HaDSoc Flashcards
What is an adverse event?
An injury caused by medical management (rather than the underlying disease) and that prolongs hospitalisation, produces a disability or both
Why has there been such a huge change in the quality and safety of health services recently?
Series of scandals- such as Bristol Enquiry (2001)
Emergence of lots of evidence indicating the patients are not safe or the services are not of a good quality:
- direct costs and legal bills –> inequitable care
- patients being harmed and receiving substandard care –> adverse events - unavoidable or preventable
- variations in h/c around the country –> not everyone is receiving the best care
What is an unavoidable adverse event?
Adverse event when the medical management had no reason to think the adverse event would occur and so are completely infallible (e.g. A drug reaction)
What is a preventable adverse event?
An adverse event that could be prevented given the current state of medical knowledge (e.g. Operations [never events], transfusion of blood to the wrong group! wrong dose of medication given, medication administered incorrectly)
What is a never event?
Events that should not happen under any circumstance
Why do medical errors happen?
INDIVIDUALS are at fault (incompetent, careless, badly motivated, negligent) Over reliance on individual responsibility - everyone is fallible, most medicine is complex or uncertain, personal effort is necessary but not sufficient to deliver safe care
SYSTEM is at fault (multiple contributions to an incident or failing of care and not the right defences built in) Most errors result from errors in the system - as they are poorly designed and don’t take into account human factors
General culture and behaviour
What is meant by human factors?
Factors that make a person human, which cannot be changed and which systems ought to try and account for, in order to avoid errors
- everyone is fallible, most of medicine is complex and uncertain, personal effort is necessary but not sufficient to deliver safe care
- many psychological responses to particular kinds of situations are highly predictable but often poorly anticipated
How can we remove human factors in order to reduce the incidence of medical error?
Avoid reliance on memory Make things visible Review and simplify processes Standardise common processes and procedures Routinely use checklists Decrease the reliance on vigilance
What are the three different types of error?
- Slips and lapses
- Mistakes
- Violation
What is meant by a slip/ lapse?
BY ACCIDENT
Error of action
Person knows what they are doing but action does not turn out as intended
What is meant by a mistake?
DIDN’T KNOW ENOUGH
Error of knowledge of planning
Action goes as planned but fails to achieve intended outcome because the wrong action was taken
What is meant by a VIOLATION?
INTENTIONAL ERROR
Intentional deviations from protocol, standards, safe operating procedures or other rules
What is equity?
Everyone with the same need gets the same care
What is inequitable care?
Patients across England vary in the extent to which they receive high quality care and in access to care
Why is equity not always the case?
Due to cost and legal bills
What is the Swiss cheese model of accident causation?
Successive layers of defences, barriers and safeguards in healthcare (layers of cheese) which hazards can penetrate through due to active failures and latent conditions/ failures (holes in the cheese) resulting in losses
What are active failures described in the Swiss cheese model of accident causation?
Acts that lead to direct harm of the patient, at the sharp end of practice closest to the patient
(E.g. Administering the wrong dose)
What are latent conditions/failures described by the Swiss cheese model of accident causation?
Predisposing conditions that make active failures more likely to occur
(E.g. Poor training, poor design of syringes, too few staff)
What is clinical governance?
A framework through which the NHS organisations are accountable for continuously improving the quality and safeguarding high standard of care by creating an environment in which excellence in clinical care will flourish
What are the NHS Outcomes framework and the 5 domain?
Specific national outcome goals and indicators in 5 domains linked to payments and financial incentives
1. Preventing people from dying prematurely
2. Enhancing quality of life for people with long term conditions
3. Helping people recover from episodes of ill health/ injury
4. Ensuring people have a positive experience of care
5. 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 CB accountable for £95 billion of public money and acts as a catalyst to change NHS culture and behaviour to drive up quality
In what 7 ways are quality and safety in NHS monitored and improved?
- Standard setting
- Commissioning
- Financial incentives
- Disclosure
- Regulation- registration and inspection
- Clinical audits
- Professional regulation
How is standard setting involved in monitoring and improving the NHS?
NICE quality standards- set of statements that are:
Markers of high quality, clinical and cost effective patient care across a pathway or clinical area that are:
- derived from the best available evidence such as NICE guidance or other NHS Evidence accredited sources
- produced collaboratively with the NHS and social care, along with their partners and service users
How is commissioning involved in monitoring and improving the NHS?
There are 211 clinical commissioning groups (CCG’s) in England
- commission services for their local populations
- drive local quality improvement through contracts
- held accountable for their progress in delivering outcomes by commissioning outcomes framework (COF) (use indicators that are shown to have a strong link with outcomes)
- COF indicators measure quality and (via NHS commissioning boards) hold CCG’s to account
How are financial incentives involved in monitoring and improving the NHS?
Quality and outcomes framework (QOF)
- sets national quality standards with indicators in primary care
- clinical organisational and patient experience
- general practices score points according to how well they perform against indicators
- practice payments are calculated based on points achieved (25% of GP practice income)
- results posted online (can compare GP practices to average for PCT and England)
How is disclosure involved in monitoring and improving the NHS?
All trusts are now required to publish quality accounts, increasing the disclosure of information about performance, both at organisational level and individual level
- published annually
- publically available
- focus on safety, effectiveness and patient experience
How is regulation (registration and inspection) involved in monitoring and improving the NHS?
Care quality commission (CQC)
All NHS trusts must be registered with the CQC since 2009
CQC considers NICE quality standards, checks quality accounts and can:
- impose registration of ‘conditions’ if not satisfied
- make unannounced visits
- issue warning notices, fines, prosecution, restrictions on activities, closure
What is a clinical audit and How are clinical audits involved in monitoring and improving the NHS?
A quality improvement process hat seeks to improve patient care and outcomes through systematic review of care against criteria and the implementation of change.
Component parts of a clinical audit:
- setting standards
- measuring clinical practice
- comparing results with standards (criteria)
- changing practice
- re auditing to make sure practice has improved
How professional regulation involved in monitoring and improving the NHS?
Undergoes extensive reform
Change from doctors being registered unless they were proven to be unfit to having to demonstrate that they are fit in order to remain registered
Change from not depreciating colleagues to duty to report on poorly performing colleagues
Why are social research methods important?
Social research is important so that we can be confident in answering questions about social life.
Policies and practices are based in social science research, and doctors need to be able to integrate and critically evaluate multiple resources
What are the two man types of social research methods?
Quantitative and qualitative
What does the choice of a social research study design depend on?
- Topic under investigation and the research question
- Research teams preferences/ expertise
- Time and money available
- Funders and/or audience
* different methods can be used in the same study (especially if complementary)
What is quantitative research?
Collection of numerical data which begins as a hypothesis, where conclusions can be drawn by deduction
Point of view of the researcher and the researcher may be distant
What are three types of quantitative research?
Experimental study designs- RCT’s, cohort, case control, cross sectional
Secondary analysis of data from other sources- official statistics (census), national surveys (conducted by charities and universities), local and regional surveys (conducted by NHS organisations, universities etc.)
Questionnaires- valid and reliable, published and unpublished
What are some advantages of quantitative research?
Reliable and repeatable
Good at describing, measuring, finding relationships between things, and allowing comparisons
Can use clear questions in questionnaires which are much less likely to yield inaccurate responses
What are some disadvantages of quantitative research?
May force people into inappropriate categories
May not allow people to express things in the way that they want
May not access all the important information
May not be effective in establishing causality
When ambiguous questions are asked in questionnaires - may result in people interpreting the question differently and giving the unwanted answer
What is qualitative research?
Collection of information using words and artefacts
Point of view of participants with the researcher close
What are four types of qualitative research?
Ethnography (studying behaviour in natural context- OVERT) and observation (just watching behaviour and not necessarily studying everything- COVERT)
Interviews- semi structured, prompt guide, clear agenda of topics, conversational in style, emphasis on participants giving their perspective
Focus groups- quick way of establishing parameters accessing group-based collective understanding of an issue
Documentary and media analysis - independent evidence (medical records and patient diaries)
What are some advantages of ethnography and observation?
Valuable insight into what actually happens
Gains access to behaviour of which individuals themselves may provide biased accounts of or be unaware of
Allows researchers to record mundane unremarkable (to participant) features of every day life which an individual may not feel worthy of commenting on
What is a disadvantage of ethnography and observation?
Labour intensive
Usually has to be combined with more qualitative studies such as more formal interviews to yield good evidence
What is an interview?
Detailed, focussed accounts relating to an issue of interst but gives someone’s professed views of explanation of the issue not an unproblematic description of the issue itself
What are some advantages of focus groups?
Flexible and quick way of establishing parameters
May encourage people to participate
What are some disadvantages of focus groups?
Not useful for individual experience
Some topics may be too sensitive
Difficult to arrange, need a fairly homogenous group and a good facilitator to manage group dynamics
What are some advantages of documentary and media analysis?
May provide historical context
Can analyse television, newspaper and media stories
What is a disadvantage of documentary and media analysis?
At risk of artful reconstructions - not entirely true accounts
How can qualitative data be analysed?
Ongoing iterative process - labour intensive
Often an inductive approach
- close inspection of data (interview / focus group transcripts)
- try to identify themes
- produce specification of themes
- assign data to themes
- constantly compare data analysis against the themes
How is qualitative research appraised?
Like quantitative research, qualitative research should be carried out robustinf
Some debate over most appropriate criteria for assessing quality of qualitative research
CASP offers one tool - rigour, credibility, relevance
Transparency around sampling, methods and analysis
Good qualitative research will leave an audit trail
What are some advantages of qualitative research?
Allows us to understand perspective of individuals
Accesses information not revealed by quantitative approaches
Explaining relationships between variables (why and how)
What are some disadvantages of qualitative research?
Not good at finding consistent relationships between variables
Generalisability (can’t infer views on a small sample on population as a whole)
What is evidence based practice?
Evidence based practice (/medicine/healthcare) involves the integration of individual clinical expertise with the best available external clinical evidence from systematic research
Argues that healthcare should be based upon the best available evidence (I.e. The findings of rigorously conducted research)
Evidence of: effectiveness (drugs, practices and interventions) and cost-effectiveness (finite resources, where should money be spent?)
Archie Cochrane called for a register of all RCT’s and criticised the medical profession for failing to take account of research
What is the role of systematic research in evidence based practice?
Systematic research has become very important in informing evidence base
- traditional literature reviews may be biased and subjective
- can address clinical uncertainty and highlight gaps or poor quality in research - critical appraisal tool to assess the quality of evidence
- offers authoritative, generalisable and up to date conclusions
- save clinicians from having to locate and appraise the studies for themselves
- may reduce delay between the research discoveries and implementation
Where do you get the evidence from for systematic research?
Medical journals
Cochrane collaboration
NHS centre for reviews and dissemination
NIHR Heath technology assessment programme
What are some practical criticisms of evidenced based practice?
Around the POSSIBILITY of evidence based practice
- may be impossible to create and maintain systematic reviews across all specialities
- challenging and expensive to distribute and implement findings
- RCT’s seen as gold standard but not always feasible or desirable (ethics)
- choice of outcomes very biomedical, limiting which interventions are trialled and therefore funded (e.g. NICE guidance)
- requires good faith from pharmaceutical companies
What are some philosophical criticisms of evidence based practice?
Population level outcomes may not apply to an individual
Evidence based medicine may make professionals ‘unreflective rule followers’
Professional responsibility/ autonomy
Might be seen as a means of legitimising rationing, with potential to undermine trust in the doctor- patient relationship and ultimately the NHS
What are some difficulties of getting evidence into practice?
Resources may not be available to implement change- financial or human
Evidence exists but doctors don’t know about it- distribution of the evidence ineffective? Doctors incentivised to keep up-to-date
Doctors know about evidence but don’t use it- habit, organisational culture, professional judgement
Organisational systems cannot support innovation- e.g. Managers lack the authority to invoke changes
Commissioning decisions reflect different priorities - what if patients say they want something else?
What three main inequalities are evident in healthcare?
Socioeconomic status
Ethnicity
Gender
What is a social class?
A segment of the population distinguished from others by similarities in labour market position and property relations
In what 4 ways can socioeconomic status be measured and classified?
Individual and their occupation- Registrar General Scheme (based on 6 social classes- professional/ business, intermediate/ lesser professions/ trade, skilled non manual, skilled manual, semi skilled manual, unskilled manual), National Statistics Socio-Economic Classification (NS-SEC) (8 classes of occupation from higher senior managerial and professional occupations to never having worked or being unemployed)
Area based - Townsend Deprivation score
Education- Years/ Levels reached
Income- e.g. in a household
What is the Townsend deprivation score?
Index of multiple deprivations On 7 domains - income - employment - health and disability - educational skills and training - barriers to housing and services - living environment - crime
Sometimes looks at just four variables: unemployment, car ownership, overcrowded housing, housing tenure
What are some limitations of the Townsend deprivation score?
Heterogeneity and transient populations
How is socioeconomic status linked to health?
The less deprived a population the higher their life expectancy and disability free life expectancy age standardised mortality rates are also higher in lower Socio-economic groups
In the UK- health inequalities are evident between and within regions; deprivation is strongly associated with ill health: the more deprived a person is the larger the proportion of their life that will be spent in ill health and the more likely they will die at a younger age
What is ethnicity?
The identification with a social group - membership of a collectivity - on the basis of shared values, beliefs, customs, traditions, language and lifestyles
How is ethnicity linked to health?
Some conditions are much more prevalent in certain ethnicities due to them having high risk factors as a result of their values, beliefs, customs, traditions and lifestyle
E.g. Cardiovascular disease has its highest % prevalence in men of south Asian origin
E.g. Cancer has its lowest prevalence in black minority ethnic (BME) groups
E.g. Infant mortality- higher rates in women of Pakistani and black Caribbean origin
How is gender linked to health?
Social (gender- roles, norms, discrimination) and biological (sex- hormonal, reproductive differences) variances between genders both affect health
Gender roles and relationships are socially constructed
Men die quicker but women get sicker
How does socioeconomic status affect individuals access to health care?
Heath tends to be manages as a series of crises
Normalisation of ill health
Event based consulting may be required to legitimise consultations
Difficulty marshalling resources needed for negotiation and engagement with health services
Tendency to use more ‘porous’ services
Doctors judgements of technical and social eligibility affects referrals and offers
How does ethnicity affect individuals access to health care?
Higher use of primary care (some groups)
Higher use of mental health consultations (South African Female elders)
Lower receipt of specialist services
Variations between and within ethnic groups; be careful to avoid simplistic classifications
Languages and social networks may deter help seeking
Stigmatisation and stereotyping
Association between ethnicity and socioeconomic status
How does gender affect individuals access to health care?
Women have a higher use of primary care - cultural expectations of what is gender appropriate
Why do inequalities in health occur? [Black Report (4) + 2]
The Black Report, department of health (1980)gives 4 reasons for health inequalities (HI) :
- Artefact explanation- HI evident due to the way statistics are collected - concern about quality of data and method of measurement
- Social selection explanation- direction of causation is from health to social postion- sick individuals move down social hierarchy and healthy individuals move up- chronically I’ll and disabled people are most likely to be disadvantaged
- Behavioural cultural explanation- ill health is due to people’s choices/ decisions, knowledge and goals- people from disadvantaged backgrounds tend to engage in health damaging behaviours, whereas people from advantage backgrounds tend to engage in health promoting behaviours
- Materialist explanation- inequalities in healthcare arise from differential access to material resources (low income, unemployment, work environments, low control over job, poor housing conditions); lack of choice in exposure to hazards and adverse conditions, accumulation of factors across life course; MOST PLAUSIBLE
- Psychosocial perspectives - effect of a stressor on health; psychosocial pathways associated with relative disadvantage act in addition to direct effects of absolute material living standards (Bio Psycho Social model)
- Income distribution- relative (not average) income affects health; countries with greater income inequalities have greater health inequalities; not the richest but societies with the most economic equality have the best health; theory that social cohesion is important in health
What are some limitations of the artefact explanation of inequalities in health?
Most discredited as an explanation as if anything data problems lead to under, not over estimation of inequalities
What are some limitations of the social selectio explanation of inequalities in health?
Plausible explanation but only minor contribution
What are some limitations of the behavioural- cultural explanation of inequalities in health?
Behaviours are outcomes of social processes not simply individual choice
Choice may be difficult to exercise in adverse conditions
Choice may be rational for those whose lives are constrained by their lack of resources
What are some limitations of the materialistic explanation of inequalities in health?
Further research needed as to precise routes through which material deprivation causes ill health
What are lay beliefs?
Constructed by people to understand and make sense of areas in their lives about which they have no specialised knowledge
Socially embedded – draw on cultural, social and personal knowledge and experience and own biography
Medical information may be rejected if it is incompatible with competing ideas for which people consider there is good evidence
What can lay beliefs impact?
Health behaviour
Illness behaviour
Compliance/ non-compliance (adherence) with treatment
What are deniers?
People who believe they don’t suffer from a condition when they do
What are distancers?
People who don’t believe they have the actual form of a condition, and thus convince themselves that they have a lesser form of the condition
What are pragmatists?
People who know they have a condition but only use preventative medication when condition becomes severe
What are acceptors?
People who accept and acknowledge their condition completely and this follow all of the doctors advice
Why may lay beliefs have formed?
To understand why and how illness happens – combination of person, familial and social sources of knowledge; people know fat, unfit, smokers are at risk of heart attack
Why it happened to a particular person at a particular time
Not infallible- everyone knows an overweight smoker who always drinks and lives a long and healthy life
When lay epidemiology does not fit ‘randomness and fate’ - the last person you would expect
What are three perceptions of health?
Negative definition
Functional definition
Positive definition
What is the negative definition perception of health?
Health is the absence of illness
More commonly held belief in lower socioeconomic groups
