Supervision for Safety

Aim

It is proposed that the Supervision for Safety project address NSW Health system deficiencies related to supervision at the point of clinical care. Specifically related to ensuring patient care plans are appropriate and deterioration in patient condition is escalated to the most appropriate level.

Benefits

The Supervision project aims to ensure the appropriate support is provided to less experienced clinicians.

The expected project outcomes include:

  • Supervision of the clinical workforce is built into core work practices; 
  • Supervision is structured to allow clinicians to be trained without compromising patient care; 
  • Supervision provided by clinicians at the point of care is appropriate for the level of expertise of the clinicians involved; 
  • Practices are in place to establish the level of expertise of less experienced staff; 
  • Supervision is treated as a skill that needs to be learned by any clinicians providing supervision; 
  • Supervision training should be facilitated for any clinicians providing a supervisory role.

Summary

The Supervision for Safety initiative originated from Recommendation 45 of the Special Commission of Inquiry into Acute Care Services in NSW Hospitals: “NSW Health should ensure within 12 months there is developed and implemented state-wide policies setting out a best practice model for the supervision of junior clinicians.”

Effective supervision comprises three components:

  1. Oversight of the provision of clinical care
  2. Training and education
  3. Administrative support required for the instigation, development and monitoring of supervision.

This CEC project aims to support implementation of effective Supervision of all clinical disciplines.

Background

A patient safety report based on 2008-2009 RCA data and published by the Clinical Excellence Commission in 2012 identified 9 barriers to effective supervision and proposed 17 recommendations.[1]

Follow up review of Root Cause Analysis reports during the period 2011-2013 were aggregated and the 2013 reports available at 21 January 2014 were subjected to content analysis (see figure 1 below). The content repeatedly exposed evidence that there was a failure to escalate deterioration to the Admitting Medical Officer or an appropriately trained delegate and those patients suffered from a lack of input from the senior treating clinician.

Figure 1

Figure 1

The Clinical Focus Report published on the CEC website in 2012 identified 54 RCAs over the period. With exclusions applied, the follow up review included 167 RCAs over nearly three years. Most of the RCAs involved were classified as clinical management (86%). The RCAs were evenly spread over the months of the year although there were a higher percentage of incidents reported in March (16%). In 85% of the 167 RCAs, the patient died and 81% were accounted for in the 51- 90 year age bands. 36.5% (61/167) of the RCAs represented patients over 75. The most reported diagnostic categories included deteriorating patients and sepsis. (See figure 2 below).

Figure 2

Figure 2

Patient care provided by unsupervised staff with limited clinical experience is unsafe and inefficient. Supervision of less experienced or unskilled clinical staff that is inadequate, haphazard, or driven by issues other than those related to patient care or optimum training, is harmful to patients and increases clinician stress and burnout.

Safe clinical care is required to be provided either directly by experienced, skilled staff, or by inexperienced staff under a level of supervision that is appropriate for the patient’s illness and circumstances, and for the level of competence of the staff member performing care.

Less experienced clinicians often form habits from more experienced colleagues who act as surrogate supervisors regardless of their ability or training to provide the supervisory role [2, 3]. Clinicians may also defer to colleagues they perceive to be ‘credible’ regardless of their experience or expertise[3]. Depending on the behaviours this can positively or negatively impact hospital (workplace) culture.

There is no model of supervision that will suit all occasions. Supervision of the clinical workforce must be patient-focused and adapted to meet the local needs of individual clinicians and disciplines,[4] tailored to cater for the needs of the sole clinician in a remote area as well as the clinician in a multi-disciplinary team in a large metropolitan hospital. In addition, it must be responsive to the changing needs of the novice as well as the professional in a novel situation.[4]

The diagnostic phase of the project is underway to determine working supervision models in NSW and identify gaps and potential tool to implement change to the culture around supervision. 

Partnerships

The Supervision for Safety Action Working Group includes representation from:

  • Agency for Clinical Innovation
  • Health Education and Training Institute
  • NSW Ministry of Health
  • Local Health Districts

Key Dates

May 2014Diagnostic data is being collected. Finalisation of this phase is expected in May 2014
May 2014Final external consultation will be extended to all LHDs during May 2014.
June 2014NSW Health policy remains in draft publication is expected in June-July 2014.
August 2014A CEC Implementation handbook is being drafted. Finalisation is expected in August 2014

Pilot Sites

The ACI Respiratory Network is supporting a survey of supervision structures to aid in development of project implementation tools May 2014. This will be followed by circulation to other clinical networks and LHDs via Clinical Governance Units.

Nepean Blue Mountains Local Health DistrictNepean HospitalNepean Hospital is supporting a pilot audit of supervision events during episodes of patient deterioration May 2014

Implementation Sites

Evaluation

Related Initiatives

Further Details

References

  1. Clinical Excellence Commission, Clinical supervision at the point of care. 2012.
  2. Thoms, G., et al., Improving clinical supervision through formal incident reporting. Medical Education, 2012. 46(11): p. 1116-7.
  3. Marshall, A.P., S.H. West, and L.M. Aitken, Clinical credibility and trustworthiness are key characteristics used to identify colleagues from whom to seek information. Journal of Clinical Nursing, 2013. 22(9-10): p. 1424-33.
  4. Wagner, S., et al., A Report: Clinical Supervision for Allied Health Professionals in Rural NSW, NSW Institute of Rural Clinical Services and Teaching, Editor 2008, NSW Health: NSW.

Contact

Marghie Murgo
Patient Safety Project Officer
margherita.murgo@health.nsw.gov.au
02 9269 5624

Dr David Storey
Clinical Advisor Patient Safety
david.storey@health.nsw.gov.au
02 9269 5608

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