Session 1: Quality and Safety in Healthcare Flashcards
1
Q
Who is accountable for quality and safety, and why is quality and safety so important?
A
- A series of scandals (e.g. Bristol Enquiry 2001) and the emergence of research evidence about quality and safety has changed the way quality and safety of health services is monitored and managed.
- The NHS, doctors and other healthcare professionals now aim to work together to assure the quality of services and the safety of patients.
Important because:
- Evidence that patients are being harmed or recieving sub-standard care
- Variations in healthcare
- Direct costs and legal bill (associated with poor care)
- Policy imperatives
2
Q
How do you define healthcare quality? (US Institute of Medicine)? What are the key principles?
A
- No needless deaths
- No needless pain or suffering
- No helplessness in those served or serving
- No unwanted waiting
- No waste
- No one left out
3
Q
What are the UK principles of healthcare quality?
A
- Safe
- Effective
- Patient-centred
- Timely
- Efficient
- Equitable
4
Q
How do we know that quality is not optimal? Give examples
A
- Variations in medical care suggest that not everyone is getting the best care.
- Variation in the provision of specific health services may be appropriate but can also suggest waste or inequity (unfairness) within the NHS. Care is often inefficient (best value for money is not delivered). If all NHS organisations were performing as well as the top 25%, it would yield a productivity gain of ~£7 billion per year.
- For example for patients with Diabetes, over 70 amputations a week in England are carried out, of which 80% are potentially preventable (if full, proper care plans are put in place). You are twice as likely to have your foot amputated if you live in the Southwest compared with the Southeast.
- Most admissions to hospital with acute exacerbation of asthma are avoidable, yet 5-fold variation in admission rates across England.
- Hip replacement was voted the greatest operation in the 20th century in the Lancet. Yet the variation in rate of provision per 1000 people in need is nearly 14-fold
5
Q
What is meant by Equity in healthcare?
A
- These variations in healthcare have no basis in clinical science.
- Gaps exist between what is known to be effective and what happens in practice.
- Patients across England vary in the extent to which they recieve high quality care and in access to care - care is INEQUITABLE.
- Equity: everyone with the same need gets the same care (managed the same way)
6
Q
What are Adverse and Preventable Adverse events?
A
- Adverse event: an injury that is caused by medical management (the care provided) rather than the underlying disease and that prolongs hospitalisation, produces a disability or both.
- Preventable Adverse event: an adverse event that could be prevented given the current state of medical knowledge.
7
Q
Are adverse events unavoidable or preventable?
A
- Some adverse events may be unavoidable e.g. a drug reaction that occurs in a patient prescribed the drug for the first time is an adverse event, but one that may be unavoidable. Another example is prescribing streptokinase may cause bleeding on the brain.
- Some adverse events are preventable e.g. operations performed on the wrong part of the body, retained objects, wrong dose/type of medication given, failure to rescue/failure to recognise the deterioration of the patient, some kinds of infections, transfusion of blood of the wrong group, medication administered incorrectly
- Worldwide incidence of adverse events is 9.2%. Around 43.5% are preventable. 7.4% are lethal.
8
Q
Descrihbe Safety in Surgery
A
- 14.4% of patients have an adverse event
- Around 38% of those events may be preventable.
- Surgery is a major cause of avoidable death and injury.
- Around 4000 “never events” in the US per year.
- Never event: an event that should not happen under any circumstance e.g. foreign body left behind after surgery (39x a week), wrong procedure (20x a week) and wrong site (20x a week)
9
Q
Is Sepsis preventable and treatable?
A
Yes
- Kills 37,000 people in the UK per year
- Each hour that it goes untreated raises risk of death by 8%.
- 50% of people with septic shock die.
- Most preventable deaths are related to quality of clinical monitoring: omissions of care e.g. patient is very ill and is prescribed Septrin on Friday afternoon. Pharmacy does not deliver it as it needs a special order. Nurse notes “drug not available” on Friday evening. This is repeated by every nurse until Monday morning. By Monday morning, patient is close to death and is admitted to ICU. He subsequently dies.
10
Q
Why does patient safety get breached?
A
- Poorly designed systems do not take account of human factors.
- Culture and behaviour e.g. when people spoke up and raised concerns, they were ignored.
11
Q
Is personal effort enough to deliver safe care?
A
NO
- All humans make errors. Most of medicine is complex and uncertain.
- Most errors result from the “system” - inadequate training, long hours, drug ampoules that look the same, lack of checks etc.
- Healthcare has not traditionally tried to make itself safe - blamed individuals instead.
- But the best people can make the worst mistakes.
- Personal effort is necessary but not sufficient to deliver safe care. The system needs to change as well
12
Q
Describe Systems and Individuals
A
- Sometimes Individuals are at fault - occasionally people are incompetent, careless, badly motivated, negligent (did not do something they should have done)
- OFTEN system failures are at fault: often multiple contributions to an incident or failing of care. Not enough or not the right defences built in (to stop individuals from doing the wrong thing).
13
Q
What is meant by Human Factors? What is the WHO Checklist to ensure care is safe?
A
- Many psychological responses to particular kinds of situations are highly predictable.
- Yet often poorly anticipated in healthcare.
WHO Checklit: Human factors thinking
- Avoid reliance on memory
- Make things visible
- Review and simplify processes
- Standardize common processes and procedures e.g. between different hospitals, etc
- Routinely use checklists.
- Decrease the reliance on vigilance; **try to make sure things go right by default rather than avoiding what could go wrong. **
14
Q
Describe poor reliability of systems
A
- Reliability of 81% to 87%
- Availability of equipment in theatres ranges from 63% to 88% (up to nearly 40% of the time, operating without all the sufficient or appropriate equipment needed to ensure patient safety and best care)
- In outpatient clinics, 15% of patients lack some type of relevant clinical information.
- Estimated 1085 incidents in UK 2005-2010
- Medication: completely different substances are often packaged exactly the same - potential to make mistakes especially when stressed or tired.
15
Q
Describe the Swiss Cheese Model
A
- Hazards are able to pnetrate the barriers leading to losses (holes in the cheese)
- Some holes due to active failures
- Other holes due to latent conditions (e.g. resident pathogens)
- Successive layers of defences, barriers and safeguards so if things do go wrong, we catch it in time to prevent things going seriously wrong. ‘layers of cheese’
- This involves plugging the gaps (e.g. can’t prevent car incidents so install air bags) and filling the holes (e.g. infection control - handwashing policies etc)
17
Q
What is meant by Latent Conditions?
A
James Reason’s Framework of Error: Latent Conditions
- Latent conditions (or failures) are the predisposing conditions.
- Any aspect of context that means active failures are more likely to occur e.g. poor training, poor design of syringes, too few staff, poor supervision
- Latent conditions can make it more likely that a baby could be given the wrong dose.
- So need defences that trap or mitigate error
- Example: administering Vincristine (chemotherapy drug that needs to be administered intravenously not intrathecally (i.e. as spinal injection). See lecture for more details.
- Latent conditions can be error provoking (time pressures, inexperience) or create long lasting holes (unworkable procedures, design deficiencies). If the syringe had been designed differently, the doctor wouldn’t have been able to inject the drug intrathecially (spinal injection).
19
Q
Describe how safety isn’t always prioritised?
A
Failure to ensure organisations are geared to safety
- Pushes focus onto short term ‘fixes’
- Encourages heroic, compensatory model (not trying to design erros out, tries to ensure someone can save the day when mistakes occur).
- Makes people rush and make mistakes => affects level of patient care delivered and patient safety
- Mistakes and ‘bodges’ get tolerated
- Overall effect of degrading safety
23
Q
Describe the NHS Outcomes Framework - what are the five domains?
A
Specifies national outcome goals and indicators in 5 domains
- Preventing people from 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 and caring for people in a safe environment and protecting from avoidable harm.
Linked to payments and financial incentives.
29
Q
Describe Financial Incentives and give examples
A
- Finance is increasingly linked to quality in the NHS. Used both to reward and to penalise. E.g.
Quality and Outcomes Framework (QOF) used in primary care
- Sets national quality standards with indicators in primary care.
- Clinical, organisational and patient experience
- General practices score points according to how well they perform against the indicators
- Practice payments are calculated based on points achieved. Points generate income for the practices - can be 25% of GP practice income.
- Results published online - can compare GO practices to average for PCT and England
Commissioning for Quality and Innovation (CQUIN - aim is to reward excellence, driving up quality)
- 1.5% of provider trusts’ income depends on achieving measurable goals agreed with the commissioners in 3 areas: safety, effectiveness and patient experience
Best Practice Tariffs
33
Q
Describe Clinical Aduit
A
- A quality imrpovement process that seeks to improve patient care and outcomes through systematic review of care against criteria (what the care should be) and the implementation of change (to current practice)
Component Parts
- Setting standards
- Measuring current practice
- Comparing results with standards (criteria)
- Changing practice
- Re-auditing to make sure practice has improved
36
Q
What is meant by COF?
A
- Holds CCGs accountable for their progress in delivering outcomes.
- Use indicators that are shown to have a strong line to outcomes.
- Drive local improvement in quality and outcomes for patients
- COF indicators measure quality
- NHS Commissioning Boards hold Clinical Commissioning Groups to account
