HCAIs Flashcards
what is an HCAI?
healthcare associated infection
how do trusts learn from each other?
through the national learning system
what can reduce the incidence of HCAIs?
root cause analysis - allows the causal factors of an incident to be identified - means that the solutions can be identified and that these events can be prevented int he future
according to WHO 2008 what is RCA?
RCA is the systematic analysis of all the factor that predisposed to or had potential to prevent an error
what are the basic principles of RCA?
react, record, respond:
critical problems
main contributory factors
what needs to be done
why are tools designed?
to capture and share the actionable learning from investigations
what are 3 examples of tools used in RCA?
5 Whys
fishbone analysis tool
tabular timeline - what happened, what should have, problem, further problems, good practice
what are examples of outbreaks of HCAIs?
stoke mandeville - 2005
Maidstone - 2006
briefly outline examples of outbreaks of HCAIs?
high number of cases of C difficile and deaths
maidstone >500 cases and 60 deaths
both due to design of service, journey and number of encounters, breaches to asepsis
how can these be overcome?
challenge visitors, wear PPE where appropriate, bare below elbows, zero tolerance, healthy challenge culture
what is the healthy challenge culture?
being able to take up issues with colleagues without feeling negative - graded assertiveness
probe, alert, challenge, escalate
what is QI?
quality improvement - a commitment to continuously improve the quality of healthcare - focusing on the needs and preferences of the people who use the service
what does QI address?
the healthcare that is being delivered compared to what should be being delivered - it focuses on changing one of the characteristics of quality - product, environment or service to make it sustainable
what is the set of methods and set of values?
values: learning, partnership, theory, context, leadership, self reflection
methods: measurement, tools, techniques, variation, cyclical change and benchmarking
what is change?
it is an attempt to improve an aspect of the system we work in
what are the basic principles of change?
eliminate any inappropriate variation and document any change
what model can be used for change?`
from Kaiser Permanente - triangle - bottom (point) is executives - set goals. Then the operational leaders who identify problems, then the clinical leaders who sequence change and then the front line staff who carry out - all surrounded by experts
what is SMART?
the criteria to set an aim Specific measurable achievable / attainable realistic / relevant time bound
what are the 4 key improvement themes in change?
involving patients, carers, staff and public, organisational and personal development, systems and process thinking and initiating, sustaining and spreading - habit
how would you produce an aim?
you need to assess how you will improve quality of care
how would you ensure confidentiality of data?
ensure the data is only used for that improvement
how is a hypothesis flexible?
it changes with learning
what sample size is used?
just enough
how would you test strategy?
sequential tests
why would you run charts?
to check if the change is an improvement
what should a method be?
observable
what are QI improvements?
clinical audit - test against a predefined standard - ensure you complete the whole clinical cycle
PDSA - repeated, rapid, small scale tests of change - audit a step further by development, testing and implementation
what does QI framework do?
uses QI methodology and a structured framework - realistic and dynamic change - makes clinical audit robust and visible
what is the PDSA cycle?
plan, do, study, act
what are the disadvantages of averages?
the give you a point on a graph but nothing variation or distribution
what is the term for achieving an endpoint?
outcome measures
what are balance measures?
checking that a change has not caused a new problem
what is statistical performance control?
display data where performance is visible to ensure that change is resulting in improvement - helps us to determine if there are gains in respect to the baseline data
