Getting Started ACP implementation package
This page contains a shortened version of the Getting Started ACP implementation package which has been developed by HNE Health Advance Care Planning Project Officers. This package was designed for services and facilities to be able to sustainably implement advance care planning processes into routine practice. The package contains tools and resources that will enable services/facilities to assess where ACP gaps are, starting points to address these gaps, resources/ tools to assist in meeting identified gap areas and HNE approved ACP resources.
ACP implementation is a quality improvement process, and ideally will be undertaken using a QI approach. A process similar to the Essentials of Care program (or as part of the EOC process) works well with sustainably implementing ACP. Remember that ACP is a team based process which requires education, processes and systems to be in place to support ACP information to be effectively communicated and actioned across care sectors.
Not all services/facilities will require all the resources and tools within the Getting Started package. The local ACP team should review package contents and use resources and tools that suit their service needs. To maintain source integrity, tools and resources available from the online package are in pdf format. Complete Getting Started packages (including word versions of tools) are available by contacting LisaK.Shaw@hnehealth.nsw.gov.au
Implementation support and assistance for services wanting to implement advance care planning is available by contacting LisaK.Shaw@hnehealth.nsw.gov.au 49246182
Section 1 Continuous Quality Improvement (CQI) self assessment
This section contains tools that can be used to identify existing ACP process gaps and some starting strategies to address same. It is recommended that this anaylsis be completed prior to beginning ACP implementation
The CQI planner enables teams to identify gaps and suggests simple strategies to address same. This tool can be used to plan and chart progress and may be used to support evidence of meeting accreditation standards 1.1.2 Care is planned and delivered in partnership with the consumer/patient and when relevant, the carer, to achieve the best possible outcomes and 1.1.7 Systems exist to ensure that care of the dying and deceased consumers is managed with dignity and comfort
A Plan Do Study Act approach has been identified as being helpful when implementing ACP processes into practice. It is recommended that services identify a small subset of clients/patients to begin ACP with, and refine appropriate process approach and resource use prior to wider implementation. A tool to support the PDSA approach is included here.
Auditing is a necessary evil to identify that 1) change is needed and 2) that change has been effective. A simple process audit tool is available here for services/facilities to be able to assess ACP process change over time. The results of audits may then be used to reflect on whether process changes are needed and whether implementation has been sustained.
ACP Organisational Approach self assessment. This tool may be used by services / facilities to assess where they are at in terms of ACP best practice principles.This tool can be reviewed annually to review current organisational ACP practices. A seperate tool has been modified for Aged Care Residential services
CQI planner 
(pdf) 36K
Process audit tool (general)
Process audit tool (residential)
ACP Organisational Assessment (General)
ACP Organisational Assessment (Aged Care)
Section 2 ACP Systems and Processes
This section contains tools and resources re systems and processes for ACP implementation. The resources and tools within this section have been used at facilities and services within HNE Health and meet best practice recommendations. Modification for local service processes and systems is encouraged. For successful ACP implementation, ACP discussions and documents should be easily accessible and available for use each time the person presents to a health care facility.
ACP implementation flowchart can be used to demonstrate how ACP discussion can be built into routine service practice. This is a generic flowchart and will need local adaptation
ACP process prompt guide can be used by clinicians as a guide to incorporate ACP into personal practice
ACP documentation process provides a summary chart of ACP documentation actions required and rationale for same
ACP divider may be laminated and used as an internal chart divider to store ACP documents behind. It is recommended that this be printed onto green paper to clearly identify divider presence in the inpatient chart.
ACP Discussion Record sample is available from education section of this site
NSW Health policies and guidelines are available from education section of this site (including NSW Health No CPR form)
Section 3 Clinician ACP resources
This section contains resources and tools that have been used within and externally to HNE Health for advance care planning discussions. This section contains only resources that have been specifically flagged as being beneficial in ACP discussion and is by no means an exhaustive collection. Resources can be pronted off and provided to patients/ familieis or may be used by the clinician to increase their own ACP discussion skill development
ACP plan/directive capacity checklist Adapted from the Capacity Asssessment Toolkit this can assist clinicians to do an informal capacity assessment on whether a person has decisional capacity to complete advance care planning documentation. Please remember that the majority of people will NOT need capacity assessment and this is NOT a formal capacity assessment tool, rather a series of questions that the clinician can use if they are uncertain as to whether the patient understands what documenting a plan entails.
ACP discussion guide an excellent resource to provide an overview of the ACP process, with examples and rationales of questions that may be used in ACP discussions.
Prognostic Indicator Guide This tool was developed by the Gold Standard Framework as part of the NHS End of Life Strategy. It contains generic prognostic indicators as well as disease specific indicators that can be used when assessing patients for end of life stage prognosis
MAPP make advance planning a priority tool. Developed as a high level prompting tool for clinicians to use to identify patients with priority end of life ACP needs. Ideally should be used in conjunction with the prognostic indicator guide
Dementia changes in the ability to live independently poster which succicently displays behaviour and functional changes associated with dementia
Dementia end stage information booklet booklet designed to discuss end stage dementia and medical treatments that families may need to consider
Hard choices for loving people excellent book which discusses life prolonging treatments and decisions that patients and families may face as the end of life approaches. PDF version may be downloaded and printed for patient / family. Please be aware that this is an American booklet and contains information which is not relevant for NSW