2.2 How could the delivery system evaluate and improve the care planning process?
A hallmark of a high-functioning system is that monitoring the quality of the processes and the products is a built-in part of the workflow, as is taking steps to improve and to address shortcomings. In well-engineered production systems, feedback loops to upstream contributors are commonplace and valued. This kind of integration of the system and enabling of management appears to be completely missing with regard to care planning for frail elder care. A responsible manager would want to monitor such elements as the presence of a documented care plan, its effective implementation, the accuracy of the information on which it was based, the articulation and achievement of the priority goals, and the confidence felt by the elderly person and family. Not only should such elements be monitored, but those responsible for building a care plan need to learn how the situation turned out and to be enabled to improve performance because they have feedback from which to learn.
Metrics of this sort are profoundly underdeveloped. A few teams monitor existence of a care plan, requiring a few key elements. Some individuals and teams follow up to see how things turned out. But Medicare’s list of 992 metrics now in use does not include even a single element on care plans except for the limited settings with limited statutory requirements. Indeed, no Medicare measures of quality incorporate the elderly person’s own preferences and goals in the evaluation of performance.
So, concerned persons should push for better metrics; involved caregivers and providers should engender processes that provide feedback; and elderly persons should have the care plans that reflect their situation and preferences.
 (Centers for Medicare and Medicaid Services Measures Inventory 2016)