Version: 4.0. Date Adopted: 21 November Name of Author: Patient Safety Group responsible Committee: Date issued for November 2017

Transcription

1 Handover Policy This policy describes the process that staff should follow when handing over the care of patients in LPT including transfers to other care providers but excluding discharge. Key Words: Handover Version: 4.0 Adopted by: Quality Assurance Committee Date Adopted: 21 November 2017 Name of Author: Jacqueline Burden, Clinical Governance Lead AMHLD & Emma Wallis, Lead Nurse CHS Name of Patient Safety Group responsible Committee: Date issued for November 2017 publication: Review date: March 2019 Expiry date: 1 September 2019 Target audience: Clinical Staff Type of Policy Clinical Which Relevant CQC Fundamental Standards? Non Clinical Regulation 9 Person-centred care

2 Contents Contents Page...2 VERSION CONTROL...3 Equality Statement...3 Due Regard...4 Definitions that apply to this policy...4 THE POLICY 1,0 Purpose of the Policy Summary of the Policy Introduction Flowchart/Process Chart Duties within the Organisation Training Needs Monitoring Compliance and Effectiveness Standards/Performance Indicators References and Bibliography...10 REFERENCES AND ASSOCIATED DOCUMENTATION Appendix 1 Policy Training Requirements...11 Appendix 2 NHS Constitution Checklist...12 Appendix 3 Appendix 4 Appendix 5 Stakeholder and Consultation...13 Due Regard Screening Template Statement Example Clinicial Handover of Care Summary

3 Version Control and Summary of Changes Version number Date Comments (description change and amendments) 18/03/13 FYPC Adult Eating Disorder Unit to be included as policy meets their handover requirements. Additions made by Paul Williams and Nikki Crust to reflect this agreement. 24/01/14 Revisions made to include arrangements for handover on transferring patients within and outwith LPT. Current policy is for AMH and LD divisions. The policy wording has been amended to include the overarching principles and requirements of handover. Operational procedures are included as appendices. 16/01/15 Revisions made to include handover arrangements for the FYPC Inpatient units. 4 April 2017 Incorporating CHS Handover Policy and removal of local templates For further information contact: Clinical Governance Lead AMHLD ( ) Lead Nurse CHS ( ) Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development and review. 3

4 Due Regard LPT must have due regard to the aims of eliminating discrimination and promoting equality when policies are being developed. Information about due regard can be found on the Equality page on e-source and/or by contacting the LPT Equalities Team. The Due regard assessment template is Appendix 4 of this document Definitions that apply to this Policy Clinically relevant issues Handover Handover sheet Transfer External handover Due Regard Those clinical matters that have a significant bearing on the quality of clinical care provided A semi structured exchange of information and awareness of the clinically relevant issues including the transfer of key issues, tasks and changes in management plan from one care professional to another. A record of the list of patients/tasks to be handed over Movement of a patient from one inpatient setting to another. This includes transfer within units, services and providers but excludes discharge. Handover to external services i.e. any services not provided by LPT Having due regard for advancing equality involves: Removing or minimising disadvantages suffered by people due to their protected characteristics. Taking steps to meet the needs of people from protected groups where these are different from the needs of other people. Encouraging people from protected groups to participate in public life or in other activities where their participation is disproportionately low. Abbreviations used not written in full within the policy DOLs Deprivation of Liberty Safeguards DNAR Do not attempt resuscitation Obs Level of observatio 4

5 1.0. Purpose of the policy 1.1 The purpose of this policy is to provide direction and guidance for the delivery of a robust handover that preserves confidentiality and ensures that all important information is conveyed relevant to the optimum care of all patients. Staff provide care in a variety of settings, shift patterns and clinical specialties and the complexity of the provision of care puts extra emphasis on the quality of information shared when one team or clinician hands over responsibility of care to the next. The information contained within this document contains the minimum standard expected within the scope of the policy. 1.2 Handover of patient care is a core task for all members of the healthcare team but will particularly apply to those with a direct role in patient care which they need to handover to another team or team member in an effective and efficient manner. The purpose of this policy is to clarify the clinical accountability and responsibility of health care professionals including medical staff and support staff who are responsible for patients care to ensure that safe appropriate clinical handover of the patient occurs and their care continues with minimal interruption and risk. 1.3 This policy applies to all staff employed within LPT and those staff working in a contracted capacity (for example agency nurses) and applies to the clinical handover procedures within the inpatient areas as stipulated below: All Adult Mental Health Services and Learning Disability Services FYPC Child & Adolescent Mental Health Services Adult Eating Disorder Unit CHS 2.0. Summary and Key Points 2.1 This policy includes requirements for handover between shifts, clinical teams and care providers i.e. in all relevant care settings identified above both internal and external to Leicestershire Partnership Trust and includes both the giving and receiving of information. It applies to all situations where clinical care is transferred from one healthcare professional to another. This principles detailed in this policy apply to all staff providing care and who must transfer their responsibilities for patient care to another team or provider including working as part of a multidisciplinary team. 2.2 The policy sets out the handover requirements both in and out of hours. Clinical services are required to have their own operational procedures for handover which may include additional service specific requirements, including procedures for recording handover. 2.3 This policy excludes the arrangements and communication requirements on discharge and that is included in the Trust s discharge policy. Standard referrals from primary care to LPT services are outside of the scope of this policy. 5

6 2.4 Handover between on-call doctors on site is as covered in the policy Handover Policy for Trainee Doctors in Psychiatry available on the LPT intranet: 2.5 Although this policy is primarily concerned with handover between clinical staff LPT must ensure that robust arrangements are in place for the communication of relevant information with other persons for their safety/wellbeing whilst working in that clinical environment. This would include staff not employed by LPT -hotel services and other contractors for example. The nurse in charge on duty or other clinical lead must ensure that all staff are made aware of any issues which may be a risk to their health and safety, including any patient associated risk. Any additional risk must be communicated to other persons who may be potentially exposed to additional risk in that clinical area. One example may be where an incident of violence and assault is ensuing or where a patient is at greater risk of causing harm to staff/other persons and the nurse in charge must ensure that this information is appropriately shared without breaching patient confidentiality. 2.6 The policy describes the principles for the safe and effective of handover of care in and out of hours, between shifts and locations/teams Introduction 3.1 Continuity of information is an essential component of the provision of safe, effective patient care. If handover is not sufficiently robust and consistent, the risk is that at best treatment offered will not be optimum and at worst, this can cause serious harm to patients. 3.2 In order to ensure that the quality of clinical care and treatment remains high round-the-clock and no significant adverse consequences arise due to inconsistent or inadequate handover between staff, a formal handover arrangement needs to be in place. Such arrangement should reduce any unintended gaps in continuity of care, should be workable, be consistent with the good practice, and auditable Flowchart/process chart 4.1 There is no flow chart associated with this policy. Clinical services are required to have their own operational procedures for handover which may include additional service specific requirements, including procedures for recording handover. 6

7 5.0 Duties within the Organisation 5.1 The Trust Board has a legal responsibility for Trust policies and for ensuring that they are carried out effectively Trust Board Sub-committees have the responsibility for ratifying policies and protocols. 5.3 Service Directors and Heads of Service are responsible for: Ensuring that the policy is disseminated, implemented and monitored within their services Ensure local procedures are developed in their services That necessary resources required to implement the arrangements in this policy are in place. 5.4 Ward/Team Managers will be responsible for: Ensuring that all staff within their teams are aware of the policy and their duty to follow it Ensure local procedures are developed, implemented and monitored in their services 5.5 Responsibility of Staff: All relevant staff are responsible for following this policy and to immediately escalate any difficulties in implementing this policy to their line manager 6.0 Standard for Handover General Principles 6.1 During clinical handover, patients should be treated and cared for in such a way as to maintain: Patient safety Necessary treatment and care Contact with appropriate staff Equality and Diversity Dignity Respect of individual needs Contact with appropriate relatives/carers Sensitivity to patient s needs, ensuring their comfort Any new environmental risks and controls in place to mitigate 6.2 Consideration should be given as to maintaining a safe environment during handover, i.e. ensuring sufficient staff are present with patients whilst handover is taking place. 6.3 Although the specific mechanism for handovers, location, timing and recording of 7

8 handover will vary between the clinical services, the following should be included as a minimum: 8 Past Medical History / Mental Health History/Legal status/dols status Reason for Admission/ Diagnosis / Mental Health History Current mental and physical health status Infection control status Observation level/specialling level Current prescribed medication Allergies Relevant risk assessments Safeguarding issues Any mental capacity issues Discharge/Leave arrangements Relative or carer feedback Resuscitation status (e.g. DNAR) Changes to Care Plans should be flagged 6.4 Handover should take place in an appropriately private area where the details cannot be overheard by any unauthorised person with dignity and respect being a critical consideration. 6.5 It is acknowledged that ward staff may make a personal record of shift handover as an aide memoir. It is the staff s responsibility to ensure that this record is kept securely and disposed of as confidential waste. Handover records will be kept in line with the LPT Information Lifecycle and Records Management Policy. Standard for Internal/External Transfers in and Out of Hours 6.6 To provide and receive the following information to ensure patient safety the following information must be included: Past Medical History / Mental Health History/Legal status/dols status Reason for Admission/ Diagnosis / Mental Health History Current mental and physical health status Infection control status Observation level/specialling level Current prescribed medication Allergies Relevant risk assessments Safeguarding issues Any mental capacity issues Discharge/Leave arrangements Relative or carer feedback Resuscitation status (e.g. DNAR) Changes to Care Plans should be flagged 6.7 A proforma has been developed for both internal and external transfers (appendix 5). The same level of information will be requested if LPT is the receiving unit and this will be recorded within the medical record.

9 7.0. Training needs 7.1 There is a need for training identified within this policy. In accordance with the classification of training outlined in the Trust Learning and Development Strategy this training has been identified as role specific training. All staff responsible for the giving of handover will be expected to have completed the handover training as part of local induction clinical services may provide additional on-going training specific to their areas and teams Monitoring Compliance and Effectiveness 8.1 Each directorate s Clinical Audit Standards and Effectiveness sub group or equivalent will commission audits against the standards identified in this policy. In addition, the LPT Patient Safety Group is responsible for commissioning clinical audits or other quality improvement activities as informed by the results of the regular monitoring process. 8.2 Duties outlined in this Policy will be evidenced through monitoring of the other minimum requirements. Where monitoring identifies any shortfall in compliance the group responsible for the Policy (as identified on the policy cover) shall be responsible for developing and monitoring any action plans to ensure future compliance. Minimum Requirements Handover requirements between all care settings, to include both giving and receiving of information Medical Out of Hours handover process- Completion of handover book at every shift change Evidence for Selfassessment Section 6.1 As above for shift handovers, see Out of Hours Policy for Junior Doctors re medical staff Process for Monitoring Clinical audit Safe and Therapeutic Observation of Handover Audit of handover books Responsible Individual / Group LPT Clinical Effectiveness Group Medical Education Committee Frequency of monitoring Annual Annual TARGET/STANDARDS Safe (CQC) KEY PERFORMANCE INDICATOR S2.4 How do arrangements for handovers and shift changes ensure that people are safe? 9

10 9.0. References and Bibliography This policy was drafted with reference to the following: LPT Handover Policy for Trainee Doctors in Psychiatry Safe handover: safe patients. Guidance on Clinical Handover for clinicians and managers (2010) National Patient Safety Agency Acknowledgement: The Wirral Community NHS Trust: Policy for the Clinical Handover of Care 10

11 Appendix 1 Training Requirements Training Needs Analysis Training topic: Type of training: (see study leave policy) Division(s) to which the training is applicable: Staff groups who require the training: Regularity of Update requirement: Who is responsible for delivery of this training? Have resources been identified? Has a training plan been agreed? Mandatory (must be on mandatory training register) X Role specific Personal development X Adult Mental Health & Learning Disability Services X Community Health Services Enabling Services X Families Young People Children Hosted Services All staff responsible for the giving of handover will be expected to have completed the handover training as part of local induction clinical services may provide additional on-going training specific to their areas and teams. On local induction thereafter as required to be determined locally Local managers N/A N/A Where will completion of this training be recorded? ULearn X Other (please specify) as part of local induction How is this training going to be monitored? Local induction records 11

12 Appendix 2 The NHS Constitution The NHS will provide a universal service for all based on clinical need, not ability to pay. The NHS will provide a comprehensive range of services Shape its services around the needs and preferences of individual patients, their families and their carers Respond to different needs of different sectors of the population Work continuously to improve quality services and to minimise errors Support and value its staff Work together with others to ensure a seamless service for patients X X Help keep people healthy and work to reduce health inequalities Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance X 12

13 Appendix 3 Stakeholders and Consultation Key individuals involved in developing the document Name Jacqueline Burden Emma Wallis Chris Crane Claire Armitage Michelle Churchard Smith Lynne Moore Lynne Ward Dawn Holding John Devapriam Mark McConnichie Mark Griffith Alana Barby Jane Martin Fran Bailey Matthew Williams Paul Williams Fran Guerra Vicki Spencer Designation Clinical Governance Lead Lead Nurse CHS Crisis Service Manager Lead Nurse Head of Nursing Practice Development Nurse Senior Matron Stewart House Interim MH Community Services Service Manager Clinical Director Specialist Clinical Director Service Manager Community Mental Health Matron Mill Lodge Senior Matron Team Lead CRHT Team Matron Team Manager Leicester Adult Eating Disorder Service Team Leader CAMHS Inpatients Clinical Governance & Quality Lead Circulated to the following individuals for comment Name Designation Members of the LPT Patient Safety Group Service Managers AMHLD Christina Brookes Clinical Governance Manager FYPC Heather Darlow Clinical Governance Lead CHS Jane Capes Senior Matron Bradgate Unit Carl Lomas Audit Team Samantha Roost Bernadette Keavney Sandra Marshall Senior MHP Eating Disorders Dot McGarrell Ward Matron The Willows Lynne Ward Team Manager The Willows Alison Wheelton Senior MHA Administrator 13

14 Appendix 4 Section 1 Due Regard Screening Template Name of activity/proposal Handover Date Screening commenced 01/08/2017 Directorate / Service carrying out the N/A Policy Author assessment Name and role of person undertaking Jacqueline Burden Clinical Governance Lead this Due Regard (Equality Analysis) AMHLD Give an overview of the aims, objectives and purpose of the proposal: AIMS: The policy stipulates the minimum standard for patient handover between shifts and teams OBJECTIVES: To ensure that the policy is followed and patient safety is maintained Section 2 Protected Characteristic Age Disability Gender reassignment Marriage & Civil Partnership Pregnancy & Maternity Race Religion and Belief Sex Sexual Orientation Other equality groups? If the proposal/s have a positive or negative impact please give brief details This policy is aimed at maintaining patient safety, whilst being transferred during shifts and/or team changes. Maintaining safety for patients in care is the Trusts priority and this policy sits alongside LPT s Health and Safety and Safe-guarding policy and guidance. Any reasonable adjustments required during the Handover process will be adhered to, to mitigate any adverse impact. There is no evidence of an adverse impact, as the policy aims to safe-guard all patients, during the process of handover, irrespective of their protected characteristics or any other equality group(s). Section 3 Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below. Yes High risk: Complete a full EIA starting click here to proceed to Part B No Low risk: Go to Section 4. Section 4 If this proposal is low risk please give evidence or justification for how you reached this decision: This policy is designed to determine the minimum standards for patient handover between shifts and teams. There should be no impact on patients with protected characteristics. 14

15 Signed by reviewer/assessor Jacquie Burden Date Sign off that this proposal is low risk and does not require a full Equality Analysis Head of Service Signed Date 16 th October

16 Appendix 5 EXAMPLE CLINICAL HANDOVER OF CARE SUMMARY DOCUMENT (Transfer) Name: DOB: NHS No.: Address and Postcode: Tel no.: Date of patient transfer: Time: NOK Name: GP Name: Address: Transfer from: Transfer to: Have NOK been notified? YES / NO Address: If no actions to be taken: Reason for admission/ Diagnosis: Reason for transfer Current level of Observations Relevant Past Medical History: Current health status including Mobility, Physical and Mental Health, skin condition, dietary needs and physical observations: MHA Status and consent to treatment provisions Current risks identified: Infection Control Status 16

17 Medicines sent with Patient? Yes No Please list/attach list Known Allergies: Notes sent with patient, number of volumes: Property/valuables sent with patient: Name of Healthcare Professional arranging transfer of Patient: PRINT NAME: Signature: Designation: Contact Telephone No: 17