Quality in elderly care is created in the present, in the meeting between the staff, residents and relatives.
This article is written from a Swedish perspective. Hopefully, it can inspire interested parties from other countries.
As a relative, it may be important to know if mom has been out for a walk today. In a nursing home, activities of various kinds are constantly taking place. At the same time, it may be that the resident does not remember if they have been outside or participated in activities. Then it is important that it is documented in a simple way.
Why traceability is important in tasks at a nursing home
Traceability plays a crucial role in ensuring that tasks in a nursing home are performed correctly and that the residents receive the care they need. By having clear and traceable documentation of which tasks have been performed, by whom and when, it creates safety and security for both the residents and the staff.
A key principle in all quality management is traceability. It should be possible to follow that all activities in a process have actually been carried out.
When a Volvo is built, everyone realizes that each car must be safe. Every part must be correctly assembled, so that it does not turn out that someone had forgotten to assemble the brake pipes correctly. It should be just as important that everyone follows the processes correctly when we work with people. At the same time, there is a challenge in that the process must be adapted to the person receiving the care.
The culture looks a bit different in health care. Somehow, people trust that all healthcare workers will do their best and that it will therefore be good. There are parts of the healthcare apparatus where this type of accuracy exists. This applies, for example, in labs and in the pharmacy world. Dental care also has more clear processes that are followed. Likewise, laboratories have full control of their processes. A sample that ends up in the wrong test tube or is handled incorrectly will not be possible to analyze or in the worst case will give incorrect test results.
When it comes to medication management, it is usually quite easy to trace what has been done. Units that have electronic signing can do it with even greater precision. But what about movement training that has been prescribed or things that have been agreed upon in the implementation plan. Likewise, it can be important to follow weight or that wounds have been redressed.
In a nursing home, it may be important to know who has been offered to participate in activities, walks or had something special to do during their own time. Also, that a resident has declined to participate. Other things that may be important to keep track of are when the resident last took a shower or when the apartment was cleaned.
It may also be important to follow up how long the residents have to wait for alarms at different times of the day and that food has been handled correctly.
What is traceability?
Traceability means that it is possible to follow a task's implementation from start to finish. In elderly care, this can involve everything from medication management, daily care and hygiene routines to social activities and documentation of care efforts. When all steps in the work process are clearly documented, it becomes possible to retrospectively go back and see what has been done, when it was done and by whom.
The importance of traceability in care
Increased safety for the residents
Traceability creates a sense of security for the residents by ensuring that all tasks are performed correctly and on time. For example, it is crucial to know when a resident has received their medicines and that the correct dosage has been administered. If something should go wrong, such as a medicine being missed or given incorrectly, it is important to be able to go back and identify exactly what happened and why. In this way, risks and problems can quickly be discovered and addressed.
Improved distribution of responsibility
With clear traceability, it becomes easier to distribute responsibility and ensure that all tasks have been performed as planned. This is especially important when several employees are involved in the care of the same person. By having a documented follow-up of tasks, such as laundry, cooking or personal hygiene, management can more easily ensure that nothing is overlooked and that all tasks are performed with high quality.
Support for management and quality assurance
Follow-up of work efforts
Traceability helps management to follow up and quality assure the business. By having clear documentation routines, it becomes easy to review how tasks are performed and to see if there are areas where improvements are needed. Traceability also gives management the opportunity to analyze the efficiency of the work and ensure that the right resources are used in the right place.
Basis for evaluation and learning
Having traceability means that there is a clear history of how the work has been performed. This information is valuable when evaluating how work processes work and if changes may need to be made. In addition, it provides a good basis for learning and skills development within the organization, as it is possible to analyze what works well and what can be improved.
Prevention of errors and misunderstandings
Reduced risk of mistakes
By having traceable documentation of all tasks, the risk of something important being forgotten or performed incorrectly is reduced. For example, traceability can show that a resident has not received their daily exercise or that a medication has been forgotten, which can be discovered and corrected in time. In this way, traceability contributes to minimizing the risks of medical injuries and other mistakes.
Prevents misunderstandings
In an environment where many employees share responsibility for the same resident, it is easy for misunderstandings to occur. Clear documentation and traceability mean that everyone has access to the same information, reducing the risk of misunderstandings about which tasks have been performed and what still needs to be done.
Traceability and transparency towards relatives
Increased security for relatives
Relatives of residents in the nursing home often feel a great concern for their relatives' well-being. By having a system for traceability, the staff can easily show what has been done, creating security and trust for both the residents and their relatives. It becomes easier for relatives to follow up on the care and feel involved in the process.
Possibility for dialogue
Traceability can also be an important part in communication with relatives. By having access to detailed documentation about what has been done and how the care has been carried out, it becomes easier to have an open and honest dialogue with the residents' relatives, which in turn strengthens confidence in the business.
Traceability is crucial in ensuring high quality and safety in elderly care. By having clear routines and documentation for all tasks, staff can reduce the risk of mistakes, improve the distribution of responsibility, and create security for both the residents and their relatives. Traceability also gives management the opportunity to follow up and evaluate the work in order to constantly improve the business.
Reflection questions - traceability:
Care staff:
- Are there areas where you should have better control over what should be done is done?
- Have you had any deviations where it has not been possible to figure out what really happened?
Manager, nurse, occupational therapist and physiotherapist:
- Is there good compliance with what has been agreed in implementation plans or prescribed in a care plan?
- Can compliance be improved by improving traceability?
Resident and relatives:
- Are the care interventions that have been decided carried out correctly?
- Do employees document so that it is possible to see what has been done?
Erland Olsson
Specialist nurse
Sofrosyne - better care every day
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