Dimension: Staff

Rationale for measurement

The presence of an adequate number of health care staff is essential for optimal patient care. High absenteeism rates can potentially affect quality of patient care and staff morale. The resultant ad hoc use of temporary staff from an external Agency to cover sick leave can also impact on continuity of care for the patient.

Measurement methodology and data sources

  • Local data set from monthly performance metrics

Target

  • 4.0%

Performance

Beaumont Hospitalimg-80

  • Beaumont Hospital absence rates – January 5.03% (35,150 lost hours = 213WTE). (target <4.0% not achieved)
  • data includes paid Covid-19 related absences
    • national data not available at time of report publication

Cavan General Hospitalimg-467

  • Cavan Hospital absence rates – January 8.26% (14,655 lost hours = 92WTE). (target <4.0% not achieved)
  • data includes paid Covid-19 related absences
    • national data not available at time of report publication

Monaghan Hospitalimg-261

  • Monaghan Hospital absence rates – January 8.54% (2,330 lost hours = 14WTE). (target <4.0% not achieved)
  • data includes paid Covid-19 related absences
    • national data not available at time of report publication

Drogheda Hospitalimg-322

  • Drogheda absence rates – January 5.42% (21,305 lost hours = 130WTE). (target <4.0% not achieved)
  • data includes paid Covid-19 related absences
    • national data not available at time of report publication

Louth County Hospitalimg-852

  • Louth Hospital absence rates – January 8.13% (3,665 lost hours = 22WTE). (target <4.0% not achieved)
  • data includes paid Covid-19 related absences
    • national data not available at time of report publication

Connolly Hospitalimg-85

  • Connolly Hospital absence rates – January 6.16% (15,617 lost hours = 91WTE). (target <4.0% not achieved)
  • data includes paid Covid-19 related absences
    • national data not available at time of report publication

Rotunda Hospitalimg-50

  • Rotunda absence rates – January 4.88% (8,092 lost hours = 49WTE). (target <4.0% not achieved)
  • data includes paid Covid-19 related absences
    • national data not available at time of report publication

National Comparator – Hospital Groupsimg-74

  • no Hospital Group currently achieving target of <4.0% for September 2023
  • national data for October, November, December 2023 and January 2024 not available at time of report publication

Rationale for measurement

The National Vetting Bureau (Children and Vulnerable Persons) Acts 2012-2016 came into effect on 29 April 2016. This legislation makes it mandatory for people who carry out relevant work or activities in respect of children or vulnerable adults to be vetted by the National Vetting Bureau (NVB) of the Garda Siochana. The Acts define relevant work or activities as ‘any work or activity which is carried out by a person, a necessary and regular part of which consists mainly of the person having access to, or contact with, children or vulnerable adults’.

Section 21 of the Act provides for the retrospective vetting of employees who are carrying out ‘relevant work or activities’ and who were not previously vetted. The Regulations (SI No. 223 of 2016) provide that applications for retrospective vetting disclosures shall be made not later than March 2018.

Measurement methodology and data sources

  • Local data set from monthly performance metrics

Target

  • 100% of employees engaged in ‘relevant work’

Performance
img-389

  • in line with legislation members of staff are not allowed to work until their Garda vetting is completed
  • national data not published

OPEN DISCLOSURE TRAINING

Introduction

Open Disclosure is an open and consistent approach to communicating with patients and their families when things go wrong in healthcare. This includes expressing regret for what has happened, keeping the patient informed, providing feedback on investigations and the steps taken to prevent a recurrence of the adverse event. Open Disclosure is important for building patient and public trust in the health system. This is supported by relevant legislation:

  • The Civil Liability (Amendment) Act, 2017, provides the legal framework to support voluntary open disclosure
  • The Patient Safety (Notifiable Incidents and Open Disclosure) Act, 2023, was signed into law on 2nd May 2023. This legislation provides a framework for the mandatory open disclosure of certain notifiable incidents. A go live date for this legislation is awaited.
  • The HSE Open Disclosure Policy, 2019 also provides a framework for open disclosure in the health service.

Rationale for measurement

It is government policy that open disclosure is in place and is supported across the health system in line with relevant legislation and HSE Policy. Training is provided in the form of:

a) briefing sessions face to face or via online module on HSELanD

b) skills workshops

c) bespoke MPS/RCSI HG Training

Measurement methodology and data source

Quarterly local data extracts, extrapolated for analysis and publication

Numerator: Number of relevant staff trained (Expressed as %)

Denominator:  Total number of relevant staff (Expressed as %)

Target

100% of relevant staff have completed either a briefing session or a skills workshop in Open Disclosure

Performanceimg-73

  • RCSI Hospitals are not achieving the target of 100%
  • national dataset not published for comparative purposes

 

EARLY WARNING SCORE

Rational for measurement

National Early Warning System (INEWS), Irish Maternity Early Warning System (IMEWS), Paediatric Early Warning System (PEWS), Emergency Medicine Early Warning System (EMEWS).

Introduction

Acute physiological deterioration is a time-crucial medical emergency. Failure to detect and treat patient deterioration in a timely manner poses a threat to patient safety. Early recognition of clinical deterioration by regular measurement and documentation of physiological parameters, followed by prompt and effective action, can minimise the occurrence of adverse events such as cardiac arrest.

Measurement methodology and data sources

The following guidelines guide clinical practice (INEWS, PEWS, IMEWS & EMEWS):

  • In September 2020 the Irish National Early Warning System Clinical Care Guideline was revised and updated to INEWS V2 (previously NEWS). This National Clinical Guideline No. 1 is relevant to all healthcare professionals working in acute settings. This guideline applies to adult (≥ 16 years) non-pregnant patients in acute settings
  • National Clinical Guideline No. 4 – Irish Maternity Early Warning System (IMEWS) should be used for women who are clinically pregnant or who were delivered within the previous 42 days
  • The Paediatric Early Warning System (PEWS) (National Clinical Guideline No. 12) should be used for patients < 16 years of age
  • National Clinical Guideline No.18 – Emergency Medicine early Warning System (EMEWS) should be used for all patients aged 16 years and older assigned to Manchester Triage System (MTS) triage categories 2, 3 and 4

These guidelines endorse the concept that facilitates the timely assessment of, and response to, the deterioration of acutely ill patients by:

  • Classifying the severity of a patient’s illness
  • Providing prompts and structured communications tools to escalate care
  • Following a definitive escalation plan
  • Providing a clear, structured response model

The above tools utilised by trained staff lead to a reduction in instances of unanticipated admission and/or readmission to ICU and in instances of unanticipated cardiac arrest.

Target

100% of Medical, Nursing & Midwifery professionals trained in the appropriate tool/tools depending on work speciality. Staff may require training on multiple tools depending on the patients they care. Training is a once off for each tool.

img-931

  • compliance measuring staff trained on INEWS since its introduction in Sep-20. Staff would have previously been trained in NEWS
  • RCSI HG hospitals are not achieving the target of 100% with the exception of Nursing in Drogheda/LCH

img-585

  • Drogheda Hospital achieving target of 100% for both Medical and Midwifery staff
  • Cavan Hospital achieving target of 100% for Midwifery staff; not achieving target for Medical staff
  • Rotunda Hospital not achieving target of 100% for Medical or Midwifery staff

img-502

  • Drogheda Hospital achieving target of 100% for Medical and Nursing Staff
  • Cavan Hospital achieving target of 100% for Medical and Nursing Staff
  • national data currently not published
  • Rotunda use NeoNEWS tool

 

Emergency Medicine Early Warning System (EMEWS)

The Emergency Medicine Early Warning System (EMEWS) has been developed in response to concerns that Emergency Department (ED) patients are at risk of clinical deterioration between the time they are triaged and the time they are assessed by a Treating Clinician and that there may be a delay in recognising this deterioration if the patient is not appropriately monitored. These patients have undifferentiated, undiagnosed conditions with the potential for rapid change in their physiological status and have only been assessed once in the ED i.e. at triage.

EMEWS is recommended for use in EDs when patients are waiting longer for review by a Treating Clinician than is recommended based on their Manchester Triage System (MTS) Categories 2, 3 & 4. EMEWS sets out a structured approach to monitoring patients in the waiting room post triage.

img-449

  • Drogheda Hospital – Nursing and Medical staff achieving 100% compliance rate.
  • Cavan Hospital achieving 68% compliance rate for Nursing staff in EMEWS. Medical staff to receive training.
  • training programme in Beaumont, Cavan and Connolly Hospitals commenced in December 2023

 

PATIENT MONITORING AND SURVEILLANCE 

Rationale for measurement

Early detection and timely management of patients admitted to hospital acutely unwell, or those who deteriorate while in hospital is essential in promoting the best outcome possible for the patient. The Irish National Early Warning System (INEWS) facilitates anticipation, early recognition, escalation, and the required clinical response to appropriate care and treatment of the acutely ill patient.

The Quality Care Metric indicators below check that the nursing assessment, patient review, necessary escalation, and documentation are completed. This is in accordance with local policies, procedures, protocols and guidelines (PPPGs) and in accordance with standards set in the National Clinical Guideline No. 1 (INEWS) and National Sepsis Management for Adults (including maternity) National Clinical Guideline No. 26:

  1. The patient’s baseline physiological observations were assessed and recorded on admission/transfer using the Irish National Early Warning System (INEWS)
  2. The patient’s physiological observations have been reassessed and recorded using the INEWS at the appropriate frequency
  3. There is documented evidence of an increased frequency of monitoring and recording of vital signs in response to any deterioration in the patient’s condition
  4. In the event of a deterioration there is documented evidence of escalation of care as per INEWS Escalation Protocol
  5. The ISBAR tool was used to document the escalation of care
  6. The nursing care provided to manage a deterioration in the patient’s condition has been recorded
  7. If infection is suspected to be the cause of the patient’s deterioration, care is escalated using the sepsis screening form in accordance with the INEWS Escalation Protocol (collected with Sepsis KPI)

The indicators 3, 4 & 5 will be used to assess the recognition and escalation (including communication) of all charts audited listing each indicator and compliance separately to identify the key areas achieving lower compliance.

Measurement methodology and data sources 

Based on total bed capacity, samples of 25% of patient records are randomly selected per month from each ward/unit with a minimum of 5 data collections per month for each ward/unit.

Target 

98% compliance of the key indicators identified. 

Performance – % Compliance – 2024

img-536

  • RCSI Hospitals did not achieve target of 98% in January 2024

 

COGNITIVE ASSESSMENT ON ADMISSION

Introduction

Acute illness and hospitalisation particularly in older adults may accelerate or trigger cognitive decline including decrease in executive functions.

Rationale for measurement

Cognitive impairment in acutely hospitalised older adults is a major risk factor associated with adverse outcomes including, longer length of hospital stay, early readmissions, functional decline, and mortality1. It is vital that healthcare staff document their assessment of a patient’s cognitive status on admission to establish a baseline and to identify if patients might need assistance with decision making.

It is important to note that although a patient may have altered cognition on admission or indeed subsequently this does not mean that assistance with decision making is required. Each patient must be evaluated in terms of their ability to understand information, retain information, and make an informed decision2.

Measurement methodology and data source

  • Health care records of patients aged > 65 years who presented to the emergency department in each acute Hospital and were subsequently admitted during the period 1st June 2023 until 31st June 2023 were audited. Cases included both medical and surgical patients
  • A pilot study was conducted in one site to test the audit tool
  • An audit tool was used to assess documentary evidence of Health Care Staffs assessment of cognitive status during admission for the cohort of patients audited. A convenience sample of 20* charts were selected from the inclusion criteria for each site
  • Audit data was extrapolated for analysis and publication
  • Both medical and nursing staff use a combination of admission proforma documents, 4AT Tool and free hand text

*Two patient charts were excluded as patients were admitted directly to Intensive Care.

Target

100% of patients have their cognitive status documented on admission

Performance

img-846

References:
1 Arieli.M Agmon.M, Gill.E & Kizony.R (2022) The Contribution of Functional Screening during acute illness hospitalization of older adults in predicting participation in daily life after discharge. Geriatrics 22:739
2 Assisted Decision Making (Capacity) Act 2015

 

DELIRIUM PREVENTION AND MANAGEMENT (TAKING ACCOUNT OF ASSISTED DECISION MAKING CAPACITY)

Introduction

Delirium is characterised by a sudden change in a patient’s cognitive function and can be linked to organic causes such as illness or injury. This condition is a medical emergency, if left untreated it can lead to longer term health decline, increased length of hospital stay, increase risks of harm and can cause death. A patient with delirium is vulnerable and their ability to make decisions can be impacted at this time.

Delirium is said to affect 20-30% of inpatients on general wards and up to 50% of patient’s post-surgery (Zhang et al 2022). This condition can be extremely frightening and distressing for the patient and their family. Approximately 40% of delirium is preventable with early detection and the right care. The condition will usually improve if the cause is found and treated. (Wilson et al. 2020).

Rationale for measurement

Appropriate assessment, early detection and a plan for care for Patients with Delirium is seen as a priority for the RCSI Hospital Group. The delirium (4AT) assessment takes account of a person’s cognitive status and therefore indicates whether a patient is in need for support in terms of Assisted Decision Making.

The Quality Care Metric indicators below check that the nursing assessment, plan of care and evaluation are completed in accordance with local hospital policies, procedures, protocols and guidelines (PPPGs) associated with delirium identification and treatment:

  • A delirium assessment has been completed
  • If a patient has delirium, a care plan has been developed
  • There is documented evidence that a care plan for the patient with delirium has been evaluated

Measurement methodology and data source

Based on total bed capacity, samples of 25% of patient records are randomly selected per month from each ward/unit with a minimum of 5 data collections per month for each ward/unit.

Target

90% compliance of the key indicators identified

Performance – 2024

img-396

References:
Meng ZhangXuemei ZhangLangli GaoJirong Yue & Xiaolian Jiang (2022) BMC Geriatrics, volume 22, Article number: 262 (2022)
Wilson, J.E., Mart, M.F., Cunningham, C. et al. Delirium. Nat Rev Dis Primers 6, 90 (2020) https://doi.org/10.1038/s41572-020-00223-4

 

CHILDREN FIRST TRAINING COMPLIANCE

Rationale for measurement

The Children First Act 2015 puts elements of the Children First: National Guidance for the Protection and Welfare of Children (2011,) on a statutory footing and places a wide range of responsibilities on HSE and its funded services. All staff are required to complete the E-Learning Module on “An Introduction to Children First”.

Measurement methodology and data source

Local data extracts from HSELanD submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed online Children First Training in the last three years).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance

Performanceimg-939

  • RCSI Hospitals did not achieve target
  • national data not available

 

STANDARD PRECAUTIONS AND HAND HYGIENE TRAINING COMPLIANCE

Rationale for measurement

Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These practices are designed to both protect healthcare workers and prevent healthcare workers from spreading infections among patients.

Measurement methodology and data source

Local data extracts from HSELand submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed Standard Precautions and Hand Hygiene Training in the last year).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance

Performanceimg-814

  • RCSI Hospitals did not achieve target
  • national data not available

 

MANUAL AND PATIENT HANDLING TRAINING COMPLIANCE

Rationale for measurement

It is the policy of the RCSI Hospital Group to reduce, so far as is reasonably practicable, the risks associated with manual handling and people handling activities. The Safety, Health and Welfare at Work, (General Applications) Regulations 2007 Act requires that training and instruction be provided to relevant staff. The theory component requires completion of the online training course.

Measurement methodology and data source

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed (practical & theory) Manual / Patient Handling Training in the last three years).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance

Performanceimg-466

  • RCSI Hospitals did not achieve target
  • national data not available

 

FIRE SAFETY AWARENESS TRAINING COMPLIANCE

Rationale for measurement

It is the policy of the RCSI Hospital Group to reduce, so far as is reasonably practicable, the risks associated with Fire. The Health and Welfare at Work Act 2005 states that employers must ensure so far as is reasonably practicable, that sufficient information, training and supervision is provided to ensure the safety of employees.

Measurement methodology and data source

Local data extracts from HSELand submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed the online component of Fire Awareness Training in the last year).

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

100% compliance. This target comprises of an online and practical element to the training. Compliance figures below relate currently to the online element only.

Performanceimg-631

  • RCSI Hospitals did not achieve target
  • national data not available

 

GDPR AWARENESS TRAINING COMPLIANCE

Rationale for measurement

The Data Protection Act 2018 states that all employees must comply with GDPR legislation including awareness training. All hospitals are legally required to comply with this legislation.

Measurement methodology and data source

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained.

Denominator

Monthly Headcount (Average paid headcount on the first and last day of the month).

Target

98% compliance

Performanceimg-34

  • RCSI Hospitals did not achieve target
  • national data not available

 

CYBER SECURITY TRAINING COMPLIANCE

Rationale for measurement

It is the policy of the RCSI Hospital Group to reduce, so far as is reasonably practicable, the risks associated with Cyber Security. The HSE Executive Management Team have deemed that Cyber Security Awareness Training is mandatory for all staff.

Measurement methodology and data source

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator

Monthly total number of staff trained (who have completed online Cyber Security Awareness Training in the last three years).

Denominator

Monthly Headcount (average paid headcount on the first and last day of the month).

Target

100% compliance

Performance

img-553

  • RCSI Hospitals did not achieve target
  • Beaumont Hospital re-configured GDPR Training to include Cyber Training. Compliance is reported under GDPR Training for this site
  • national data not available

 

SEPSIS TRAINING

Background

Sepsis is a common and time-dependent medical emergency. It can affect a person of any age and from any social background.  While it may occur more frequently in people with certain underlying medical conditions, it can also occur in healthy individuals. In 2016, the number of deaths amongst in-patients with a diagnosis of sepsis within Irish hospitals was 2,735. Sepsis is responsible for 37,000 deaths annually in the UK.

Internationally, approaches to optimal sepsis management, which are based on early recognition of sepsis with timely intervention within the first hour, have reported reductions in mortality from severe sepsis/septic shock in the order of 20-30%.

Rationale for measurement

In 2014 the National Clinical Effectiveness Committee (NCEC) introduced the National No 6 Sepsis Clinical Guideline. This guideline endorsed the concept of ‘Sepsis Six’ – a set of six tasks to effectively manage patients with sepsis. This was supported by Sepsis training on HSELanD.

The original guideline was replaced in 2021 by an updated version Sepsis Management for Adults (including maternity) National Clinical Guideline No. 26, (2021), DOH. This revised guideline outlines the tasks to be completed in patients with sepsis. These interventions are termed the ‘Sepsis Six’ and (include blood cultures, blood tests, administration of IV antimicrobials and intravenous fluids, monitoring of urine output and administration of oxygen if required) to be completed within one hour by practitioners. The revised guideline also outlines the concept of Sepsis Six + 1 for maternity patients which includes the Sepsis Six but adds in the assessment of fetal wellbeing for pregnant women.

This guideline is supported by a revised module Sepsis Management for Adults (including maternity) on HSELanD which needs to be completed by relevant staff every 3 years.

Methodology

Quarterly reports from individual hospitals on the number and category of clinical staff who have completed:

  • Introduction to Sepsis Management for Adults (including maternity), HSELanD.
  • Obstetrics & Gynaecology staff will also have completed PROMPT (or equivalent accredited Obstetrics & Gynaecology Sepsis Module, e.g. Rotunda Hospital Obstetric Emergency Training, RHOET)

Target

  • 95% compliance

Performanceimg-115

  • the breakdown of Connolly Hospital staff trained on HSELanD Module in Q3 and Q4 2023 not available at time of report publication

Sepsis training by staff discipline and site – Q4-23 data

img-223

  • Cavan & Monaghan Hospitals, Drogheda & Louth County, Beaumont and Rotunda Hospitals did not achieve the target of 95% of staff trained in Sepsis management
  • national data not published
  • a total of 3,515 staff trained on the revised HSELanD module, Q4-23

 

COMPETENCY TRAINING

The delivery of safe, evidence-based care in maternity services ultimately depends on the competency of clinical staff. Consequently the RSCI Hospital Group will be measuring attendance rates at training in two key areas cardiotocography and neonatal resuscitation.

 

CARDIOTOCOGRAPHY (CTG) TRAINING

Rationale for measurement

CTG is a technical means of recording the fetal heartbeat and the uterine contractions during pregnancy. CTG monitoring is used to assess fetal wellbeing and allows early detection of fetal distress. The inappropriate use or interpretation of fetal surveillance can contribute to adverse obstetric outcomes therefore accurate interpretation of the CTG is a core skill for all staff providing antenatal and intrapartum care.

Measurement methodology and data sources

Local data extracts submitted monthly and extrapolated for analysis and publication.

Numerator: No of staff trained (Expressed as %)
Denominator: No of staff eligible for training (Expressed as %)

Target

100% of relevant clinical staff are up to date with CTG training within the 2 year period.

Performance

Performance data for monthly reporting period:

img-495

  • Cavan Hospital is achieving the target for training compliance
  • Drogheda Hospital is not achieving the target for Consultant (n=2), NCHD (n=5) and Midwife (n=6) training compliance
  • Rotunda Hospital is not achieving the target for Consultant (n=4), NCHD (n=7) and Midwife (n=1) training compliance

 

RESUSCITATION TRAINING

The Neonatal Resuscitation Programme® (NRP®) was developed by the American Heart Association and the American Academy of Pediatrics. The course conveys an evidence-based approach to care of the newborn at birth and facilitates effective team-based care for healthcare professionals who care for newborns at the time of delivery.

Rationale for measurement

Over 90% of babies born make the transition from life in the womb to life outside the womb at delivery, perfectly smoothly. A small percentage will require assistance. The NRP is intended to optimise the skills of staff in caring for these babies.

Measurement methodology and data sources

Local data extracts submitted monthly and extrapolated for analysis and publication.

Target

100% of relevant clinical staff are up to date with NRP certification (or UK equivalent) within the 2 year period.

Performance

Performance data for monthly reporting period:

img-626

  • Cavan Hospital is achieving the target for training compliance
  • Drogheda Hospital is not achieving the target for NCHDs (n=1) training compliance
  • Rotunda Hospital is not achieving the target for NCHDs (n=1) and Midwives (n=6) training compliance

 

COMMUNICATION TRAINING

Introduction

Effective communication, either between health care professionals or between healthcare professionals and their patients, is essential. Suboptimal communication has the potential to lead to dysfunctional team activities and interpersonal conflicts. It can have a negative impact in the quality of patient care and can result in an increase in complaints and referral to professional regulatory bodies. The Joint UK Commission on Accreditation of Healthcare Organizations, noted that 65% of sentinel events are associated to miscommunication1.

Rationale for measurement

For decades, educators and patient advocates have stressed the importance of optimal communication as an important healthcare staff competency. There is a consensus about the essential elements of good communication skills relevant to medical encounters and the need to teach those skills to healthcare professionals. Several studies have demonstrated a strong association between healthcare worker training in, and later use of, patient-centred communication skills in medical encounters. Such training programs have led to improved healthcare professional self-confidence in communication skills, as well as improvement in patient satisfaction2-6.

Measurement methodology and data sources

Monthly report from individual hospitals on the number and category of clinical staff who have completed:

Data Source

Quarterly local data extracts, extrapolated for analysis and publication

  • Numerator: Number of relevant staff trained (expressed as %)
  • Denominator: Total number of relevant staff (expressed as %)

Target

95% compliance

Performance
img-765

  • RCSI Hospitals are not achieving the target of 95%
  • national dataset not published for comparative purposes

img-866

  • RCSI Hospitals are not achieving the target of 95%
  • National dataset not published for comparative purposes

 

References:

  1. Theresa M Fay-Hillier, Roseann V ReganMary Gallagher Gordon: Communication and patient safety in simulation for mental health nursing education. Issues Ment Health Nurs 2012 Nov;33(11):718-26
  2. Vermeir P, Vandijck D, Degroote S, et al.: Communication in healthcare: a narrative review of the literature and practical recommendations.Int J Clin Pract. 2015;69(11):1257–67.
  3. Makoul G, Schofield T. Communication teaching and assessment in medical education: an international consensus statement. Patient Educ Couns. 1999;37(2):191–195.
  4. Duffy FD, Gordon GH, Whelan G, Cole-Kelly K, Frankel R, Buffone N, et al. Assessing competence in communication and interpersonal skills: the Kalamazoo II report. Acad Med. 2004;79(6):495–507.
  5. Manuela Ferreiraa , Cláudia Brásb *, Maria do Céu Barbieric. Clinical Communication and Adverse Health Events: Literature Review: 2nd International Conference on Health and Health Psychology. 2016.
  6. VermeirD. VandijckS. DegrooteR. PelemanR. VerhaegheE. MortierG. HallaertS. Van DaeleW. BuylaertD. Vogelaers. Communication in healthcare: a narrative review of the literature and practical recommendations. Volume 69, Issue11, November 2015, Pages 1257-1267.