Professional skills in clinical practiceChapter 1

Patients must be able to trust doctors with their lives and wellbeing. To justify that trust, the profession has a duty to maintain a good standard of practice and care and to show respect for human life. In particular a doctor must:

In all of these matters, doctors must never discriminate unfairly against their patients or colleagues. They must always be prepared to justify their actions.

Good communication is integral to medical practice. Communication is important not only in professional-patient interactions, but also to share information within the healthcare team. The benefits of effective communication include good working relationships and increased patient satisfaction. Effective communication may also increase patient understanding of treatment, improve compliance and, in some cases, lead to improved health. It engenders meaningful and trusting relationships between healthcare professionals and their patients.

The doctor-patient relationship is improved. The doctor is better able to seek the relevant information and recognise the problems of the patient by way of interaction and attentive listening. As a result, the patient's problems may be identified more accurately. Good communication helps the patient to recall information and comply with treatment instructions. It may improve patient health and outcomes. Better communication and dialogue, by means of reiteration and repetition between doctor and patient, has a beneficial effect in terms of promoting better emotional health, resolution of symptoms and pain control. The overall quality of care may be improved by ensuring that patients’ views and wishes are taken into account. Good communication is likely to reduce the incidence of clinical errors.

Effective communication skills may relieve doctors of some of the pressures of dealing with the difficult situations. Problematic communication with patients is thought to contribute to emotional burn-out and low personal accomplishment in doctors, as well as high psychological morbidity. Being able to communicate competently may also enhance job satisfaction. Patients are less likely to complain if doctors communicate well.

Accurate documentation and record keeping is important for both clinical and legal reasons. Records provide a means of communication and record of events. Patient records should be:

Clinical governance is a framework through which healthcare organisations are accountable for maintaining and improving the quality of their services, by creating an environment in which excellence is allowed to flourish. It embodies three key attributes:

Clinical governance addresses those structures, systems and processes that assure the quality and accountability. It ensures proper management of an organisation's operation and delivery of service. Clinical governance is composed of the following elements:

It is no longer acceptable for any clinician to abstain from continuing education after qualification. The continuing professional development of clinicians is the responsibility of the individual and his employer. It is the professional duty of clinicians to remain up-to-date.

Clinical effectiveness is a measure of the extent to which a particular intervention 3works. The measure on its own is useful, but it is enhanced by considering whether the intervention is appropriate and whether it represents value for money. In the modern health service, clinical practice needs to be refined in the light of emerging evidence of effectiveness. It also has to consider aspects of efficiency and safety from the perspective of the patient.

Good professional practice has always sought to change in the light of evidence from research. The time lag for introducing such change can be very long. Reducing the time lag and associated morbidity requires emphasis not only on carrying out and implementing research. Techniques such as critical appraisal of the literature, project management and the development of guidelines, protocols and implementation strategies are all tools for promoting the implementation of research practice.

Poor performance and practice can too often thrive behind closed doors. Processes which are open to public scrutiny, while respecting individual patient and practitioner confidentiality are an essential part of quality assurance. Open proceedings and discussion about clinical governance issues should occur. Any organisation providing high quality care has to show that it is meeting the needs of the population it serves. Health needs assessment and understanding the problems and aspirations of the community require the cooperation between healthcare organisations, public health departments, local authorities and community health councils. The system of clinical governance brings together all the elements which seek to promote quality of care.

Risk management can be defined as a proactive approach that addresses the various activities of an organisation. It identifies the risks that exist and assesses each risk for the potential frequency and severity. It eliminates the risks that can be eliminated and reduces the effect of those that cannot be eliminated. It establishes financial mechanisms to absorb the consequences of the risks that remain. Risk management involves consideration of:

Compliance with statutory regulations can help to minimise risks to patients. This can be further reduced by ensuring that systems are regularly reviewed and questioned. Maintenance of medical ethical standards is also a key factor in maintaining patient and public safety and wellbeing. It is vital to ensure that clinicians work in a safe environment. Poor quality is a threat to any organisation. They need to reduce their own risks by ensuring high quality employment practice, a safe environment and well-designed policies on public involvement.

Risk management is essential to:

Risks can be clinical or non-clinical. Once a risk is identified it must be analysed:

Consideration needs to be given to measures to control the risk. It may be possible to totally eliminate the risk. If it can not be eliminated, the risk should be minimised. Funding for risk management is part of every hospital's budget through the Clinical Negligence Scheme for Trusts and existing liabilities schemes.

Clinical audit is the review of clinical performance and the refining of clinical practice as a result and the measurement of performance against agreed standards. It is a systematic, critical analysis of the quality 4of medical care, including the procedures used for diagnosis and treatment, to help to provide reassurance that the best quality of service is being achieved, having regard to the available resources. Clinical audit is an assessment of total care and can assess:

Medical audit involves a systematic approach that highlights opportunities for improvement and provides a mechanism for change. It is not simply case presentations at morbidity and mortality meetings. The audit cycle (Figure 1.1) involves:

Audit techniques include:

Comparative audit requires:

There are approximately 600,000 deaths per year in England and Wales. The cause of death is certified by the attending doctor in 75% cases. Of the 150,000 deaths referred to the coroner, 60% are referred by doctors, 38% by the police and 2% by the Registrar of Births, Marriages and Deaths. Initial investigations are conducted by coroner's officers. They are often retired policemen. A death certificate may be issued after discussion with a coroner's officers. Coroners hold inquests for about 10% of deaths that they certify.

A death should be referred to the coroner if:

The Coroner's Act 1988 defines when an inquest should be held. Inquests are held in public and may involve a jury. The purpose of an inquest is to determine:

The coroner is not concerned with civil or criminal liability. A coroner may record the cause of death as:

For an allegation of negligence to succeed claimant must prove:

All healthcare professional have a duty to become and remain competent. The level of skill will depend on experience and seniority of the professional. If a senior delegates responsibility to a junior he must be sure the junior is competent. Otherwise he remains responsible for any resulting error - vicarious liability. A breach of duty of care occurs if the healthcare professional fails to reach the proficiency of his peers. This is known as the Bolam test. It applies equally in treatment, diagnosis and advice. The breach can be something done (commission) or something not done (omission). A doctor can not be negligent if he acted in accordance with relevant professional opinion and this principle applies even if another doctor would have adopted a different practice. Ignorance is not a defence for negligence. Errors of clinical judgment (e.g. wrong diagnosis) often do not amount to negligence.

Actionable harm or damage is the disability, loss or injury suffered by the claimant. 6However negligent the defendant has been, the claimant must have suffered quantifiable harm. Quantifiable harm includes:

There may also be an element of contributory negligence. This occurs if the actions of the claimant is judged to have made the situation worse and can reduce the amount of damages awarded.

Causation is the link between actionable harm and breach of duty of care. The harm has to have occurred as a result of the actions of the defendant.

The burden of proof lies with the claimant. The standard of proof is the civil standard of balance of probabilities. Actions must be brought within 3 years. Different rules apply for children and mentally ill. If a claim is brought, the solicitor issues a Letter of Claim. A Letter of Response should be provided within 3 months. If the case continues, claim forms are raised by the solicitor and submitted to the court.

The Woolf report in 1994 noted that in medical negligence cases there was a disproportionate relationship between the costs and the amounts awarded. There were long delays in the settling of claims and unmeritorious cases were often pursued. Clear-cut cases were defended longer than should have been and success rate was lower than for any other personal injury litigation. There was less co-operation between opposing parties and 90% of litigants were legally aided. Woolf has proposed case management by the courts, alternative means of dispute resolution, court-based experts and judges with specialist medical knowledge. The future may include no-fault compensation, early settlement using fixed tariffs depending on the injury caused and greater use of mediation to settle disputes.