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 are able to better manage their time, and patients are given more ways to access quality care more efficiently.

But if delegating is not done carefully, it can put patient safety at risk.

Accountability

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

The General Dental Council’s Standards guidance on delegation (principle 6) warns that “although you can ask someone to carry out a task for you, you could still be held accountable if something goes wrong”.

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

Competent staff

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 GDC reminds registrants: "You should only carry out a task or type of treatment or make decisions about a patient’s care if you are sure that you have the necessary skills and are appropriately trained, competent and indemnified.”

GDC guidance further states: “If you delegate a task to another member of the team who does not feel that they are trained or competent to carry it out, you must not take advantage of your position by pressurising them into accepting the task.”

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 for 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 is clear in its guidance on communication and teamwork that:

"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".

The GDC states within its delegation guidance (principle 6.1.6):

“As a registered dental professional, you could be held responsible for the actions of any member of your team who does not have to register with the GDC (for example, receptionists, practice managers or laboratory assistants). You should ensure that they are appropriately trained and competent".

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. This is particularly common in dental practices and secondary care. 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 that 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.

For doctors, 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. It is clear that doctors would 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.

Similar standards apply to dentists and the risks were highlighted in the case of a patient who attended their dental practice for teeth whitening. The consent process was delegated to dental nurses who provided an information sheet that the patient was then asked to sign. The patient raised a complaint after treatment, stating they had expected better results. The practice eventually had to refund the treatment cost as it became clear that the patient’s questions and expectations had not been adequately addressed – a vital part of the consent process. The GDC makes clear in Standards for the Dental Team that the obligation to obtain consent rests with the clinician providing the treatment:

“You must make sure you have valid consent before starting any treatment or investigation. This applies whether you are the first member of your team to see the patient or whether you are involved after other team members have already seen them. Do not assume that someone else has obtained the patient’s consent.”

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) – January 17
• MDT working for hospital doctors: managing risks around communication and boundaries – January 26
• MDT working for GP practices: managing risks around systems and boundaries – March 29.
• Browse all MDDUS Zoom courses.

Kay Louise Grant is a risk adviser at MDDUS