Heart Failure Smart Goals

This page is to give you some examples of SMART goals written by teams using PKB with their Heart Failure (HF) patients.

Patient pathway

1. HF Nurse calls the patient, explains HF diagnosis, checks PKB to see if they are registered, if not collects email and adds to webv/PKB. Explains PKB Pathway and next steps. (Send pre-questionnaire-or tell patient to complete? send a plan or ask a patient to start it?? TBC)

2. 1st Appointment is in PKB ready for patients to view.

3. Patient registers and is told to access the library for information on the pathway.

4. Patient completes a pre health questionnaire and starts a care plan.

5. Nurse reviews care plan before/at first F2F appointment, adds to the plan. Books next appointment for 2 weeks’ time (if symptom tracking currently under threshold its virtual if over its F2F)

6. Patient receives notification plan has been updated and the next appointment details in PKB.

7. Patient continues to monitor symptoms via the care plan before the next appointment.

8. Nurse reviews care plan before/on appointment, continues uptitration. Books next appointment for 2 weeks’ time (if currently under threshold its virtual if over its F2F)

9. Patient continues to monitor symptoms via the care plan before the next appointment.

10. Nurse repeats the process until the patient is on max titration, then books an ECHO for the patient.

11. Echo appointments are in PKB for patients to view.

12. Patient attends ECHO

13. Nurse discharges the patient from this pathway and sends a post health questionnaire.

SMART GOAL Examples

Goal 1

Specific:

Improve patient satisfaction by delivering care through PKB, with the use of secure messaging, a care plan to track symptoms (which is regularly reviewed) and access to a library of resources.

Measurable:

Baseline medical satisfaction consultation sent at registration and again sent at discharge; results compared against satisfaction when discharged.

Team wishes to see a marked improvement (%) in patient satisfaction score at the end of the PKB pathway. (How Much?)

Measure access to the library, symptoms and messages sent.

Achievable:

All HF nurses to be trained on PKB to be able to use care plans and messaging with each patient. Pre and post live comms to the patient regarding new service and what’s included, make the whole department aware of patient pathway changes and the date it starts, nurses to make sure questionnaire is sent at registration and at discharge.

Relevant:

Better self-management of patients with HF by number of symptoms tracked and care plans viewed

Better patient experience by using the satisfaction questionnaire.

Patients feeling more in control of their health and hospital care with the use of a condition specific care plan.

Time-Bound:

Care plan and workflow to be ready for Team go live. Patient questionnaire and clinical engagement stats review at 3 months (has all Pat sent/completed questionnaire) and 6 months and 9 months post go live.

Goal 2

Specific:

To reduce the total number of F2F appointments with each patient during the pathway (all patients will have their initial f2f Appointment). Patients given a symptom tracking care plan to complete (enter time) , nure reviews care plan before 2nd apt to see if they cross the threshold and need a f2f apt. Need the average number of appts and what the threshold is going to be, is it the same for all patients, men/women/age ect At what point is a nurse checking the `CP? Intime to change appointments??

Measurable:

Measurable by how many virtual appointments are used as currently Pathway is 100% f2f

Team wishes to see a reduction (%) in patient F2F appointments.

Measure cost saving for not having to run a f2f appointment (currently?)

Achievable:

All HF nurses to be trained on PKB. Pre and post live comms to the patient regarding new service and what’s included, make the whole department aware of patient pathway changes, nurses to make sure they offer virtual call where possible and recording the virtual appointments used.

Relevant:

Better self-management of patients with HF by number of symptoms tracked and care planaccess.

Freeing up nurse’s time.

Free up patient time can they find out what the journey times from the patient’s home addresses would have been?

Cost effective

Time-Bound:

Care plan and workflow to be ready for Team go live. Clinical engagement stats, review at 3 months and 6 months and 9 months post go live.

Goal 3

Specific:

Clinicians and patients are able to communicate more effectively and in a more streamlined fashion via the use of the PKB care plans and messaging functions. This feeds into goal no 1 as patient’s satisfaction scores will be higher.

Measurable:

Measurable by the number of care plans created comparable to those edited.

Measurable by the number of messages sent and threads within that massage and period of time it took to read the messages. All non urgent communication done through PKB instead of calls and emails). 50% of all patient communication to be done through PKB)

Record baseline number of calls at the beginning of the project

Achievable:

All HF nurses to be trained on PKB. Pre and post live comms to the patient regarding new service and what’s included, make the whole department aware of patient pathway changes, nurses to make sure messages and care plans are actioned asap timeframe suggested to patient.

Relevant:

Better self-management of patients with HF by number of messages sent/received and care plans created and edited.

Freeing up nurse’s time by using PKB messaging instead of calls (-convenience, improvement of workload/time)

Free up patient time

Cost effective

Time-Bound:

Expect to reduce call numbers by 50% after 6 months with the use of PKB messaging. Nurses/coord to record every three months, on the first Tuesday of the month, how many calls they have and how long they are.

Care plan and message engagement reviewed every three months . (check maybe monthly? Weekly? )

Goal 4

Specific:

Tracking attrition rate improvement

Measurable:

Measurable by seeing a reduction in the number of ‘appointments’ patients need from the start of referral pathway to discharge, compared to those numbers pre PKB Pathway.

Achievable:

All HF nurses to be trained on PKB. Pre and post live comms to the patient regarding new service and what’s included, make the whole department aware of patient pathway changes and date this new pathway starts. Nurses to make sure patients are completing the care plan symptom tracking effectively and in a timely manner.

Relevant:

• Better self-management of patients with HF by a number of ‘appointments’ needed generally compared to previous.

• Cost-effective

Time-Bound:

Within one year, a patient will have 50% of their apt with the HF team virtually. Appointment, and care plan Stats to be reviewed every three months.

Goal 5

Specific:

A reduction in the overall ECHO DNA Rate. By patients taking an active part in their own self-care of HF and also having access to their appointments within PKB.

Measurable:

Measurable by the number of DNA pre PKB and the Number 3 months post live and 6 months post live.

Achievable:

All HF nurses to be trained on PKB. Patient comms letting patients know they have a PKB patient portal with with a care plan, symptom tracker, resource library and clinical and appointments letters in their record. Patients encourages to add an ECHO Care plan to their record with key information about the scan and why it is important. Team send out ECHO consultations within PKB to patients every six months.

Relevant:

Better self-management of patients with HF by number of attendances to ECHO compared to previous.

Cost effective

Time-Bound:

To reduce 50% of DNAs within 9 months. DNA stats to be reviewed every 3 months by the team manager.

Heart failure team - self-monitoring pathway

Goal 1

Specific:

Provide all patients in the team (currently 750) with a PKB record and have a process for patients to register with their record via Trust email registration.

Measurable:

Baseline, when the heart failure team goes live, PKB registration stats will show how many of the 750 patients have registered through email registration. Every week PKB sends the team registration stats for review. One month post go live, 25% patient registrations achieved. Two months post golive 50% patient registration achieved. Three months post golive, 70% registered.

Achievable:

All patients are invited to register when added to the Heart failure team and reminders to register sent regularly, aiming for 70% registration rate.

Heart failure team trained on PKB and to check if the patient is registered with PKB at each interaction. Team trained on how to add an email address and how to add a carer to the patient's record once the carer has registered with their own PKB patients record. Carer’s added when the patient is unable to access PKB themselves.

Hospital integration completed for patients to get an email to register and reminders to register with each interaction.

Relevant:

• Providing patients with a digital record, including care plans, blood results, appointments and clinic letters.

• Improve access to patient data

• Patients having access to their heart failure care plan and pathway to echo.

• Cost saving for the trust. Providing patients with a personal health record, receiving their results and letters digitally.

• New patients in the heart failure team are automatically added to the PRT through PKB integration.

Time-Bound:

One month post go live, review if 25% patient registrations achieved. Two months post go live review if 50% patient registration achieved. Three months post golive review if 70% has been achieved.

Goal 2

Specific:

Provide a digital Heart Failure care plan to support patients to better self manage their heart failure.

Measurable:

Baseline, patients aren't getting a digital care plan while on the waiting list and they have no way to self manage their heart failure. After the heart failure team goes live, weekly clinical engagement stats on care plans are added and read to be shared with the team weekly. After two months, 25% of patients have added a care plan.

Achievable:

Heart failure team trained on PKB and the care plan feature. When the team has any interaction with the team, the team checks if patients have registered with their PKB record and if they have added the heart failure care plan.

Patient comms about care plans added to the teams sharing information on the patient's record. Patient comms sent alongside clinic letters on how to add care plan to their record and whats included in the plan/PKB record i.e. library

Care plan information added to the library.

Relevant:

• Providing patients with a digital care plan

• Improve access to patient data

• Patients having access to their heart failure care plan and pathway to echo.

• Reduce calls

• Reduce unnecessary appointments with GP/A&E/urgent care,

• Start on medication, once they the medications is titrated, they have an echo, then discharged (PKB being used to get to an echo faster)

• Self engagement, with educations, to take BP and have labs

• Provide all patients in the team with a heart failure care plan, allow them to track and monitor symptoms related to their heart failure while they wait for an echocardiogram.

• Currently 750 patients in the team are waiting for an echo. The average patient waits 12 months to get an appointment to get onto the heart failure pathway.

Time-Bound:

One month post go-live, weekly stats to be reviewed by the team to make sure the care plan is being added by patients and read.