Great audit result

Hi Gillian,

Great  news, we did very well with the audit.

The Lead Auditor tells us she cannot see we have any corrective actions to complete!

Also she acknowledged a CI  from one of the Quality Improvements I completed. She was very impressed with the Quality and risk management systems via your Policies and procedures and says we are using your systems to the max.

Well, where would we be without your Policy and Procedures, they are great to work with – thank you.

kind regards

Rose Kennedy (Dixon House – Greymouth)

Leadership of your team

 

Empathy and perspective are two concepts well known Leadership author Simon Sinek speaks about in relation to leaders. He talks about the real job of a leader as not being in-charge but taking care of those in our charge.  How many leaders play the blame and shame game when things don’t go as planned?  Instead how would it be if leaders in aged care services worked in accordance with a Leader’s Oath.  My version is noted below as an example.

You may want to create your own for your organisation, or adopt this.

The Leader’s Oath

I focus on the betterment of this organisation above my own career needs

I  focus on accountability above the need to be popular

I focus on caring for those in my charge over being in charge

I focus on clarity above certainty

I share clear expectations

I hold myself accountable for all employees poor performance including my own

I welcome respectful challenges

I will table the tough issues

I treat all interactions as though my career depends on a successful outcome

I am committed to personal and professional development

I am focused on excellence.

 

While the above Leadership Oath forms a focus for clinical leadership, it’s necessary to make sure your nurses are familiar with the ARRC funding agreement responsibilities for Registered Nurses. These are also clearly defined in the HCSL policies and procedures to ensure they’re integrated into practice.  The ARRC includes time-frames for nursing documentation responsibilities, while the nursing council guidelines for delegation define staff delegation of staff working under the supervision of Registered Nurses are appropriate led and supported. When we refer to tabling the touch issues, one key aspect of leadership is holding staff accountable.  Nurses are often not keen to hold others responsible for their conduct and performance and therefore avoid performance managing staff when performance is below the expected standard.  This in turn means the service provided will be below the expected standard.  If you want to provide the best care and support to those in your care, these are skills you must learn and put into daily practice. To learn more about these skills and others needed for leading a team of care and support staff, go here.

Spiritual care and Pastoral Care

As we age, the need for spiritual care and pastoral care often come to the fore.  This is particularly so as people near the end of their life.  The need for comfort and peace of mind on a holistic basis.  Let’s firstly lets define the difference between these two concepts.

Pastoral care is an ancient model of emotional and spiritual support that can be found in all cultures and traditions. It has been described in our modern context as individual and corporate patience in which trained pastoral carers support people in their pain, loss and anxiety, and their triumphs, joys and victories. Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain and can help him or her heal emotionally as well as physically, rebuild relationships and regain a sense of spiritual wellbeing.

For most of human history, in all major religions, an ultimate goal of spiritual practice was accomplishing a good death. When this goal was held in common by the whole society, spiritual care could focus on the interaction between a dying person and his or her caregivers.

A number of clergy have commented to me that spiritual care is not recognised by many aged care facility staff as important. They have frequently commented on services being interrupted by staff activity, or being asked to hold services or provide pastoral care in areas of the facility that are very close to the main entrance or actually in main thoroughfare areas. This is not respectful of the needs of the residents who choose to attend, or the need to peace and calm to receive spiritual care. In learning more about the importance of these concepts, it may support good holistic care for residents if you were to discuss with the clergy and pastoral care workers whether the circumstances being provided for them to support residents are appropriate.

To read more on this topic go here.

 

Critical thinking – the foundation of good nursing practice

There are lots of ‘trendy’ words in each work environment but one of the most important concepts which appears to be increasingly missing particularly in aged care nursing is that of critical thinking and reflective practice. Critical thinking is the core foundation of good nursing practice.

It is essential to evaluate what is occurring clinically for those in care and regularly reviewing what is being done for each individual resident along with what else needs to be done in order to provide the best care. The skills of critical thinking may not be instinctive for example for those nurses coming from a schooling system which promotes ‘rote’ learning and deters from challenging senior staff.  To question another may be seen in some settings as disrespectful however in the field of clinical care, to challenge and question is essential.  The attributes of those who critically think and reflect on nursing practice and care outcomes use evidence-based practice (EBP) guidelines including current EBP policies and procedures to form decisions.

Some of the skills of critical thinking are more important than others and certainly the ability to reflect while communicating with other members of the team is essential to safe and person centred care.  The nurse who has developed critical thinking skills is able to interpret, understand and explain the meaning of information. This can be event based or data based eg; reading lab result forms. Investigating possible interventions based on the information at hand and analysing which will achieve a desired outcome is also part of reflecting and critically evaluating a clinical scenario.  Assessing the value of information to determine it’s relevance, reliability and credibility in relation to a particular clinical presentation is also necessary.

There are potential barriers to optimising clinical outcomes by clinical staff when a pre-determined bias or fixed mind-set are applied to a set of data or resident clinical presentation. It’s only in the bringing together of information through evaluation, analysis, communicating, referencing EBP guidelines and a growth mind-set that care can be optimised.

Click here to read more on critical thinking.

 

 

Audit Tips for Clinical Documentation

Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents include:

 

  • Age Related Residential Care (ARRC) contract
  • NZS 8134:2008 Health and Disability Services Standards
  • Clinical best practice (EBP) guidelines – eg; Lippincott
  • The Code of Health & Disability Consumers Services Rights 1996

 

Clinical documentation errors of any type noted during audits will result in partial attainments at best.  This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.

 

Below are some of the common compliance gaps which relate to clinical documentation:

   
General compliance

gaps

Missed signatures off notations.

Not dated.

Not signed by the author with a full signature.

No designation written with signature.

Not legible.

Inconsistent structure of resident files.

Unclear or unsecured archiving of documents.

Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing.

Initial assessments

including InterRai

Not completed within time-frames defined in ARRC.

Baseline recordings at time of admission not recorded.

Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions.

Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments.

Failure to re-assess for each period of admission eg; respite care.

Clinical risk

Assessment not describing risk.

Risk not reflected in care plan interventions.

Lack of risk reviews.

Level of risk noted in interRai assessments not included in care planning

Progress notes

Not recorded in on a shift by shift basis.

Lack evidence of regular registered nurse input.

Writing beyond the bottom line of the page.

Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well).

Lack evidence of interventions being implemented.

Lack evidence of RN response to clinical symptoms reported by care staff.

Lack of evidence of rationale for PRN medication administration or the resulting effect.

Short Term

Care Plans

Not developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness).

24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours).

Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse.

Not recorded as resolved or transferred to Long Term Care Plan.

Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes.

Long Term

Care Plan (LTCP)

Not reflective of all presenting potential and actual medical / clinical problems.

Not documented within 3 weeks of the date of admission (ARRC requirement).

Not changed at the time of health status / functional change.

Interventions not reflective of each medical diagnosis.

Interventions not changed within LTCP to reflect changes recorded in care plan evaluations.

Frequency of clinical assessment for each actual clinical presentation eg; pain.

Do not clearly indicate the level of function, assistance required for each component of care / support.

Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services             for the elderly etc.

Care Plan

Evaluations

Review of care plans not reflecting changes in residents health status as they occur.

Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation.

Not completed within ARRC defined time-frames (at least six monthly).

Multi-Disciplinary

Input

Lack evidence of MDT input into care plan reviews and/or evaluations.

Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning.

Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian.

Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical           consultation notes however not evidenced as having been done.

Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc.

Policy and

procedures

Not consistent with service delivery as noted in clinical documentation.

 

Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.

If you have any comments to make about this article, please contact us here.

 

Staffing levels – is skill-mix the formula for success?

Last month we reflected on how friendly our nursing workforce is and reflected on a degree of bullying in the workplace. This month we look at the discussion around whether mandated staffing levels in aged care as a ratio of care to residents would improve care services?

Rather than numbers of personnel alone, to provide safe and appropriate nursing services, staffing skill-mix (taking into consideration the workforce diversity, layout of buildings and location of resources) is essential to ensuring appropriate effective staffing. These factors are not taken into account or provided for within the industry funding levels which puts additional pressure on those working in aged care services.

While performing statutory (temporary) management roles over past years, adequate numbers of staffing alone hasn’t guaranteed safe and appropriate care. Nursing outcomes for residents have been reliant on a mix of highly skilled staff working in conjunction with newer or less experienced staff.  There could be 10 staff on duty but if none of them have had previous experience working in aged care services, these staff are set-up to fail in performance of their duties, and the resident care outcomes are likely at risk.

SNZ HB 8163:2005 – ‘Indicators for safe aged-care and dementia-care for consumers‘ is a national document which includes formulas for staffing levels based on acuity of residents. This document sets the industry guidelines and although not mandated, defines staffing from a best practice perspective. Numbers alone as already mentioned is not sufficient.  The 2005 guidelines didn’t take into account the size of the facility in relation to economy of scale and appropriate cover in conjunction with the minimum staffing requirements in the ARRC.  Having been implemented in 2005 when resident needs were less complex than they are in 2018, it’s well past time to review how staffing mix is determined and more importantly how the industry will fund it.

ANZAC day commemoration

On the 25th April each year we remember those who went before us to fight for the protection of others.  While emphasis is often on those who died in service to their country, it’s also a time to remember those who returned from war changed and altered forever by the experiences they’ve had.  Not just for the soldiers going and returning to war but their family.

The mother who describes holding her son as he heads off to the front line. Embracing him, breathing in his smell which a mother knows so well.  Holding her head against his chest hearing the beat of his heart wondering if she’ll ever be able to hold him and hear his heart beat again.  Feeling the harshness of the fabric of his uniform and wondering what other harshness he’ll encounter.

The soldier as a member of a family, not only left grieving mothers behind but were sometimes already parents themselves going off to war leaving wives and children behind.  All family members impacted in their own way from their own perspective of events.  How does a wife or child accept the decision of the men in their life going to war, to do ones duty leaving children wondering why they were being deserted in favour of the uncertainty of battle? Those children then growing older day by day until the time they themselves are in their 80’s and find themselves still welling up in tears at the memory of the day their father left to go to battle. Not understanding but seeing the change in the father who returns, different, distant and ill from the effects of sand breathed into his lungs while stationed in Egypt.  The soldier returning, having nightmares of horrors seen which cannot be unseen or forgotten. Limbs and body intact but emotional scars and ongoing adverse health issues.  Not all wounds are visible.  Those who were victims of war yet no memorial bears their name.

I visited the Gallipoli exhibit at the Museum of New Zealand ‘Te Papa’ (our place) in Wellington last November with my mother and sister.  I was mesmerized and deeply affected by the raw emotion depicted in the models created for the exhibit by Weta Workshop. The image of this nurse, Staff Nurse Lottie Le Gallais who was on board the hospital ship Maheno which set out from Wellington. She’d hoped to catch up with her brother but the model shows the anguish of the moment she receives her returned letters to him saying “killed, return to sender”.  I can’t imagine the strength needed to sustain such pain amidst the anguish of war but still carry on to serve those needing care.

A time to ponder on the Anzac values of courage, compassion, commitment and comradeship and see if they are reflected in our own organisations as relevant to care services. This Wednesday, 25th April, Anzac day is a time to reflect and be grateful – lest we forget.

 

 

 

Workplace Culture

Workplace culture is a term bandied around a lot but what does it actually mean and how can it be measured?  When I ask staff at facilities during training sessions what they see their point of difference is, they frequently reply saying ‘we’re friendly’, or ‘we care’ or ‘we provide a homely environment’.  While these are all nice to have, they would actually be expected as a basic standard.  They are not specific and not anything different to the care facility down the road.

Mary Barra, Chairwoman and CEO of General Motors (GM) states that at GM, they prefer to talk about behaviours rather than culture as behaviours can be changed very quickly and are apparent straight away. She talks about the need for rapid change with the inclusion of technology and advancements in artificial intelligence being used more frequently.  While those are starting to be present in some aged residential care settings, what is true of both GM and aged care is rapid change and the need to adapt quickly.  This isn’t going to happen by accident and needs clear direction, guidance, leadership and engagement of all those involved.

Mary Barra also refers to bringing products to market that bring people freedom, rather than talking about cars or transportation. She focuses on the outcome for their clients.   What is the key outcome you’re wanting to provide for those in your environment and how is that defined in your values?  How is it implemented by your staff and how do you measure success on those outcomes?

managers oath as I’ve mentioned before is a good place to start in defining the governance or leadership direction of organisations. Values and key performance indicators (KPIs) or quality objectives / measures need to align to this.To ensure consistent progress regular review of those KPIs or quality measures needs to occur and acted on according to the outcomes.  Policies and procedures to guide consistent best practice are an important part of ensuring clear direction for staff while setting parameters for performance.  Information reduces confusion and promotes change. Practice creates confidence not only in the staff but also in the resident and those observing their care.

Diabetic diets – clinically appropriate in aged care or not?

When balancing the clinical needs, requests and preferences of each resident in-conjunction with their right to choose, a number of factors need to be taken into consideration.  We all recognise that theory and practice can change over time so when I asked Liz Beaglehole (Registered Dietitian) her professional view on this topic is, she offered the following:

 

The recommendation for older adults with diabetes in aged care facilities with stable diabetes is to provide an unrestrictive diet as much as possible. The notion of a ‘diabetic diet’ is outdated due to the increased risk of hypos and unwanted weight loss.

 

This is very individual however, a frail 80 year old woman with diabetes will likely have no diet restrictions however an obese 70 year old who may be otherwise stable would benefit from a more restrictive diet.  Advice from a dietitian for individuals is recommended.

 

Overall, guidance from the resident about their wants is probably what determines the diet provided. This may be in accordance with recommendations or not.

 

Generally, the medications should be fitted to the usual eating pattern of the resident.  In aged care facilities there are regular meals and generally balanced carbohydrates over the main meals (assuming good food intake) so usually this is fine.  If someone has a reduced food intake, and is on insulin then a unrestrictive diet would be best.

 

For my menu planning I tend not to plan any special diabetic options on the cycle menus.  I may include a low fat / low sugar dessert option if sites request, but generally my philosophy for aged care is not to restrict foods!

 

Liz is involved with a PEN (practiced based evidence in nutrition) review of the question ‘Do institutionalized, older adults (65 years of age or older) who closely follow a diet prescription have better control of their chronic disease (e.g. diabetes) than those who do not?‘ This is due by the end of March so further practice updates from this review may be available then.  Liz noted that generally the evidence suggests there are no benefits with a prescriptive diet vs a more liberal one.

This article was kindly contributed by Liz Beaglehole NZRD (Canterbury Dietitians).

Food Control Plan registration update

Those of you who are members of the New Zealand Aged Care Association (NZACA) may be aware that we (Healthcare Compliance Solutions Ltd) have been contracted by the NZACA to develop what is known as an Industry Body Customised Food Control Plan (FCP). This is to be approved by the Ministry of Primary Industries (MPI) and made available to all NZACA membersThis customised plan comes under section 40 of the Food Safety Act and has been developed with the intention of streamlining audit process for Age Related Residential Care providers to use. There is an extended date for registering under this plan. 31st March was the date noted for registration however for this process, the date for completion of the registration process for use of the Industry Body NZACA FCP will be 31st May 2018. 

 

Instead of registering with the local Council, those members who are taking advantage of the national customised food control plan will register directly with Ministry of Primary Industries.  What is being worked towards currently is for this plan then to be audited by your Certification Designation Auditor Agency auditors in conjunction with your other audits. It is our understanding that the deadline for registering with MPI has changed to take the Food Control Plan approval into consideration so please check with NZACA to verify when you need to have your registration completed by.

 

How far have things progressed currently?  We have submitted the draft of the customised plan to MPI for approval.  The content of this plan goes beyond the standard Food Control Plan as it will need to also meet Certification and ARRC funding agreement audit criteria. This is designed to be an all in one set of documents so that as noted, it assists with the streamlining of audit.  We understand this approval process could take 4 – 6 weeks with a period of refinement if necessary and finalising of the documentation to follow, before a Gazette notice would be published.  This notice is necessary to proceed with association members using the Industry Body customised FCP as part of their other certification audit processes.

 

A huge thank you to Liz Beaglehole (Registered Dietitian) from Canterbury Dietitians who assisted at short notice with the reviewing of documentation contents which form part of the FCP.

 

There is work to be completed behind the scenes in an attempt to align audit time-frames which are not the same for all providers so while the intent is clear, the reality of achieving what we are setting out to do, is yet to be confirmed.

 

We support the work of the NZACA and were very pleased to be able to support the age care sector in this way.  We undertake to do what we can to support this process to a successful outcome.  NZACA will be updating their members as we work through this process.  If you are not a member, this may be a good time to join to take advantage of just one of the benefits they offer to support their members.

If you would like further support with the implementation of your Food Control Plan, please feel free to contact us.