Clinical Governance - the HEMS Charter
Background
The aspiration of clinical excellence in prehospital care has been difficult to realise for many years. An over emphasis on the "transport" element of patient care, response times and simple belief that the standards of clinical care in emergency situations can be compromised simply because the situation was an emergency have hampered clinical thinking and standards. However, experience tells us that much of the work of the UK's helicopter air ambulances is highly predictable, easy to train for and ideally suited for the same standards of governance that exist in hospital and in non emergency situations.
The governance framework embraced by the UK HEMS aims to produce clinical excellence through many routes: the adoption of best practice, clinical and non clinical audit, clinical and non clinical risk management, development of a shared mental model through multi-professional meetings and operational guidelines, regular peer review and clear lines of medical accountability. The framework is entitled the HEMS charter.
The HEMS Charter
Principles
• The charter aims to support clinical practice in individual organisations by providing a minimum benchmark and framework for a clinical governance structure.
• Interpretation & application of the charter is left to individual units.
Charter Structure
The Charter embraces clinical governance through the following headings:
1.Human Resources
2.Clinical Audit
3.Best Practice
4.Risk Management
5.Competency Based Training, Appraisal and Re-validation
6.Organisational Structure
7.Core Documents
8.Information Governance
Human Resources
The personal specification, job description, for all clinical staff should be defined. Clear lines of reporting and accountability should in place. New staff should undergo a formal induction addressing all headings under the charter. Personal copies of policies should be made available to all clinical staff.
All clinical staff should be subject to the same human resources scrutiny with regard to fitness to practice ( eg hepatitis status, offender status / access to minors)
Medical Director
Reports to Trustee Board
Accountable to Charity Chairman
Person Specification
Essential Criteria
Registered with the GMC
Member of the UK Specialist Register
Have experience of anaesthesia / ITU.
Previous operational experience of HEMS work.
Participation in NHS appraisal system or equivalent.
Experience in managing & training junior doctor.
Desirable Criteria
Broad range of aeromedical work
Diploma or Fellowship in Immediate Care
Prehospital Emergency Care Course
MIMMS, ALS, ATLS Certification
Flight Doctors
Person Specification
Essential Criteria
Registered with GMC
Experience in Emergency Medicine
Experience in anaesthesia / ITU
Successfully completed HCC / or a competency based assessment by the medical director (if waiting for HCC)
Desirable Criteria
Diploma or Fellowship in Immediate Care
Pre-hospital Emergency care Course
MIMMS
Experience in other acute care specialties
NOTE: all doctors practicing pre-hospital RSI must be capable of independent practice in anaesthesia, and have experience in the transport of the ventilated patient. This is desirable for medical directors of RSI competent organisations.
Flight Paramedics
Person Specification
Essential Criteria
Registered with HPC
Successfully completed HCC or a competency based assessment by the medical director (if waiting for the HCC)
Desirable Criteria
Diploma or Fellowship in Immediate CarePrehospital Emergency care Course
MIMMS
Organisational Structure
In accordance with Charity Law and the COMPACT agreement, and in the interests of sound corporate governance, each unit should have a defined medical director and deputy. To avoid a conflict of interest, these should be independent of the NHS Ambulance Service. There should be a formal clinical governance committee reporting to the board of trustees. See appendix.
Clinical Governance Committee
Each unit should have its own clinical governance committee. These should have a defined structure, meet at least twice a year and have a nominated non clinical chair. There should be clear reporting lines from and to the committee.
The committee should include representation from:
Anaesthesia / Critical Care
Emergency Medicine
Neurosurgery
Orthopaedics / General Surgery
Other specialties can be seconded as required.
The function of this committee is to interpret the UK HEMS Clinical Advisory Group’s recommendations to a local level and approve each organisation’s clinical SOPs. They should also review Adverse Occurrences, inspect the Risk Register and look at any other issues which may impact on the delivery of quality clinical care.
The medical director should sit on the committee and be prepared to represent its views to the UK HEMS CAG.
Multi-disciplinary Governance Forum
This should meet at least every six months to include a minimum of one notes audit session, one longitudinal audit session and one best practice session. As many crew members as possible should attend these meetings.
Multi-disciplinary Daily Briefing Meeting
Each unit should have a multidisciplinary operational meeting at the beginning of each shift. This should be evidenced
Best Practice
All members of the team should have access to clinical journals either hard copy or electronic access. A six monthly journal club should take place and include all clinical staff. Annual attendance of all clinical staff at a relevant national conference is considered mandatory.
Each unit should have a mechanism whereby updates in clinical practice are available to all members of staff. Clinical practice should be enshrined in a set of clinical standard operating policies that is signed off by the clinical governance committee. These should undergo annual review.
Member organisations will undergo an annual clinical review from a medical director of another charter member. A clinical governance pro-forma will be completed to demonstrate that each member of the HEMS charter is maintaining the highest possible standards of clinical governance. A copy of this should be sent to the medical director of the local ambulance service.
External clinical staff from other units should be encouraged to undergo observer shifts at sister units on annual basis.
Each unit should provide immediate (i.e. less than 5 minutes) consultant clinical support and advice for duty crews.
There should be a named consultant for each patient episode. The consultant must have the same personal specification as the medical director.
Medical records should be stored in accordance with NHS guidelines with a nominated Caldicott Guardian.
Regular meetings between chief pilot, senior paramedic and medical director should take place.
Audit
Each unit should undertake an audit of all clinical documentation at least every six months. A quarterly multi-professional longitudinal audit of clinical care should also take place. A "single issue" audit of practice should also take place quarterly.
A fortnightly audit of six consecutive missions by medical director or a nominated deputy is required.
Morbidity and Mortality Review. All patients that die should be reviewed on a monthly basis by the medical director or deputy. Other occurrences should also be regularly reviewed, these will depend on the unit, but may include missions where pre- hospital anaesthesia was performed, or surgical airways required. These should be presented at one of the multi-disciplinary team meetings.
Units can provide an ongoing measure of excellence by measuring Key Performance Indicators (KPIs).
Safety
Each unit must have a clearly defined mechanism for reviewing incidents / occurrences which provides a strategic oversight of safety issues. Ideally this will be a multi-disciplinary safety committee with a defined constitution, chair and reporting structure. The committee should provide a minimum six monthly review of incidents and occurrences and provide strategic oversight of safety issues.
Any serious incidents should be reported to UK HEMS for the lessons learnt to be disseminated to other member organisations
Clinical Occurrence / Incident Reporting System
Each unit should have a demonstrable occurrence reporting system accessible to all members of staff and a defined system of communicating lessons learnt to all relevant staff.
Medical Indemnity Insurance
Each unit should have clear medical indemnity insurance & clear lines of accountability.
Equipment Maintenance & Review
Procedures should be in place to ensure individual pieces of equipment are maintained to manufactures standards and that operational equipment undergoes daily checks.
Risk Register
It is recognised that not every unit will be able to meet all these standards all the time. A Risk Register must be maintained which details where there are weaknesses, and what processes have been put in place to mitigate against these.
This must be reviewed by the safety organisation and the clinical governance committee whenever they meet.
Training
All clinical staff must be selected because they have shown a commitment to excellence in the care of patients in the pre-hospital environment. Before being allowed to practice independently they must demonstrate that they are competent in the field. Therefore all clinical staff should go through:
• An induction period of at least one day
• A signing off process for new staff by a consultant who fulfils the person specification of the medical director.
Each unit must have a clearly defined set of competencies, with details on how they are tested and revalidated. The actual competencies are outside the scope of this document, but a minimum set is given below. The best mechanism for testing these for new staff is on a Helicopter Crew Course (HCC), but some units may need to develop alternate methods of instruction.
The HCC aims to provide a core knowledge and skill base. It should be the aspiration of every unit to ensure their crews are put through a HCC before they practice independently, and certainly within three months of starting employment In service training should continue and competency should be assessed at individual units by peer supervision. Each medical director should undergo a medical director course.
Core Documents
Each organisation must have the following documentation:
• Standard Operating Procedures (clinical and non clinical)
• Induction Pack
• Incident Reporting Policy
• Resource manual for equipment
• Code of Conduct
• Contract for all staff
• Risk Register
Information Governance
Every medical organisation will need to hold confidential information about patients for audit, legal and professional purposes. It is important that there is a clear strategy for information governance. The core document within this is the Information Security Document which must ensure confidentiality, security but appropriate accessibility to records. All member organisations should appoint a Caldecott Guardian, who should be independent of the medical director and chief executive, to ensure the highest standards are maintained. This person must receive appropriate training for the task.