Accountability and new ways of working

As a healthcare professional, you have a “duty of care” not to cause foreseeable harm to others – whether patients or colleagues – and are personally accountable for your acts or omissions. However, the degree to which you may be held accountable depends on your knowledge-base and experience.

When accepting responsibility for any aspect of patient care, you must ensure that you are competent to carry out the tasks requested of you and be able to evidence that competence. You must also ensure you are working within the parameters of your job description. If you work outside of your job description or carry out tasks which you are not deemed competent to perform, this will fall outside of the employer accountability and vicarious liability which is discussed later in this article.

The same principles apply if you are extending your practice beyond your original remit or taking on a new role.

• The job description must include the additional areas of work or new duties.

• You should have received additional education and training to ensure that you are competent.

• You should have evidence to demonstrate your competence.

• The parameters of your new practice will usually be guided by protocols.

• The organisation’s risk management team and executive board should have approved the extended scope of practice or new role.

It is essential that as you adopt new ways of working and your practice evolves, that your job description is updated and any additional education and training required is arranged. You must acknowledge the limitations of your knowledge, skills and competence, and should therefore refuse to undertake any duties beyond your limits.

If you are delegating to others you must ensure that the people you are delegating to are competent to carry out the tasks asked of them.

Supervisor accountability and delegation

As a supervisor, you need to be able to perform the duties you are training and assessing others to complete. Many NHS organisations and professional bodies will decide standards of practice for supervisors and they may stipulate additional education and training that you should attend. As a supervisor, you must ensure that duties you are delegating to others are only delegated when that person is trained and competent to carry them out.

The General Medical Council’s Duties of a Doctor (2006) states: “When you delegate care or treatment you must be satisfied that the person to whom you delegate has the qualifications, experience, knowledge and skills to provide the care or treatment involved. You must always pass on enough information about the patient and the treatment they need.” The same principle applies to all supervisors.

The Nursing and Midwifery Council’s, The Code. Standards of conduct, performance and ethics for nurses and midwives (2008) states:

• You must establish that anyone you delegate to is able to carry out your instructions.

• You must confirm that the outcome of any delegated task meets required standards.

• You must make sure that everyone you are responsible for is supervised and supported.

During training, you should hold supervisory meetings with trainees to discuss and document progress. If you are delegating to someone who you have not supervised through the training phase, then you should confirm competence first and ensure the duties that you are delegating are within the member of staff’s job description.

After training it is essential that those you supervise maintain their competence through continuing professional development and, as a supervisor, you should support this ongoing review of competence.

If a member of staff feels that what they are being asked to do is beyond their level of competence or outside of their job description, they should refuse to perform the duties and you should respect this decision. Further training may be required until the person feels confident and competent to perform the duty requested.

Employer accountability and vicarious liability

As the employer, your organisation will bear liability for acts or omissions carried out by healthcare staff if:

• Their role in the organisation has been approved.

• Education and training has been provided to ensure competence and appropriate supervisory arrangements are in place.

• The employee has an agreed job description within which they are practising.

So, when new roles are developed or practice is extended, organisations should:

• Check the risk management and clinical governance issues.

• Ensure that an appropriate job description is in place.

• Ensure appropriate training is available to ensure competence.

• Ensure a suitable supervisor is overseeing the new role.

• Have a process for ongoing review, to monitor any changes to the work of the member of staff and amend the job description as required.

The National Patient Safety Agency published Seven Steps to Patient Safety – A Guide for NHS Staff in 2004. Step 3 refers to developing systems and processes to manage risks and identify and assess what could go wrong. Step 5 is about developing ways to communicate openly and effectively with patients. Both steps are essential as part of employer accountability when developing new roles or extending existing roles.

Accountability to the regulators

The regulation of professional groups of healthcare staff who have reached a national standard of practice is undertaken to safeguard the public, and to ensure that only those people who have reached the standard can use the title associated with those standards e.g. “nurse”.

The regulators record when a national standard has been met by placing the name of the person on the appropriate professional register. They can carry out random checks to ensure that staff in a professional group are maintaining the standard of practice and they also record changes to the status of those people on the register such as the acquisition of additional qualifications, for example. If a professional’s practice is called into question, the regulators would be involved in judging fitness for practice.

Not all healthcare staff are regulated so local responsibility to ensure competence and standards of practice as outlined in the employer section are essential. If an individual is working outside of the duties for which they gained primary regulation, they must undertake to produce a portfolio of evidence that demonstrates competence in the new areas of work and they must have a job description outlining the parameters of the role.

Transparency

Patients must, at all times, be fully informed about who will be delivering their care. It is essential that you present yourself for what you are. It would be misrepresentation if you presented yourself in a white coat, which would be generally seen by the public as the dress of a doctor, when you are not medically qualified unless you explain exactly who you are. For those delivering duties previously performed by doctors, such as a Surgical Care Practitioner, you should always take time to explain who you are, how you have been trained and how you will be contributing to patient care as part of the team. You need to also check that the patient and relatives have understood the information you have given.

Patient and user information leaflets are a very useful resource to provide written confirmation of your discussions. You must always acknowledge the views of the patient and if they wish to be seen by a doctor or another healthcare provider, their wishes must be upheld.

Record keeping

Accurate documentation is essential at all times throughout the patient journey. Records can be called as evidence should any aspect of patient care be called into question. Therefore, healthcare staff are accountable for ensuring that all documentation is clearly written, concise, precise and comprehensive. Every entry in a patient record should be signed, dated and the time of entry documented.

Conclusion

It is essential that all healthcare staff are confident and competent to carry out any tasks related to patient care. They can be called to account for their actions or their omissions and any documentation made in the patient notes or charts may be called as evidence should the care be called to question.

Supervisors must ensure that they only delegate duties when they are sure the person they are delegating to, is competent and confident enough to carry out the task. The principles of employer accountability have also been outlined. Individuals who have extended their practice beyond the traditional remit must ensure that their job description covers the duties being requested of them and ensure that they have evidence to demonstrate competence by attaining additional education and training which is signed off by a supervisor.

Further reading
1 Dowling et al. (1996). Nurses taking on junior doctors’ work: a confusion of accountability, British Medical Journal (1996). 312: 1211 – 1214 (11 May).

2 General Medical Council: Duties of a doctor. London. GMC, 2006.

3 Nursing and Midwifery Council. The Code. Standards of conduct, performance and ethics for nurses and midwives. London. NMC, 2008.

4 National Patient Safety Agency. Seven Steps to Patient Safety – A guide for NHS staff. London. NPSA, 2004.

5 Savage J., and Moore, Lucy. (2004), Interpreting Accountability – An ethnographic study of practice nurses, accountability and multidisciplinary team decision making in the context of clinical governance. Royal College of Nursing.                                                                                      

Jackie Younger
Jackie Younger, director of Leading Workforce Solutions, provides advice and support to enable new ways of working, service redesign, change management, organisational development – as well as team leadership and management training. Prior to running her own consultancy company, she was National Practitioner Programme Lead – formally part of the Department of Health Modernisation Agency New Ways of Working Team.