Week 1 - Quality and Safety

Question 1

Define an adverse event.

Answer 1

An injury that is caused by medical management (rather than the underlying disease) that prolongs hospitalisation, produces a disability or both

Question 2

Define an adverse preventable event.

Answer 2

An adverse event that could be prevented given the current state of medical knowledge

Question 3

What is clinical governance?

Answer 3

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

Question 4

State the quality improvement mechanisms employed by the NHS.

Answer 4

1. Standard setting
2. Commissioning
3. Financial incentives
4. Disclosure
5. Regulation, registration and inspection
6. Clinical audit and quality improvement - local and national

Question 5

What is a NICE Quality Standard?

Answer 5

A set of statements that are;

1. Markers of high quality, clinical and cost-effective patient care across a pathway or clinical area
2. Derived from the best available evidence such as NICE Guidance or other NHS accredited sources
3. Produced collaboratively with the NHS and social care, along with their partners and service users

Question 6

What is a clinical audit?

Answer 6

A quality improvement process that seeks to improve patient care and outcomes through a systematic review of care against criteria and implementation of change

Question 7

Outline the practical criticisms of evidence-based practice.

Answer 7

1. May be an impossible task to create and maintain systematic reviews across all specialties
2. May be challenging and expensive to disseminate and implement findings
3. RCTs are seen as the gold standard but not always feasible or even necessary/desirable, e.g. due to ethical considerations
4. Choice of outcomes often very biomedical and therefore may limit which interventions are trialed and therefore which are funded (e.g. NICE Guidance)
5. Requires good faith on the part of pharmaceutical companies (i.e. trusting that all relevant evidence is in the public domain)

Question 8

Outline the philosophical criticisms of evidence based practice.

Answer 8

1. Does not align with most doctors’ modes of reasoning, i.e. deterministic vs probabilistic causality
2. Aggregate population-level outcomes does not mean that an intervention will work for an individual
3. Potential of EBM (or its implementation e.g. through NICE or clinical governance) to create unreflective rule followers out of professionals
4. Might be understood as a way of legitimising rationing, with potential to undermine trust in the doctor-patient relationship and ultimately the NHS
5. Professional responsibility/autonomy

Question 9

Give the criteria a screening test should fulfill before a screening test can be considered.

Answer 9

1. Should be simple and safe, screening healthy people
2. Precise and valid (i.e. it should tell the truth)
3. Acceptable to the population
4. Distribution of test values in the population must be known
5. An agreed cut-off level must be defined and agreed
6. Must be an agreed policy on who to investigate further
7. If the test is for a particular mutation or set of genetic variants, the method for their selection and the means through which they must be kept under review in the programme should be clearly set out

Question 10

Define lead time bias.

Answer 10

When a screening programme leads to earlier diagnosis but not improved survival

Question 11

Define length time bias.

Answer 11

When a screening programme diagnoses a larger proportion of slower growing tumours than fast growing tumours leading to the false impression of improved survival

Question 12

What are latent conditions?

Answer 12

Contexts within which active failures occur: e.g. organisational processes, understaffing, poor communication

Question 13

State two generic health-related quality of life instruments.

Answer 13

1. SF-36

2. EQ 5D

Question 14

State the disadvantages of generic health-related quality of life instruments.

Answer 14

1. Loss of detail
2. Loss of relevance
3. May be insensitive to changes that occur as a result of intervention
4. May be less acceptable to patients

Question 15

State the reasons why evaluating any health promotion intervention can be difficult.

Answer 15

1. Design of the intervention
2. Possible time lag to effect - delay
3. Initial effects might wear off - decay
4. Many potential intervening or concurrent confounding factors
5. High cost of evaluation research

Question 16

What are the consequences of having a negative definition of health?

Answer 16

1. Individuals who have a negative definition of health regard health as the absence of illness
2. Therefore, they are less likely to engage in preventive interventions such as smoking cessation in the absence of symptoms

Question 17

Outline reasons why individuals from lower socioeconomic groups are less likely to attend screening.

Answer 17

1. May have more difficulty in mobilising resources required to attend
2. May be more likely to have a negative definition of health, manage health as a series of crises and not perceive need for attending preventive services such as screening
3. Lack of cultural alignment

Question 18

Outline reasons why it is important for doctors to have an understanding of lay beliefs.

Answer 18

1. Lay beliefs can influence health behaviour
2. Lay beliefs can influence illness behaviour
3. Can help understand compliance/non-compliance with treatment

Question 19

What does the term “specificity” mean in relation to screening programmes?

Answer 19

How good the test is at identifying correctly people that do not have the condition

Question 20

What is the central component of Wilkinson’s theory of income distribution?

Answer 20

The most egalitarian societies have the best health

Question 21

Outline the advantages of quantitative methods.

Answer 21

1. Could investigate relationship between things
2. Could include a large number of people
3. Could check reliability by using test/retest on a sample of respondents
4. Could establish validity by comparing with some other measures of concerns
5. Could use an existing questionnaire with demonstrated validity and reliability

Question 22

Outline some disadvantages of quantitative methods.

Answer 22

1. Might miss important issues, particularly if these were unanticipated
2. Might force responses which don’t really represent the individuals’ concerns
3. Might not allow individuals to express their real concerns
4. Might not allow full understanding of why individuals behave in the way they do

Question 23

Outline some criteria to establish whether a health-related quality of life measurement instrument is good to use.

Answer 23

1. Is there published work showing that the reliability and validity of this instrument have been established?
2. Have there been other published studies that have used this instrument successfully?
3. Is there anything about the way the instrument was developed that might affects its appropriateness for use by you?
4. Is it suitable for the area of interest?
5. Does it adequately reflect patients concerns in this area?
6. Is the instrument acceptable to patients?
7. Is it sensitive to change?
8. Is it easy to administer and analyse?

Question 24

What is meant by the term stigma?

Answer 24

Stigma refers to the identification and recognition of a negatively defined condition, trait, attribute or behaviour in a person or group of persons

Question 25

Differentiate between enacted and felt stigma.

Answer 25

Enacted stigma is the real experience of prejudice, discrimination and disadvantage as the result of a particular condition. Felt stigma is the fear of enacted stigma.

Question 26

Explain why it is desirable to have a low proportion of false positive results with any screening test.

Answer 26

1. A false positive indicates an individual may have the disease when they do not
2. The implications of this are that it turns them into a patient when they are not actually ill
3. They will be offered diagnostic testing which may be invasive and unpleasant and result in increased anxiety and risks

Question 27

What is lead time bias?

Answer 27

Lead time bias refers to a situation where early diagnosis falsely appears to prolong survival

• Screened patients appear to live longer but only because they are diagnosed earlier
• In fact, patients live the same length of time but longer knowing that they have the disease

Question 28

State the criteria required for a screening programme to be implemented relating to treatment.

Answer 28

1. Effective evidence-based treatment must be available
2. Early treatment must be advantageous, i.e. not just bring forward the date of diagnosis
3. There should be an agreed policy on who to treat
4. Clinical management of the condition and patient outcomes should be optimised in healthcare providers before participation in screening programme

Question 29

What is the national tariff?

Answer 29

A fixed price that commissioners pay providers for a given service

Question 30

What is the main function of a clinical commissioning group?

Answer 30

To commission secondary and community healthcare services

Question 31

State advantages of adopting an explicit approach to rationing.

Answer 31

1. Transparency/accountability
2. Opportunity for debate
3. Involve use of evidence-based practice
4. More opportunities for equity in decision making

Question 32

State some disadvantages of an explicit approach to rationing.

Answer 32

1. Systems of explicit rationing can be very complex
2. Heterogeneity of patients and illnesses
3. Patient and professional hostility
4. Impact on clinical freedom
5. Some evidence of patient distress