NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MEDWAY ALERTS POLICY. Documentation Control

Transcription

1 NOTTINGHAM UNIVERSITY HOSPITALS NHS TRUST MEDWAY ALERTS POLICY Documentation Control Reference GG/INF/008 Approving Body Senior Management Team Date Approved 24 Implementation Date 24 Summary of Changes from Policy amended to signpost to other sources Previous Version of alert information Future management of alerts list set out Supersedes Version 3 ( Patient Alerts Policy (MEDWAY) Consultation Undertaken Health Records Management Group (27/10/15) Date of Completion of September 2015 Equality Impact Assessment Date of Completion of We September 2015 Are Here for You Assessment Date of Environmental September 2015 Impact Assessment (if applicable) Legal and/or Accreditation Implications Data Protection Act 1998 Care Quality Commission Outcome 21 Records Target Audience All staff Review Date December 2018 Lead Executive Author/Lead Manager Director of ICT/Medical Director Deborah Coombs Records Manager Ext: 63975,

2 Further Guidance/Information Alerts relating Aggression Violence and Harassment Policy and Dangerous Persons (MAPPA) only: Neil Mart Head of Organisational Quality Risk and Safety Ext: Medway PAS Alerts General enquiries on use and assistance via ICT Helpdesk Ext:

3 CONTENTS Paragraph Title Page 1. Introduction 4 2. Executive Summary 4 3. Policy Statement 5 4. Definitions (including Glossary as needed) Roles and Responsibilities Policy and/or Procedural Requirements Training, Implementation and Resources Impact Assessments Monitoring Matrix Relevant Legislation, National Guidance 14 and Associated NUH Documents Appendix (1) Proposal for a New Medway pas Alert Appendix (2) List of Medway PAS Alerts Categories and Types Appendix (3) Equality Impact Assessment Appendix (4) Environmental Impact Assessment Appendix (5) Here For You Assessment Appendix (6) Certification Of Employee Awareness 24 3

4 1.0 Introduction Nottingham University Hospitals NHS Trust recognise that the use of electronic alerts functionality within the Medway PAS can improve patient care and staff safety by highlighting vitally important clinical, social or safety factors that may need to be taken into account for individual patients. The Medway PAS allows electronic alerts to be added to patients records, and these alerts then appear at many transaction points within the system. Medway PAS alerts are only one of a number of potential sources of information relevant to clinical, social or safety factors. Other important sources of information that should be taken into consideration are (although not this list is not exclusive): Referral information Hand- written Clinical and Pharmacy records Verbal questioning and confirmation of alerts/allergies etc from a patient/family or carers. Red patient wristbands indicating an allergy or sensitivity 1.3 This Policy describes how Medway PAS Alert functionality may be utilised as method of highlighting a potential patient safety risk or other problem about a patient to a health professional, and other members of staff. 2.0 Executive Summary 2.1 DO View, note and observe alerts recorded on Medway and required actions for every patient Be aware the Medway Alert may not be the only source of Alert information for a patient View Medway Alerts in context with other sources of information. Where possible add Medway alerts as part of normal professional record keeping practices Keep alerts up to date - remove them/have them removed when no longer applicable 4

5 Make sure Medway alerts are accurate Where possible the wording of the Medway should be discussed with the patient. Only use formally agreed alerts don t edit or adapt existing alerts. e.g. Add free-text information on a Violent Incident using an incorrect alert category when the Trusts Aggression, Violence and Harassment Policy has not been followed. 3.0 Policy Statement Nottingham University Hospitals NHS Trust utilises the Medway PAS Alerts function to highlight important information about a patient to appropriate members of staff. The system is operated in the interests of both patient and staff safety. The presence of a patient alert is indicated on the Medway PAS via a pop up on the patient demographics record and by a red alert ribbon on the patients banner across the top of the screen throughout the modules. It is possible for patient s to have multiple alerts recorded. The Trust recognises that the use of too many electronic alerts may cause the benefits to be lost or alert priorities to become unclear. In order for the patient alerts system to be effective, it is important that there is an immediate and significant benefit of staff being able to see an alert quickly - which outweighs the risk of not having that information available. It also recognises that the recording of an electronic patient alert in no way replaces the need for clinical staff to detail potential problems more fully within individual patient s casenotes. 4.0 Definitions 4.1 Medway Alerts fall into 3 categories: Clinical Alerts - Ensure any allergies, sensitivities or significant clinical patient information is immediately noticeable on every PAS record. 5

6 Administrative Alerts - Make staff aware of any special requirements or patient circumstances. e.g. Interpreter required, Impaired Hearing Staff Alerts Highlight safety/security issues. These generally relate to the Aggression Violence and Harassment (AVH) Policy and Multi Agency Public Protection Arrangements (MAPPA) or processes adopted within the Emergency Department for special case management. 5.0 Roles and Responsibilities 5.1 Committees The Health Records Management Group (HRMG) Requests for new Clinical and Administrative Alerts will be sent for consideration and approval to the HRMG /or for non-clinical alerts to the Information Governance Committee (via the Records Manager). Once approved ICT Services will add the alert to the system for general use. 5.2 Individual Officers All Staff Staff are responsible for keeping Alerts accurate themselves or for requesting a responsible person to make the change. (See section 6.6). Staff are responsible for checking both electronic alerts and written records on each occasion of patient contact, to ensure existing alerts remain relevant and to identify any changes or additions Health Care Professionals All Health Care Professionals are responsible for ensuring alerts are kept accurate, relevant and up to date and requesting changes to alerts via responsible staff in line with this policy. 6

7 5.2.4 ICT Services Applications Management Team Are responsible for setting up new alert types on Medway, maintaining the available list of alerts and for auditing and reporting on use of the alerts system The Records Manager Is responsible for maintenance of this policy on behalf of the Health Records Management Group and the Medical Director/Director of ICT The Head of Organisational Quality Risk and Safety Is responsible for creating, maintaining and deleting AVH Alerts on Medway in accordance with the AVH Policy and the interrelated Protocol for adding Violent Patient Markers to the Medical Records of Violent, Aggressive or Abusive Patients and/or Associates. Is responsible for adding MAPPA alerts in response to Trust notifications onto individual patients records and for registering MAPPA alerts for individuals who are not patients but whom NUH has been advised are within the Nottinghamshire area, may possibly access Trust services in the future and who are deemed to present a significant danger to staff or other patients Administrators - Restricted Alerts Restricted Alerts must be monitored and kept up to date by the Team or person authorised to add/maintain them. 6.0 Policy and/or Procedural Requirements 6.1 Alert Groups There are 17 Alert Groups available on Medway, within these are multiple Alert Types. Alert Group 1 Allergy 7

8 2 Anaesthesia 3 Cardiology 4 Drug Trials 5 Endocrine 6 Haematology 7 Immunology 8 Living Will 9 Microbiology 10 Obstetrics 11 Paediatrics 12 Patient Administrative Alert 13 Pt Tracking Alerts Restricted for use by individual alert administrators 14 Safeguarding Restricted for use by individual alert administrators 15 Staff Alert Restricted for use by individual alert administrators 16 Transfusion 17 Virology 18 Information Alert 6.2 Alert Types These are the specific alerts that are available on the Medway system from a drop down pick list. Appendix 2 of this policy contains a full list of Alerts available for use. Restricted Alerts 6.3 Restricted alerts can only be added, edited or removed by a specific alert administrator working within an area of specialist expertise, both clinical (e.g. meticillin-resistant staphylococcus aureus (MRSA) and administrative (Private patients/overseas Visitors), and/or covered by specific policies (e.g. Aggression, Violence and Harassment). ICT Services maintains a list of staff authorised to create and maintain restricted Clinical Alerts. Those responsible for creating and maintaining restricted Alerts are detailed below. 8

9 6.4 Group Alert/s Authorised and Maintained by: Patient Overseas Verified Overseas Visitor, Liable Admin Alert Visitors for Charges - Inform OVS Officer Patient Admin Alert Overseas Visitors Safeguarding Adult with Safeguarding alert Safeguarding Child with Safeguarding alert Safeguarding ED External Register call ED (Emergency Department) Ext Identified Overseas Visitor, Not Liable for Charges OVS Officer aware Safeguarding Team Safeguarding Team ED Administrator Staff Alert See A&E Notes ED Administrator Staff Alert ED Staff see ED ED Administrator Alert Register Staff Alert Caution: Verbally Aggressive Head of Organisational Quality Risk and Safety Staff Alert Caution: Violent Incident Head of Organisational Quality Risk and Safety Pt Tracking Alerts All Individual alert administrators Alert Content All fields marked with a red asterisk (*) on Medway have to be completed when adding an alert, these are: Alert group - picklist selection Alert type - picklist selection Allergen - (appears if group allergy is chosen) picklist selection Reaction - (appears if group allergy is chosen) picklist selection Reason- there is one option : Refer to Notes Risk level - there is one option: Refer to Notes Applied at - will default to 9

10 the date and time of input Applied by - will default to the user logged on at the time The Comments field should be used for minimal information only, where extensive detail is required the Notes field should be utilised. Drug allergy alerts will have a status of Provisional until authorised. A member of staff can authorise a drug allergy alert at the request of a clinician. Access Levels Medway Alerts has been set up to allow all staff with PAS access all patient alerts. Only a restricted number of staff will be able to add Alerts with the Categories of: 6.7 Patient Tracking Alerts Safeguarding Alerts Staff Alerts Accuracy of Alert information All staff must appreciate that the Data Protection Act applies equally to patient alerts as to any other part of a record held by the Trust. Staff are reminded that information contained within alerts will normally be subject to disclosure on receipt of a Subject Access Request under the Data Protection Act. Thus all information recorded on Medway or in the casenotes should be accurate as to matters of fact. 6.8 If an alert is based on patient reporting rather than proven, e.g. allergy, then this should be documented in the Notes within the alert Audit Trail All Alert entries are electronically auditable and can be traced to author. 10

11 7.0 Training and Implementation 7.1 Training Training will be provided by the ICT Services Training Team. 7.2 Implementation Staff will be informed of the policy by Trust Briefing. New users of Medway will be informed within Medway training. 7.3 Resources No additional resources are required. 8.0 Trust Impact Assessments 8.1 Equality Impact Assessment An equality impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.2 Environmental Impact Assessment An environmental impact assessment has been undertaken on this draft and has not indicated that any additional considerations are necessary. 8.3 Here For You Assessment 11

12 A Here For You assessment has been undertaken on this document and has not indicated that any additional considerations are necessary. 12

13 9.0 Policy / Procedure Monitoring Matrix Minimum requirement to be monitored Responsible individual/ group/ committee Process for monitoring e.g. audit Frequency of monitoring Responsible individual/ group/ committee for review of results Responsible individual/ group/ committee for development of action plan Responsible individual/ group/ committee for monitoring of action plan Policy is reflective of Health Record Keeping Policy compliance Policy is reflective of risk management requirements. Practice in recording of Administrative and Staff Alerts is reflective of other Policy requirements e.g. AVH Policy and the Data Protection Act Health Records Management Group Health Records Management Group Information Governance Committee Via Trust Heath Record Keeping Audits Exception reports Exception reports Formal review annually By exception or Incident Reporting By exception or by Incident Reporting Health Records Management Group Health Records Management Group Information Governance Committee Health Records Management Group Health Records Management Group Information Governance Committee Health Records Management Group Health Records Management Group Information Governance Committee 13

14 10.0 Relevant Legislation, National Guidance and Associated NUH Documents Legislation The Data Protection Act National Guidance Records Management: NHS code of practice (DoH) April Associated NUH Documents(with NUH referencing) GGINF005 Health Record Keeping Policy Clinical Audit and Service Evaluation Procedure 14

15 APPENDIX 1 PROPOSAL FOR A NEW MEDWAY PAS ALERT Before completing this proposal please ensure that you have read the Trust which can be found on the Trust Policies and Procedures site under Governance (Information). Your request should be ed to the Records Manager: Deborah.coombs@nuh.nhs.uk It will then considered at the next Health Records Management Group and you may be asked to attend to discuss details of your proposal. Please answer the following questions: Questions What Alert is required? Who is proposing the Alert? Proposal response Why is the Alert required? What is the benefit to: - the patient - The Trust/the Department/the Clinical Teams Is the Alert a permanent condition? (NB: generally alerts for temporary conditions are not approved unless there is sufficient evidence that the department can maintain the status of the alert on the 15

16 patients record efficiently in line with the patients care) I What is the expected action of staff upon seeing the Alert i.e. what does your department expect staff to do? Where a non- clinical action is required, it should be obvious to the viewer of an Alert. What are the expected numbers of patients? Do you intend to add retrospectively or just prospectively? Who is expected to create alerts and how to you intend to maintain them on a day to day basis? Does access to add or delete these alerts ned to be restricted? Once added to the system and to the policy, how do you intend to communicate the existence of the alert and any change in protocol? i.e. Trust Briefing, memos etc. What would you propose that the Alert on the system should read? Any other supporting information. 16

17 LIST OF MEDWAY PAS ALERT CATEGORIES AND TYPES APPENDIX 2 Please see separate document published on SharePoint. This is constantly updated to ensure a comprehensive and up to date list of available alert types and categories is available. 17

18 Equality Impact Assessment (EQIA) Form (Please complete all sections) APPENDIX 3 Q1. Date of Assessment: 5 th March 2013 Q2. For the policy and its implementation answer the questions a c below against each characteristic (if relevant consider breaking the policy or implementation down into areas) Protected Characteristic a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups experience? i.e. are there any known health inequality or access issues to consider? The area of policy or its implementation being assessed: b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality Race and None Not applicable Not applicable Ethnicity Gender None Not applicable Not applicable Age None Not applicable Not applicable Religion None Not applicable Not applicable Disability None Not applicable Not applicable Sexuality None Not applicable Not applicable 18

19 Pregnancy and None Not applicable Not applicable Maternity Gender None Not applicable Not applicable Reassignment Marriage and None Not applicable Not applicable Civil Partnership Socio-Economic None Not applicable Not applicable Factors (i.e. living in a poorer neighbour hood / social deprivation) Area of service/strategy/function Q3. What consultation with protected characteristic groups inc. patient groups have you carried out? N/A Q4. What data or information did you use in support of this EQIA? N/A Q.5 As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? N/A Q.6 What future actions needed to be undertaken to meet the needs and overcome barriers of the groups identified or to create confidence that the policy and its implementation is not discriminating against any groups N/A What By Whom By When Resources required Q7. Review date March 2016 APPENDIX 4 19

20 Environmental Impact Assessment The purpose of an environmental impact assessment is to identify the environmental impact of policies, assess the significance of the consequences and, if required, reduce and mitigate the effect by either, a) amend the policy b) implement mitigating actions. Area of impact Environmental Risk/Impacts to consider Action Taken (where necessary) Waste and materials Soil/Land Water Air Is the policy encouraging using more materials/supplies?no Is the policy likely to increase the waste produced?no Does the policy fail to utilise opportunities for introduction/replacement of materials that can be recycled?no Is the policy likely to promote the use of substances dangerous to the land if released (e.g. lubricants, liquid chemicals)no Does the policy fail to consider the need to provide adequate containment for these substances? (e.g. bunded containers, etc.)no Is the policy likely to result in an increase of water usage? (estimate quantities) NO Is the policy likely to result in water being polluted? (e.g. dangerous chemicals being introduced in the water)no Does the policy fail to include a mitigating procedure? (e.g. modify procedure to prevent water from being polluted; polluted water containment for adequate disposal)no Is the policy likely to result in the introduction of procedures and equipment with resulting emissions to air? (e.g. use of a N/A N/A N/A N/A 20

21 Energy Nuisances furnaces; combustion of fuels, emission or particles to the atmosphere, etc.)no Does the policy fail to include a procedure to mitigate the effects?no Does the policy fail to require compliance with the limits of emission imposed by the relevant regulations?no Does the policy result in an increase in energy consumption levels in the Trust? (estimate quantities)no Would the policy result in the creation of nuisances such as noise or odour (for staff, patients, visitors, neighbours and other relevant stakeholders)?no N/A N/A 21

22 Appendix 5 - We Are Here For You Policy and Trust-wide Procedure Compliance Toolkit The We Are Here For You service standards have been developed together with more than 1,000 staff and patients. They can help us to be more consistent in what we do and say to help people to feel cared for, safe and confident in their treatment. The standards apply to how we behave not only with patients and visitors, but with all of our colleagues too. They apply to all of us, every day, in everything that we do. Therefore, their inclusion in Policies and Trust-wide Procedures is essential to embed them in our organization. Please rate each value from 1 3 (1 being not at all, 2 being affected and 3 being very affected) Value Score (1-3) 1. Polite and Respectful 1 Whatever our role we are polite, welcoming and positive in the face of adversity, and are always respectful of people s individuality, privacy and dignity. 2. Communicate and Listen 1 We take the time to listen, asking open questions, to hear what people say; and keep people informed of what s happening; providing smooth handovers. 3. Helpful and Kind 1 All of us keep our eyes open for (and don t avoid ) people who need help; we take ownership of delivering the help and can be relied on. 4. Vigilant (patients are safe) 1 Every one of us is vigilant across all aspects of safety, practices hand hygiene & demonstrates attention to detail for a clean and tidy environment everywhere. 5. On Stage (patients feel safe) 1 22

23 We imagine anywhere that patients could see or hear us as a stage. Whenever we are on stage we look and behave professionally, acting as an ambassador for the Trust, so patients, families and carers feel safe, and are never unduly worried. 6. Speak Up (patients stay safe) 1 We are confident to speak up if colleagues don t meet these standards, we are appreciative when they do, and are open to positive challenge by colleagues 7. Informative 1 We involve people as partners in their own care, helping them to be clear about their condition, choices, care plan and how they might feel. We answer their questions without jargon. We do the same when delivering services to colleagues. 8. Timely 1 We appreciate that other people s time is valuable, and offer a responsive service, to keep waiting to a minimum, with convenient appointments, helping patients get better quicker and spend only appropriate time in hospital. 9. Compassionate 1 We understand the important role that patients and family s feelings play in helping them feel better. We are considerate of patients pain, and compassionate, gentle and reassuring with patients and colleagues. 10. Accountable 1 Take responsibility for our own actions and results 11. Best Use of Time and Resources 1 Simplify processes and eliminate waste, while improving quality 12. Improve 1 Our best gets better. Working in teams to innovate and to solve patient frustrations TOTAL 12 23

24 APPENDIX 6 CERTIFICATION OF EMPLOYEE AWARENESS Document Title MEDWAY ALERTS POLICY Version (number) 4 Version (date) 24 I hereby certify that I have: Identified (by reference to the document control sheet of the above policy/ procedure) the staff groups within my area of responsibility to whom this policy / procedure applies. Made arrangements to ensure that such members of staff have the opportunity to be aware of the existence of this document and have the means to access, read and understand it. Signature Print name Date Directorate/ Department The manager completing this certification should retain it for audit and/or other purposes for a period of six years (even if subsequent versions of the document are implemented). The suggested level of certification is; Clinical Divisions Divisional General Manager or nominated deputies Corporate Directorates - deputy director or equivalent. The manager may, at their discretion, also require that subordinate levels of their directorate / department utilize this form in a similar way, but this would always be an additional (not replacement) action. 24