The System

1
The System

• The System is a series produced by TVC in
  collaboration with BSIR and supported by The
  Healthcare Foundation.
• These support materials focus on Interventional
  Radiology issues.

2
Changing The System
Patient safety is paramount focus for the NHS and
many other professional bodies worldwide. Despite
previous efforts there is much room for
improvement. Many of the issues in a large
structure such as the NHS are cultural and
institutional. Staff feel disempowered and unable
to change or influence The System. We
encourage you to use this film with its linked
support material to make positive changes to
patient safety.
3
Guidance for Learning outcomes

• The following slides are an aid to discussion for
  your team. They aim to show the main areas of
  learning identified in the film but are not an
  exhaustive list.
• Take time to consider the points raised
• Note potential areas of action
• Take the three most important areas and decide
  how you will progress.
• Book the follow up meeting for the actions now-
  and review progress

4
Strategy to generate discussion

• Tackle each theme in turn
• Identify key issues for each theme
• Ask what local issues you have or share
• Answer any direct questions we have asked
• Discuss ways forward to address each issue

5
Action

• Watch the film now it lasts 15 minutes
• Jot down a list of themes you think it raises
• Restart the PowerPoint to discuss the themes

6
Themes identified in the film

• People consent, staff conflict
• Procedure sedation and analgesia
• Equipment biliary stent unavailable
• Process Handover and post-operative care, 24/ 7
  services
• Environment 24/7 services
• Underlying systemic issues
• You may have identified others .

7
Patient consent

• The film shows an episode
• of consent
• How was consent established and think how it
  could be improved?
• The following specific questions may be useful

8
Patient consent- discussion

• Are patients seen at an IR outpatient clinic ?
• Are elective patients consented in the
  department- why?
• Do all patients receive patient information
  leaflets?
• Have you audited this process?
• Consent
• How can we ensure this is done by the operator
  or staff familiar with the procedure

9
Patient consent Best practice

• Primary operator consents is the default
• Any consent delegation clearly defined
• Elective cases consented at clinic
• Audit of consenting practice
• Regular staff education re consenting process
• Understanding of incapacity consent
• Understanding of research consent

10
Sedation

• The patient received sedation during the
  procedure.
• As a group discuss how sedation was undertaken in
  the film and how it could be improved
• The following discussion points may be helpful

11
Sedation-discussion points

• Poor communication
• Anxious patient
• Patient thought they were getting a GA
• Sedation protocol
• consultant over-ruling nurse
• over sedation and reversal
• Conflict within the team
• Had a GA been considered

12
Sedation- Best practice

• Better communication reduces patient anxiety
• Agreed pain protocol with anaesthetic input
• Strategy for managing breakthrough pain
• Regular audit of protocol effectiveness
• GA lists for identified procedures
• biliary drainage, TIPS, vertebroplasty, AVMs

13
Staff conflict

• Staff conflict is demonstrated during the
  procedure
• As a group reflect on why this happened and how
  this can be prevented
• The following discussion points maybe useful

14
Staff conflict- discussion points

• How can a team brief help understand the relative
  roles of team members?
• Departmental protocols can help reduce conflict-
  how do we make sure all parties know the current
  protocols?
• Inevitably protocols cannot be followed for every
  case. Can we agree beforehand as a team the
  process for moving from the protocol?

15
Staff conflict- Best practice

• Self respect and respect for others
• Culture of openness
• Team meetings
• Immediate de-brief after case
• Understanding of grievance procedures
• aim to avoid this by the above measures

16
Benefits of a Team conference

• Education
• Encourages discussion within the MDT to address
  issues in a non clinical environment
• Helps to abolish the Blame Culture
• Raises awareness of wider aspects of patient
  safety
• Raises the question Could we do better?

17
Pre-operative checklist

• What are the issues in the film ?
• Discuss as a team how the pre-operative checklist
  is used in your department.
• The following discussion points may be useful

18
Pre-operative checklist- discussion points

• Issues
• No radiology checklist or brief done !
• Coagulation status
• wrong patient, same name
• Stock control
• only one stent
• Ultrasound machine not available
• borrowed by Obstetrics

19
Pre- op checklist- Best practice

• Checklist/brief/pause for each case
• Audit practice of this
• Stock control management
• responsibility and process clear
• barcode system Tesco, Asda etc
• Emergency equipment bag to go
• e.g. PPH off main site

20
Post-operative care

• The film demonstrates a number of possible issues
  with post-operative care ?
• Discuss as a group how your team provides post-
  operative care. What issues does the film raise?
• The following discussion points may be useful

21
Post-operative care

• How are aftercare instructions delivered to the
  ward?
• Are written instructions given for each case?
• Are thresholds for intervention identified- eg if
  BPlt100 then seek medical advice
• Are the common complications of the procedure
  known to the ward?
• How might improvements be made in aftercare
  instructions for your patient groups?

22
Post- Operative Care- Best practice

• Written instructions in the case notes
• Pre-printed version for common procedures
• Is patient going back to most appropriate ward
• Explicit instructions needed
• e.g. can care of the elderly ward manage the
  groin
• Are ward team aware of clinical situation
• Has possibility of HDU / ITU been considered

23
24/7 services

• The film shows difficulty in contacting an
  Interventional Radiologist out of hours
• Consider how out of hours provision is provided
  in your unit
• The following specific questions may be useful

24
24/7 services- discussion

• Does your unit provide robust 24/7 IR services?
• Is there any variation in services OOH?
• Do you have suitable nurse and radiographer
  cover?
• If you cant provide some elements of OOH cover
  do you have arrangements with a neighbouring
  centre?

25
24/7 services - Best practice

• 24/7 cover for all acute sites
• Interventional radiologist (s),Nurse (s),
  Radiographer
• Ensure staffing levels (safety) maintained at
  night
• If not possible make arrangements for network
  cover from adjacent centre(s)
• Has possibility of HDU / ITU been considered

26
Morbidity and Mortality Meetings

• Although not a theme of the film we hope you
  agree cases such as this should be discussed at a
  regular
• M M meeting.

27
MM Meetings- Discussion

• Does your unit hold regular MM meetings?
• Are all staff groups invited and do they attend?
• How do you record results from the meeting?
• Are the results and actions of the meeting
  reviewed?

28
Morbidity and Mortality Meetings

• Suggested minimum standards
• Regular meeting schedule
• Record of attendance
• Structured format
• Structured record and actions consider using the
  methods in the references
• Regular 6-12 month review of previous meetings

29
Resources

• The following resource list may be useful. We
  have provided current copies of the documents in
  a separate folder on this CD when possible.
  Documents are regularly updated and users are
  asked to check on line for latest versions.

30
Resources

• Health Foundation
• Human Factors and systems
• Royal College of Radiologists
• Standards for 24 hour Interventional radiology
  provision. Update 2014
• Standards for patient consent particular to
  radiology, Second edition. Update 2015
• NPSA checklist guidance RCR 2009 (2012 and under
  review)

31
Resources

• Royal College of Radiologists (Cont)
• NPSA RCR checklist RCR 2010 Update 2013
• RCR vascular standards 2011 Update 2014
• Department of Health/ Nat Imaging Board
• Interventional Radiology Improving Quality and
  Outcomes for patients 2009
• Interventional Radiology Guidance for Service
  Delivery 2010

32
Resources

• NHS Improvement
• Towards Best Practice In Interventional Radiology
  2012
• Morbidity and Mortality
• http//www.ahrq.gov/downloads/pub/advances2/vol2/a
  dvances-deis_82.pdf

33
The System

• Full copies of this film are available to BSIR
  members via office_at_bsir.org
• Copies for other organisations may be obtained
  from The Health Foundation info_at_health.org.uk