Putting the standard into practice

Personalised Care and Support Plan
1.
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About this toolkit

2.
Icon for Diabetes test

Getting to grips with the standard

3.
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Getting people on board

4.
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Taking stock and planning

5.
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Putting the standard into practice

6.
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Shared resources and learning

Putting the standard into practice

Having agreed your roadmap with stakeholders, you can now begin making the changes and putting the standard into practice in your organisation.

From piloting the information standard and developing a training programme, through to monitoring and measuring its successful adoption.

Develop a detailed timetable

Based on your high-level roadmap, develop a detailed timetable for change with dates and responsibilities clearly identified. This will signal to stakeholders when the change programme will begin, how long it will take and prepare them to fulfil their role in making it happen.

Consider the following when pulling together your timetable:

Phases – a phased approach to implementation is often helpful to manage systems and stakeholders. It also reduces the risk of issues accumulating, as you can address them at each phase.

Piloting – a small scale trial at the start of a project can help to refine your plan and test systems and requirements.

Stakeholder management – share your timetable for change as early as you can and provide regular updates to stakeholders, so they are engaged in whether progress is being made with implementation and how they can contribute, as needed.

Plan and procure system changes

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Procure the system changes needed ensuring that systems will be delivered that are conformant with the standard. See NHS England procurement guidance.

diabetes monitor device

Agree how the team will be involved in testing the software to ensure it is conformant and meets local requirements.

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Technical message standards can be found in the NHSE API catalogue. New APIs will be required for sharing data generated by the person as part of their self-management with electronic records.

If you have a bespoke system it needs to be updated to comply with the PRSB Diabetes Record information standard. If your system is purchased off the shelf, you are responsible as a provider to check that it complies with the standard.

The PRSB Standards Partnership Scheme was established to support providers and suppliers in demonstrating compliance with PRSB standards. Further information on requirements can be found in the information standards notice (ISN) and PRSB standards conformance guide.

Piloting

We recommend piloting a small-scale trial; implementing the information standard for a small number of users or in a small locality. After these users have been trained, the project team can make charts of the processes involved – these charts will form the basis for training all users to access and utilise the information standard.

There are several advantages to running a pilot:

Reduces the risk of a full-scale implementation as adjustments and modifications can be made as a result of the pilot

Improves processes through evaluation of the process charts produced during the pilot
Develops training materials through conversations with users from the pilot who can share their learnings.

The short film below looks at some of the next steps PRSB has been taking to pilot and test the standard.

Training

When you are ready to implement the information standard on a wide scale, you will need to develop training materials. You can use our example slides and training schedule as part of your training initiative.

Your training plan

Make a list of stakeholders who will need to be trained and produce a timetable of training

Work through the example training schedule to develop your plan.

Multiple training sessions can be helpful for your staff to engage and have a greater lever of understanding

Different groups of users will have different learning styles. Take this into account when designing the type of training you offer.

Safety case and hazard log

Every information standard built by PRSB includes a safety case and a hazard log. These additional documents are written based on the NHS guidance – PRSB, as developers of the data model, use DCB0129 guidance (for manufacturers of health IT systems).


Why use a safety case and hazard log?

The purpose of the safety case and hazard log is to identify the hazards which could cause a person harm because of using the standard, along with how that hazard can be mitigated. There are different types of mitigation – through system design, testing, user training or business control processes.

Blood glucose monitor

When implementing the Diabetes Record Information Standard you should consider and mitigate hazards using the documentation. Any suppliers you work with must:

  • Develop their own safety case and hazard log, using NHS guidance DCB0160
  • Have registered clinical safety officers to ensure the systems implemented are safe for use and person care
  • Run risk assessments to determine the likelihood and consequence of a risk happening.

 

As part of ongoing clinical risk management, it is recommended that regular clinical risk assessments are undertaken. This can be done using a recognised tool e.g., SWIFT or BOW TIE.

 

Resources

Monitor, measure and adjust

Once you have implemented the Diabetes Record Information standard, you’ll want to measure the success of your implementation, e.g. how often the elements within standard are being used and whether it is improving care and/or patient experience. 

 

Analysing the results

  • Are the expected benefits being achieved?
  • If not, why not and how could this be improved?
  • What has been learnt that would improve the process and outcomes?
Diabetes self care

You should expect to go through iterations to get your implementation right over time. This gives you a chance to review data on the effectiveness of the changes and course correct as needed in iterative cycles:

Define clear roles and responsibilities

Reflect on the data you have gathered

Make adaptations to your system or processes

Celebrate and publicise successes

Repeat

Go to

Putting the standard into practice
Develop a detailed timetable
Plan and procure system changes
Piloting
Training
Safety case and hazard log
Monitor, measure and adjust

PRSB Standards Explained

Why we need standards to record our health and care information in a consistent way so that it can be made available whenever it is needed.

Read More

Making change happen

Transformation programmes need clear goals, the right leadership and engaged staff and stakeholders. Get started by reading our information on transformational change.

Read More

PRSB Support Available

If you have a question for PRSB, please contact our support team. We have an expert team who can help you find the answer, or direct you to the right place.

Read More

Personalised care and support planning for people with severe mental illness

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides more detailed explanations about each element of the plan, including advice on how the planning process might be best conducted.
These questions might form a checklist for current plans to be compared with. 

1. Does the plan include an About Me section in which the service user, in their own words, can indicate the information they want to be available about their lives, their values, their interests, and priorities, available for all those who may care for them?
2. Is the approach to developing a care plan patient centred and engaging, allowing plans to be based on patient priorities goals, and aspirations, along with the actions they plan to take and the support that they will receive?
3. Is there space for a “formulation” to be recorded in which the person receiving care and the professionals who provide it, share and record the personal meaning and the origins of the person’s difficulties?
4. Are relevant procedures and therapies recorded?
5. Where relevant, are one or more contingency plans included for anticipatable disruptions, exacerbations, or deterioration, and do they include advice on what to do and points of contact for those called upon to respond?
6. Where relevant are additional supporting plans incorporated, (an example being an “educational and health plan” for someone with a neurodevelopment disorder)
7. Is a version of the plan available to a service user (if they wish to have it) in a form and format that they can understand and find to be of value?
8. How is a version of the plan available to the GP and other key parts of the health and care system?

Work conducted by PRSB and partners recently has looked specifically at the suitability of this approach to the development and documentation of care and support plans for people with Severe Mental Illness. This resulted in an updated version of the standard (v1.4), for use by any service and for any group of service users, but with some modifications to ensure that it meets the needs of this community. The approach to a patient centred process of identifying goals, hopes, and values, and the support needed to achieve them, is fully compatible with and can be conducted using, specific tools in use in mental health, such as DIALOG, DIALOG+, and ReQoL, for example. 

Where analysis indicates the need for improvement in the content and process of personalised care and support planning for patients with Severe Mental Illness, specific improvement projects should be instituted to co-design with service users and their representatives, and the relevant staff groups, new approaches, and documentation that would be of value in delivering improvement. The toolkit includes a range of existing resources that could be used to engage in this improvement work, including signposting to relevant existing approaches informed by patient experience-based design.

Moving to a single holistic plan

A review of a sample of current care plans, and the way they have been developed, may be helpful in identifying the priorities for this improvement. The PRSB Implementation Guide provides A key development, consistent with national policy on support for Personalised Care across all health and care sectors, is the move towards an individual with complex needs having a single, integrated, care plan, rather than a series of plans developed by different parts of the health and social care system in isolation of one another. For a patient with severe mental illness, the related concerns and challenges might form a very prominent part of such an integrated plan; many will also have concurrent health challenges and needs. The intention is that the relevant services work together to plan and wrap support around the patient and their family in an integrated way, rather than as a series of sequential or disconnected encounters in which the service user or their friends and family have to adopt the role of the integrator.

A starting point would be to agree priority groups of service users who may already have more than one care plan because they need care from more than one part of the system of health and social care. This could be initiated by looking at service users registered with some sentinel practices or PCNs. Alternatively, the approach might focus initially on people with defined co-morbidity or risk that entails collaborative care with agencies beyond specialist mental health services.

The focus here is on the process of care planning and agreement on what should be shared, rather than solely on the technology used;

1. What is the process to agree which professional will initiate care planning and act as the “lead point of contact” for the service user?
2. Will initial plans be agreed with the service user in joint consultations or sequentially? Where and how will they be conducted?
3. What will be the process to agree the elements of the plans which should be available to professionals and potential authorised users beyond the immediate care teams, (A&E services, Ambulance Services, Social services, etc.) with the service user’s consent?
4. How will elements of the plan be updated following consultations in a way which is proportionate, to allow contact and progress notes to be maintained by the service conducting the consultation, whilst avoiding unnecessary work for partners in care if there is no significant change to the personalised care and support plan?
5. What are the implications for workload, logistics, and administration arising out of these decisions?

The answers to these questions and others will best be elicited through focused joint working, grounded in real, or at least realistic examples. This will entail process mapping, and co-design with a range of professionals, service users, and families. Resources from the toolkit and outputs from the Simulation element of this project will be valuable. Some organisations would adopt an approach such as a Rapid Process Improvement Workshop, planned over several weeks and conducted over a number of sequential days, to develop prototype ways of working that could be tested in the field.

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.”