HadSoc Flashcards
Recognise quality and safety in healthcare as an important responsibility of
doctors
Ok
Why is Quality and Safety of Patients important?
There is evidence that patients are being harmed
Wide Variation
Direct Costs
Legal Costs
What defines Quality of Care?
Safe Effective Patient-Centred Timely Efficient Equitable
What does variations in national care mean?
Care is not Equal
Can suggest waste
Inequity
Not following guidance?
Theories as to why safety problems occur
Over-reliance of individuals
Human Factors
Reliability of Systems
Operational Defects
What is an adverse event?
Injury caused by medical management that prolongs hospitalisation, disability or both.
Can be preventable or unavoidable
What is a never event?
Examples..
Event that never should happen
Operating on the Wrong site
Foreign Objects
Wrong procedures
What is the Framework of Error?
The active failures and latent conditions which go together to create the “Swiss Cheese” model
What are some NHS quality improvement mechanisms?
Standard Setting Commisioning Incentives Disclosure Registration and Inspection Feedback/Data Gathering Audit
What is Clinical Governance?
A framework that means NHS organisations are accountable for improving continuously, safeguarding high standards and creating a successful environment
How do we avoid human factors?
Avoid reliance on memory Make things visible Simplify processes Standardise common processes Use checklists
Define QOF
Quality and Outcomes Framework
In Primary Care
Creates National Standards
GPs fulfill criteria and get payment for them
What is CQUIN?
Commissioning for Quality and Innovation
Get income for achieving goals in safety, effectiveness and patient experiences
What are National Tariffs?
Give set amount for each treatment
Penalty if mistakes
No money for never events
Increase efficiency
What is the Process for Quality Improvement?
Plan- Set the goal
Do
Study- did it work?
Act- plan the next cycle to improve
Criticism of Evidence Based Medicine
Difficult to maintain systematic reviews in some specialties
Can’t always do RCTs
Outcomes are very bio-medical
Requires trust in pharmaceutical companies
Challenging/Expensive to disseminate
May create a culture where we just follow guidelines
What are some difficulties to get evidence into practice?
Clinicians stuck in their ways
Resources may not be available
CCGs have different priorities
May create “rationing”
What is Quantitative?
Describe some Quantitative methods?
Collection of numerical data
Often use Questionnaires, can do RCTs, Cohort and Cross-Sectional Studies
Usually use closed questions
Can be self-completed or administered
What is Qualitative?
Methods?
Collection of information, focuses of PoV and insights into behaviour
1) Interviews
2) Focus Groups
3) Documentary/Media Analysis
4) Ethnography and Observation
How can Social Class affect Health?
Higher Classes report better general health
Fewer Birth Problems
How can Health be affected by Ethnicity?
Culture can affect how you act/treat yourself
Genetic Factors
Access to Resources
How can Gender affect Health?
Female- lower mental health
Male- Violent death, higher mortality
Explanations for Inequalities:
Black Report, the BAMS explanation
Behavioural - ill health is due to peoples’ choices, knowledge and goals. Disadvantaged more likely to engage in risky behaviour, useful for health education but it victim blames (not always your choice)
Artifacts - Due to collection of data (mostly discredited as if anything it would underestimate problems)
Materialist Explanation- Due to unequal access to resources. Lack of choice in exposure to hazards
Social Selection - Causation is health –> Social position, illness leads to lowering hierarchy . Plausible but only minor contribution.
Explanations for Inequalities:
Psychosocial
They add to direct effects of living standards
Increased stressors in lower classes
Stress impacts health
Explanations for Inequalities:
Income Distribution
Relative income affects health
Larger the income gap in nation the worse the health.
Redistribute wealth to reduce inequality
Measuring InEQUITY
Utilisation Studies - Measure the receipt of services
What is inequity?
Inequalities that are unfair and avoidable
Why is it important to understand lay beliefs?
Can be socially linked
Have various sources
Not just watered down medical knowledge so may not make sense to us
Vary between people
Can impact adherence/compliance and general behaviour
What is a lay belief?
The way people with no specialised knowledge understand and makes sense of illness
What is lay referral?
When a patient speaks to a friend/family member for advice on whether to see a doctor or not
What is the symptom/illness iceberg?
Just a symptom like indigestion presenting, not seen as too bad but hiding an underlying condition e.g IBD
What is a health behaviour? What is illness behaviour?
Activity undertaken to maintain health and prevent illness.
How people interpret their symptoms, whether it is a risk and how they behave
What are the determinants of health and disease?
Physical Environment
Socioeconomic Environment
Genetic
Behaviour
What are the 3 levels of prevention?
Primary - prevent onset of disease (reduce exposure to risk factors)
Secondary - detect and treat disease at early stage e.g screening
Tertiary - minimising the effects of an established disease
What are the types of health promotion?
Public Health - reform the physical environment
Education- Target individual behaviours
Promotion- broader approach, include political/social aspects
What are 3 problems with health promotion?
Victim Blaming - focuses on individuals responsibility
Surveillance - monitoring the population “nanny state”
Consumption- lifestyle choices are tied with identity not necessarily a choice
Why is it difficult to analyse the effects of health promotion?
Due to their design (Multipart? Confounding Factors?)
Lag time
High cost of research
What influences illness behaviour?
Lay referral Information and Understanding Culture Visibility of the problem Tolerance threshold and the extent it affects them
What are some ways to evaluate the success of health promotion?
Impact Evaluation- Assess immediate effects
Outcome Evaluation- Long Term Consequences, can be affected by delay/decay of impact
Process Evaluation- Assess how it was implemented. Successful? Easy? Are People doing it, Why/Why Not?
What is a Chronic Illness?
Chronic Illness is a condition that has a long term impact, on lives, can have co-morbidities.
Symptoms can vary day-to-day but can only be controlled, not cured.
Why is it important to think about Chronic conditions?
Takes up a lot of the NHS budget
Half of GP appointments
70% Inpatients
Need to think of Psychosocial Aspects
What is the “work” of Chronic Illness?
1) Everyday Life Work - Coping Strategies; Normalisation
2) Illness Work - Managing Diagnosis, Symptoms and Slef Management
3) Emotional Work - Work to protect the well-being of OTHERS
4) Biographical Work - Loss of Self
5) Identity Work - Stigma, Self Perception
What is Stigma?
A negatively defined tract, characteristic or behaviour which shows a “deviant” status.
Can be felt or enacted, discreditable and discrediting
What is the difference between discreditable and discrediting stigma?
able : no visible signes but people’s reactions change when they find out e.g. HIV
-ing : physical signs/known
Some can be both: Epilepsy
Why are Chronic conditions disabling?
Symptoms (Medical Model) Social Oppression (Social Model)
What is the sociological approach to chronic illness?
Looks at how people manage their illness in everyday life and how it affects their social interaction and role performance
What is an Illness narrative?
Storytelling and Accounting practices that occur when ill
How do we classify disability?
WHO has the ICF (International Classification of Function, Disability and Health)
Integrates medical and social models of disability and recognises the importance of wider environment
Give some detail about ICF…
It looks at the Conditions,
Split into:
Impairment (of Bodily Function)
Limitation (to Activity)
Restriction (of Participation)
Environmental and Personal factors that can add to it
How do we measure Health?
Mortality
Morbidity
Patient-Reported Outcomes
Why should we measure Health?
Indicate need for Healthcare
To target resources
Assess effectiveness and quality of Care
Monitor patient’s progress
Why use Patient Reported Outcomes?
See well-being from patient’s points of view
Increase in Chronic conditions that need managing not cure
How can we utilise PR Outcomes?
Clinical Audit
Assessing Cost-Benefit
To measure health of populations
To measure quality of services
Compare interventions in Clinical Trials
What programmes are currently being assessed by NHS PROMs?
Groin Hernias
Varicose Veins
Knee/Hip replacements
What are the Challenges of PROMs?
Time - Collecting and Analysing the Data
Money
May not be used properly
May be hard to use in some areas of healthcare e.g emergency care, mental health
Define: Health-Related QoL
The functional effect of an illness and it’s therapy on a patient, AS PERCEIVED by the patient
What does the Health-Related QoL include?
Physical Function
Symptoms
Global Judgement of Health
Psychological & Social Well-being
Cognitive Function
Personal Constructs
Satisfaction with Care
How do you measure HR QoLs?
Quantitative- General and Specific Instruments
SF-36, EQ-50 and Oxford Hip Score
Describe these? Pros and Cons…
Qualitative- can be very appropriate in some case, it shows a good initial view at the dimensions of QoL, hard to utilise especially in RCTs and also costly with time and money
What is Screening?
A systematic attempt to detect an unrecognised condition by tests/examinations/procedures that can be applied sort the population into who probably have/not got a disease
What happens to those who have a positive test?
They are high risk so have further tests to determine if they actually have the disease or not?
What are the problems?
Over-diagnosis
False Positives - Stress
False Negatives
People don’t present between the screening programmes as they have their “negative” result
Why do we screen?
Improve patient outcomes compared to the usual presentation
Screen if there is improvement if treat early
What do we currently screen for?
Breast Cancer
Bowel Cancer
Cervical Cancer
AAAs
How do we decide whether or not to screen?
Disease Factors
Must be important (affect many or fatal)
Needs to have well understood risk factors/epidemiology
Must have a stage which can be detected early
Other Primary preventions must be considered
Go over calculations for Screening Validity
How test for Sensitivity?
Specificity?
PPV?
NPV?
How do we decide whether or not to screen?
Test Factors
Simple
Safe
Must be acceptable
Must be precise and valid
How do we decide whether or not to screen?
Treatment Factors
Must have an advantage to early detection
Treatment must be available (EB)
Must agree who to treat, where the cut off is (AAA)
Clinical Management must be optomised
How do we decide whether or not to screen?
Programme Factors
Must be Effective
Quality Assurance
Need to be able to Council,
Diagnose and Treat
Opportunity-Costs
Parameters must be open to the public
Issues with Screening?
Lead Time Bias Length Time Bias Selection Bias False Positive/Negatives Sociological Criticism - Victim Blaming Opportunity Costs
Draw out the Structure of the NHS
Secretary of State National Board Regional Hubs/Local Offices CCGS Hospitals/GPs Patients
How can Clinicians be involved in management?
Clinical Directors
Medical Directors
What Management Skills should we have?
Strategy - Plan/Decide/Analyse
Financial - Prioritise/Budget
Operational - Execute Plans
Human Resources - Manage People/Teams
In what ways can Clinicians help manage?
Help with Resource Allocation
Decision Making
Contract Management
Be Partners and Leaders
What is Cost-Effectiveness Analysis?
Compare interventions with the same outcome (e.g. reduce BP)
Compare in terms of cost per unit outcome
Could cost more but also have a better outcome, is it worth it?
What is Cost Benefit Analysis?
In/Output Costs are given a value and compared
“Willingness to pay”
What is Cost Utility Analysis?
Uses QALYs
Do Cost/QALY
Focuses on Quality of Health Obtained
What is Cost Minimisation Analysis?
The interventions have the equal outcome
Only looks at the input (resources used)
Not used much as not often do they have the same effectiveness of outcome
e.g. different types of prosthetic
What is a QALY?
A Quality Adjusted Life Year Combines QoL and Survival years Allows comparison 1 QALY = 1 year of perfect health 1 QALY = 10 years with 10% "Perfect" Health Estimated with the ED-5D
What are the advantages of using QALYs?
Use it in cost utilisation studies: make a cost per QALY
Compare different interventions
Takes Quality of Life into account, not just length
What are the disadvantages to using QALYs?
Don’t distribute care by need but efficiency
May disadvantage common conditions
Don’t include impact on family/carers
What is Healthcare Economics?
A system which understands that resources are scarce and wants to maximise the social benefit that can be gained from the same budget/resources, in an efficable and efficient way
What is an Opportunity Cost?
The value of
the next best alternative use of those resources. Measure it in benefits foregone
What are technical and allocation efficiency?
Technical - Looking at the best way of meeting a need
Allocation - Choosing which need to meet
What is Economic Analysis?
It looks at the Input (resources) and the Output (Benefit and Values) of different interventions.
It allows more information to be given to make a decision
How do you measure Benefits of Interventions?
Impact on Health
Saving Resources
Improves QoL/Productivity
What is the difference between explicit and implicit rationing?
Explicit - Reasoning can be seen, based on defined rules
Implicit - Allocation by individual’s decision but criteria aren’t published
What is wrong with implicit rationing?
Inequality in care
Personal Bias - Abuse/Discrimination
Doctors are unwilling to do it
“Social Deservingness”
What are the advantages of Explicit rationing?
Transparent Accountable Same for everyone Evidence based Opportunity for Debate
What are the disadvantages of Explicit rationing?
Complex Patients' cases are different Patients/Doctors can dislike it Impacts clinical freedom Patient distress
What are some advantages to using already published instruments when measuring PROMs? Any Cons?
They have already been tested for reliability and validity
Can compare across different groups well
Can be used indiscriminately and inappropriately
Describe the SF-36
Pros
Short Form 36
Looks at the Dimensions of QoL and gives a score for each area
Can’t add up for an overall health score
General- can be used in all populations
Acceptable to Patients
Takes only 5-10 mins to complete
It is reliable and valid and retest score is consistent (internal consistency)
Describe the EQ-50
Set of 50 questions
Looks at 5 Dimensions, asks you to rate how you feel about each (no problems, little or a lot of a problem)
Gives you an overall score for health between 0-1
Valid and Reliable
Lots of Population Data available
Good for Economic Evaluations
What are the Pros and Cons of General Instruments?
Pros:
Can use in all populations including disease free
Can assess the health of the general population
Can compare different groups
Can see if any unexpected results of treatment
Cons:
Can be too general- less detail, not relevant..
Less sensitive to change
May be less acceptable to patients
What is a specific instrument?
A way of assessing PROMs specific to a disease (asthma) site (hip) or dimension (pain or depression)
What are the Pros and Cons of Specific Instruments in PROMs
More acceptable to Patients
Relevant
Sensitive to Changes
Can’t be used in disease free
May not see any unexpected results of an intervention
Limited Comparison, only internal and within the population
What is Lay Epidemiology?
Problems with this?
The set of observations and interpretations a lay person makes about the health of those around them, which influence the way they view illness and its causes
E.g. Fat person who smokes is a “heart attack waiting to happen”
If people you expect to get ill don’t and vice versa, people make start to view illness as random which can affect health promotion programmes
What are the principles behind health promotion?
That it is: Empowering Participatory Holistic Intersectional Equitable Sustainable Multi-Strategy
What is health promotion?
The process of enabling people to increase control over and improve their health
What are the aims of Public Health England?
To protect and improve the health and wellbeing of the general public by:
empowering communities
enable professional freedoms
unleashing evidence based ideas
What are the 5 types of health promotion?
Social Changes - smoke free areas
Empowerment
Education - inform about access to help
Behaviour Changing - campaigns (stop smoking, healthy eating)
Preventative Approach - seeking early help
What are some dilemmas in Health Promotion?
Ethical ones, in interfering with people's lives Victim blaming Reinforces Negative Stereotypes "Fallacy of Empowerment" Unequal distribution of responsibility Prevention Paradox
What is the Policy Background to the growth of interest in Patient’s views
2000 - Formally organising care around patients
2001 - Set out how they wanted patient involvement
2006 - Duty to consult patients on planning care, changing services
2010 - Healthwatch, strengthen patient voices and encouraging use of surveys and use information to help patients choose their care
How can patients give feedback?
Review and Rate on NHS Choices, Other Forums and Sites
Friends and Family Test
What does Healthwatch England do?
It strengthens the patients voices towards those who comission and deliver care
Consumer Champion
Local ones sit on Health and Wellbeing Board
What is PALS?
The Patient Advice and Liasson Service
It provides confidential advice about health, treatment, the NHS and the complaints procedure
What is the Complaints Process?
Problems?
Complaint is made to CCG or Hospital
CCG may pass it on to hospital or H or CCG will deal with the complaint
If the person is satisfied then no further action is take
If not, it can go to the Ombudsman
Complicated process
People need support to make complaints
What is the Job of the Health Ombudsman?
Problems?
To conduct independent reviews of complaints that weren’t handled (correctly)
They can be very slow
How can we investigate patient’s views?
Indirectly- Complaints and Ombudsman Reports
Directly (Quantitative and Qualitative)
What is a qualitative approach of seeking patient’s views?
Focus Groups
Interviews
Observation
Generally good at seeing how patients evaluate care
Can be used to create quantitative methods of seeking views
What is a quantitative approach of seeking patient’s views?
Positives?
Surveys Cheap, Easy, Little Training Already used methods are tested for reliability and validity Anonymity Guaranteed Can monitor progress
What are disadvantages of DIY surveys for patient’s views
Not tested for validity or reliability
Can’t compare
Don’t comply to basic standards
What do complaints tend to be about?
Poor Communication Skills
Content of Care - inconvenience, hotel aspects, continuity, hygiene, waiting times
What is the Functionalism Sociological Approach to the Patient-Professional Relationship?
Lay person don’t have the technical competence to remedy their illness.
They go into the “sick role” of helplessness, don’t do social responsibilities.
Medicine restores the social equilibrium.
Consensus and Reciprocity
What is the Conflict Sociological Approach to the Patient-Professional Relationship?
Doctor holds bureaucratic power
Have monopoly on defining health
Patient must submit
Medicalisation
What is the Patient-Centered Sociological Approach to the Patient-Professional Relationship?
Partnership in Care
Shared Decision Making
Co-operative
What is the Interpretive Sociological Approach to the Patient-Professional Relationship?
Focuses on meanings of social situations
What is sensitivity?
How good the test is at identifying who does have the condition
What is specificity?
How good the test is at correctly identifying those who do not have the condition
Define: Clinical Governance
The processes where healthcare organisations and workers have a duty to contiuous improvement of care and tp maintain a safe environment in which high standards of care can thrive.
Define: Clinical Audit
CA is a systematic review of an aspect of care against specific critera, where a change is implemented then continuously reviewed to see whether there is improvement/the goal has been reached (e.g PRO, experience, system performance etc)
The Cycle of Clincal Auditing
1) Plan - set critera and standards
2) 1st audit - evaulate current
3) Implement Change
4) 2nd audit/review
What is the negative predictive value?
The likeliness that a negative test really is a negative result
what is the positive predictive value?
The likelihood that a positive test is actually the presence of the disease
Which out of sensitivity, specificity, PPV and NPV can change? And Why?
PPV and NPV
They are affected by the prevalence of the disease in a population
What is the prevention paradox?
That interventions that work on a population level, don’t have much effect on an individual
