Metro North staff and rehabilitation patients at STARS.
Person-centred goal setting in rehabilitation at STARS
The Surgical, Treatment and Rehabilitation Service (STARS) is committed to delivering high quality rehabilitation services. This includes involvement of patients and their families in decisions about their care as part of the team. STARS established a patient goal setting working party in April 2021 to lead the implementation of interprofessional, patient and family-centred goal setting across all rehabilitation units. A participatory-action approach was used to observe, plan, implement and evaluate the goal setting model at STARS.
Our initial exploration of practice indicated that goal setting was being conducted separately within disciplines. While the goals being set were important and recalled by patients, they were usually not written in patient language, with some duplication of goals across professions. Patient and family interviews highlighted opportunities for improvement in provision of education about goal setting and rehabilitation, engagement in the process of goal setting and increasing awareness of goals. A survey of clinicians provided an understanding of the need for clear processes, resources, and training to facilitate effective goal setting by teams.
A comprehensive person and family-centred goal setting process was developed with input from clinicians, patients, and families. The evidence-based resources developed by the Statewide Rehabilitation Clinical Network (SRbCN) Goal setting in Rehabilitation Project sponsored by Clinical Excellence Queensland were adapted to suit the local context. Training was provided in multiple formats with support provided for key activities including team huddles and case conferences. During implementation, focus groups were held and practice audits completed to gather feedback and guide refinement of resources and processes. This iterative process of observation and feedback to continually improve practices is ongoing, including continually seeking feedback from patients and families about their experiences. The process has now been implemented on two of the STARS rehabilitation wards with the third ward due to commence in November. The person centred approach has led to improved patient satisfaction and team collaboration
We would like to formally acknowledge and thank Metro North Health, Healthcare Excellence and Innovation (HEI) for financially supporting Stage 1 of this project, as well as all of the staff and consumers who provided their time in speaking with us.