Learning with Patients

I have had a fantastic week. I have had the privilege of spending a couple of hours in the company of some of our local service users. There was a group of us chatting, and we heard a bit about some of their experiences. One of them said something which really hit home – and reminded me of some of the comments made by the late Kate Granger (hellomynameis…). When staff interact with a patient or relative, they often neglect to listen. The interaction can be perfunctionary, garnering the essentials for the task, but not really listening. This lowers the patient experience, as they need staff to have the patience to hear the wider concerns.

This started a train of thought. How often do we REALLY listen to our service users? What valuable insights could they offer? This isn’t just about learning from complaints and concerns, or involving them in investigations – we should be thinking wider than that.

Each month, my team produce a report on the trends and themes of incidents. The predominant themes rarely change, and are probably highly similar to those in your own organisation (falls, pressure ulcers, handover…). Most organisations have collaboratives, groups and initiatives to address these topics, and these have led to some great improvements, from ‘End PJ Paralysis’, so patients maintain their mobility, to work on reducing the pressure journey in transfers. But what we don’t do – is ask the patients.

How much could we gain if we ran focus groups with the collaborative experts, and a group of patients or other service users? How does it feel to be the person sat in the chair for hours, knowing the staff are very busy, wanting to move about, go for a walk? We are trying to solve difficult issues without the involvement of one of the key characters in the scenario. Of course I have no idea if new solutions would be generated. But isn’t it worth a try?

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Patient Safety

This week, the news was circulated that we had a number of patients with flu, or influenza. And it got me thinking about patient safety. We use the phrase all the time, in fact, we use it so often, that we sometimes forget its meaning.

 

Patient Safety is a not an action, its a way of being.

 

There are plenty of definitions of patient safety. The WHO describes it as the prevention of errors and adverse events associated with healthcare. An adverse event would include cross transmission of an infection, such as flu, while in healthcare. We can, of course, address this through handwashing, placing those with flu in a side room etc… But we can also become vaccinated ourselves, to reduce the risk of getting the virus and passing it on ourselves. We can look after not just our patients, but ourselves. A healthy individual is better able to perform at their best.

 

This isn’t just about physical care either. Compassionate care is one of the core 6 C’s, and a vital part of patient experience, itself a core element of Quality, as defined by Ara Darzi in ‘High Quality Care for All’.

 

Delivering compassionate care means avoiding burnout, compassion fatigue, that point at which mental stress overtakes our ability to care. It can happen to anyone. We are responsible for trying to manage our own stress, and for looking after our colleagues, being alert for warning signs of burnout.

 

Patient Safety is not an action, or a series of actions. It is a way of being. It involves not just our interactions with our patients, but our interactions with our colleagues, and our interactions with ourselves.

 

In 2019 – make a pledge to look after yourself, so you can help look after others.

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Governance for Ward Leaders – Part 7 – Duty of Candour

In this series I have been talking about points of Governance for ward leaders. I probably largely mean ‘new’ ward leaders, as this is intended to be an introduction for those who haven’t had to deal with these issues before.

Today I wanted to talk about Duty of Candour. This has been around for a while, and probably longer than you think. The now defunct National Patient Safety Agency published guidance on ‘Being Open’ in 2009, which was very similar to the current requirement. But many clinicians were practising the principles of Duty of Candour for years before.

At its heart, Duty of Candour has three principles:

  1. Transparency
  2. Honesty
  3. Empathy

Adding those up, like an equation, should result in an apology – the word, ‘sorry’.

 

Sorry

But it isn’t always as easy as that. Often clinical staff worry about whether they will cause more upset by telling a family that there was an error involved in the care of a person who has since died, particularly if the error wasn’t related to their death.

 

But the key is to put yourself in the shoes of the relative. How would you feel if you found out anyway, but that the staff hadn’t told you? Given that we haven’t yet found a way to train ward leaders on mind reading, the best policy is to err on transparency, and the sooner the better. Telling the patient while they are still on the ward, or the family is far better than telling them weeks later.

 

I was seriously impressed this week, by a member of staff in my own organisation. This person had made an error, and a senior person had been to apologise. But the individual member of staff then went themselves to apologise in person. That will have taken courage; but I’m sure that the patient will feel much better about it as a result.

 

Transparency, honesty, empathy and saying sorry are inextricably linked. We are open and honest because we have empathy, and can put ourselves in the patient’s shoes. We say sorry because we have empathy, and we would naturally apologise when being open and honest.

 

As a ward leader, you will sometimes apologise for errors that have happened. And it is important that comes from you, as it helps the patient or their family realise that you, as the senior person, take this seriously.  But there is also a benefit from an individual staff member who made a mistake saying sorry. That requires a further element in the equation: courage. But it will help your patient, or their family, it will help your staff come to terms with their error, and help them grow as a professional. And part of your role as a leader is to help your staff grow as professionals. So take a leaf out of excellent practice, and encourage / support them to apologise as well.

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Governance for Ward Leaders – Part 6 – Staff Support

I have been writing a weekly blog recently covering the elements of governance essential for ward leaders, from incidents, basic investigations, risk and assurance. This week I want to talk about something really close to my heart; staff support.

In our careers we all face moments which are suddenly very challenging. What happens if there is an investigation about an error or concern about an event in your team. It is natural for the staff to feel they will be in trouble, that there will be something put on their record. There is something known as ‘the second victim’. That is the member of staff who made an error, who is a caring individual and feels wretched as a result. Its very very difficult to come to terms with an error that led to harm. There is also such a thing as third victim, those around who may have witnessed the event. While the investigators should be putting them at ease – you, as leader, are closer to them, and it is your job to be the primary support.

First, assure the staff, repeatedly if necessary, that an incident investigation is about working out what we can do about the system to help ensure other staff don’t find themselves in a similar situation in future. This is different from an HR investigation, where disciplinary action could be on the cards. For that reason, the two types of investigation operate in different ways.

So how can you support your staff?

  1. Make it clear what type of investigation it is.
  2. Ensure the staff write detailed statements as soon as possible, with as much as they can remember.
  3. Let them know they can still have someone with them if they want. They don’t need a union rep for an incident investigation, but they would be welcome to bring anyone for support if they are worried.
  4. Ensure you know what the organisations staff support mechanisms are, be alert for signs of ongoing worry that may benefit from counselling through Occupational Health.
  5. Liaise with the investigation team; where would your staff feel more comfortable being interviewed? Is there a time that would be less stressful?
  6. Check with the investigation team that the notes from the meeting will be shared before being taken as fact, and whether the member of staff will be able to read the report before being finalised, or soon after.
  7. Discuss the learning from the incident with your team. There are times the investigators may want to speak to staff before any debrief, or they may want to attend the debrief – but please do hold one. Encourage the team to talk about what happened, and what can be done to avoid it happening again.
  8. Put together some solutions and discuss these with the investigators. It is far better that the team where an incident happened are engaged in developing solutions – I find it often leads to better improvements.
  9. After the interviews, while waiting for the report, spend some time catching up with the staff involved to check they are ok, and whether they would benefit from someone to talk to about it. Sometimes an event hits people later, and as ward leader, you need to be prepared for that.
  10. Finally, thank the team for their cooperation, their hard work in bringing about change, and acknowledge that it can’t have been easy. Help the team draw a line under the past so they can move forward to continue delivering compassionate care.

 

We have all heard about compassion fatigue, emotional fatigue where those in caring roles struggle to maintain the caring attitude. A serious incident is a factor that can really knock a person’s ability to maintain high standards and compassionate care.  As ward leader, you have a big role in helping staff to maintain their compassion and standards. But don’t expect to do that alone. Do ask for help – for yourself as well as the team. You are also human. So please, if you or your staff are finding it difficult, get in touch with your Matron, or the Risk Team, or Occupational Health – or other routes in your organisation. Don’t just carry on one foot in front of the other. Look at it this way – you will also be helping your organisation realise what needs to be in place for staff in the future. The support needed is another piece of learning that must come out of an investigation, so we can improve to help staff continue to be the brilliant people they are.

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Governance for Ward Leaders – Part 5 Assurance, a 6 point plan

I have been writing about Governance specifically for ward leaders, band 6 or 7 staff who are trying to run a department, who are probably clinical experts, but for whom the governance topic is new. And yet suddenly, you are expected to deliver in this arena. Coincidentally this week, I was asked to give a talk on Quality and Assurance as part of a development programme for Allied Health Professionals. And there isn’t a great deal of guidance on the topic of assurance. So here is my take.

The dictionary will define assurance as a positive statement designed to give confidence. All well and good. But I’ve had my Chief Exec turn round after I’ve suggested in a report that the Board be ‘assured’, to ask what the basis for that assurance is. It was a very good point. We often talk about something giving assurance, when there is evidence elsewhere to the contrary.  There are six steps you need to take to deliver effective assurance:

  1. Identify the issue
  2. Assessment
  3. Collate evidence
  4. Consider gaps
  5. Develop actions for the gaps
  6. Report and Monitor progress

Firstly, you need to work out what the issues are. These may be obvious, or not. They could come from incidents, complaints, claims, or a walk round or visit. Consider what it is you are trying to deliver in your area, and then what could stop that from happening.

Once you have your issues, then think about what assessment there is currently around that. If it is something like falls or pressure ulcers, there may be a dashboard – but this isn’t always the case. If you are putting in some sort of assessment or audit – think about how much work this will entail. Those assessments that can be built into routine practice tend to work better.  Try to ensure you are bringing in all the evidence; is there any other data around this issue being collected? Is it worth considering data from other areas? For example, if you are looking at falls, it would be worthwhile knowing if a ward with a similar cohort of patients averages less falls.

Once you have all the evidence, you can analyse it, and decide if the evidence is enough. Do you need more assessment? What is being done around the issue already, and where are the gaps? Is it a gap in assessment, or a gap in practice? How can it be reduced or closed? Any action needs to have a single lead (never give an action to everyone – that just means everyone assumes someone else will do it), and a timescale.

The last stage is around reporting and monitoring. Pull your assessment and actions into a report. Where that goes depends on the structure of your organisation, but most Trusts will have a clinical governance structure within clinical areas. That is always a good place to start. Present the assessment (evidence), with the action plan. This then provides assurance that:

a. You know what the problems are

b. You are monitoring through assessment

c. You have a plan to improve the situation.

Those three points are what any good management structure looks for in assurance. I would be more worried about an area that couldn’t describe the issues, or had no means of assessing whether things were getting better or worse. But if I see something from a ward leader that identifies the issues, gives evidence of where they are based on assessment, and then includes an action plan – I’m then happy that this is being effectively managed, and unless they ask for support, I can leave the leader to manage the situation.

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Governance for Ward Leaders – Part 4 – Risk Registers

Managing a ward is not easy, and governance is rarely taught in nurse training over the generalised concepts; so many ward leaders feel they are working this out on their own, which is why I wanted to help. In this blog series I cover some of the aspects of governance as they apply to ward leaders. These are not covered in depth, but sufficient for you to start seeing how this would apply to your area. I am happy to respond to any questions.

This week I wanted to talk about risk registers. Arguably, that is where I should have started, but I felt it might be easier if I started the blog with something more familiar, incident reporting, and clinical audit. These give you a good idea of what is going wrong, but don’t predict what could go wrong. For that, nothing beats the human brain. And the more human brains, the better. Hopefully, as ward leader, you are holding fortnightly or monthly team meetings. This is the best place to start talking about risk registers.

Start by drawing a big cross on a piece of paper. Everything above the horizontal line is your department, below is from outside. To the left of the vertical line is what is going wrong now, the incidents, complaints, poor audit results etc…. Everything to the right of the vertical line is what could happen in the future.

Risk identification

Then discuss what you are trying to achieve in your ward – are you aiming to get patients back to baseline to get home? Are you aiming to give compassionate care? These aims should shape your risks, as your risks are what could prevent your team from achieving these. Then ask the staff for their view. Get them talking. What could stop them delivering compassionate care and getting patients back to a baseline for discharge? Initially most of what they say, you will certainly be expecting. They will probably mention falls, pressure ulcers, staffing, for example. But gradually, as those have been written down, they will start to expand to other possibilities. This process is called risk identification.

Once this is done, there is a process of assessment, something you can do after the meeting and report back. Are any of the concerns already on a wider directorate or divisional risk register? The chances are, pressure ulcers, for example, is already on a Trust risk register. The question is then, are there more actions you need to take locally, which would warrant this being on your local register, or is it being managed sufficiently already? If you are regularly going over 40 days without a pressure ulcer, then I’d suggest it was being managed. If you are getting new pressure ulcers every week, then perhaps more needs to be done locally.  Then score each of the risks. How bad could it get on a scale of 1-5 (where 5 results in deaths and 1 is no harm), and how likely is it to happen (where 5 is every 4 weeks, 1 is every 3 years). There will be guidance on scoring in your local Risk Management Policy. Any risk scoring over 8, which isn’t already being managed appropriately and is on a more senior Risk Register, should be added to your local Risk Register.

At this point, I’d report back to your team meeting, and discuss the next stage. What are you already doing as a team, or the wider organisation, to control the risk? Are there policies or guidelines in place? Regular reports, a dashboard? A link nurse? Controls are anything that is already happening. Then, what else needs to happen – these are your actions. Ideally, you want actions that help prevent the risk (eg. stop patients developing pressure ulcers), actions to help detect the risk (is there anything needed to ensure you spot pressure damage at the earliest opportunity), and actions as a contingency (what happens if someone develops a pressure ulcer?).

You can make risk registers very complicated. That isn’t necessary. Keep it simple. Think of it as a four stage process:

  1. What are we trying to achieve?
  2. What could prevent that?
  3. What are we doing already to deal with that (our controls)?
  4. What do we need to do extra (our actions)?

Last point. A risk register is no use if you just write it once and leave it. Make sure it is kept up to date, that there is progress on the actions on a monthly basis. Ideally it should be a regular item on your team meeting. Risk Registers are about good leadership, and good leadership is about leading a team, not doing things in isolation.

 

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Governance for Ward Leaders Part 3 – Clinical Audit

Clinical audit has become such an integral part of the day job, that many of us don’t really think about it anymore. It has become an accepted thing, and, for ward leaders, is often done as a response to a senior dictat. I would be very surprised if any of the ward leaders who read this don’t have a requirement to do some form of audit, from hand hygiene, to something around pressure ulcers or falls. Do you feel you are ‘audited out?’.

Relax. This isn’t about giving you more work, but giving you back some control. In week one of this series, I talked about incidents. In week 2, it was small investigations, a measured response to some incidents that was a cut down root cause analysis, focused just on the key principle (why). But if you want your ward to be improving safety, you do need a way to measure that improvement. Given that I’m trying to lose weight at the moment, think of it like dieting. You can spend months thinking you are trying to cut back, only to find your clothes getting tighter. It’s only when you start to step on the scales that improvements really happen. Measuring helps.

But clinical audit isn’t just about measuring. That’s where much of the current audit work falls down. Its really about the cycle, the audit cycle. Measure where you are, consider a change, then measure again.

Your incidents may give you an idea of areas which need looking at, or it may be obvious from talking to the team. Perhaps you have done an investigation and established a ‘why’, you may even have an idea of the change that would help. You could just go ahead and implement it, but that doesn’t always work in the long term. I used to work in a clinical environment where change would be introduced, along with knowing glances and smiles. Three months down the line, and everyone just went back to the way they had always done it. The key to improvement is embedding change – and that doesn’t just happen, it takes effort. Measurement and clinical audit can help here.

Think about doing a small audit before the change, and, ideally, get one of your team to do it. That way this won’t be an ‘imposed’ change, it will be something they will have planned with you – and that engagement in the process is more likely to help them shift their mindset to embrace the change. Even the most positive people can resist change when they feel it has been imposed without good cause. So do the audit; a small sample – ensure the questions are geared towards measuring the issue you have concerns about. For example, if we are talking omitted medication, it may be observational about how the medication round is done (but that can mean a member of staff is taken out of the numbers temporarily), or it could be a retrospective look at the medication charts, noting how many missed medications there were, what time they were due (are they happening more at certain points in the day?), what staffing was like on those days etc… Bring in the key aspects which might impact on this.

Once you have the results, discuss them with the team. What do they think about the findings? What do they feel would make a difference? If the idea for the change comes from them, they are far more likely to stick with it. Agree the changes, then agree a date when it starts. It could be the next day, but is the whole team aware? You may need a week to ensure the message has got to everyone who needs to be involved. Make the change, let it run for a week or so, then measure again. Same questions (you could add a couple more, but don’t take any away), try to replicate the original audit as much as possible, even down to the same person doing it, particularly if its observational. For example, the results of a hand hygiene audit can vary by 30% simply based on who the observer is (yep, some of us are far more forgiving than others…).

Once the results are in, compare them to the originals. Or, better still, get the person doing the audit to compare the results with another team member. Let your team own the audit. Then discuss the findings as a team. Has the change worked? Is a different change needed? A further change? Or leave the existing change in place and audit again in a months time? To really embed something, you need to keep the measurement going for around 4 months, otherwise you risk old habits and routines sliding back in place.

Clinical audit can be a very powerful tool for the ward leader to drive real change, and demonstrate just how effective you are, and it doesn’t necessarily involve more work on your part either. This is just a brief overview; your Trust will have a team who can talk you through how to frame your audit and record it on the Trust systems (most Trusts have a way to record all clinical audits that take place).

Next week, do you have any risks? Risk assessments and then leading to risk registers.

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