms and templates used to capture and share information. During the pilot we heard about hard copy Dialog response forms; locally generated templates for collating information from different systems; letters and emails to GPs; images, poems or other non-text artefacts that service users might want to include in their ‘about me’ or care plan.

2. Understanding the multi-views of the group. Such groups are always a community of multiple points of view, traditions and interests. 
• Different participants in the group will have different roles and will bring to the group and their roles their own histories, language, and ‘rules’. During our Stocktake preparations and workshops we worked with psychiatrists, mental health nurses, occupational therapists, social workers, transformation leads and voluntary sector representatives, all professions and interests with their own language, approaches professional ‘rules’ but united in their interest in care plans, care planning.

3. Activity systems (like the ICSs) take shape and get transformed over periods of time. ‘Historicity’ is a term coined to express how the group’s problems and potentials can only be understood against their own history. 

 

• ‘We’ve always done it this way’, ‘that didn’t work before’, ‘it’s always like this’, ‘it wasn’t always like this’, ‘they are changing things again’, are all typical statements that often frustrate those charged with overseeing change initiatives. Without addressing the experiences that lie behind such comments you risk repeating mistakes of the past, alienating your stakeholders or just not understanding the real starting point for your transformation project. This is particularly the case for the implementation of the PCSP standard, the success of which will be largely reliant on point-of-care practices and information protocols as well as having systems which are user friendly and appropriately configured.

4. The central role of contradictions as sources of change and development. Contradictions are not the same as problems or conflicts. Contradictions are historically accumulating structural tensions within and between activity systems. Collectively addressing contradictions in how policy, practice, culture and technology interact will empower teams to find genuinely novel solutions for apparently intractable challenges, like interoperability and shared care plan/planning. 

This links to the fifth principle that:

5. the possibility of expansive transformations in activity systems. As the contradictions of an activity system are aggravated, some individual participants begin to question and deviate from its established norms. In some cases, this escalates into collaborative envisioning and a deliberate collective change effort. “An expansive transformation is accomplished when the object and motive of the activity are re-conceptualised to embrace a radically wider horizon of possibilities than in the previous mode of the activity.”

Successful teams have the functional skills to lead a task, benefit from diversity, and are led in a way that creates time and space for reflection; the ability to take stock periodically, of the task and of the way in which the team is engaged in delivering it. Your stakeholder analysis [HYPERLINK] should help you assemble the most appropriate team and identify how the team interacts and relates to other stakeholders like sponsors, services users, etc.

The variation in the size, both in terms of population served and numbers of constituent organisations, and of complexity, between Integrated Care Systems, precludes the possibility of any prescriptive guidance on the way in which this team is assembled.

Engeström’s expansive learning cycle of learning actions explains how there are 7 stages of learning actions;