HadSoc Flashcards
What is clinical governance?
delivering on the legal duty of NHS trusts to put in place systems for monitoring and ensuring that quality of care is provided. Represents a framework through which NHS organsiations are responsible for continuously 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 is the health and social care act 2012?
This act has a duty to improve quality. It states that the Secretary of State must exercise the functions of the Secretary of State in relation to the health service, with a view to securing continuous improvement in the quality of services provided to individuals.
o Effectiveness of the services
o Safety of the services
o Quality of the experience undergone by patients
o In regard to the quality standards prepared by NICE
How has it been suggested that healthcare is inequitable?
by variations in healthcare, which suggest that not everyone is getting the best care- variations in who receives high quality of care, and access to care
e.g. twice as likely to have foot amputated due to diabetes in you live in SW, compared to SE. More thorough feet check may have meant preventability.
what is equity?
everyone with same need gets same care
what is an adverse event?
an injury caused by medical management rather than underlying disease, that prolongs hospitilisation, produces a disability, or both.
what is a preventable adverse event?
an adverse event that could be prevented given the current state of medical knowledge
examples of variations in healthcare?
5-fold variations in asthma admission rates to hospitalts with acute exacerbations across England
14-fold variation rate per 1000 people in provision of hip replacements
what is meant by care being inefficient?
the best value for money care is not being provided
example of an unavoidable adverse event?
a drug reaction in a patient prescribed drug for 1st time
examples of preventable adverse events?
operations on wrong side of body
wrong dose/type of drug
failure to rescue- patient may deteriorate and attention is not given in time
some kinds of infections
preventable adverse events in terms of surgery?
leaving behind a foreign object
wrong procedure
wrong site
example of a preventable adverse event where medication was given via the wrong site?
vincristine- chemotherapy drug that is administered IV, but between 1975 and 2001, 14 people dies in the UK as drug given intrathecally- as spinal injection
why does harm occur in the NHS?
over-reliance on individual responsibility:
all humans make errors, everyone is fallible
most of medicine complex and uncertain
most errors result of system- inadequate training, long hours, lack of checks, ampoules that look the same
personal effort is necessary but not sufficient to deliver safe care
how has the WHO said we can address human factors to ensure a systems based approach to promote quality in healthcare?
avoid reliance on memory make things visible review and simplify processes standardise common processes and procedures routinely use checklists reduce reliance on vigilance
describe a model used to explain why patient safety problems occur
One human factors model is the Swiss
Cheese Model of organisational accidents.
The Swiss Cheese Model hypothesises that in any system there are many levels of defence. Examples of levels of defence would be checking of drugs before administration, a preoperative checklist or
marking a surgical site before an operation. Each of these levels little ‘holes’ in it which are caused by poor design, senior management decision-making,
procedures, lack of training, limited resources etc. These holes are known as ‘latent conditions’.
If latent conditions become aligned over successive levels of defence they create a
window of opportunity for a patient safety incident to occur. Latent conditions also increase the likelihood that healthcare professionals will make ‘active errors- lead directly to a patient being harmed whilst delivering patient care. When a combination of latent
conditions and active errors cause all levels of defences to be breached a patient safety
incident occurs.
Patient safety incident typically due to a series of seemingly minor events all happen consecutively and/or concurrently so on that one day, at that one time, all the ‘holes’ line up and a serious event results
types of error in administering healthcare?
- Slips and lapses
Error of action
Person knows what they want to do but action does not turn out as intended
E.g. wanted to give a baby 0.05mg of a drug but gave 0.5mg instead - Mistake
Error of knowledge or planning
Action goes as planned but fails to achieve intended outcome because the wrong action was taken
E.g. perfect administration of migraine treatment, but problem was a brain tumour - Violation
Intentional deviations from protocols, standards, safe operating procedures or other rules
E.g. not using aseptic technique when inserting a catheter
why does violation occur in healthcare causing problems with safety?
There is a perceived benefit. Less trouble for the staff, saves time, reduces distractions while doing the round.
Assumed absent or minimal consequences. Do not consider it likely there will be negative
effects for the patient or consequences for themselves. The process or rule may not appear to have value
situation of Elaine Bromiley, 2005: human factors contributing to harm occuring with patient care?
Doctors failed to recognise a standard can’t intubate can’t ventilate crisis when Elaine Bromiley was admitted to hospital for routine sinus surgery and during the anaesthetic, she experienced breathing
problems and the anaesthetist was unable to insert a device to secure her airway
Loss of situational awareness – the stress of the situation meant that the consultants
involved became highly focussed on repeated attempts to insert the breathing tube. As
a result of this they lost sight of the bigger picture i.e. how long these attempts had
been taking. This ‘tunnel vision’ meant they had no sense of time passing or the
severity of the situation
• Perception and cognition - actions were not in line with the emergency protocol. In the
pressure of the moment many options were being considered but they were not
necessarily the options that made the most sense in hindsight
• Teamwork – there was no clear leader. The consultants in the room were all providing
help and support but no one person was seen to be in charge throughout. This led to a
breakdown in the decision making process and communication between the three
consultantswww.patientsafetyfirst.nhs.uk 5
• Culture – Nurses who sensed the urgency early on brought the emergency kit to the
room, and then alerted the intensive care unit. They stated that these were available
but did not raise their concerns aloud when they were not utilised. Other nurses who
were aware of what was happening did not know how to broach the subject. The
hierarchy of the team made assertiveness difficult despite the severity of the situation.
What is the NHS outcomes framework?
This is intended to provide a national level overview of how well the NHS is performing in order to monitor and improve quality and safety in the NHS.
It specifies national outcome goals and indicators in 5 domains:
preventing people from dying prematurely
enhancing QOL for people with LT conditions
helping people recover from episodes of ill health/injury
ensuring people have a +ve experience of care
treating and caring for people in a safe environment and protecting from avoidable harm
The NHS outcomes framework provides a national overview of how the NHS is performing, holds the Health Secretary and NHS comissioning board accountable for £95bn of public money and acts as a catalyst to change NHS culture and behaviour to drive up quality
what is NICE?
National Institute for Health and Care Excellence- sets quality standards based on best available evidence, aims to define what high quality care should look like.
In April 2013 they were established in primary legislation, becoming a Non Departmental Public Body (NDPB) and placing them on a solid statutory footing as set out in the Health and Social Care Act 2012. They then took on responsibility for developing guidance and quality standards in social care, and name changed to reflect this.
what is a NICE quality standard?
a set of statements that are:
markers of high quality, clinical and cost-effective patient care across a pathway or clinical area
derived from best available evidence e.g. NICE guidance or NHS evidence accredited sources
and produced collaboratively with NHS and social care, along with their partners and service users
example of a NICE quality standard for stoke
11 statements, including:
brain imaging within 1 hr of arrival if indicated
screen for swallowing within 4 hrs
urinary incontinence reassessed after 2 weeks
What are clinical comissioning groups?
groups that are authorised to comission healtcare services for their local populations
drive quality through contracts
Supported by Commissioning Support Units which work in partnership with healthcare commissioners, healthcare providers, local authorities and others, to enable excellence in the commissioning and delivery of healthcare services.
Successful comissioning- delivering right outcomes at the right cost
How are CCGs held accountable for their progress in delivering outcomes?
The Clinical Commissioning Group Outcomes Indicator Set (CCG OIS) is an integral part of the NHS Commissioning Board’s systematic approach to quality improvement. Its primary aim is to support and enable clinical commissioning groups (CCGs) and health and wellbeing partners to plan for health improvement by providing information for measuring and benchmarking outcomes of services commissioned by CCGs to drive local improvement in quality and outcomes for patients
human factors indicated in patient safety incidents?
Cognition and mental workload Distractions The physical environment Physical demands Teamwork
What is the QOF?
Introduced in 2004 as part of the General Medical Services Contract, the Quality and Outcomes Framework is a voluntary incentive scheme for GP practices in the UK, rewarding them for how well they care for patients. Practices aim to deliver high quality care across a range of areas, for which they score points
Sets national quality standards with indicators in primary care
General Practices score points according to how well they perform against the indicators
Practice payments calculated based on points achieved
Results published online annually so can make comparisons
Example of a financial incentive to reward quality in healthcare
What are Best Practice Tariffs?
Best practice tariffs (BPTs) help the NHS to improve quality by reducing unexplained variation and universalising best practice.
Standards must be met to get the max amount of money for that practice.
What are quality accounts?
way of disclosing information about performance, focus on safety, effectiveness and experience of patients, published annually and are publically available.
All trusts required to publish them, so increased info disclosure at organisational and individual level
Describe the CQC
Since 2009, all NHS trusts must be registered with the CQC. which can impose conditions of registration if it is not satisfied, can make unannounced visits, can issue warning notices, fines, prosecution, restrictions on activities, closure, and check quality accounts.
Independent regulator of all health and social care services in England
What is a clinical audit?
process of quality improvement that seeks to improve patient care and outcomes through sytematic review of care against criteria and implementation of change
Example of an audit cycle for hand hygiene
Topic: hand hygiene
Research evidence: NICE quality standards
Criteria and standards: washing hands on entering a ward
First evaluation: 50% of drs did this
Implement Change: put up a poster at the entry to a ward
Second evaluation: 75% of drs did this
Component parts of a clinical audit?
Setting standards
Measuring current practice- collecting data
Compare results with standards
Change practice
Re-audit to make sure practice has improved
Problems of getting evidence into practice?
Drs don’t know about it- dissemination ineffective, drs not incentivised to keep up to date- lot of reading, systematic review help with this
Drs don’t use the evidence- habit, organisational culture, professional judgement- decision made based on that individual pateint in a certain clinical situation
Organisational systems cannot support innovation e.g. managers lack clout to invoke changes
Commissioning decisions reflect different priorites e.g. if patients say they want something else
Resources not available to implement change- financial or human
why might an area exhibit inequality in healthcare, but not inequity in access to healthcare?
inequality- things are different, whereas inequity is when these differences are unfair and avoidable, or not accounted for by clinical need.
So inequality in areas may respond to the needs of the population e.g. more healthcare services for the elderly pop in 1 particular region compared to another, this wouldn’t be inequitable because everyone with the same need is still getting the same care.
Describe how health is linked to socioeconomic status in Britain?
This represents the social and economic position of a person in relation to others in society, which can be classified as individual-based e.g. occupation, and geographical area-based. Life expectancy and disability-free life expectancy are both higher in those areas which are less deprived.
Age standardised mortality rates, hence accomodating for confounding factor of age, are also higher in lower socioeconomic groups.
Rate of still births, perinatal, neonatal and infant deaths are much higher for those people with lower income occupations
describe associations in Britain between health and ethnicity
CVD: highest prevalence in men of S.Asian origin, Bangladeshi=worst
Cancer: lower % prevalence in BME groups
Infant mortality: higher rates in women of Pakistani and Black Caribbean origin
Mental Health: people from BME (black and minority ethnicity) groups more likely to be diagnosed with mental illness), highest reported % poor mental health in women of pakistani and black caribbean origin, but smaller differences than diagnosis rates
what is health behaviour?
activity undertaken for purpose of maintaining health and preventing illness
what is illness behaviour?
activity of ill person to define illness and seek solution
what is sick role behaviour?
formal response to symtpoms, inc seeking formal help and action of person as patient
why might smoking be more prevalent among manual workers in comaprison to managerial and professional groupings?
higher social class- professional jobs, more likely to have +ve definition of health so incentives to give up smoking more evident for groups who could expect to remain healthy- focus on LT investments so quitting is rational choice
for lower social class- manual workers, incentives to quit are less clear as focus on ST- improving immediate environ, smoking=coping, so may be a normalised behaviour, so smoking would be rational choice
what can lay beliefs impact on?
health behaviour- difficulty accepting advice e.g. stopping smoking to prevet cervical cancer if contradicts their lay beleifs
illness behaviour
adherence/non-adherence to tment e.g. asthma:
deniers- say they don’t have asthma
distancers- deny having proper asthma
pragmatists- use preventive medication only when bad asthma, so accepted they had asthma, but saw it as a mild acute illness- so not managed as an ongoing chronic condition
won’t take medication if don’t accept asthmatic identity- no drugs and no attendance to asthma clinics, or stigma associated with asthmatic identity
what are lay beliefs?
how people understand and make sense of health and illness, constructed with no specialised knowledge from the person but drawn from many different cources e.g. media, family, friends, own experience with a dr, and so they are not simply the result of having less medical knowledge
people reluctant to accept knowledge that contradicts their lay beliefs
why do we want to measure health?
want indication of need for healthcare- want to know service requirement so as to not waste resources
target resources where most needed
assess effectiveness of hcare interventions
evaluate quality of hcare services
use evaluations of effectiveness to get better value for money
monitor patients’ progress
commonly used measures of health?
mortality
morbidity
patient-based outcomes
pros and cons of mortality as measure of health
easily define
not always recorded accurately- reason died?
not good way of assessing outcomes and care quality, especially as most procedures are not life or death situations
pros and cons of morbidity as measure of health
routinely collected e.g. disease registers
collection not always reliable/accurate
tells us nothing about patient’s experiences of condition when looking at clinical outcomes
not always easy to use in evaluation
what is a patient-based outcome to measure health?
want to assess patient’s well-being from their point of view, e.g. HRQoL, health status
patient-reported outcome measures (PROMs) are measures of health that come directly from patients and can be used to measure patient-based outcomes, and work by comparing scores before and after tment or over longer-periods
why do we want to use patient-based outcomes?
increase in conditions where aim is managing rather than curing e.g. chronic diseases like RA
biomedical tests- just 1 part of picture
need to focus on patient’s concerns- patient-centered care
need to pay attention to iatrogenic effects of care e.g. SEs of part. medication, doing more harm than good
what can patient-based outcomes be used to do?
clinically- montior progress of patient assess benefits in relation to cost clinical audit measure health status of populations compare interventions in clinical trial measure of service quality
