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Working environment

Policies, protocols and guidelines

Doctors have a professional duty to care for the safety and wellbeing of their patients. Although good diagnostic and therapeutic skills are important in this regard, they can be let down by a poorly designed office environment, incompetent or uncaring staff, or an absence of clear and workable policies, protocols or guidelines to support your clinical work. If you arrange lab tests for a patient, for example, you need to feel confident that you will immediately be aware of any significant results.
Doctors have a professional duty to care for the safety and wellbeing of their patients

Years of research and development in clinical risk management have demonstrated how protocols and recognised guidelines can help to control some of the most risky areas of practice (such as repeat prescribing and following up test results). We would advise you, though, not to introduce so many protocols that they become confusing or hard to remember, or prohibit the exercise of judgment where this may be necessary.

It is best to introduce a judicious mixture of policies (which set out the guiding principles for staff to apply when exercising their judgment), protocols (which are a series of steps that must be followed without deviation) and guidelines (a description of the practice’s preferred method of performing a task, or series of tasks).

Policies

Policies are broad statements about principles, coupled with guidance for staff on how they’re expected to comply with those principles. A confidentiality policy, for example, might start with a statement that the practice respects and upholds the principle of patient confidentiality, and why.

Try to make the policy as succinct as possible
It might then go on to describe in broad terms what this means in practice – eg, that all staff must sign a confidentiality agreement and that breaches of confidentiality are treated as serious offences; that patient information is not to be shared with third parties without the patient’s consent; that information is only to be shared within the healthcare team on a need-to-know basis; that records are to be kept securely, etc.
Try to make the policy as succinct as possible; save the finer details of implementation for your protocol and guideline documents. Some of the areas for which you will need policies are listed in Box 9.

Box 9: Policy areas

  • Confidentiality
  • Chaperones
  • Aggressive or violent patients
  • Child protection
  • Delegation and supervision
  • Employing locums
  • Advertising
  • Relationships with service suppliers
  • Complaints from patients and carers.

Protocols and guidelines

The difference between a protocol and a guideline is not always clear, the two words often being used interchangeably. For the purposes of this booklet, however, we make the following distinction:

Protocols provide staff with step-by-step rules that they must follow without deviation. They lend themselves to administrative systems that (a) can easily be standardised, and (b) represent an area of high risk for patients.

Protocols provide staff with step-by-step rules that they must follow without deviation

Protocols provide staff with step-by-step rules that they must follow without deviation. They lend themselves to administrative systems that (a) can easily be standardised, and (b) represent an area of high risk for patients.

The most obvious of these is test results, which are often implicated in incidents of avoidable harm to patients (see the case report "A missed opportunity" for an example).

Guidelines are less prescriptive descriptions of the general approach to take when dealing with situations where more variables are likely to be encountered. They allow more room for personal and professional judgment.

Guidelines are less prescriptive descriptions of the general approach to take when dealing with situations where more variables are likely

A guideline for obtaining consent to treatment is a good illustration of this: as each patient’s circumstances is different, a step-by-step rigid protocol would not be flexible enough to accommodate those differences.

A guideline, on the other hand, would make sure that you covered essentials like satisfying yourself that the patient has decisional capacity and ensuring that all the material risks and benefits have been discussed and noted in the patient’s records, without dictating exactly how you should go about it.

Case report: A missed opportunity

Mrs A, a 34-year-old school secretary, attended a new GP practice when she moved house. As part of her routine new patient health check, she had her urine analysed by the practice nurse and proteinuria +++ was detected. Dr D saw Mrs A immediately after this and issued a repeat prescription for her long-term antidepressant medication. No comment upon the proteinuria or a plan of investigation was recorded in the notes.

Dr D saw Mrs A one month later when she was having difficulty coping in her job due to depression and a family crisis. Again, no comment was passed upon the proteinuria. Seven months after this, Mrs A came to see Dr E as she had suffered a few days of urinary frequency and urgency with dysuria. Dr E prescribed a course of trimethoprim, but did not ask for a urine sample. Dr E’s record made no reference to the proteinuria detected at registration, so presumably he had not noticed.

Mrs A saw Drs D and E for a range of unrelated minor complaints over the next three years. After an acute illness she was admitted to hospital and found to be suffering from acute-on-chronic renal failure of uncertain aetiology. Her condition progressed over the next few years to end-stage renal failure requiring dialysis, and ultimately she had a successful renal transplant. Mrs A started a legal claim against both doctors, alleging negligence in failing to take notice of, or act upon, her significant proteinuria when she first registered with the practice.
No comment upon the proteinuria or a plan of investigation was recorded in the notes

Expert opinion

A GP expert thought the practice’s system for reporting new patients’ abnormal urinalysis results was extremely flawed.

Often the nurse wrote up her notes whilst the patient saw the doctor, and this information was placed in the file later.

Dr E was criticised for not looking back to check the recent urinalysis that he knew would have been conducted at the registration visit, when he saw Mrs A shortly after with a urinary complaint.

Even if he had not done this, it was felt that repeat urinalysis and urinary culture should have been performed, given Mrs A’s symptoms. The case was settled for a moderate sum.

Dr E was criticised for not looking back to check the recent urinalysis that he knew would have been conducted at the registration visit

Learning points

  • Urinalysis is an extremely useful and inexpensive screening tool in both primary care and hospital outpatient/emergency settings for detecting occult diabetes or urinary-tract pathology. Unfortunately, its widespread use often leads to it being overlooked, being seen as something “that is just done”. It should be considered as an investigation result like any other, and failure to act upon an abnormality can lead to missed opportunities to treat or prevent serious disease.
  • It is important to have systems in place that allow all the relevant information from a patient’s previous consultations, diagnoses, medication and recent investigations to be taken into account during a consultation. This is particularly important when patients first attend a practice, as information lost at this stage may cause and compound error in future visits.
  • Dr E was criticised for not checking back to a previous consultation. It is good practice to review quickly what happened the last couple of times the patient was seen, particularly when seeing a new patient.

Further information

A study of 400 clinical risk self-assessments carried out by MPS Risk Consulting in the UK in 2006 found that 84% of practices had risks associated with test results. These risks included:

  • Not having a tracker system in place to ensure that patients are followed up.
  • Not having a system in place to show when all of a patient’s test results have been returned.
  • Not recording test results onto a computer.
  • Allowing non-clinical staff to inform patients of their results and the treatment required.

This case report first appeared in MPS Casebook, 15(3) September 2007

84% of practices had risks associated with test results
84%

Box 10 lists some of the functions and behaviours that should be controlled by protocols or guidelines; it is by no means an exhaustive list, but it includes the functions that typically contribute to adverse incidents if they are not running efficiently or effectively.

Some functions – infection control, for example – may require a mixture of guidelines and protocols. You could use the list as a starting point for identifying the risks in your own practice.

Invite staff to a brainstorming session to assess the level of risk posed by the various systems already in place and to identify where vital systems are lacking. You can then collectively design protocols and guidelines to minimise the risks.

An example of the type of issue that might come up is the problem of maintaining patient confidentiality on the telephone. Some practices have solved this problem by issuing patients with unique identifiers, such as codewords or numbers, to use when they call for the results.

Once you’ve introduced a protocol or guideline, it should be dated and then reviewed at regular intervals

Once you’ve introduced a protocol or guideline, it should be dated and then reviewed at regular intervals to make sure it’s working properly and to revise and refine it if any flaws are identified.

In addition to scheduled monitoring, you should also carry out ad hoc reviews and adjustments to your protocols and guidelines whenever they’re implicated in a complaint or adverse incident.

Box 10: Examples of protocols and/or guideline-driven functions

Protocols:

  • Prescribing
  • Elements of infection control such as hand-washing, cleansing and sterilising instruments, etc.
  • Getting test results and informing patients
  • Security of clinical records
  • Access to records
  • Taking and passing on messages
  • Telephone consultations
  • Handling pathology specimens
  • Referrals and arranging investigations
  • Disposal of medical waste
  • Storage of dangerous drugs.

Guidelines:

  • Obtaining consent to treatment
  • Referrals guidelines
  • Dealing with difficult patients
  • Certificates
  • Root cause analysis
  • Dispensing
  • Accommodating cultural differences
  • Offering and using chaperones
  • Infection control
  • Dealing with complaints
  • Confidentiality