Leadership and Governance

Consent

  • to align with ethical principles - autonomy

  • support:

    • informed consent - patient can understand/make decision, get full explanation, comprehend information, act voluntarily

    • truth-telling - give full information to patient

    • confidentiality - not sharing patient information without their consent

  • getting consent: CORU code of conduct and ethics

HSE National Consent Policy 2022

  • patients have legal and ethical rights to control their own lives, make informed decisions about their lives, decide what happens to their bodies

  • ongoing process

Steps to Getting Consent

  • healthcare worker providing intervention explains information to patient in way they can understand

  • healthcare worker needs to be qualified

  • give full information about the intervention

  • information about risks and benefits

  • information about alternative intervention options

  • information about what will happen if don’t go with intervention

  • give time for patient to ask any questions they have

  • patient can give written, verbal, non-verbal, or implied consent

  • when sure patient has decision-making capacity, can understand and remember information go ahead with intervention

  • clearly document information provided, patient agreement, type of consent obtained

  • Not valid consent if:

    • information not explained in a way patient could understand

    • patient doesn’t get sufficient information on risks/benefits of intervention

    • patient doesn’t get information on alternative options or information on what happens if they don’t get the intervention

    • they don’t have decision-making capacity

    • if person giving information about the intervention doesn’t have sufficient knowledge to give all information and answer patients questions

    • if person is in a state where they cannot remember and understand information (e.g. due to sedation, medicine, intoxication, fatigue, destress, condition)

    • they are acting under duress

      • threats/pressure from third party (family/therapist/other) and patient feels they have to consent

      • linked to safeguarding

Patient Refusing to Consent

  • respect valid consent

  • document: intervention offered and declined, detail what was explained to patient, alternative interventions provided, patient’s decision to refuse intervention

Patient Withdraws Consent

  • can withdraw at any time, even during intervention

  • if they withdraw: stop intervention, listen to and understand persons concerns, explain consequences of not doing intervention

  • document - refusal to consent

Open Disclosure

HSE Open Disclosure Policy 2019

  • Concerning safety incidents:

    • Harm event: unintended harm to patient

    • No-harm event: no actual harm caused but believed could have harmed

    • Near miss event: harm prevented by chance or quick save but could have caused harm

  • Aligns with duty of candour

Steps In Practice

From Open Disclosure Policy 2019 and National Open Disclosure Framework 2023

  1. Safety Incident occurs

  2. Staff member that detected incident will assess and talk with principal therapist to determine level of response (low or high response) - can use HSE risk assessment tool to support decision

  3. Communication with patient within 24-48 hours (often meeting with patient and with a manager or colleague)

    • acknowledge the situation and impacts on patient

    • offering factual explanation of how and why happened

    • listening to patient’s experience of event

    • offering honest and meaningful apology

    • reassure patient about ongoing care - shared decision making about ongoing care and management of incident

    • reassure and discuss steps that will be taken to ensure event does not happen again

  1. Patient support: entitled to acknowledgement, explanation, apology, reassurance

  2. Staff support: encouraging reporting incidents, communication skills training, support through open disclosure process

  3. Promoting an Open Disclosure Culture: developing a ‘just’ culture that acknowledges people make mistakes, and focus on learning and improvement

  4. Governance: governance frameworks (policy, legislation, clinical governance and monitoring) and accountability structures should be in place

  5. Monitoring and Evaluation: ongoing reporting, recording and measuring open disclosure practices

    • ongoing and consistent monitoring

    • reporting - to identify safety incidents

    • recording - documenting meeting, what was discussed, and agreed actions

    • reviewing - patient involved in review

Safeguarding

HSE Policy: Safeguarding vulnerable persons at risk of abuse (2014)

Types:

  • physical

  • sexual

  • financial

  • institutional

  • discriminator

  • neglect

  • psychological

Risk Factors

Personal

  • impaired social skills or judgement

  • impaired capacity

  • physical dependence

  • requires support with PADLs

  • lack of knowledge on how to defend against abuse

Organisational

  • low staff levels

  • high staff turnover

  • no ongoing staff training

  • reduced policy awareness

  • weak or inappropriate management

Procedures

  • concern raised due to

    • observation of incident

    • observation of signs of abuse

    • disclosure from vulnerable person

    • disclosure from friend/family

    • anonymous report

    • organisational complaints report

Day 1

  • immediate protection of person

  • listen, reassure, support person

  • if concerned about criminal offence - report to Garda

  • record and preserve physical evidence

  • document ASAP

    • when concern raised

    • who was involved and witnesses

    • what happened/what was disclosed - factual and in persons own words

    • relevant information such as past incidents

  • report to line manager/designated officer/safeguarding and protection team

  • Line manager/designated officer conducts preliminary screening process (within 3 days)

Self Neglect

Can manifest as:

  • poor hygiene

  • life threatening behaviour

  • mismanagement of financial

Procedure

  • consider possibility and discuss with person

  • go to safeguarding and protection team for support

  • assess

    • person’s awareness of referral and reactions to

    • gather information about concerns - info from other staff and previous attempts to intervene

    • meet with person to understand views and wishes

    • MDT meeting and possible comprehensive assessment

  • plan

    • lead person work with manager to co-ordinate and review

    • develop safeguarding plan with team and patient (if agree and has capacity)

    • build trust and monitor well-being - if disagrees and has capacity

  • review continuously

Ethics and GDPR

CORU code of professional conduct and ethics (2019)

  • Beneficence - acting for the wellbeing of the patient

  • non maleficence - avoiding doing or risking harm to the patient

  • autonomy - individuals have the right to make their own decisions

  • justice - fair and equal treatment of patients

GDPR and Confidentiality

Principles of GDPR

  • lawful, fairness, transparency

  • purpose limitation

  • data minimisation

  • accuracy

  • storage

  • integrity and confidentiality

  • accountability

Decision Making Capacity

Assisted Decision Making Act (2015) and the National Consent Policy (2022)

Principles

  • presume capacity

  • unwise decisions to not equal a lack of capacity

  • no lack of capacity until all supports are given

  • if lack capacity use least restrictive intervention

  • align assessment and intervention with clients will and preference

  • capacity is time and decision specific

Assessing

  • OT, SLT, SW, doctor, nurse, midwife

  • understand client circumstances before assessment

  • fully explain to patient why being assessed

  • lead by therapist proposing intervention

  • functional assessment - holistic review - MDT involvement (Usher and Stapleton, 2022)

  • institutional factors - limits functional assessment use as less staff and time, more adherence to risk management than patient autonomy (Usher and Stapleton, 2022)

  • cognitive assessment is not a capacity assessment - overemphasis on cognitive assessments (Usher and Stapleton, 2022)

  • Mindful of power imbalances in decision making - staff, environment, family (Usher and Stapleton, 2022)

Have Capacity If Can:

  • understand information about the decision

  • retain the information

  • use and weigh the information

  • communicate the decision

Supports

  • visual aids

  • AI

  • Language use

  • advocates

  • time

  • location

Levels of Assistance

  • decision making assistant

  • co-decision maker

  • decision making representative

  • attorney

  • designated healthcare representative

Decision support service: clients register with for assistance

QI and PDSA

Key Elements

  • PDSA - small changes/interventions to support confidence, efficacy, and reduce resistance to change

  • stakeholder involvement - people impacted by the change - important for buy in (Crowfoot and Prasad, 2017)

  • Oversimplifying and unclear on steps leads to failed projects (Reed and Card, 2016)

  • Institutional limitations include resources and time limiting consistent data collection and reflective practice, more focus on doing than reflecting - leads to less time in study phase and adapting actions (Reed and Card, 2016)

  • Example topics: creation and use of templates, clinical pathways, increasing use of standardised assessments, modifying tools used in practice

PDSA Steps

Model of Improvement

  • SMART Goal

  • Measurement of change

  • Ideas for change

  • example: 90% of all patients will receive OT initial contact within two days of admission by June (Ige and Hunt 2022)

PDSA

  • plan - aim, predicted outcomes, data collection, who, what, when, where, why, SWOT

  • do - carry out and document

  • study - evaluate success, planned vs obtained outcomes, what worked and didn’t work

  • act - revise plan, adjust based on what worked or didn’t

Career Progression

Quality Improvement Guide and Toolkit (2024)

Career Development framework (RCOT 2024)

Career development framework (RCOT 2024)

  • requires you have all four: professional practice, facilitation of learning, leadership, evidence, research and development

Leadership and Development

  • leadership is a foundation for improvement (Guide and toolkit 2024)

  • shows accountability - aligns with ethics and CORU continual development requirements

  • develop skills for senior role

  • develop professional profile

Communication and Teamwork

  • autonomy and teamwork skills

  • develop communication skills

  • giving and receiving feedback

  • supporting peers

  • developing a culture of communication and learning to better support staff and clients

Reflection and Evidence

  • critical thinking

  • reflective skills

  • challenging complacency

  • evidence based practice

  • client centred care