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, AVM`s

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 BP<100 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 can’t 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. M&M Meetings- Discussion • Does your unit hold regular M&M 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/advances-deis_82.pdf

33. The System Full copies of this film are available to BSIR members via: office@bsir.org Copies for other organisations may be obtained from The Health Foundation: info@health.org.uk