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  8. Developing Advanced Practice Roles: Clinical Governance

Developing Advanced Practice Roles: Clinical Governance

Robust clinical governance is fundamental to safe and effective clinical practice. Dietitians working in Advanced Practice or Advanced Clinical Practice often undertake extended and/or advanced practice roles where patient safety is paramount.

Healthcare Professionals (HCPs) must be aware of the legal and professional boundaries, the ‘scope’, of the role, and must ensure that they have sufficient training, supervision and preparation to undertake the role safely and effectively to the required standard.

Comprehensive clinical governance will minimise the risks to patients, the employer and the healthcare professional undertaking these emerging advanced roles. 

The following guidance was developed to identify key considerations relating to Advanced Practice roles, in addition to local policy and practice.

Legal standards

There are two legal standards that apply to the expansion of practitioners’ roles:

  1. The constitutional standard (‘the rule of law’) that requires the practitioner to act within the law
  2. The minimum quality standard (‘the rule of negligence’2) that requires a practitioner who takes on a role or task previously performed by a doctor, to perform that role or task to the same standard as medical staff.

Fundamental considerations

The practitioner is required to:

  1. Hold current and valid registration as a healthcare professional with HCPC. Adhering to the relevant professional standards is essential
  2. Hold professional liability cover, relevant to the role
  3. Demonstrate capability and aptitude to perform at an advanced practice level as defined by local policy and practice, and the relevant UK AP/ACP Framework
  4. Maintain evidence to demonstrate clinical competence for any roles undertaken
  5. Define the role and scope of practice formally, ensuring that these details are included in your job description
  6. Practise within your scope of practice, and committing to undertake relevant Continuous Professional Development (CPD).

As an NHS employee, you are eligible for the organisation’s indemnity insurance as long as you are appropriately trained, can evidence that you met the desired competencies and it is written into your job description. Some organisations use generic job descriptions; however, it is essential that you have a specific job description including duties that are beyond the traditional role of a dietitian.

Delegation of medical tasks

Delegation is defined as the transfer to a competent individual, with the authority to perform a specific task in a specified situation. These principles relate to the development of Advanced Practice/Advanced Clinical Practice roles as various tasks may be delegated, and therefore consideration of the scope of practise should be considered at all times.

Healthcare professionals are accountable for all aspects of their practice, including accountability for what they choose to delegate, and agreement, or not, to undertake activities which are delegated to them.

The HCPC states that “Our standards recognise that anyone moving into a new role will need to receive appropriate training and support which might include supervision. In addition, if work is being delegated to you, the person who has delegated that work will need to continue to provide appropriate supervision and support.”

The General Medical Council3 states that “When delegating care you must be satisfied that the person to whom you delegate has the knowledge, skills and experience to provide the relevant care or treatment; or that the person will be adequately supervised.”

If the delegate operates outside the agreed scope of practice, they could be subject to a claim of medical negligence. Should any error occur, a record must be kept as evidence of clinical competence, to include training and audit of performance.

Insurance Provision

You must be able to justify how any activity you undertake sits within the scope of dietetic practice

All HCPC registered Dietitians are “required to have a professional indemnity arrangement in place as a condition of your registration with HCPC”. When registering/renewing registration, “you will be asked to make a professional declaration to confirm that you have (or will have) one in place and that it provides the appropriate level of cover”.

As defined by HCPC, appropriate cover depends on a combination of factors including:

  • the practice area or areas you work in
  • the service users you work with
  • the risks involved with your practice

The purpose of this is to ensure service users are able to recover compensation they may be entitled to, if harmed due to negligence on the part of the practitioner. More information about HCPC insurance requirements.

BDA Insurance Cover

The BDA insurance policy only provides cover for nutrition and dietetic practice. Therefore, if the main purpose of your Advanced Practice role is providing nutrition and/or dietetic expertise then it will be covered under the BDA policy, subject to the terms and conditions of the policy. However, if the activity, you are undertaking is invasive, surgical, or high risk you must complete and submit this form.

You should await further correspondence from the BDA, as this will require further agreement with the insurers. Please be advised responses on complex insurance queries can take the insurance company significant time to respond to. We therefore recommend you make the enquiry before taking on the activity/role.

As part of the policy, a member must be working within their personal scope of practice meaning that: 

  • They have the relevant knowledge, skills, training and support to adequately equip them to perform the activity safely and effectively, 
  • they have documentation to support competency, where appropriate
  • the activity is completed often enough to maintain competency and they complete all relevant future training as required
  • the task is included in their job description.

In addition to the above, you should also ensure that you are covered by your employer’s indemnity provisions by discussing this directly with your organisation. 

It is your individual responsibility to ensure that you have appropriate insurance in place for your role so please ensure you have read and understood any policy you are covered by. For further information related to the BDA Insurance cover, including the full policy document and terms and conditions, please visit our web pages.

This table also covers the scenario where the Advanced Practitioner is working across organisational boundaries.

Organisational Responsibility Considerations for Advanced Practice

Service Level Agreement / Contract

 

Roles and responsibilities are clearly defined

 

 

 

Priorities and strategic direction set and communicated

 

Resource allocation

 

 

Employee of the organisation; hence eligible, if practising within scope and job description, for organisation indemnity.

Roles and responsibilities are captured in the job description and person specification.

Employees are banded appropriately and reimbursed for the increased responsibilities and risk they accept through working in an Advanced Practice posts.

All stakeholders should be aware and have a clear understanding of the referral criteria, boundaries of the role and upward escalation and onward referral.

Contractually provided time should be built into the job plan, covering supervision, Continuing Professional Development (CPD) and the range of activities to support working across the 4 pillars within the multi-professional framework. 

Examples:

NHS England
Health Education England
Monitoring arrangements

Line of accountability, frequency and content of reporting, clinical supervision arrangements.

Clear responsibilities and pathway for escalation if a task sits outside of these e.g. delegate to responsible clinician.
Procedures to cover sickness, annual leave, maternity leave, emergency leave Advanced roles are likely to have core tasks covered by medical teams, often defaulting to on-call rotas.
Care Quality Commission (CQC) in England, Healthcare Improvement Scotland (HIS) and Healthcare Inspectorate Wales (HIW), Regulation and Improvement Authority in Northern Ireland (RIANA) If scope of practice covers key regulations then the AP should report accordingly to the CQC/HIS/HIW/RIANA, lead for the employing NHS organisation where appropriate.
Complying with legislative requirements

Hold professional liability cover, with specific reference to advanced or extended roles.

Regular audit and supervision, as required.
Organisational and committee structures, systems and processes are in place Link in with Advanced Practice lead in board or trust to establish and embed these.
Clinical Effectiveness Comments
Clinical audits and outcomes measures. Ensure relevant clinic audits are undertaken as well as outcomes data (using valuated tools where available) and act on this data to drive service improvements locally and nationally. Use digital processes such as SNOMED where possible. 
Service redesign Evaluate pathways of care with patient and public involvement taking into account: staffing, incidents, audit and research.
Research and Development There must be protected time and mechanism for sharing research activities and findings to medical and research teams and others relevant.
Job planning

BDA Advanced practice job planning

NHS England job planning
Clinical Risk Management Comments
Incident reporting and response Incidents are investigated; underlying system issues and root causes identified which could include : Near miss, medication incident, adverse drug event, adverse drug reaction, clinical incident, open disclosure, expression of regret, incident rating process, patient involvement and communication.

Managing Risk - Risk assessment tool


Risk register

Risks should be proactively and reactively identified


Missed diagnosis, lack of sufficient follow-up plan when investigation ordered, risk of allergies/medication history/medical history incomplete, missed diagnosis of a serious condition,  deteriorating patient, serious adverse event due to delay in diagnosis, failure to clearly communicate to patient that AP is a non-medical practitioner, inappropriate staffing levels, staff poor performance, advanced practitioner  works outside of scope of practice, risk of manual handling incident; medical devices failure, lack of appropriate cover in absence.
Patient safety and quality Mandatory training, safety and quality indicators defined, monitored and reported, innovation and research into safety supported.
Medicines Management

Non-medical Prescribing - How is competence being maintained? Ensure you are on the local register are following local protocols as defined by your NHS employer.


Are patient groups or patient specific directives in place if required?


Non-medical Prescriber updates/competencies being met.
Clinical/medical emergency plan Adverse drug reactions, anaphylaxis, red flags, cardiac arrest, first aid and medical kit well stocked, accessible and maintained.
Procedures for managing patient journey Ongoing monitoring, follow-up procedures, patient recall procedures, transition out of service and onward referral, discharge procedure and plan, self-discharging procedure
Clear lines of accountability and protocols for communication with other services  
Chaperone policy  Where appropriate; may also require review of Consent procedures in light of increased role/responsibilities.
Structured clinical, administrative and combined team meetings Attendance at organisation/network Advanced Practice meetings.
Education and Training Comments
Scope of practice document Ensure that patient, colleagues and all relevant across the health economy, understand this.
Advanced Practice recognition Ensure you are familiar with, and meeting the relevant Advanced Practice framework: Scotland, Wales, Northern Ireland, England. In England, there are two routes to Advanced Practice recognition (supported ePortfolio or taught route). Find out more.
 
Continued Professional Development (CPD)

Ensure this is identified in job planning; sufficient time and resources/funding available for necessary updating. Learn more.

CPD should include multi-professional learning and be across all 4 pillars.


Ensure inclusion of Leadership training as the staff member progresses.
Supervision and mentorship structure For new Advanced Practitioners/Advanced Clinical Practitioners agree supervisor, mentor and buddy, clinics run concurrently with medical staff, peer support of Advanced Practice trainee. Learn more.
 
Linking into other organisation Advanced Practitioners and regional and national networks.
 
Community and consumer participation Comments
Patient involvement Annual patient satisfaction surveys, qualitative patient interviews for initial evaluation, patient representative on service planning, monitoring or review committees, resources available to support active participation of consumers in care, consumers participate in health service governance, priority setting and strategic business and quality planning, co-design/co-production projects.
Policies that support equality diversity and inclusion Can all key target groups access and use the service equally?
Learning from complaints, sharing complements Sharing with all stakeholders.
Patients, carers understand the Advanced Practice role Patient information explaining the role and who is responsible for different aspects of treatment.

This has been adapted from a table produced by Hannah Morley1  Physiotherapist in 2019 and is reproduced with her permission. https://media.churchillfellowship.org/documents/Morley_H_Report_2019_Final.pdf