delegated practice: structural delegation · delegated practice: structural delegation resource...

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© State of Queensland (Queensland Health) 2013. No part of this document may be reproduced without the express permission of Queensland Health.

Delegated practice: structural delegation

Resource

Estimate: 15 mins

Professor

Lynn Robinson

Professor Lynn Robinson is the Director of Research and Development at the Centre for Innovation in Professional Learning (CIPL), The University of Queensland, where her interests are in large-scale professional workforce capacity development, particularly using online networks. Before joining CIPL in 2010, she had a long career in the health care sector encompassing general practice, hospital administration, health system reform and health systems research. She has had a lifelong interest in education and has taught many thousands of health professionals on topics related to clinical leadership, teamwork, innovation and quality and safety.

Multimedia resource In addition to the lecture transcript below, this lecture is available as a multimedia presentation (audio over PowerPoint slides).

Delegated practice: structural delegation Estimate: 15 minutes

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Delegated practice: structural delegation

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Slide Transcript Enter your notes

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In this session we are going to look at the concept of structural delegation and we will unpack this at the three levels of the health care system at which structural delegation happens: • the macro-level, the level of the design of the whole health system in the jurisdiction • the meso-level, the organisational level at which health services are managed to deliver care • and the micro-level or coal face, where the individual clinicians work with each other to deliver specific care to patients and clients.


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So let’s have a look at structural delegation, in the context of delegated practice, working with assistants. Increasingly, in a move to improve the quality and availability of health care, we are as a health care system, looking at re-designing models for care. We have particular challenges in Australia, and indeed these are shared in the western world, with a shortage of health professionals in almost every category. We also have the tyranny of geography here in Australia, where we have large numbers of people living in rural and remote communities, but they have an even smaller proportion of health workers available to them. And so, increasingly, we’re looking at innovation in the way we think about the delivery of care. This innovation is really leading us very much towards working in teams, and within teams to looking at traditional roles, and extending the roles of people who are trained in some aspects of care delivery, but could be doing more to the benefit of the patient and their own job satisfaction.


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Increasingly we’re focusing on actually creating environments where teams can work cohesively in an integrated fashion, to ensure that the patient is the centre of care but that the appropriate care can be delivered by best using the skills of the team. The matching of roles and training to the level of complexity of the tasks that need to be undertaken is an important part of this. Where does structural delegation come into that? Well structural delegation, I guess, is really a fancy term for the scaffolding in the system for the role of an assistant in the delivery of the care plan. This scaffolding includes things like policy, legal and legislative and regulatory environments for new and extended roles, the types of things that allow us to define roles within a team, which could include, for example, job descriptions, local standards of practice, scope of practice documentation, and potentially protocols and the like. And it also includes definitions of the supervisory relationship, standards for supervision, the required training for


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supervisors, and the way that that will be monitored. And finally we need to look at what kind of quality systems we need to put in place, and how we need to adapt our quality assurance systems to incorporate the new ways of working in teams so that we can actually monitor the performance of not just the team but the individual performance of roles within that team; and how those things lock together. And ultimately of course, that’s about assuring the quality of the care for patients and consumers.


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It’s helpful to consider this scaffolding at three layers – the macro, the meso and the micro layers. At the macro layer, we’re really talking about governance and parts of the scaffolding that actually appear within the health care system itself. Though it’s not normally the province of clinicians themselves, it’s important that someone has actually considered the legislative and regulatory environments. In most instances of delegated practice, there needs to be very little if any change to the legislation. And indeed, our legislation provides for quite a lot of delegation within the scope of practice of all our registered health professionals, provided it’s linked with that notion of responsibility being with the registered health professional. Occasionally there are regulatory boundaries or requirements for the alteration of regulation. One typical example would be, for example, the Poisons Act regulations in regards to what can and can’t be delegated from pharmacists, nurses or medical practitioners. So it’s important to be


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aware of that, and if necessary, to actually consider whether regulatory changes are required to support improved teamwork. And then there’s the central policy issues. Is it necessary, for example, to develop standards of practice or codes of practice? Sometimes a scope of practice for new definitions of roles within the team, like clinical assistants, allied health assistants or rehabilitation assistants and physician assistants. It’s commonly thought of in terms of change management, that this macro scaffolding layer, while important as forming a sort of legal boundaries or regulatory boundaries around improving the structure and functioning of teams, is not really our main focus in looking at structural delegation. The next level, the meso level, the organisational level, is probably where most of the focus would happen for us in terms of introducing new or extended roles within teams.


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At the macro layer in Queensland Health the governance guidelines for allied health support staff are a policy, which have been developed by Queensland Health, as a part of this scaffolding. They address broad policies and procedures relating to the implementation and operation of delegated practice, in this instance allied health assistants and their supervisors and managers. You will certainly like to have a look at this document at your leisure.


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The meso level of structural delegation covers the organisational level of care, and it’s how we think about the health service delivery models that we’re working with. Although as an individual you may have limited role here, I think it’s very important at the least to understand this scaffolding, because as you carry out your day-to-day responsibilities as a clinical supervisor, or indeed in some instances, as a delegatee or assistant, you need to understand and be familiar with all of the policies and structures that inform your role and responsibilities. Generally theses are enabling, but where necessary, to ensure safety and quality, these organisational policies and procedures may put boundaries around what can and can’t be done by different members of the team. You might like to consider how much of this level of scaffolding is in place in your work setting. Definitions of the scope of practice of both the supervisor or the assistant, definitions of standards of practice, expectations of people in different roles. Do you need a credentialing system? Local training systems, or achievement of


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competencies in different ways, maybe important prerequisites for being able to undertake a role, either as a supervisor or an assistant. We’re all familiar with job descriptions. I think one of the challenges in introducing working with assistants in teams, when this is a new model, is that folk tend to focus on the development of the job description for the assistant, perhaps failing to recognise that some adaptation of responsibilities for those people who are undertaking the supervisory roles also needs to be done at the time of the introduction. Have a look at your job descriptions and make sure that they now line up, and they actually support the model of care that you’re trying to work with. It’s also extremely important that lines of accountability are made explicit, particularly in an environment where perhaps the clinical supervisor may not be the line manager of the assistant. In this situation, the difference between the line of accountability to the management structure may need to be clarified relative to the lines of accountability in terms of a delegated practice model.


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For example, if an allied health assistant or a community rehab assistant holds accountability for the day-to-day delivery of a rehabilitation programme in the community, and that clinical accountability may go to a physiotherapist or an occupational therapist, who’s actually mapped out the care plan to begin with, that may be a different reporting relationship from the rehab assistant’s chain of command in an organisational sense in terms of their performance appraisal, say. It’s very important to actually make these explicit and to work out how the two relationships work in co-operation. I think another thing that may be forgotten is that this is not all a one-way process from clinical supervisor to assistant. In fact, far from it. We’re talking about teamwork here, and so it’s equally important that there be standards for the supervisory process, that the ability of the assistants to be accountable for their work within a team, is very much dependent on the quality of the supervision. And as supervisors, we need to be prepared to be held to account to standards as well and take


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this role as seriously as we do other professional responsibilities.

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I just want to mention here the Calderdale Framework. Originally developed in the United Kingdom for Effective Workforce Solutions, the Calderdale Framework is a workforce development tool that engages frontline staff at all levels to ensure safe and effective patient centred-care. It provides a clear and systematic method for reviewing skill mix, developing new roles, identifying new ways of working and facilitating service redesign by: • Identifying tasks carried out in teams • Deciding which can be delegated or skill-shared across professional boundaries • Creating local competencies to standardise how tasks are carried out • Providing structured training and competence assessment for professional skill sharing and delegated practice • Establishing governance processes to


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support clinicians • Establishing systems to sustain the model of practice in the long term. It’s quite probable that the Calderdale Framework has been used in the development of your own service delivery models in your local teams for allied health assistants. You might like to reflect on whether this has happened, perhaps speak to somebody about the process that has preceded your current situation.


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Now at the micro level, this is where the teamwork really comes into its own and you can have quite a lot of local adaptation. In terms of the care delivery process that your team is involved in, you may have policy and procedure manuals that guide the actual delivery of care, and hopefully these will be evidence-based and consensus developed with all the members of the team participating in the development. You may have specific protocols or care plans. The example that I was using earlier, is a typical example of this, where a rehab team will share a well-documented rehab plan for an individual patient. And this is the basis of the teamwork. It’s around the care plan itself that the tasks and processes are undertaken. And there will, of course, be local quality activities. It’s important to consider when you’re looking at how you monitor the quality of your patient care as a team, that you also incorporate quality activities that surround the supervisory relationship, and the performance of people in their


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roles as assistants and as supervisors in the team. And teamwork processes – things like team meetings, when and where you will discuss, when and where will there be feedback provided, what about when variance happens within the care plan? Then you need to consider the supervisory relationship. How does the line of communication happen? Will it be remote? Will it be by observation? What techniques will be used to actually ensure that your team is producing a quality result for patients? At the very least, you would want to consider and make explicit within your team, notions of what assistants can expect of their supervisors, and how this will be carried out. And that supervisors need to be aware and participatory in defining that relationship, and of course, working hard to make it work.


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So in summary, we’ve unpacked the scaffolding for both implementing a change from traditional practice to newer models of delegated practice and discovered that work is required to put in place appropriate systems at all levels from potentially state-wide legislation, regulation and policy to the policies and procedures and teamwork in specific organisational units. Each layer plays an important role in building-in safety and quality into patient care. Armed with this mind-map, you might like to run the ruler over your particular situation to identify the strengths and weaknesses of the structures around your own delegated practice scenario.


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References 1. McConnell CR. Delegation vs empowerment: What, how and is there a difference?

Health Care Superv. 1995 14 (1), 69-79. 2. Allied Health Workforce Advice & Coordination Unit. Models of care: Meeting individual

& community needs through workforce redesign [pamphlet]. [Undated]. Queensland Government.

3. Calderdale and Huddersfield NHS Foundation Trust. Developing the role of the Assistant Practitioner. NHS Employers. Available from: http://www.nhsemployers.org/SharedLearning/Pages/DevelopmentofAssistantPractitionerRoleusingtheCalderdaleFramework.aspx

Further Information! The ‘Delegation flowchart’ can be found in the Appendices of both facilitator and participant kits.


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Learning Goals

Have you met these Learning Goals?

• Understand the concept of structural delegation as it applies to clinical supervision

• Describe the macro, meso and micro scaffolding that underpins structural delegation


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mai

Using an implementation checklist in your local setting

Group learning

Estimate: 15 mins

Table of contents 1.0 A checklist tool for implementing an Allied Health Assistant role 2.0 Using the checklist in your clinical setting

Learning Goals

• Discuss the concepts of responsibility and accountability as they apply to allied health professionals and allied health assistants

• Apply systems to assist implementation of models of care incorporating allied health assistants

Reflection If your team is working progressively through the materials in this workshop over a period of weeks, take a moment to quickly refresh your memory of what you have previously covered in this workshop before continuing on with this new topic.


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1.0 A checklist tool for implementing an Allied Health Assistant role

Instructions

Working together as a team, have a go at filling out the ‘Checklist for implementing an Allied Health Assistant role’.

Further Information!

A copy of the ‘Checklist for implementing an Allied Health Assistant role’ can also be found in the Resources section of your workshop guide.


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Checklist for implementing an Allied Health Assistant role [1, 2]

Task / Decision Applicable Yes / No

Actions Required Completed

(Tick if yes)

Identify need

Identify resources required

Identify any regulatory/legal requirements which will impact the supervisor/ assistant role

Supervisor Define scope of practice

Assistant

Supervisor Define standards of practice

Assistant

Supervisor Write/modify job description

Assistant

Supervisor Define training/ credentialing system

Assistant

Review/update organisational chart

Define relationship between supervisor and assistant

Review specific policy and procedures

Review/establish quality activities specific to supervisor/assistant role

Establish teamwork processes:

• lines of accountability

• lines of communication

• meetings

• feedback


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2.0 Using the checklist in your clinical setting

Group discussion questions 1. Share your thoughts about how the ‘Checklist for implementing an Allied

Health Assistant role’ can be useful for your team and workplace.


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References

1. Kleinman CS, Saccomano SJ. Registered nurses and unlicensed assistive personnel: an uneasy alliance. Journal of Continuing Education in Nursing 2006;37(4):162-70. 2. Parkman C. Delegation: are you doing it right? AJN 1996;96(9):43-7.

Learning Goals

Have you met these Learning Goals?

• Discuss the concepts of responsibility and accountability as they apply to allied health professionals and allied health assistants

• Apply systems to assist implementation of models of care incorporating allied health assistants

Authority

This training program has been developed by The University of Queensland’s Centre for Innovation in Professional Learning for use by The Department of Health and Hospital and Health Services established under the Hospital and Health Boards Act 2011 (Qld).


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