Improving the Quality and Safety of Care: Learning from Francis and Other Reports Flashcards
Describe the Bristol Royal Infirmary scandal.
List 5 conclusions that were made.
List 2 recommendations that were made.
- Following the death of 29 babies due to improper cardiac procedures in the late 80s - 90s, an investigation was made.
- It was found that the culture and regulation of medicine was to blame:
1 - There was a culture of secrecy in which the trust board shut itself off from what was happening in the hospital.
2 - There was a culture of fear in which staff felt unable to report concerns.
3 - There was a culture of bullying.
4 - There was a lack of external monitoring.
5 - There was a lack of transparency.
- Recommendations included:
1 - Patients should be more involved in decisions.
2 - There should be more systematic and external forms of appraisal.
Describe the Harold Shipman scandal.
List 4 inquiries that were made.
- A doctor who is estimated to have killed over 200 patients in 20 years.
- A wide range of inquiries were made, including inquiries into:
1 - Regulation of primary case.
2 - Regulation of controlled drugs.
3 - The role of other agencies such as the coroner.
4 - The prioritisation of professionals over patients.
Describe the Mid-Staffordshire scandal.
List 5 conclusions that were made.
- Substandard performance and unsafe care especially in A&E between 2005-2008:
1 - 45% higher mortality rates than average.
2 - Patients were neglected, poorly assessed and poorly treated.
3 - Care for the elder was particularly poor.
4 - Staffing was overstretched and poorly trained.
5 - Meeting targets and resource constraints were prioritised over safety.
- The Healthcare Commission rated the trust as excellent.
List 4 purposes of reports.
1 - To determine the significance or causes of an event, and allocating responsibility.
2 - To make recommendations and engender learning.
3 - To facilitate expression of public outcry - catharsis.
4 - To be legitimate practice.
List 4 results that health reports tend to show.
1 - Regulatory failure.
2 - Organisational goal displacement.
3 - Dysfunctional cultures.
4 - Unsafe behaviours.
List 4 reforms reforms that are ongoing in the current healthcare system.
1 - There is a move away from a sole focus on professional entry via training and licensure.
2 - Environments are being created where wrongdoing is more difficult.
3 - Systems are being established to more thoroughly detect wrongdoing.
What was the Francis report?
How many recommendations were made and which issues did they address?
- The inquiry that was made to the Mid-Staffordshire case.
- It was reported in February 2013.
- It made 290 recommendations on a wide range of issues, including:
1 - Why things went unnoticed for so long.
2 - What appeared to be the problem.
What was the estimated cost of the Francis report?
£6m.
List 5 specific findings of the francis report.
1 - Water was left out of reach.
2 - Assistance with feeding was not provided for patients.
3 - Patients were left in excrement-soiled bed clothes for lengthy periods.
4 - Patients were not assisted in their toileting.
5 - Wards and toilets were left in a filthy condition.
List 4 of Francis’s diagnoses of the culture of the Mid-Staffordshire hospital during 2005-2008.
1 - Lack of compassion.
2 - Fear of trouble.
3 - Disengaged staff.
4 - Failure of leadership.
List 6 themes for Francis’s recommendations to the Mid-Staffordshire hospital.
1 - Common values.
2 - Fundamental standards.
3 - Openness / transparency / candour.
4 - Compassionate and committed nursing.
5 - Strang patient-centred leadership.
6 - Accurate and relevant information.
List 5 recommendations made from the Francis report to the Mid-Staffordshire hospital.
1 - Real-time reporting.
2 - Improve openness of reporting.
3 - The need for a staff college for managers and leaders (known as the NHS leadership academy).
4 - Better staff support.
5 - Act on one’s duty of candour to inform patients and families of care failures.
List 4 types of factors that contribute to a negative culture in the healthcare system according to Francis.
Give an example of each factor.
1 - Habituation, e.g. tolerance.
2 - Pressure, e.g. targets.
3 - Reaction, e.g. disengagement.
4 - Behaviour, e.g. uncaring.
List 4 types of factors that contribute to a positive culture in the healthcare system according to Francis.
Give an example of each factor.
1 - Compassion, e.g. awareness of patient experience.
2 - Openness, e.g. listening to patient complaints.
3 - Reaction, e.g. engagement.
4 - Behaviour, e.g. welcoming.
Define safety culture.
A set of assumptions and practices necessary for health care organisations to provide optimum care.
