Week 2 Flashcards
Improving the quality and safety of care setting the scene
Evolving evidence on the scale and nature of the problem
Changing thinking about the sources or causes of the problem
Developing interventions to tackle the problem
Evidence of harm
1 in 10 10% hospital in patients of which 10-13% experience death (1-1.3%)
Estimated fourth leading source of death after heart disease and cancers
These are all estimates extrapolated from data with variable sample size and using retrospective reviews
Growing consensus suggests that around 10% of patients admitted to hospital experience some type of adverse events that would prolong their care result in disability or even cause death
‘Bad apples’- bad people
Individuals who are malevolent and intent are causing harm
Individuals who are poorly trained or skilled
Individuals who are past their best
‘Bad barrels’- problem systems
Bad behaviour can flourish because of ‘bad barrels’ or systems
Fail to detect and exclude bad apples
Provide conditions for good apples to turn bad
The old way of thinking
Errors and risk are inevitable feature of medicine- there but for the grace of god
Individuals and teams can have bad days
Individual skills will depreciate over time
There will always be bad apples need for regulation
A new way of thinking
Mistakes and safety issues are rarely the fault of individuals or teams alone
A range of factors enable or exacerbate the potential for things to go wrong
Refocus attention away from bad apples to bad barrels -the system factors
Human error
Deliberate- non compliant violations
Unintentional:
-execution error: attention based, memory based
-thinking error: rule based mistake, knowledge based mistake
Understanding the roots of safety
Active errors: are the sharp end of individual performance, decision making or cognition
Latent errors: are located upstream in the environment or work organisation and influence how individuals perform
Swiss cheese model
Active errors: patient safety incident
Latent conditions: poor design, procedures, management decisions etc
Root causes in healthcare
Institutional context factors
Vincent’s framework
Patient characteristics: complexity of condition, language etc
Task factors: design, clarity, availability of rules, accuracy of task
Individual factors: knowledge, skills, motivation etc
Team factors: communications, decision making, supervision, clarity of roles
Work environment: staff levels, skills mix, shift patterns, equipment management
Organisational and management factors: finance and resources, structures and process, cultures, policies and procedures
Institutional contexts: economic, regulatory context
Towards systems thinking
Quality and safety breaches often associated with poor and erroneous performance in the clinical micro system
-Incompetent, underskilled, outdated or malevolent professionals
-Poor team work
Individual blame and discipline has two immediate problems;
-discourages openness and conceals evidence
-neglects systems factors and reinforces individual factors
Bristol royal infirmary
29 babies died during cardiac procedures between 1980s and 1990s
Focus on the culture and regulation of medicine, re: substandard performance
-old boys network
-culture of secrecy
-lack of external monitoring
-lack of transparency with families
Key recommendations:
-patients should be more involved in decisions
-more systematic and external forms of appraisal and performance review
-more explicit concern with patient safety
Harold shipman
Estimated to have killed over 200 patients over 20 years
Wide ranging inquiry- 5 reports
-regulation primary care
-regulations of controlled drugs
-the role of other agencies such as coroner
Fifth report:
-GMC prioritised the profession over patients
-need for culture change
-more robust, external and transparent forms of regulation
-sharing of information between agencies
Mid Staffordshire
Substandard performance and unsafe care esp in A&E between 2005-08
Key findings:
-27-45% higher mortality rates
-patients neglected poor assessed and poorly treated especially elderly
-staffing-overstretched and poorly trained
-priorities-meetings targets and resources constraints at the expense of safety
-trust was rated as excellent by healthcare commission
Hitting target missing the point
What do inquiries do
Determine the significance and causes of an event
Allocate responsibility and blame
Make recommendations for change
Expression of public outcry and cathartic outlet
Ritual of re legitimation (or whitewash) be seen to do something
What do inquiries show
Regulatory failure- why did no one stop it happening
Organisational ‘goal displacement’ -why was care not valued
Dysfunctional cultures- why is safety not valued
Unsafe or unchecked behaviours- why did they act like that
Continuing problems (Berwick 2013)
NHS staff not to blame- it is the systems and constraints they face that lead to patient safety problems
Reassert the primacy of working with patients and carers
Use quantitative targets with caution not displacing better care
Ensure responsibility for safety and improvement are vested clearly
Give the people of the NHS career long term help to learn, master and apply modern methods for quality control, improvement and planning
Make sure pride and joy in work, not fear, infuse the NHS
Recommendations include Berwick
To improve training and education
Mastery of quality and safety sciences for all staff
The NHS should become a learning organisation
Supervisory and regulatory systems should be clear
All incentives should point in the same direction
Impact of Berwick report
One year after the report a survey found that training and support for staff to improve the processes of care was the area where least progress had been made (health foundation et al 2014)
Much remains to be done to support the ambition that the NHS should become a learning organisation committed to continuous improvement
Reliance on regulation and inspection as the mainstays to promote safety and quality has increased
The cycle of fear described in the Berwick report stronger than ever and hinder the development of the learning culture it advocated
National reporting and learning system
Incident reporting: staff document and communicate experience, foster reporting culture
Stratify and analyse incident data: determine the significance of events, determine the underlying causes
Learning and improvement: develop local and system wide recommendations, action and audit change
Reporting safety events
Reporting systems common in other sectors
Standardised documentation and sharing of frontline events
Enables greater understanding of individual events from which to develop aggregate understanding of common safety issues
Barriers to reporting
Practical barriers to incident reporting: access to computer/paperwork, time and resources
Prgamatic barriers: purpose and role of reporting, why do it, who does it benefit
Classification barriers: what to report and in what ways
Feedback and communication barriers: lack of positive reinforcement
Cultural barriers: fear of punishment
Cultural barriers: beyond blame
Emphasis on creating a safety or reporting culture- move away from blame culture
Blame and fear still big factors
Inevitability and normalisation of harm
Taboos and codes of conduct
Protecting reputation
Concerns about bureaucracy
Concerns about management control
The problem of culture change
Cultures not easily managed (nor are they genetic)
Cultures are not acquired through conditioning
Rewards and incentives are a very basic (poorly aligned) way of shaping culture (lack of meaning)
Meaning in the reward not in the behaviour it aims to produce
This is important for patient safety
Transforming safety knowledge (waring 2009)
Interpretation of safety experiences :
-ambiguous, emotional, intersubjective
Reporting as ‘narrow narratives’:
-experiences recorded in the form of who what when where, focus on pre determined categories and types, immediate actions
Managerial narratives: de contextualised and abstract, summary points, risk assessment
Does quality improvement improve quality Dixon woods and Martin 2016
Fidelity in the application of QI methods is often variable
QI work is often persued through time limited, small scale projects, led by professionals who may lack the expertise, power of resources to instigate the changes required
There’s insufficient attention to rigorous evaluation of improvement and to sharing the lessons of successes and failures
Too many Qi interventions are seen as magic bullets that will produce improvement in any situation regardless of context
Too much improvement work is undertaken in isolation at a local level failing to pool resources and develop collective situation and introducing new hazards in the process
Classical (Pavlovian) conditioning
Unconditioned stimulus: the stimulus is in the reflex that automatically elicits an unconditioned response
Unconditioned response
Conditioned stimulus
Neutral stimulus
Conditioned stimulus
Dog and bell:
-unconditioned stimulus (food) and unconditioned response (salivation)
-by associating the neutral stimulus (ring of bell) with the unconditioned stimulus you get systematic association -conditioning procedure
-this leads to the neutral stimulus (bell) becoming conditioned stimulus which triggers conditioned response (salivation)
Classical conditioning in nature
Often associated with learning experiences of fear or pain
Classical conditioning mechanism may amplify the experience of pain
Little Albert (Watson and rayner 1920)
Albert 9 months old
Frightened of loud noises UCS
Not afraid of white rats neutral stimulus
Watson paired sight of white rate with loud noises
After classical conditioning Albert developed a fear of white rats conditioned stimulus
Phobias- generalisation
Operant (instrumental) conditioning Skinner 1938
Subjects learn to associate their own behaviours with consequences
Behaviours that result in satisfying consequences will be strengthened whereas behaviours that are punished will be weakened
Skinner able to train pigeons to learn or decrease certain behaviours depending on reward or punishment
Principles of operant conditioning
Reinforcement:
-positive: add pleasant stimulus to increase/maintain behaviour
-negative: remove aversive stimulus to increase/maintain behaviour
Punishment:
-positive: add aversive stimulus to decrease behaviour
-negative: remove pleasant stimulus to decrease behaviour
Difference between classical conditioning and operant conditioning
Classical: stimulus-stimulus associations
Operant: response-outcome associations, consequences
Alcoholism
How classical conditioning and operant conditioning contribute to alcohol misuse/dependence
How could techniques based on classical and operant conditioning principles be used in treatment
Learning without association
Social (observational) learning
Bandura bobo doll experiments 1961-1963:
Children were exposed to adults who beat, kicked, yelled at bob doll
After observing the children started beating the bobo doll the same as adults did after being upset by not being allowed to play with other toys
The children who didn’t observe the abusive adults behaviour were less likely to engage in such aggressive behaviour against the doll
Social/ observational learning
Learn by watching other peoples behaviour and it’s consequences
Imitation/modelling
Doctors are powerful models
Some behaviours are difficult to learn without observation (eg clinical skills)
Mirror neurons neural basis for social learning
Mirror neurones are neurones that fire both when subject is performing an action and when the subject observes someone else performing same action
Because humans and primates learn and match through observation and imitation it’s possible the mirror neurons system provide them a way to which observation can be translated into action
Learning and memory
Inextricably linked
Ability to learn depends on ability to remember
Ability to remember depends on prior learning
Three stages of memory
Encoding: process of transferring info to one memory stage to next, initially from sensory memory into short term then into long term
Storage: maintaining info at a particular stage, temporary except in long term memory
Retrieval: process of bringing info stored in long term memory to the conscious level in short term memory
A simple model of memory
External stimuli —> sensory memory—> short term STM—> LTM
STM
Limited capacity (memory span task: 7+/- 2)
Short duration less than 30 seconds
Maintenance via rehearsal (working memory)
Forgetting via displacement (limited capacity; primacy and recency effect)
LTM
Unlimited capacity
Variable duration
Forgetting via interference and/or decay (use it or lose it)
Cues and context aid retrieval
Nonsense syllable retrieval Hermann Ebbinghaus 1885:
Forgetting curve after 2 days little more forgetting
Types of LTM
Declarative memory: facts, data, events :
-episodic memory: personal experience
-semantic memory: general factual info
Procedural memory: how to do things
Memory and medical consultations
Patients remember ~50% info less for anxious or elderly people
Important to take into account when conducting clinical consultations that patients recall less than we expect them to
Examples of causes of memory impairment
Diffuse brain disease- dementia
Focal brain disease- amnesias
Physiological disturbance- delirium
Psychiatric illness- schizophrenia, depression, anxiety, dissociative disorders
Amnesia
Classification of amnesia depends on the relationship with the moment in time when the focal brain damage occurs:
Retrograde amnesia: cannot remember events prior to brain damage
Anterograde amnesia: cannot later remember events that occur after brain damage
Structures of the brain that play a role in memory
Prefrontal cortex
Hippocampus and amygdala in temporal lobe
Subcortical structures like basal ganglia implicit memory so is the cerebellum
Neocortex
Symptoms of anterograde amnesia
Difficulty learning new information
May be disorientated and confused
Personality, intelligence and judgement may be unaffected
Will generally have a good memory for the past up to the time of brain injury
May have trouble holding a job
LGBTQI
Stands for lesbian, gay, bisexual, transgender, queer, intersex
Covers approximately 5-7% of UK population
Various other abbreviations used too (eg LGBTQIA+) but intention is to be inclusive of all people who do not identify as heterosexual or cisgendered
Why worry about LGBTQI mental health
Greater health needs and poorer health outcomes:
-52% of LGBT people in Britain experienced depression in the past year. Another 10% think they might have done
-3 in 5 experience anxiety
-1 in 8 13% LGBT people aged 18-24 said they’ve attempted to take their own life in the last year
-almost half of trans people have thought about killing themselves in the past year
For context the NHS digital report that fewer than 1% of the general adult population attempted suicide in the past year and 5% had thoughts of it
Specific needs and barriers
1 in 7 LGBT people have avoided seeking healthcare for fear of discrimination from staff
1 in 8 have experienced some form of unequal treatment from healthcare staff because they are LGBT
1 in 4 have witnessed healthcare staff make discriminatory or negative remarks about LGBT people
One in 10 LGBT people have been outed without their consent by healthcare staff in front of other staff or patients
One in 20 have been pressured to access services supposed to change or suppress their sexual orientation and or gender identity whilst accessing healthcare services
Different types of dysphoria
Gender dysphoria: clinically significant distress or impairment relating to strong feeling of being a gender other than that assigned at birth
-effectively treated with aligning and affirming therapies
-including hormonal treatment and supporting social transition
-suppression of puberty in adolescents can reduce suicidality
Similar dysphoria experienced by those who identify as queer but feel unable to express their authentic queerness
-anxiety, depression, disordered eating
-gay men more likely to have body dysmorphia compared to heterosexual men
Pathologising difference
England 1553 buggery act
France 1791 ‘crimes against nature’, medical examinations
19th century onwards: sexual inversion, neuroendocrine hermaphrodites, Oedipus, phobic
Classification: APA-DSM: Peri war 1920, DSM II in 1968 to 1973. WHO ICD: (intl statistics inst. 1893) ICD 6 in 1967 to 2019 in ICD11
UK laws and rights
1533: buggery act
-1835: last execution
-1861:S61 offences against the person act
Wolfenden report 1957: not punishable if private
Sexual offences act 1867: limited decriminalisation: private 2 people >21, limits overturned by European court of human rights in 2000
Section 28 (1988) of local government act: repealed 2000 in Scotland, 2003 in England 2003
2000: HM armed forces removed ban
2002: adoption and children act amended in 2005
2004: gender recognition act
2008: human fertilisation and embryology act
2009: equalisation of age of consent
2014: same sex marriage (except NI)
Why might the LGBT community experience a greater rate of mental illness compared to heterosexual cisgendered people
Othering
Queer trauma
Queer identity management
Minority stress theory
Adverse childhood experiences
Othering
The perception or representation of a person or group as fundamentally alien from another (usually) more powerful group
Where individuals/ groups are defined as not fitting in with the social Norms this group is alien to the social identity of the dominant social group
‘Curing’ difference: change efforts
Sexual orientation/ gender identity change efforts
-so called conversion therapy
-operates from a premise of status being flawed:
— spiritually/ religiously
— mentally
—physically
—socially
No evidence of benefit
Evidence of harm: short and long term
Not the same as affirming approaches:
-consensual safe space to explore
-self acceptance
Minority stress theory
Distal (prejudice)
Exclusion
Isolation
Proximal (response)
Masking
Avoidance
—chronic stress——
-participation
-opportunities
-CVD risk
-mental illness
-cancer risks
-wound healing
-disrupted and limited networks
The LGBTQ+ community experience more childhood ACEs
Adverse childhood experiences ACEs
-abuse
-neglect
-family disruption
-substance abuse
Impact on brain development
Association with 2x chronic disease and mental illness
In school: 75% harassment, 35% physical abuse, 12% sexual assault
Family: dysfunction, neglect, intimate partner violence
How consultations may be affected
We know that people who experience childhood trauma:
-greater rate of chronic illness
-delayed presentation
-multiple, complex, intersecting problems
-mistrust
Patients from the LGBTQ+ community may:
-fear judgement or outing
-have been pressured into conversion therapy
Inclusive practices
Consider environment
What implicit signals of heteronormativity are there
Allyship
-active bystander
-reflective of privilege
-use it to support and platform others
Understand how your privilege positions you
Your own characteristics such as age, race, gender empower you to speak up and be vocal about harassment- especially when you are not the target or representative of the target group
Trauma informed care
Aware of and sensitive to triggers
Understand that presentation (transference) can be heavily influenced by past traumatic events:
-the way they experience and make sense of their symptoms
-the way they distrust others around them
-they way they may interact others around them
Specific therapeutic approaches
-support groups (survivors trust)
-eye movement desensitisation and reprogramming EMDR
