HaDSoc Week 1

Question 1

What is clinical governance?

Answer 1

A framework through which NHS organisations are accountable for continuously improving quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish

Question 2

Describe evidence demonstrating problems of quality and safety in healthcare

Answer 2

Quality:
Variations in medical care/ provision of specific health services across the country - can suggest not everyone is getting the best (inequity) or right care (waste) e.g. Higher relative risk of diabetic amputation in various parts of the country compared to others, CCGs across the UK not following NICE guidelines on hip replacements, having inconsistent requirements or having no commissioning policy
Safety:
Evidence that worldwide incidence of adverse effects 9.2% with 43.5% of these being preventable and 7.4% being lethal
14.4% of surgery patients have an adverse event, 38% of which are preventable
5% of deaths in English acute care deemed preventable - mostly related to omissions of care
Sepsis kills 37000 people per year
Shipman
Staffordshire
Bristol heart babies

Question 3

What is an adverse event?

Answer 3

An injury caused by medical management as opposed to underlying illness, which prolongs hospitalisation and/or leads to disability

Question 4

Why are a lot of adverse events unavoidable?

Answer 4

Side effects of drugs which are producing more benefit than harm
Drug reaction that occurs in a patient prescribed the drug for first time (unknown allergy)

Question 5

What is a preventable adverse event?

Answer 5

An adverse event that could be prevented given the current state of medical knowledge

Question 6

Why have quality and safety become so important?

Answer 6

Evidence patients are receiving substandard care or being harmed
Evidence of variation in quality of care across country
Direct costs and legal costs of poor quality of care or patient harm
Policy imperatives

Question 7

How do we define healthcare quality?

Answer 7

Safe - no needless death
Effective - no needless pain or suffering
Patient centred - focus on patient needs and priorities
Timely - no unwanted waiting
Efficient - no waste
Equitable - no one left out - give everyone with the same need the same care

Question 8

Define equity

Answer 8

Giving everyone with the same needs the same care

Question 9

Why does it matter that there are variations in healthcare?

Answer 9

Patients across England vary in the extent to which they receive high quality care and in access to care - inequitable
Inappropriate care is wasteful

Question 10

Give some examples of preventable adverse events

Answer 10

Operations performed on wrong body part
Retained objects
Wrong dose/type of medication given
Failure to rescue - vital signs deteriorate and aren't noticed
Some kinds of infections

Question 11

What is a never event?

Answer 11

A preventable adverse event where the evidence is so clear that they should never occur

Question 12

What are the two main reasons that adverse events occur?

Answer 12

Poorly designed systems that dont take account of “human factors”
Culture and behaviour of people working in healthcare

Question 13

What do we mean when we say the system is over-reliant on individual responsibility?

Answer 13

All humans make errors
Everyone is fallible - cognitive limitations, forgetful, when we are tired dont perform as well
Most medical practice is complex and uncertain which increases the likelihood of mistakes
Healthcare system compounds this complexity by providing inadequate training, long hours, ampoules that look the same, lack of checks, different approaches to doing the same thing in different places
Traditionally not been concerted efforts to make healthcare systems better
Blame the individual
But the best individuals can make mistakes
Personal effort is necessary but not sufficient to deliver safe care
Human responses to particular kinds of situations are highly predictable because they occur frequently and most people do them but for some reason they are not well anticipated in health care systems

Question 14

So is it always the system that is to blame for unsafe practice?

Answer 14

No occasionally people are incompetent, careless, badly motivated, negligent
But system failures are often at fault - multiple contributions to an incident or failing of care, not enough or not the right defences built in

Question 15

What were the findings of the research into clinical system safety issues?

Answer 15

On a day to day basis there are an awful lot of challenging inconveniences that healthcare staff are faced with
The staff are aware of these problems and they know how to deal with them
Develop work-arounds that work for the individual staff member
Easier than trying to redesign the system so that it works better
Encourage heroic, compensatory model - dependence on individual brilliance which is impossible all the time
Makes people rush and make mistakes
Mistakes get tolerated
Overall effect of degrading safety

Question 16

How does culture and behaviour affect safety?

Answer 16

Power dynamics
Stress
Poor communication 
Work-arounds
Heroic, compensatory model - dependence on individual brilliance
People rush and therefore make mistakes
Mistakes start to get tolerated
Blame individuals for mistakes

Question 17

What is James Reasons framework of error?

Answer 17

Active failures - lead directly to the patient being harmed
E.g. The administration of the wrong drug dose
Latent failures/ conditions - predisposing factors that make the active failure more likely e.g. Poor training, poor syringe design, poor supervision, too few staff
Need defences to prevent or mitigate the consequences of the active failure
Swiss cheese model

Question 18

What is the Swiss cheese model?

Answer 18

At the front have the active failure
In the other layers of cheese/barriers - if have less holes or latent failures in them could have prevented the active failure from happening

Question 19

Give an example that demonstrates the Swiss cheese model

Answer 19

Vincristine - Nottingham 2001
Latent failures - Patient late leading to changes in procedures
Pharmacy sent two syringes with drugs in one bag
Doctor not trained on new policy of this hospital - no yellow boxes
Syringes similar in appearance and design
Doctors unfamiliar with protocol/procedure
Doctor didn’t challenge the senior doctor
Doctor did not read route of administration
Active failure:
Doctor administrated vincristine intrathecally

Question 20

What are some different types of latent failures?

Answer 20

Error provoking - time pressures, inexperience

Background problems with the system - long lasting holes - unworkable procedures, design deficiencies

Question 21

How do we make the system safer?

Answer 21

Avoid reliance on memory
Make things visible - visible prompt
Review and simplify processes
Standardise common processes and procedures
Routinely use checklists
Decrease the reliance on vigilance - people are fallible

Question 22

Give an example of research that has been done into making healthcare systems safe

Answer 22

Pit-stop handovers - everyone knows their role
Having clear procedures for what happens if things go wrong
Knowing what order things have to happen in
Errors dropped from 39% to 11.5%

Question 23

How is quality and safety monitored and improved upon in the NHS?

Answer 23

Standard setting
Commissioning
Financial incentives
Regulation, registration and inspection
Clinical audit and quality improvement- local and national

Question 24

What is NICE?

Answer 24

National institute for health and care excellence - sets quality standards based on best available evidence
Aim to define what high quality care should look like

Question 25

What are NICE quality standards?

Answer 25

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 - NICE guidance or NHS evidence accredited sources
Produced collaboratively with the NHS and social care, along with their partners and service users

Question 26

Give some examples of NICE quality standards

Answer 26

VTE Prevention – seven statements, including: • All patients risk-assessed using tool on admission • Verbal and written advice offered on discharge
Stroke – 11 statements, including: • Brain imaging within one hour of arrival if indicated • Screen for swallowing within four hours • Urinary incontinence reassessed after two week

Question 27

Describe how commissioning leads to better quality care

Answer 27

200 clinical commissioning groups in England
Commission services for their local populations - tailored to needs of a particular population –> get the best health outcomes
Quality through contracts

Question 28

How is financial incentive used to improve quality of health care in England?

Answer 28

Used to reward and penalise
QOF - primary care - 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 the indicators
– Practice payments are calculated based on points achieved (25% of GP practice income)
– Results published online –> better results –> more service users –> more money
CQUIN - 1.5% provider trust’s income - based on safety, effectiveness, patient experience
National tariff - consistent basis for commissioning services, incentivise efficiency, reward best practice - HRGs (groups of treatments using same level of resources) - given set amount of money for the type of HRG - based on typical cost for treatment - efficient trusts can make a surplus –> reinvest elsewhere, inefficient trusts can lose money (avoidable complications etc.), never event will receive no money at all

Question 29

How does disclosure improve quality of healthcare?

Answer 29

Increasing emphasis on disclosing information about performance to patients and the public
Organisational level and individual level
All trusts are required to annually publish “Quality Accounts” (and make them publicly available)
Focus on safety, effectiveness, and experience of patients

Question 30

How does registration and inspection improve quality of healthcare?

Answer 30

NHS trusts (and other providers, e.g. general practices) must be registered with the Care Quality Commission
The CQC can impose “conditions” of registration if it is not satisfied
Can make unannounced visits
Can issue warning notices, fines, prosecution, restrictions on activities
Can close particular areas or entire organisations

Question 31

Describe how clinical audit and quality improvement improve quality of healthcare

Answer 31

Clinical audit: a process of identifying quality of care, trying to change it, then seeing whether it has changed
Involves:– Setting standards
– Measuring current practice
– Comparing results with standards (criteria)
– Changing practice
– Re-auditing to make sure practice has improved
Quality improvements are opportunities for medical students
and junior doctors
- Opportunity to learn a skill and make a real difference to care
- Systematic efforts to make changes that will lead to better:
– Patient experiences and outcomes
– System performance
– Professional development

Model for improvement, including plan-do-study-act cycles
– What’s the problem? – What should we do about it? – Has this addressed the problem? – How to build on this, or what to do
differently?
- Tries to build on audit cycle by going beyond feedback as a route to improvement, continuing the process, adapting it, making it a routine part of care organisation and delivery