Statement in relation to HDC Report

Statementb from Capital & Coast DHB follows

Statement in relation to HDC Report
(Case 05HDC11908)

Comments from Dr Judith Aitken, chair, Capital & Coast District Health Board

The death of a patient in our care in 2004 was a tragedy and Capital & Coast District Health Board (C&C DHB) sincerely apologises to the patient’s family for the loss of their loved one.

The Board takes full responsibility for the events leading up to this unfortunate outcome.

The HDC has noted in his report that C&C DHB failed “to provide safe and appropriate care for a very unwell patient (and that) in addition to the clear system failure, several individual doctors and nurses must accept responsibility for their failure to provide appropriate medical and nursing care.” We acknowledge and accept these comments.

We have contacted the family and have met to express to them directly our apologies and deep regret.

Recommendations from the Health and Disability Commissioner (HDC), along with recommendations from an internal management review, are being given very serious consideration by the Board. We intend to adopt all changes necessary to ensure greater responsiveness to patients’ needs, and to their safety in our care.

This tragic event and these review processes have triggered comprehensive Board evaluation of many critical areas of concern.

In particular, we have carried out significant reviews of our hospital processes and clinical practice, and have made a great many improvements over the past three years.

While many of these improvements have been in direct response to issues raised by the HDC, others had already been identified and implemented through our own longer term developmental planning, auditing and resource improvement processes.

These changes have substantially increased our confidence in the way we currently, and in future will, respond to patients’ needs.

Our determination to ensure safe, high quality, continuous and responsive patient care has been reinforced. The Board and all our staff are committed to continuously improving these systems and procedures, and to fully disclosing all information relating to a patient’s care (while at the same time preserving their rights to privacy).

A number of steps have been, and are being, taken to improve our systems and processes; including:
- Investing in a series of workshops for staff, to improve the way they talk to each other and to patients and their families;
- Improving the documenting process to support the clear relaying of instructions and observations between medical staff;
- Reviewing and improving access to nicotine replacement therapy for nicotine-addicted patients to complement our Smoke Free Policy;
- Reviewing the scope of practice of nursing staff and changing procedures to provide staff members with appropriate, focused supervision when necessary;
- Setting up a regular audit system to ensure that all deaths reported to the Coroner are treated as Reportable Events;
- Reviewing our serious event policy to ensure family are given sympathetic, respectful responses, with prompt and reliable information, after the unexpected death of a family member.

Some other initiatives, which have their genesis in our wider quality improvement processes, will also help to avoid recurrence of events such as the current case, including;
- The introduction of a radiology imaging system (PACS), which provides clinicians with greatly improved access to digital patient images;
- Implementing a new care planning system that focuses on individual patients and streamlines the process of patient admission through to discharge;
- Increased staffing levels;
- The development of a specialist Medical High Dependency Bay and increased bed numbers and staffing in the Intensive Care Unit;
- Implementing a new comprehensive system for electronically recording a patient’s health record. Once implemented, this will enable electronic ‘sign-off’ of clinical test results by the responsible medical staff.

A comprehensive action plan has been developed to ensure any outstanding issues are addressed.

This event has led us to critically review our clinical audit and reporting systems, to more effectively identify issues and errors through our review processes for reportable and serious events – including unexpected death. We will also continue to carry out highly focused clinical audits, as well as particular quality monitoring projects, using all the processes for risk management that are at the Board’s disposal.

We want to assure the community that we have taken significant steps to address the concerns raised immediately after the patient’s death, and in the three years since.

The Board, managers and all our staff are committed to ensuring that patient safety remains paramount in our delivery of care.

Our top priority is always the safety and appropriate care of our patients and we will continue to provide the very best services we can.

ENDS

Additional Information in relation to HDC Report
(Case 05HDC11908)

The following provides additional detail about the changes that have already been, or are in the process of being, implemented.

1) Further details on changes made as a result of this event:

Open disclosure
Reinforcement of policies on open disclosure of all information relating to a patient’s care. We will be careful to distinguish a patient’s right to privacy, while fulfilling our obligation to provide the full information relevant to a patient’s care.

Communication skills for staff:
We have invested in a series of workshops for staff to help them improve their skills to effectively communicate with patients.
The defining principle of these workshops is that if we can enhance these skills, we can make a significant difference to patient outcomes, we can work better with patients, and improve both patient and staff satisfaction.
The programme is currently being evaluated, with the intent to offer a broadened range of education opportunities that strengthen the strategy and focus.
We are also developing a plan to communicate better to staff about how to utilise our emergency response teams, such as the Medical Emergency Team which can provide valuable assistance when a patient becomes seriously ill.

Reliable documenting process:
We have introduced the Admission to Discharge Planner. This is a multi-disciplinary care planning system which focuses on each individual patient, streamlining their experience from admission to discharge and ensuring continuous and appropriate care. This process outlines the responsibility of clear relaying of instructions and observations between clinical staff, so there is a full understanding of the treatment required.

Handover processes
This was an issue raised for both nursing and medical staff. Initially this was discussed with only the staff involved in this event, but subsequently there has been an organisation-wide policy created around handover of information for nursing staff, and clear expectations are set out for medical staff in their orientation programme. All medical staff are required to document a plan of care for patients, particularly over weekends, that describes what the treatment is, when treatment is to be given and by whom.

Scope of professional practice:
The scope of practice for enrolled nurses differs from that of registered nurses. Changes have been made to ensure enrolled nurses are provided with appropriate, focused supervision. One of the key changes in policy has been to ensure enrolled nurses do not work night shifts, but carry out duties only when more supervision is available.

Smoking:
One of the challenges of care of patients who are nicotine-addicted is to ensure the DHB complies with Smokefree legislation (which requires a smokefree workplace environment), but also considers the immediate needs of the patient.
We implemented our Smokefree policy in January 2005. We have also reviewed and improved access to various relief options and boosted support for these patients in a way that complements our policy.
We are currently in the process of reviewing our policy, in light of the HDC’s recommendations.

Reporting deaths:
We are implementing a regular audit and reporting system to assess all deaths at our hospitals. This has improved our reporting and prompt initiation of investigations when necessary. All deaths that are reported to the Coroner are recorded as reportable events.
The reportable events system on deaths is now better understood by clinicians, and reports are written with greater transparency in mind.

Informing families:
We are reviewing our procedures and are improving training for staff to be able to effectively interact with family members in the event of a death. All families need to be given sympathetic and respectful responses to requests for information about their family member, in a prompt and reliable manner.

2) Further details on changes made after previously being identified through our longer term developmental planning, auditing and resource improvement processes:

The PACS radiology imaging system:
A new digital image system (PACS) is being implemented to allow for the viewing and storing of radiology images, removing the need for printed films and giving doctors faster access to patient images.
Clinicians will be able to view the images on the computer network wherever they are, streamlining access to patient medical information and enhancing patient care.

Patient Journey:
The Patient Journey is a project that has been underway in the organisation for the past year. It focuses on two streams of work. One of these is the journey for patients who come to us in an acute condition. The journey focuses on what happens to the patient during their arrival in the Emergency Department and how they progress through the organisation to discharge and with arrangements for appropriate care in the community. The investigation phase of this project has finished and we are now looking at trialling solutions for problems that have been identified along the patient journey pathway.

Staffing:
We continually strive to establish and maintain the right mix of clinicians to provide patients with the very best care.
A concerted and targeted recruitment campaign has led to an increase of 450 health professional staff over the last five years.
Some 120 of these are doctors and nurses in the services affected by this report. The investment in these staff is about $12 million of the DHB’s budget per year.
C&C DHB is now comparatively well staffed with junior doctors. Our Clinical Leaders now undergo a leadership programme. A performance development programme for consultants is currently being worked on. All Consultants go through the credentialing system by C&C DHB to define their scope of practice and fitness.
Our nursing staff now take part in a robust performance review process as part of the Professional Development and Recognition Programme. This has been assessed and accredited by the Nursing Council.

Safety and Quality:
There has been significant investment in quality and safety over the past three years. Some examples of the many areas we have invested in include:
The Quality Improvement Unit, which now has eight staff;
Eight Quality Facilitators working in services;
The role of the Clinical Nurse Educator has been established to work with Charge Nurses in the wards;
Offering nine post-graduate courses for additional nurse training, including an acute assessment skills course, with a view to improve the skill level of Registered Nurses working in our hospitals.

Research:
C&C DHB has taken the lead by investing in and carrying out national research into the use of oxygen in hospitals. It is hoped this research will help improve outcomes for patients by establishing the appropriate way to use oxygen as part of a full treatment plan.

Medical High Dependency Bay:
The Medical High Dependency Bay is a four-bed unit within the Medical Ward that provides a ‘step-up’ facility for patients who are seriously unwell, as defined by clinical criteria. Patients have the benefit of specialist non-invasive ventilation equipment and other infusion treatments. A multi-disciplinary team – including a high nurse-to-patient ratio (1:2) – ensures those in care are constantly watched over. The facility is for patients who need more supervision and care than being in a ward can offer.

Electronic Health Record:
We are in the process of implementing a very innovative and comprehensive system that will enhance the electronic system holding every patient’s health record. This means clinical staff can have immediate access to the patient’s comprehensive medical history, reducing the diagnostic and treatment prescription risks. It will also include a formal requirement for electronic ‘sign-off’ of clinical test results by the responsible medical staff.

ENDS

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