Collaborative goal setting and decision making when working as part of a multidisciplinary team, and respect for the professional skills of all team members

The principle

Collaborative goal-setting with the patient and multidisciplinary team, and genuine mutual respect between team members regardless of professional hierarchy, are essential to effective complex/chronic disease management - a care plan developed in isolation by a single clinician without this collaborative process risks being poorly matched to the patient's actual goals and to the practical realities other team members can identify
Increasingly emphasised across chronic and complex care given growing recognition that effective long-term management requires genuine multidisciplinary collaboration rather than a single treating clinician working in isolation with occasional referral to other services

Different team members (nursing, allied health, primary care, specialists) each hold distinct, valuable perspectives on a patient's care based on their specific scope of practice and type of contact with the patient - respectful, collaborative goal-setting that genuinely incorporates these different perspectives (and the patient's own priorities) produces a more realistic, comprehensive, and ultimately more successful care plan than one developed by a single clinician working in professional isolation

Structured multidisciplinary team meetings/case conferences provide a forum for genuinely collaborative goal-setting and care planning, particularly valuable for complex patients with multiple involved services
Explicit elicitation of the patient's own goals and priorities (not assumed by the team) should anchor the collaborative goal-setting process, consistent with patient-centred care principles

Structured, collaborative multidisciplinary goal-setting processes (case conferences, shared care planning meetings) that genuinely incorporate all relevant team member perspectives and the patient's own priorities
Respectful team communication and hierarchy-flattening practices that allow all team members' relevant observations and expertise to genuinely inform the care plan, not just the most senior clinician's view

Multidisciplinary case conference models, patient goal elicitation as the anchor for collaborative planning, hierarchy-flattening team communication practices, risk of poorly-matched care plans from clinician-isolated planning

A care plan developed by a single clinician in professional isolation, without genuine collaborative input from other team members and the patient's own goals, risks being poorly matched to what the patient actually wants and to practical realities that other team members (who may have different, valuable perspectives from their specific type of contact with the patient) would otherwise identify - this is why structured, respectful multidisciplinary collaboration is increasingly emphasised as a core component of effective complex care, not simply a courtesy

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