Staff Sickness Policy

When contacting someone about sickness, it goes without saying that we need to be understanding.

Each department should have a clear reporting procedure – usually to call in at 9 am and speak to the duty consultant or secretary

Need to find out

  • what is wrong
  • how long they are likely to be off work
  • Anything that needs to be picked up while they’re off
  • Discuss how often they need to keep in touch

When they return, they should have a return to work interview

They should fill in a self certification

Short term sickness: <28 days

If frequent ad hoc, may need further meeting, looking for themes in reasons for absence.  May be good to have this meeting with occupational health +/-HR

Fit note: supplied by the GP, addresses how the employer can help with return to work

If an employee does not produce something, this is an unauthorised absence

  • Discuss with HR
  • May result in a disciplinary meeting (they may wish to bring a union rep to this)

Sickness logged by secretary – ensure that she also emails all consultants!

Unauthorised absence (Raj who has gone to India kite surfing)

This is a disciplinary procedure and may result in dismissal – when he has a back to work interview he will definitely want to bring a rep.

HOWEVER it is important to maintain an open mind until all the facts are confirmed…

 

 

Who can help with what/who to delegate to

Matron

  • Lead nurse
  • Responsible for:
    • nurses
    • infection control in the department including the general cleanliness
  • May also be line manager for the ENPs (or they may have their own manager)

ED Manager

May be responsible for

  • Setting priorities
  • Planning for future development
  • Balancing budgets
  • Ensuring value for money and quality in the services provided
  • Rota management/staffing (this may also be covered by an admin person who looks after several departments

Secretary

  • Can contact people on your behalf, ask questions
  • However they may require specific directions
  • Can arrange meetings
  • Book rooms for meetings
  • Contact locum agencies
  • Reply to emails on your behalf

Clinical lead

  • Advice if feel out of your depth
  • May be responsible for your appraisal

Press and Media

Usually the role of the comms department/press department. They have specific training

Key to let them know if there is an SI which may make the news eg death of a child, local celebrity

If as a consultant we wish to become involved in this area, wise to get specific training

If a related question comes up in the viva consider

  1. is this something I could comment on anyway? If not delate/defer to someone who can/is interested eg patient groups
  2. Should the comms department be involved eg a visit to the new paediatric department

 

 

 

 

Advanced Directives

This is probably more relevant to the OSCE but it may come up in the management.  The information is from here

  • The person making the directive must be aged 18 yrs or older
  • The person must be mentally competent when the directive is made
  • The directive must specify the treatment refused
    • It may also specify the circumstances in which the refusal is to apply
  • The person must not have subsequently withdrawn it or appointed an attorney to make the decision
  • The person making the directive has not done anything inconsistent with the terms of the directive
  • The individual lacks capacity to make decisions at the time the directive is invoked.

The directive must be

  • Written down
  • Clearly indicate that it is to apply even if life is at risk
  • Signed and witnessed.

 

Tarifs

So… haven’t quite managed to persuade myself to look at this document yet but the link is here

 

Quality Indicators in the ED

Announced in 2010, implemented from April 2011.

 

  1. Ambulatory Care

Initially focused on

Cellulitis

Deep vein thrombosis

Both these conditions had >60% potential to avoid admission if used appropriately

Review and assess the way we manage these cases and attempt to embed ambulatory care into departmental practice

Achieving

Liaison with medicine if they already have a dedicated ambulatory care area

Correctly classifying the patients who reattend eg for abx for cellulitis

 

  1. Unplanned re-attendance

Should be between 1-5%

  1. Total time spent in the ED

Should be <95%

The single longest wait should be no more than 6 hours – this includes patients waiting for a level 1 bed

  1. Left without being seen

>5% is an area of risk, patients who leave the ED before the required detailed formal clinical process is completed are known to be at risk of adverse events

 

  1. Service experience

will look at – steps which have been taken regularly to assess experience of the ED or UCC

  • what has been done to improve services
  1. Time to initial assessment

Full initial assessment for cases arriving by ambulance – should be within 20 mins of arrival or handover by ambulance crew

 

  1. Time to treatment

Should not be >60 mins, median time reported

Rate of missing data should be <5%

***Avoid use of hello clinician who adds little value ***

Should not use junior staff who lack the experience to make definitieve clinical decisions

Avoid excessive front loading

 

  1. Consultant sign off

This now includes 4 main groups

Chest pain in >30 yr olds

Febrile illness in <1 yr old

Abdominal pain in adults >70 years old

Unscheduled returns (with the same complaint) within 72 hours

 

How can we achieve these?

 

 

 

 

 

 

 

Making a Business Case

Details of the developer and other partners to the schemeKey areas to include:

  • Background
  • Executive summary
  • Strategic context
    • for example will help meet performance targets, will help patient safety
  • Development proposal
    • Brief description of the options
  • Preferred option
    • Reasons for choosing the preferred option
  • Details of the proposed development
  • Details of the developer and other partners to the scheme
  • Legal and financial implications and affordability:
  • Funding options
    • Details of funding streams to be provided for the scheme, e.g. 3PD, Local Authority grants, private loan arrangements, lease rentals from proposed tenants, etc
  • Timetable
  • Management arrangements
  • Other resource implications
    • Need for additional clinicians, administrative staff, etc
  • Risk assessment
    • An assessment of any factors that are likely to have a significant impact on the scheme
  • Key benefits and outcomes
    • Summary of the main beneficial aspects of the development scheme including improvements in patient satisfaction, quality of care, staff morale, operational aspects such as faster response to enquiries to patients, communications etc
  • Conclusion
  • Appendices

**Taken from ‘The Knowledge’ management booklet**

Example management exam questions:

  1.  You are keen to have a CDU in your department as you feel that it would help.  Currently all patients are referred to the medics/surgeons or breaching if they go beyond 4 hours

Answer

Background: this is quite a common solution that many departments have used to address their 4 hour wait.  Unfortunately it is not always possible to process patients in 4 hours.

Executive summary: Summary of all the points below

Developmental proposal: the options available

  1. Ward style option: beds, toilet facilities, fully nursing staffed.
  2. Chaired area only for patients expecting to go home but awaiting results or attending for ambulatory care.
  3. Combination of the two options

Preferred option: will entirely depend on the demographics and acuity of patients who are waiting in the department more than 4 hours.  Is there a bed issue with inpatient specialties?  In which case it could be argued that funding for another ward would be better spent on inpatient beds and a chaired area is appropriate.

Details of the proposed option – need to go into considerable detail with regard to funding, plans, where, when, how, staffing,

Legal and financial implications and affordability – this will be where the business manager can help!

Funding options: again where the business manager can help!

Timetable

Management arrangements: likely to be managed by the ED but there may be a shared space arrangement

Other resource implications e.g. need for additional staff (medical, nursing, clerical)

Risk assessment: would be tailored individually

Key benefits and outcomes: in this case – better flow, better morale, better patient care,

Conclusion

Appendicies

 

 

Recruitment and Assessment

Consultant interviews

NHS Appointments of Consultants Regulations 1996

  • Minimum of two adverts
  • Interview panel should contain a lay member, External professional assessor (college representative), Chief executive (or deputy), Medical director (or deputy), Consultant from the trust (same speciality), Medical school representative (if teaching position), Human resources representative

 

Work placed based assessments

These are a form of formative assessment consisting of mini-CEX, DOPS and CBD examinations.

Strengths

  • Can explore all of the areas on Millers pyramid
  • Can be learner-led but can also be trainer-driven
  • They provide a structure to inform debriefing through a series of carefully worked out descriptors that can be used consistently be different observers
  • They reinforce an educational culture
  • Identify trainees who are struggling and are in need of extra support early in training
  • It identifies areas for improvement that are based on supportable evidence
  • Can be used to sample widely across different workplace tasks relevant to the overall curriculum
  • Offer the possibility to engage with a range of different assessors
  • A series if WPBAs inform assessments of learning, which are essential waypoints for the judgement on progress throughout training
  • Should be used together with more traditional summative assessments of learning

 

Limitations

  • Not sufficiently reliable to stand alone and as such need to be used together with end-point high stakes ‘know how’ and ‘show how’ assessments of learning
  • May be used opportunistically rather than in a planned manner
  • Low scores tend to be seen as a failure by trainees rather than assessment for learning opportunities
  • WPBAs may be performed late during a training period as so avoid the potential for learning (used summatively rather than formatively)
  • Early success with WPBAs may de-motivate trainees
  • There is clear evidence that weaker trainees are the least likely to seek feedback and therefore they need to be closely monitored through a structured learning plan
  • They are time consuming
  • Some assessor judge in relation to where assessors should be in their opinion at that point in their training rather than the endpoint of a particular stage of training
  • Making negative judgements is culturally difficult for trainers unless support is in place for them as well as the trainees

 

 

 

Consent and Capacity

Capacity

Mental Capacity Act

  • Presumption of capacity unless established otherwise
  • Implied consent for areas such as venepuncture, physical examination, small wound closure, ECG recording may be demonstrated by cooperation with the procedure
  • Treatment may be provided without patient consent provided the treatment is immediately necessary to save life or prevent serious deterioration
  • Persons detained under MHA on ground of mental illness may be treated without consent for mental disorder
  • Physical health problems related to mental disorder may also be treated
  • If short term restraint is required in the ED, this is restriction rather than deprivation of liberty (therefore don’t usually need to fill in DOLS paperwork

 

Determining Capacity

  1. Understand the information given to them that is relevant to the decision
  2. Retain that information long enough to be able to make the decision
  3. Use or weight up the information as part of the deciosn making process
  4. Communicate that decision

 

Capacity to consent may be may be affected by many factors, however all practical and appropriate steps should be made to give a patient the best chance of being able to make a decision

 

A person may make a decision which is considered to be unwise by others if they have the capacity to do so, although a decision of this kind should prompt a re appraisal of reality and ensure that the patient is not delusional.

However if the person has capacity their decision must be respected even if this may result in the death of the person or unborn child

 

If a patient is lacking ability to make a decision or it is not possible to obtain consent, treatment can be provided without patient consent provided that the treatment is immediately necessary to save life or prevent serious deterioration. A presumptoms should be made in favour of provided life sustaining treatment.

 

All relevant information should be considered including patient’s past wishes, a valid and applicable advance refusal of treatment, their beliefs and values, and any other factors the patient may consider if (s)he were able to do so.

 

The views of others should also be taken into consideration:

  • Next of kin
  • Carers
  • Person with LPA
  • Deputy appointed by the patient by the court

 

Best interests decision may also include with holding or stoping treatment

 

Consent

Only the patient can consent to procedures. We should ensure that any consent decision was made by the patient and that they were not under undue pressure by family or others.

 

The Bolam test:

Should advise the patient of all significant possible and and/ or unavoidable risks however unlikely, the potential benefits of treatment, the risks incurred by doing nothing.

 

Clinician responsible for providing the treatement is responsible for ensuring that valid consent has been obtained.

 

A competent patient can withdraw consent at nay time; their wishes must be respected.

 

Even if the patient does not wish to know, enough info should be given to ensure that a valid consent has been achieved, eg what is likely to be involved, the pain involved and how this will be managed, and any serious risks. Their refusal to discuss should be documented carefully.

 

Children

 

16 – 17 yr olds have capacity therefore can consent to and refuse treatment. Parents may also provide consent on their behalf (under the Children Act). Complex cases may need discussion with Trust Lawyers.

 

However if refuse treatment, this may be over-ruled by the courts if they are likely to suffer harm as a result.

 

Under 16

May consent if they have capacity

Good practice to involve both child and their parents in discussions

Children who lack capacity can be treated if consent is provided by parents, temporary carers, local authorities or courts.

 

Mental Health

Patients detained may be treated for their mental disorder. Physical problems may be treated if they are part of the mental illness.

 

However it cannot justify treatment for physical conditions unrelated to the mental disorder. If necessary and cannot wait until the mental illness has been treated, capacity should be carefully considered, if no capacity treatment should proceed.

 

 

 

Police and the Emergency Department

GMC Guidance:

  • Confidentiality is central to trust between drs and patients; however appropriate information sharing is essential to efficient provision of safe effective care for patient and wider community
  • Disclosure may be justified if failure to disclose may expose others to a risk of death or serious harm. Should always seek patient’s consent however
    • This is particularly pertinent if others remain at risk especially children
    • You should inform the patient before doing so if practicable and safe, even if you are going against their consent
  • Knife crime: inform the police quickly whenever a person arrives with a gunshot wound or an injury from an attack with a knife, blade or other sharp instrument
  • Should make a professional judgement about whether disclosure of personal information about a patient including their identity is justified in he public interest
  • The police are considering
    • Risk of further attack
    • Risk to staff, patients and visitors to the ED (eg during the troubles sometimes paramilitaries would send members to finish their victims off…)
    • Risk of another attack near to or at the site of the original incident
  • Don’t usually need to disclose personal information in the initial contact

 

Disclosing without consent

  • If the patient is unable to consent, information can be disclosed if it is justified in the public interest eg.
    • Failure to disclose may put the patient or someone else at risk of death or serious harm
    • Disclosure is likely to help in the prevention, detection or prosecution of a serious crime
  • If there is any doubt a decision can be made in conjunction with the consultant in charge or the trust Guardian
  • Should tell the patient that you have disclosed to the police unless you believe that this will put you or others at risk or will undermine the purpose of the disclosure
  • Document in the notes
  • If not public interest, don’t disclose – police can seek an order from a judge or a warrant
  • Should document if further investigation is required eg if are fit to hold a firearms license

Children – if arrive with gunshot or knife would will trigger appropriate child protection concerns and management

 

Also need to be aware of children in DV incidents

Disclosures required by statute

  1. known or suspected case of certain infectious disease
  2. regulatory bodies with powers to access records as part of duties to investigate complaints, accidents or health professional’s fitness to practice
  3. Should try to get consent where possible

 

Disclosures to court

  • if ordered by a judge or presiding officer, but only if relevant – if not about specific case (i.e. about a relative) can object
  • Should not disclose without patients’ express consent unless required by law or justified in public interest

 

Disclosures about patients who lack capacity

  • make care of patient first concern
  • respect the patient’s dignity and privacy
  • support and encourage the patient to be involved in decision
  • Also consider if lack of capacity is permanent or temporary
  • consider previously expressed preferences
  • any legal/power of attorney
  • views of relatives
  • what the rest of the healthcare team feel
  • May need to share personal info with relatives but should only share what is strictly necessary

Disclosures if patient is a victim of neglect or abuse

– if patient lacks consent should share

 

MPS factsheet

  • should tell the patient you are disclosing where possible
  • should not disclose info about an identifiable 3rd party who is not a healthcare professions

 

Disclosures required by statute

  • NHS counter fraud
  • Disclosures to GMC
  • Coroners investigations
  • Courts or litigation – see GMC guidance

 

Disclosures to protect the patient or others from harm

  • serious communicable disease
  • reduce risk of death or serious harm to patient or third party
    • g. because of gunshot or knife wounds
    • NB document, seek advice

 

Reporting to the DVLA

 

DVLA and DVA are largely responsible for deciding if a person is medically unfit to drive

DVLA publishes an extensive list, however their medical advisors are also available for advice if this is required

You should inform the patient that the condition may affect their ability to drive and that they have a legal duty to inform the DVLA about the condition. If the patient is uncapable of understanding, the DVLA should be informed immediately

If the patient continues to drive and you are unable to persuade them to do so, or if you discover they are driving, you should contact the DVLA. However you should inform the patient of your decision.

 

Doctor in Difficulty

Patient safety is main concern

Other considerations:

  • Periods of transition can be associated with a deterioration in clinical performance
  • Serious performance issues are rare
    • NB these often have a complex background
    • Take advice and seek support

General Principles

  • Early identification of problems and intervention is essential
    • Disappearing
    • low work act
    • ward rage
    • Rigidity
    • bipass syndrome – nurses and juniors avoid seeking the doctors opinion
    • Career problems
    • Insight failure
    • lack of engagement in educational processes
    • Lack of initiative/appropriate professional engagement
    • inappropriate attituesa
  • Establish and clarify the circumstances and facts as quickly as possible
  • Remember poor performance is a ‘symptom not a diagnosis’
    • explore the
      • clinical performance of the individual
      • personality and behavioural issues
      • sickness/ill health
      • environmental issues
    • If correct diagnosis made, can get effective remediation
    • Document clearly
    • Communicate misgivings

Traffic light framework

screenshot-2015-04-15-08-30-16

A Diagnostic framework…

screenshot-2015-04-15-08-13-51

Advice to manage

  • Clinical performance
    • focused retraining
    • extended period of clinical supervision
  • Personality and behavioural issues
    • clinical supervision
    • developmental mentoring
    • Feedback using video etc
  • Health issues
  • Environmental issues
    • lack of resources
    • unrealistic work demands
    • poor clinical management
    • poor support
    • substandard working environments

 

HEKSS Trainee Support Guide

Concerns may come through a number of ways…

  • professional examinations
  • regular NHS appraisals
  • assessments
  • clinical governance frameworks
  • clinical audit activities
  • litigation
  • information from colleagues
  1. Explore concerns

Unless serious, educational supervisor is best placed to deal with initial concerns

Also need to discuss with TPD

Should also discuss with the trainee in order to get their perspective

 

  1. Agree a plan (SMART)

Record the meeting and plan advised

SMART:

Specific

Measurable

Achievable

Realistic

Time scale

3. Pass on information

To the deanery

 

  1. Address issues

screenshot-2015-04-15-08-33-57

 

screenshot-2015-04-15-08-34-17

screenshot-2015-04-15-08-34-29

screenshot-2015-04-15-08-34-50screenshot-2015-04-15-08-34-40screenshot-2015-04-15-08-34-50

screenshot-2015-04-15-08-35-00

 

Good record keeping

 

Trainee should be made aware of any discussions and should be given a copy of any documentation

 

Trainees in difficulty should be discussed at LFG

Role of Supervisor

  • Address the issue as soon as possible
  • take more formal steps if any concern about patient safety
  • look beyond to try to establish the underlying cause
  • focus on evidence and facts
  • share information on a need to know basis

Employer

needs to deal with employment issues inc performance, grievance, discrimination, whistleblowing and potential disciplinary matters are dealt with appropriately

 

HEKSS should be informed if

  • progression is likely to be affected
  • issues which may have an impact on revalidation
  • additional funding required
  • trainees at risk of receiving an unsatisfactory outcome at ARCP

TSS offers guidance and retraining

 

3 tiers of support

  • Educational supervisors in each of trusts +/- College Tutors
  • Programme leads/DMEs
  • HEKSS careers team

 

Doctor in difficulty: locum (my own strategy)

  • Checks before:
    • Ideally use Dr known to department – either trust bank or previous trainee
    • CV
    • Using a reputable agency
    • Ensure no current issues/concerns before employing
    • Some departments have policy to employ locum initially during the day to ensure that is supervised before allowing to work the night
  • If problem has occurred
    • Pull notes of the patient plus others which (s)he has seen
    • Is there a clinical issue
      • Pure clinical
      • Poor communication
      • Missunderstanding
      • Blind spot/lack of knowledge
      • Not listening to advice given (I would classify this as the most serious)
    • Probity
  • Consider if should continue to work in the department until this has been resolved
    • If suspending them, inform other consultants!
    • Work with supervision?
    • Day shifts only?
    • Inform the RO for the agency to ensure that they are aware and can address this training need

 

Consultant colleague in difficulty

Less likely to come up in viva as usually dealt with by clinical lead

However key features include

  • Patient safety is paramount
  • Discretion
  • Responsible officer
  • Occupational Health where appropriate

 

When should a Dr be suspended?

Haven’t managed to find a reference for this

  • If involved in a SI/never event?
  • Lots of incidents
  • Locum
  • Any other ideas?

 

 

 

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