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Page 1 of 21 Date Issued: 5th^ October 2018
Accountability Handover Policy
For Registered Health Care
Professionals
(Including Intra-Area Patient Handover / Transfer,
and Handover at a Change of Shift)
Issue Date:
v 2 .0, 13
th
November 2017
v2.1, 5
th
October 2018
Disclaimer Overarching policy statements must be adhered to in practice. Clinical guidelines are for guidance only. The interpretation and application of them remains the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. The Author of this clinical document has ultimate responsibility for the information within it. This clinical document is not controlled once printed. Please refer to the most up-to-date version on the intranet. Caution is advised when using clinical documents once the review date has passed. Clinical Document Template v4.0 12- 05 - 2014
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CONTENTS
SECTION DESCRIPTION PAGE
1 INTRODUCTION 2
2 SCOPE OF DOCUMENT 4
3 DEFINITIONS AND/ OR ABBREVIATIONS 6
4 ROLES AND RESPONSIBILITIES 7
5 NARRATIVE 8-
5.1 Assessment of need 8 5.2 Considerations following accountability handover for intra-ward transfer
5.3 Accountability Handover Sheets and Stickers 9 6 EVIDENCE BASE / REFERENCES 10 7 EDUCATION AND TRAINING 10 8 MONITORING COMPLIANCE 11 9 CONSULTATION 12 10 EQUALITY IMPACT ASSESSMENT (EIA) 12 11 KEYWORDS 12 12 APPENDICES (list)
Appendix A – Supporting Guidance: ED / UCC Handover and Transfer Pathway Appendix B – Supporting Guidance: Ward Shift to Shift Accountability Handover Pathway Appendix C – Supporting Guidance: Ward Transfer Pathway Appendix D – Yellow Internal Transfer Handover Sticker (Representational copy) (FKIN030343) Appendix E – Accountability Handover Record Sheet (FKIN030344) (Representational copy) Appendix F – ED / UCC Internal Transfer Handover Document (Representational copy) Appendix G – Equality Impact Assessment Form
DOCUMENT CONTROL (Last page) 21
1. INTRODUCTION
1.1 Sherwood Forest Hospitals NHS Foundation Trust (The Trust) is dedicated to outstanding care , its shared values and behaviours, to the delivery of high quality safe care. It recognises that the handover of patients forms a key component of high quality hospital care.
1.2 The accountability handover process has at its core a set of practices fundamental in helping to achieve the highest standard of patient centred care.
1.3 It is a tangible recognition or acceptance that nurses adhere to the principle of taking professional ‘ responsibility for the care they provide and answer for their own judgments and actions in a way that is agreed with their patients, and the families and carers of their patients, and in a way that meets the requirements of their professional bodies and the law ’ (Manley et al 2011).
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receive, and increased and unnecessary duplication of questions and therefore negatively affecting their perception of care the Trust provides.
1.14 This policy will also provide guidance to monitor and evaluate if a safe, consistent and appropriate practice standard for handover is being achieved.
1.15 Patient information relating to the care received in clinical areas and if specific key items of care are handed over will be observed.
1.16 Accountability both legally and professionally is required of all registered professionals who are responsible and answerable for their actions and may be asked to justify them.
2. SCOPE OF DOCUMENT
This clinical document applies to:
Staff group(s)
Registered Nurses and Midwives (NMC) including bank and agency staff. HCA’s – health care assistants. Operating Department Practitioners (HCPC registered) AHP’s who are involved in the prescription of treatment and interventions for patients that is required to be handed over.
Clinical area(s)
All in-patient areas at all hospital sites are required to use the accountability handover process when handing over patient care. In-patient areas: (adult and paediatrics, Operating theatres and recovery rooms, Day Surgery Unit, Endoscopy, Cardiac Catheterisation Lab, ICCU, Assessment areas - adults and paediatrics including ED (Emergency Department, Kings Mill), UCC (Urgent Care Centre, Newark) and wards. (Kings Mill Hospital, Mansfield Community Hospital and Newark Hospital).
Documentation
Use of the yellow Internal Transfer handover Sticker (Appendix D) is required for all patients who require transfer of care from one clinical area to another ensuring there is a standardised approach to handing over the fundamental components of information required to enable a safe and succinct handover. With respect to ED, the yellow internal transfer document will be incorporated into the ED specific documentation.
Shift to Shift Handover Accountability Record Sheet (appendix E) must be completed following a decision to admit. It must be completed in entirety prior to a patient transferred to a ward, or within 6 hours of the decision to admit being made. This document must also be completed at bedside shift to shift handover of care. The completed documents will form part of the patient’s integrated record of care and should remain insitu as part of this record. As this document / sheet follows the patient during their in-patient stay it provides a template for ensuring there is a standardised approach to handing over the fundamental components of information required to enable a safe handover.
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ED / UCC Shift handover and transfer process is detailed in appendix A
Ward shift to shift Accountability Handover process is detailed in appendix B
Ward to ward internal transfer process is detailed in appendix C
Patient group(s)
Patients who are being transferred: from ED to assessment areas; EAU, TAU, SAU, AECU, from ED to ward areas, and between ward areas (including to the Discharge Lounge, MCH and Newark) are required to be transferred with an internal accountability handover record and yellow internal transfer handover sticker. to and from theatre, ICCU, Endoscopy, Cath. Lab. occurs using the local accountability handover document incorporated in the specific pathway for each area. from KMH, other NHS organisations and community settings to MCH and Newark a verbal handover is given and recorded on their SBAR profoma.
Exclusions:
The following patient groups are all exempt: o those attending the Trust’s out-patient’s departments for consultations, o and those who are due to be discharged home.
In addition Maternity Unit patients are exempt as this aspect of their care is covered in the following procedural document: o Maternity Unit Guideline for Handover of Care on Site.
It is required that medical staff adhere their specific processes and policy regarding patients that require review or assessment by another speciality or when the care of patients are handed over from shift to shift.
Related Trust policies and guidelines and/ or other Trust documents:
Clinical Record Keeping Standards Policy Medicines Policy Nutrition and Hydration Policy Medical Equipment User Training Policy Medical Device Management Policy Observations and Escalation Policy for Adult Inpatients Escort and Transfer Policy for Adult Patients Handover of maternity Care on Site Guideline
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SBAR Situation; Background; Assessment; Recommendation ED Emergency Department EAU Emergency Assessment Unit TAU Trauma Assessment Unit SAU Surgical Assessment Unit AECU Ambulatory Emergency Care Unit ICCU Intensive Critical Care Unit UCC Urgent Care Centre – Newark
4. ROLES AND RESPONSIBILITIES
4.1 The Chief Nurse is responsible for the content and implementation of this policy.
4.2 Divisional Heads of Nursing are responsible for ensuring that necessary measures are in place to support the safe implementation and monitoring of the use of the policy in practice. They will need to take measures where practice has been deemed potentially unsafe.
4.3 Matrons are responsible for ensuring that all staff accountable to them are aware of this policy and adhere to its standards. It is the manager’s responsibility to investigate and rectify any discrepancies identified.
4.4 Ward Sister/ Charge Nurses/Departmental Leader will act as role models and are responsible and accountable for the policy implementation among staff in practice, and the monitoring of standards and best practice associated with it. They will ensure that all staff in the sphere of their responsibility have access to training to develop the skills and competence, this includes the completion of the associated work books and study sessions in a timely manner. The ward leaders will be expected to complete the monthly nursing metrics without exception to provide assurance of compliance in relation to Accountability Handover. For areas that generate non-compliance ward leaders with the assistance from matrons will be required to formulate an action plan, implement learning and provide feedback where necessary.
4.5 All Registered Healthcare Professionals have, as part of their professional standards both a duty of care to their patients and accountability for their practice standards. This is a requirement of their Regulatory Body in order to practice (in the case of Nursing, the NMC, AHP’s, the HCPC, or medical colleagues the GMC). In addition all registered healthcare professionals are personally responsible and professionally accountable in ensuring that they receive and handover all aspects of patient information that is relevant for the continued optimisation of patient care. It is the responsibility of the registered healthcare professional to ensure the safe transfer of patients from clinical areas to the receiving area either ward area or assessment area. It is also the responsibility of the registered health care professional to ensure that an appropriate handover of a patient’s care to the receiving clinical area occurs prior to the patient leaving the area. It is therefore required of the Registered Member accountable for that patient care’s to delegate and instruct the transfer of patients taking into account the clinical needs of the patient and the competency of those undertaking this activity. Responsibility and accountability for delegation of actions to healthcare support workers remains at all times with the Registered Nurse undertaking the delegation
It is the responsibility of the ward based registered healthcare professional to ensure all relevant transfer documentation is fully completed prior to leaving the clinical area. It is
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the responsibility of the receiving nurse to ensure they have signed the yellow internal transfer accountability handover sticker on receipt of handover.
It is the responsibility of the registered nurse to ensure they have fully completed and signed the Accountability Handover Record Sheet at the point of bedside handover. The receiving nurse will ensure they have assessed agreed and highlighted actions from the given handover and sign in receipt of shift handover of care.
4.6 All Healthcare Support Workers in common with their registered nursing colleagues have a duty of care to their patients and are therefore required to undertake all activities as per the relevant policy. They must ensure that they undertake any activities / actions in accordance with the relevant Trust policy. Those who are directly involved in the transfer of patients under direction of a Registered Nurse must sign the appropriate section of the accountability handover document relevant to that area.
5. NARRATIVE
5.1 Assessment of need
5.1.1 The ‘minimum safe standard’ (Intra-ward Transfer SOP, Accountability SOP) regarding the transfer of patient care and accountability handover between areas / individual practitioners is that a verbal handover of patient information occurs remotely from one registered practitioner to another. For additional guidance see: Appendix A – Supporting Guidance: ED / UCC Handover and Transfer Appendix B – Supporting Guidance: Ward shift to shift Accountability Handover Pathway Appendix C – Supporting Guidance: Ward Transfer Pathway
5.1.2 It is acknowledged that in certain circumstances and clinical areas this is the only feasible method of handover of patient care (eg ED to EAU). This however must occur prior to a patient leaving an area.
5.1.3 This verbal handover will enable staff in the assessment area or receiving ward to forward plan for receipt of the patient and ensure equipment, the environment and appropriate staff are optimised to maximise care standards.
5.1.4 It is the responsibility of the receiving nurse on receipt of the patient and following verbal handover to check and confirm that all of the items that have been handed over are factually accurate ensuring that the verbal account of the patients care is accurate.
5.1.5 In all other instances the transfer of patient accountability between staff, and at handover time, must take place face to face with the nurse handing over care using SBAR principles. The nurse receiving care accepts responsibility and accountability for that patients care at that time.
5.1.6 All staff involved in patient handover are required to ensure that the appropriate handover process is followed and where a patient is transferred to another clinical area / department the appropriate mode of transport, escorting personnel and equipment required for that patient’s needs are utilised and adheres to the processes and guidance described in the Trust’s Escort and Transfer Policy for Adult Patients
5.1.7 In instances where a non-registered staff member undertakes handover face to face in the absence of a registered colleague, a verbal handover between registered staff in the
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6. EVIDENCE BASE / REFERENCES
NMC (2015) The Code: professional standards of practice and behaviour for nurses and midwives
NMC (2013) Accountability and delegation: What you need to know.
NMC (2015) Accountability and Delegation A Guide for the Nursing Team.
NMC (2010) Standards for Competence for Registered Nurses.
Intensive Care Society (2009) Levels of Critical Care for Adult Patients
Manley (et al 2011) Principles of Nursing Practice: Development & Implementation Nursing Standard 25 (27).
http://www.npsa/nhs.uk/ - National Patient Safety Agency
7. EDUCATION, MANDATORY TRAINING AND REGULATION
Accountability handover as a Trust priority is a process that is discussed with new employees during nurse / HCA on induction sessions. In addition it is embedded through other training that is attended by nursing staff: nurse focus days. It is an area where audit is conducted monthly, results are fed back to ward leaders and Matrons with support and educational input provided where necessary.
Trust Registered Nursing Staff
All registered nursing staff are required to familiarise themselves with this policy, the process involved in accountability handovers and must read and sign the induction pack that is available on every clinical area. If there are any items of that require clarification / explanation it is the responsibility the registered nursing staff member to discuss it with the Ward Sister / Charge Nurse or his or her deputy.
Non-compliance with the process will result possible disciplinary action by means of the Trust disciplinary process. All registered staff hold the responsibility for assessing patients for transfer and identifying the appropriate escort and method of transport which should be recorded on the yellow internal Accountability Handover sticker.
Agency Nursing Staff
All registered nurses are accountable for their practice and should adhere to the Code of Professional Conduct governing fitness to practice. They are required to adhere to the practices involved in handing over of patients to registered colleagues and ensuring that the information, actions and omissions are correct and does not compromise patient care or confidentiality.
“Lack of knowledge, skill or judgement which means a nurse or midwife is unfit to practise” and “Lack of competence is a lack of knowledge, skill or judgement of such a nature that the nurse or midwife is unfit to practise safely.”
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Nurses or midwives who are competent and fit to practise should: have the skills, experience and qualifications relevant to the part of the register they have joined. Demonstrate a commitment to keeping those skills up to date, and deliver a service that is capable, safe, knowledgeable, understanding and completely focused on the needs of the people in their care” (NMC 2010)
Student Nurses
A student nurse is as part of his/her training programme / progression towards registration required to achieve set objectives as laid down by their academic institution / university. It is encouraged that as part of this process, student nurses actively involve themselves in the process of undertaking accountability handover for patients. Accountability for the process even though it is undertaken by the student nurse remains with the responsible Registered Nurse.
8. MONITORING COMPLIANCE
Minimum Requirement to be Monitored
(WHAT – element of compliance or effectiveness within the document will be monitored)
Responsible Individual
(WHO – is going to monitor this element)
Process for Monitoring e.g. Audit
(HOW – will this element be monitored (method used))
Frequency of Monitoring
(WHEN – will this element be monitored (frequency/ how often))
Responsible Individual or Committee/ Group for Review of Results
(WHERE – Which individual/ committee or group will this be reported to, in what format (eg verbal, formal report etc) and by who)
Incident themes and trends involving accountability handover/ handover reported will be categorized according to level of risk.
Divisional Governance Teams
Incident reporting: Datix
As required Divisional Governance Forums
Compliance with handover documentation standards
Ward leaders/ Matron
Nursing Metrics Monthly Ward assurance Forum
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Supporting Guidance: ED/UCC Handover and Transfer Pathway
Appendix A
All patients who present to ED: Accountability for patient care rests with the nurse allocated to care for that patient whilst they are in ED or UCC. Completion of the accountability handover section incorporated onto the front sheet of the ED paperwork must be completed. Shift to shift Handover: When patient care is handed from one nurse to another nurse (minors to majors, majors to the resuscitation area or shift to shift) the accountability handover section incorporated on the front sheet of the ED paper work must be completed.
For all ED patients that are discharged : The discharge section found in the back page of the ED paperwork must be completed.
For all patients admitted: Transferring and receiving areas will liaise with each other to confirm ability to accept patient. The nurse in charge of the patients care is responsible for ensuring the yellow accountability transfer section (found on the back page of the ED documentation) is fully completed in preparation for the transfer (appendix F). The RN in charge of the patients care will undertake an assessment of the patient to determine which type of escort is required for transfer in line with the Escort and Transfer Policy for Adult Patients****. This will then be documented upon the yellow accountability transfer document found on the back page of the ED paperwork.
Telephone Handover from RN to RN if Patient Does not Require Nurse Escort: It is the responsibility of the RN in charge of the patients care to provide a verbal handover using the SBAR format.
Handover to Receiving Ward: Handover will be given by the transferring escort using the yellow accountability transfer document. The receiving area MUST sign the yellow transfer document following handover of care (appendix F).
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Following the verbal handover the RN handing over the patients care
and the RN accepting the patients care must sign the Accountability
Handover Record Sheet (Appendix E) in order to complete the
handover process.
Supporting Guidance: Ward Shift to Shift Accountability Handover Pathway:
Appendix B
All patients that are admitted on to a ward area: As part of the admission process the Accountability Handover Record Sheet (appendix E) must be completed. It must be completed in its entirety prior to a patient being transferred to a ward area or within 6 hours of the decision to admit being made. The bedside Handover must occur immediately after the ward safety briefing
Shift to shift handover. Verbal: Introduce on-coming RN to patient at the bedside, informing them you are handing over care.
Liaise with patient and reassess pain score and analgesia control.
Handover any key events from previous shift using SBAR.
Agree clinical condition of patient by performing visual assessment and NEWS check.
Handover if any amendments are required to plan of care or frequency of care.
Handover any risk assessments that will require implementing/ammending. For example: falls, bedrails, Enhanced Observations, VIP score etc
Agree foreseeable key actions for receiving RN.
Documentation Check:
Electronic observations and escalation (agree escalation status).
Medication Chart (checking infusions, rate, prescription. Check for any omissions taking particular note of critical medications)
Ward Safety Briefing: Handover of all patients to all staff who are due to commence the next shift. Critical information should be discussed – any key events from previous shifts, NEWS, Falls, Pressure Damage, deterioration or AND.
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Internal Transfer Handover Sticker (Ward) (Representational copy)
INTERNAL TRANSFER ACCOUNTABILITY HANDOVER STICKER
S
Presenting Complaint / Diagnosis: Relevant History / Treatment Plan:
B
Allergies: Red allergy wrist band in situ? Y / N White wrist band : Y / N Is the patient at risk of falls? Y / N Has the patient fallen within the last 72 hrs? Y / N
A
Has an Enhanced Patient Observation Risk Assessment been performed? Y / N Level: Normal Close Constant Has an Enhanced Patient Support Risk Assessment performed?Is the Patient fit to ‘OUT-LIE’^ as Patient Outlier Policy & Decision Tool? Y / N / NA^ Level: Y / N Pressure area Assessment: Safeguarding Concerns and actions: Sepsis Screening Tool Completed? Y / N (^) Mobility Status: Does this patient have capacity? Y / N (^) Infusion details : Is this patient confused? Y / N Blood Glucose Level: Catheter i n s i t u Y / N Transfer NEWS score: Isolation Required Y / N Resuscitation Status FULL / A.N.D. Ward Specific Information: R Recommendations, Omissions^ &^ Outstanding:
I have assessed this patient & confirm they may be transferred without the accompaniment of an RN. Date: Time: Signed: (RN) Print: (RN) Patient must be electronically transferred to the receiving area’s holding bay on Medway PAS prior to leaving the ward: I have^ Y / N provided a verbal handover for this patient’s care to the receiving ward and transfer responsibility & accountability for their care to the receiving RN. Transferring Nurse Signature _____________RN initials____________Date___________Time__________Ward_____ Receiving Nurse Signature ______________RN initials___________ Date____________Time___________Ward______ Version 4, March 17. FKIN
Appendix D
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Accountability Handover Record Sheet (Representational copy)
Appendix E
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Appendix G – Equality Impact Assessment (EqIA) Form (please complete all sections)
Name of service/policy/procedure being reviewed: Accountability Handover Policy for Registered Healthcare Professionals New or existing service/policy/procedure: E xisting Date of Assessment: 21/11/ For the service/policy/procedure and its implementation answer the questions a – c below against each characteristic (if relevant consider breaking the policy or implementation down into areas)
Protected Characteristic
a) Using data and supporting information, what issues, needs or barriers could the protected characteristic groups’ experience? For example, are there any known health inequality or access issues to consider?
b) What is already in place in the policy or its implementation to address any inequalities or barriers to access including under representation at clinics, screening?
c) Please state any barriers that still need to be addressed and any proposed actions to eliminate inequality
The area of policy or its implementation being assessed: Wh ole policy
Race and Ethnicity: Nil Not applicable None Gender: Nil Not applicable None
Age: Nil Not applicable None
Religion: Nil Not applicable None
Disability: Nil Not applicable None
Sexuality: Nil Not applicable None
Pregnancy and Maternity:
Nil Not applicable None
Gender Reassignment:
Nil Not applicable None
Marriage and Civil Partnership:
Nil Not applicable None
Socio-Economic Factors (i.e. living in a poorer neighbourhood / social deprivation):
Nil Not applicable None
What consultation with protected characteristic groups including patient groups have you carried out? None required
What data or information did you use in support of this EqIA? Job descriptions for registered professionals who will be using the policy – focusing on communication
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NMC requirement for language skills
As far as you are aware are there any Human Rights issues be taken into account such as arising from surveys, questionnaires, comments, concerns, complaints or compliments? No
Level of impact From the information provided above and following EqIA guidance document (insert link), please indicate the perceived level of impact:
Low Level of Impact
For high or medium levels of impact, please forward a copy of this form to the HR Secretaries for inclusion at the next Diversity and Inclusivity meeting.
Name of Responsible Person undertaking this assessment: Alison Davidson
Signature: Alison Davidson
Date: 21/11/
