1: Quality and safety

Question 1

Describe some evidence of problems with quality and safety in healthcare

Answer 1

Evidence of preventable harm and substandard care
Variations in healthcare - inequity
Gaps in what is known to be effective and what happens in clinical practice

Question 2

What are some ways to define quality?

Answer 2

• Safe
• Effective
• Patient-centred
• Timely
• Efficient
• Equitable

Question 3

Define EQUITY

Answer 3

Everyone with the same need gets the same care

Question 4

What is INEQUITABLE CARE?

Answer 4

Patients vary in the extent to which they receive high quality care and in access to care

Question 5

ADVERSE EVENT

Answer 5

An injury caused by medical management rather than underlying disease
Can be unavoidable e.g. first time penicillin allergy

Question 6

PREVENTABLE ADVERSE EVENT

Answer 6

An event that could be prevented given the current state of medical knowledge

Question 7

NEVER EVENTS

Answer 7

Events that should not happen under any circumstance - usually preventable

Question 8

Why do medical errors happen?

Answer 8

• Everyone is fallible
• Most are system errors, do not take into account human factors, not enough defences built in, multiple contributions to an incident
• Healthcare not traditionally safe - blames individuals

Question 9

What are the three types of error?

Answer 9

• Slips and lapses - errors of action - not as intended
• Mistakes - error of knowledge or planning, action goes to plan but wrong action
• Violation - intentional deviation

Question 10

Describe the swiss cheese model of accident causation

Answer 10

Successive layers of defences.

Hazards can penetrate the barriers leading to losses - all holes line up when barriers breached at once

Question 11

What are active failures?

Answer 11

Happen closest to the patient, and lead directly to harm.

Human factors - non-recognition, loss of situational awareness, persistence with wrong course etc.

Question 12

What are latent problems?

Answer 12

Predisposing conditions that make the active failure more likely - context. Can be error provoking or create long lasting holes. E.g, similar packaging, organisational processes, poor comms

Question 13

What is a systems based approach?

Answer 13

Suggests errors are due to multiple errors - rather than the fault of the individual

Question 14

How can human factors be removed?

Answer 14

• Avoid reliance on memory
• Standardise common procedures
• Use checklists often
• Make things visible
• Review and simplify processes
• Decrease reliance on vigilance
• Learn from other industries
• Discourage latent errors

Question 15

Name some system factors

Answer 15

Institutional, hospital, departmental, work environment, team, individual practitioner, task, patient characteristics

Question 16

What is the NHS outcomes framework?

Answer 16

Specific national goals and indicators in five domains, linked to payments and financial incentives.

Question 17

Name 8 NHS quality improvement mechanisms

Answer 17

1. Standard setting
2. Commissioning
3. Financial incentives
4. Disclosure
5. Regulation
6. Data gathering and feedback
7. Clinical audit
8. Professional regulation

Question 18

Describe NHS standard setting

Answer 18

NICE quality standards
Based on the best available evidence
Set of statements with markers across a pathway or clinical area, of high quality, clinical and cost effective patient care

Question 19

Describe commissioning

Answer 19

There are 211 CCGs in England, which commission services for local populations. They drive quality through contracts

Question 20

Describe financial incentives for high quality care

Answer 20

QOF: quality and outcomes framework. National quality standards with indicators in primary care. GPs score points according to how well they perform against indicators - payments are based on this. Results online
CQUIN: commissioning for quality and innovation. Achieving measurable goals achieved with commissioners

Question 21

Describe disclosure and quality accounts

Answer 21

All trusts have to publish quality accounts about performance. Published annually with a focus on safety, effectiveness and patient experience.

Question 22

Describe regulation with the CQC

Answer 22

Care quality commission.
All NHS trusts registered since 2009, check NICE quality standards and quality accounts. Can impose registration conditions, make unannounced visits, issue warnings, fines, prosecute.

Question 23

What is clinical audit?

Answer 23

A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against criteria and the implementation of changes

Question 24

Describe the steps of clinical audit

Answer 24

Choose topic and research evidence
Criteria and standards
First evaluation
Implement change
Second evaluation
Back around circle

Question 25

What is clinical governance?

Answer 25

A framework through which all NHS organisations are accountable for continually improving the quality of care and safeguarding high standards, by creating an environment in which excellence in clinical care will fluorish