Domains 13 Flashcards
Define clinical governance
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.
What are the objectives of clinical governance ?
• High standards of care
• Transparent
• Responsibility
• Accountability
What are the elements of clinical governance?
○ Education and training
○ Clinical audits
○ Clinical effectiveness
○ Research and development
○ Openness/ transparency
duty of the professional clinician
It is the duty of the professional clinician, to remain up-
to-date via Continuing professional development (CPD)
Clinical audit aim
Cyclical process with the goal of refining the clinical practice by measuring performance against agreed standards of care
How to implement Change in Practice in the light of evidence-based research?
Change in Practice in the light of evidence-based research
• This is done via critical appraisal (the process of carefully and systematically examining research evidence to judge its trustworthiness, its value and relevance in a particular context)of the literature, the development of guidelines, protocols and implementation strategies
Processes which are open to public scrutiny, while respecting individual patient and practitioner confidentiality,
and which can be justified openly, are an essential part of quality assurance
Balancing the risk components
• Risks to patients
• Comply with statutory regulations, Uphold medical ethical standards
• Risks to practitioners
• Occupational exposure, safe environment physically and mentally
• Risks to the organisation
• Decrease risk by implementing high quality employment practice a providing a safe environment
Define quality?
A Strategy for Quality Assurance (1990)
Quality = the degree to which health services for individuals and
populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge.
SIX AIMS OF QUALITY IN HEALTH CARE
Mnemonic:STEEPE
Safety
• Safety of patients & staff.
• Full Disclosure of Possible complications of procedure
Timelines
• Reduced wait time and avoid delays
Effective
• Evidence based decisions, NNT vs NNH
Efficiency
• Maximum gain for minimum input
Patient centred care
• Respect for patient values, beliefs, dignity.
• Emotional & physical wellbeing
Equality
• Absence of discrimination
Frameworks for Improving Quality
Ask
○ What are we trying to accomplish?
○ How will we know that a change is an improvement?
○ What change can we make that will result in Improvement?
》》 plan: make a plan for the test of change, including predictions of results and how data will be collected.
》》Do : Test change on a small scale, document data, observations and problems that occur
》》 Study : use data from previous stages to build new knowledge and make predictions
》》 Act : adopt the change or use knowledge grained to plan or modify the next test of action
》》Study》》act 》》plan》》 Do 》》
What are the steps in the leaner sigma process for quality improvement?
○ Define : goals of the improvement project. Obtain necessary support and resources and put together a project team
○ Measure : establish appropriate metrics. Measure baseline performance of the current system.
○ Analyze : examine the system for possible areas of improvement
○ Improve: the system through implementation of ideas. Statistically validated improvements
○ Control : institutionalise the new system and monitor its stability over time.
Clinical Audit Definition
A quality improvement process that seeks to improve patient care and
outcomes through systematic review of care against explicit criteria and the
implementation of change
Key components of an audit
The key component of clinical audit is that performance is reviewed (or audited) to ensure that what you should be doing is being done
Types of audit
• Standards-based audit
• Adverse occurrence screening and critical incident monitoring
• Surgical audit (Data collected on all surgical cases – evaluate outcomes)
• Peer review (peer review of a specific individual case)
• Patient surveys and focus groups
What are medical adverse events?
• “event attributable to medical management” (not the course of
disease)
• Preventable AE: - due to error
• Negligent AE – satisfies the criteria for negligence
Three part test for negligence:
• Reasonable foreseeability of harm;reasonable precautions to prevent the occurrence of such foreseeable harm; and.failure to take the reasonable precautions.
1. Duty of care
2. Breach of this duty
3. DIRECTLY due to this breach – harm was caused
Classes of medical error:
- Error of execution – outcome not as intended
- Error of planning – path to achieve outcome taken was not correct
Types of error:
Diagnostic
• Therapeutic
• Preventative
• Other (equipment)
Cost of error:
• 1999 (United States) – direct and indirect costs $37.6 billion
• Of which $17 billion preventable (58% of total number of AE’s)
• In aviation 68% of crashes are due to human error
Death due to error:
Exceeds the 8th leading cause of in-hospital mortality
To err is human meaning
• Humans are vulnerable to distraction / bias / error
• Contributing factors / latent threats usually add up in sequence to
allow error
James Reason’s model of accident causation
Latent defects plus failures of
redundancies = error
Shortfall of root cause analysis
• Root cause analysis can always find a failure on the part of an operator
• If the analysis stops at this point, the operator may be wrongly blamed
Normal accident theory (NAT) vs High reliability organisation theory (HROT)
• NAT – complex systems working tightly together
• eventually lead to accidents under increased production pressure
• Thus – assumes risk as a part of the job
• HROT aims to attempt high risk activities with minimal accidents
• Due to the benefits we derive from these activities
•HRO’s rely on a culture of safety
• Because not having the op isn’t always an option
Characteristics of HROs
HROT aims to attempt high risk activities with minimal accidents
• Due to the benefits we derive from these activities
• HRO’s rely on a culture of safety
• Thus amelioration of risk is the primary focus
Hey element of an HRO
• Culture of safety
• Optimal structures and procedures (incl appropriate hierarchy)
• Training and practice / simulation
• Organisational learning (audit cycles, focus on QI not on blame)
Crew (cockpit) resource management (CRM)
• Utilisation of all available resources to achieve safe (flight)
operations
○ These involve:
• Cognitive skills
• Interpersonal skills
CRM key points in health care
1- Know the environment!
- and resources available
2- Anticipate and plan
- the 5 (6) P’s of planning
3- Call for help early
4- Exercise leadership and followership with assertiveness
- “The views of a single person
dominate the thinking of the group”
5- Distribute the workload
- 10 seconds for 10 minutes
6- Mobilise all available resources
7- Communicate effectively
- and with a closed loop
8- Use all available information
9- Prevent and manage fixation errors
- situational awareness
10- Cross check and double check
- acknowledge the assistant’s concerns and check them
11- Use cognitive aids
- e.g. the WHO checklist
12 - Reevaluate repeatedly
13 - Implement good teamwork
- flatten the hierarchy and be approachable
14 - Allocate attention wisely
15 - Set priorities dynamically
Performance-shaping factors
• Difficult to quantify effect, but effect is palpable
• “Society expects preparedness, not impairedness”
• American Society of Anaesthesiology:
• “If in doubt about their health, then anaesthesiologists should seek
evaluation and care”
• But: sense of duty vs judgment
Performance-shaping factors: Ambient noise and music
• OR noise > most office spaces
• Background vs instances
• Music – some studies show no effect on surgical performance
• What about teamwork and communication?
• Patient care is top priority, so continue as long as it doesn’t hurt
Performance-shaping factors: Reading and other distractions
• Low workload periods – does not impair vigilance (Weinger, 2009)
• Could counteract boredom
• AGAIN:
• Patient safety is top priority
• Distractions at critical periods = dangerous
• Interruptions (anything requiring short period of attention), however,
affect prospective memory – dangerous later
• The sterile cockpit
• During critical periods
• Only operationally relevant information / distractions should be allowed
Sleep deprivation and fatigue
• NTSB strictly regulates work and rest (incl. air, land and maritime
transport)
• Medicine rarely has the same protection
• Amount of sleep is genetically determined (avg 7 – 8 hrs)
• Sleep debt – “eye for an eye” (cannot be repaid by other means)
• Shift work, interrupted sleep, decreased total sleep impair rest and
accrue sleep debt
• Circadian rhythm determines
two periods of decreased
performance:
• 2am – 6am
• 2pm – 6pm
• Sleep affects:
• Mood (and interpersonal skills)
• Vigilance
Effects of sleep
• Sleep affects:
• Mood (and interpersonal skills)
• Vigilance
Sleep deprivation and fatigue negative effects
• Microsleep – “napping off” while meant to be wakeful
• Fatigue impairs awareness of microsleep
• Microsleep – reduced vigilance and performance
How to Minimize effects of sleepiness on performance
• Light therapy (“zeitgebers”)
• Education
• Sleep hygiene
• Rest breaks at work
• Strategic napping (decreases microsleep)
Minimising effects of sleepiness on
performance
• Medications
• Medications
• Caffeine
• Knowledge of pharmacology improves usefulness
• Modafinil – low side effects
• Melatonin – assists sleeping during unusual periods, e.g. daytime
Aging effects on performance
• Not per se a determinant of impaired overall performance
• Continual reevaluation ensures good performance
• Experience in middle-aged has shown to outperform adaptability
of younger professionals
Illness and drug use
• All are temporarily ill
• 8% of all physicians could be
diagnosed with alcoholism
• Work performance is often the
last to become impaired by chronic
addiction (late sign)
• Ironically, protocols exist to deal with the practitioner impaired
by substances, but few avenues exist for assisting the practitioner
impaired by life / work
How can we adapt and stay on par?
• QI and audit cycles
• “The current care system cannot do the job. Trying harder will not
work. Changing the systems of care will.”
- IOM report 1999, To Err is Human
Quality improvement vs Quality assurance
• Quality assurance - Blame
• Assure quality
• Does not discriminate between random (systematic) variation and specific
(causal) variation
• Punishes all deficiencies
• Continuous quality improvement - Improvement
• Limits of control
• Accepts random variation
• Adresses specific variation as an opportunity to improve
“Professionalism starts with commitment to achieve something more satisfying than immediate
personal gain and requires commitment and devotion to quality, excellence and personal sacrifice that goes beyond an eight-hour day.
Professionalism must rest on solid base of education, experience and skill and must encompass real respect for other professionals and
patients”
Euro-American Physician Charter on
Medical Professionalism3 fundamental principles
– Patient Care
– Patient Autonomy
– Social Justice
Euro-American Physician Charter on
Medical Professionalism
• 10 professional responsibilities and commitments
– Professional Competence
– Scientific Knowledge
– Professional Responsibilities/ Accountability
– Honesty
– Confidentiality
– Appropriate Patient-Doctor Relationship/ Humanism
– Quality Improvement
– Access to Care
– Distributive Justice
– Declaring Conflicts of Interest
Definitions of professionalism elements
• Adherence to medico-legal and regulatory
facets of practice with Appropriate
Certification
• Maintenance of Personal Health: Mental and
Physical Well-being
• Career Sustainability
• Management of Adverse Events
• Commitment to Important Public Service and
Good
• Ethical consideration of an action matter of
internal reflection; before, during and after
the deed
• Reflective practice conducive to continued
improvement and accountability
An “internal personal audit cycle for quality
assurance and improvement”
7 Pillars of professionalism
Elements of professionalism
Be the best
Professionals strive to excel. It takes effort and commitment to remain at that standard and to even look to excellence. A maritime professional focuses at the expectations of his position and seeks out the skillset, knowledge and training to reach them.
Be dependable
Seafarers accept the duties of the role and position and keep their promises, meet their commitments, learn from their mistakes, and take responsibility for their errors. For instance, a Master is accountable for all; this could be an ultimate praise for professionalism.
Be a team player
Take for example ship navigation and/or mooring operations. They do not necessarily imply professionalism. It is mainly about how you plan yourself; how you communicate and cooperate with your mates. Professionals know how to contribute to a larger cause and make others around them better.
Be respectful
Harassment, aggressive attitude, and offensive personal habits can face suspension of seafarers’ contracts. The multicultural nature of shipboard work requires every seafarer to adapt to the diversity and understand the positive aspects. Good business etiquette is a sign of respect for those around you, respecting others is not only good, it is good for your career.
Be positive
It important that a seafarer, his/her collogues and the organisation maintain a positive, resilientoutlook even when things get tough. There are many methods by which stress could be reduced while working andmindfulnessis one of them.
Be ethical
Those working in acknowledged seafaring professions exercise specialist knowledge and skill. Responsible maritime professionals work to avoid any ethical lapses and weigh their options carefully when facing ethical delimmas.
Competence, Knowledge, Conscientiousness, Integrity, Respect, Emotional Intelligence, Appropriateness, and Confidence.
Accepting Responsibility
• Accountability and Duty of Care
• Acceptance of a very special type of responsibility: the welfare of our patients
• Responsibility FOR but also TO our patients
• Recognition of need in our fellow human beings and responding to that need
• We become moral persons when we accept and practise responsibility
• Some personal sacrifice may ensue
• Commercial nature of medicine this may seem unrealistic; but aspiring to this type of practice, may in the end lead to better work satisfaction, more engagement and less litigation.
Education by Humiliation
• “Taught by Humiliation: When Senior Doctors
Bully Junior Doctors People Die”
• Medical Journal of Australia 2018: 25-50% of
doctors have experienced bullying/
discrimination or harassment at work
• Staff Survey 100 USA hospitals alarming
– 71% respondents agreed unprofessional behaviour
and poor communication contributed to medical error
– 27% respondents believed unprofessional behaviour
contributed to a patient’s premature death
Workplace Bullying
Depression, anxiety, fatigue
Reduces performance and affect self-esteem
Poor satisfaction leading to poor engagement
Question18
You are tasked with decreasing the risk of surgical site infection in your hospital.
a) Name a quality improvement method, whose steps you would use.
Question18
You are tasked with decreasing the risk of surgical site infection in your hospital.
b) Briefly describe your approach using one of the accepted quality improvement tools available,
explaining the steps
Question 4
Please explain the process and goals involved in a Clinical Audit that would be used to investigate an
increased incidence of unintentional extubation on your multi-disciplinary intensive care unit. Please
use diagram/s to describe the processes involved. [10]
Question 17
Discuss the advantages and limitations of large, multicentre, pragmatic randomised controlled trials
(i.e. the large international trials measuring the practical clinical effectiveness of interventions in a
relatively undefined sample population) as evidence base in perioperative decision making. [10]
Question 10
Following a critical incident, you are asked by your hospital manager to produce a protocol for the
safe handover of patients between an anaesthesiologist and intensivist. List the salient points to
be included
Question 14
a) During a laparotomy the medical and nursing students wish to capture the image of an
excised teratoma on their cell phones. Discuss how you would advise them. (3)
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b) What steps should be considered to protect patient confidentiality on multimedia educational
platforms? (3)
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d) You are asked by a surgeon to anaesthetise a patient for an emergency procedure. You
believe that the procedure is not in the best interests of the patient. How do you proceed? (4)
Question 2
An adverse incident of oxygen cylinder injury to a patient in the MRI scanner has occurred in your
hospital. The patient was transported from the intensive care unit. Explain the different ways that
the incident should be prevented in future
Question 4
A junior trainee reports to you just before the operating lists are about to start, that she thinks that
the specialist allocated to supervise her is under the influence of alcohol or drugs.
a) List the individuals, and their potential needs and rights you need to take into account when
considering how you would approach this issue. (5)
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b) Briefly describe how you would approach this problem, balancing all the needs and the need
to keep clinical services going?
Question 5
Regarding the term “Clinical Governance”
a) Define, or explain briefly, your understanding of the term “clinical governance”. (4)
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b) Using your understanding, give at least two (2) examples of the different clinical governance
roles and responsibilities that each of the following categories of staff have when providing
care for a full-day operating list. (6)
i) Registered scrub/theatre nurse responsible for the list.
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ii) Anaesthetic registrar responsible for anaesthesia care.
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iii) Clinical head anaesthesiologist for the department who is not in theatre that da
