policies and procedures

 by Gillian Robinson

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.

 

 

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 by Gillian Robinson

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.

 

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 by Gillian Robinson

Understanding the Change Process

When undertaking a change management process in care facilities, I’ve identified 5 distinct phases of reaction from managers and staff.  These have often occurred after I’ve been appointed to perform the role of statutory (temporary) manager by a DHB. This is generally after risk to residents has been identified following an audit or a serious complaint.

As a temporary manager, often there is a facility manager in place however for a range of reasons doesn’t have the resources or knowledge to meet the needs of the residents to a standard that satisfies audit outcomes.

Phase 1 is on first arriving and there is relief on the part of the staff and manager (if there is one) on the basis they have the view that I’m there to ‘save the day’, make things right and then they can get on with running things.  Comments such as “you should have been called in a long time ago” are common.

Phase 2 is where the staff and in place management start to realise that I’m not going to do all the work for them and my role is that of mentor and coach. Further to that the role includes assistance with obtaining necessary resources to support clinical and operational practices. This is where push-back and resistance starts to show as people resist change and try to hold stead-fast to those practices that have got them to the point they’re at.  As pressure increases for change to occur, resistance increases and at times sabotage of the new way of doing things starts to appear.  As one provider put it recently “they’re ever so nice to your face and will stab you in the back”. The denial phase plays out and the anger phase starts.

Phase 3 is a time when divisions start between those who want to embrace change knowing it’s intended to improve and make the workplace safer for staff and more so, safer for residents; and those who don’t have insight to recognise the need for change.  The need for people to remain in their comfort circle doing what’s known and predictable is incredibly strong for a large number of people. This slows momentum and the temporary manager starts to get the blame for things being wrong.  Such comments as ‘it was all fine before the DHB stepped in, they just need to back off and let us get on with it’ are also commonplace in this phase. Sometimes senior staff at the facility will contact their DHB and say the temporary manager is unreasonable, not doing anything and needs to be removed. All as an attempt to get rid of the person they see as pushing them outside their comfort circle and affecting maintaining of the status quot. The bargaining phase can continue for quite some time but this often depends on how direct and steadfast the response is to the bargaining strategies.

Phase 4 occurs when there is the start of the depression phase and realising that solid work, participation by all and a willingness to take on new ideas and learn new ways of doing things needs to occur. The real work has started by the willing few in the early phase and continues and now the collective change can start to be evident.

Phase 5 is acceptance that the temporary management or change management process was necessary. Staff start to commend the new way and embrace new ideas recognising that things are actually better now than they’ve been before.  As people always have choice about coming on board with change or leaving, invariably there are some staff and sometimes managers or even members of Governance who continue to resist seeing a new way is needed and those few will leave the organisation or continue to resist.

I’m able to observe which phase an organisation is operating in by the response of those working there and was intrigued to read of exactly this same set of steps in a book titled ‘Expert Secrets’ written by Russell Brunson. Some of you who are familiar with the work of Elisabeth Kübler-Ross will also recognise these phases as reflecting her stages of grief.

Acceptance is hard as people take the need for change as a criticism when in my view, people don’t fail; systems do!!

in News
 by Gillian Robinson

Clinical online tools for Aged Residential Care

HCSL are pleased to announce that from January 2018, you will be able to access clinical online tools for:

  • Initial assessment and initial care plan.
  • Short term care plans (and evaluations)
  • Long term care planning (and evaluations)
  • Progress notes
  • Restraint/ Enabler restraint management (and evaluations)

All mobile device compatible so you can be with your residents rather than stuck in the office!

HCSL bringing cost effective, specifically designed tools for the New Zealand residential care sector.  The Corporates have their tools, why shouldn’t you have the same advantage?!

 

To find out more and get a no obligation free quote for use contact us here.

 

in Services
 by Gillian Robinson

Testimonial from Tainui Village – New Plymouth

Upon reading one policy everything fell neatly into place. I found her documentation to be outstanding.  It is very reassuring to know that every policy and procedure is the most up to date and designed to meet audit requirements.  All her forms are easily accessible and very user friendly.   We can instantly benchmark against others.  At the click of a button we can analyse falls, infections and adverse events.   Creating graphs and other information for Board reports takes minutes rather than hours.

Having come from a background of many years in QA, HSE and Electronic Document Management in the Oil and Gas Industry, when I entered the aged care sector, it was a huge “eye opener”.  After sitting through several handovers and meetings and listening to discussions on medications etc I felt as if I was listening to a foreign language.  Oh my goodness I thought and then Gillian’s documentation arrived together with a visit from her shortly after.

Gillian’s enthusiasm and commitment for both the aged care sector and her documentation is contagious.  I feel I can now discuss, with the knowledge I have acquired in a few short months, aspects of aged care I never knew existed.  Gillian is only a phone call or email away and all queries are always answered promptly, no matter how minor.

 

Thank you very much Gillian.

Lois Lash – Quality Assurance

Tainui Village –  October 2017

 

in Testimonials
 by Gillian Robinson

Testimonial from Shoal Bay Villa Dementia Care

Dear Gillian

As noted previously, I have sold my business.  Thanks so much for your fabulous support and encouragement and especially the ‘find me’ conversations we had; so without much ado, I will say ‘cherrio’ and depart quietly.

I wish you the very best going forward with all your ventures and I am sure you have something new on the go as you never seem to sit still….

Warmest regards

Nadene Elrick

Owner – Shoal Bay Villa (Northcote, Auckland)

in Testimonials
 by Gillian Robinson

Attendee Testimonial for Aged Care Education Study Day – July 2017

Topics included: Quality & Risk Management, Clinical Leadership, Clinical Documentation, EPoA, ARRC, Communication and Difficult Conversations

 

I am writing this endorsement on behalf of my colleague and myself, in relation to our attendance at the study day you hosted 5 July 2017.

The topics you presented were most relevant to our Registered Nurse role within the aged care sector, and between us both provided new learning opportunities, as well as refreshing the current knowledge we already held.

You addressed each session in a professional and engaging manner that held our attention, complemented by comprehensive written material as well as PowerPoint presentations, along with plenty of opportunity for questions and comments from the floor.

Gillian you are one of very few speakers that is able to hold my attention for more than one session let alone a whole study day, a perfect balance between speech and conversational styles!

We were also most impressed by the quality of the complementary gift bag that was given to each attendee containing not only goodies to help us through the day, but with something to take back to the workplace, I acknowledge both Cubro and Ebos for their support with this.

The venue was great with easy access and good parking, and it was clean and refreshing providing plenty of comfort and personal space for those attending. I will be recommending my associates to make a note in their diary for next time. Thank you Gillian

Kind regards

Lyn Black

Bloomfield Court Retirement Home – Canterbury

in Testimonials
 by Gillian Robinson

Dysphagia Diets – Are we all understanding each other?

Dysphagia diets and a lack of understanding of how to implement them consistently, is increasing risk to residents in aged residential care services.

Texture modified diets are commonly used in aged care facilities to manage the risk of aspiration pneumonia and choking with eating and drinking.  Residents with dysphagia may be placed on a texture modified diet following assessment with a speech and language therapist.  However there are often a range of terms used for texture modified diets, and differing opinions on exactly how the diets should be prepared.

 

Confusion with terms, and the types of foods and fluids offered leads to increased risk of harm for the resident.  This is particularly obvious when transferring from one facility to another.  Information on texture modified diets is passed to the new facility who may use different terms.  For example a site may report ‘this resident requires a soft diet’ and the interpretation of this diet at the new facility is to puree all food.

 

The International Dysphagia Diet Standardisation Initiative (IDDSI) is a framework to standardise terminology and offer simple testing methods to check that the preparation of the diets are correct. Dietitians New Zealand and Speech Language Therapists of New Zealand have endorsed in principle the IDDSI framework.

The goal is to reduce the risk of harm for our patients and residents due to miscommunication and poorly prepared texture modified diets.  It is important to note that the framework relates to dysphagia diets only.  Residents may be on a modified diet due to other factors not related to dysphagia.  For example a resident with no teeth may need softer foods but can actually manage sandwiches.

The good news is that for many sites, there is very little change needed as they are already using the correct terms.  The diagram above shows the new terminology and the minimal change in wording;
  • ‘Smooth puree’ becomes pureed (which is also extremely thick fluids)
  • ‘Minced and moist’ remains unchanged
  • ‘Soft diet’ becomes ‘soft & bite sized’
  • Moderately thick and mildly thick remain unchanged for thickened fluids
The IDDSI framework assigns standard colours and numbers to assist with easily identifying texture modified foods and fluids.  Some manufactures of texture modified foods and fluids are looking at ways to incorporate the terms, colours and numbers onto their food packaging.

 

Food and Fluid Preparation and Testing

The IDDSI framework offers simple tests to check that the thickness of the fluids or the size of the particles for modified foods are correct.  The tests use forks, spoons, fingers or syringes – equipment that is readily available at sites.

With training and education on how to do these tests, kitchen staff and managers will be able to easily check their texture modified diets and thickened fluids are prepared correctly.

 

IDDSI App and Website

The IDDSI framework have developed many resources and videos to assist with the standardisation process.

Download the app https://play.google.com/store/apps/details?id=com.appdataroom.iddsi&hl=en

or go to www.IDDSI.org

or ask your dietitian and speech language therapist for more information.

 

Where to From Here?

Here are some small steps to help implement the IDDSI framework at your site:

  1. Stop using any terms that are not on the framework. The term ‘mouli’ is not recognised and should not be used to describe a texture modified diet.
  2. Download the app or look at the IDDSI website to familiarise yourself with the framework.
  3. Try testing one of the textures you currently prepare. Does the ‘puree diet’ your site produce pass the spoon tilt test?  Does the size of the minced food for ‘minced & moist diets’ fit between the prongs of a fork?  Is the size of meat offered for residents on the ‘soft & bite size diet’ the size of your thumb nail?
  4. Ask your dietitian or SLT for further training on the correct testing and preparation of dysphagia diets.

This article was contributed by Liz Beaglehole NZRD (Canterbury Dietitians) and Anna Miles PhD, Speech-language Therapist, Senior Lecturer, Speech Science, School of Psychology. The University of Auckland.

in News
 by Gillian Robinson

Success Leaves Clues

Success leaves clues but often these aren’t being picked up so you miss the learning and miss the opportunity to recognise growth or gain continuous improvement in your audits.

In residential care, HealthCert (MoH) Certification processes appear solely to promote a goal of verifying compliance with requirements. Looking deeper however, the goal of meeting requirements ensures the protection and support of those in your care. This can then be evidenced in a way that’s reflective of service received as meaningful, safe and appropriate by individual residents.

It’s no longer an expectation that you’ll have a number of partial attainments as a result of an external audit. The expectation is full compliance and showing evidence of continuous improvement, going over and above the base ‘pass-mark’ brings you into line with your high performing peers. I’ve heard managers say “but it’s the Auditors job to find things wrong so we expect to get partial attainments.”  That is out-dated thinking and doesn’t fit the current audit and compliance environment or continuous improvement philosophy.

Systems can’t be implemented to show compliance, if staff are not looking at policies and procedures, or using them to guide services and care of residents. If individual staff or managers do what they think best, based on previous experience, without verifying whether that practice is still appropriate or best practice, they do themselves and residents a disservice.

Success leaves clues.  It’s apparent when quality systems are implemented, outcomes are checked in a measurable way, recorded, examined, analysed and greater gains identified for future implementation.  This is a cycle and if you have the right tools to record your continuous improvement projects on, you too will be in the elite who are out-performing those who continue to have multiple partial attainments (deficits) in audit.   Don’t be a provider that looks at others saying it’s ok for them; they have this or that or the other reason for their success but we don’t have those things so we can’t achieve.  Don’t make others extraordinary to let yourself off the hook.  You can have, and deserve to have, all the recognition for the amazing work you perform just like others who are achieving four years.

The lack of a robust up to date quality system, along with deficits in implementation, will lead you down an expensive compliance track. Expensive in loss of reputation as audits are published and accessed online by the public, expensive in loss of time trying to figure things out yourself, increased risk to residents, loss of financial resources as you end up being audited more often than would have otherwise been necessary. The better you achieve at audit, the longer your period of certification, the less often you are audited and therefore less often you’re paying auditors fees!

A common failing in the care facilities under Temporary Management has been from the lack of a proven quality system and application of that system into service provision. I’ve been contracted into a number of sites as a Temporary Manager over the years and this has consistently been the case.

If you would like a free Continuous Improvement Project template to help you identify and record your success, contact us and we’ll email it to you.

Go here to read testimonials from a few of our clients.

in News
 by Gillian Robinson

Influenza season

Prepared for winter coughs and colds?

Winter is fast approaching and now is the time to be preparing your facility for the season’s usual crop of influenza, coughs and colds.

Last year the elderly were hit hard with, not just influenza, but also other respiratory viral infections. Many were admitted to hospital with complications such as pneumonia.

The predominant circulating influenza strain in 2016 was Influenza A, H3N2, different from the previous year’s Influenza A, H1N1. Although covered by the vaccine, last year’s predominant strain changed slightly from what was covered in the vaccine and there were numerous reports of laboratory confirmed cases of young vaccinated adults who still acquired influenza. Despite this, vaccination still affords some protection and symptoms are less severe than without it. This is the same for the elderly whose uptake of the influenza vaccine is not so good – experts agree that there are still benefits from the elderly having an annual influenza vaccine.

Some of the other respiratory viruses last year that caused severe disease in our elderly included coronavirus, rhinovirus and parainfluenza.

 

Check list for winter virus planning

  • Encourage and offer seasonal influenza vaccination to both staff and residents
  • Ensure hand sanitiser is available for visitors at the entrance of the home
  • Consider displaying a poster discouraging visitors with symptoms – a poster is available from CDHB communications
  • Remind staff and residents about good cough etiquette / respiratory hygiene
  • Have a good stock of tissues and hand sanitiser for residents
  • Remind staff to stay off work if sick – no-one wants their germs!
  • Educate staff about S&S of influenza – not all residents will display fever or cough
  • Keep residents in their rooms if symptomatic and introduce droplet precautions, i.e. droplet masks for staff providing cares
  • If you suspect an outbreak then confirm the outbreak[1] and introduce control measures[2]

Ensure all infections are logged into you infection register (for HCSL QA online uses – this is part of your infection log process) – remember your outbreak notification requirements as per your policies and procedures.  If you would like more assistance with this please contact us.

 

This article kindly contributed by: Ruth Barratt RN, BSc, MAdvPrac (Hons) – Independent Infection Prevention & Control Advisor (Canterbury)

Infectprevent@gmail.com

[1]  Infection Prevention & Control Guidelines for the management of a respiratory outbreak in ARC / LTCF

[2] A Practical Guide to assist in the Prevention and Management of Influenza Outbreaks in Residential Care Facilities in Australia

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