Responsible Clinician Documentation in General Surgery: can we do better?

H Shaikh, E Zarook, A De Zanna, S McCluney

Introduction

At Whipps Cross Hospital, every patient should have the correct named consultant for the appropriate encounter on CRS. This reduces inappropriate workload, helps to ensure investigation results are actioned by the correct person, it means other health professionals are aware of the correct team to contact, and is essential for appropriate clinic follow up on discharge. All of these relate to patient care and are important for patient safety.

Aims and methodology

The Surgical Access list is updated at least daily and reflects the most accurate method of determining which general surgical (GS) patients are admitted under which consultant. This is often not reflected on CRS and can affect patient care as described above. We compared the surgical access list to CRS for any given week. Data collected between 9th to 16th June showed that only 76% of GS in-patients had the correct responsible consultant named on CRS. Our aim was to improve this to 100%.

Continue to collect data, continue to educate juniors rotating onto general surgery about ensuring named consultant surgeon is correct

Collected data at two to four monthly intervals to see if improvements in percentage of correct responsible surgical clinicians made and sustained

Identify barriers to the correct responsible surgeon being named on clinical documentation – noted that mainly errors were occurring from patients admitted through ED

Liaised with Switchboard, ED matron, rota-coordinator and junior doctors, emphasis on ensuring the day consultant was the admitting consultant throughout the on-call week

Percentage of correct named general surgical consultants

Results

Week beginning 9th June: 76% correct

Post intervention, week beginning 28th June: 100% correct Intervention repeated after junior doctors rotated to ensure they were aware of how to change named consultant if incorrect on CRS

Week beginning 2nd December: 89% correct

Reflections and further work

Communication between the surgical department and other departments including ED and medical staffing is key to ensure good handover and accurate responsible clinician documentation. As junior doctors rotate through the specialty, it is important for them to be informed about ensuring each ward patient has the correct surgical consultant on CRS, and how to change this if incorrect.

Further QI projects to check percentage of correct named consultants, to review if named consultant on discharge is correct and if not, impact on clinic follow up/ follow-up investigations.