1 Quality & Safety

Question 1

Why have quality and safety become such important issues?

Answer 1

• There is evidence of patients being harmed / substandard care
• There are variations in healthcare (inequity)
• There are direct costs and legal bills as a consequence of substandard care quality and safety
• Policy has dictated that they become important issues

Question 2

How is QUALITY of healthcare defined?

Answer 2

SEPTEE
Safe - there are no needless deaths
Effective - there is no needless pain or suffering
Patient-centred - the focus is on a patient’s specific needs
Timely - There is no unwanted waiting
Efficient - Minimal waste
Equitable - no one is left out / same for all with similar needs

Question 3

How can we tell there is a problem with health quality?

Answer 3

There is evidence of VARIATION in data across CCGs:

1. limb amputations for those with type I and II diabetes
   vary widely depending on geographical location
2. Hip replacements depending on geographical location require different levels of pain before treatment

There is NO BASIS for this variation in clinical science - thus this is evidence of INEQUITY

Question 4

Define EQUITY

Answer 4

Everyone with the same need gets the same care

Question 5

Define Patient Safety

Answer 5

The avoidance, prevention and amelioration of adverse outcomes stemming from the process of healthcare

Question 6

What evidence is there that there are problems concerning quality and safety in the NHS?

Answer 6

EVIDENCE OF PROBLEMS OF INEQUITY & EFFECTIVENESS:
1. limb amputations for those with type I and II diabetes
vary widely depending on geographical location
2. Hip replacements depending on geographical location require different levels of pain before treatment

Moreover: BRI Paediatric Heart Surgery, Harold Shipman and the Francis Report into events in the Mid-Staffordshire Hospitals suggest problems are present.

Question 7

What is an adverse event?

Answer 7

An injury caused by medical management (rather than the underlying disease), that prolongs hospitalisation AND/OR produces a disability.

These can be PREVENTABLE but also UNAVOIDABLE!

Question 8

What is an preventable adverse event?

Answer 8

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

Question 9

What is an example of an unavoidable adverse event?

Answer 9

A patient drug reaction with no warning in the notes.

Question 10

Give some examples of preventable adverse events

Answer 10

Operations performed on wrong limb
Retained objects e.g. swabs
Wrong dose/drug given
Central line infections

Question 11

How frequent are adverse events? i.e. what is there incidence?

Answer 11

9.2%, of which 43.5% were thought to be preventable and 7.4% were lethal. Thus, 0.7% of hospital admissions lead to a fatal adverse event.

Question 12

What is there incidence of adverse events in surgery?

Answer 12

Higher than the general incidence of adverse events at 14.4%, of which 38% are considered preventable.
Thus surgery is a major cause of avoidable death and injury.

Question 13

What is a NEVER EVENT?

Answer 13

A serious incident that is completely preventable if guidance is followed e.g. amputation of the wrong limb

Question 14

Why do ADVERSE EVENTS happen?

Answer 14

1. Poorly designed systems that do not account for HUMAN FACTORS
2. Culture and behaviour of groups and individuals

i.e. FAULT OF SYSTEM or FAULT OF INDIVIDUALS

Question 15

What are HUMAN FACTORS?

Answer 15

Highly predictable human responses to particular situations. These are often poorly anticipated in healthcare. e.g. ampoules are the same shape for a plethora of drug types and can all fit into different access points i.e. an IV drug can easily be given intrathecally.

Question 16

Who is at fault for adverse events?

Answer 16

The SYSTEM largely, but INDIVIDUALS are at fault sometimes- incompetent, careless, negligent

Question 17

How can culture cause an adverse event?

Answer 17

A fault of both the system and the individuals concerned. CULTURE e.g. hierarchy of juniour doctors to their seniors may mean they spot a mistake but are too intimidated to point it out.

Question 18

What are some SYSTEMIC contributors to adverse events?

Answer 18

Faulty equipment
Similarly shaped/labelled drugs
No safety checkpoints/process

Question 19

How do the problems facing the NHS at present promote adverse events?

Answer 19

The NHS is working at close to capacity. Healthcare professionals are RUSHING and are TIRED –> Mistakes & bodges

Question 20

Describe James Reason’s Framework of Error

Answer 20

The theory describes the role of ACTIVE FAILURES and LATENT CONDITIONS (as holes in swiss cheese). Successive chunks of cheese are the BARRIERS & SAFEGUARDS, which if the holes (active failures & latent conditions) line up can be bypassed, leading to ERROR & and ADVERSE EVENT

Question 21

What is an ACTIVE FAILURE in James Reason’s Framework of Error?

Answer 21

Acts that lead directly to a patient being harmed.

Occur at the sharp end of clinical practice. An active failure takes place after latent conditions have allowed barriers and safeguards to be bypassed, leading directly to an adverse event.

Question 22

What are LATENT CONDITIONS in James Reason’s Framework of Error?

Answer 22

These are the PREDISPOSING CONDITIONS to error and are often faults in the SYSTEM.
e.g. poor training, poor design of equipment that disregard human factors, too few staff & poor supervision.

Question 23

What are the role of DEFENSES, BARRIERS & SAFEGUARDS in James Reason’s Framework of Error?

Answer 23

The role of the defenses are to trap or mitigate the active failure. e.g. colour coded equipment.

Question 24

Name an example that James Reason’s Framework of Error (Swiss Cheese Model) can be applied to

Answer 24

The administration of Vincristine intrathecally.

Question 25

How can we make healthcare safer?

Answer 25

Factors at a patient>task>individual>team>work environment>Departmental>Hospital>National Policy level can help.

Question 26

How can we combat human factors to make healthcare safer?

Answer 26

Avoid reliance on memory
Simplify processes
Standardise processes between hospitals
Routinely use checklists

Question 27

Define CLINICAL GOVERNANCE

Answer 27

A framework which makes NHS organisations have a legal duty to CONTINUOUSLY IMPROVE, MONITOR and ENSURE the quality of their services and SAFEGUARDING HIGH STANDARDS of CARE.

Question 28

What does the Health and Social Care Act 2012 say?

Answer 28

NHS HEALTH AND SOCIAL CARE ACT - responsibility of Secretary of State for Health to promote effectiveness, safety and quality

Question 29

What quality improvement mechanisms are present in the NHS?

Answer 29

1. Standard Setting: NICE standards
2. Commissioning
3. Financial Incentives e.g. CQUIN , QOF & Tarriffs
4. Disclosure e.g. of surgeon’s mortality stats, drives quality
5. Regulation, registration & inspection: CQC inspection
6. Audit

Question 30

Describe the role of STANDARD SETTING in ensuring quality in the NHS

Answer 30

NICE sets standards, which are a set of statements outlining markers of high quality clinical and cost effective patient care based on the best available evidence.
e.g. VTE prevention guidance

Question 31

Describe the role of COMMISSIONING in ensuring quality in the NHS

Answer 31

Commissioning drives quality through contracts and the competition of the private sector. It also localises the services provided to match local demands.

Question 32

What are the FINANCIAL INCENTIVES used to drive quality in the NHS?

Answer 32

QOF
CQUIN
TARRIFFS

Question 33

Explain the role of QOF, Quality of Outcomes Framework

Answer 33

Practices gain QOF points for performance indicators e.g. being able to produce databases/registers of patients.
Points generate additional income.
Upto 1000 points available, each worth circa £165
Equate to circa 65% GP practice income

Question 34

Explain how CQUIN Works (Commissioning Quality and Innovation)

Answer 34

1.5% of provider trusts e.g. UHL income depends on achiveing measurable goals in 3 areas: quality, effectiveness & patient experience

Question 35

How do NATIONAL TARRIFFS encourage quality?

Answer 35

They incentivise efficiency and thus reward the best practice.
HRGs or Healthcare Resource Groups are clinically similar treatments which use common levels of healthcare resource. Provider trusts are paid a set fee to provide these services by commissioners.

Efficient trusts can make a surplus from the money paid for the HRG. Inefficient trusts will make a loss. If a never event occurs, they are not paid.

Question 36

What is an HRG (healthcare resource group)?

Answer 36

HRGs or Healthcare Resource Groups are clinically similar treatments which use common levels of healthcare resource. Provider trusts are paid a set fee to provide these services by commissioners as part of National Tarriffs.

Question 37

How does DISCLOSURE encourage quality?

Answer 37

Publishing of data e.g. surgeon’s mortality stats and annual hospital QUALITY ACCOUNTS drives quality by making providers comparable and makes them strive to be the best.

Question 38

How does REGISTRATION drive quality?

Answer 38

NHS trusts MUST be registered with the CQC, Care Quality Commission. The CQC inspect trusts, can make unannounced visits, issue warnings, fines, prosecute and restrict services.

Question 39

Describe how a clinical audit works.

Answer 39

1. Study and identify quality of care
2. Make a change that you think will improve quality, usually from an evidence base
3. Study your change
4. Compare results
5. Change/ keep practice the same
6. Reaudit

The results can then be fed back to the staff by TRAINING.

Question 40

Define Clinical Audit

Answer 40

A process of identifying quality of care, changing it and then seeing if your change has improved quality.

Question 41

What is QUALITY IMPROVEMENT and how does it differ from clinical audit?

Answer 41

A model for improvement involving PLAN-DO-ACT CYCLES. Tries to go beyond traditional audit by making it a routine part of care delivery and organisation. Goes beyond simple feedback.

Question 42

How could data for your audit be obtained?

Answer 42

Case Record Reviews