Improving Nurse Record KeepingNORTHERN IRELAND

NURSING/MIDWIFERY AGENCY EVENTFRIDAY 25TH JANUARY 2013

The quality of a registrants record keeping is a reflection of the standard of their professional practice. Good record keeping is a mark of a skilled and safe practitioner, while careless or incomplete record keeping often highlights wider problems with that individual's practice.’ (NMC 2007)

NMC Fitness to Practice Hearings

Failure to Maintain Adequate records06/07: 7.48%

07/08: 10.37% 08/09: 8.53%09/10: 9.57%

10/11: 4%(10/11 No. 6 frequently occurring)

Incomplete records through poorly documented:

• Admission / discharge arrangements• Risk assessments• Essential monitoring reports• Engagement with family members• Engagement with other professionals

Themes Arising from Northern Ireland Public Inquiries 2003 - 2008

Recommendations:

3 –Trust Board must review governance arrangements and satisfy itself that it is meeting in full its responsibilities for patient safety, quality of care and record-keeping.

Public Inquiry into the outbreak of Clostridium Difficile in Northern Trust Hospitals. (2011).

January 2009 Purpose Meeting

Literature Review: Factors Influencing Quality of Registrant Record Keeping

The Value and Purpose of Record Keeping

Audit

Information Recorded

Competence to Record

Professional Supervision

Patient Awareness/ Inclusion

Issues Related to Time

….to develop tools for registered nurses that will facilitate

improvement in record keeping.

Piloting the Practice Improvement Programme

Choice of Wards• 5 Medical wards

Improvement Achieved

Learning and Development•Team development•Leadership development•Networking•Shared vision•Championing good practice•Proactive in changing practice•Learning and development in practice

Percentage Increase June 2009 – April 2010

  % Increase

Admission & Risk Assessment 11.4

Admission & Risk Assessment (N/A) 25.2

Care Planning 42.4

Care Planning (N/A) 37.4

Discharge Planning 32.9

Mandatory Requirements 41.2 Health Care Support Worker, Student and Error Entries 50

Ave. Total % Inc 34.4

Baseline measurement and continuous audit

Implement learning and development

activities or development of practice activity

Improvement Cycle (Adapted from Deming, 2000)

Re-auditCompare analysis

Sustaining improvement

Four Sections:

Each Section has a Corresponding Section of:

Section 1

Section 2

Section 3

Section 4

Aim:To implement an agreed Regional HSC

Nursing Document, and improvement methodologies, tools and resources developed during the RRKI to facilitate improvement in the standard of nurse record keeping in Northern Ireland and to promote a culture which supports person-centred record keeping practices.

Chair: Alan Corry-Finn, WHSCTProject Lead NIPEC: Angela DrurySteering Group members:Royal College of NursingRoyal College of MidwivesQueens University BelfastClinical Education CentreWHSCT, SEHSCT, NHSCT, BHSCT, SHSCTDHSSPS2 Executive Directors of Nursing

Two strands:• Facilitated within HSC Trusts ( 5

Secondment Band 7 Professional Officers – one in each Trust)

• Strand 1: Piloting a new document and development of standards for nursing and midwifery record keeping practice

• Strand 2: Implementing the Record Care tools and resources

• Evaluative methods being used throughout the project

• Final report

• Intended outcome = improved record keeping practice evidenced through audit scores

Paula Boyle SHSCT

Jane PattersonSEHSCT

Sandra HoggWHSCT

Siobhan ShannonNHSCT

Sonya McVeigh BHSCT

Angela DruryNIPEC(Lead Officer)

Progress so Far

• Trusts have implemented the new document• Workshop undertaken in November to evaluate

and refine document• Stream lining of risk assessment tools• Standards production and consultation• Practice Improvement Programme being

implemented• Monthly audit cycles recording significant

improvement• Future continuation proposal under discussion• Contact with RCN

Progress so Far

• Contact with Nursing banks and Agencies• Contact with Universities and representatives

for pre-registration nursing programmes.

So What? – Implications for Agency Staff

• Raise awareness – feedback from HSC Trusts

• Standards document

• Potential for future work with agency staff in this area of practice

• Access to tools and resources via website