MANAGING CLINICAL RISK

Edition 13 | December 2011

IN THIS ISSUEDeterioration consensus statement released 2

ISBAR for clear communication 4

Communication, teamwork and escalation – What makes effective fetal monitoring? 5

Doctors’ performance program rolls out 6

PAM plan rolled out across Victoria’s public health system 8

In the healthcare system, caring for patients involves numerous contacts and handovers between multiple healthcare practitioners and employees.

During the course of a four-day hospital stay, a patient may interact with as many as 50 employees – doctors, nurses, technicians, administrative staff and others. Hospital staff, in turn, will collaborate with both internal and external parties in the course of their shift.

Not surprisingly, miscommunication and ineffective teamwork can create situations where adverse events may occur.1

Communication and teamwork in a clinical setting

Liz Cox, the VMIA’s Clinical Risk Manager, says that poor communication and teamwork are common factors which may contribute or lead directly to adverse patient events.

“When healthcare professionals are not communicating effectively, patient safety is at risk for several reasons,” she says.

“Simple things like lack of critical information, misinterpretation or wrong timing of information, unclear orders or instructions, and overlooked or miscommunicated changes in status are examples of where communication can go wrong.

“Not all incorrect or mis-timed communication results in an adverse result,” says Liz, “but some communication errors – like medication mistakes, delays in treatment and wrong-site surgeries – can cause significant harm or even worse, death.”

Poor communication is not simply the result of poor transmission or exchange of information. Communication failures are far more complex and can be related to hierarchical differences, concerns with upward influence, conflicting roles and role ambiguity, and interpersonal power and conflict.

Liz explains that good teamwork is the other side of the coin.

“Effective teams are characterised by trust, respect and a sincere spirit of working together. This is especially true in healthcare where a teamwork model requires an interdisciplinary approach which coalesces a joint effort on behalf of the patient, with a common goal from all the disciplines involved,” she says.

Above: A team meeting courtesy of the Royal Women’s Hospital

(Cont. on page 2)

2 | Managing Clinical Risk July 2011 www.vmia.vic.gov.au

Managing Clinical Risk

Communication and teamwork Continued from page 1

“The upside is that most of these hurdles can be overcome with an open attitude and encouragement of mutual respect and trust.”

Studies from overseas indicate that improved teamwork and communication are rated by healthcare workers as among the most important factors in improving both clinical effectiveness and job satisfaction2.

Effective communication and teamwork promote improved information flow, more effective interventions, improved safety, enhanced employee morale, increased patient and family satisfaction, and decreased length of stay.

“When effective communication and teamwork come together, the result encourages good clinical practice, and assists the prevention of errors and adverse events,” says Liz.

“Clinicians and healthcare workers should never underestimate their importance in relation to reducing adverse events and improving patient safety.”

References:1 Professional Communication and Team

Collaboration. Michelle O’Daniel and Alan H. Rosenstein

2 A Team Approach: working together to improve quality. Cartlett C, Halper In: Frattalie, C, ed. Quality improvement digest. Rockville, MD: American Speech-Language-Hearing Association.

Deterioration consensus statement releasedAustralian Health Ministers have endorsed the recently released National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration as the national approach for recognising and responding to clinical deterioration in Australian acute care facilities.

The Australian Commission on Safety and Quality in Health Care developed the National Consensus Statement following an extensive consultation process.

The comments and views expressed in submissions were taken into account in developing the final Consensus Statement. The feedback received during the consultation process has been summarised in the consultation report.

The National Consensus Statement is available at health.gov.au/internet/safety/publishing.nsf/Content/RaRtCD_ConStat

The Rapid Response Systems Conference will be held in Sydney 7-9 May 2012. For more information or to register visit rapidresponsesystems.org

Emergency nurse absenteeism In September this year, Flinders University’s School of Nursing & Midwifery released a report, Understanding the Willingness of Australian Emergency Nurses to Respond to a Disaster.

Belinda Mitchell, a VMIA Risk Management Adviser, was one of the paper’s key investigators, and says that absenteeism among emergency nurses has a significant impact on the ability of a health service to function effectively during critical times.

“Emergency nurses are the frontline responders,” she says. “The factors which influence their willingness to respond to a disaster are poorly understood, so this study sought to provide some insight.

“We hope that the results will help in workforce planning and, therefore, help to mitigate adverse clinical events.”

Copies of the report can be obtained at: www.flinders.edu.au/nursing/researchhigherdegreeshub Visit: Our research programs and projects > Major research programs > Population health > Flinders University Disaster Research Centre

Features of effective teamwork and communication include:

• Opencommunication–regularand routine communication and information sharing

• Anon-punitive,respectfulenvironment

• Cleardirection–wellestablishedrolesand tasks for team members

• Sharedresponsibilityforteamsuccess

• Acknowledgementandprocessing of conflict

• Anenablingenvironmentwhichincludes access to needed resources.

www.vmia.vic.gov.au Managing Clinical Risk July 2011 | 3

Recent publications

Risk Insight: Missed Test Results – Improving the diagnostic processThe VMIA in collaboration with other stakeholders, have developed a report

to address concerns about risk associated with follow up of diagnostic tests. A workshop was held on 20 September 2011 to define the issues. This Risk Insight outlines the discussion and outcomes of the workshop, with a focus on addressing concerns about the risks associated with the follow up of diagnostic tests.

Risk Insight: The Deteriorating PatientPatients admitted to hospitals are presenting with increasingly complex conditions.

While advancement in therapies has improved clinical outcomes, problems continue to be identified regarding the response to deteriorating patients in acute hospitals. This Risk Insight summarises the VMIA roundtable discussion which identified gaps, risk management issues and potential improvement projects for management of the deteriorating patient.

Risk Insight:Safer Diagnosis – Improving the diagnostic process to reduce risks to patientsMisdiagnosis, missed

diagnosis and delayed diagnosis are common causes of medico-legal claims and have been repeatedly identified as areas in which there are potential for better risk management and quality improvement. This Risk Insight examines these issues.

Risk Insights can be downloaded from the VMIA website www.vmia.vic.gov.au/riskinsights

Ineffective teamwork is widely recognised as a significant causative factor in obstetrics incidents. This is further compounded by fragmented training for the multidisciplinary team.

PROMPT (Practical Obstetric MultiProfessional Training) is a maternity safety program developed in the UK, which is now being piloted in eight Victorian public hospital maternity units. The PROMPT program is a team-based simulation training that is conducted within the hospital’s delivery suite.

Julie Lodge, Clinical Nurse Educator-Midwifery at the Ballarat Health Services, says, “being able to train as a team right where we work has been central to the success of PROMPT.”

“We’ve seen improved clinical outcomes for mothers and babies which we can attribute directly to PROMPT.”

Another program known as TeamSTEPPS® is an evidence-based teamwork training system designed to improve collaboration, communication and patient safety within healthcare organisations. TeamSTEPPS® – an acronym for Team Strategies and Tools to Enhance Performance and Patient Safety – was developed by the US Department of Defense. It targets four critical

competencies of effective teamwork: leadership, mutual support, shared mental model and communication.

The program is now being piloted by the Victorian Quality Council at five sites in Victoria with the aim of improving multidisciplinary teamwork and the communication of clinical information among healthcare professionals. The expected project completion date is March 2012.

Case studies in teamworkNewborn Intensive and Special Care training at the Royal Women’s Hospital.

Managing Clinical Risk

4 | Managing Clinical Risk July 2011 www.vmia.vic.gov.au

ISBAR for clear communication

ISBAR is a communication tool designed to improve the clarity of information exchange in a clinical setting, most particularly to help make telephone referrals quick, informative and unambiguous.

In 2009, the VMIA partnered with Southern Health to promote ISBAR as a simple, practical tool for guiding staff in how they structure and exchange clinical information.

Based on a situational briefing tool used by the US Navy, and tested in the Southern Health Simulation Centre with fifth year medical students, ISBAR stands for:

Identify: Self and patient.

Situation: State the purpose of the call/contact and is it urgent?

Background: Tell the story.

Assessment: Your interpretation of the situation and degree of certainty.

Request: State what you want from the other person.

ISBAR was initially piloted at one Southern Health site, and was then rolled out to additional sites over an 18-month period. Almost 8,000 staff were trained in the use of the tool via more than 250 face-to-face presentations, and later through a specifically developed e-learning education package.

“Before ISBAR, there was very little formal training around communication to clinicians within our organisation,” says Monica Finnigan, Quality Practice Improvement Manager, Quality Unit, Southern Health.

“Investigation into the causes of adverse events within Southern Health revealed

that 30 percent had communication as a contributing factor,” she adds.

“Feedback from patients also indicated that improvements in communication were required. The timing for ISBAR was just right.”

As part of the rollout, visual aids were developed, including ISBAR posters, notepads and stickers to attach to phones. In conjunction, referral forms were developed using the ISBAR structure, including the Diagnostic Imaging Request Form and the Emergency Department-to-Ward Transfer Form.

Post-pilot successBallarat Health Services volunteered to participate in the pilot using ISBAR in the setting of telephone referral. This pilot was undertaken in the Emergency Department and Critical Care Units and involved training medical, nursing and allied health staff.

Denise Fitzpatrick, Clinical Risk Coordinator, Governance and Risk Management Unit, Ballarat Health Services says that before ISBAR, consultant medical staff could become frustrated at the quality of handovers.

“Communications and reports at handover and when making a telephone call about a patient were either too wordy and unfocused, or there were gaps because the person handing over had not prepared appropriately,” she says. “ISBAR has streamlined the process and made it consistent, informative and effective.”

“Within the service more broadly, the Director of our Emergency Department is very keen to have all residents and registrars trained in ISBAR to streamline the handovers between medical staff across the organisation. It guides the user in preparation even before the conversation takes place.”

Denise says ISBAR has proven so popular that Ballarat Health has “a keen and eager” number of wards and departments lining up to be the next group trained.

At Southern Health, ISBAR continues to be integrated into the culture of the organisation and is an ongoing tool to improve the clarity of clinical information.

“We are continuing to actively promote and encourage use of the tool in other health services and in other settings,” says Monica Finnigan.

“Effective communication and teamwork in healthcare are vital. ISBAR definitely has a part to play.”

For more information on ISBAR or to download a copy of the ISBAR tools and templates, visit www.vmia.vic.gov.au/isbar

The VMIA is committed to supporting the implementation of ISBAR across Victorian health services. Free start up kits will be available at the next ISBAR Workshop on 8 March 2012 at the VMIA.

For more information, contact VMIA Client Learning Services on Email: training@vmia.vic.gov.au Phone: 03 9270 6870 Or register online at: www.vmia.vic.gov.au/clientrainingprograms

This workshop has been designed for clinicians, directors and managers responsible for quality and risk management/patient safety.

The professional healthcare environment is complex and busy, involving people with varying levels of knowledge, skills and backgrounds. ISBAR is a tool which demonstrates the power of simple, effective communication in the demanding and sometimes chaotic healthcare environment.

www.vmia.vic.gov.au Managing Clinical Risk July 2011 | 5

How important is effective communication in the delivery suite?Good communication is vital. In the birth suite, communication, teamwork and appropriate escalation of management is time critical and could make the difference between a good outcome and a poor one.

Your specialty is fetal surveillance. What is fetal surveillance and how does it work?Fetal surveillance is an assessment of fetal wellbeing, antenatally (before labour) or intrapartum (during labour). It can be as simple as detection of fetal movement by the mother or of fetal growth by measuring the mother’s abdomen. It can involve assessment of fetal oxygenation by observing the fetal heart rate pattern via cardiotocography (CTG). Higher level assessment is typically undertaken using ultrasound on of a range of parameters, including fetal growth, placental function or fetal blood flow. It is critical that any

form of fetal assessment is done properly by trained clinicians or the information obtained may be inaccurate, potentially resulting in inappropriate management.

What is the RANZCOG FSEP?The FSEP is a not-for-profit program with the sole aim of reducing fetal morbidity and mortality through standardised and appropriate fetal surveillance education, based on the RANZCOG Clinical Guidelines.

Specifically, the program focuses on improving clinicians’ understanding of the physiology of fetal heart rate control. This allows them to attain better quality information regarding fetal wellbeing from the CTG, which can facilitate appropriate management for the mother and fetus.

Why are communication and teamwork important in fetal monitoring? Accurate communication of the results of any form of fetal surveillance is almost

as important as the assessment itself. Teamwork between the range of clinicians who care for women, their babies and families is the only way to care for them effectively and safely.

What is the key message you teach in fetal surveillance?Our assessment tool is the only valid and reliable assessment of its kind in this country. Health service management needs to take up the FSEP and support staff to undertake regular training. Ideally, this will become a mandatory part of their annual training – just like fire drills and CPR training.

For further details regarding the FSEP and its suite of products, visit www.fsep.edu.au

Communication, teamwork and escalation What makes effective fetal monitoring?

Mark Beaves is a midwife and the Clinical Manager of the RANZCOG Fetal Surveillance Education Program, known as FSEP. Mark spoke at the VMIA’s Risk Forum in November about recent developments in the FSEP’s suite of products, including their now valid and statistically reliable assessment tool. He told us about the FSEP for this issue of Managing Clinical Risk.

6 | Managing Clinical Risk July 2011 www.vmia.vic.gov.au

Managing Clinical Risk

The process was created in response to a recognised need to support senior doctors in their professional development and aims to strengthen the relationship between senior doctors and their health services. It provides a suite of processes and tools to support clinical practice and implementation of the credentialling policy.

Partnering for performance has been designed to complement existing programs, and has been used by healthcare providers to strengthen existing performance development processes for senior doctors.

Dr Ian Graham is Director of Medical Services for an alliance of four regional health services, comprising 14 hospital

sites across the Grampians Region of Western Victoria.

His responsibilities include credentialing, appointment, definition of scope of practice and performance management of a large group of medical practitioners working in a range of rural settings.

“The Partnering for performance program offers us a robust framework for building an effective medical performance management system,” says Ian. “Our doctors include local and international medical graduate general practitioners as well as visiting specialists. Most of the medical practitioners run their own private practices and spend a relatively small amount of time in the health services where they usually work on a fee-for-service

basis. Partnering for performance helps us to ensure that, while they are working within the health services, their performance, practice and outcomes are monitored and that any issues are appropriately addressed.”

Ian explains that this helps to ensure the quality, safety and continuity of patient care and is also integral in recruiting and retaining new medical practitioners in rural areas.

“Partnering for performance puts a strong emphasis on the importance of a vibrant, inclusive healthcare organisation and developing a culture of learning and improvement for all health professionals at all levels of training and professional development,” he says.

Dr Caroline Clarke, Executive Director Medical Services Royal Victorian Eye and Ear Hospital, says that given she employs several part-time Visiting Medical Officers, the program affords her better visibility and understanding of what they are contributing to the hospital, what they would like to be contributing and how the hospital can support them.

“We anticipate that having a formal structure will only improve the engagement and dialogue with them,” she says. “Partnering for performance has an important role to play.”

For more information on Partnering for performance, visit: www.health.vic.gov.au/clinicalengagement/pasp/index.htm

Doctors’ performance program rolls outAs part of its work to facilitate safe, high quality healthcare, the Victorian Department of Health has recently implemented a performance development and support process for senior doctors called Partnering for performance.

The Great Healthcare Challenge, 11–14 October 2011The VMIA was a major sponsor of The Great Healthcare Challenge, the recent national forum on achieving patient-centred outcomes, held in Melbourne.

Forum delegates heard from a range of local and international speakers on the major issues affecting healthcare quality and safety. Key themes included: leadership and vision, innovation and reform; clinical governance, technology, ICT and eHealth; and appropriateness of care and patient-centred outcomes.

At the forum, the VMIA launched the new Safety Climate Survey Guidelines document – a survey for measuring patient safety. The VMIA was also pleased to present an ISBAR workshop focusing on awareness and implementation of the ISBAR principles, which was well attended.

The Safety Climate Survey Guidelines are available on the VMIA website. Visit www.vmia.vic.gov.au/safetyclimatesurvey

DescriptionA 35 year old woman with two children was managed under a shared care arrangement between her GP/obstetrician and the hospital’s maternity services during her third pregnancy. At the commencement of her antenatal care, it was agreed that the baby would be delivered by an elective lower uterine section caesarean section (LUSCS), due to a fourth degree vaginal tear with the previous delivery. At 30 weeks gestation, the patient signed the LUSCS consent form.

At a subsequent antenatal attendance, the patient advised that she wanted a sterilisation procedure (tubal ligation) to be performed at the same time as the LUSCS. As such, another consent form, for LUSCS with tubal ligation, was completed.

The hospital obstetrician delivered the baby by elective caesarean section at 39 weeks and three days without complications. The sterilisation was not performed at this time and the patient was not informed that it had not occurred. The patient was discharged home with no contraception advice and was advised to make an appointment with her GP/obstetrician for a six week check up.

Ten months later, the patient was diagnosed with acute myeloid leukaemia requiring urgent chemotherapy. She was also discovered to be six weeks pregnant.

Following discussions with the oncologist about the risks associated with first trimester chemotherapy and the risk of delaying treatment, the patient decided to terminate the pregnancy.

Sequence of eventsThe patient signed two consent forms. The first was signed at 30 weeks and specified that a ‘caesarean section’ (only) would be performed as the means of delivery. The second form was signed at 36 weeks, and specified that the procedure to be performed was a ‘caesarean section and sterilisation (clips)’.

The patient underwent the elective caesarean section and the baby was

born healthy, however sterilisation was not performed at that time. She was not informed of this.

Ten months later the patient attended her GP with symptoms of extreme fatigue and feeling generally unwell. Blood tests were performed and the patient was discovered to have leukaemia as well as being in the early stages of pregnancy. Subsequent bone marrow biopsy revealed that the patient was suffering with acute myeloid leukaemia requiring immediate chemotherapy.

The patient was advised that treatment of leukemia occurring during pregnancy was complicated, and consideration must be given to her immediate health, the health of the foetus and to the possible long-term effects that chemotherapy may have on the foetus. Thereafter she decided to undergo termination of the pregnancy.

AllegationThe patient alleged that the hospital had breached its duty of care to her in three respects:

1. By failing to perform sterilisation at the time of the caesarean section at her request;

2. By failing to inform her that a sterilisation had not been performed at that time; and

3. By failing to provide her with post-caesarean section contraceptive advice.

ResultThe claim was settled on confidential terms without proceeding to trial.

Legal issuesThe hospital admitted it had breached its duty of care to the patient by failing to perform the sterilisation at the time of the caesarean section, and by failing to inform her that the sterilisation had not been performed at that time.

Patient perspectiveThe patient was dissatisfied with her treatment, primarily because the sterilisation was not performed and that she was not

informed of this fact. Subsequently she fell pregnant and underwent a termination.

Sequence of eventsFollowing the signing of the original LUSCS consent form at 30 weeks gestation, the theatre booking service was notified. At 36 weeks the second consent form (which included sterilisation) was signed, but the theatre booking service was not advised of the change in the surgical procedure.

The ward staff who prepared the documentation to accompany the patient to theatre were not aware that the patient had signed two consent forms. Only the first consent form (just for the caesarean section) was included in the current admission documentation, consistent with the theatre bookings list.

Consequentially, theatre staff were not aware that the patient was to undergo sterilisation at the time of the caesarean section. During pre-operative checking, the patient was not aware that the elective caesarean section did not include sterilisation.

www.vmia.vic.gov.au Managing Clinical Risk July 2011 | 7

Analysis: Lessons learned1. Shared care documentation can be challenging in maintaining continuity of care for patients. Agencies should have clear and concise policies to manage the consent process and appropriate logging methods to highlight active consents that are clearly identified in the medical record. They should consider working towards a situation where multiple consents are eliminated and all procedures consented to on a single form.

2. During the surgical checklist procedure and ‘time out’ checking process in theatre, it is important to ask the patient to explain the procedure they believe that they are undergoing.

3. Postnatal care episodes, including the six week check up with the GP/obstetrician, would have afforded further opportunities to fully review the patient’s management. However, in this case, a discharge summary from the hospital was not provided to the GP.

An additional procedure request by a patient was not communicated effectively between medical, maternity and theatre staff. Subsequently, a tubal ligation was not performed despite a belief by the patient that it had been.

Case study: Lesson learnedHospital breaches duty of care in managing procedural consent

www.vmia.vic.gov.au

Managing Clinical Risk

© VMIA 2011

We value your feedbackPlease provide any feedback to clinicalriskenquiries@vmia.vic.gov.au or contact us on 03 9270 6900.

Visit www.vmia.vic.gov.au for previous editions.

The information provided in this document is intended for general use only. It is not a definitive guide to the law, does not constitute formal advice, and does not take into consideration the particular circumstances and needs of your organisation. Every effort has been made to ensure the accuracy and completeness of this document at the date of publication. The VMIA cannot be held responsible and extends no warranties as to the suitability of the information in this document for any particular purpose and for actions taken by third parties.

Invoices for medical indemnity insurance premiums have, subsequently, been sent to the individual health services and hospitals and all medical indemnity insurance premium invoices for the 2011-2012 renewal year have now been paid in full.

The VMIA will conduct a client survey in January to gauge how effective communication about the model has been during the first year of implementation.

“We’re interested in finding out what the client’s experience has been regarding the PAM roll-out and to determine how we can improve for 2012-2013,” said Chris

Tsoukalas, the VMIA’s Manager, Client Services, General Government.

For 2012-2013, premium sensitive claims data to be used in the PAM calculations have recently been sent to all health services and hospitals for review. As a result, there has been extensive feedback received from clients. This process, along with the VMIA’s internal claims review and external actuarial review, ensures that the data used in the model is accurate.

FAQs and guidelines for the model are currently being updated and will be available on the VMIA’s website shortly.

A PAM working group was established across the VMIA and Department of Health to manage its implementation in 2011-2012, and to co-ordinate the ongoing reporting and development of the PAM in the Victorian public health sector. Feedback from the sector is very important and will be regularly reviewed by the PAM working group as part of the ongoing development process.

The People Matter Survey is an annual review conducted by the State Services Authority (SSA) to provide organisations with benchmarked information on workforce culture and climate in the Victorian public sector.

The survey includes measures of job satisfaction and the way managers and work groups operate within participating organisations. SSA uses the survey results to inform policy.

In 2011, 58 of the 117 organisations who participated in the survey from across the

sector were health services. Health service respondents accounted for 48 percent of the 18,481 surveys completed across the sector.

In 2012, eight patient safety questions have been included in the People Matter Survey for health services only. These questions have been selected from the Safety Climate Survey Toolkit developed by the Victorian Quality Council (VQC) and the VMIA.

The questions will enable health services to obtain a benchmarked indication of staff perceptions on patient safety in

their organisation in addition to workforce climate and organisational culture.

The VMIA, SSA and the Victorian Quality Council have partnered to support health service organisations to reduce survey ‘fatigue of staff’ and to better understand barriers to improving organisational culture and patient safety.

For further information on the People Matter Survey, contact Merryn Lancaster, Principal Advisor Development and Projects at merryn.e.lancaster@ssa.vic.gov.au

PAM rolled out across Victoria’s public health system

The Premium Allocation Model (PAM) was fully implemented across all Victorian public health services and hospitals from 1 July for the 2011–2012 renewal year.

Newsflash: People Matter Survey now includes patient safety questions – get on board!