Patient Safety and Quality in the NHS Flashcards
1
Q
What was true of the quality and safety of health services up until about 15 years ago?
A
Often poorly monitored and managed
2
Q
What has changed the poor monitoring and management of health services?
A
A series of scandals and the emergence of heatlh research evidence about quality and safety
3
Q
What do the NHS, doctors, and other healthcare professionals now aim to do?
A
Work together to assure the quality of services and safety of patients
4
Q
Why is quality and safety important in healthcare?
A
- Evidence that patients are being harmed, or receiving sub-standard care
- There are variations in healthcare
- Direct costs and legal bills
- Polcy imperatives
5
Q
What is meant by safe healthcare?
A
No needless deaths
6
Q
What is meant by effective healthcare?
A
No needless pain or suffering
7
Q
What is meant by patient-centered healthcare?
A
Focus on patients’ needs and priorities
8
Q
What is meant by timely healthcare?
A
No unwanted waiting
9
Q
What is meant by efficient healthcare?
A
No waste
10
Q
What is meant by equitable healthcare?
A
No one is left out
11
Q
Why do we known that quality in healthcare is not optimal?
A
Variations in medical care suggest that not everyone is getitng the best, or the right, care
12
Q
Are variations in provision of specific health services ever appropriate?
A
They may be
13
Q
What may variation in the provision of specific health services suggest?
A
Waste or inequity within the NHS
14
Q
Give two examples of where there is variation in the provision of specific health services
A
- Variations in diabetes related amputations across the country
- Variations in hip replacements across the country
15
Q
What % of CCGs did not follow NICE and clinical guidance on referral for hip replacement, or had no commissioning policy?
A
73%
16
Q
What could lack of adherence to guidance on referral for hip replacement or commissioning policy lead to?
A
Too many or too few referrals
17
Q
What % of CCGs required patients to be in various degrees of pain of immobility, or required patients to loose weight, before hip replacement surgery?
A
44%
18
Q
What problematic gaps exist in healthcare?
A
What is known to be effective, and what happens in practice
19
Q
Why is care in England inequitable?
A
Patients across England vary in the extent to which they recieve high quality care and in access to care
20
Q
What is equity?
A
Where everyone with the same need gets the same care
21
Q
What is an adverse event?
A
An injury that is caused by medical management, rather than the underlying disease, and that prolongs the hospitalisation, produces a disability, or both
22
Q
Give an example of an adverse event that is unavoidable
A
A drug reaction that occurs in a patient prescribed that drug for the first time
23
Q
What are preventable adverse events?
A
Adverse events that could have been prevented given the current state of medical knowledge
24
Q
Give 5 examples of preventable adverse events
A
- Operations performed on the wrong part of the body
- Retained objects
- Wrong dose/type of medication given
- Failure to rescue
- Some kinds of infections
25
How many people does sepsis kill in the UK every year?
37,000
26
How much does the risk of death increase with every hour sepsis goes untreated?
8%
27
What is the worldwide incidence of adverse events?
9.2%
28
What % of adverse events are lethal?
7.4%
29
What are most problems leading to adverse events related to?
Quality of clinical monitoring leading to omissions of care
30
What % of surgical patients have had an adverse event?
14.4%
31
What % of surgical adverse events may have been preventable?
Around 38%
32
How many 'never events' occur in the US each year?
4000
33
Give 3 examples of 'never events'
* Foreign objects left behind
* Wrong procedure
* Wrong site
34
What are surgical adverse events a major cause of?
Avoidable death and injury
35
What theories are there as to why patient safety problems occur?
* Poorly designed systems that do not take into account 'human factors' - there is a **over reliance on individual responsibility**
* Culture and behaviour
* System failures often at fault
* Operational defects
* Failure to ensure organisations are geared to safety
36
Why do all humans make errors?
Everyone is fallible;
* All have cognitive limitations
* All forget things
* Get tired, and don't perform as well as we can
37
What is the problem with most medical practice being complex and uncertain?
* Increases likelihood of mistakes
* Healthcare system often compounds complexity
38
In what ways do healthcare systems often compound complexity?
* Inadequate training
* Long hours
* Ampoules that look the same
* Lack of checks
* Different approaches to doing the same thing in different places
39
Traditionally, who is blamed when things go wrong in healthcare?
Individuals are blamed instead
40
What is the relationship between personal effort and delivery of safe care?
Personal effort is necessary, but not sufficient to delivery safe care
41
What is true of many human responses to particular kinds of situations?
They are highly predictable, occur frequently, and most people do them
42
What is the problem with predictable human responses in healthcare?
They are often poorly anticipated
43
When are individuals at fault in healthcare?
People can be;
* Incompetent
* Careless
* Badly motivated
* Negligent
44
Why may a healthcare system fail?
Not enough, or not the right, defences built in
45
What is the reliability of systems?
81-87%
46
What is the availability of equipment in theatres?
Ranges from 63 to 88%
47
What % of patients lack some type of relevant clinical information in outpatient clinics?
15%
48
How often are nurses interrupted, according to a US study?
Every 6 minutes
49
What % of nurses time is spent working around operational failures?
10-12%
50
Why is there a failure to ensure organisations are geared to safety?
* Pushes focus onto short term fixes
* Encourages heroic, compensatory model
* Makes people rush and make mistakes
* Overall effect of degrading safety
51
What is the problem with healthcare systems encouraging a heroic, compensatory model?
Dependence on individual brilliance is impossible all the time
52
What does James Reasons framework for error say causes error?
* Active failure
* Latent conditions
53
What are active failures?
Acts that lead directly to the patient being harmed
54
Where do active failures occur?
At the 'sharp end' of practice, closest to the patient
55
What are latent conditions?
The predisposing conditions - any aspect of context that means active failures are more likely to occur
56
Give 4 examples of latent conditions?
* Poor training
* Poor design of syringes
* Too few staff
* Poor supervision
57
What can latent conditions be?
* Error provoking
* Time pressures
* Inexperience
58
What do latent conditions create?
Long lasting 'holes'
59
Give two examples of long lasting 'holes' that can be latent conditions
* Unworkable procedures
* Design deficiencies
60
What is needed to trap or mitigate the active failure?
Defences
61
What defences are there to trap or mitigate the active failure?
* Protocols
* Procedures
* Custom
* Practice
62
What needs to happen for an active failure to occur?
All barriers need to be breached at once
63
What system factors impact safety?
* Institutional
* Hospital
* Departmental factors
* Work environment
* Team factors
* Individual practioner
* Task factors
* Patient characteristics
64
What can be focused on to make the system safer?
Human factors
65
What human factors can be changed to make the system safer?
* Avoid reliance on memory
* Make things visible
* Review and simplify processes
* Standardise common processes and procedures
* Routinely use checklists
* Decrease reliance on vigilance
66
What does the Health and Social Care Act of 2012 say that the Secretary of State for Health must do?
Exercise the functions of Secretary of State in relation to the health service, with a view to securing continuous improvement in the quality of services provided to individuals, including;
* The effectiveness of services
* The safety of services
* The quality of experience undergone by patients
67
What does the Health and Social Care Act of 2012 say the Secretary of State must do in discharging the duty described?
Have regard to the quality standarsd prepared by NICE
68
Draw a diagram illustrating the quality improvement system
69
What quality improvement mechanisms does the NHS have?
* Standard setting
* Commissioning
* Financial incentives
* Disclosure
* Regulation, registration, and inspection
* Clinical audit and quality improvement
70
Who sets quality standards?
The National Institute for Clinical Excellence
71
What do NICE set quality standards based on?
The best available evidence
72
What do NICE aim to do?
Define what high quality care should look like
73
What do NICE produce?
A set of statements that are markers of high quality, clinical, and cost-effective patient care across a pathway or clinical area
74
What are the NICE guidance based on?
The best available evidence
75
Who are NICE guidelines produced with?
Collaboratively with the NHS and social care, along with partners and service users
76
How many Clinical Commissioning Groups are there in England?
More than 200
77
What do CCGs do?
Comission services for their local populations
78
How do CCGs drive quality?
Through contracts
79
What is finance increasingly linked to in the NHS?
Quality
80
How is finance used in the NHS to induce quality?
Both as a reward, and to penalise
81
Where is the Quality and Outcomes Framework used?
In primary care
82
What does the Quality and Outcomes Framework do?
Sets national quality standards with indicators in primary care
83
What are the Quality and Outcomes Framework based on?
Clinical, organisational, and patient experience
84
How is the Quality and Outcomes Framework used to incentivise quality?
General practices score points according to how well they perform against the indicators. Practice payments are calculated based on points achieve, and points generate income for practices
85
What happens to the results of the Quality and Outcomes Framework?
They are published online
86
What does CQUIN (Commissioning for Quality and Innovation) provide?
1.5% of a trusts income
87
What does how much income a trust gets from CQUIN depend on?
Measureable goals agreed with commissioners in three areas;
* Safety
* Effectiveness
* Patient experience
88
What is the National Tariff intended to do?
* Provide a consistent basis for commissioning services
* Incentivise efficiency
* Reward best practice
89
How does the National Tariff incentivise efficiency and reward best practice?
Payment by result
90
What facilitates payment by result?
Healthcare Resource Groups (HRGs)
91
What are HRGs?
Standard groupings of clinically similar treatments which use common levels of healthcare resources
92
What is there for each HRG?
A set fee that goes from commissioners to providers
93
What happens when a hospital treats a patient, with respect to HRGs?
* The diagnosis and treatment are recorded and coded
* The HRG (and so tariff) is assigned
* The appropriate bill is sent to commissioner
94
Do different kinds of treatment for the same presentation have the same tariffs?
No
95
How does the National Tariff system link with quality?
* Tariff is based on typical costs for different treatments
* If avoidable complications occur, the trust lose money
* If a 'never event' occurs, there is no payment at all
96
How does the tariff being based on typical costs for different treatments ensure quality?
Efficient trusts can make a surplus, whereas inefficient trusts can lose money on a given treatment, so there is an incentive to become more efficient over tiem
97
Why can efficient trusts make a surplus with the National Tariff?
Do things for less they are paid by the tariff, and reinvest the money elsewhere
98
What is there an increasing emphasis on, regarding disclosure?
Disclosing information about performance to patients and public
99
On what level is disclosure encouraged?
Organisational level and individual level
100
What are all trusts required to annually publish?
'Quality Accounts'
101
What is the focus on with disclosure?
* Safety
* Effectiveness
* Experience of patients
102
What must NHS trusts and other providers, *e.g. GPs*, be registered wtih?
Care Quality Commission (CQCs)
103
What powers do CQCs have?
* Can impose 'conditions' of registration if not satisfied
* Can make unannounced visits
* Can issue warning notices, fines, prosecution, and restrictions on activities
* Can close particular areas, or entire organisations
104
On what level does clinical audit and quality improvement occur?
Local and national
105
What did all junior doctors have to do until recently?
Conduct a clinical audit as part of their training
106
What can junior doctors now do, regarding clinical audits, as part of their training?
Clinical audit, quality improvement projet, or a combination of the two
107
What is quality improvement?
An opportunity to learn a skill, and make a real difference to care
108
What will systematic efforts to make changes lead to?
* Better patient experiences and outcomes
* Better system performance
* Professional development
109
What is a clinical audit?
A process of identifying quality of care, trying to change it, and then seeing whether it has changed
110
What does a clinical audit involve?
* Standard setting
* Measuring current practice
* Comparing results with standards (criteria)
* Changing practice
* Re-auditing to make sure practice has improved
111
Give an example of an approach to clinical audit?
Model for improvement, including 'plan study do act' cycles
112
What questions are asked in the model for improvement?
* What is the problem?
* What should we do about it?
* Has this addressed the problem?
* How to build on this, or what to do differently?
113
What does the model for improvement try to do?
Build on audit cycle by going beyong feedback as a route to improvement, continuing the process, adapating it, and making it a routine part of care organisation and delivery
114
What have NHS trusts had the legal duty to do since April 1999?
Put in place systems for monitoring and ensuring quality of care provided
115
What is clinical governance?
Delivering on the duty of putting systems in place for monitoring and ensuring quality of care
116
What do all doctors work under?
Duties of clinical governanace
117
What is the definition of clinical governance?
'A framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish'
