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Multidisciplinary Team WorkingThe Productive Community HospitalTM

Releasing Time to Care

Version 1This document is for clinical leaders, department managersand senior therapists

CH_MDT_PDF:PRINT 11/8/08 16:00

© Copyright NHS Institute for Innovationand Improvement 2008

Releasing Time to Care: The ProductiveCommunity HospitalTM – MultidisciplinaryTeam Working is published by the NHSInstitute for Innovation and Improvement,Coventry House, University of WarwickCampus, Coventry, CV4 7AL

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ISBN: 978-1-906535-43-8


Contents

03

Page

03

09

15

19

35

57

61

69

Contents

Multidisciplinary Team (MDT) Working

Prepare (getting ready)

Assess (understand how we are doing)

Diagnose (what does good MDT working look like?)

Plan (discuss and agree changes)

Treat (test the agreed changes)

Evaluate (assess the impact of the changes)

Case studies

The Productive Community Hospital Multidisciplinary Team Working


04

PatientFlow

ManagingDrug Administration

Good StockManagement

Admissionand Discharge

ForwardPlanning

MultidisciplinaryTeam

Working

HandoverInpatients

DayHospital

MIU

Inpatients

DayHospital

MIU

Too

lkit

Pati

ent

Invo

lvem

ent

Project Leader’s Guide

Executive Leader’s Guide

Kn

ow

ing

Ho

w w

e ar

e D

oin

g

Clin

ical

Lea

der

’s G

uid

e

The Productive Community Hospital

These modules create The Productive Community Hospital


Multidisciplinary Team (MDT) Working

What is it?

A practical way to improve MDT working on your ward/department, focussing on integrated working andimproved communication.

Why do it?

To give patients safe, reliable and coordinated care by:• clearly identifying roles and responsibilities• joined-up patient assessments that remove duplication and avoid repetition for the patient• good documentation that supports a way of working in a more productive way

To improve the experience for staff by:• reducing repetition of information recording and transfer• maximising the time for direct patient care• improving the documentation by making it easier to access and to understand what is happening to

the patient

05 The Productive Community Hospital Multidisciplinary Team Working


What it covers

This module will help you improve your MDT working by demonstrating:• how you currently work as an MDT• who are the key people that should be involved• what tools you will need to use• how to evaluate your improved MDT working and make continuous improvement to sustain the changes

you have made

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What it does not cover

This module will not describe best clinical practice. It will help you identify areas that could benefit fromimprovement work, understand how they could be improved and help you to make it happen.


Learning objectives

After completing this module, you will:

• understand how to prepare for the module• develop audit as an activity• understand how the MDT currently works• understand what is meant by productive MDT working• develop the MDT to work more productively


How will you achieve theseobjectives?The first three objectives will bemet by the step-by-step approachwithin this module to help you toassess the current ways of workingand diagnose the problem areas by performing four pre-improvement audits. These are:• induction quality audit• MDT meeting quality audit• record keeping audit• MDT meeting summary audit.

By carrying out these audits you will be able to identify what you do well and not so well in MDTworking.

As you work your way through this module you will be able toidentify what needs to changeabout the way the you work as anMDT.

By repeating these audits you willbe able to measure the differencesmade to your MDT working.

The last two objectives will be met through a step-by-stepapproach to describe what a good process is and how you can achieve it.


The 6 phase process

All of the modules in the ProductiveCommunity Hospital series arebased on the standard nursingprocess of: prepare, assess,diagnose, plan, treat and evaluate.

While illustrated using a patientcare cycle, the six phase process is the same as the genericimprovement cycle Plan, Do, Study, Act and gives clinical staff astructured approach to improvingclinical area processes that is verysimilar to the care cycle they arefamiliar with.

It is a cyclical process of continuousimprovement. Once you haveworked your way through thismodule, you should return to theassess section and repeat the steps.The results that you capture eachtime will show how you haveimproved since the last time.

As you work through the moduleyou will be reminded about thestage of the process that you areworking on.

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The 6 phase process

Prepare Assess

Diagnose

Plan

Treat

Evaluate

• decide who will be involved • talk to staff• gather information

• review the current MDT workingprocesses

• assess how well you are working

• identify how MDT working could be improved

• audit the processes and identify changes

• prioritise what you want to change• plan new processes

• determine the test period• run the new processes

• analyse the information

• embed the new process• communicate the success


In order to know how well you are doing and help you treat any problems that you find with your MDT processesyou will need to use the tools listed below.

The tools

010

Tool

Interviews

Video

Good Practice Induction Questionnaire

Good practice Induction Template

Roles and Responsibilities for Staff Induction

Shared Care Records Examples 1 and 2

Good Practice MDT Summary Document

Toolkit reference number

Toolkit General Section 2

Toolkit General Section 4

MDT Working Tool 1

MDT Working Tool 2

MDT Working Tool 3

MDT Working Tool 4

MDT Working Tool 5

Copy the module checklist on page 65. Completing this will help you monitor your progress throughout the module.


011

Prepare


12

Involving the right people

Decide who will be involvedTo achieve effective MDT workingyou will need to engage with allmembers of the team.

• establish a core team who will lead and take responsibility for the work in this module. These might include those listed in the box

• widen this group when you require more involvement from other members of the staff and patients

Who? What will they do?

Core module team

Ward/department manager or seniortherapist

Ward/department MDT staff

Patient/carer

• take the lead for implementing this initiative• communicate the goals and objectives• encourage and support the team throughout

the initiative• keep the focus on searching for opportunities

for improvement

• be willing participants in the discovery of issues and implementation of new approaches

• bring a fresh perspective and a unique insight• ensure that improvements are patient focused


1. Talk to staffUse Toolkit General Section 2.You will need to talk to staff andget their views on the way theycurrently structure their day: • what currently happens? • what causes problems?• what they would like from

improving the structure of the working day?

2. Talk to patientsUse Toolkit General Section 2.To ensure that MDT workingsupports patient-centred care, theviews of patients should be soughtas part of your general preparation.

You should seek guidance from yournursing director or your patient andpublic involvement lead.• what is the patients’ experience

of the day?• how would they like to be

involved?• what would they like to happen?

3. Gather information from patient complaints• look back over the past year and

identify any complaints that relate to treatment/appointments that have been missed

4. Gather information from incident reports• look back over the last 50 incident

reports and identify any regarding patients that have missed necessary treatments/care due to lack of coordination of the working day

5. Obtain your trust policy orguidelines for documentation andthe policy on confidentiality.

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The 5 step process



14


15

Prepare - milestone checklistMove on to Assess only if you have completed ALL of the items on these checklists

Checklist

Decide who will be involved

Talk to staff

Talk to patients

Gather information from patient complaints

Gather information from incident reports

Obtain your trust policy or guidelines for documentation

Tick if complete

Effective teamwork checklist

Did all the team participate?

Was the discussion open?

Were challenging questions discussed and agreed by all?

Did the team remain focused on the task?

Did the team focus on the area/process, not on individuals?

Tick if yes



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17

Assess


Assess the current MDT working processes

To assess what happens now,develop a description of how youcurrently work as an MDT. You cando this by taking a step-by-stepapproach.

There is added value in gettingeveryone involved in understandinghow you work together, to agree onhow things currently happen andwhat the future state should looklike.

Do this by:• identifying the key people who

are involved in the MDT. Thesewill include the ward/departmentmanager and a representativefrom each staff group in the MDT,for example the physiotherapists,occupational therapists, nurses,doctors, social workers, patientsand carers

• describing the current way youplan and work as a team. Focuson:- how often you meet as a team- how many of the team regularly

meet- how long the meetings take- how satisfied you are with the

content and outcomes ofmeetings

• describing what an ideal MDTworking situation would look like in your team’s view. This isyour ‘ideal future state’

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Assess - milestone checklistMove on to Diagnose only if you have completed ALL of the items on these checklists.

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Checklist

Understand of how the MDT processes currently works

Ensure that all the staff have been able to give their feedback on current MDT processes

Make sure that all members of the MDT are represented

Understand how often the MDT meet as a team

Understand how the ideal MDT would work

Tick if complete




Were hard questions discussed and agreed by all?



Tick if yes



20


Diagnose

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The audit process

To help you diagnose the currentstate of your MDT process,undertake the following pre-improvement audits specific to this module. These are:• induction quality audit• MDT meeting quality audit• record keeping audit• MDT meeting summary audit

At the end of each audit,communicate your results to the team.

Induction Quality Audit

Staff to completean inductionquestionnaire one month afterthey commencedemployment

MDT MeetingQuality Audit

Take a videosample of theidentified MDTmeeting –approximately 45 minutes inlength. Use thisto assess theproportion (%)of value-addingtime during themeeting, confirmthe length ofmeeting andidentify thenumber ofpeople-minutesinvolved

Record Keeping Audit

Count thecompletenessand duplicationof key qualityindicators, usingcurrent caseload.

Count how manypages make upyour currentrecords.

Count length oftime to completeassessmentdocumentationon five patients.

Count timeto locateinformation forfive patients

MDT MeetingSummary Audit

Count thecapture of post-MDT meetinginformation forpatients on yourcurrent caseload

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Induction quality audit

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• set up a working team withrepresentatives from each staffgroup

• devise the audit questionnaire• review the Good Practice

Induction Questionnaire• change it so that it is right for

your ward/department ie, insertnames of specific departments andwards

• share the questionnaire with theteam and ask for comments fromthe working group and wider staff

• update the questionnaire basedon comments received

• identify which groups of staff youwant to complete an inductionquestionnaire, include medicalofficers and therapists

• identify the members of stafffrom these groups who haverecently joined the team (withinthe last 12 months)

• issue the questionnaire and askstaff to complete and return it bya specified date

• analyse the results• record what staff found helpful

and what needs to be changed

Once established as a regular audit you should ask all new staff tocomplete the induction questionnaire one month after they start work.

Available in the Toolkit, MDT Working Tool 1.

This audit tells you how effective your induction processes are.



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MDT meeting quality audit

1. Inform staff when the audit willtake place and why.

2. Identify an MDT meeting atrandom to be audited.

3. Obtain a video recorder.Refer to the Toolkit, GeneralSection 3, for guidance on videorecording.

4. Record the whole of themeeting.

5. Schedule at least two hours toreview the film with a group ofyour team members. Invite atleast one person who wasn’t atthe meeting to give anindependant opinion.

6. Ensure that everyone is familiarwith the seven types of waste(see opposite page). The seventypes of waste are normally usedin lean thinking. This is a way oflooking at processes andidentifying how they can bemade more efficient by takingaway the things that hold up theprocess. For example having towait for people to arrive for themeeting to be able to start.(Continued on page 24)

This audit will tell you how effectively you utilise your MDT meeting andhow much wasted time and effort takes place.


Summary of the seven different types of waste normally assessed in a lean process review.

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Waste Type

Waiting

Stock

Motion

Transport

Rework

Overprocessing

Overproduction

Description

Tasks that cannot be performed due to waiting for people, equipment, information or materials. In the context of MDT meetings this means waiting for people to arrive,waiting for the notes.

Any build-up of stock that is in excess of that which is required to meet demand. Any queuing of work and/or clients. In the context of MDT meetings this means theduplication of information from more than one party, having to read throughnumerous records to find the information.

Unnecessary movement of people. In the context of MDT meetings this meansbringing people to the meeting that do not need to be there.

Unnecessary movement of materials and equipment. In the context of MDT meetingsthis means collecting and bringing records and information that are not required forthe meeting.

Repeated work due to a prior failure to deliver a correct service. This could be due topoor information at the time. In the context of MDT meetings this means having tore-request actions which have not been completed as planned.

Work that adds no value from the client’s point of view. In the context of MDTmeetings this means sharing information or talking about items that are not relevantto the meeting.

Doing more than is required or earlier than it is required. In the context of MDTmeetings this means discussing in too much detail than is required for the meeting.



7. Draw a time-line on a big piece of paper which has the elapsed time across the top, split into five minuteintervals, and rows for each of the seven types of waste. Give everyone a pad of sticky notes and a marker pen(see example below.)

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StartPoint

waiting

stock

motion

transport

rework

overprocessing

overproduction

Five minute intervals

5 10 15 20 25 30 35 40 45 50


8. Review the first five minutes ofthe video together, each personwriting the waste that they seeon a sticky note. Agree whatwas identified as waste and postit on the brown paper.

9. Replay the rest of the film in five minute intervals and geteveryone to place their stickynotes on the brown paper wherethey believe there was waste.

10.At each stage agree what timewas value adding and record thiswith the marker pen.

11.Calculate a value-addedpercentage as: (value-addedtime / total time) x100.



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Record-keeping audit

1. Undertake both a qualitative(quality) and quantitative(quantity) audit of recordkeeping. Assess your currentcaseload for completeness of theinformation. You might want totake a percentage of your recordsor a number of patients ratherthan the whole of your caseload.Include all of the MDT members’records in this audit. Identifywhat you and your team considerto be important indicators ofquality record-keeping.

These could include the following:• medical assessment• nursing assessment• allied health professional

(AHP) assessment• care plan• discharge plan

2. Identify the three mostimportant issues or presentingproblems for your patients andcreate a simple table. For example:• pain• mobility• personal care requirements• presence of discharge plan

This audit will tell you how comprehensive and complete your records are.


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Important indicators of quality record keeping

Medical assessment

Nursing assessment

Allied healthcare professional assessment

Care plan

MDT meeting follow-up plan

Frequently presenting problems/issues for your patient

Pain Mobility Personal care

% completed in any record


Create a simple table to collect your information as example below.


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3. Using the records that you have identified, establish the percentage of completeness for each area. The examplebelow shows five important indicators of quality in the left hand column. It then identifies three frequentlypresenting problems for patients - fatigue, anxiety and depression and pain. The team then assessed their currentpatient notes to identify if these problems were recorded in the quality indicator element of the notes.

Important indicators of quality record keeping

Medical assessment

Nursing assessment

Allied healthcare professional assessment

Care plan

MDT meeting follow-up plan

Frequently presenting problems/issues for your patient

eg, Fatigue Anxiety and depression Pain

20 75 100

90 50 100

50 20 20

75 80 100

50 80 100

% completed in any record


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4. To provide a quantitative audit of your record keeping, start bymeasuring the time taken tolocate the important indicatorsof quality. Use five typicalpatients and search for andsummarise the information.

5. Count the number of pages inthe complete sets of all therecords you currently use, byMDT group, then calculate theaverage.

MDT Group

Nursing

Medical

Physiotherapy

Occupationaltherapy (OT)

Total

Time to locate the important indicators of quality

MDT Group

Nursing

Medical

Physiotherapy

OT

Total

Average

Average number of pages in record



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6. Now assess the length of time it takes for the individual MDT group members to complete the admissionassessment documentation. Time five admissions and then average the time for each MDT group.

MDT group

Nursing

Medical

Physiotherapy

Occupational therapy

Total time

Average (Total time/no.of MDT group members)

Patient 1 Patient 2 Patient 3 Patient 4 Patient 5


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MDT meeting summary audit

1. With your team, identify theimportant information to recordfollowing the MDT meeting.These could include:• patients personal details• completed initial assessment• identification of the responsible

person for the patient• identifying when the next

review will take place• expected discharge date

2. Establish percentagecompleteness for each recordthat is being audited.

This audit will tell you how well you document your MDT meetings.

To make a qualitative judgement on the completeness of the meeting records, undertake an audit of yourinformation recorded in notes following the MDT patient review meeting. Use your current way of recording theoutcome of the MDT meeting and follow the next steps.

MDT Group

Patient’s personal details

A completed initial assessment

Identification of the ‘responsible person’

Identification of when the next reviewwill take place

Expected discharge date

Recorded post MDT meeting

90%

75%

50%

65%

40%



Diagnose - milestone checklistMove on to Plan only if you have completed ALL of the items on these checklists.

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Tick if completeChecklist

Give all staff the opportunity to fill in an induction questionnaire

Make sure that all types of MDT are represented in the audits

Be very clear about how effectively you use your MDT meetings

Time how long your MDT meetings take

Identify where there is waste in your meetings

Know what your ‘value-added’ time is for your MDT meetings

Complete a record-keeping audit to understand the completeness of the records

Know how complete your MDT meeting summary records are

Understand your current induction processes. What happens when staff join your wardor department now? Do you know how staff feel about it?








Tick if yes



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Plan

37


Planning productive MDT working

Having diagnosed the current statusof your MDT working, this sectionwill take you through the planningsteps to help you to treat your MDTworking and make it better.

This will help to make your MDTworking better by: • creating a common induction for

all staff• creating guidelines for effective

MDT meetings • creating a shared care record• creating a MDT meeting summary

document

Do this by using the following -MDT Working Tools 1 to 5:• Good Practice Induction

Questionnaire• Good Practice Induction Template• Roles and Responsibilities for Staff

Induction• Shared Care Records Examples 1

and 2• MDT Meeting Summary Template

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39

Having a common induction processis important to identify the rolesand responsibilities of everymember of your team. This isparticularly important in the MDTsetting to make the best use ofeveryone’s skills. The guidance inthis module is for staff needinginducting to the ward ordepartment. It is in addition to the trust induction and anyprofession/team specific inductionfor staff.

The objectives of the guidance ondeveloping a common inductionprocess are to:• set out the expectations of new

staff to the ward/department interms of the expected behaviourof new members of the team

• formalise their integration andtheir role in the team

• explain how the ward/departmentworks and what theward/department expects of them

• provide a ‘buddy’ system toorientate them to the hospital

• provide the health and safetyinformation they need

• provide a common induction to all staff

Creating a common induction process



Improve your current induction process

1. Identify information that isrequired in the induction pack.

2. Use the information from theinduction quality audit youundertook to see what new staffmembers reported about theirinduction to theward/department.

3. Look at existing inductioninformation and templates.

4. Draft a template with all theidentified areas included.

5. Identify who the inductionprocess is aimed at – this mayinclude doctors, admininstrators,nursing staff and support staff.

6. Set up a working team withrepresentatives from each groupof staff.

7. Review the Good PracticeInduction Template, ToolkitMDT Working Tool 2.

8. Modify the template you havedrafted, taking account of thegood practice example and theinput from the working team.

9. Share the induction template andask for comments from theworking group and wider staff.

10. Update the induction templatebased on comments received.

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An example of a good induction process

1. Complete the induction over aperiod of two weeks.

2. Begin the induction by providinga basic overview of your roleand that of your team.

3. Provide the inductee with aninduction pack, based on theinduction template that youdeveloped. It will includeinformation such as theorganisation’s structure,department layout, site map,how to access policies andprocedures, and theward/department philosophy.

4. Allocate a buddy to the newmember of staff. The buddy willusually be a junior member ofward staff. A buddy will

orientate the new staff memberto the building to ensure theyhave sufficient knowledge torespond in an emergencysituation and then provideongoing support and guidancein the first few weeks.

5. Plan time to review theinduction with the new staffmember together with their linemanager and to sign off theinduction when it has beencompleted.

An example from a test site, Toolkit MDT Working Tool 3. Youmay wish to develop some goodpractice guidelines for your ward.



An example of good induction materialThis is a partial example, from one of the test sites, of some of the information that you might want to include in your induction pack for new staff. It will help them to understand who all the different people are and what they do.

Role

Clinical manager

Nurse

Health careassistant (HCA)

Medical staff

Overview

Has overall responsibility for the running of the clinical area, nursing staff, visiting staff andadministrators for their area

The role of the nurse is to ensure the delivery of safe, evidence-based, quality care. Theywork within an interdisciplinary team of nursing, therapy and other clinical and administrativestaff. They provide a broad range of therapeutic activities that will be specified by theindividual programmes of care for patients/users. Nurses are also responsible for theassessment of care needs and the implementation of patient care within their clinical area; thiswill include admission and discharge, providing support, supervision and education to patients,relatives, and staff. The senior nurse will also deputise for sister/charge nurse/manager in theirabsence including team leadership and intervention in emergency situations

HCAs are responsible for supervising and assisting patients with the activities of daily living,participating in handover and reporting incidents to the nurse in charge. They should bevigilant, caring, and observant at all times and treat each individual (patient, relatives orcolleague) with respect and dignity. The HCA must give clear, accurate and timelyinformation to appropriate staff at all times

Medical staff form part of the MDT that manages the patient’s care plan. They provideongoing medical assessment, diagnosis and timely review of the patient. They haveresponsibility for liaising with MDT members, goal planning, improving outcomes anddischarge planning

42


43

Holding effective MDT meetings

Examples of ineffective meetingpractice include:• the team is not clear on the

purpose of the meeting• the objectives are not stated• the right team members are

not present• participants are not prepared• meetings are not conducted with

a complete agenda• meetings start and end late• quieter participants are not

encouraged to participate• actions are not assigned to

individuals with agreed timescales• leaders arrive late for meetings• leaders seem to call/attend

meetings routinely rather thanout of necessity

The objectives for effectivemeetings are to:• reduce the amount of meetings

that you attend or callunnecessarily

• improve the quality of theoutcomes that you achieve in yourmeetings to support patient care

• improve the responsiveness toactions being followed up byparticipants

• improve the quality of thepreparation that is undertaken formeetings

• improve the quality ofconversations in the meetings

• improve the level of participationin meetings

Making meetings more effective will reduce the time required for themeeting, as well as improving staff attendance and representation.Importantly it should lead to a better outcome for the patient.



44

Actions for holding effective MDT meetings

1. Ask yourself: • do I need to hold a meeting

at all? • what am I hoping to achieve

through the meeting? • who needs to be there in

order to accomplish these objectives?

• what do I know about my participants and to what level of formality do I need to go?

• based on the answers to the above, what is the most appropriate forum for the meeting?

2. Understand the criteria forholding an effective meeting. The three key criteria forachieving this and how thesecan apply to you, both as anorganiser and participant.


45

3. Identify who will attend theMDT meeting and set up aworking group withrepresentatives from allprofessions.

4. Review your objectives andcriteria for the meeting andrecord these to maintain focus.

5. Agree with the working groupappropriate meeting intervals toadequately address patient care.Think about the average lengthof stay of patients or thenumber of attendances in a planof care. For example, where theaverage length of stay is 72hours, daily meetings areappropriate, where the averagelength of stay is three months,weekly meetings may be moreappropriate.

6. Agree a suitable agenda for themeeting. For every patient youwill need to cover:• background• action taken to date• update• next steps

7. Allocate a time to discuss eachpatient. They will not all take thesame amount of time. Allowenough time to confirm the nextsteps for each individual patient.

Patient name

• action to date

• update

• next steps

Lead participants

Responsible clinician

Active MDT members

Chair

MDT meeting agenda



46

8. Agree a set of meeting groundrules with the working group. As a minimum these groundrules should include:• starting and finishing the

meeting on time• holding the meeting in an area

away from disturbance – ideally in an office where the door can be closed

• designating members of staff to cover the ward whilst the MDT meeting is being held.

• Appointing an appropriate deputy to cover periods of absence for every member

9. Prepare for your meeting, youshould consider the followingpracticalities:

Identify the chairperson

Schedule the meeting for a time and place that is convenient for all

Identify the names of the patients to be discussed

Book the venue, ensuring the room is suitable

Book the equipment ie, projector, flip charts, tea/coffee

Assign a note taker to capture minutes and actions

Notify the participants (these should be only essential attendees)for cases to be discussed

Send the agenda out in advance of the meeting with clear objectivesfor the meeting

Organise the relevant patient files in order of patients to be discussed

MDT preparation meeting checklist

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47

10.Agree how documentation will be updated and shared.

11.Agree a start date for the newmeeting format with theworking group.

12.Publicise the start date with acopy of the meeting ground rules

13.Set a date for the working groupto review the success of the newmeeting format after one month.

14.Once the meeting has begun it isimportant to allow all participantsto contribute. It is important thatwhichever MDT member ischairing the meeting managesthe dynamics of the meeting. Thismay mean that they have to dealwith participants who are silent,dominant, or negative. Here are

some tips for dealing withdifficult participants:• members who are silent.

Make sure that you engagewith all the members of themeeting where possible. Thiscan be achieved by asking forviews, or experiences such as‘What do you think x?’ or ‘Iknow you have undertakensomething like this before,what were your experiencesx?’ If your meeting is large, you could considerbreaking into smaller groupsto develop input

• members who are vocallydominant.Try to redirect discussion toother members: ‘We allrecognise your expertise in thisarea, but let’s hear from someothers in case some new ideas

emerge.’ ‘Does anyone elsehave something they wouldlike to add?’

• members who are negative.Try to probe the negativity inorder to clearly articulate andvalidate the concerns. Try toredirect the discussion to othermembers of the meeting: ‘Let’snot shoot down this ideaprematurely; what do youthink x?’. If the behaviourpersists, consider speaking tothem after the meeting to helpthem understand the impact oftheir negativity on themeeting



15.It can be frustrating to be in ameeting that is ineffective.Offer this guide to theparticipants to help make themeetings they attend moreeffective.

• know why you are there

• be there on time

• stay on the subject

• don’t cause problems for the leader

• be open to the ideas of others

• help the leader control the meeting

• share best practice

Effective meeting tips

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49

Creating a Shared Care Record

The objectives of a shared carerecord are to:• increase effectiveness of the

patient record as a communicationtool amongst the MDT members

• reduce the number of places eachdisciplines’ assessment is storedand the amount of repeatedinformation

• provide a communication processthat allows access to all membersof the MDT, including the socialworker

• provide a single document withall MDT staff contributing

• make the documentation easierfor everybody to use andunderstand

Using a shared care record will help to optimise clinical outcomes by standardising the care planning process where possible, and allowing for shared understanding of assessments and care delivery.



50

Actions for creating a Shared Care Record

1. Identify who will use the SharedCare Record and set up a workinggroup with representatives fromall professions.

2. Review the audits youundertook on record keeping to identify what you need toinclude as key requirements.

3. Identify any areas of overlap inthe notes and draft an outline ofa record that will reduce theseinto one document.

4. Review existing guidance such asNICE guidelines, National ServiceFrameworks (NSFs) andprofessional regulatory bodyguidance to ensure thatimportant information iscaptured in your shareddocument. Remember yourrecords should comply with localand national guidelines fordocumentation including thesingle assessment process (SAP).

5. Decide which parts of thedocument need to be uni-disciplinary (eg, just nursing) and which are multidisciplinary(eg, assessment of ability of thepatient to feed themselves).

Note: the Shared Care Record ismade up of two elements; Firstly ithas discipline-specific informationand secondly it has genericinformation that may be collectedby any member of the MDT. Eachdiscipline completes their ownassessment on the template and asother information is obtained by theMDT, such as progress, outcomes,planned interventions; it is added tothe joint section of the template.

Examples of Shared Care Recordsare available in the Toolkit, MDTWorking Tool 4.


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6. Review the examples of goodpractice shared/joint records.

7. Modify the Shared Care Recordto reflect the audit findings andthe input of the working group.

8. Consider including assessment or screening tools to improveefficiency. This choice depends onthe function and purpose of theunit, but could be a functionalImprovement assessment. This willallow you to quickly understandthe priority issues/problems forthe patient and plan yourinterventions and your nextdetailed assessment requirements.Two examples of initialassessment/screening tools aregiven at the end of this section.

9. Distribute the Shared CareRecord to the working groupand wider staff and ask forcomments.

10. Update the template based oncomments received.

11. Agree with the working groupand your line manager how theShared Care Record will beupdated and communicated.

12. Agree a start date with theteam and your line manager.

13. Publicise the start date with acopy of the Shared Care Recordand guidance notes forcompletion.

14. Set a date for the workinggroup to review the success ofthe template after one month.

Examples of Shared Care Recordsare available in the Toolkit,MDT Working Tool 4.


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Creating a Shared Care Record - The Barthel Index

The Barthel Index is widely used in the rehabilitation setting. It is provided here as an example of a clinicaloutcome measure to help prioritise intervention and detailed assessment.

With help Independent

1. Feeding (if food needs to be cut up = help) 5 10

2. Moving from wheelchair to bed and return (includes sitting up in bed) 5-10 15

3. Personal toilet (wash face, comb hair, shave, clean teeth) 0 5

4. Getting on and off toilet (handling clothes, wipe, flush) 5 10

5. Bathing self 0 5

6. Walking on level surface (or if unable to walk, propel wheelchair) 0* 5**score only if unable to walk

7. Ascend and descend stairs 5 10

8. Dressing (includes tying shoes, fastening fasteners) 5 10

9. Controlling bowels 5 10

10.Controlling bladder 5 10

Mahoney FI, Barthel D. “Functional evaluation; the Barthel Index.”Maryland State Med Journal 1965;14:45-61. Used with permission.


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Creating a Shared Care Record - The Distress ScoreThe Distress Score is a palliative care assessment tool that was used by one of the test sites. It is provided here asan example of another clinical outcome measure.


Holland JC et al. Clinical practice guidelines in oncology: distress management.National Comprehensive Cancer Network 2005 (version 1).


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Creating a MDT meeting summary document

The MDT meeting involves severalstaff from a range of disciplines,providing their own professionalperspective of each patient theycare for. The meeting provides theopportunity to transfer informationand come to agreed decisions oncare planning.

The objectives of the MDT meetingsummary document are to:• document discussions taking place

at the MDT meeting and to plancare accordingly

• facilitate good communicationbetween the MDT members inwhich a summary of findings andactions are recorded as a result ofthe MDT planning meeting

• include a named professional andtime frame for completion / reviewof each task

• provide information which wouldbe useful to all MDT members


1. Identify any existing national,international or local guidanceon patient assessment or MDTworking.

2. Review the good practice MDTMeeting Summary Template.

3. Identify who will use the MDTMeeting Summary Template and set up a working group with representatives from all professions.

4. Using the record keeping auditsyou have undertaken, identifythe key information you want torecord. This is likely to include:• element of need• plan of care• responsible professional• review period

5. Modify the template for localrequirements.

6. Share the template and ask forcomments from the workinggroup and wider team.

7. Update the template based oncomments received.

8. Agree a start date with the team and your line manager.

9. Publicise the start date.

10. Issue a copy of the template andguidance notes for completion.

11.Set a date for the workinggroup to review the success ofthe template after one month.

An example of the MeetingSummary Document is available inthe Toolkit, MDT Working Tool 5.



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Using the MDT meeting summary document that you have createdOnce you have created thesummary, you need to use it. The following steps will help you in the planning phase:• identify who should attend the

MDT meeting. It may be mostappropriate to nominate ‘coremembers’ and to ensure that theyare able to attend on a regularbasis

• each MDT member should have anominated deputy to coverperiods of absence

• identify the average length ofstay of patients on the unit andset meeting intervals toadequately address patient care.This interval will become thedefault time period for taskcompletion/review

• if possible arrange for anadministrator to record themeeting summary documentation.They should not need tocontribute to discussions, otherthan to clarify administrativedetails

• decide which format to documentthe meeting (electronic, paperetc). If possible, use a projector todisplay electronic documentationin real time. The whole team cantherefore agree the final,completed summary for eachpatient before it is saved. This alsoallows easy retrieval if morecopies are required

• record in a diary the dates bywhich tasks must be completed,ensuring each professional hasaccess to this diary

• agree who will receive a copy of the MDT meeting summary -patients, GP, etc.

• identify who is responsible forsharing the MDT meetingsummary and how


Plan - milestone checklistMove on to Treat only if you have completed ALL of the items on these checklists.

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Checklist

Create a common induction process?

Create a shared care record?

Create an MDT meeting summary document?

Engage with all staff and patients (where appropriate)

Tick if complete







Tick if yes



58


Treat

59


Treat

During the treat phase you will betesting the agreed changes.

What are you going to test?• have we improved the experience

for patients?• have we improved the experience

for staff?• have we reduced waste?• does everyone in the team

understand the new process?• are we sticking to the new

process?

Before the test starts:• determine what the time period

will be for the test. • it needs to be:

- long enough to allow for failures- short enough to change and retest

• identify additional temporarydata collection methods

• agree the time collection methodand who is going to do it

• set the start and end dates – andcommunicate them to everyone

• update all staff personally onprogress, at meetings and acrossall shifts

During the test:• get daily feedback from staff and

patients (where appropriate) onhow they feel the new process isworking

• invite visitors and/or seniormanagement to view your newdocumentation and comment onthe process

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61

Treat - milestone checklistMove on to Evaluate only if you have completed ALL of the items on these checklists.

Checklist

Test period defined

All staff informed

Try out (test) the new process

Time new processes (where applicable)

Get staff, patients and family feedback on the new MDT working process

Film the MDT meeting process

Tick if complete







Tick if yes



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Evaluate

63


Evaluate progress

1. Collect informationOnce you have been working in the new way for the agreedtime period you will need torepeat:• induction quality audit• MDT meeting quality audit• record-keeping audit• MDT meeting summary audit

2. Analyse the informationSet up a review meeting to include the original core team for The Productive CommunityHospital Programme.

Use the results from the auditsto help you to evaluate thechanges made.

3. Further improvementThis information will help you to understand where you need to go back to. Decide where there are still opportunities forimprovement and repeat theprocess until your future state is achieved and sustained.

4. Communicate successDon’t forget to tell people, staff and patients, what you haveachieved, verbally and on yourcommunications board.

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65

Evaluate - milestone checklistWhen you have completed the checklists below, go to the module checklist on page 65.

Checklist

Talk to staff, patients and relatives about the new MDT working process

Look at the before and after process times

Look at the before and after value added times for the MDT meetings

Communicate success

Tick if complete







Tick if yes



How to sustain the change?

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Monitor and audit continually

Ensure leadership attention

Do not stop improving

• conduct the audits regularly to ensure that the changes that you have made are being continued and are working

• ensure that senior managers are engaged and informed of what you are doing

• give regular feedback about the progress that you are making at meetings which involve key people

• ensure that you display and discuss the audit results with department staff regularly to keep up the pace of change

• encourage the department staff to continue to find new and better ways of doing things – it is not about doing this once but about improving things continuously

• encourage staff to suggest and implement changes themselves


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MDT module checklist

All new staff receive an induction pack

A shared care record is used to record patient care

MDT meeting summary documentation is clear, concise and produced in a timely way, as agreed by the team

MDT meetings are run on time and to an agreed agenda

Duplication has been removed from the patient care record where possible

Regular audits are carried out to monitor induction quality, MDT meetingquality, record-keeping and MDT meeting summary

Staff feel that they receive and record all the information that they require to deliver safe and effective care every time

Staff feel like they spend less time looking for information

Patients don’t feel that they are being asked the same questions over and over again

Module checklistThe grid below allows you to measure your performance against the checklists for this module. You should copy this page and shade in the boxes according to your achievement of the measure (green for complete, amber for in progress and red for not started). Your progress will then be clearly visible.

Before After 2weeks

After 4weeks

After 8weeks



Have we met the learning objectives?

Five objectives were set at thebeginning of this module.

• test how successfully theseobjectives have been met byasking three team members (ofdiffering grades) the questions inthe grid on the next page. Askthe questions in the secondcolumn and make an assessmentagainst the answer in the thirdcolumn

• if all three team members’responses broadly fit with theanswer guidelines then thelearning objectives of the module have been met

• note the objectives where thelearning has only been partly met and think about the way that you can approach themodule next time

Remember, the results of thisassessment are for use inimplementing this module and arenot a reflection on individualperformance in any way.

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Objectives

Understand what goodpreparation for the module is

Understand how the MDTcurrently works

Develop the MDT to workmore productively

Develop audits as an activity

Understand what is meantby productive MDT working

Question (ask the team member)

Describe the things that you needto do in the prepare stage of themodule

Explain how you learnt about thecurrent state of MDT working

Why use a staff induction and howdoes it work?

Where do the audits fit into theMDT module and how do theywork?

What does good MDT workingmean to you?

Answers for outcome achieved

• establish a core team• talk to staff and patients• find information relating to complaints• obtain policies on documentation

• understand how the team currently works• identify the good/bad things about the

current process

• helps to ensure an understanding of theroles and responsibilities of the MDT

• all new staff receive a pack and a buddy and will have a review with their linemanager

• they are part of the diagnosis• they give a measure of the current

situation

• good performance which we can measureand show improvement

• all the team know what is happening to the patients and their ongoing needs areclearly identified



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Case studies


Induction for new staff - Queen Mary’s Hospital

The hypothesisQueen Mary’s Hospital believed that staff who have a good qualityinduction are more likely to be able to work effectively as part of the MDT.

Their objectives They wanted to assess the currentinduction process and develop astandardised methodology whichmet the needs of both the existingstaff and the new members joiningthe team.

Rationale for developmentIn discussions about MDT workingon their wards the subject of juniordoctor rotation was raised and howthey all worked very differently andas a result did not get theopportunity to feel part of theteam. The MDT at Queen Mary’sHospital considered whether theward’s philosophy and expectationswere ever clearly conveyed to thedoctors.

It was generally considered thatexpectations were not set out clearly and that MDT working wasaffected by this. Therefore the teamdecided to create a junior doctorinduction programme for the nextrotation. Following the teamdiscussion it was decided to developthe concept to include all new staff rather than tailor it to thedoctors only.

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Their measuresThe induction audit assessed theperceptions of new staff on thequality of the induction process andcontent. This was conducted beforeand after the improvements to theprocess were made.

Qualitative resultsNew staff members felt they were better orientated to the ward and that the buddy systemwas beneficial.

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Measure

Orientation to the ward was sufficient

Appointing a buddy was important to you

Result

28% improvement

94% agreed



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Chippenham Community Hospital -effective meetings

The hypothesisChippenham Community Hospitalbelieved that they could improvethe content and process of the MDTmeetings by applying good practiceprinciples to what they do. Theybelieved this would optimiseinformation sharing about patientsand ultimately improve patient care.

Their objectives They wanted to analyse theefficiency and effectiveness of theMDT meeting process withinan inpatient setting. This wouldallow them to set improvementobjectives and to targetimprovement initiatives.

Rationale for developmentBeech Ward at ChippenhamCommunity Hospital consideredpatient goals to be at the centre ofits rehabilitation process. It had awell defined process and tool forsetting patient goals when theywere admitted to the ward.

However, staff often found that theMDT goal-setting meeting was notrun in a standardised format andfelt that there was room forimproved efficiency and quality. The staff wanted to develop a morestandardised approach which wouldreduce the time required for themeeting, and also improve staffattendance and representation.

To do this they needed toeffectively analyse their currentMDT meeting and then developbaseline measures from this, whichwould allow them to assess theimpact of improvement ideas.

Their findingsChippenham Community Hospitalfound that by implementing theirimprovements they increased thevalue-added time within themeeting. The meetings were alsoshorter with less people-minutestaken up with the meeting. Theycontinue to improve their meetingeffectiveness and plan to repeat thevideo analysis.


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Quantitative resultsThe baseline audit of the MDTmeeting was completed, measuringlength of the meeting; number ofpeople-minutes taken up by themeeting; and the amount of valueadded time in the meeting. This was repeated after theimprovements were put in place.Refer to the table for the results.

Measure

Length of meeting

No. of people-minutes involved

% Value-adding time during the meeting

Pre-improvement

90 minutes

360

48%

Post-improvement

45 minutes

170

82%



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Settingup the

PC

Findinglast

assess-ment

Repeatinto tocomelate-

comer

Silencewhile

inputting

Re-visitgoals

alreadydiscussed

Irrelevantdiscussionto goal-setting

Huntingdirectory

on PC

Feeding backcurrent issues

not yet writtenup in record

Nursesfeedback via

pieces of paperREWORK

Wait for print-out / hole-

punch / collate

Settingup the

PC

Sallyhunts

and findsnurses

Sallyrepeats

questions

Findinglast

assess-ment

Lookingfor infoin notes

Ask Sallyto chasenurses

Sallyrepeatswhatnursessaid

Tellingthe typistwhat to

type

Clarifying diaries/ finding next file / changing

places

Beech ward goal-setting meeting 22/05/07BEFORE improvementsProcess map of first 20 minutes done on 30/05/07

Talking about the patient

01:30

Sally talks to nurses

01:06Typing up

01:00

00:00 10:00

10:00 20:00

Value adding time

Total value-adding time = 09:39 = 48%

36%

Talking about patients and inputting

06:00Value adding time 60%



Beech ward goal-setting meeting 16/08/07AFTER improvementsProcess map of first 20 minutes done on 30/05/07

Meeting prep by chair (1 person)(10 mins, convert to 2.5 mins waste

as only one person rather thanprevious 4)

Hunting for areview date in

notes(10 secs)

Re-writingthings fromscreen notes

(5 secs)

Computer andprinter

problems(10 secs)

Looking up oldgoal planning

sheet(40 secs)

00:00 10:00

10:00 20:00

Value adding time 67%

Talking about patients and inputting

09:45

Talking about patients

06:40

Value adding time 97%

Total value-adding time = 16:25 = 82%

Notes on two other improvements1 - The overall length of the meeting has reduced by 50% (from 90 to 45 minutes)2 - The overall number of person-minutes involved in the meeting has reduced:

Patients discussed in batches according to the therapist input needed who can then leave the meeting.eg, Sally (SLT) left this meeting half way through saving 40 person-minutes.Typically meeting now consumes 170 person-minutes instead of 360 previously.


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Farnham Hospital & Centre for Health -Shared care recordThe hypothesisFarnham Hospital & Centre forHealth believed that having ashared document which recordedthe assessment of the patient andthe interventions would improvecommunication and continuity forthe patient.

Their objectivesFarnham Hospital wanted todevelop a template which enabledjoint assessment by the nurses,physiotherapists and occupationaltherapists. They wanted the notesto be patient orientated ratherthan profession orientated and forinformation to be written on a single process sheet. They alsowanted to reduce the amount ofpaper in the MDT documentationto improve the process for staff.

Rationale for development In discussion with the MDT therewas general dissatisfaction withwhere patient information wasbeing written and how it wasineffective as a communication tool.Each discipline’s assessment was in adifferent place with a lot ofrepeated information that was feltto be unnecessary. The patientswere being asked the sameinformation by different staff andthey felt that this did not inspireconfidence. Social Services wereparticularly dissatisfied as they feltthe information they put in thenotes was not read and also theirrequests for information from othermembers of the MDT wentunanswered.

Generally there was frustration that the notes were not in a singletimeline with all MDT staffcontributing, instead each memberof the team wrote in their ownsection of the patient’s notes andrarely did each discipline look ateach others notes. Informationabout the same issue was recordedin different sections of the notesand the patient was asked the samequestions repeatedly.

Their findingsFarnham Hospital found developingthe new documentation and newways of working challenging andthis work is still being reviewed andrefined. However, the results thatthey are achieving make the workworthwhile.


Qualitative results‘We have had feedback frompatients that it’s very tiring havingeach discipline come in and assesswhen they are first admitted. Wefeel this was not reflected in themeasures initially, it didn’t reallyoccur to us until after.’

‘The time spent admitting a patient,for each discipline, is now reduced;however more significantly, thetime spent with the patient isreduced even more. Normally Iwould argue that less time isnegative, but patients like the factthat they do not have to repeat thesame info.’

Before improvement‘Difficult to find information from

other disciplines. Information written in so many different places’

‘Poor continuity and lots of repetition’‘OT paperwork not kept in care plan’‘Very difficult to obtain a time line

of patients’ journey’

After improvement‘Enjoy doing joint assessments with

the physiotherapists’‘Gain a lot from joint assessments

and the patient is not so exhausted by continual assessment’

‘Very little repetition anymore’‘Everyone is writing on the MDT

progress sheet so can easily determinewhat has happened with the patient on a daily basis and previously’

‘Much easier to feed back information to relatives’

Quantitative resultsFollowing the introduction of theshared care record:• the number of continuation pages

had reduced from 10 pages toone page

• the time taken to determine thepatient timeline (a qualityindicator), from the current casenotes fell from 118 seconds perpatient to 25 seconds per patient

• the number of patient notescontaining an MDT discharge planincreased from zero to 100%

• 100% of records had no duplicateinformation

• the total admission process timereduced from between 200 and280 minutes to between 60 and110 minutes



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St Benedict’s Day Hospital -MDT meeting summary and shared care record Meeting SummaryThe hypothesisThe MDT at St Benedict’s PalliativeCare Day Hospital in Sunderlandbelieved that recording theoutcome of the MDT meetingwould improve communicationbetween the team and with thepatients and carer. This would makeplanning for interventions and fordischarge easier and more efficient.

Their objectivesTheir objectives were to documentdiscussions taking place at the MDT meeting and to plan careaccordingly. They wanted tofacilitate good communicationbetween the MDT membersaccording to a nationally-recommended structure of holistic care1.

Rationale for development The MDT meeting involved stafffrom a range of disciplines,providing their own professionalperspective of each patient theycare for. The meeting provides theopportunity to transfer informationand reach consensus decisions oncare planning. Patient advocacy and autonomy needed to bemaintained, and all care needed tobe in the patient’s best interests.Prior to this project, the MDT’sdiscussions were recorded in eachpatient’s notes, but this lacked thestructured holistic approach. It wasknown, for example, that spiritualand carer-related issues were poorlydocumented. Furthermore, therewas ambiguity around delegationand review of tasks.

Consequently, care was planned butsometimes failed to beimplemented and these failureswere not identified until the nextmeeting (ie, 6 weeks later).

Their findingsSt Benedict’s found that theirrecorded planning of care improvedsignificantly. Initially, whilst carewas being planned successfully,there was no safety net to ensurethe completion or review ofinterventions. They decidedtherefore to include a named‘responsible person’ with the dutyof ensuring tasks were undertakenand to set an acceptable time framein which to do it. The first cycle ofthe documentation audit wascompleted in April 2007 and hasbeen done twice since.

1 Richardson A, Tebbit P, Brown V, Sitzia J, on behalf of the Cancer Action Team (2006)Assessment of Supportive & PAlliative Care Needs for Adults with Cancer, London: King’s College London.


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An audit of the key informationthey wanted to see in the postmeeting notes was undertaken for patient notes. This was repeatedafter the MDT meeting summarydocument was introduced.

The record of key information was improved in all of the areas,with significant improvements inthe capturing of when the nextreview would be and who wasresponsible for the actions.

Quantitive resultsbetween April and August 2007

Quality Area

Core patient information

Overall assessment of patient needs

Overall identification of responsible person

Overall documentation of review period

% Change

+48

+4

+202

+580



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Shared care recordQualitative resultsAn audit of the key indicators they wanted to see in MDT patient record was undertaken for patient notes in thecurrent caseload. This was repeated after the shared record was introduced. The record of key information wasimproved in all of the areas, with significant improvements in the identifying and capturing of fatigue, anxietyand depression of individual patients. This has led to the department utilising staff more effectively to provideinterventions in these areas. Between April and August 2007

Have the following areas been recorded?

Problems

Medical assessment

Nursing assessment

AHP assessment

Care plan

Follow up plan

Fatigue

+29

+120

+536

+118

+157

+79

Anxiety and depression

+141

+44

+300

-13

+406

+43

Pain

+257

+7

+28

+18

+66

+450

% Change


AcknowledgementsThank you to all staff at:

Chippenham Community Hospital, Wiltshire PCT

Farnham Hospital and Centre for Health, Surrey PCT

Grindon Lane Primary Care Centre, Sunderland TPCT

Queen Mary’s Hospital, Roehampton, Wandsworth PCT

St Benedicts Day Hospital, Sunderland TPCT

NHS Institute for Innovation and Improvement

Staff from our improvement partners

Members of the Expert Panel

Thanks also go to:

Liz Thiebe, Head of Productive Series, NHS Institute for Innovation and Improvement

Julie Clatworthy, Clinical Lead, NHS Institute for Innovation and Improvement

Helen Bevan, Director of Service Transformation, NHS Institute for Innovation and Improvement

Maggie Morgan-Cooke, Head of Productive Ward/Productive Community Hospital, NHS Institute for Innovation and Improvement

Sue Deane, Clinical Facilitator, NHS Institute for Innovation and Improvement

Kim Parish, Clinical Facilitator, NHS Institute for Innovation and Improvement

Clare Neill, Communications Associate, NHS Institute for Innovation and Improvement

Ray Foley, Associate, NHS Institute for Innovation and Improvement


Website: For more information please visit www.institute.nhs.uk/productivecommunityhospital

Contact the Productive Community Hospital team:[email protected]

ISBN: 978-1-906535-43-8Copyright © NHS Institute for Innovation andImprovement 2008 all rights reserved


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