Patient safety & quality in the NHS Flashcards
Who work together to assure the quality of services & safety of patients?
NHS
Doctors
Other healthcare professionals
What is 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
What does the Health & Social Care act of 2012 state?
Secretary of State must exercise the functions in relation to health service, with a view to securing continuous improvement in the quality of services provided to individuals
- Effectiveness & Safety of services
- Quality of the experience undergone by patients
- In regard to the quality standards prepared by NICE
Name some problems with quality of healthcare
Evidence of patients being harmed or receiving sub-standard care
Variations in healthcare - not everyone getting the best
Care often inefficient (not best value for money)
What is equity in care?
Everyone with the same need gets the same care
What is inequitable care?
Patients across England VARY in extent to which they receive high quality care and in access to care
Not fair
What is an adverse event?
An injury caused by medical management (rather than underlying disease) & that prolongs the hospitalisation, produces a disability or both
- May be unavoidable e.g. drug reaction 1st time
What is a preventable adverse event?
Adverse event that could be prevented given the current state of medical knowledge
Operations - “never events”, leaving foreign object in, wrong procedure, wrong site
Failure to rescue patient - no intervention
Wrong blood transfusion
Wrong dose/type medication or administered incorrectly
Why do medical errors happen?
Everyone is fallible
Most medicine is complex & uncertain
Most errors results from the ‘system’ e.g. inadequate training, long hours, ampoules look the same
Personal effort necessary but not sufficient to deliver safe care
What types of error occur?
Slips & lapses - error of action
- Person knows what they want to do but action doesn’t turn out as intended
Mistake - error of knowledge or planning
- Action goes as planned but fails to achieve intended outcome because the wrong action was taken
Violation
- Intentional deviation from protocols, standards, safe operating procedures or other rules
Describe the Swiss Cheese Model of Accident Casuation
Successive layers of defences, barriers, safeguards (layers of cheese)
Hazards able to penetrate barriers leading to losses (holes in cheese)
Active Failures - Sharp end of practice, closest to patient
Latent Conditions/Failures - Predisposing conditions that make active failures more likely to occur, can be error provoking (time pressures), can create long lasting holes (unworkable procedures)
Describe the NHS Outcomes Framework
Specific national outcome goals & indicators in 5 domains, linked to payments & financial incentives
- Prevent people dying prematurely
- Enhancing quality of life for people with long term conditions
- Helping people recover from episodes of ill health/injury
- Ensuring people have a positive experience of care
- Treating & caring for people in a safe environment & protecting from avoidable harm
Who does the NHS Outcomes Framework hold accountable?
National overview of NHS performance
Holds health secretary & NHS CB accountable for £95bn public money
Acts as catalyst to change NHS culture & behaviour to drive up quality
What are NICE quality standards?
Set of statements that are:
Markers of high quality, clinical & cost effective patient care across a pathway or clinical area that are:
- Derived from best available evidence (NICE/NHS accredited source)
- Produced collaboratively with NHS & social care, along with their partners & service users
E.g. strokes - 11 statements, brain imaging within 1 hr of arrival if indicated, screen for swallowing within 4 hrs
What are Clinical Commissioning Groups (CCGs)?
Around 200 CCGs
Commission services for their local populations
Drive up QoC through contracts
