5.4 Review the extent to which systems, processes, and practice facilitate positive outcomes

Course: NVQ Level 5 Diploma In Leadership & Management for Adult Care

Unit 5: Person-centred practice for positive outcomes

LO5: Lead continuous improvement in carrying out health and care procedures where required

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5.4 Review the extent to which systems, processes, and practice facilitate positive outcomes

Systems, processes, and practices that facilitate positive outcomes for patients include effective communication among caregivers, patient-centered care plans that are collaboratively developed and updated with the input of patients and families, continuity of care across transitions in care settings, comprehensive medication management, and timely interventions to prevent or mitigate deterioration in health.

Processes and practices that facilitate positive outcomes for patients include those that promote wellness and patient autonomy, such as care coordination among treatment providers, continuity of care across settings (including referrals to community-based services), systems of care that are organized around the needs and preferences of the population served, timely provision of information to patients and families about diagnosis, treatment options, and anticipated outcomes, including serious untoward effects, plans for end-of-life care when appropriate, availability of services to support independent living or to provide caregiver support, and access to advance directives.

Systems that facilitate positive outcomes include those that measure patient experience of care in a standardized way with fidelity across all clinical settings, and public reporting of patient experience measures compared to other institutions or regional performance, where possible.

Patient-centered care plans are collaboratively developed and updated with the input of patients and families.

Promoting wellness refers to health education, disease prevention, early diagnosis for identified risks or illnesses, encouraging healthy behaviors (such as smoking cessation), identifying environmental hazards at home or in the workplace that can cause or worsen illness, providing resources for home management of chronic conditions, and encouraging or assisting with adherence to recommended treatments.

Effective communication among caregivers includes effective written and oral communication within facilities, between providers, among care teams, with patients/families/caregivers, through technologies such as telehealth, and across settings (e.g., ambulatory to inpatient or long-term care to acute care).

Continuity of care across transitions in care settings includes ensuring that the patient’s clinical record is available and accessible during transitions, including transitions between different providers, facilities, and treatment teams.

Systems of care that are organized around the needs and preferences of the population served include systems that allow for coordination among primary care and specialty providers, including those working in different facilities or under different reimbursement arrangements.

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