‘Preserving the Past, Recording the Present, Informing the Future’ by John McGonigle

The above title comes from the National Records of Scotland website and you may be wondering ‘what on earth does that statement have to do with me, both privately and in my role in the NHS?’. Well the answer to that question is quite possibly more than you might think at first glance.

Preserving the Past

You may have received a gift of a book on Genealogy at Christmas or visited a website to get some guidance on tracing your family history. Without access to the appropriate records you would not get very far with your research. You may feel frustrated at being unable to make any progress in proving that you are actually 292nd in line to the throne or verifying that you are a distant cousin of Barack Obama, but other than the disappointment factor no real damage is done. Disappointment is not the word I imagine anyone would use should they discover any gap in their health record or that their record was unavailable for any reason.

Recording the Present

During the course of our everyday business within the NHS we record information relating to the events of that day e.g. recording details of medication administered to a patient, completing a purchase order for stores, etc. The details recorded provide an accurate picture of the current situation that we or our colleagues can use with confidence to continue the treatment of a patient or progress the order.

Informing the Future

By the collection, analysis and publication of information drawn from various sources it is possible to assist determination of future requirements for our society in fields such as predicting education needs, assisting in the formulation of flood prevention measures and healthcare provision to name just a few. By ensuring that records are accurate, securely stored and readily available it enables even the most complex analysis to be undertaken.

Records Management

Information is the main asset that all businesses and organisations have in common and good records management enables them to manage their activities professionally and efficiently. Recently though, there have been a number of issues in a variety of areas that have brought the subject of records management into the minds of the general public. For example:

  • How many of us were affected by the hacking of customer information at TalkTalk ?
  • Apparently there was the embarrassment (to put it mildly !) for some when Ashley Madison had their systems hacked into
  • Various banking issues have resulted in direct debit payments being missed because accounts were shown, incorrectly, to have insufficient funds
  • Missing information resulted in a number of issues in the Glasgow Bin Lorry enquiry
  • Approximately 8000 paper health records were destroyed at NHS Grampian due to a flash flood in a basement at Aberdeen Royal Infirmary

The headlines associated with these incidents caused emotions ranging from mild concern to outright panic. Although most of the above examples could be relatively easily resolved or the concerns mitigated by prompt action (with the possible exception of the one at Ashley Madison!) the damage to an organisations’ reputation was already done.  Eventually customers get compensation or they move their business to another company. Which is fine until it happens all over again e.g. there have been several issues in the recent past at TalkTalk. Imagine then, the impact on your life that would result from missing or incomplete health records and associated information on even just one occasion. How would you feel …Betrayed? ..Angry? …Disappointed? …Surprised or possibly not surprised at all? In this case it is not as simple as changing mobile phone contracts or switching bank accounts. There is only one NHS and we are all entitled to assume that our health records are managed professionally and in line with all current legislation e.g. The Data Protection Act 1998, Freedom of Information Act 2000 and more recently, the Public Records (Scotland) Act 2011.

The Public Records (Scotland) Act 2011

John M 1 This Act fulfils one of the main recommendations of the 2007 Historical Abuse Systemic Review (the Shaw Report). The Shaw Report found that poor record keeping often created difficulties for former residents of residential schools and children’s homes, when they attempted to trace their records for identity, family or medical reasons.

One of the aims of the Public Records Act (Scotland) 2011 is to achieve improvements in the standard of record keeping in all 270+ public authorities in Scotland.   The Act requires every authority to prepare a Records Management Plan (RMP) setting out proper arrangements for the management of the authority’s public records and submit it to the Keeper of the Records of Scotland for agreement. NHS Dumfries & Galloway are currently in the process of creating their RMP for submission by the end of February 2016 to the Keeper for assessment.  

The RMP encompasses 14 elements of records management as defined by the Keeper. For each element we are required to submit a response together with detailed supporting evidence. Several NHS Dumfries & Galloway policies relating to Records Management, Information Security and Information Governance have been updated to ensure that they meet the Keepers’ requirements – please ensure that you are familiar with the latest documentation.  

The demands around the security, accuracy and availability of our personal information will undoubtedly continue to grow. Current and future legislation (there is another abuse enquiry currently under way in Scotland that may result in updated legislation) will help to ensure that, together with the commitment and professionalism of everyone, records management within NHS Dumfries & Galloway is of the highest possible standard and will indeed ‘Preserve the Past, Record the Present and Inform the Future’.  

For more information on the Public Records Act (Scotland) Act 2011 please click here or contact John McGonigle, PRSA Project Manager. Tel: 01387 244189 or internally 34189. Email: john.mcgonigle@nhs.net

Sometimes you can’t see the wood for the trees… by Laura White

In September 2015 when my team and I were at the glittering Excellence in Care Awards ceremony at Easterbrook Hall after being nominated for not one, but two awards, I found myself pondering what it took for us to get from our lowest low to our highest high…

In early 2014 the Healthcare Environment Inspectorate walked into ICU unannounced and unearthed a catalogue of issues that turned our world upside down. In an instant our team went from a well-oiled machine to a rusty old tractor not knowing how to function.

The title of the blog sums up what we thought, as an organisation none of us could see what the Healthcare Inspectorate saw, we were in fact too close, too involved. For all our nursing care was never in question, we still doubted our abilities as nurses and wondered whether we were failing at the job we worked so hard at and got so much satisfaction from. The shame and embarrassment of having our place of work discussed in the newspapers and throughout the hospital, whilst trying to ‘keep it together’ still caring for critically ill patients and their families, was an overwhelmingly stressful time for all of us. The whole time we seemed to only have one question for each other…”How did this happen?” We put all our time and effort in to caring for our patients, did it matter that there wasn’t a record of the shelves being wiped down? Yes it did.

Laura 1

We listened to feedback, sought advice and did extensive research around the way we did things. We really dug deep and relearned our roles to include a vast new array of cleaning and infection control measures. It took months of liaising with the Infection Control Team, Domestic Services, Medics, Management, and Estates to name a few. There was clarification sought for EVERYTHING, from everyday things like bed bathing a patient to the fear of the effects of excessive Actichlor on our health.

The transition period between the inspection and the refurbishment of ICU put strain on everyone involved, however during this time it became apparent how well we pulled together, worked as a team and were committed to putting the broken pieces back together in order to be the best we could be. Staff came in to help in their own time, worked extra shifts and there was actually a lot of excitement about working in the newly refurbished unit, it was like a blank canvas. Don’t get me wrong, it wasn’t all plain sailing, the months following the inspection included periods of extremely low staff morale, increased sickness absence and an emotionally fragile workforce who at times found it difficult to talk about what happened to us. We eventually found that discussing the experience with colleagues and other professionals did help to rid us of some of the mixed emotions we were struggling with. Thankfully there did come a time when we realised we had to stop looking back and start looking forward and take the good from a bad situation.

We slowly began to regain confidence in ourselves and became very proud of our ‘new’ unit. During this time it became clear just how many of us had ‘a touch of OCD’! There were times when you could probably have eaten your dinner off the floor in ICU, and we just stopped short of putting Actichlor in our cereal! We now work relentlessly keeping our very extensive cleaning schedule up to date and everyone is involved in adhering to our philosophy of cleanliness, God help anyone who tries to put their gloves and aprons in a domestic stream waste bin! We really are acutely aware of everything now.

We knew that changing habits would be the hardest part but also that these changes had to be sustainable and over time these changes have become the new norm for us. These are the changes which are now the norm to the new staff that have joined us since the inspection and will undoubtedly evolve and develop in the future, as everything does in nursing.  The HEI inspectors have since returned to the unit and saw a drastic improvement in all aspects of cleanliness, which we knew they would.

Laura 2

Winning the Excellence in Care award for Infection Prevention in a way closed the chapter on the hard times we faced in 2014 and reinforced to us how we took the best from it and got to where we are today. We are dedicated, committed and knowledgeable in Infection Prevention and have regained the confidence we lost when our unit was put under the microscope.

As the saying goes “what doesn’t kill you makes you stronger”.

Laura White is the Senior Charge Nurse for ICU and Surgical HDU at DGRI

 

Ten Things I Have Learned About Governance by @craigwhitephd

“Everybody involved in overseeing, planning, delivering and supporting healthcare services in Scotland has a role to play in ensuring that our governance procedures improve, assure and result in necessary remediation to drive the quality of our healthcare services” 

Extracted from ‘Governance for Quality Healthcare in Scotland – An Agreement’, Scottish Government Health and Social Care Directorates, NHSScotland. Available at: http://tinyurl.com/qualitygovernance (Accessed 17th December 2013)

From 2010-2013 I worked as Assistant Director in the Medical and Nurse Directorates of NHS Ayrshire and Arran, supporting and advising on the Board’s Clinical and Healthcare Governance activity.   A significant amount of time (as you would expect given the role) was spent in dialogue regarding ideas and requirements for changes in systems and processes – a common thread across all governance, learning and improvement work.

Craig 1I quickly realised that there were many different views and experiences in respect of how governance and improvement work had been experienced, understood, discussed and approached.

I was recently asked by colleagues in NHS Ayrshire and Arran’s Mental Health Services Directorate to speak at their annual clinical governance and improvement symposium.  My talk focused on ‘ten things that I have learned about governance’.

These are outlined below:

1 – What have you done about it?

Governance is about being able to identify what action is required and demonstrate that this has been effectively implemented.

 2- Adopt an open ‘questioning’ mindset

Craig 2Engage and support questions that drive forward a focus on understanding systems, making sense of contributors and understanding relationships between people, processes and wider organisational climate and culture.

 3- It’s not about you

Systems, processes, organisational climate and cultures are more powerful than any one individual.  It’s not personal, even though there may be many who think it is and try to make it so.  Stay focused on the people who we are employed ‘to serve’ – this is the ‘key’ unifying factor in terms of focusing on what matters to the people that use services being provided.

4- Defensiveness is dangerous

Craig 3Defensive and dismissive reactions can significantly weaken good governance – energy is taken away from learning, dialogue, and the generation of ideas for change, development and, most importantly, the implementation of plans for improvement.

5-That’s not your job/that’s my job

There needs to be clear, shared and accepted understanding of what individual roles and responsibilities are. Delivery of ‘best in class’ governance practices is always more effective when roles and responsibilities were clear and understood in practice.

6-Clarify your intentions

Personal and organisational custom and practice can mean that intention/personal meaning that is attached to actions is incorrect.  I quickly learned that if colleagues had not had the opportunity to consider the same theoretical models of healthcare governance as I had, they would sometimes attach meanings about intent of my actions that then became unproductive. 

This could lead to perceptions of unjustified interference, thankfully often addressed by making sure intent was clarified – for example, saying ‘My intent in asking about how this action has been progressed is to provide an update to Mr Jones’ widow who is frightened to come into hospital herself now in case we have not improved the systems’ would often help focus action around what mattered. 

7-It’s all about measurement and change

Governance, improvement and performance have more in common than people think or believe that they have.  Data for dialogue – to understand systems, inform ideas for change and examine whether changes have resulted in improvements or delivery of a stated aim is what matters.

8-Some people don’t “get it”

A well-developed understanding of the legal, professional, moral and policy imperatives regarding governance does not always seem to have been an essential recruitment criterion. It’s insufficient to issue policies and guidance and hope that actions will be effectively taken as a result.  Good governance also depends on a grounded and comprehensive understanding of what matters most to the people using services.

Craig 4

 9-Impact is everything

The impact of getting it right (even after getting it horribly wrong) can be profound for everyone involved.  Trust can be restored when there is an authentic and honest ‘reaching out’ to connect with the lived experience of all who are touched by the encounters that are reflected in governance and improvement conversations.  

10-Did I say impact is everything? – I meant transparency is everything

People who use services, people who might need to use them and the staff who work within them have a fundamental right to know what is happening – what is going well, what hasn’t gone well, what has been done, whether it worked and how they can become involved with efforts to continuously improve service quality.

Some closing remarks…..

Craig 5Governance and assurance doesn’t need to stifle improvement activity.  The following simple model for healthcare governance process was based on the work of the late Avis Donabedian and, I believe, demonstrates how governance process can be entirely resonant with improvement focused thinking and action.

  • Information on the quality of care is collected (through a range of sources)
  • Information is then interpreted to identify what action is needed
  • Agreed actions are then documented
  • The impact of taking these actions is then monitored through agreed measurement and reporting processes
  • The information on this impact is then considered against agreed aims, this in turn again provides information for further interpretation:      
    • Has this made a difference? 
    • Are things better?
    • What have we learned?
    • What do we need to next to make this more reliable?

Craig 6

Good governance consists of a set of simple steps. Although they are often difficult to implement consistently and reliably they can be powerful enablers to support a learning and improvement focused approach to governance and accountability.

Footnote

The views outlined in this blog are personal views based on professional experience while Assistant Director (Healthcare Governance and Assurance), NHS Ayrshire and Arran 2010-2013.

 About the Author

Professor Craig White is now Divisional Clinical Lead (Quality and Planning), The Quality Unit, Health and Social Care Directorates, Scottish Government.   

Email: craig.white@scotland.gsi.gov.uk Twitter: @craigwhitephd