Clinical Governance Flashcards
RCA
If high level incident Chronology Gather data Action plan Think of task factors , patient factors, team factors and communication
Patient complaints
Local resolution - PALs
If not then ombudsman
Cqc inspection 5 domains
Safe Effective Caring Responsive Well led
Care pathways
Document best practice
Scale up so all receive same level of care
Reduced errors
Good clinical outcome, cost reduction, patient satisfaction, teamwork
Business case plan
Value for tax payers money Support stp Outline risks and opportunity Case for change Summary of options Appraisal of options Assessment of preferred option in terms of strategy, viability, capacity, cost, does it need investment Stakeholder mapping Patient involvement
Investigating an incident
Datix Review notes Serious incident Duty of candour Rapid action review with division Time frame within 72hours Commissioner must be informed within 48hours Meet with family Do they want copy of report? Escalate to divisional managers, patient safety team and executive team within trust, commissioners Serious incident framework RCA
Timeframe for an rca
First draft withinin 45days
Final commissioner report within 60 days
What’s in an rca
Summary of events
Where learning points
What went wrong
Action plan
Investigate by those not involved in case
Publish report and implement changes
Take statement from all in team
Responding to a complaint
Acknowledge within 3 days
If severe then scope meeting within 48hours
Quarterly governance report
Incident management
Report on local risk management system and safeguarding lead
If serious incident then report on strategic executive infortmaiton shsten(STEIS)
Above within 72hours
Within 3working days- initial review and submit to commissioner
Identify lead investigator and analysis and submit final report 60 working days
20 days for commissioner to review it and close
Comissioning cycle
Strategic planning
Assess needs review service provision and decide on priorities
Procuring services
Design them
Capacity and demand
Monitoring and evaluating
Patient choice manage performance. Patient views
Four pillars of population health
Wider determinants of health
Lifestyle and behaviours
Integrated health system
Places we live
Three areas of public health
Health protection outbreaks
Health promotion education, housing, community, monitoring of specific disease
Improving services clinical effectiveness , service planing, audit clinical governance
Public health intelligence
Group data into populations, analyse by information analysts
Give to commissioners clinicians and policy makers
