L04 - Improving the Quality & Safety of Care Flashcards

1
Q

Describe the Bristol Royal Infirmary scandal.

What conclusions and recommendations were made?

A
  • 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

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2
Q

Describe the Harold Shipman scandal.

What inquiries were made?

A
  • 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

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3
Q

Describe the Mid-Staffordshire scandal.

What conclusions were made?

A
  • 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
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4
Q

What are the purposes of reports/inquiries?

A

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

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5
Q

What do reports/inquiries tend to show?

A

1 - Regulatory failure

2 - Organisational goal displacement

3 - Dysfunctional cultures

4 - Unsafe behaviours

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6
Q

What are problem systems?

A

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

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7
Q

What were the 6 themes for Francis’s recommendations to the Mid-Staffordshire hospital?

A

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

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8
Q

What 3 key tensions are associated with the Francis report?

A

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?

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9
Q

Describe the difference between active errors and latent errors.

A
  • 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)
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10
Q

List 4 types of factors that contribute to a negative culture in the healthcare system.

A

1 - Pressure, e.g. targets

2 - Reaction, e.g. disengagement

3 - Behaviour, e.g. uncaring

4 - Habituation, e.g. tolerance

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11
Q

List 4 types of factors that contribute to a positive culture in the healthcare system.

A

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

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12
Q

Define safety culture.

A

A set of assumptions and practices necessary for health care organisations to provide optimum care

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13
Q

What are the attributes of good safety culture?

A

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

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14
Q

Define culture.

A

The distinct characteristics of a social group or community shared between members, transmitted to newcomers & reflected in (and changed by) activities of members

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15
Q

Define organisational culture.

A

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

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16
Q

What is the problem with culture change?

A
  • Cultures not easily managed
  • Cultures not acquired through conditioning

Rewards & incentives are a very basic (& poorly aligned) way of shaping culture (lack of meaning) -> the meaning is in the reward, not in the behaviour it aims to produce