Patient Who Should Read This Policy Target Audience All Staff Version 1.0 October 2016
Ref. Contents Page 1.0 Introduction 4 2.0 Purpose 4 3.0 Objectives 4 4.0 Process 4 4.1 Types 4 4.2 Content 5 4.3 Notification 5 4.4 Monitoring and Removal 5 4.5 Temporary s 6 4.6 Permanent s 6 4.7 Manual Records 6 5.0 Procedures connected to this Policy 7 6.0 Links to Relevant Legislation 7 6.1 Links to Relevant National Standards 7 6.2 Links to other Key Policies 8 6.3 References 8 7.0 Roles and Responsibilities for this Policy 10 8.0 Training 11 9.0 Equality Impact Assessment 11 10.0 Data Protection and Freedom of Information 11 11.0 Monitoring this Policy is Working in Practice 12 Appendices 1.0 s Types 13 2.0 Patient Change Request form 18 3.0 Information Help-Desk s Notification Guide 19 Version 1.0 October 2016 2
Explanation of terms used in this policy s - An electronic flag that is applied to a patient s electronic record to highlight vitally important clinical, social or safety factors that may need to be taken into account for individual patients. These falls into four categories: 1. Clinical s - Ensure any allergies, sensitivities or significant clinical patient information is immediately noticeable. Also patients subject to Community Treatment Orders, Mental Health Act detentions, etc. 2. Administrative s - Make staff aware of any special requirements or patient circumstances e.g. Impaired Hearing, disabilities, CPA status, etc. and inform users of any historical alerts. These also ensure that staff are aware of patients whose capacity to give informed consent diminishes as a result of their condition. 3. s - Highlight safety/security issues. These generally relate to the risk of aggression or violence, ownership of weapons, sexually inappropriate behaviour, risks from known patient associates, police alerts, registration on the sex offenders register, etc. These can also relate to environmental factors such as the presence of a large dog at the property or a high crime area. 4. Safeguarding - these link to potential risks of harm to the patient or an individual linked to the patient. The also include where a child has been placed on a Child Protection Plan; this alert may appear on the child s records as well as the parents (if known to the Trust). Patient Administration System (PAS) - An electronic patient administration system which records the patient's demographics (e.g. name, home address, date of birth) and details all patient contact with the Trust recording clinical correspondence, clinical information etc. Version 1.0 October 2016 3
1.0 Introduction Black Country Partnership NHS Foundation Trust recognise that the use of Patient s can improve patient care and the safety of staff and other members of the public by highlighting vitally important clinical, social or safety factors that may need to be taken into account for individual patients. Electronic systems within the Trust allow electronic alerts to be added to patients records, and these alerts appear at many transaction points within the system. 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 this list is not exclusive): Referral information Hand- written records Verbal questioning and confirmation of alerts/allergies etc. from a patient/family or carers NHS Litigation Authority (NHSLA) standards require the organisation to have approved documentation in place which describes the process for managing Patient s which act as a mechanism to immediately highlight specific risks. This Policy describes how the functionality will be utilised as method of highlighting a potential problem with or some important information about a patient to health professional and other members of staff. 2.0 Purpose The purpose of this policy is to ensure that patient alerts are applied as appropriate to a patient record with a clear process for reviewing and managing active alerts. Additionally it aims to provide a process for creating new alerts and alert categories. 3.0 Objectives Ensure that staff are aware of their responsibilities for the use of patient alerts Make clear the standards for managing alerts on clinical information systems Outline clear processes for monitoring compliance Ensure that staff receive appropriate training to their role 4.0 Process Patient s will be managed centrally by the Business Intelligence Department; they will be responsible for adding and closing alerts on the PAS and the generation and issue of monthly reports. 4.1 Types The Trust utilises standards Types under each of the four Categories, a full list of the Types is available within Appendix 1. The Type is a top level view of the ; the Type selected for the alert must provide a basic overview of the risk or the alert type. Further details about the alert, and associated risk, will be available within the Content. Requests to add an Type are to be made to the Information Help-desk, the Patient Change Request form (Appendix 2) must be completed. The Business Intelligence Department will then present the form to the Information Governance Steering Group for approval. The Information Help-desk will confirm the outcome of the IGSG to the requester. If the Type is required for an immediate alert a Version 1.0 October 2016 4
temporary alert will be created with an existing Type which is the nearest match to the ; if the new alert is approved the existing will be updated, if the alert is not approved then the temporary alert is made permanent. 4.2 Content The Type is not enough information for staff as this is a generic header; therefore it is important to include relevant information within the Content. Within s there is the ability to include information for the person who is accessing the alert; this is known as the Content. This includes (but is not limited to): - Specific details about the risk; to expand on the Type - Actions that staff need to take; for example, two staff members to be in attendance at each contact - How to obtain further details; for example, Contact the Safeguarding Team Where a Legacy is raised the Content will be standardised with the following information: - Type - Date alert was raised - Date alert was closed 4.3 Notification There must be documented evidence to suggest that the alert needs to be disseminated Trust Wide. This evidence is to be maintained within the individuals Health Record or Safeguarding Record. The individual raising the alert is responsible for ensuring that this is documented within the records. The need for the alert is notified to the Information Helpdesk via the IT Services Desk; http://fusion.smhsct.local/ (see Appendix 3 for the step by step access guide). When notifying the Information Helpdesk of the alert you must ensure you include the following information: - Type - Content (text to be included within the Notes) - Removal Date (if known) or if the is permanent. - Patient identifier; this can be the NHS Number and/or OASIS number Once received the Information Helpdesk will add the within 24 hours (except weekends) and confirm to the requester once the is active. Where the requested does not fall within the Types given within this policy the Information Helpdesk will refer the alert to the Information Governance Manager for review and possible discussion with the Information Governance Steering Group. Any risks will be raised whilst awaiting approval from the IGSG. 4.4 Monitoring and Removal Once an is raised they must be monitored and removed as soon as they are no longer relevant, with the exception of permanent alerts. All alerts must be reviewed on a monthly basis. Reports will be generated on a monthly basis by the Business Intelligence Department and provided to the Group Quality and Safety Groups to review the. Version 1.0 October 2016 5
Notification is required to confirm that the is still valid; if the is no longer valid the must be updated or removed. Where the Type remains valid but the Content is required to be updated; the updated Content is to be forwarded to the Information Help-desk to be amended. Once received the Information Help-desk has 48 hours to complete the update. Where the is no longer valid confirmation of this is to be received by the Information Help-desk. If there is a need to replace the Type with a Legacy this must be included within the removal notification. If additional information is required within the Content this must be approved by the Group Quality and Safety Groups and confirmation of this passed to the Information Help-desk. 4.5 Temporary s There are 3 types of temporary alerts: 1. An alert with an end date given at the point the alert is created; this is usually a short term end date for example; an Environmental Risk may only be applicable for a Month as the patient has a date to move house. Where an end date is given the alert will automatically be removed within 48 hours after the end date. 2. A request for a new Type has been raised; in this case an alert is raised on a nearest match basis. No end date is set within the Content but the Information Help-desk maintains an action to review once the IGSG have made a decision about the request for a new Type. Following the outcome from the IGSG the alert is no longer classed as Temporary is the new Type is not approved. If the new Type is approved the temporary alert is removed and the new is created. 3. Out of hours; if an urgent alert is required out of hours (i.e. evenings and weekends) an appointed member of the Safeguarding Team can raise this within OASIS. The request must be sent to the Information Help-desk as per the Notification process, however as well as the information highlighted within section 7.3 the notification must include that the was raised out of hours. The alert raised by Safeguarding must be the Urgent Notification Type with details placed within the Content. Once the has been received by the Information Help-desk this will be replaced by the appropriate Type. 4.6 Permanent s There are only three Types are classed as permanent alerts: - Legacy - Manual Records Destroyed - Allergies Once these alerts are placed onto the system there is review or end date required for the. 4.7 Manual Records Where manual records are utilised, at the point a patient alert notification is sent to the Information Helpdesk the staff member must update the Patient s Divider within the manual records to indicate that an alert has been raised. You must select the relevant tick box on the front of the divider and complete the corresponding section stating Further details are available on the Electronic Record. Version 1.0 October 2016 6
Staff must consult the PAS along with the manual records when reviewing s prior to contact with the patient. 5.0 Procedures connected to this Policy Localised SOPs are currently being produced in relation to this Policy. The SOPs will provide the department s internal process for monitoring and updating alerts. 6.0 Links to Relevant Legislation Data Protection Act (DPA) 1998 The Data Protection Act 1998 became law in March 2000. It sets standards that must be satisfied when obtaining, recording, holding, using or disposing of personal data. The law applies to data held on computers or any sort of storage system, including paper records. There are 8 enforceable principles of good practice. Data should be: Fairly and lawfully processed Processed for limited purposes Adequate, relevant and not excessive Accurate Not kept longer than necessary Processed in accordance with the data subject's rights Secure Not transferred to countries outside the European Economic Area (EEA), without adequate protection Health and Safety at Work Act 1974 This Act is the major piece of health and safety legislation in Great Britain. The Act introduced a comprehensive and integrated system to deal with workplace health and safety and the protection of the public from work activities. The Act places general duties on employers, employees, self-employed, manufacturers and importers of work equipment and materials. Responsibilities are placed to produce solutions to health and safety problems, which are subject to the test of reasonable practicability. Various regulations are made under the Act, which have the same scope, many of these evolving from European Directives, which enables the potential to achieve clear and uniform standards. 6.1 Links to Relevant National Standards Records Management Code of Practice for Health and Social Care 2016 A guide to be used in relation to the practice of managing records. This Code is relevant to organisations who work within, or under contract to NHS organisations in England. This also includes public health functions in Local Authorities and Adult Social Care where there is joint care provided within the NHS. The Code is based on current legal requirements and professional best practice. It will help organisations to implement the recommendations of the Mid Staffordshire Version 1.0 October 2016 7
NHS Foundation Trust Public Inquiry relating to records management and transparency. Patient Policy Essence of Care Benchmarking for Record Keeping 2010 'Essence of Care 2010 - Benchmarks for Record Keeping' provides best practice guidance to determine that people benefit from records that promote communication and high quality care. It ensures that people are able to access their care records in a format that meets their needs and that those records are safeguarded. 6.2 Links to other Key Policies Health Records Policy This policy is intended to be a comprehensive guide to all staff involved in the handling of health records and the associated documentation providing a framework for consistent and effective record management enabling the Trust to ensure that there is a systematic and planned approach to the management of health records, from the moment the record is created until their ultimate disposal. Information Governance Policy The purpose of this policy is to provide clarity, coherence and accountability for staff to deal consistently with the many different rules about how information is handled such as those set out in Data Protection Act 1998 and Freedom of Information Act 2000. Health and Safety Policy This policy aims to promote and enable an organisational and systematic approach to the development of Health and Safety procedures and protocols throughout the Trust and to set out the requirements of the Trust to demonstrate and achieve legislative compliance. Care Record Keeping - Standards and Practice Policy The purpose of this policy is to outline standards of record keeping that the Trust expects of all those involved in the delivery of care to patients/clients. Safeguarding Adults at Risk Policy The Purpose of this policy is to provide guidance for staff to assist them in identifying adults at risk and recognising abuse. Safeguarding Children Policy The purpose of this Policy is to set out the Trusts standards and expectations in respect of safeguarding children. This is to ensure that the interests and safety of children within the Trust are recognised by all staff and that as a result, these children are protected at all times. Data Quality Policy The purpose of this document is to set out a clear policy framework for maintaining and increasing high levels of data quality within the Trust. 6.3 References Essence of Care Benchmarking for Record Keeping NHSLA Risk Management Standard 1.8 Version 1.0 October 2016 8
Data Protection Act (DPA) 1998 plus the Information Commissioner s Office (ICO) guidance on the DPA and use of violent warning markers. Health and Safety at Work Act 1974 Information Governance Toolkit Version 1.0 October 2016 9
7.0 Roles and Responsibilities for this Policy Title Role Key Responsibilities All Staff Adherence - Ensure that when identifying a patient requiring an alert, it is appropriate and in line with this policy - Check 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 - Monitor and update alerts; if they are aware of any discrepancies in relation to the and the current patient status/risk Business Intelligence Department Operational they must raise this with the Information Help-desk - Manage the process of adding alerts to the PAS in line with this policy Information Governance Steering Group Group Quality and Safety Groups Quality and Safety Steering Group Trust Board Responsible - Requests for new Clinical and Administrative s will be sent for consideration and approval to the Records Management Sub Group who will in turn report their decision to the Information Governance Steering Group (IGSG). For non-clinical alerts the IGSG will be responsible for approving the Monitoring - Monitor the management of patient alerts on clinical information systems within their group. Membership is representative of the group as a whole multi-disciplinary in nature, with a mix of representatives from each of the service areas, professional leads, practice development professionals and representatives from clinical sub-groups - Receive the results and recommendations of all completed clinical audits - Monitor any subsequent actions plans to completion - Authorise documentation to be used within the group Scrutiny and Performance Strategic Overview - Oversee the implementation of a systematic and consistent approach to the management of patient alerts on clinical information systems. The Group is chaired by the Medical Director and reports progress to the Executive Committee - Review the annual Patient Clinical and Quality Audit report - Approve the addition of new categories and alerts for clinical information systems - Strategic overview and final responsibility for overseeing this policy in the Trust. This includes meeting legal responsibilities and for the adoption of internal and external governance requirements Medical Director Executive Lead - Responsibility for this policy has been delegated by the Chief Executive to the Director of Medicine who is responsible for ensuring a systematic and consistent approach to the management of patient alerts on clinical information systems across the organisation Chief Executive Accountable - Ensure that this policy is implemented within the Trust. Operational responsibility has been delegated Version 1.0 October 2016 10
8.0 Training What aspect(s) Is this training covered in the Which staff groups of this policy will Trust s Mandatory and Risk How often will Who will ensure and If no, how will the Who will deliver the require this require staff Management Training Needs staff require monitor that staff have training be delivered? training? training? training? Analysis document? training this training? n/a n/a n/a n/a n/a n/a n/a 9.0 Equality Impact Assessment Black Country Partnership NHS Foundation Trust is committed to ensuring that the way we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group. The Equality Impact Assessment for this policy has been completed and is readily available on the Intranet. If you require this in a different format e.g. larger print, Braille, different languages or audio tape, please contact the Equality & Diversity Team on Ext. 8067 or email EqualityImpact.assessment@bcpft.nhs.uk 10.0 Data Protection and Freedom of Information This statement reflects legal requirements incorporated within the Data Protection Act and Freedom of Information Act that apply to staff who work within the public sector. All staff have a responsibility to ensure that they do not disclose information about the Trust s activities in respect of service users in its care to unauthorised individuals. This responsibility applies whether you are currently employed or after your employment ends and in certain aspects of your personal life e.g. use of social networking sites etc. The Trust seeks to ensure a high level of transparency in all its business activities but reserves the right not to disclose information where relevant legislation applies Version 1.0 October 2016 11
11.0 Monitoring this Policy is Working in Practice What key elements will be monitored? (measurable policy objectives) Where described in policy? How will they be monitored? (method + sample size) Who will undertake this monitoring? How Frequently? Group/Committee that will receive and review results Group/Committee to ensure actions are completed Evidence this has happened Patient s that have: Passed the mandatory review date Due to pass mandatory review date in next 30 days since last review (95% of alerts reviewed before passing mandatory review date) Patient s - appropriateness and supporting information (95% alerts are appropriate and 95% of alerts have good quality supporting information) 24 hour turnaround (excluding weekends) of the centrally managed patient alerts (95% 24 hour alert turnaround) 4.0 Process Report to Group Manager, Clinical and Service Leads EHR Clinical Dashboard 4.0 Process Patient Clinical and Quality Audit - 5 random alerts from each service for each alert type are reviewed 4.0 Process Report - to be included as appendix in the Patient Clinical and Quality Audit Information Team Monthly Group Quality and Safety Group Information Governance and the Information Team Information Team Annually Monthly/ Annually Group Quality and Safety Group Group Quality and Safety Group Group Quality and Safety Group Group Quality and Safety Group Group Quality and Safety Group Minutes of meetings/ action plans signed off Minutes of meetings/ action plans signed off Minutes of meetings/ action plans signed off Version 1.0 October 2016 12
Appendix 1 s Types The below table provides the Type broken down within the four Categories Category Type Code Description Administration Legacy LEGACY Administration Administration Administration Administration Administration Manual Records Destroyed Do Not Disclose Address to Parents Do Not Disclose Address to Spouse Communication Needs Confidentiality MRD PARENTS SPOUSE To notify that there have been previous alerts which are no longer valid. To notify that the manual records for the patient have been destroyed in accordance with the relevant retention schedules. Do not disclose information to the patient s parents; details of what is to be withheld are to be included within the Content. Do not disclose information to the patient s spouse; details of what is to be withheld are to be included within the Content. Could relate to either a language or someone who needs a Sign Language Interpreters, Lip speakers, Deafblind Interpreters, Scribers, needing information on different coloured paper, in large print, audio tape, Braille, CD, disk, video, DVD etc. Some people may need to use Typetalk, Textphone or a minicom etc. may be made in relation to the outcome of Accessible Information Standards and could relate to the carers communication needs as well as the patients. Used to identify that the patient has specific instructions regarding who can be informed of their condition, contact details and location of any Crisis Plan Version 1.0 October 2016 13
Category Type Code Description Administrative Administrative Administrative Social Care Involvement Capacity Declaration Mental Health Act Used to identify a patient known to Social Services. The risk assessment should contain the Service and contact name and details Used to highlight a patient who does not have the capacity to give informed consent or a patient with a history of diminishing capacity when their condition deteriorates. Patient subject to the Mental Health Act Used to identify a patient where staff need to know there is a communicable infection Clinical Infection INF Clinical Allergy Any patient allergy Clinical Clinical Clinical Safeguarding Substance Abuse Physical Health Non Conformance Child Safeguarding Concerns CSAFE Used to highlight patients who are at significant risk of self-neglect beyond the normal expectations of their illness, through their personal circumstances or an indicator of deterioration or relapse of their condition Used to highlight patients with a physical health comorbidity such as diabetes, heart conditions, etc. This alert highlights patients with a history of or needing support in complying with their treatment/medication for their mental health or physical health condition Where there are concerns raised in relation to the patient (where the patient is the child) or about a child within the patients care. This will be known to the Safeguarding Team. Safeguarding LAC [local authority name] LAC*** This will be known to the Safeguarding Team. The LAC will be registered with the authority name. Version 1.0 October 2016 14
Category Type Code Description Patient is subject to MARAC Safeguarding MARAC MARAC This will be known to the Safeguarding Team. Safeguarding Placement panel PLACEMENT*** This will be known to the Safeguarding Team. Used to highlight patients who are at significant risk of self harm beyond the normal expectations of their illness or an indicator of deterioration or relapse of their condition. This includes suicide ideation or previous suicide attempts, a history of overdosing, a history of selfharm, etc. Safeguarding Risk of Self Harm This includes risk of selfneglect beyond the normal expectations of their illness, through their personal circumstances or an indicator of deterioration or relapse of their condition. A Child Protection Plan is in place for the patient (if the patient is the child) or a child in the patients care. Safeguarding Safeguarding Safeguarding Public Safety s Child Protection Plan Vulnerable Adult Urgent Notification Do Not Visit Alone DNVA This will be known to the Safeguarding Team. There are safeguarding concerns/risks in relation to the Adult. The individual will be known to the Safeguarding Team. This is a temporary alert which is raised out of hours with the detail of the alert outlined within the content. Home/community visits are not to be undertaken alone, more than one staff member to be present. Version 1.0 October 2016 15
Category Type Code Description Public Safety s Aggressive AGG Public Safety s Carries Weapons WEAPON Public Safety s Do Not Admit ADMIT Public Safety s Missing person Public Safety s NHS Security Must Not be s Seen Alone ALONE s No Home Visits NHV s s s Potential Risk of Violence Restrict Where Patient to be Seen Risk to Patients POT RESLOC STFPAT s Risk to Females FEM s Threats THREATS s Violent V s Risk to Males Known risk of violence and/or aggression towards other individuals. There is a risk that the patient may carry a weapon, weapons are accessible to the patient or weapons are within the patients home. Patient is not to be admitted This patient has been reported missing NHS Security from NHS Protect A set number of staff (either male or female) are to be present at each contact. No Home Visits are to take place There is a potential risk of violence and/or aggression, although the patient has never actively been violent towards a member of staff. There are specified locations where the patient can been seen There is a risk to staff and other patients. No female staff to provide patient care. Possible risk to females in relation to sexual offences, violence, etc. There have been threats made by the patients The patient is known to have been violent towards staff, patients and other individuals. No male staff to provide patient care Version 1.0 October 2016 16
Category Type Code Description s s Risk of Harm to Others Known Sex Offender This alert highlights potential/actual violence and aggression, know possession of weapons, sexual assault/inappropriateness, arson, etc. Patient is currently on the sex offence register. This could be the patient has known violent associates, known risk of street violence, conditions inside or outside of the patients residence, etc. s s Environmental Risks Pets This could also be that there is poor or broken street lighting, gas/electric risks, structural damage and/or unsafe parking in or around the patient property Patient residence has aggressive dog, exotic pets etc. Version 1.0 October 2016 17
Appendix 2 Patient Change Request form Request for a new Type Before completing this from please ensure that you have read the Trusts Clinical Information Systems Patient s Policy which can be found on the intranet. Your request should be raised on the Information Team helpdesk via the intranet It will then considered at the next Quality and Safety Steering Group and you may be asked to attend to discuss details of your request Please answer the following questions: Questions What alert is required Why is the alert required What is the benefit to: - the patient - The Trust/the Department/the Clinical Teams Is the 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 patients record efficiently in line with the patients care) What is the expected action of staff upon seeing the 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. What are the expected number of patients Are the alerts to be added retrospectively or prospectively 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 should the alert description read Any other supporting information Who is requesting the alert: Name: Role: Group: Service: Response Version 1.0 October 2016 18
Appendix 3 Information Help-Desk s Notification Guide STEP 1: Access the IT Services page on the Intranet, available via Online Tools. STEP 2: Select Service Desk STEP 3: Log in to your account This is your Username and Password that you use to access your PC Version 1.0 October 2016 19
STEP 4: Select Submit a Ticket STEP 5: Select Information Helpdesk Then click Next Version 1.0 October 2016 20
STEP 6: Complete the Ticket Details User Details: this is your details. Your Computer Name is not required. Support Issue: Select one of the following options from the drop down menu: - /Marker Request - /Marker Removal Your Message: Include within the main space the Type and Content and the OASIS number or patient identifier for the patient. STEP 7: Click S Version 1.0 October 2016 21
Policy Details Title of Policy Unique Identifier for this policy State if policy is New or Revised Patient Policy BCPFT-IG-POL-03 New Previous Policy Title where applicable Policy Category Clinical, HR, H&S, Infection Control etc. Executive Director whose portfolio this policy comes under Policy Lead/Author Job titles only Committee/Group responsible for the approval of this policy Month/year consultation process completed * n/a Information Governance Medical Director ICT Project Manager Quality and Safety Steering Group April 2014 Month/year policy approved September 2016 Month/year policy ratified and issued October 2016 Next review date September 2019 Implementation Plan completed * Equality Impact Assessment completed * Previous version(s) archived * Disclosure status Yes Yes n/a B can be disclosed to patients and the public * For more information on the consultation process, implementation plan, equality impact assessment, or archiving arrangements, please contact Corporate Governance Review and Amendment History Version Date Details of Change 1.0 Oct 2016 New Policy for BCPFT Version 1.0 October 2016 22