Session 1 - Whatever it is Flashcards
What changed quality and safety standards in the NHS?
The emergence of research evidence about quality and safety
Define clinical governance
A framework through which NHS organisations are accountable for continuously improving the quality and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish
What did the 2012 health and social care act make the secretary of state responsible for?
o Effectiveness of the services
o Safety of the services
o Quality of the experience undergone by patients
o In regard to the quality standards prepared by NICE
Give three quality problems in NHS
Evidence that patients are being harmed or receiving sub-standard care
Variation in healthcare suggest that not everyone is getting the best care
NHS inefficiency
What is equity?
Everyone with the same need gets the same care.
What is inequitable care?
Patients across England vary in the extent to which they receive high quality care and in access to care.
What is an adverse event
An injury caused by medical management (rather than the underlying disease) and that prolongs the hospitalisation, produces a disability, or both
What is a preventable adverse event?
An adverse event that could be prevented given the current state of medical knowledge
Give five preventable adverse events
Operations - Foreign objects, etc Transfusion of blood of the wrong grouo Wrong dose of medication give Wrong type of medication given Incorrectly adminstered medication
Give three reasons medical errors occur
o Everyone is fallible
o Most medicine is complex and uncertain
o Most errors result from “the system” – e.g. inadequate training, long hours, ampoules that look the same, lack of checks etc.
What role does personal effort play in avoiding mistakesd?
Necessary but not sufficient to provide safe care
Give three types of error
Slips and lapses
Mistake
Violation
What is a slip and lapse?
Error of action
Person knows what they want to do but action does not turn out as intended
E.g. wanted to give a baby 0.05mg of a drug but gave 0.5mg instead
What is a mistake?
Error of knowledge or planning
Action goes as planned but fails to achieve intended outcome because the wrong action was taken
E.g. perfect administration of migraine treatment, but problem was a brain tumour
What is a violation?
Intentional deviations from protocols, standards, safe operating procedures or other rules
E.g. not using aseptic technique when inserting a catheter
Outline the swiss cheese model of accident causation
o Successive layers of defences, barriers and safeguards
Layers of cheese
o Hazards are able to penetrate the barriers leading to losses
Holes in the cheese
What are active failures?
Happen at the sharp end of practice, closest to the patient
E.g. administration of the wrong dose
What are latent conditions?
Predisposing conditions that make active failures more likely to occur
E.g. poor training, poor design of syringes, too few staff
What is NHS outcomes framework?
Specific national outcome goals and indicators in 5 domains, linked to payments and financial incentives
Give five areas of NHS outcomes framework
o Preventing people from dying prematurely
o Enhancing quality of life for people with long term conditions
o Helping people recover from episodes of ill health/injury
o Ensuring people have a positive experience of care
o Treating and caring for people in a safe environment and protecting from avoidable harm.
Who is accountable for NHS outcomes?
Health Secretary and NHS comminsing body
What are nice quality standardS?
o Markers of high quality, clinical and cost effective patient care across a pathway or clinical area that are:
Derived from the best available evidence such as NICE guidance or other NHS Evidence accredited sources
Produced collaboratively with the NHS and social care, along with their partners and service users
What i a clinical commisioning group? Give two things they do
There are around 200 Clinical Commissioning Groups
o Commission services for their local populations
o Drive quality through contracts
What holds CCGs accountable for their outcomes?
Commissioning Outcomes Framework (COF) used by NHS commisioning boards
What is the quality and outcomes framework?
o Sets national quality standards with indicators in Primary Care.
o Clinical, organisational and patient experience
o General practices score points according to how well they perform against indicators
How valuable are QOF to GP practices?
25% of income
What is a quality account?
All trusts are now required to publish quality accounts, increasing the disclosure of information about performance, both at organisational level and individual level.
o Published annually
o Publically available
o Focus on safety, effectiveness and patient experience
What is the care quality commission? Give three powers it has
All NHS trusts must be registered with the Care Quality Commission since 2009. The CQC considers NICE quality standards, checks quality accounts and can:
o Impose registration ‘conditions’ if not satisfied
o Make unannounced visits
o Issue warning notices, fines, prosecution, restrictions on activities, closure
What is a clinical audit?
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against criteria and the implementation of change.
Outline the process of an audit?
o Setting standards
o Measuring current practice
o Comparing results with standards (criteria)
o Changing practice
o Re-auditing to make sure practice has improved
Explain how a systems-based approach can promote quality in health care
o Avoid reliance on memory
o Make things visible
o Review and simplify processes
o Standardise common processes and procedures
Errors dropped from 39% of patients to 11.5%
o Routinely use checklists
o Decrease the reliance on vigilance
