1. Recording Care – The Nursing Challenge Angela Reed, Senior Professional Officer Michelle Burke, Professional Officer

2. ‘In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purpose of comparison....’
Florence Nightingale 1863

3. ‘Mrs Harry denies a series of charges dating between 1998 and 2006 and related to alleged failures to ensure adequate nursing staffing levels and appropriate standards of record keeping, hygiene and cleanliness, administration of medication, provision of nutrition and fluids and patient dignity.’

4. What it’s not.....

5. What it is.....
Practice!

6. Evidence Base
Literature Review: Factors Influencing Quality of Registrant Record Keeping (2009)
The Value and Purpose of Record Keeping
Audit
Information Recorded
Competence to Record
Professional Supervision
Patient Awareness/ Inclusion
Issues Related to Time

7. Recording Care
2009
2010
2011
2012/13
2014
2015
2016

8. & ‘s
“It ain’t what you do it’s the way that you do it, and that’s what get results…” X X

9. Outcomes
Regional person-centred nursing assessment and plan of care document What √
Standards for Nursing and Midwifery Record Keeping Practice How √
Improved record keeping practice - 30% increase in audit scores Results!

10. Partnership with Practice
How?
Time and Effort
Partnership with Practice
Work-based learning
Improvement demonstrated in Practice
Encouraging and engaging with teams

11. Outcomes
System of accountability to regionally monitor standards of nurse record keeping practice
Endoscopy Day Case Record
Under 24 hour stay record
Health Care Support Worker Practice
Regional Abbreviations policy (sep project)
Children’s in-patient record
Review of NOAT
Review of Record Keeping Guidance and Standards

12. Ongoing Work Children’s improvement cycles
Learning Disabilities record and improvement cycles
Care planning
Key Performance Indicator development
Review of web resources
Links to revalidation

13. Audit Tool: Short NOAT

14. Audit Tool: NOAT

15. Short NOAT

16. Audit Tool: NOAT

17. Quarterly Quality Focus

18. Learning

19. Learning Regional Sign-up
Leadership (Executive Nurse to Champion – CNO commission)
Facilitation
Listen to the frontline
Clear goals
Accountability
Tenacity and Enthusiasm
Value and mark achievement
(Never give up)

20. How did we get here?
Continuous Recording Care audit cycles demonstrated that compliance targets for care planning were unmet against the indicators within the NIPEC Online Audit Tool (NOAT) each reporting quarter.

21. Approach so far….. Information meeting November 2014
Care planning summit January 2015
Meeting Strand 1 March 2015
Presentation to EDoNs/CNO / CE NIPEC April 2015
Review of NHSCT approach May 2015
ERG meetings June, July and August 2015
Pilot Aug Sept 2015

22. Approach so far…..
Evaluation presented to EDoNs/CNO / CE NIPEC November 2015
Funding agreed for facilitation Jan 2016
Pilot Feb/April 2016
Evaluation May/June
Meeting EDoNs/CNO/ CE NIPEC July 2016

23. PACE
PERSON
ASSESSMENT
PLAN OF CARE
EVALUATION

24. PACE

25. Pilot and Evaluation 3 wards selected in each HSC Trust
Children's ward BHSCT
Mix of experience using PACE
Baseline evaluation data
8 week pilot across all records
Midway evaluation review
End of pilot evaluation

26. Evaluation Tools Agreed at Steering Group Directed by frontline staff
Resources developed
Training provided
Learning from the pilot

27. Evaluation Tools Service delivery:
Improved satisfaction response in relation to nursing care
Methods of data collection:
Patient  satisfaction surveys
Patient experience:
Evidence of greater inclusion
Evidence of participation in care processes
Evidence of better communication
NOAT audit
Patient  surveys
Observations in practice
Nursing care outcomes:
 Improved nursing care planning
Benefits for staff:
Evidence of greater expressed autonomy
Time spent recording nursing care
Time spent with the patient recording nursing care
Evidence of reported improved professionalism
Evidence of reported greater job satisfaction
Focus group
Time in Motion Study

28. Agreement – Once for NI

29. Spread Plan

30. Resources