The Health Protection Agency has suggested that one in ten hospital patients experiences an incident that puts their safety at risk, around half of which could be prevented, and the RCN has identified the need to reduce nurses’ paperwork considerably. This article reports a successful project that set out to tackle these two issues by developing a risk-based nursing assessment system that is simple to use, reduces unnecessary paperwork and reduces the risk of harm to patients.
It outlines how the initiative was introduced, as well as obstacles encountered during the process. The risk-assessment tool received positive feedback from nursing staff as it reduces paperwork while providing a risk-based assessment of care needs.
Heather Sud, RGN; Jane Gorman, RGN, are both associate directors of nursing, planned care, Mayday Healthcare NHS Trust, Croydon.
In the NHS at present, assessing risk has become part of the process of supporting patients and maintaining safety in the hospital setting. Documentation of risk is key to reviewing and improving patient care and forms the basis of future investigations. It is vital to keep accurate records to measure fluctuations in patients’ recovery and respond appropriately to changes. A multidisciplinary partnership is essential in enhancing patient care and preventing the waste of resources. The National Patient Safety Agency (2004) highlighted the importance of risk assessment when it published Seven Steps to Patient Safety. These steps included the need to integrate risk-management activity, involve patients and implement solutions to prevent harm.
Risk prediction generally means using a systematic and proven method of identifying people who may be likely to deteriorate or suffer an exacerbation of a pre-existing risk. Risk management is essential in the NHS as it allows practitioners to minimise both the risk itself and the consequences of an adverse event. It can also provide an early-warning system and maximise the probability of a positive outcome.
The recently reviewed NMC (2008) code of conduct states that, ‘You must make a referral to another practitioner when it is in the best interest of someone in your care. You must keep clear and accurate records of assessments you make.’ In other words, registered nurses must act to identify and minimise the risk to patients. In addition, the Health Act 2006 states that an NHS body must:
- Make a suitable and sufficient assessment of the risk to patients with respect to healthcare-associated infections (HCAIs);
- Identify steps that need to be taken to reduce or control those risks;
- Record the findings.
The Department of Health’s Standards for Better Health (DH, 2004; updated 2006) puts particular emphasis on patient safety. It makes recommendations to ensure that ‘patient safety is enhanced by the use of healthcare processes, working practices and systemic activities that prevent or reduce the risk of harm to patients’. The DH is adamant these standards are not optional and the Healthcare Commission now measures all trusts against them yearly. One of the standards states: ‘Healthcare organisations [must] continuously and systematically review and improve all aspects of their activities that directly affect patient safety and apply best practice in assessing and managing risks to patients, staff and others.’ It also says they must keep patients, staff and visitors safe by having systems in place to ensure the risk of HCAIs is reduced, with particular emphasis on high standards of hygiene and cleanliness.
According to the RCN (2004), nurses will always need an assessment tool to guide their daily nursing practice in terms of their professional accountability and responsibility. For any tool to be effective it must be integrated into daily activity - as a standalone initiative it is unlikely to have a significant impact.
Increasing amounts of paperwork are a significant concern for nurses and any tool needed to reduce this rather than increase it. Nurses now collectively spend more than one million hours each week on paperwork (RCN, 2008). A survey of 1,700 nurses, reported at the RCN 2008 conference, showed they feel this is undermining their ability to spend time supporting and caring for patients and relatives.
Providing healthcare is risky for both patients and service providers. Risk management helps practitioners to reduce and minimise risk as part of a quality programme. The focus is on delivering better services as safely as possible. For this to be effective, good reporting systems must be in place and begin with the identification of specific risk. This must then be subjected to a process of assessment, and reporting and management systems should be designed. Clinical governance has allowed practitioners to put these processes in place to analyse systems and move away from the individual ‘blame culture’. The DH (2000) first developed this idea in An Organisation with a Memory, which set out to identify how best to learn from failures in the NHS. The report also set out comprehensive risk-management systems, learning lessons from industry and its management of risk.
It was in this culture and with all these factors in mind that we began to design a risk-assessment system that could be used to evaluate individual patients’ level of risk in specific areas.
In our trust, nursing documentation consisted of a 20-page series of checklists, known as the nursing assessment proforma (NAP), which was designed by senior nurses, specialist nurses and a nurse consultant. Although widely credited as a valuable and comprehensive nursing tool, data collected via performance indicators over 12 months showed nursing assessment failed to meet the required standard in over 60% of cases. The analysis also found that completion of this tool had not affected outcomes of care. In view of this, we agreed this current practice could not continue as it did not meet service need and posed a potential risk to patient safety.
Developing the tool
As a result of these findings, we decided to investigate whether introducing a hospital-based risk-assessment tool would improve safety. A small working party was set up to investigate how improvements to patient assessment could be made. Until this point, nursing assessment had been influenced by using a reactive, problem-solving framework rather than taking a proactive approach.
Having identified an absence of patient assessments within nursing documentation, it became clear there were further issues:
- Collecting data related to patient care was difficult;
- Review of nursing practice highlighted the need for a baseline assessment of patients’ health and mobility status before and during admission;
- Nurses were often failing to observe the NMC code of conduct related to recordkeeping;
- When questioned, nurses reported that time constraints and the complexity of documentation contributed to poor compliance;
- Completing the NAP did not generate any outcome measures;
- There were no trigger mechanisms to initiate referrals;
- Poor compliance with electronic records was evident.
We decided to develop a tool based on risk assessment as this would:
- Allow clinical staff to target interventions at those most in need;
- Allow a comparison of risk factors;
- Amalgamate a series of risk tools in one document;
- Act as a trigger to generate referrals to nurse specialists and, in turn, more in-depth assessment;
- Reduce delays in accessing specialist help, thereby reducing inappropriate care and facilitating early referrals, which will impact positively on lengths of stay;
- Act as a measure of nursing interventions needed;
- Provide a method of bringing together different expert assessments, thereby ensuring that a total holistic assessment remained in place;
- Encourage nurses to collect evidence to support their decision-making.
The risk scores to be included were identified from a number of nursing assessment models, including Roper et al’s (2000) model, which is based on 12 activities of daily living. We also included benchmarks identified in The Essence of Care (DH, 2001, revised 2003). The final agreed format for the tool consists of 10 risk assessments. Three examples are shown in Table 1.
The following categories of risk assessment are included in the tool:
- Malnutrition Universal Screening Tool (MUST);
- Visual infusion phlebitis score;
- Bowel dysfunction;
- Patients at risk (PAR) score
- Pressure ulcers.
This risk tool was developed for use in a range of settings in the acute sector. It was felt that employing ‘lean thinking’ methodology would increase compliance with tool completion by increasing staff motivation and morale. Lean thinking involves five basic principles that characterise a lean enterprise (Womack and Jones, 1996). Each risk category generates a score that has been carefully correlated to give parity across the risks, so all scores range from zero to six.
We invited three wards - a medical ward, a surgical vascular ward and an elderly care ward - to take part in a pilot. Each had motivated ward managers with a good track record for change projects. Qualified nurses on the wards were asked to complete the risk assessment for each patient on admission and then weekly thereafter. Each individual patient score was amalgamated onto a weekly ward ‘master copy’ and scores were totalled for both individual patient and each risk. These documents were accessible to all members of the multidisciplinary team, with reassessment if there was any change in patients’ individual conditions.
Risk-based care plans have been produced to accompany each category. The care is divided into triggers that are classified as low, medium and high risk, depending on each patient score generated.
The results showed 100% compliance in all areas. All patients in the pilot had an individual holistic assessment that was reviewed weekly with measurable outcomes. The tool’s introduction led to a whole-system approach as it prompted nursing staff to highlight immediately those patients who needed referrals to nurse specialists for advice. Increased emphasis was placed on collaborative working between nurse specialists and ward staff.
Initial analysis also allowed us to identify the following:
- Men fall more frequently than women;
- The medical ward had the highest infection risks but one of the lowest HCAI rates overall;
- The elderly care ward consistently had the highest number of patients who were vulnerable;
- Anecdotal evidence from the elderly care ward suggested its risk of patient falls was higher than other areas and this tool provided formal evidence that this was correct.
The information gained proved invaluable and has enabled us to tailor the care we offer to patients. We found the tool could be used to identify patients ready for discharge home. Those with the lowest risk scores were usually the fittest and required the least nursing care - as such the tool allowed discharge teams to highlight these patients as ready to go home. Conversely, those patients with the highest scores were generally the most unwell and the tool could be used in the allocation of nursing staff. In this way it worked as a type of dependency tool and ensured those patients who were most ill were cared for by the staff who were most skilled. Identifying those most at risk also meant they could be placed in the most appropriate sections of the clinical area. This was particularly evident when reviewing the tool’s use on our surgical ward. Staff had reduced HCAIs by 65% by using the tool to place patients appropriately in the ward, with those found to be at high risk not being placed next to those known to have an infection.
Feedback from those who have been using the tool has also been positive, with staff commenting it is user friendly, less time-consuming than the original 20-page assessment document and could be completed following simple direction. Nurses felt they were able to make a good assessment of patients based on risk factors. The tool initially takes approximately 10-15 minutes to complete, but is quicker after the first assessment. This means it releases nurses back to direct care and reduces unnecessary and burdensome paperwork.
Other benefits of the tool include the fact that it:
- Offers a rapid trigger mechanism for patients at high risk;
- Uses ‘lean thinking’ methodology;
- Can be used with current IT systems to form a quality reporting system and fits into the electronic recordkeeping system, eventually being synchronised to national service frameworks and NICE guidance;
- Gives instantaneous results;
- Contributes to dependency and workload planning;
- Identifies problem areas using a risk-based system;
- Identifies high-performing areas;
- Introduces personalised recordkeeping;
- Meets NMC standards for recordkeeping.
However, the tool does have disadvantages. This was the second major redesign of nursing documentation in two years and it requires investment of time and activity from senior nursing staff to train and embed it in practice, while being led and monitored by the matron. It was envisaged that the tool would enable nursing staff to make proactive referrals to nurse specialists, but this does not happen currently. For example, patients are only referred to the pain nurse specialist when they are identified with pain, as the current system does not allow proactive identification of those who may experience pain or any of the other risks. Another example is the bowel nurse specialist, who could become involved with high-risk patients, but does not do so currently as no system has been available to highlight such patients. This tool offers the opportunity to refer patients with high risk scores to the appropriate nurse specialist before a problem develops, and this is one aspect of the tool that needs developing before this system can be described as fully integrated.
This initiative has developed a tool that:
- Is simple to use;
- Offers a comprehensive assessment system;
- Reduces unnecessary paperwork;
- Provides a comprehensive profile of each patient on a weekly basis;
- Integrates risk-management activity;
- Promotes reporting;
- Increases the opportunity for collaborative working;
- Creates a system to reduce harm to patients.
Future plans for the tool include:
- Adapting it to electronic recordkeeping systems - collaboration with the IT department has already been implemented to start this process;
- Linking it with national service frameworks and NICE guidance.
Implications for practice
The tool has proved more effective than ever expected. Compliance has continued following completion of the pilot and adoption of the tool across the planned care directorate. This is in no small part due to the fact the ward staff liked the tool immediately and found it easy to complete. It has offered a holistic approach that, when used in conjunction with clinical judgement, proves extremely effective. In essence, the tool is the key to ward-based risk management and patient evaluation.
Department of Health (2004, updated 2006) Standards for Better Health. www.dh.gov.uk
Department of Health (2001, revised 2003) The Essence of Care: Patient-focused Benchmarking for Health Care Practitioners. www.dh.gov.uk
Department of Health (2000) An Organisation With a Memory. www.dh.gov.uk
National Patient Safety Agency (2004) Seven Steps to Patient Safety - Your Guide to Safer Patient Care. www.npsa.nhs.uk
Royal College of Nursing (2008) RCN conference 2008, Dr Peter Carter, RCN chief executive and general secretary.
Roper N. et al (2000) The Roper-Logan-Tierney Model of Nursing: Based on Activities of Living. Edinburgh: Elsevier Health Sciences.
Womack, J.P., Jones, D.T. (1996) Lean Thinking: Banish Waste and Create Wealth in Your Corporation. New York: Free Press.