Are you delegating safely?

MULTI-DISCIPLINARY team working is very much becoming the ‘norm’ in healthcare settings.

There are many benefits: staff get the opportunity to learn and expand their skills, those who delegate across the team can better manage their time, and patients have more ways to access quality care more efficiently.

But delegating must be done carefully to avoid putting patient safety at risk.

Accountability

Clinicians must remember that while they can delegate responsibility for a task, they cannot delegate accountability. If something goes wrong, the doctor who delegated the task could still be held accountable.

The General Medical Council’s guidance on delegation and referral emphasises: “When you delegate care, you are still responsible for the overall management of the patient”.

Competent staff

The GMC guidance makes it clear you must be satisfied that the individual you are delegating to is appropriately trained and competent to do what you are asking. They must have sufficient knowledge of the intervention and its associated benefits and harms, as well as any alternative options for treatment and care.

It is also important that the individual being delegated to feels competent and is comfortable with carrying out the task. The GMC reminds all registrants in Good medical practice that they “must recognise and work within the limits of your competence”.

GMC guidance also states that clinicians are not accountable for the actions (or omissions) of those to whom they delegate care or make referrals but they will be accountable for decisions to transfer care and steps taken to make sure that patient safety is not compromised. The guidance is clear: “You must be prepared to explain and justify your decisions and actions”.

Asking for help

It is also crucial that the person you are delegating to understands the point at which they should seek further information or advice, and from whom. That colleague must make sure they are available to offer support if needed.

Training new team members

New members of staff, such as nurses or healthcare assistants joining the team, should be provided with an appropriate induction process which is formally recorded as part of their employment history. They must be given time to adjust to their new environment and gain the necessary skills before tasks are delegated to them.

At first, it may be advisable to only delegate simpler tasks appropriate to their abilities, before increasing complexity as they become more confident. Recognised supervisory processes should also be in place. This may require temporary changes, such as restructuring of appointments to allow work-shadowing, or reshuffling consultation rooms to ensure the person is within easy reach of a colleague who can provide help. The key message is to be as flexible as possible until the member of staff is capable of working more independently.

The GMC states in its guidance on communication and teamwork:

"When you do not provide your patients’ care yourself, for example, when you are off duty, or you delegate the care of a patient to a colleague, you must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient".

Common scenarios

Delegating note-taking

One area that MDDUS advice teams often encounter relates to the delegation of note-taking to more junior members of the team. While this type of delegation can be very helpful in freeing up clinician time, it is important that processes are in place to regularly check the accuracy of these notes. We have seen cases where no record has been made of examinations carried out on ward rounds. Other incidents include tests not being requested because the person taking the notes had misheard instructions and did not record this correctly, meaning no appropriate follow-up was undertaken.

The bottom line is, where note-taking is delegated, the responsibility remains on the delegating clinician to ensure that the records are clear, legible, accurate and can be readily understood by others. The name or initials of the treating clinician must be recorded.

Delegating consent

Consent and shared decision-making processes can be complex, and this type of delegation is routinely used in some multidisciplinary teams for specific interventions.

The GMC advises in its guidance on decision making and consent that a number of considerations should be explored before delegating the consent process to a colleague. Doctors still hold responsibility for ensuring the patient is given the information they need to make an informed decision, has had time to consider their decision and that they have a realistic expectation of the outcomes.

Key points

• Ensure the person you are delegating to is competent and has the appropriate knowledge and skills to carry out the task safely.
• New team members should undergo comprehensive induction training, with supervision processes put in place to support them until they can work more independently.
• Follow the appropriate regulatory guidance on delegation and referral.

Further information

Learn more about these issues by signing up to one of our interactive zoom courses, taking place in early 2023:

• Building safety into delegation (for doctors and dentists) – March 24
• MDT working for hospital doctors: managing systems and boundary risks – March 29
• Browse all Zoom courses for hospital doctors.

Kay Louise Grant is a risk adviser at MDDUS