2.2 Safety and quality issues arising in the case of Mrs H
Patient-centred care emphasises collaboration and shared-decision making between the healthcare team and the patient and family.(1, 3, 4) It encourages patients and families to participate in their care and advocates for patient dignity and respect.(4) The NSQHS Standards provide guidance in specific clinical areas of patient care.(1) The Comprehensive Care Standard discusses the requirement for an individualised comprehensive care plan which addresses the patient’s health issues and risks of harm and identifies the support people a patient wants involved in communications and decision-making about their care. (1) As identified in the Ombudsman report and the fishbone diagram, the care provided to Mrs H, fell below the expected standard of care. The fishbone diagram provides a list of contributing root causes that contribute to each factor. The Standard further identifies the requirement to apply screening and assessment processes to identify patients at risk of harm including malnutrition and injury from falls. It is unknown whether Mrs H’s malnutrition was identified by staff, however it is evident that this was not rectified as is mandated by the Standard. Patients with poor nutrition are at greater risk for adverse outcomes including impaired wound healing, pressure areas, infections, increased length of stay, readmission and mortality. (1, 5, 6) The health organisation has a responsibility to have guidelines which address falls prevention and post-fall management, and minimises harm from falls.(1) Mrs H’s falls and injuries sustained were not documented. Due to the discussed limitations, it is unknown whether these falls are due to gaps in systems, policies or procedures; or whether they are attributed to individual staff non-conformance. It should be noted that clinical governance and quality improvement systems are not effective if errors are not reported. Increased time and requirement for documentation results in potentially less time providing direct patient care. (7, 8) However in the case of Mrs H, neither accurate documentation nor quality clinical care was provided. Possible contributing root causes are identified in the fishbone diagram above.
The Ombudsman report listed numerous failings of the hospital in their dealings with Mrs H’s niece featuring communication breakdowns. This resulted in unnecessary distress for both Mrs H and her niece. It also directly conflicts the NSQHS Standard and concept of patient- and family-centred care. Contributing root causes identified in the fishbone diagram included overarching systems as well as individual factors (e.g. individual communication skills, attitude, fatigue etc.). Transfer points between facilities are associated with communication breakdowns and preventable adverse effects.(4, 9) The discharge plan for Mrs H was inadequate with there being poor transfer arrangements and no handover to the home. Poor communication and information sharing at the point of transfer is associated with reduced quality of care and adverse outcomes.(10) The Partnering with Consumers Standard states that information needs for ongoing care are required to be provided on discharge.(1)
Health professionals are central in the role of providing health information to patients.(11) The extent to which patients can understand, evaluate and apply information to make effective decisions about their health care is connected to their health literacy. (11, 12) Low levels of health literacy occur disproportionately in the elderly. (11) In addition to this, people with complex communication needs, such as Mrs H, have an additional barrier which restricts or limits their ability to comprehend, recall and act on the information provided to them. The National Safety and Quality Health Service Standards provide guidance in specific clinical areas of patient care.(1) It recognises the role that health literacy and communication plays in the delivery of safe and high quality patient-centred care. If patients do not understand the information presented to them, they cannot be informed participants in their care.(4) In the case of Mrs H, communication was difficult, and no personalised plan was developed to aid staff. This resulted in a major disparity between expected and delivered care. The fishbone diagram highlights a few factors which may have contributed including inadequate communication skills of staff. It then further dissects possible reasons for this which includes (but is not limited to) lack of understanding of and skills for collaboration, inadequate training staff fatigue or staff attitude. A personalised care plan for Mrs H may have included an Alternative or Augmentative Communication (e.g. communication boards, gesture or signing systems).(13) The expectation for adequate communication is also expressed in the Australian Charter of Healthcare Rights which state that a person has the right to receive open, timely and appropriate communication about their healthcare in a way they can understand.(14) The Australian Bureau of Statistics documented that nearly 60% of Australians have low health literacy.(15) Lower health literacy is associated with higher use of health services, lower quality of care, an increase in the prevalence of adverse health outcomes and reduced patient satisfaction. (11-13, 16)
As a consequence of the failure to personalise Mrs H’s care, her dignity and individuality were compromised. A once independent, dignified woman who took pride in her clothing was transferred to an aged care facility agitated and distressed, soaked with urine and dressed in clothing that were sizes too big for her and not her own. The International Charter for Human Values in Healthcare and Australian Charter of Healthcare Rights, focus on the rights of patients and values that should be present in every healthcare interaction.(14, 17) The charters discuss the importance of compassion and respect for persons. The care provided to Mrs H was in direct opposition to these charters. Dignity can be promoted or reduced, especially in care situations, by individual attitudes and interactions, the environment and organisational culture.(18) Meyer (2009) stated that when dignity is present, people feel more valued, in control and are able to make decisions about their healthcare. Conversely, if dignity is absent people lack control, feel humiliated, ashamed or embarrassed and may be unable to make decisions for themselves. (18, 19)

2.3 “What happened next”
As identified in the Ombudsman report, the Trust has recognised some of the possible contributing factors for the inadequate care provided to Mrs H. They created plans to address some of the issues and prevent a similar event from reoccurring. The study days to determine staff attitude, knowledge and beliefs is only the beginning of the process. The learnings gathered during this process needs to be utilised to reform policies and procedures (if required) and be transferred into an education program that is delivered to the staff. As described in the NSQHS Standards, a health organisation has the obligation to review and maintain the currency and effectiveness of their policies and procedures; and monitor and act to improve adherence.(1) Communication was a reoccurring theme throughout the report. In addition to the stated points of concern for the study days, how staff attitudes and expectations influence their priorities and use their time to communicate, also needs to be addressed. In the literature, time is often seen as a barrier to effective communication.(6)(9) However the scheduling of extra time alone may not be adequate to ensure communication success.(6) The Trust should provide staff training with the aim of developing a range of adaptive communication skills. A key shortcoming in the care of Mrs H resolved around her discharge. The discharge procedures need to be redesigned, with patient discharge involving contribution from patients and families, as well as healthcare professionals. The appointment of an admission and discharge co-ordinator is the first step in this process. While money cannot replace the anxiety and distress experienced by Mrs H prior to her death or her niece, it hopefully adequately contributed to replacing lost belongings and funeral arrangements.

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3.0 Recommendations
1. An education program targeted towards health professionals should be implemented to assist with the development of adaptive communication skills.
2. Information and training should be provided to healthcare professionals, administrators, patients and families about building collaborative relationships and implanting patient-centred care.
3. The Trust should provide education to staff on documentation standards required and the most efficient strategies to complete these.
4. The Trust should review documentation policies and procedures to ensure unnecessary and unessential documentation is not requested from staff in order to increase the time able to be spent at the bedside.

4.0 Conclusion
In conclusion, this report identified quality and safety concerns in the care provided by the NHS Trust to Mrs H. A fishbone diagram was developed to identify contributing root causes based on the information provided by the Health Service Ombudsman. These findings were then compared with the NSQHS Standards. The steps taken by the Trust to prevent a similar event occurring were analysed and further recommendations were provided. ?

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