Context This improvement work was done in the Paediatric Emergency Care Centre (PECC) of a busy district general hospital, which sees about 20,000 children every year. The work involved a collaboration of the nursing and medical staff in the PECC.
Problem When a child attends the PECC, a set of notes is generated which includes a Safeguarding Checklist on the second page. It is the responsibility of the clerking doctor to complete this for every child they see. It contains ten questions aimed at identifying children who could have experienced non-accidental injury (NAI). An audit showed that this checklist was only being completed 20% of the time. This was unacceptable as it put children at risk and contravened a basic trust policy.
Assessment of problem and analysis of its causes To establish why checklist completion was poor, a random sample of non-consultant emergency doctors was given an anonymous questionnaire. The questionnaire, consisting of 5 multiple choice questions and a final open question, aimed to establish the barriers facing staff completing the checklist. A process map outlining a child’s journey through the emergency floor and the above audit made it clear that the checklist was a barrier. Feedback indicated that the checklist itself was busy, unclear and difficult to use. As a result, I set about redesigning the checklist.
Intervention The Safeguarding Checklist now consists of 9 questions with the option to tick “yes”, “no” or “not applicable” for each of them. Once they have been completed, there are instructions on how to categorise your findings into “green”, “yellow” or “red”, indicating the level of risk. Following this, there are bullet point directions of the next steps to take for each category.
Strategy for change The redesigned checklist was integrated in to the new PECC notes, replacing the previous version. The clerking clinicians complete the checklist but nursing staff assist in prompting them to do so. The questionnaire results were presented at a departmental meeting. Once the first draft of the redesigned checklist was completed, it was shown to PECC staff for feedback, which was incorporated in the final version.
Measurement of improvement Following the introduction of the new checklist, the notes of all children under five were audited five days a week to measure how often the checklist was being completed. Results after five months show it is being completed on average 65.6% of the time. Although this is an increase from 20%, it still does not meet our aim of 100%.
Effects of changes There is clearly an improvement in completion of the checklist but we aim to improve further. By increasing the use of the checklist, we hope to avoid further serious case reviews and promote a safeguarding culture within PECC.
It was difficult to bring together feedback from different sources to produce the final checklist. It was also challenging to create something that was simple and clear but still included all the important information.
Lessons learnt I learnt staff engagement, PDSA cycles and process mapping are key to making improvements. I also learnt that having an open and safe environment to express opinions leads to the some of the best suggestions.
Next time, I would survey paediatric doctors and ENPs in addition to emergency care doctors as they also complete the checklist while clerking.
Message for others Without regular measurements, we could not tell if the checklist was being used. To find out it is being used poorly through a serious case review is not acceptable. By regular measurement, we have weekly data which provides more detailed information on completion rates. Staff engagement was vital to improving the checklist and increasing compliance, as detailed above.
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