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Team action plan


Following a baseline assessment such as the Primary Care Team Assessment, the next step is to develop a team action plan and identify the key areas you wish to work on.


These key areas could be directly related to self-management support or earlier steps required to develop a strong foundation for self-management support.

Simple action plan template


Download and edit Word version OR copy the template below and adapt for your team.

Example: team assessment and action plan at Island Bay Medical Centre


The Primary Care Team Assessment (PCTA) was completed by a cross-section of the team at Island Bay Medical Centre (IBMC). Responses were received from GPs, nurses and reception/admin staff. Analysis of the data showed consistently high scores for the following areas:


  • engaged Leadership

  • population management

  • data-driven improvement

  • continuity of care

  • good communication with patients

  • broad-range of services provided by nurses

  • involving patients in decision making

  • development of care plans.


However, in other areas, there was a wide range of responses scoring in the beginning, improving, consolidating and advanced ranges. These areas include:


  • workflows for clinical teams

  • medication management

  • access to pharmacy support

  • access to behavioural or mental health services

  • linking patients to community support and services

  • the role of health workers

  • staff effectiveness at building patient understanding

  • the principles of patient-centred care.


A workshop with all the team was organised where the results were fed back and discussed. Two main issues were identified through the discussion:


  1. There had been a significant turnover of staff at IBMC over the preceding year to eighteen months. The introduction of new team members brought new ideas and different ways of doing things and this, in turn, led to variability in service delivery and resource utilisation.

  2. The team had consistently scored themselves highly for ‘development of care plans’. However, through the discussion, it became clear that there were differing views around what is meant by a ‘care plan’ as opposed to a ‘treatment plan’.


Most of the issues with a wide range of responses in the PCTA are fundamental components of care planning. Given this, the group identified care planning as an area they wanted to focus on as part of their action plan. A subsequent workshop was conducted with a facilitated discussion around their current diabetes annual review (DAR) care planning process.


Issues and opportunities


The following issues and opportunities were identified: 

  • Some tasks do not require clinical input and clinical time is wasted on these.

  • It could be useful to look at a patient plan and identify what happens at each visit

  • How are patients supported to prepare for regular diabetes appointments?

  • Children with diabetes are treated by the DHB then discharged at 18. The current transfer to primary care is not well supported. A young person with diabetes may not have any other reason to visit a GP and is used to the DHB system of recall so may not initiate contact with GP.

  • Annual reviews can seem like a massive undertaking for patients and nurses. About 60% of people eligible for annual review complete them. Could be more forward-looking rather than review of last year

  • The need for a regular visit can be discussed with a nurse – if someone has been to the DHB recently, they may not need their recall appointment

  • We need to be using a consistent care plan for diabetes. IT must be easy to use and access. The common form is good for patients but not sufficient as care plan - also need clear information for the clinical team (e.g. Compass new form, the promise, care-pad plan). Need goal setting, able to add information such as foot check results

  • Often need to repeat information as it becomes more relevant to people (e.g. re-explain hypos after their first hypo)

  • Better follow-up re eye-screening (why it is important and making sure it’s done – especially when it can become a problem if not managed well with young people)

  • A good question to check prior knowledge:‘Tell me what you know about your diabetes already?’

  • Using ‘teach-back’ to check understanding. 

This list was narrowed down and priority problems identified:

  • DAR can seem like a massive undertaking for patient and nurse.

  • DAR could be more proactive. May be useful to plan and identify what happens at each visit.

  • How are patients supported to prepare for their regular visits?

  • The need for regular review can be negotiated between the patient and nurse, this should be flexible and reactive to individual’s needs.

  • There is a need for consistent care planning.

  • Better follow up re retinal screening and foot checks.

  • Some tasks do not require clinical input time is wasted on this – recalls.


The Island Bay Medical Centre Care Planning Implementation Action Plan was developed. The team elected to start with a focus on diabetes. 

Current plans


Island Bay MC now has an established working group of GPs nurses and admin staff who meet regularly and are steadily developing/trialling new policy, process, tools, and resources. The nurse leader coordinates this work. There is a schedule of ongoing education that includes internal updates and externally facilitated workshops. 


*The picture at the top of the page shows some of the team at an externally facilitated care planning training session held in June 2017 showing how differently we all interpret the 'same instructions'! The exercise in the photo clearly highlighted for the team the importance of the ABCs – Ask, Build, Check (where Check = “Check you’ve been clear”).

Explore the other sections in Implementing Self-Management Support

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