5E health and social service quality

Question 1

Development of clinical guidelines and quality standards: who is responsible for development of national clinical guidelines and quality standards in England?

Answer 1

NICE

Question 2

Development of clinical guidelines and quality standards: What is the purpose of NICE clinical guidelines

Answer 2

• assess how well different treatments and ways of managing a specific condition work and whether they represent good value for money

Question 3

Development of clinical guidelines and quality standards: What is the purpose of NICE quality standards?

Answer 3

• clarify what represents high quality care by providing measurable indicators of both process and outcomes of care
• measure and improve the quality of care

Question 4

Development of clinical guidelines and quality standards: What are the principles underlying the development of NICE guidelines (there is a mnemonic)

Answer 4

Developing Standards That Appease Consultants Egos

• development principles are important to ensure guidelines are accepted by the profession

DEVELOPMENT PROCESS
- use a standard process and standard way of analysing the evidence, which are respected by stakeholders

STATUS
- advisory rather than compulsory but should be taken into account by clinicians when planning individual patient care

TRANSPARENCY
-clarify how each recommendation was agreed

AIM
- to improve the quality of care for patients

CONSULTATION
- take account of the views of those who might be affected by the guideline (patients, clinicians, managers etc)

EVIDENCE
- based on best available research evidence and expert consensus

Question 4

Development of clinical guidelines and quality standards: Local guideline development (8 stages)

Answer 4

• locally organisations may be to adapt or develop specific guidelines
• steps in the process should include

1. Define the clinical issue
2. establish a local guideline working group
3. Identify existing guidelines (regional and national)
4. Appraise the validity of these guidelines
5. Adapt the guideline to fit local circumstances
6. Pilot the guideline and identify any problems encountered
7. Establish disseminations and implementation strategies
8. Monitor the impact of the guideline on an ongoing basis

Question 5

Development of clinical guidelines and quality standards: AGREE guidelines (what does AGREE stand for, how might these guidelines be used? what 6 criteria are guidelines appraised against? (theres a mnemonic!)

Answer 5

• AGREE= Appraisal of Guidelines for Research and Evaluation in Europe
• this can be useful in both evaluating and developing guidelines

SCARES

1 SCOPE AND PURPOSE
- clear definitions of the guideline objective, clinical question and group of patient to whom these guidelines apply

2. CLARITY AND PRESENTATION
   -specific unambiguous recommendations
3. APPLICABILITY
   - target users clearly defined, costs and other barriers discussed
   - Auditing criteria outlines
   - guideline piloted
4. RIGOUR OF DEVLOPMENT
   - systematic appraisal of evidence
   -explicit consideration of the benefits/risks
   - evidence of external review prior to publication

5 EDITORIAL INDEPENDANCE
- editors independent of funding body
- conflicts of interest reported

6. STAKEHOLDER INVOLVEMENT
   - range of professionals and patient involvement

Question 6

Application of guidelines and quality standards: What 4 levers can be used to promote adoption and implementation of guidelines

Answer 6

1. inclusion in the ANNUAL OUTCOME FRAMEWORKS (these report national performance of health and social care systems and provide a benchmark for comparing local services)
2. Incorporation into CONTRACTS between commissioners and providers with rewards and personalities attached to performance
3. Inclusion in INSPECTION and MONITORING regimes
4. Inclusion in organizational PERFORMANCE MANAGEMENT TOOLS

Question 7

Public and patient involvement in healthcare planning: In what 3 different capacities can public be involved in health care planning?

Answer 7

1. as a consumer of healthcare or carer
2. as leaders of community groups (ie minority ethnic groups)
3. Representatives of groups with specific health interests (eg breast cancer support groups)

Question 8

Public and patient involvement in healthcare planning: What is healthwatch

Answer 8

• statutory organization responsible for ensuring patient and public involvement in health service planning in England
• At a national level Healthwatch is part of the CQC
• locally a healthwatch member sits on the health and wellbeing board
• they also provide feedback to the CQC and providers

Question 9

Professional accountability: what is professional accountability?

Answer 9

• the principle that individuals are responsible for the quality of service that the organization delivers

Question 10

Professional accountability: what did Donaldson argue about professional accountability?

Answer 10

• Donaldson argued they accountability for quality and outcomes is a matter both for the individual practitioner and the their employing organization
• the organization has a duty to provide the culture, support and resources needed by the individual to provide high quality care

Question 11

Professional accountability: Why have changes in the systems monitoring professional accountability been strengthened in the UK over recent decades? (4)

Answer 11

1. public awareness of several serious untoward incidents
   2 recommendations in reports such as the Fifth Report of the Shipman Inquiry
   3 Recognition that efforts to reduce healthcare costs may have impacted clinical quality
   4 Changes to the autonomy afforded professionals working in other fields

Question 12

Professional accountability: How have the systems monitoring professional accountability changed in the UK over recent years?

Answer 12

• When the NHS was first established clinicians were held responsible through their professional bodies (ie GMC)
• in recent years clinicians have partly ceded their high degree of professional autonomy and self regulation in favour of:

1. a regulatory system involving members of the public (half of the GMC’s 24 members are lay people)
2. Statutory oversight of the professional bodies by the Professional Standards Authority for Health and Social care ( a non-departmental public body that is funded by the department of health and answerable to parliament)
3. Explicit standards of accountability such as clinical governance

Question 13

Clinical Governance: when was the term first introduced ?

Answer 13

First introduced in the NHS in 1998

Question 14

Clinical governance: define clinical governance

Answer 14

• the government consultation document ‘a first class service: quality in the new NHS’ defined clinical governance as:

’ a framework through which organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish’

Question 15

Clinical governance: when did clinical governance become a statutory duty?

Answer 15

• The health Act 1999 enshrined clinical governance as a statutory duty for all NHS organisations

Question 16

Clinical governance: what does the department of health diagram of clinical governance include?

Answer 16

• 5 ‘foundation stones’ of practice including teamwork, systems thinking and accountability
• 7 ‘pillars’ of clinical governance including staffing, risk management and clinical audit/quality improvement
• a ‘capping stone’ of the partnership between patients and professionals

Question 17

Clinical governance: what are the principles of clinical governance?

Answer 17

• introduction of clinical governance required a change in the culture of accountability- away from considering clinical standards the responsibility of a single professional group (ie doctors) and towards regarding it as the responsibility of the whole organization)
• based on the principle that good SYSTEMS of clinical care improve patient outcomes
• clinical governance involves demonstrating that these systems are working well
  ie in terms of risk management, clinical governance would require demonstration that an incident reporting system was working effectively.

Question 18

Role of professional bodies: What professional bodies are involved in regulating doctors?

Answer 18

1. GMC
   - controls entry to the national register of doctors and specialist registrars
   - sets standards for medical education and training
   - takes action where standards are not met
2. Practitioner Performance Advice
   - advisory body where concerns can be raised about professionals
   - advises organisations on how to manage these cases
3. Medical Royal Colleges
   - set and monitor the standards of post graduate training

Question 19

Professional bodies: other than the GMC name at least 2 other professional bodies

Answer 19

• General dental council
• nursing and midwifery council
• UK public Health Register

Question 20

Professional bodies: what do all professional bodies do?

Answer 20

• maintains a register of accredited professionals
• states how professional competence should be maintained
• Hold hearings when serious professional misconduct is alleged
• Are overseen by the Professional Standards Authority for Health and Social care
• maintain ongoing evidence of professional’s competence to practice

Question 21

Professional bodies: what does the UK PHR do?

Answer 21

• public health specialists without a medical or dental background are regulated by the UKPHR
• performs same functions as GMC but, differently, its disciplinary procedures and sanctions are not underpinned by law

Question 22

Appraisal: what is appraisal?

Answer 22

• a regular, non-threatening, confidential dialogue between a manager and an employee, aimed at:
• reviewing progress towards previously agreed objectives
• setting new objectives
• Identifying development needs

Question 23

Appraisal: what is revalidation?

Answer 23

• revalidation of doctors was introduced by the GMC in 2012
• requires doctors to revalidate their license to practice every 5 years
• this process involves regular appraisal during which doctors must demonstrate that they are up to date and fit to practice
• a similar system is operated by UKPHR

Question 24

risk management: who is at risk in healthcare?

Answer 24

there are risks to:
-patients
- practitioners
- providers
- commissioner

Question 25

risk management: what is risk management?

Answer 25

• risk management involves identifying, monitoring and minimising risk, through a range of means
• In England, systems of clinical governance provide the framework for organisational risk management

Question 26

Risk management- risk to patients: how frequently are patients harmed?

Answer 26

• patients are harmed in around 10% of all hospital admissions

Question 27

Risk management- risk to patients: why are patients at such risk?

Answer 27

• there is risk associated with all types of healthcare- both from clinical errors but also as a known consequence of the treatment/ procedures
• patients can be more vulnerable to existing hazards ie many people carry MRSA but immunocompromised are at a substantially higher risk of infection
• risks to patients cannot be eliminated, only minimised

Question 28

Risk management- risk to patients: where does information come from?

Answer 28

1. reports (ie the Francis enquiry into Mid Staffs showed what can happen in terms of risk to patients)
2. National Reporting and Learning System - a central database of patient incident reports (reporting is largely voluntary)
3. Clinical negligence claims
4. data from death registries
5. Hospital activity data
6. National surveys

Question 29

Risk management- risk to practitioners: What risks are there and how are they mitigated?

Answer 29

1. Infection (immunisation, PPE)
2. Safety (security, COSHH regulations adhered to)
3. Stress
4. Litigation (hold medical indemnity)
5. Provide appropriate care-ensure up to date with current regulations

Question 30

Risk management- risk to organisations/providers: How can organisations reduce their risk?

Answer 30

1. ensure high quality employment practice (including locum procedures and reviews of individual and team performance)
2. providing a safe environment
3. ensuring adherence to safety standards and establish policies
4. ensure associated organisations (ie GPs, community pharmacies) are covered by the same clinical governance frameworks by ensuring they agree to comply with the standards of the organization with which they are associated

Question 31

Risk management- risk to organisations/providers: what are risk registers?

Answer 31

• In the UK clinical governance arrangements are integrated with a strong risk management framework
• this includes maintenance of risk registers
• A risk register ensures clinical governance risks feature highly on the priorities of the board of directors of all NHS organisations

Question 32

Risk management- risk to organisations/providers: Negligence- who is responsible for managing them?

Answer 32

• NHS Resolution is responsible for handling all claims made against the NHS
• they also share learning from claims
• highest value claims tend to relate to maternity services