Out of hours, but not without risks

Julie Price, MPS’s Clinical Risk Programme Manager, looks at the risks associated with out of hours (OOHs) care

The quality of OOHs services has come under scrutiny in recent years after several high profile and tragic cases of patient harm.

In the UK, David Gray¹ received a fatal overdose of painkillers prescribed by an OOHs doctor in 2008. In 2005, Penny Campbell² died from multiple organ failure after consulting eight OOHs doctors over four days. Could this happen in Ireland? Are there risks with Irish OOHs care?

To understand the risks associated with OOHs care provision, it is important to look at the data relating to complaints and claims. MPS undertook an analysis of 526 complaints notified to MPS over a six-month period during 2006. Of these 526 complaints, 86 involved OOHs as either the primary organisation complained about or in addition to the principal GP.

Box 1: Lack of urgency – an MPS case

A 65-year-old patient with back pain was triaged by the nurse. The nurse offered the patient an appointment at the primary care centre. The patient rang back saying the pain was worse and requested an urgent visit. The nurse requested a home visit by a doctor within two hours. When the doctor finally visited the patient some four hours later the patient was not at home; the wife having called for an ambulance. The patient was diagnosed with a leaking aortic aneurysm.

Risk assessment of OOHs service

Developing systems that reduce the likelihood of patient harm and introducing standards for staff to follow are vital to ensure high quality care

Developing systems that reduce the likelihood of patient harm and introducing standards for staff to follow are vital to ensure high quality care. A core function of MPS Educational Services is to proactively undertake clinical risk assessments of OOHs service providers to ensure that the organisation has safe and robust systems in place; to assist in identifying existing and potential risks; and to ensure quality care is provided and reduce harm to patients.

How an OOHs organisation can ensure they provide a quality and safe service to patients:

1. Leadership – clinical and corporate governance

It is important that OOHs organisations adopt robust clinical and corporate governance strategies to ensure the continued success of the organisation.

The organisation’s expertise and support on the Board should be considered, it may be useful to have, in addition to clinicians, other professionals such as, a solicitor, an accountant, a lay person. Positions of the Board should be on a rotation, ie, for a period of five years. The rotation of key positions, etc, should be defined in the Memorandum and Articles of Association.

All staff should have up to date job descriptions and contracts of employment.

An appraisal system for staff should be in place; it is important that all staff at the organisation have an opportunity to discuss their achievements and concerns relating to their work performance with their line manager. The OOHs organisation could consider undertaking 360^o appraisals for key members of staff. Training should be linked to the appraisal process.

Meetings held at the organisation should have an agenda and be minuted. It would be wise to ensure that meetings are recorded, dated and reviewed for both accuracy and “matters arising” at the next meeting. The quality of the minutes may be seen as an indicator of managerial standards within the organisation.

Box 2: Common risk areas in OOHs identified by MPS

Leadership of the organisation
Call handlers – giving clinical advice and prioritisation of calls
Staffing – inadequate recruitment
Poor communication
Not documenting consultation following a home visit
Handling of test results
No individual responsible for ensuring equipment is checked
Not providing effective risk management strategies that will help nursing clinicians to take steps to reduce risk in their care delivery
Inadequate audit of clinical performance of nurses and doctors working in the organisation.

2. Communication

One of the main problems for doctors working in the OOHs setting is that they do not always know the patients and do not have access to the patient’s medical history, relying solely on the patient’s account of their illness.

Listening is as important as talking and having an effective dialogue with the patient can lead to a more accurate diagnosis and therefore reduce the risk of medical errors occurring

Effective communication skills

Price et al (2007)¹ agree that effective communication is one of the most powerful risk management tools. It is a well-recognised fact that poor communication can be a key contributory factor to both complaints and claims. Communication is both verbal and non-verbal, listening is as important as talking and having an effective dialogue with the patient can lead to a more accurate diagnosis and therefore reduce the risk of medical errors occurring. Clinicians working in out-of-hours care should therefore review, improve and adapt their communications skills to reflect some of the associated barriers of communication that they may encounter as part of their care delivery.
Team communication

Fundamental to patient care is communication – between all members of the team and between the healthcare team and the patient. Better communication between staff and patients is a priority for improving patient safety.

Ensure that there is an effective and efficient system for passing information onto other healthcare professionals, including a system for prioritising calls. Ensure that all calls are communicated to the patient’s own GP.

Ensure that there is good communication between all staff to aid the smooth running of the OOHs service

Ensure that there is good communication between all staff to aid the smooth running of the OOHs service. Meetings are essential to help communication between staff and to discuss problems. Ideally, they should be held regularly with an agreed agenda and minute taking, to ensure that any problems or ideas can be discussed and followed up in a formal way.

Risk management should be an integral part of the team meeting agenda, allowing the opportunity to review any patient safety incidents and a review of the service’s risk register. It is important that concerns regarding patient care, etc, are not lost in the system but are reported to another healthcare professional to ensure that the continuity of patient care is not jeopardised.

3. Recruitment and induction of clinical staff

To ensure a standard and even handed approach to recruitment, the organisation should agree a robust recruitment protocol to be followed for all applicants. The medical director will need to acknowledge that the applicant has met the agreed criteria prior to arranging an interview. At the interview the applicant should be supplied with a copy of the ‘Doctors Handbook’ and given an overview of the service.

The following should be considered:

Proof of training requirements should be provided, eg, resuscitation, safeguarding children and vulnerable adults. Ensure this training is kept up-to-date.
The induction programme should ensure that new members and locums have a thorough working knowledge of the appropriate OOHs systems.
Instruction should be provided to the new doctor on the equipment, checking procedures and other details for safe use of all equipment.
Ensure that shadowing and mentoring arrangements are implemented in accordance with Recommendation 12 in the Colin-Thomé and Field report².
Doctors’ contracts should include a clause which states that if the doctor has been suspended or referred to the Medical Council they must inform the organisation.
Doctors should be informed of the procedure for reporting significant untoward incidents and ‘near misses’.
Emphasise at induction that it is the doctor’s responsibility to ensure he/she adequate indemnity cover.
It is impossible to know what hours any member of the OOH team are working due to other professional commitments and what, if any, increased risk this places on the organisation. This could be usefully considered by the clinical governance team.

4. Clinical audit of performance

In order to ensure quality assurance across the out-of-hours service and a consistent approach to patient care it is essential to audit clinicians’ performance on a regular basis and to provide feedback. Audit is part of clinical governance and should be undertaken to ensure that clinical practice is continuously monitored and that deficiencies in relation to set standards of care are remedied.

MPS suggest that the Royal College of General Practitioners (RCGP) (2007) Out of Hours Clinical Audit Tool3 could be used; an accredited audit tool

MPS suggest that the Royal College of General Practitioners (RCGP) (2007) Out of Hours Clinical Audit Tool³ could be used; an accredited audit tool which can be used for all staff groups, ie, doctors, nurses and call handlers. The tool aims to cover the core aspects of all OOH contacts.

The aim of a generic set of criteria and a generic tool for a variety of staff (including clinical and non-clinical staff) is to promote consistency in quality and standards. It is designed to capture the main components of patient contacts with OOH services while providing a framework to examine and develop the quality of calls and consultations, using established educational approaches for good practice.

MPS recommend that clinical audit is commenced with the ‘red eye’ doctors and maybe, if member GPs are willing to take part, rolled out to the participating members and associate members. We appreciate that this will be a major culture shift for the organisation and commencing the audit with the ‘red eye’ doctors may be a beneficial starting point.

Experiential learning

The very nature of out-of-hours work means that clinicians have to make diagnostic decisions and management decisions, often at an early stage in the disease process, in patients with whom they have probably had no previous acquaintance. It would be surprising therefore if a significant number of these diagnosis and management decisions turned out to be incorrect with hindsight.

During in-hours work GPs generally have the opportunity to reflect on the consequences of their clinical decisions and use their day to day clinical experience to constantly reflect on how they practise and manage patients and also identify learning needs, ie, a process of experiential learning. As a consequence of this reflection, when faced with the same clinical situation again they may do things slightly differently.

If you do not reflect on what you do, you will always carry on doing what you have always done. The difficulty is that doctors who work in the out-of-hours setting may not have the opportunity to reflect on the consequences of their clinical decisions as they are unlikely to receive any feedback about their clinical management.

Having managed a patient any further information about the subsequent healthcare and outcome for that patient will be available from their own GP but not the out-of-hours doctor. You may wish to use follow-up slips so that an OOHs doctor can request from the registered doctor some details on the outcome of the patient.

On reflection of the cases the OOHs doctor might manage things differently if presented in future with a similar situation if they were aware of the outcome for the patient and how things were subsequently managed. An example might be a patient who was managed for back pain over the weekend who, on Monday morning, had clear symptoms of cauda equina. The OOHs doctor may never get to hear about the outcome; it may be that their management was entirely appropriate but without feedback they do not have the opportunity to reflect on whether they would have done anything differently.

Having managed a patient any further information about the subsequent healthcare and outcome for that patient will be available from their own GP but not the out-of-hours doctor

5. Telephone triage

Telephone triage is difficult and good communication skills are essential. Triage clinicians must have excellent listening skills to notice non-visual clues the patient is giving regarding pain, anxiety, fear and level of comprehension. The triage clinician must assess the patient’s symptoms including a full assessment of the patients’ medical history.

This can be frustrating for patients as they may not appreciate that OOHs care providers will not have access to their clinical records. However ensuring completeness of this detail will help to mitigate against any missed information. The use of algorithms, via computer software decision making tools, allows the clinician to follow pathways to determine the most appropriate course of action.

Box 3: Telephone triage

Essential points to consider:

Telephone triage consultations should be contemporaneously documented.
Telephone triage consultations do not give a nurse the opportunity to assess clinical signs, hence the documentation of the history needs to be thorough.
Clinicians should be aware that visual body language cues are lost in the context of a telephone conversation.
If telephone consultations are recorded then the patients should be and there should be robust procedures in place for storage, retrieval and transcription.
The use of algorithms, via computer software decision making tools, allows the clinician to follow pathways to determine the most appropriate course of action
Ensure that telephone triage training is provided for all healthcare professionals undertaking this, including use of the algorithm, where appropriate.
Ensure that a clinical audit of performance is undertaken for each clinician including listening to calls made.

6. Medical records

It is important that a computer system is available at all OOHs centres for the healthcare professional to record their consultations notes. Ideally there should be provision of a computer in the mobile units. Direct access to the system would enable doctors to record contemporaneously to the patient record, negating the need for the record to be transcribed by reception staff or drivers.

In MPS’s experience it is common practice for OOHs home visit consultation notes to be recorded directly by the doctor into the service’s electronic patient records. The notes are most commonly typed on a laptop computer to the ‘Adastra’ system in a service’s vehicle while the doctor is driven to his next call.

Complete and contemporaneous records are essential for the maintenance of good quality patient care and are needed if a complaint or claim is made. Some courts take the quality of the record as an indication of the care provided to the patient.

It is important that a computer system is available at all OOHs centres for the healthcare professional to record their consultations notes

7. Incident reporting

It is imperative that all staff working within OOHs care are made aware of the purpose of incident reporting of patient safety incidents. The occurrence of patient safety incidents within an organisation can have serious implications for all those involved, including the patient, family, staff and the organisation itself. Reporting when things go wrong is essential, as is looking at the underlying causes of patient safety incidents and learning how to prevent them from happening again.

When things go wrong it is easy to apportion blame to an individual (human error), but closer analysis of the incident may reveal that there could be many underlying causes, which contributed to the incident. These causes extend beyond the individual staff member involved. For example, incidents may occur because:

The staff member has not had sufficient training.
The policy/procedure that they are working to is not robust, is outdated or does not reflect current best practice.

Ensure that any associated risks have been identified and appropriate measures put in place to minimise harm to patients or staff as appropriate

Ensure that any associated risks have been identified and appropriate measures put in place to minimise harm to patients or staff as appropriate. This process involves identifying and analysing risks, identifying any required action and associated costs and ensuring that there is system in place to regularly review any risks.

Risks can be identified through incidents, complaints, audits, team meetings and through new legislation and policy. Promote a safety culture which is open and fair – for sharing information and ensuring that lesson are learnt with all members of the OOHs care team.

References

Price et al (2007). Emerging risks in out-of-hours primary care services. Clinical Governance: an International Journal 11(4) 289-298
Dr Colin-Thomé and Professor Steve Field, General practice Out-of-Hours Service. Project to consider and assess current arrangements. Department of Health, London(2010):
Royal College of General Practitioners Out-of-Hours Clinical Audit Tool (2007)

Case study: Northdoc

By Dr Mel Bates, Medical Director

There is a famous scene in the movie, Jaws, where Roy Scheider eyeballs the shark for the first time. He walks backwards with a shocked look on his face and says “You’re going to need a bigger boat.” We, in Northdoc, felt a bit like this after the clinical risk assessment we commissioned the MPS to do on D-Doc in 2011. We felt afterwards that we were going to need a bigger team, a bigger Board, and a bigger partnership.

D-Doc is the GP OOHs service covering the majority of the population of north Dublin city and county. It started on 26 November 2006. The quality of the service to patients who attend D-Doc depends on the participation of experienced local GPs. There are three strands to the service, with Northdoc providing doctors and medical governance, CareDoc providing nurse triage, and the HSE providing the infrastructure (centres, cars, computers) and other staff (nurses, drivers, call takers and receptionists).

We developed protocols and guidelines and by 2011 we felt we were ready to measure ourselves against international standards and invited MPS to carry out the audit

We operate from five centres, with up to three cars at the weekends. Ninety five per cent of the shifts up to midnight are covered by local general practitioners. In 2012 we had 97,000 contacts to the service. The first few years were challenging. Our main focus was on change management and simply filling the roster. We developed protocols and guidelines and by 2011 we felt we were ready to measure ourselves against international standards and invited MPS to carry out the audit.

On the day

The MPS assessors were both charming and thorough. They were obvious fans of the 1970s detective series, Columbo, starring Peter Falk: “That’s great, but there’s just one more thing that bothers me.” In the face of this approach, Liam Quinn (manager) and I confessed to crimes we had never committed. Over two and a half days, every contribution to the service, from Northdoc, the HSE and CareDoc, was scrutinised in forensic detail.

In-depth face-to-face interviews with drivers and on call doctors and managers were achieved in a finely choreographed schedule. The data from 164 questionnaires returned by doctors and nurses working in the service were collated and measured against similar audits in mainly UK-based GP co-ops. All documentation relating to any policies or protocols in Northdoc was examined, including the Doctor’s Handbook (our GP guide to practical medical issues met in out of hours).

The outcome:

The MPS team found the staff throughout D-Doc to be very dedicated and ambitious to further develop the service. They were impressed by the medication protocols, the Doctor’s Handbook, the robust complaints handling procedures, and the quality of the leadership and management in Northdoc. The fact that we volunteered for the risk audit demonstrated our drive for quality and our wish to meet best standards.

Having one person doing all the duties of the Medical Director was not sustainable and restricted development of the service

They made many observations:

Having one person doing all the duties of the Medical Director was not sustainable and restricted development of the service.
Upskilling the Board would pay dividends.
The complaints handling service needed to be upgraded and delegated.
Recruitment protocols needed to be upgraded and delegated.
More monitoring of the quality of the service including clinical performance auditing, meeting target response times, and promoting a culture of feedback within the organisation to promote quality was recommended.
More robust capacity planning.
Regular patient satisfaction surveys.
Computers in the cars to allow contemporaneous note taking.
Internet access in the centres to allow ready availability of up-to-date guidelines.

Lessons learnt:

A risk assessment begins as a single event and quickly becomes an ongoing process of assessment and review. Out of this process, we have discovered this paradigm: Patient’s safety = doctor’s safety = corporate safety. Anything we do to promote patient safety benefits our GP members and protects the company which is responsible for managing their out of hours service. Fifteen months on, we have implemented almost all of the MPS recommendations. We will, in all probability, look into the jaws of another audit in the future – but next time, we will have more confidence in our boat.

If you are interested in booking a risk assessment for an OOHs service provider, please contact [email protected] or contact +44 113 241 0624.

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