NEUROPSYCHOLOGICAL REHABILITATION, 1999, 9 (3/4), 241–251

Goal Planning and Neurorehabilitation:

The Wolfson Neurorehabilitation Centre Approach
T.M. McMillan
Wolfson Neuro-Rehabilitation Centre, St George’s Healthcare, Wimbledon,
London and Department of Psychology, University of Surrey, Guildford, UK

C. Sparkes
Wolfson Neuro-Rehabilitation Centre, St. George’s Healthcare, Wimbledon,
London, UK

This paper describes the process of goal planning and discusses its usefulness as a
simple, time sparing, client centred tool which provides basic data on outcome
and audit information on the process of rehabilitation. Data on a sample of 100
cases admitted for neurorehabilitatio n are presented. Significant correlations
between achievement of long-term goals and changes in standard measures of
outcome such as the Barthel Disability Index and 10 metre walk time were found
across admission. It is argued that goal planning can be the core procedure for
neurorehabilitation , which in addition provides audit information and a simple, if
unsophisticated measure of change.

INTRODUCTION
Throughout the 1990s there has been increasing emphasis on the development
and use of outcome measures in neurorehabilitatio n as tools for estimating
effectiveness. Cost pressures in health and social services have led to reorgani-
sation of services, restrictions on their development, and actual cuts. The
general heightening of perception that there are limits to resources, would seem
to have gone hand in hand with an increasing emphasis on the need to demon-
strate that all clinical interventions are effective, in order that this can be taken

Requests for reprints should be sent to Professor T.M. McMillan, Department of Psychology,
University of Surrey, Guildford, Surrey, GU2 5XH.

Ó 1999 Psychology Press Ltd

242 McMILLAN AND SPARKES

into account in the planning of health care (see Calman, 1998). In neuro-
rehabilitation, establishing effectiveness has proved to be more difficult than in
some other areas because most neurorehabilitatio n is post-acute and as time
since injury increases, it properly concentrates on disability and handicap
rather than on impairment. As impairment can often be measured objectively, it
is usually simpler and easier to measure, but most interventions in neuro-
rehabilitation are aimed towards reducing disability/handicap, which in turn
reflect quality of life issues more directly, are often multifactorial and at least
partly subjective in nature.
In attempting to establish measures that are sensitive, valid, and reliable in a
cost-sensitive environment, there is an inevitable tension between perceiving a
need to collect appropriate outcome data and the cost of doing so in terms of the
loss of clinically directed time. In general terms, the more sensitive and the
more comprehensive the measure, the longer it takes to complete and the more
likely that extensive staff training is required in order to ensure reliability. In
this sense a goal planning approach which incorporates a simple audit of
outcome is the least expensive in terms of lost direct clinical contact, but the
outcome data are gross and may be insensitive to degrees of change.
Goal planning is not new (see Houts & Scott, 1975) and has been used in
many rehabilitation units in many settings and for many years. It has been used
with varying degrees of sophistication and with positive outcome in a number
of diagnostic groups including children with cerebral palsy (Bower, McLellan,
Arney, & Campbell, 1996), adults with acquired brain damage (Ward &
McIntosh, 1993; Webb & Glueckhauf, 1994; McGrath, Marks, & Davis, 1995),
psychiatric patients (Houts & Scott, 1975; Rothery et al., 1995), older adults
(Barraclough & Fleming, 1986), spinal injuries (Kennedy, Walker, & White,
1991; MacLeod & MacLeod, 1996), learning difficulties (Fuchs & Fuchs,
1986; Flexer, Newberry, & Martin, 1979; James, 1981; Sturmey, 1992), sports
injuries (Theodorakis, Beneca, Malliou, & Goudas, 1997), and in non-clinical
settings such as industry (Arvey, Dewhirst, & Boling, 1976). A number of prin-
ciples have been developed from the experience of professionals and clients,
from formal research and from examples of good practice in clinical
psychology. For example Houts and Scott (1975) revised the strategies devised
by McLelland and Winter (1969) and used them successfully with poorly moti-
vated long-term hospitalised mental health patients. Houts and Scott stated five
principles of goal planning.

1. Involve the patient.

2. Set reasonable goals.
3. Describe the patient’s behaviour when the goal is reached.
4. Set a deadline.
5. Spell out the method (the rehabilitation plan should be sufficiently clear
and specific such that anyone reading it would know what to do).
 GOAL PLANNING AND NEUROREHABILITATION 243

Others have reported the benefits of setting goals, goals that are specific, chal-
lenging, and that are subdivided into long- and short-term goals (Bar-Eli,
Hartman, & Levy-Kolker, 1994; Locke and Latham 1990; Tubbs, 1986). In this
paper the use of a goal planning system that takes account of the above princi-
ples is described in a post-acute setting for rehabilitation of central nervous
system injury. Advantages and disadvantages of the process are highlighted
together with preliminary outcome data.

The Wolfson Neuro-Rehabilitation Centre (WNRC)

The system that is described here has been used at this centre with all brain
injured patients for 2.5 years. The WNRC is a national health service regional
neurological rehabilitation centre, which has 32 beds and accepts cases with
acquired brain damage, multiple sclerosis, and chronic pain as inpatients or day
patients from any time after they are medically stable, to several years
post-injury. Patients are admitted to individual or group-based programmes.
Data are presented here only for individual patients. The length of admission
for individual patients varies from 4 weeks (assessment only) to several
months. The multidisciplinary team consists of clinical psychologists, medical
staff, nurses, occupational therapists, physiotherapists, speech and language
therapists, and social workers. Other specialisms such as neuropsychiatry,
dietetics, and chiropody are available on a consultancy basis.

Principles of Goal Planning

Long-term goals (LTGs) should be achievable before discharge, and normally
last for the duration of the admission. The decision about whether the LTGs are
achievable before discharge is a value judgement, which relies on the experi-
ence of the team, both in working with brain injured people and with goal
planning. LTGs should usually relate to disabilities or handicaps, because the
purpose of the admission is to improve day-to-day functioning and for such
changes to generalise and be maintained after discharge. Improvement in an
impairment is unlikely to alter quality of life and less likely to be maintained
after discharge. In some circumstances LTGs might relate to impairments, for
example, if the patient is extremely disabled and each progressive step in
recovery is expected to be very small. Short term goals (STGs) are added for
each long-term goal. It is expected that STGs can normally be achieved within
1 or 2 weeks. Short-term goals may represent impairments, but are usually
directed towards disability and are hierarchically organised building blocks
geared towards reducing handicap. As the admission progresses, further long
term goals may be added to the list when the team have greater understanding of
the client’s problems. If a goal is not achieved, it is always recorded as such;
once written and agreed that goal can never be modified, but if it is not achieved
a new goal based on and similar to the original can be added. Non-clinical
244 McMILLAN AND SPARKES

research in organisational behaviour suggests that task performance is

improved by setting (specific) challenging goals rather than “easy” or “do your
best” goals, or no goals at all (see Smith, Locke, & Barry, 1990). Hence the
principle that goals should be challenging but realistic was adopted.
In addition, goals must:

• Be client centred.
• Be realistic and potentially attainable during admission.
• Be clear and specific.
• Have a definite time deadline.
• Be measurable.

The client is the patient, who must remain the focus for the rehabilitation at all
times. Goals are client centred when they involve the patient directly and are
devised in discussion with the patient. Plans of action concern staff activity and
are associated with specific STGs. This is an important distinction, which
forces the team to focus on targets for the patient. It prevents staff from being
distracted by actions that they feel they must take (i.e. essentially goals for the
staff), reducing the likelihood of a “fog” of energetic staff activity which masks
the absence of any real progress or improvement in the patient’s quality of life.
The same holds true for relatives/carers; goals may involve the patient and the
relative but there cannot be LTGs/STGs which are set for relatives/carers to
achieve alone, independently of the patient; these would be plans of action. An
example of a long-term goal could be, “will be discharged home by [date] with
care support of three hours or less per day”. One of the STGs leading towards
this could be, “will achieve independent transfers from wheelchair to bed and
bed to wheelchair by [date]”. The term “to be able to” must never be included,
as the client may in principle be able to do many things, but does very little. A
plan of action might be for the social worker to contact local social services and
arrange care support in the home; this however is not a short-term goal because
it does not directly involve the patient, it is a plan of action which requires
action only by staff. In order for the patient to go home, his or her relative may
need to learn how to lift the patient safely, this is also a plan of action because it
involves staff and the relative and is not an STG for the patient.

Process
The patient is allocated to a “Chair” (see below) and a team pre-admission. The
size of the team and specialisms within it depend on the needs of individual
cases, and varies between three and seven staff. Within the first 2 days after
admission, the multidisciplinary team meet for 15 minutes and formulate a
Plan of Assessment of the patient’s problems, allocating one or more named
team members to each element of the assessment. At the end of the first week of
 GOAL PLANNING AND NEUROREHABILITATION 245

admission the team meets for the first Goal Planning Meeting (1 hour) and
make a detailed Problem List (largely of disabilities); a provisional discharge
date is set, potential LTGs are formulated, and the patient and relative then join
the meeting (and from then should effectively be part of the team). The patient
is informed of the provisional discharge date at this meeting. LTGs are then
discussed with the patient and STGs associated with the LTGs are agreed
between team and patient. Both LTGs and STGs are documented. Plans of
action associated with the STGs are also documented. The patient/relative is
given a copy of the STGs for the following week/fortnight if this is of help to
them. Progress is reviewed and logged every 2 weeks in a 30 minute meeting
with the team (every week in some cases, e.g. if behaviour management is
needed); at each review further STGs are set and any additional LTGs are
added. If any LTG or STG is not achieved or is only partly achieved, the reason
for this is recorded.
Relatives/carers are encouraged to attend and to contribute to the Goal
Planning Meetings. Discharge arrangements are reviewed and summarised in
the last week of admission in the Goal Planning Discharge Meeting which takes
up to 1 hour. Additional to the goal planning process may be one (or more) case
conferences with attendance of relevant outside agencies such as social
services.
The total time required for goal planning meetings in an average case,
admitted for 8 weeks would be approximately 4 hours.

Chairs
Each patient is allocated a designated staff member who acts as a Chair
throughout their admission. Chairs are a key element in the goal planning
process, which demands that they are experienced in neurorehabilitation . In
order for the process to make optimal use of the team’s time, the Chair has to be
aware of potential areas of disablement, be prepared to probe and question
other team members in a constructive fashion, be able to resolve areas of
disagreement in a way that is in the patient’s best interest, and ensure that goal
planning procedures work and that a discharge report is produced. They must
be able to formulate LTGs and STGs in a way that is unambiguous and precise
and which leads to a clear conclusion in terms of whether the goal has been
achieved or not.
The responsibilities of Chairs include:

• Chairing all goal planning meetings.

• Keeping the content of these time-limited meetings focused on the
patient’s goals.
• Ensuring that the treating team are clear about aims of admission and
length of stay.
246 McMILLAN AND SPARKES

• Being an active member of the treating team.

• Ensuring that documentation is completed (including outcome
measures).
• Ensuring good communication between all relevant parties.
• Attending case conferences.
• Co-ordinating production of the multidisciplinary discharge report.
• Encouraging the patient, relatives, and the team to be realistic.
• Making clear arguments for change in discharge date to the business
manager.

All Chairs have to undergo training over two or three sessions (3–5 hours in
total). This includes the principles of goal planning, advantages and disadvan-
tages of goal planning, how the system operates within the unit (most prospec-
tive Chairs are already aware of this), case examples, role play, and examples of
audit information and its uses. In almost all instances prospective Chairs will
have been working in the Centre for at least 6 months and will thus be familiar
with the goal planning procedure, and in addition they will have had 2 or more
years of experience of working in brain injury rehabilitation. There are monthly
problem solving sessions for existing chairs and a quality assurance procedure
is being developed to ensure consistency of the process. New staff learn the
basic goal-planning system during the course of their clinical work and from
existing chairs. Specific senior staff are available to discuss any problems and
provide support to Chairs. On average there are about 10 Chairs in the WNRC,
each will chair 2–3 cases at any one time, in addition to having clinical respon-
sibilities with other patients.

Outcome and Audit

Outcome is represented here as the proportion of goals achieved, partly
achieved (more than 50%), or not achieved. This outcome data has been
compared with data from established outcome measures, which were collected
on admission and at discharge. These measures are the Barthel (Wade, 1993),
the 10 metre walk time, and number of steps taken when walking 10 metres.
Reasons for not achieving goals are divided into four areas which are
patient/carer, staff, internal administration, and external administration. These
four areas are subdivided into a total of 30 variables (variance codes). These
variance codes can be used for the purpose of internal audit to facilitate
improvement of the service. More than one code can be attributed to each failed
goal; variance codes are allocated to failed/partially achieved goals by the
Chair (examples of commonly used variance codes are given in Table 3).

Advantages of the Goal Planning System

• It is a simple system.
 GOAL PLANNING AND NEUROREHABILITATION 247

• It makes certain that the aims of admission are clearly documented.

• It ensures early consideration of discharge.
• It is client centred (patients and relatives/carers are involved).
• It builds team working.
• It makes efficient use of staff time.
• It incorporates a measure of outcome.
• It removes artificial distinctions between measurement of outcome and
client centred activity.
• It is useful for audit.
• It does not require extensive staff training.

Disadvantages of the Goal Planning System

• It does not provide systematically collected data on all possible
disablements.
• It may be insensitive as an outcome measure.
• Chairs must be experienced in neurorehabilitation .

AUDIT OF 100 CONSECUTIVE

NEUROREHABILITATION CASES
These were cases admitted for individual (not group) treatment. The average
age was 43 (SD 15, median 42, range 15–79). More than half of the admissions
were for stroke (39%) or traumatic brain injury (14%). Others had diagnoses of
multiple sclerosis (9%), brain tumour (9%), other central nervous system
(11%), chronic pain (6%), peripheral nervous system (6%), spinal injury (5%)
or rheumatological conditions (1%). In terms of physical dependency, 24%
required minimal nursing care (independent for personal care), 38% required
some assistance (e.g. transfer with help from one other person, some help with
self-care, such as cutting up food), and 38% were dependent (e.g. needing two
people to transfer, dependent for self-care, and requiring help or monitoring
from nurses hourly or constantly).
The median time since diagnosis/injury was 7 months (range < 1–288) and
the median length of stay was 42 days (average 48, SD 32, range 7–300).
Sixty-eight percent of cases were admitted from home and 92% were
discharged to home (Fisher’s Exact Test < .001). The average number of LTGs
was 6.0 (SD 2.5, range 1–17) and the average number of STGs was 21.5 (SD
1
11.0, range 0 –64). The percentages of LTGs that involved impairment,
disability, and handicap were 13%, 54%, and 34%, respectively. The

1
One patient became ill early in admission.
248 McMILLAN AND SPARKES

percentages of LTGs that were judged (retrospectively by TM) to be client

centred and measurable were 97% and 83%, respectively.
Table 1 shows evidence for improvement on standard outcome measures
between admission and discharge. Note that cases where the measure was inap-
propriate were excluded (ie if able to walk perfectly on admission, or if unable
to walk on admission and walking was not a realistic goal). Data were complete
for goal planning in all but one case, but was missing on standard measures for
17 cases. The majority of LTGs were achieved (78%), with 38% of cases
achieving 95% or more of their LTGs. Relatively few goals were partially
achieved (12%) or not achieved (10%). No LTGs were achieved in only three
cases. Changes between admission and discharge on the standard measures and
the total numbers of LTGs and STGs achieved is given in Table 2. Improve-
ment in Barthel score and reduction in number of steps required when walking
10 metres was associated with larger numbers of LTGs achieved. The number
of LTGs achieved did not vary depending on whether Barthel scores changed
or did not change across admission (t = 0.99, df 38, P > .05).
Overall, the longer the stay in the Centre, the greater the numbers of LTGs
(rho = .27, P < .01) and STGs (rho = .57, P < .001). There was no relationship
between length of stay and the proportion of LTGs achieved (P > .05).
LTGs were not achieved or were only partly achieved most commonly
because the goal was overly ambitious. Other relatively common causes were
poor motivation/compliance from the patient, and patient illness (see Table 3).

DISCUSSION
Goal planning is potentially attractive because it can incorporate an outcome
measure, a focus for clinical audit, is a relatively simple procedure, and because
it is client involving. As a measure of outcome, it has been criticised on several
grounds (Sturmey, 1992). These include (1) that equal weighting is given to all
goals; no attention being paid to the content and the quality of the goals, and (2)

TABLE 1
Differences between Admission (A) and Discharge (D) on Standard Measures

Mean (SD) df t P (2-tailed)

Barthel A 16.1 (4.5) 40 –3.6 = .001*

Barthel D 18.9 (1.9)
Steps A 35.0 (40.7) 42 2.9 = .005*
Steps D 26.2 (25.7)
Walk time A 30.0 (29.4) 44 4.8 = .001*
Walk time D 27.6 (31.3)

* also significant using Wilcoxon’s Test, P < .001

 GOAL PLANNING AND NEUROREHABILITATION 249

TABLE 2
Correlations between Change Scores across Admission for Standard Measures
and Total Number of LTGs Achieved or Partially Achieved (Spearman, 2-tailed)

Barthel Steps Walk

LTG A 0.49** –0.37* –0.23

LTG P –0.14** 0.13* 0.10
STG A 0.25** –0.18* –0.25

* P = .02; ** P = .001

that there can be little attention paid to the generalisation of skills acquired
across settings. The first criticism has merit; however, this criticism could be
made of more complex outcome measures, because the “importance” of a goal
is always partly subjective and ratings of quality may be unreliable, even if
goals are weighted. The second criticism may apply less to neurorehabilitatio n
settings, especially with the trend in favour of community based work,
discharge to home, outreach, follow up, and vocational schemes in recent
years.
Is goal planning simply a process which can be audited and not a measure of
therapeutic outcome? Goal planning is thought to be a fundamental determi-
nant of the performance of organisations (Smith et al., 1990). In a learning
disabilities setting, the introduction of goal planning was found to improve
such practical outcomes as workshop productivity (Flexer et al., 1979) and
school achievement (Fuchs & Fuchs, 1986). In this paper there was a

TABLE 3
Reasons why LTGs were not Achieved

Variance code Frequency Number of cases

Patient poorly motivated 8 7

Patient unwell 15 5
Patient fatigue 1 1
Patient disagrees with goal 1 1
Patient not available 6 4
Patient compliance poor 5 4
Patient recovered naturally 1 1
Goal over-ambitious 93 44
Staff absence not covered 1 1
Department closed 3 1
Home care not available 1 1
Funding not extended 2 2
Local therapy unavailable 2 2
250 McMILLAN AND SPARKES

relationship between change on the limited battery of standard outcome

measures (of disability) given and LTGs achieved (88% of which were related
to disability/handicap) suggesting that the number of LTGs achieved is a
simple, if unsophisticated, indicator of outcome of rehabilitation. This should
be further explored by expanding this battery and including psychosocial
measures of disability/handicap.
Part of the purpose of using outcome measures is to monitor and improve a
clinical service, and perhaps to persuade purchasers of its effectiveness. Goal
planning is useful here, because it involves a simple measure of the proportion
of client centred and measurable LTGs achieved, and provides a dataset which
allows information to be selected for specific purchasers across key variables
such as diagnostic group, time since injury and cost sensitive factors such as
nursing dependency and length of stay. The Chairing process can be audited
against percentage of LTGs that are measurable and client centred, proportions
of LTGs that represent disability/handicap, data collection on standard
measures, a systematic checklist of tasks that the Chair should complete, and
client satisfaction questionnaires.
In this study, a little over three quarters of LTGs were achieved and the main
reason for non-achievement was that the goal was over-ambitious. Given that
task performance is improved by setting challenging goals (Smith et al., 1990),
this is not unreasonable, and arguably some LTGs should not be achieved if the
goal planning process is optimal.
A modification which might improve service delivery could be to include a
checklist of potential needs at the Problem List stage to reduce the possibility of
any disability/handicap being overlooked. An example of this which has been
used successfully with spinal injury patients is the Needs Assessment Checklist
(Kennedy & Hamilton, 1999).
The data presented here may be considered tentative, given the absence of a
reliability study and the limited battery of standard measures used. Goal
planning in isolation, is not recommended as an alternative to using standard
measures of outcome, but given that the LTGs are individually constructed and
client centred, a less comprehensive battery of standard measures may be
necessary.

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Manuscript received 17 February 1999
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