Ward Round & Case Conference

Good Practice Guidelines &

Standards

Version 1.0 April 2003

Contents Page

Introduction 3

Members of the Multidisciplinary Team involved 3

The Case Conference & Ward Round Standards 4

Format of the Case Conference & Ward Round 5

Cover and Information Provision in the Absence of Regular Team Member

5

Admission / Transfer Criteria (to be added) 6

Role of Multidisciplinary Team Members 7

The Role of the Chairperson 7

Consensus Decision Making 7

The Role and Responsibilities of the Notetaker 8

The Role of Participating Professionals 9

Guidelines for Nursing Staff 9

Guidelines for Goal Setting 10

Guidelines for Reviewing Case Conferences- From a patient perspective

- From a case conference perspective

11

Guidelines for Completing Pathology Specimen and Investigation / Referral Follow Up Proformas

12

Information Systems to Support Case Conferences 13

Useful Tips and Hints 14

Appendices - Information Update in the Absence of Professionals- Case Conference Review for Clinical Teams - Patient Focused Case Conference Review- Follow Up for Receipt of Pathology Specimen Results- Investigation / Referral Follow Up

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2

Introduction

These good practice guidelines and standards have been developed following observations of case conference & ward round practice and in conjunction with all members of the multidisciplinary teams.

It has been agreed that clinical teams undertake both case conferences and ward rounds, in which each member of the multidisciplinary team feels able to contribute effectively to the planning of a patient’s discharge home or to an alternative care environment and that their contribution in doing so, is valued.

Core Members of the Multidisciplinary Team attending Case Conferences

Nursing Staff Consultant Staff Grade Physician Physiotherapist Occupational Therapist Social Worker Elderly Care Liaison Nurse

Associate Members of the Multidisciplinary Team attending Case Conferences (depending on location)

Ward Discharge H.C.S.W.’s Care Transfer Team Stroke Team Speech and Language Therapist

Multidisciplinary Team members involved in Ward Rounds

Consultant Staff Grade Physician Nursing Staff with appropriate support

Support for nursing staff undertaking ward rounds may be from Ward Clerks, Ward Discharge H.C.S.W.’s or H.C.S.W.

The Standards

1.0 All core members and associate members of the multidisciplinary team will attend the case conference and at the agreed time.

2.0 Cover is provided for professionals not able to attend case conferences.

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2.1 If cover is not able to be provided, relevant and up to date written information is provided in advance of the case conference.

2.2 It is the responsibility of the individual professional team to provide this cover/information.

3.0 All members of the clinical team are adequately prepared for the ward round/case conference and have a good understanding of the patient’s condition and current status.

4.0 All actions from the previous week have been carried through.

5.0 All results/investigations have been seen prior to the ward round and are filed within the patient’s notes.

6.0 The multidisciplinary team plan realistic timescales for the patient’s anticipated recovery and at an early stage agree a discharge date and this plan is communicated to the patient.

7.0 The patient’s recovery is measured against this plan and adjustments made accordingly. 7.1 All patients are comprehensively reviewed after being in hospital for 10 days (acute setting) or 21 days (Bucknall) or on the nearest case conference to this date, and subsequently thereafter.

8.0 At each case conference, any developments during the preceding week are discussed and evaluated.

9.0 Any decisions made at the ward round and case conference are fully explained to the patient and/or their relatives/carers depending upon the patient’s conditions and wishes.

10.0 The decisions made and actions for each professional are accurately recorded in the patient’s notes in a standardised format.

Format of the Case Conference and Ward Round

Case conferences and ward rounds will be conducted in one of the following formats, depending on local agreement at ward level.

- Case Conference followed by Ward Round.- Ward Round followed by Case Conference at a set time. - Ward Round followed by a Case Conference at a set time followed by Ward Round.

No matter which format is followed, there is an agreement that all members of the multidisciplinary team know:

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- the day and the start time for both the ward round and the case conference.

Any changes to days or timing are discussed with all members of the multidisciplinary team.

Cover and Information Provision in the Absence of the Regular Team Member

As standard 2.0 indicates cover is provided in the event that the regular team member cannot attend the case conference.

If cover is not provided then relevant and up to date information should be provided in a consistent format (see appendices - Information update in the absence of Professionals). This proforma has been devised to ensure consistent information is provided in the absence of any professional and as a means of ensuring that decisions are not delayed.

It is the responsibility of the individual professional team to provide this cover/ information. In the case of information provision, this should be in advance of the case conference to enable review by the professional who shall be contributing this information on the absent person’s behalf.

Whilst for the most part, individual professional groups are ward attached, in some instances, other colleagues of the same profession may be allocated a specific case. It is the responsibility of the ward-based professional to obtain updates from their colleagues for the case conference discussions.

Admission / Transfer Criteria

The admission / transfer criteria are to in the process of being developed.

Transfer Criteria

For Consultant initiated transfers to other care settings, specific goals and treatment plans should be documented in the patient’s notes.

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Role of Multidisciplinary Team Members at Case Conference

As well as representing their professional group and following the standards, the following roles should be allocated from within the team.

Chairperson Notetaker

These roles can be rotated within the multidisciplinary team. It is the responsibility of the clinical teams to decide how these roles are allocated. The Role of the Chairperson

The Chairperson will undertake the following responsibilities:

- Keep the case conference focused and to time- Ensure each professional viewpoint is considered- Ensure each action is allocated to a specific individual - Ensure a consensus decision is reached regarding patient

treatment plans and future care arrangements. - Ensure that the case conference follows a structured format- Ensure that that at the end of a patient discussion, a clear plan of

action is evident.

Consensus Decision Making (TTI Developments 1994)

A consensus decision has the following characteristics:- Uses all the resources of the group- All group members must participate actively - Power must be distributed evenly among them - Consensus decision making productively resolves controversies

and conflicts- All group members must contribute their views and their reactions

to proposed alternatives, no one should be allowed to remain silent.

- For a group to achieve consensus, time must be allowed for everybody to state their opposition to the decision and to state it fully enough to get the feeling that others understand them.

- Consensus decision making requires careful listening and effective communication by the group members.

- If consensus is gained, the commitment to implementing the decision will be greater than with other decision making methods, e.g. by majority

The Role of the Notetaker

It is difficult to both participate and contribute to a case conference at the same time. The accurate recording and documentation of the

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discussion and the decisions reached is important for the continuity of patient care and to support timely and appropriate discharge.

The documentation within the progress notes of the CCP document should be as follows:

Date Case conference

N (Nurse) - P (Physio) -OT -Med (Medical) -SW (Social Worker) - Other (please specify) -

Agreed action and by whom:

The records should reflect the contribution of each professional and the agreed action that is determined following the multidisciplinary discussion.

Responsibilities of the Notetaker

- To accurately record the contributions of each team member and the agreed actions.

- To ensure that the documentation can be easily understood by individuals who were not present at the case conference.

- To summarise the agreed actions, if needed.

The Role of all Participating Professionals

- Be prepared. - Have up to date information for all your caseload and those of your

colleagues, if appropriate. - Ensure actions agreed previously have been followed through. - Ensure effective communication with patients and their carer’s and

ensure that their views are represented at the case conference. - Be clear on your own actions for each patient and ensure follow

through.

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- Ensure adequate support for colleagues new to the case conference process.

Good Practice Guidelines for Nursing Staff

- Ensure off duty is allocated to provide adequate cover and support for ward rounds and case conferences.

- Ensure that Nursing Staff know in advance that they will be participating in the ward round / case conference and which patient groups (teams) they will be representing. If possible, involve nursing staff from individual teams / sides.

- Ensure off duty is allocated to Nursing Staff participating in the case conference / ward round to allow preparation time and follow up time for actions and communication.

- Team Leaders / Named Nurses, if not participating, to provide adequate and up to date information for the case conference / ward round.

- Team Leaders / Named Nurses to take responsibilities for follow up actions.

- Consider the involvement of H.C.S.W.’s in the case conferences. - Senior staff / Modern Matrons to attend case conferences in a

supportive / monitoring capacity.

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Guidelines for Goal Setting

For the wards, where goal setting is carried out, the goals should meet the SMART philosophy.

SpecificMeasurableAgreedRealisticTime Related (use dates rather than

timespans)

In addition, when reviewing goals in a multidisciplinary forum, the following should be discussed:

- When the goal was originally set in terms a date- Progress towards goal achievement- How long has the goal being in place for, is the progress as

expected?- Any modification of the goal or the interventions- Is the goal likely to be achieved and if so, in what

timespan? - Does this fit in with the anticipated discharge date and

outcome- Decide whether goals should be reviewed as part of case

conference.

For the reviewing of the goals to be effective, then team members must be: - proactive in communicating the goals to colleagues, to patients

and their carers- for the goals to be accurately monitored- prepared for goal setting in terms of knowledge of progress

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Guidelines for Reviewing Case Conferences

Proformas are available for the reviewing the effectiveness of Case Conferences in general and also specific reviews of patient discussions. These can be found in the appendices.

The Ward Manager and the Consultant in negotiation with the Clinical Team should arrange for a baseline review to be carried out and an action plan formulated for both the case conference and also the patient review.

It is suggested that the reviews for the case conference and the patient reviews should be carried out separately due to time constraints. However, individual teams may decide that they wish to conduct a full review at a single case conference. This should be agreed with the clinical team as it may extend the time of the case conference.

It is suggested that the reviews should be followed up in 3 months and then at a time to be determined by the clinical teams, but at least twice a year.

For the patient reviews, it is suggested that whilst these may be conducted at a single case conference, it is more likely that they will be spread out over 3 consecutive weeks. In either event, patients should be selected for review should be discussed at the beginning, the middle and at the end of the case conference meeting. This will identify any changes to the process, which occurs as the case conference progresses towards its closure.

The patient focused audit tool may also be used by individual professionals to assess their own development needs at case conference or as an aide-memoir for points to be discussed.

Once completed, please forward a copy of the review and the action plan to the Patient Pathway Improvement Manager, who will be willing to assist with any audits, action planning and subsequent implementation of the action plans.

By sending the review and the action plan, the Patient Pathway Improvement Manager will be able to share further good practice throughout the wards and be aware of any updates / support needed.

Guidelines for Completing Pathology Specimen and Investigation/ Referral Follow Up Proformas

Both of these forms should be used to document all pathology specimens and investigation/ referral requests for individual patients.

The forms whilst individual for each patient should be held centrally in a file for access by nursing, medical, ward clerk and phlebotomy staff.

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The purpose of this system is to enable staff to be adequately prepared for ward round and case conferences as it gives an indication of which investigation dates and results are outstanding, enabling timely follow up.

Pathology Specimen Proforma

This form should be used to record all specimens sent to the pathology lab, for example, blood, urine, sputum, and faeces. The type of specimen and the nature of the test should be recorded, for example:

Type of Specimen

Test DateSent

Results received

Blood FBC 17/4/03 19/4/03

Urine MSU 19/4/03

Blood INR 19/4/03 19/4/03

Blood U&E’s 19/4/03 20/4/03

Sputum C&S 19/4/03

Investigation / Referral Proforma

This proforma should record all investigations, for example, ultra sound scans, CT scans, COPD appointments and Consultant referrals, barium meals/ enemas.

Filing of the Forms

Once a patient has been discharged, the original forms should be filed in the patient’s notes. A copy of the form should be held on the individual ward in a central file for audit purposes, if required.

Information Systems to Support Case Conferences

Within the CHIPS Information System, there are several information screens and report menus available to advise of progress with regards to length of stay data and other patient information.

For Length of Stay Information

Main Menu In Patient Management System Option No. 3In Patient Menu Option No. 1 Report Menu Option No.3Summary Ward Information between dates Report No 11. You will need to input the following: Run the Report

Location – ward code 12

Dates for when you want the report to cover.

Wait for report to be collated.

Current Ward Stay

For current information about in-patient length of stay.

Main MenuIn Patient Management System Option No. 3In Patient Menu Option No. 1 Ward Stay Option No. 41

It is suggested that this report should be printed off for the case conference to review progress towards discharge.

Future Report Development

Ward Stay ReportA ward stay report is currently being developed which will give data relating to the length of stay and discharge destinations of patients who have been discharged. Further information to follow.

Barthel ReportsSince April 2003, data relating to Barthel scores on admission and discharge have been inputted into the system. Reports will shortly available to give information relating to wards for patients who have been discharged.

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Think about the order that the patients are discussed each week. So that the patient at the end of the ward isn’t always discussed in a hurry!!!

PREPARATION, PREPARATION, PREPARATION!- is the key to asuccessful case conference

Everyone’s opinion matters – it is your responsibility to make your voice is heard on behalf of your patient.

Think about any distractions you may have during the case conference and ward round and try to ensure that you are well supported!

Are you well supported?

Ensure the patient’s view is represented.

Avoid continuing with goals without proper review and evaluation!

Ensure goal evaluation where relevant is discussed at case conference

All patients to have a TEN DAY (CGH) acute review of progress or a 21 DAY (Bucknall) rehabilitation review.

Think about the case conference as a meeting and plan an agenda for the order of the patients to be discussed with the most complex patients being discussed first.

Avoid the “give them another week” trap, plan effectively for the next 7 days and anticipate recovery times.

Evaluate as a team the effectiveness of the case conference.

Once all assessment information is available, as a team, plan a discharge date.

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Appendices

North Staffordshire Combined Healthcare NHS Trust

Information update in the absence of Professionals Report made by: Date:

Name of Patient Progress since last Case Conference

Update on Agreed actions from last Case Conference

Issues/ Prognosis for recovery/ goal attainment

Ward: Date:

1.0

Preparation

Original Source – PPI Manager Apr 03

North Staffordshire Combined Healthcare NHS Trust Case Conference Review for Clinical Teams

1.1

Did all staff feel adequately prepared for the ward round / case conference?

1.2

Were the majority actions carried out from the previous week?

1.3

Are notes and x-rays available and readily accessible?

1.4

Were the majority of investigation reports available and filed in the patient’s notes?

1.5

Are investigation request cards readily accessible? 1.6

Overall assessment of preparation.

2.0

Participation and Decision Making

2.1

Did all professionals feel that they participated adequately in the case conference?

2.2

Was consensus reached by the team as to the key actions / decisions?

2.3

Were the professionals present who needed to provide information / make decisions? If not, was the relevant information available?

3.0

What did we do well?

Original source – PPI Manager Apr 03

North Staffordshire Combined Healthcare NHS Trust Case Conference Review for Clinical Teams

4.0

What could we improve?

Original source – PPI Manager Apr 03

North Staffordshire Combined Healthcare NHS Trust Patient Focused Case Conference Review

Patient: Ward: Unit No: Date:

1. Was there a clear understanding of patient’s previous abilities to enable effective and realistic goal

planning?

2. Was information available 3. Were the following areas covered in relation to the patient’s The patient’s social history; Washing Continence Psychological Type of house; Dressing Pressure areas Barthel score Carers / services involved; Lifting and

Handling Waterlow Scale Medication

Patient’s views about the future; Mobility Falls ResuscitationRelatives / carers views about the future.

Nutrition Falls Score

4. Was the progress of the patient over the previous 7 5. Are the patient’s needs reflected on a 24-

6. Were all staff clear about the key decisions / 7. Were all actions clearly allocated to an

8. Was the involvement of the patient adequate? 9. Were the patient’s views fully considered?

Original Source – PPI Manager Apr 03

North Staffordshire Combined Healthcare NHS Trust Case Conference Review for Clinical Teams

1 Was there a clear plan for the next 7 days? 1 Were the timescales for discharge

Original source – PPI Manager Apr 03

North Staffordshire Combined Healthcare NHS Trust

Name of Patient: Unit No:

Follow Up for Receipt of Pathology Specimen Results

Type of Specimen

Test Date Sent

Results received

Type of Specimen

Test Date Sent

Results received

Original source – PPI Manager April 03

North Staffordshire Combined Healthcare NHS Trust Name of Patient: Unit No:

Investigations / Referral Follow Up

Type of investigation /

referral requested

Date Request

ed

Date sent

Date of Appointment

Transport arranged

Escort arranged

Results received

Original source – PPI Manager April 03