L04 - Improving the Quality & Safety of Care Flashcards
Describe the Bristol Royal Infirmary scandal.
What conclusions and recommendations were made?
- Death of 29 babies due to improper cardiac procedures in 1980s - 90s
- Investigation found that the culture and regulation of medicine was to blame:
1 - Old boys’ network
2 - There was a culture of secrecy in which the trust board shut itself off from what was happening in the hospital
3 - There was a lack of external monitoring
4 - 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.
What inquiries were made?
- Doctor estimated to have killed over 200 patients in 20 years
- A wide range of inquiries were made, including inquiries into:
1 - Regulation of primary care
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.
What conclusions 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, particularly the elderly
3 - Staffing was overstretched and poorly trained
4 - Meeting targets and resource constraints were prioritised over safety
- The Healthcare Commission rated the trust as excellent
What are the purposes of reports/inquiries?
1 - To determine the significance or causes of an event, and allocating responsibility
2 - To make recommendations for change
3 - To facilitate expression of public outcry - catharsis
4 - To be a ritual of re-legitimation
What do reports/inquiries tend to show?
1 - Regulatory failure
2 - Organisational goal displacement
3 - Dysfunctional cultures
4 - Unsafe behaviours
What are problem systems?
Systems:
1 - In which bad behaviour/bad apples can flourish - it is enabled by the system
2 - That fail to detect & exclude bad apples
3 - That provide conditions for good apples to become bad apples
What were the 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 - Strong patient-centred leadership
6 - Accurate, useful and relevant information
What 3 key tensions are associated with the Francis report?
1 - Problem: focus on targets rather than patients - solution: zero tolerance for falling below standards?
2 - Problem: lack of acceptance of responsibility - solution: centralised constitution and standards?
3 - Problem: low morale, sickness and turnover - solution: mandatory compliance, practice scrutiny and revalidation?
Describe the difference between active errors and latent errors.
- Active errors: errors that occur at the sharp end of individual performance
- Latent errors: errors that are located upstream in an organisation which enable, exacerbate and condition active errors
- (Swiss cheese model)
List 4 types of factors that contribute to a negative culture in the healthcare system.
1 - Pressure, e.g. targets
2 - Reaction, e.g. disengagement
3 - Behaviour, e.g. uncaring
4 - Habituation, e.g. tolerance
List 4 types of factors that contribute to a positive culture in the healthcare system.
1 - Openness, e.g. listening to patient complaints
2 - Reaction, e.g. engagement
3 - Behaviour, e.g. welcoming
4 - Compassion, e.g. awareness of patient experience
Define safety culture.
A set of assumptions and practices necessary for health care organisations to provide optimum care
What are the attributes of good safety culture?
1 - Mindfulness to danger & situational awareness
2 - ‘Just’ culture that fosters openness
3 - Transparency & sharing of info
4 - Positive & reflexive attitude to learning
5 - Effective leadership that promotes goals of safety
Define culture.
The distinct characteristics of a social group or community shared between members, transmitted to newcomers & reflected in (and changed by) activities of members
Define organisational culture.
The pattern of shared basic assumptions that a group has learned as it solved its problems of external adaptation & internal integration. It has worked well enough to be considered valid & therefore, to be taught to new members as correct way to perceive, think & feel in relation to those problems