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FPH exam > 1C evaluation and assessment of healthcare > Flashcards

1C evaluation and assessment of healthcare Flashcards

1
Q

name the Bradshaws types of needs

A

F- Felt need
E- Expressed need
N- Normative need
C- comparative need
(E)

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2
Q

Define felt need

A

Need as perceived by an individual, what a patient feels they require to feel better

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3
Q

Define Expressed need

A

Either what is demanded (ie attending for services) or need which is vocalised

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4
Q

Define Normative need

A

Need as deemed by a physician. Ie need based on professional judgement

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5
Q

Define comparative need

A

Relative need of different groups. ie the needs of one area compared to another

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6
Q

Definition of a HNA

A

A systematic method of identifying the unmet health and healthcare needs of a population and making changes to meet the unmet need

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7
Q

What may HNA focus on

A

HNA may focus on different:
-population groups
-illnesses
- procedures or interventions

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8
Q

Wagstaff and Culyer’s definition of need

A

Equate the need for interventions with the potential to benefit from them. Ie even if a person is unwell, if they cannot benefit from intervention, they have no need for that intervention

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9
Q

HNA: definition of need for HNA

A

Need is said to exist when there is an effective, acceptable intervention and the potential for health gain.

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10
Q

HNA: factors impacting demand

A

Demand is a poor proxy measure for need.

Demand is influenced by:
- illness behaviour
- knowledge of services
- accessibility of services
-media

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11
Q

HNA: what are JSNAs

A

-joint statutory health needs assessment
- statutory requirement for local authorities with CCGs/ICSs through the health and well being board
- explicitly consider the social needs of the population
- involve non health agencies in the assessment
- opportunity to consider wider determinants of health

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12
Q

Stevens and Raftery’s 3 approaches to an HNA

A
  1. Corporate
  2. Epidemiological
  3. Comparative
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13
Q

HNA: Corporate approach (4 advantages and 2 disadvantages)

A
  • Approach based on eliciting the views of stake holders (ie patients, service users, charities, public, politician, professionals)
  • can be conducted relatively quickly
  • No need to collect large amounts of data
  • responsive to interested parties
    -incremental process so small changes can be made, a little at a time, based on stake holder feedback
  • small changes may not be appropriate when large change needed
  • Change can be drive by power rather than need
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14
Q

HNA: Epidemiological approach

A
  • this approach considers the epidemiology of the condition, current service provision, the effectiveness and cost effectiveness of interventions and services
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15
Q

HNA: comparative approach

A
  • compares service provision between different populations
  • may use data from surveys of hospital activity data
  • compares observed findings with those that would be expected bsed on a reference population. Population needs to be standardised to allow comparison (ie for age, comorbidity etc)
  • local service provision may be effected by a number of factors not just different need
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16
Q

5 stages to conducting a health needs assessment according to health development agency (now part of nice)

A
  1. Scope
  2. Identify potential priorities
  3. Selection of priorities for change
  4. change
  5. review
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17
Q

HNA stage 1: scope

A

Identify:
P-population of interest
A- aim of HNA
R- resources required for HNA
R- risks invovled
S-stakeholders

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18
Q

HNA stage 2- identify potential priorites

A
  • gather various data to describe the population
  • may involve collecting quantitative and qualitative data
  • data is analysed to give information on health need, this includes discussion with stakeholders
  • current level of service provision is reviewed as well as evidence of effectiveness
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19
Q

HNA Stage 3: Selection of priorities for change

A
  • identify which issues are most important, leading to priorities for action
    -priorities may be based on:
    1. size and severity of impact
    1. availability of effective intervention
    2. local commissioning priorities
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20
Q

HNA stage 4: change

A

-implement changes using change management techniques (ie action planning, monitoring, risk management)

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21
Q

HNA: stage 5: review

A
  • learn from the project, disseminate fundings and identify the next priority
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22
Q

HNA sources of data: routinely collected data (does it over/under estimate and why?)

A

tends to underestimate burden of need as it does not include:
-unmet need (ie cannot access services)
- self care
- people paying for treatment privately

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23
Q

HNA sources of data: epidemiological data (does it over/under estimate and why?)

A
  • tends to overestimate need as it includes:
    1 people who cannot benefit from treatment (ie too sick for operation)
    2. people who do not want treatment
    3. people who have already been treated.
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24
Q

what is participatory needs assessment and why is it useful

A
  • involvement of the local community in the needs assessment
  • ofent produces qualitative rather than quantitative data
  • involving the local community in all stages of the needs assessment can improve accuracy of results and increase acceptance of findings
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25
Q

List 5 things required for successful participatory needs assessments

A
  • clear objectives (so the public know exactly what is up for consultation/discussion)
  • recognised methods of data collection/ data sources
  • clear communication
  • hearing voices, which are important, but often not heard ( ie ethnic minorities, elderly)
  • involvement of community in all steps of the process
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26
Q

what is the main type of data collected in participatory needs assessment and what methods can be used to collect data (4 methods)

A
  • tend to collect qualitative data
    -can use:
    1. interviews with key informants
    2. Focus groups
    3. group work shops
    4. visual methods (ie mapping or transect walks)
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27
Q

what is a transect walk

A

where participants are given low cost cameras or encouraged to use mobile phones to take photos in order to illustrate their needs

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28
Q

what is health utilisation data used for (3 things)

A
  • in many developed countries health utilisation data is routinely collected and can be used for:
  • commissioning
  • research
  • paying service providers
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29
Q

What is a health utilisation minimum data set and what is likely to be included? (5 areas)

A
  • a minimum data set is often outlined to ensure that the needed data is gathered for each care episode.

Minimum data sets often include:
1. Demographics (DOB, address, name, sex)
2. Clinical information (diagnosis, procedures, prescriptions)
3. Pathway/ service use (referred to where and when, Duration of stay, referral appointment date)
4. Provider details (clinical team/ consultant)
5. bespoke/ specific data (PROMS, satisfaction data ie friends and family test, research data)

  • health utilisation data can be looked at across multiple care episodes for one patient to gather information on clinical performance across a clinical pathway
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30
Q

what are 2 key contextual factors which must be considered when interpreting healthcare utilisation data in order to ensure it is interpreted appropriately?

A
  1. Patient mix (sicker patients/ more co-morbidities get ill more often, take longer to recover and tend t have worse outcomes)
  2. System factors (service utilisation will be affected by other service availability ie alcoholic admission on friday night will be admitted for longer if there are not weekend community detox services.)
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31
Q

service utilisation data:
measure and interpretation of referral and appointment date data

A

MEASURE: waiting times
INTERPTATION: indicators of barriers to access due to:
- insufficient resources
- suboptimal care pathway
- lack of effective preventative measures

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32
Q

service utilisation data:
measure and interpretation of duration of stay

A

MEASURE: number of bed days
INTERPRETATION: can give indication of:
- morbidity (ie fewer bed days may suggest people arrived less sick)
- efficiency ( fewer bed days for same procedure may indicate more efficient service)
- effectiveness (feweer bed days for same procedure may indicate better perioperative care)

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33
Q

service utilisation data:
measure and interpretation of episodes of care and patient/clinical data

A

MEASURE: number of admissions/admissions for diagnosis
INTERPRETATION: indicator of: volumes of care provided, Appropriateness of care (ie is there a high number of admissions for diagnosis appropriate for community management)

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34
Q

service utilisation data:
measure and interpretation of date of this admission and date of previous admission

A

MEASURE: Readmission rate
INTERPRETATION: indicator of morbidity (sicker patients –> higher readmission), effectiveness (ineffective care –> readmission)

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35
Q

service utilisation data:
measure and interpretation of A+E attendance/emergency care attendance

A

MEASURE: Unplanned care rates
INTERPETATION: indicator of barriers to access due to inadequate care pathway, lack of preventative measures

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36
Q

health service research/ evaluation: limitations of using RCTs (5)

A

When conducting studies of health services, the gold standard RCT might not be the most appropriate use of study design

  1. resources (not enough money or time)
  2. Timeliness (may take years to see health benefits of an intervention)
  3. Policy changes (national policy changes can require rapid changes to local health services which RCTs do not allow for)
  4. multi site study challenges (different organization of health services can mean that it is hard to conduct studies across multiple sites)
  5. Organisational challenges (studies are often concerned with health service organization, it is impractical to reorganise half a health service in order to study impact)
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37
Q

health service research/ evaluation: study design for assessing acceptability

A

Epidemiological study design (ie cross sectional study)

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38
Q

health service research/ evaluation: study design for effectiveness (when experimental design not possible)

A

Epidemiological study design (cross sectional, cohort, case-control)

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39
Q

health service research/ evaluation: study design for effectiveness (when evidence base does not exist)

A

Experimental/ quasi-experimental ie rct

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40
Q

health service research/ evaluation: study design for effectiveness (when evidence base does exist)

A

Systematic review

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41
Q

health service research/ evaluation: study design for efficiency

A

economic evaluations (cost benefit, cost utility, cost effectiveness analysis)

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42
Q

health service research/ evaluation: study design for implementation/quality

A

quality improvement tools (ie PDSA)

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43
Q

factors influencing choice of study design in health service research/evaluation (5)

A
  1. aim of study (ie if want to know about acceptability use cross sectional survey, if want to know effectiveness of new intervention use a trial)
  2. whether the study is for summative or formative purposes (in may health services it is better to refine and tweak interventions as implemented (PDSA cycles allow for this), however this cannot be done in RCTs
  3. resources available
  4. whether the service is existing, new or proposed (if existing it is unlikely there is a suitable comparison group so cross sectional survey might be most appropriate. IF a new service you could implement in some areas only and compare with areas without it)
  5. what is the exisiitng evidence base (if there a re lots of studies you may just need a lit review)
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44
Q

Maxwells 6 dimensions of quality

A

EEEAAR (remember EAR 3,2 1)

Effectiveness (at an individual level)
Efficiency and economy (is the service providing the best value for money)
Equity (could the service be more fair)
Access (can one subgroup use the service more easily that other subgroups)
Acceptability
Relevance (is the service relevant to the needs of the whole community(

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45
Q

components of donabedians framework for assessing quality of health care (4)

A

Donabedian described 3 elements to assessing quality of health care

Structure–> process –> outcome

However output is often also included

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45
Q

health service quality assessment: what is included in structure and give examples

A

The THINGS you need for healthcare

ie buildings, staff, beds, drugs

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45
Q

health service quality assessment: what is included in process and give examples

A

This is the activity that is undertaken

ie staff training, prescriptions, operations, referrals, hand washing

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46
Q

health service quality assessment: what is included in output and give examples

A

This is the result of the activities undertaken in process

eg. waiting times, number of operations, length of stay

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47
Q

health service quality assessment: what is included in outcomes and give examples

A

The end result/the change in health status

ie mortality, morbidity, discharge, patient satisfaction

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48
Q

health service quality assessment: advantages (1) / disadvantages (1) of using structure measures to assess healthcare quality

A

Advantage: easy to collect
Disadvantage: may not be comparable between systems, ie one country may have more nurses but they may not be so highly trained.

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49
Q

health service quality assessment: advantages (2)/ disadvantages (1)of using process measures to assess healthcare quality

A

Advantages:
1 relatively easy to collect in centralised healthcare services such as the NHS.
2. Some process measures directly link to outcome ie vaccine delivery

Disadvantages:
1. Many process measures may not link to outcomes ie if lots of prescriptions given for treatment of a condition but these patients would be better treated with a different intervention

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50
Q

health service quality assessment: advantages/ disadvantages of using outcome measures to assess healthcare quality

A

Advantages: the ultimate aim of health care is to improve health outcomes

Disadvantages:
1. Not necessarily related to health service performance as will also be affected by the case mix
2. health outcomes often take a time to develop so cannot be assessed in a short term study
3. Difficult to link intervention/ service to health outcome rather than other factors.

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51
Q

name a system for measuring health

A

WHO ICF - international classification of functioning, disability and health

52
Q

What is the international classification of functioning, disability and health and what are its core domains

A
  • framework for describing and organising information on an individuals function and disability
  • it can be used to measure an individuals health/disability through surveys
    -can also be used in clinical settings for assessment
  • conceptualises a persons level of functioning as a dynamic interaction between:
    1. Health condition (disorder or disease)
    2. Body functions and structures
    2. Activities
    2. Participation
    3. environmental factors
    3. personal factors
53
Q

International classification of functioning, disability and health: what is included in the body structures and functions section?

A

Includes pathology and clinical measures

ie temp, BP, examination findings

ie prostate enlarged on exam

54
Q

International classification of functioning, disability and health: what is included in the activities section?

A

symptoms and health status. Self reported measure of what the person can do

ie activities of daily living scale

eg. self report of number of trips to the toilet a day (prostate enlarged)

55
Q

International classification of functioning, disability and health: what is included in the participation section?

A

Effect of disability on life
usually self reported this is the extent to which the condition effects the persons normal life

ie Health related quality of life score

eg. cannot go to the cinema as needs to toilet too often

56
Q

International classification of functioning, disability and health: what is included in the environmental factors section?

A

Barriers/ facilitators to function and participation in the environment.

Self reported or observed

eg workplace only has one toilet (barrier) enlarged prostate

57
Q

why is measuring health related quality of life important?

A
  • Increasingly being used as an endpoint in clinical trials
  • treatments which do not extend life but have a significant impact on HRQoL are important
  • ## equally measuring HRQoL can highlight treatments, which might extend life, but with significant side effects making them unacceptable
58
Q

Who should complete HRQoL scales?

A

Unless they are unable, they should be completed by the patients themselves

59
Q

Describe 3 components of quality of life which are often assessed on HRQoL scales

A
  1. EXPECTATIONS- difference between what a patient expected/hoped for and their present experience (ie professional pianist is likely to be more effect by finger loss than a window cleaner.
  2. NEED- ability/ capability of the person to meet the basic functions of living (ie sleeping, eating, drinking)
  3. NORMAL LIVING- ability of a person to do things they want to do (rather than being free of disease or symptoms)
60
Q

Health related quality of life scales: generic scale example

A

Short form 36 (SF36)

61
Q

Health related quality of life scales: disease specific scale example

A

Functional assessment of cancer therapy

62
Q

Health related quality of life scales: specific aspects of quality of life scale example

A

Hospital anxiety and depression scale

63
Q

Give examples of measures of health care acceptability (3 broad areas)

A
  1. complaints and compliments:
    -informal (conversations with staff, cards, social media)
    • formal complaints
  2. Surveys:
    • national staff surveys
    • friends and family tests
    • PROMS
    • GP surveys
    • local bespoke surveys
  3. sentiment analysis of social media (ie twitter)
64
Q

Assessing health care acceptability: Factors affecting responses to surveys (4)

A
  1. Individual (every persons have different values around what is acceptable)
  2. patient group (young vs old, day cases vs inpatient all have different needs)
  3. service (community, inpatient, targeting vulnerable patients will have different needs)
  4. Priorities (there may be a trade off between humanity and accessibility (ie trade off between seeing own GP and getting appointment soon)
65
Q

Assessing health care acceptability: what are PROMS. What 4 conditions are they standardly used for in NHS

A

-Patient reported outcome measures are a way of assessing quality of care from a patient perspective
- use a self completed questionnaire which asks standardised questions at different points along a patient journey
- collected routinely for:
1. hip replacement
2. knee replacement
3. hernia
4. varicose veins

66
Q

What are population health outcome indicators

A

Population health outcome indicators reflect, at a population level, the effect of healthcare and public health priorities and activities

Crucially, it is aggregated data.

67
Q

Where can you find population health outcome indicators for england

A

OHID publishes public health profiles via fingertips

68
Q

What might population health outcome indicators reflect (3)

A
  1. health at a timepoint
  2. change in health over a period of time
  3. change in health status as a result of an intervention
69
Q

What can population health outcomes be used for (4)

A
  1. Prompt the assessment of local health outcomes
  2. Monitor variation in health and health care
  3. Monitor trends in healthcare (ie is the effectiveness of health care improving)
  4. Monitor quality of life
70
Q

characteristics of a useful population health indicator (4)

A

VACS

  1. Valid- indicator must be valid and precise
  2. Availability- indicator data should be available at an appropriate geographical level (ie for common conditions should be available at small area level)
  3. Consistency- should be selected consistently and regularly. IF definition or data collection method changes this will impact on monitoring of trends over time
  4. Suitablity- indicators should be suitable for making appropriate comparisons between population subgroups, ie if and indicator is ti be used for monitoring inequalities then it must be possible to link dtaa to data on ethnicity, deprivation, age, gender etc
71
Q

Individual indicators of deprivation

A

1 national statistics socio-economic classification (NSSEC)
2. Education level
3. housing
4. occupation
5. co-modities (car ownership etc)

72
Q

what is the national statistics socio-economic classification

A
  • Indicator of individual deprivation used in UK
  • replaced the old social class 1-V system
  • splits people into 8 broad categories based on:
    1. their occupation
    2. level within that occupation
  • a person or household is assigned a category based on the occupation (or former occupation) of the the household reference person (person who owns the accommodation or is responsible for renting it)

1 = higher managerial and professional occupations
8= never worked and long term unemployed

73
Q
A
74
Q

area level indicators of deprivation used in England (4)

A
  • Index of multiple deprivation (2019)
  • Jarman
  • Townsend material deprivation score
  • Castairs index
75
Q

Area deprivation indicators: index of multiple deprivation (what is it, how is it calculated)

A
  • composed of data from 7 areas (I eat every lovingly created hearty hamburger)
  1. Income
  2. Employment
  3. Education skills and training
  4. Living environment
  5. Crime
  6. Housing
  7. Health
  • each domain is built from local indicators and can be looked at individually
  • the 7 domains are weighted and combined into one IMD score
  • results are issued at lower super output area level but can be aggregated
    -LSOA covers about 1500 people (whereas wards vary massively in size)
    -cannot compare IMDs from different years as the scores are calculated differently
76
Q

Mnemonic for remembering IMD 2019 components

A

I eat every lovingly created hearty hamburger

  1. Income
  2. Employment
  3. Education skills and training
  4. Living environment
  5. Crime
  6. Housing
  7. Health
77
Q

Jarman score

A
  • initially developed as a way of measuring GP workload and making payments for greater deprivation
  • now be superseded by the Carr-hill formula
    -Uses census data
  • score includes:
    1. one parent families
    2. Unemployed
    3. elderly living alone
  • can be used to look at small areas
  • does not indicate the number of people in an area who are deprived
78
Q

Townsend material deprivation score

A
  • uses census data
  • data from 4 domains, defined by the proportion of households who:
    1. Have >1 person per habitable room
    2. have no car
    3. are not owner occupied
    4. include a person who is unemployed
  • can be used to look at small areas
  • easy to calculate
  • data from census and so may be out of date
  • does not indicate the proportion of people living in the area who are deprived
79
Q

Carstairs score

A
  • similar to townsend index but uses an unweighted combination of 4 variables (different to townsend)
  • can be used to cover small areas
  • uses census data which is often out of date
80
Q

Healthcare evaluation: formative Vs summative evaluations

A

FORMATIVE: Evaluations can be conducted whilst an intervention is ongoing in order to inform ongoing intervention
SUMMATIVE: evaluation is conducted at the end of the intervention

81
Q

Healthcare evaluation: Prospective vs retrospective evaluations

A

evaluations can be prospetcive or retrospective

Advantage of prospective is that they can be built into the service design to ensure appropriate data is collected to answer evaluation objectives and ensure data collection is complete.

82
Q

steps in designing a healthcare evaluation (8)

A
  1. DEFINE SERVICE TO BE EVALUATED
  2. OUTINE STUDY AIMS AND OBJECTIVES (ensure SMART objectives used)
  3. SELECT APPROPRIATE STUDY DESIGN
    (RCT, non experimental (case-control, cohort, ecological, cross sectional), qualitative)
  4. SELECT APPROPRIATE MEAUSRES TO BE USED (will depend on evaluation framework used ie donabedian, maxwells, study design, resources available, study aims and objectives)
  5. INDENTIFY HOW AND WHEN TO COLLECT DATA (summative or formative)
  6. COLLECT AND ANALYSE DATA
  7. INDENTIFY RECOMMENDATIONS
    8 DISSEMINATE FINDINGS
83
Q

Quality assessment vs quality assurance

A

QUALITY ASSESSMENT
- part of the quality management process
- evaluations may be used to assess quality
- quality management process for a survive will include protocols to ensure the service is optimally delivered and indicators to monitor whether success is being achieved
- 2 examples of quality assessment processes:
1.GP quality outcome framework
2. healthcare provider performance against national targets (ie 2 week cancer wait)

QUALITY ASSURANCE
- the process of guaranteeing quality, ensuring that a service meets a defined standard
- if quality indicators are being measured and quality standards are being met, through the quality management process than quality assurance can be given

84
Q

what is horizontal equity

A

Requires equal healthcare for equal need

85
Q

What is vertical equity

A

Requires unequal healthcare for unequal need

ie sicker people treated first on waiting list

86
Q

What are the 4 dimensions of horizontal equity

A

Silly ants underneath hats

1.Equal SPENDING for equal need
2 Equal ACCESS for equal need
3. Equal USE for equal need
4. Equal HEALTH for equal need

87
Q

Horizontal equity dimensions: Equal SPENDING for equal need (describe and advantages and disadvantages)

A
  • budgets allocated based on health need (ie based on an areas standardised mortality rate or deprivation)

advantages: simple to measure as budgets can be clearly identified

disadvantages: whole range of factors impact need- ie if community service rural/urban will also affect cost of delivery as staff have to travel further

88
Q

Define equity

A

Equity is not the same of equality. Equity is concerned with fairness- people who have equal need being treated the same AND people who have unequal need being treated differently.

Hard as what is equitable may be subjective

89
Q

Define equality

A

People being treated the same

90
Q

Horizontal equity dimensions: Equal ACCESS for equal need (describe and advantages and disadvantages)

A

People with equal need should be able to reach health care equally. Access can be considered in terms of removing barriers to healthcare, if all barriers are removed access will be equal.

Access/ barriers may be geographical, financial, time (ie only open in office hours), cultural etc

ADVANATGES: key principle of NHS so measuring and considering is essential

DISADVANTAGES: often intangible barriers ie cultural so hard to measure. Measures of access can often actually measure use.

91
Q

Horizontal equity dimensions: Equal USE for equal need (describe and advantages and disadvantages)

A

Concept assumes that people with the same need for healthcare will have the same demand, so any difference in use will reflect barriers to use.

ADVANTAGES: overcomes he problem of intangible barriers so easier to measure

DISADVANTAGE: assumes there is no difference in healthcare demand between people with the same needs

92
Q

Horizontal equity dimensions: Equal HEALTH for equal need (describe and advantages and disadvantages)

A

The ultimate aim of the NHS/ healthcare

ADVANTAGES: the gold standard

DISADVANTAGES: affected by things outside of the control of healthcare ie genetics

93
Q

Inverse care law

A
  • evidence of lack of horizontal equity

Julian Hart seminal paper
Showed that in the areas of greatest need there tends to be least access to good medical care

94
Q

Inverse equity hypothesis

A
  • Victoria et al in 2000
  • demonstrated that public health interventions can increase health inequalities as they tend to reach higher socioeconomic groups first
  • demonstrated for Brazil Child Health where although mortality and morbidity had decreased overall the inequity ratios had grown.
95
Q

What is clinical audit

A

A systematic review of care as measured against explicit criteria

96
Q

What is clinical governance

A

A local system for ensuring quality of patient care and for making ongoing improvements

97
Q

What is the difference between clinical audit and research

A

Very similar and can be used to answer similar questions.

Key difference is whether the results are generalisable outside the setting in which it was conducted.

Research–> results can be generalised outside of the study setting
Audit–> results are pertinent only to the study setting

98
Q

stages of clinical audit

A
  1. Plan:
    - what to audit
    - what guidelines to audit against
    - scope of audit (what patients are included, over what time period)
    -sampling strategy (ie interval sampling (all patients attending clinic between jan and march) or two stage sampling (study only a small number of patients first and only expand to larger number of patients if results are equivocal)
  2. DO
    - collect the data, can use patient registries, notes, IT systems
  3. STUDY
    - analyse the data, summarise findings and establish recommendations and disseminate
  4. ACT
    - implement the finding, consider adopting change management techniques
99
Q

Organization established to improve the impact of clinical audit on healthcare quality in England

A

Healthcare Quality Improvement Partnership

100
Q

What is the healthcare quality improvement partnership?

A
  • established to improve the impact of clinical audit on healthcare quality in England and Wales
  • HQIP funds the national clinical audit and patient outcomes programmes in england
  • this conduct national audits across a range of conditions ie national neonatal audit programme
101
Q

Facilitators to good audit (5)

A

TROSS

Time- protected time for audit
Resources- good IT systems, dedicated audit staff, funding for conducting audit and implementing changes
Organizational culture- whole team participates in audit and change implementation, supportive learning environment with a no-blame culture
Strategy- need for audit included on job roles, strategic plan for priority audits
Skills- staff training, dedicated audit staff

102
Q

What is a confidential enquiry?

A

A national investigation into a serious untoward incident

103
Q

Give to examples of confidential enquiries in England

A

The francis report- a confidential enquiry into Mid Staffordshire NHS foundation trust where > 200 excess deaths occurred

National confidential enquires into patient outcomes and deaths (NCEPOD)

104
Q

What is NCEPOD

A

National confidential enquiry into patients outcomes and deaths

Organization which looks at a range of conditions and conducts enquiries into patient care.

Aims to improve healthcare standards by reviewing patient care and undertaking confidential surveys.

Not audit as there is generally no accepted standards against which to audit

ie produced a report giving recommendations for care delivery to patients presenting with acute bowl obstruction

105
Q

what is the purpose of confidential enquiries

A

To establish what went wrong and to draw lessons which can be shared and acted upon.

106
Q

What do confidential enquiries produce?

A

A report which contains recommendations on how to minimise risk.

Sometimes they also contain self audit tools so healthcare organisations can assess their own risk

107
Q

what is the delphi method

A

A technique for generating expert consensus about a particular issue without the need for face to face meetings

108
Q

Who can be experts in the delphi method

A

Can be professionals or simply people with the relevant experience

Need to be careful when selecting experts as those most willing to be involved may not be the ones with the most important contributions

109
Q

Steps in the Delphi method

A

Step 1: contact and survey experts (can include both quantitative (scales) and qualitative questions)
Step 2: views of group are shared anonymously amongst the group highlighting areas of disagreement
Step 3: experts are invited to change their responses in light of step 2
Step 4: steps 2 and 3 are repeated until consensus is reached (or response rate falls below accepted standard)

110
Q

What is consensus for the delphi method

A

complete consensus is very rarely achieved. Accepted consensus may be anything from 51% up depending on the study

111
Q

Give 4 advantages of the delphi method

A
  1. Can be a good way of getting expert consensus on areas where there is little research or to engage people who otherwise are hard to reach
  2. Time -efficient- do not need to align diaries
  3. anonymity and written process reduces some of the down sides of face to face (ie all opinions are given equal weight- can reduce the impact of personality)

4.encourages identification and revision of errors but encouraging review of answers

112
Q

Give 4 disadvantages of the delphi method

A
  1. Does not always produce useful results- Sometimes development requires unconventional thinking rather than iterative consensus
  2. written format not appropriate for everyone
  3. open to manipulation from administrators

4 dependent on response from experts and sustained engagement

113
Q

levels of preventative strategy: primary prevention

A

Measures to stop disease developing or delay onset of disease in those at risk of disease (but who do not currently have the disease)

ie immunisation, low dose aspirin to those at risk of MI

114
Q

levels of preventative strategy: secondary prevention

A

Measures to detect early departures from health and to introduce appropriate treatment and interventions

ie most screening programmes

115
Q

levels of preventative strategy: tertiary prevention

A

Measures to reduce or eliminate long-term impairments and disabilities resulting from disease

ie blood glucose monitoring in those with diabetes

116
Q

what are the 2 possible approaches to preventative strategies with an example of each)

A
  1. POPULATION APPROACH (whole population receives health intervention ie seat belt legislation)
  2. HIGH RISK APPROACH (individuals at high risk receive intervention ie chlamydia screening in young women)
117
Q

What is the prevention paradox, who proposed it, and what does it mean for preventative strategies

A

Prevention paradox was proposed by Geoffrey rose in 1992.

It outlines that, given the larger number of people who are deemed lower risk, for many diseases most cases of the disease will occur in those who are at lower risk.

Focusing on high risk individuals only will therefore have a lesser impact on reducing cases of disease.

However, a large number of low risk individuals will have to make a change and only a small proportion of those will receive any individual benefit.

The result is that a combination of population based and high risk preventative strategies are usually the most effective.

118
Q

Preventative strategies: advantages (5) and disadvantages (5) of the high risk approach

A

Advantages:
1. Easier for health care professionals to focus on individual change
2. High risk individuals are usually aware of their exposure and therefore increased risk whereas many in population may never have been exposed
3. Easier to motivate someone who is at high risk to initiate change
4. can be cheaper than population wide approach
5. society tends to prefer approaches focused on individual change

DISADVANTAGES:
1. tends to medicalise prevention
2. does not tend to focus on underlying behaviours
3. ignores that most cases of a disease may occur in the non-high risk population
4. may have little impact on overall disease burden
5. can be expensive to identify those at risk

119
Q

Preventative strategies: advantages (5) and disadvantages (5) of the population wide approach

A

ADVANTAGES:
1. accounts for the fact that most cases of disease may occur in the non-high risk population
2. recognises that society has big influences on individual behaviour
3. In situations where there is a dose- response relationship between exposure and disease, shifting the entire populations exposure a little can have big impacts on disease prevalence

DISADVANTAGES
1. there can be societal /political resistance to population wide approaches
2. Can be more expensive to deliver
3. If there is not a dose-response association between exposure and disease population wide strategies may be less effective

120
Q

What are health impact assessments

A

Health impact assessments are systematic processes which consider the likely public health impacts of a new policy, project or programme.

These might be policies relating to transport, economy, infrastructure, employment etc

121
Q

Who proposed health impact assessments in their own right

A

The WHO Ottawa charter for health promotion proposed health impact assessment as an analogous process to environmental impact assessments.

EIA sometimes considered health but usually only superficially.

122
Q

what are environmental impact assessments

A

EIAs are a systematic process for establishing the likely environmental impacts of a new policy, programme or project.

They are required for certain projects before project initiation

123
Q

What are the stages to an health impact assessment?

A

5 stages (SSARM)

  1. Screening
  2. Scoping
  3. Appraisal
  4. recommendations
  5. monitoring
124
Q

Health impact assessment stage 1 (screening): what is included

A

Seeks to answer the question - is there any health relevance of this policy, project or programme.

This is a selection process which assesses the potential for the policy, programme or project to affect the health of the population

125
Q

Health impact assessment stage 2 (scoping): what is included

A

For those projects identified in screening a scoping process begins.

Initially a steering group is arranged including all the organisations involved in the project.

This group will decide the questions the HIA will address and set boundaries for the appraisal of health impacts.

It will be decided whether the HIA will consider health impacts at the:
- individual level (ie lifestyle)
- environmental level (eg air/water pollution)
- Institutional level (eg service availability)
-combination of the 3

It will also be determined who is responsible for decision making and reporting

126
Q

Health impact assessment stage 3 (appraisal): what is included

A

This is the main part of HIA

Includes:
- analysing the programme, policy, project
- profiling the affected population
- Identifying and characterising potential health impacts
- looking at the evidence base

The appraisal can be rapid (days-weeks) or in depth (weeks- months) depending on what was decided in the scoping exercise.

127
Q

Health impact assessment stage 4 (reporting): what is included

A

conclusions are written along with recommendations to minimise any potential negative impacts and maximise any potential positive impacts

128
Q

Health impact assessment stage 5 (monitoring): what is included

A

Actual impacts are monitored to enhance the evidence base for future HIAs and assess the extent to which the recommendations were adopted.

129
Q

What are the key challenges with health impact assessments (3)

A
  1. EVIDENCE
    - impacts of previous similar projects may not have been assessed
    - quantitative data often has more impact but collecting it may not be feasible
    - evidence often collected from multiple sources, often coming from stakeholders with differing perspectives
  2. IMPLEMENTATION
    - ensuring recommendations are adopted can be challenging
    - decision makers need to be actively involved in the HIA
  3. TIME AND RESOURCES
    - quick decisions are often needed limiting the rigour of the HIA
    - this should be explicitly acknowledged in the report.

FPH exam (23 decks)

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