Governance, Audit, IT, etc Flashcards
What is clinical governance?
GMC definition
- System through which organisations are accountable for continuously improving quality of services
- Safeguarding high standards of care
- Contributes to safety and quality of patient care
- Early identification of risks and concern
- Lead to individual, team and wider organisational learning
Whose legal responsibility is it for clinical governance in an NHS trust?
- Trust board is responsible for quality of care provided by the trust
- Trust board, Chief Exec
- Annual reviews of clinical governance
- Summarising quality of care and implementation of good clinical governance
Whose practical responsibility is clinical governance in an NHS trust?
- All levels
- Medical director, nursing director, clinical director, consultants, nurse managers, and then all staff
What are the 7 pillars of clinical governance?
PIRATES
- Patient and public involvement
- Information
- Risk management
- Audit
- Training and education
- Effectiveness/evidence-based practice (clinical effectiveness)
- Staff management
Pillars of clinical governance
- What is clinical effectiveness and research?
- Any treatment must provide best outcome for the patient
- Evidence-based approaches
- Sticking to and implementing new guidelines
- Using experience to improve
- Researching to enhance future care
Pillars of Clinical Governance
What is risk management?
- Identifying problem areas in treatment
- Improvement through learning from previous issues
- Reduce risks by implementing risk systems
- Thorough risk assessments
- Reporting of incidents and near misses
- Robust systems in place to understand, monitor and minimise risk to patients and staff
- Blame-free culture
Pillars of Clinical Governance
What is patient and public involvement? (PPI)
- Patient questionnaires, patient forums, representatives from patients on practice and hospital boards
- Ensures improvements are made from the patient’s perspective
- Patient Advice and Liaison Service
- Local patient forums
- Foundation Trust Board of Governors
Pillars of Clinical Governance
What is Audit?
- Monitor the quality of clinical care being carried out
- Review of health practices against agreed standards
- Repeat the audit cycle
What is the audit cycle?
- Identify an issue or problem
- Identify a standard (NICE, RCOG, FSRH)
- Collect data on current practice
- Assess conformity of clinical practice with the standard
- Implement change
- Closing the loop: re-audit
Pillars of Clinical Governance
What is Staff management?
- Ensure those employed are suitable to carry out the work
- Underperformance can be highlighted and helped to improve
- Professional development of staff encouraged
- MAST training
- Appropriate recruitment and management of staff
- Encouraging staff retention
Pillars of Clinical Governance
What is education and training?
- Staff should have continual training to ensure they are up to date with their knowledge, to provide the best care possible
- Ability to achieve further education, attend events, lectures, webinars, courses
- Appraisals
Pillars of Clinical Governance
What is information and IT?
- Patient information should be up to date and correct
- Confidential through correct storage and management of data
NHS England Complaints Policy
Who can make a complaint?
- A person themselves
- A representative acting on behalf of a person who has died / is a child / has incapacity / has given consent to a third party to act on their behalf / has delegated authority to act on their behalf / an MP acting on behalf of a constituent
What is the statutory duty of local authorities re. complaints processes?
Statutory duty to commission independent advocacy services to provide support for people to make a complaint about their NHS care or treatment
What is PALS?
- Patient Advice Liaison Service
- Provide a point of contact for patients, their families and their carers
- PALS officers will be in local hospitals
Is there a time limit for making a complaint?
- Must not be made later than 12 months after the date occurred (or later if the matter of the complaint came to the notice of the complainant after 12 months)
When must acknowledgements be made after a complaint has been submitted?
- Must be within 3 working days
- Will be in writing (unless exceptional circumstances where it can be verbal but this must then be followed up in writing)
- Must include an offer to discuss the handling of the complaint
- Must include information about the local NHS Complaint Advocacy Services
- Will address any issues of consent
What are the 5 aims of the CQC?
To monitor and inspect services to see whether they are
- Safe
- Effective
- Caring
- Responsive
- Well-led
(the 4 priorities are excellence, caring, integrity and teamwork)
If improvements need to be made as per CQC, what must the CQC ensure / advise?
- What improvements must be made and by when
- Hold the care provider to account (i.e. issuing cautions / fines / prosecution)
- Limit what the care provider may do for a set time
- Can place the provider in ‘special measures’ which gives them a clear timetable to improve the quality of care
What are the 7 Caldicott Principles for data protection?
- Justify the purpose(s) of using confidential information
- Only use it when absolutely necessary
- Use the minimum that is required
- Access should be on a strict need-to-know basis
- Everyone must understand his or her responsibilities
- Understand and comply with the law
- The duty to share information can be as important as the duty to protect patient confidentiality
What is the information life cycle?
- Collection
- Storage
- Use
- Sharing
- Archiving
- Disposal
What are the principles of GDPR?
- Is it lawful and fair to share/access the information?
- Are we ensuring that information is limited in the share and not excessive?
- Are we limiting the purpose the data is used and shared?
- Is the information accurate?
- Are we keeping the information for a limited period of time and not hoarding the data?
- Are securing the information appropriately?
- Is responsibility and Accountability for this information in place? (Policies)
What is the role of the Caldicott Guardian?
- A Caldicott Guardian is a senior role for an organisation which processes health and social care personal data
- They make sure that the personal information about those who use the organisation’s services is used legally, ethically and appropriately, and that confidentiality is maintained.
- Caldicott Guardians should be able to provide leadership and informed guidance on complex matters involving confidentiality and information sharing
What is a risk assessment matrix?
- A grid combining the likelihood and consequence of a risk
- A risk might have a low likelihood of occuring, but if it did, it would have significant consequences
- Equally, a risk may occur every day but have little consequence
- Each trust will have their own local risk assessment matrix
A clinical risk has occurred, what are the 3 steps of analysis of the risk?
- Identifying the range of responses for dealing with the risk
- Preparing a risk reduction action plan
- Implementing the plan within a specified time frame
Describe a formative assessment
Range of formal and informal assessment procedures conducted by educators during the learning process to provide feedback and modify going forwards
Describe a summative assessment
- Measures the outcome of an educational outcome
- Finals / membership exams / required for attaining progression
Describe a norm referenced test (medical education)
- Designed to compare and rank test takers in relation to one another
- Results are relative to a norm
Describe criterion-referenced tests
- Performance is judged according to an expected level or criteria that is not dependent on other test takers
Describe vicarious learning
- Observational learning derived from hearing or observation, rather than direct instruction
Describe transformative learning
- Someone undertakes critical reflection that leads to change in their attitude, beliefs and/or perspective
Describe experiential learning
- Learning through personal experience, a form of active learning
What is the London Protocol for analysing patient safety incidents?
- Identify incident and take decision to investigate
- Select members of the investigation team
- Gather data (such as records, interviews, protocols) and relevant physical items
- Determine chronology of the incident
- Identify care delivery problems (unsafe acts, failure to act, incorrect decisions)
- Identify contributory factors (such as inadequate training, lack of supervision)
- Devise an action plan
What is the two-stage test of capacity?
- Diagnostic component: is there a mental impairment?
- Functional component: does this impairment hinder the ability to understand, retain, and evaluate information provided to reach a decision, and to communicate any decision made
What is the Data Protection Act 2018?
Legal framework to manage how personal information is used in the UK
What is the Information Commissioners Office?
Regulated and enforces data protection law
What is the Computer Misuse Act 1990?
Gaining unauthorised access to computer material
According to the Freedom of Information Act, how long does an organisation have to respond to a FOI request?
20 days
What is Miller’s Pyramid (medical education)
- Heard of
- Knows about
- Knows
- Knows how
- Shows how
- Does
What is Blooms Taxonomy (medical education)
- Remember
- Understand
- Apply
- Analyse
- Evaluate
- Create
What is Pendleton’s Rules (medical education)
Shit sandwich
What is Gibbs Reflective Cycle?
- Description
- Feelings
- Evaluation
- Conclusions
- Action
