quality and safety Flashcards
quality strategy 2010
3 quality ambitions
- Safe
- Effective
- Person centred
Realistic medicine – shared decision making – pt at centre of care plan
6 links for quality strategy
- Effective
- Equitably
- Efficient
- Person centred
- Safe
- timely
scottish government plan 2018
oral health improvement plan
- Focus on prevention
- Child to adult
- Reducing oral health inequalities
- Meeting the needs of an ageing population
- How to meet their needs – dentures, managing complex existing tx
- More services on the high street
- Upskill dental teams so not having to refer pts to hospitals
- Improving information for pt
- Issue – poor communication and lack of information
- How to invest to improve this? Social media/ written information?
- Evidence based needs to be up to date – checked regularly for accuracy and updated
- Quality assurance and improvement
- Workforce
- Implications of delayed intake 2021?
- Finance
chapter 7 of oral health improvement plan
quality assurance and improvement
- Director of dentistry
- in each health broad areas – 14
- leadership role – help communicate issues from each professional who fulfil their role
- regulations and powers
- no regulations over private work – COVID issue
- NHS boards powers to prevent GDPs working where there is clear danger to pt care
- Whistle blowers, pt complaints, fellow colleagues, dentist themselves
- Responsible dental reference service
- Sample pieces of work to assess quality of care, tx and if tx match pt needs
- Practitioner with problems pathway
- Consistent approach on how to work with the practitioners
- Support – stress, demands of job
- Consistent approach on how to work with the practitioners
- Quality indicators database
- Quality assurance and improvement approach
delivering quality standards requires
- Education and training
- Clinical effectiveness – evidence-based practice
- How to take academic knowledge into practice
- Openness on poor performance and practice
- E.g. airline – learning culture not blame culture
- Processes and systems to manage poor performance
- Need transparency
- Risk management
- Protected learning time
quality assurance means for clinical care
What mean for me – my career, my pt – clinics, lectures etc
What I’m working on – how I impact on it and that impacts pt care
formal quality improvement activity within the NHS
- Clinical audit
- Peer review
- Significant event analysis – critical incident review
- Not victimising
- Whole system approach to assess
- Research project
- Scottish Dental Practice Research Network – Dundee??
Quality improvement projects/ Scottish patient safety initiative
why bother with quality improvement
why not focus on tx taught to do
2018 data
- £359.7 million spent on oral health care each year
- Does it improve oral health outcomes?
- Hypothesis SPEND MORE = BETTER HEALTH?
- What else can influence oral health?
- Are we delivering quality?
How do we prove dental health improvement has happened
- Redesign dental services to become more preventative focussed rather than focus on fee per item
Oral health influences – not just dental, diet, shopping, societal
health equity
- Systems and processes in place in deliver
- Accessible services
- Reduced barriers
- Language
- Literacy and numeracy
- how to measure it
Covid – reduce staff and pt footfall
How to ensure prioritise those that need care - backlog
- messaging from clinics and practices
- but business plan coming into play – practices need to see private pts/fee pts esp as reduced footfall but cannot neglect NHS pts
- salaried from government to top up as only seeing 20-30% pts a day now
inverse care law
Those that need care may not be accessing
But those who don’t may be the ones accessing
why does inverse care law stil exist
- Cost
- Access
- Time of work
- Money to pay for tx, travel
- Use of emergency dental services
- Not able to operate at maximum capacity now due to COVID
- So emergency dental services working extra – e.g. university students not able to register, unable to get appointments as freely
- Increase session times – need cleaning times, fallot times
- Bring in extra on call dentist
- Knowledge – role for other HCP to promote visit to dental team
- pharmacy
- SIMD and information from payment systems
Self reported information
what is quality improvement
Combined an unceasing effort of everyone – HCP, pts and families, research, tax payers, administrators, educators
To make chances that will lead to
- Better professional development
- Better system performance
- Better pt outcome
3 aims of quality improvement
- Better professional development
- Better system performance
- Better pt outcome
is QI continuous
yes
“everyone in healthcare really has 2 jobs when they come to work every day: to do their work and to improve it”
- Open ears
- Listen to feedback
- Need improve
what can quality improvement look like?
- Context
- People/relationships
- Co-created system answer is generally in the room – communicate, teamwork
- Systems and processes
- Cleanliness champions
pt safety
-
Preventing pt being harmed by the care they recieve
- pt centreed - too much/not enough care
-
If harm does occur identify and analyse it and learn from it to prevent it recurring
- Open and transparent
- DATIX
- independent practice systems
- is peer review possible to try and collaborate this individual practice data on wider scale
- Open and transparent
3 most common factors for issues in quality
- medical complexity
- ageing population risk
- need most up to date prescription, up to date history to develop accurate Tx
- shared decision making
- ageing population risk
- system failures
- human factors
2 most common solutions for issues in quality
- from people in room - discussions
- reducing adverse events
why be concerned with pt safety in primary dental care
- High volume (dentist benefit from booked in appointments)
- Increasingly complex
- Medical, ageing populations, technology, drugs
- Real harm – adverse events in primary care (impact on secondary care)
- 12% admission to hospital
- 5.5% deaths in hospital (when GA done in primary care setting)
- 76% of incidents in primary care are preventable
Huge volume pt – huge potential for things to go wrong
Why not celebrate when things go right
quality improvement story
5 aspects
- Issue – 1m people NHS in 36 hours
- Measure- how to protect patients
- Prevent- inexcusable harm
- Safe- medicines and devices
- Learn- from mistakes
e.g. lessons leart from quality improvment
- Communication
- Have a plan
- Listen to all the team players
- Take control
duty of candor
Responsibility to reach out to pt and say when things go wrong, apologise
possible harms related to other aspects of care
Organisation
Environment
Individuals
Team
e.g.
- Poor administrative systems
- Poor communication
- Not enough equipment
- Stressed
- Understaffed
- Hierarchy
- Poor leadership
HUMAN CLINICAL FACTORS
overarching aim of quality improvement
Deliver high quality and safe healthcare to patients & the population by
- Reducing variance
- Increasing reliability
- Reducing hierarchy
- Developing the team
- Leadership
- Learning from failures
5 fundamental key principles of quality imporvement
- Knowing why you need to improve (aim)
- Having a feedback mechanism to tell you if improvements are occurring
- Developing effective changes that will result in improvement
- Testing and adapting changes before attempting to implement
- Knowing when and how to make changes permanent (implementing)
model for improvemtn
A model for learning and change
- Predict
- How to make better
improved quality together involves
- Person centred care
- Shared decision making
- Model for improvement
- Measurement and reliability
- Testing changes
- Improving quality together
issues with hierarchy
complex
Easier to implement change in individual practice than public dental setting
what gets in the way of quality improvment (5)
- Performance management
- Waiting lists
- Surveillance
- Staff shorting resulting in gaps in rota
- Training rotation
7 key ingredients for quality
- Leadership
- Culture
- Ownership and involvement
- Relationships
- Learning from failure
- Recognise and celebrate success take everyday processes for granted
- Sustain and spread
6 quality improvement tools
- Collaborative
- Bundles
- Pt involvement surveys, following pt journeys
- Trigger tools
- Safety climate
- Process mapping
questions to pt should be
it’s all about people and relationships
- What matters to you?
- Instead of – What’s the matter with you?
3 opinion questions
After consultation (not in dental setting anymore)
- What was good
- What could be improved
- How did you feel
Actually, writing thoughts – open ended – complement 1-10 Qs
Harder to analyse but can be very rich
care bundle
set of evidence-based interventions that when used together significantly improve outcomes
- Aims to ensure pt receive optimum care at every contact
- Right care by right HCP, right time, right place,
Structured easy of improving processes of care to deliver enhanced pt experience
Bundle Vs Audit
- Audit – identifies whether individual measures are being implemented
- Bundle – data collection tool to sample whether optimum care is being delivered
Bundle – regular collecting data, is optimum care at every snapshot
reason for bundle analysis
helps develop a checklist of what should be done for certain situations
e.g. pt on high risk medication for dental care
fishbone diagram
cause and effect analysis
what to do once id causes
apply model of improvement for developing actions
e.g. causes and actions after model for improvement for wrong tooth extraction
Causes (some adverse events had more than one):
- Human Error emerged as cause for 6 events.
- Failure of supervision emerged as cause for 5 events.
- Documentation or transcription errors emerged as cause for 3 events.
- Complication of surgery emerged as cause for 2 events.
- Handover process failing emerged as cause for 1 event.
- Standard operating procedure was not followed for 2 events.
Model of improvement used to develop actions
Actions
- Extraction protocol – confirm patient details, get patient to point at tooth etc
- Handover sticker from all departments (pink sticker)
- Minimise verbal errors
- WHO checklist
- Huddles
safety climate survey
anonymous
- Understanding the importance of a positive safety culture
- Thinking about it
- Measuring your safety climate
- Discussing it and reflecting on results
- Focussed action to improve
5 domains
fed back to develop an action plan as a team
implementing quality improvement
slow process - chasm - don’t give up
4 groups of people to consider in quality improvement plan
- Population
- Pts
- Staff
- yourself
their roles
ultimately PATIENT CENTERED
key messages when developing quality improvement plan
What went well?
What could be the potential barriers?
- How harms occured and understand complexity
- Busiest/most stressful times- look after each other
What have I learnt?
- How will this session influence my work?
- How will it change my practice?
