Goal setting can be defined as the identification of and agreement on a behavioural target which the patient, therapist or team will work towards over a specified period of time. The setting of goals is central to effective and efficient rehabilitation (National Clinical Guideline for Stroke; RCP 2016, 5th edition).
At the MDT meeting Charlie has been nominated as the key worker for Dorothy Kildare; a new stroke patient just admitted to the unit. Prior to going to see Dorothy, Charlie re-familiarises himself with the unit’s patient-centred goal setting process. There are various ways of implementing goal setting clinically but currently there is no nationally recommended framework for delivering it. The following are two examples of frameworks which can be used. Also refer to your own local guidelines and pathways.
For further information on the terms used in these frameworks see the Additional Information box below.
Having looked at the unit’s process Charlie reminds himself of what is required for effective patient centred goal setting.
Thinking of what is necessary for effective MDT patient-centred goal setting has reminded Charlie that it can be a complex and time consuming process to deliver. He reflects on what the overall benefits of goal setting are for the patient and the team.
For effective in-patient patient centred goal setting what is required? (Questions & correct answers in bold)
Yes – There must be full team commitment and engagement in the process. All staff need to be on board, engaged with the process and recognise the value of goal setting; without this goal setting will fail.
No- There must be full team commitment and engagement in the process. All staff need to be on board, engaged with the process and recognise the value of goal setting; without this goal setting will fail.
Maybe-There must be full team commitment and engagement in the process. All staff need to be on board, engaged with the process and recognise the value of goal setting; without this goal setting will fail.
No – Professionals should prescribe all the goals as the patient isn’t capable of making these decisions and doesn’t understand their illness. Professionals should recognise that the patient is an expert and equal in the process. Goals are more important to a person when they have been involved in making them.
Yes– Professionals should prescribe all the goals as the patient isn’t capable of making these decisions and doesn’t understand their illness. Professionals should recognise that the patient is an expert and equal in the process. Goals are more important to a person when they have been involved in making them.
Maybe- Professionals should prescribe all the goals as the patient isn’t capable of making these decisions and doesn’t understand their illness. Professionals should recognise that the patient is an expert and equal in the process. Goals are more important to a person when they have been involved in making them.
Yes – Goals must be clear, specific, easily understood by and communicated to everyone and have a specified time frame. Effective goal setting relies on clear, specific, measurable and timed goals with good open communication between all parties.
No- Goals must be clear, specific, easily understood by and communicated to everyone and have a specified time frame. Effective goal setting relies on clear, specific, measurable and timed goals with good open communication between all parties.
Maybe- Goals must be clear, specific, easily understood by and communicated to everyone and have a specified time frame. Effective goal setting relies on clear, specific, measurable and timed goals with good open communication between all parties.
Yes – Setting aside time is important in this process and should be seen as a priority. Time spent identifying a proper patient focused rehabilitation programme may potentially reduce the overall rehabilitation length of stay and positively impact on outcomes.
No- Setting aside time is important in this process and should be seen as a priority. Time spent identifying a proper patient focused rehabilitation programme may potentially reduce the overall rehabilitation length of stay and positively impact on outcomes.
Maybe- Setting aside time is important in this process and should be seen as a priority. Time spent identifying a proper patient focused rehabilitation programme may potentially reduce the overall rehabilitation length of stay and positively impact on outcomes.
Maybe – The patient’s relatives and carers should always be involved in the patients goal setting. This can be of benefit but it is essential to remember that relatives/carers may have a different agenda/direction to that of the patient. Additionally patients may not wish their carer or relative to be involved.
Yes- The patient’s relatives and carers should always be involved in the patients goal setting. This can be of benefit but it is essential to remember that relatives/carers may have a different agenda/direction to that of the patient. Additionally patients may not wish their carer or relative to be involved.
No- The patient’s relatives and carers should always be involved in the patients goal setting. This can be of benefit but it is essential to remember that relatives/carers may have a different agenda/direction to that of the patient. Additionally patients may not wish their carer or relative to be involved.
Yes – Goals must be reviewed and evaluated at the set date. Reviewing at the specified date is vital to ensure that outcomes are evaluated and that new goals are set.
N0- Goals must be reviewed and evaluated at the set date. Reviewing at the specified date is vital to ensure that outcomes are evaluated and that new goals are set.
Maybe- Goals must be reviewed and evaluated at the set date. Reviewing at the specified date is vital to ensure that outcomes are evaluated and that new goals are set.
Maybe – As qualified professionals we should be able to deliver it without training. MDT patient centred goal setting is complex and requires a consistent approach therefore for it to be effective and for staff to feel competent training and support is recommended. As well as working with their teams to learn how to work in this way.
Yes- As qualified professionals we should be able to deliver it without training. All professionals have skills in communicating with patients and identifying professional aims and goals. MDT patient centred goal setting requires a consistent team approach and for it to be effective training and support is recommended. As well as working with their teams to learn how to work in this way.
No- As qualified professionals we should be able to deliver it without training. All professionals have skills in communicating with patients and identifying professional aims and goals. MDT patient centred goal setting requires a consistent team approach and for it to be effective training and support is recommended. As well as working with their teams to learn how to work in this way.
Yes – The key worker role requires a person to be an active listener and good communicator. To optimise the process and ensure patients feel fully involved the key worker must listen to the patient, all members of the team, be the communication link between the patient and the team and advocate for the patient.
No- The key worker role requires a person to be an active listener and good communicator. To optimise the process and ensure patients feel fully involved the key worker must listen to the patient, all members of the team, be the communication link between the patient and the team and advocate for the patient.
Maybe- The key worker role requires a person to be an active listener and good communicator. To optimise the process and ensure patients feel fully involved the key worker must listen to the patient, all members of the team, be the communication link between the patient and the team and advocate for the patient.
No – Goals relate solely to the key worker’s profession. The goals should be the patient’s goals therefore they can relate to any profession.
Yes- Goals relate solely to the key worker’s profession. The goals should be the patient’s goals therefore they can relate to any profession.
Maybe- Goals relate solely to the key worker’s profession. The goals should be the patient’s goals therefore they can relate to any profession.
Maybe– All goals should be achievable. Goals should be possible but not necessarily achievable. Goals can be aspirational but the ‘building blocks’ for these should be broken down into achievable goals.
Yes- All goals should be achievable. Goals should be possible but not necessarily achievable. Goals can be aspirational but the ‘building blocks’ for these should be broken down into achievable goals.
No – All goals should be achievable. Goals should be possible but not necessarily achievable. Goals can be aspirational but the ‘building blocks’ for these should be broken down into achievable goals.
No – A dietitian would not be required to input to a patient’s goals. Depending on the patient’s priorities any member of the team may be involved in goal setting. For example a patient may wish to reduce their risk factors by losing weight therefore need input from a dietitian.
Yes- A dietitian would not be required to input to a patient’s goals. Depending on the patient’s priorities any member of the team may be involved in goal setting. For example a patient may wish to reduce their risk factors by losing weight therefore need input from a dietitian.
Maybe- A dietitian would not be required to input to a patient’s goals. Depending on the patient’s priorities any member of the team may be involved in goal setting. For example a patient may wish to reduce their risk factors by losing weight therefore need input from a dietitian.
Charlie recognises that it is challenging to implement but that there are many benefits to using patient-centred goal setting. He takes a moment to reflect on the value of goal setting.
Page last reviewed: 13 Jan 2021
