Flashcards in HadSoc Session 1 Deck (35):
What do variations in medical care and variation in the provision of specific health service indicate?
Over/undertreatment and waste/inequity
Everyone with the same need gets the same care
Do variations in healthcare have a basis in clinical science?
What is an unavoidable adverse event?
An injury caused by medical management that leads to prolonged hospitalisation +/- disability e.g. Drug reaction in first administration
What is a preventable adverse event?
An injury caused by medical management that leads to prolonged hospitalisation +/- disability that could have been prevented given current medical knowledge e.g. Wrong operation site
What percentage of English acute hospital deaths are deemed preventable?
What are avoidable deaths in English acute care hospitals thought to be mostly due to?
Quality of clinical monitoring allowing omissions of care
How can over-reliance on individual responsibility lead to harm in healthcare?
Everyone is fallible and systems often cause errors by inadequate training, long hours etc. Combined with a tradition of blame
How can individuals cause harm in healthcare?
May be incompetent, careless, badly motivated or negligent
How can system failures lead to harm in healthcare?
Multiple contributions to an incident with not enough/not the right defences built into the system
How can culture and behaviour lead to harm in healthcare?
Not challenging seniors etc
How do human factors lead to harm in healthcare?
Highly predictable psychological responses to particular situations are poorly anticipated in healthcare
How do microsystems lead to harms in healthcare?
Each has a large number of errors that must be worked around therefore time is wasted learning operational routines rather than transferable procedure skills
What leads to degraded safety?
Failure to ensure organisations are geared to safety --> focus in short-term fixes, encourages heroic, compensatory model, people rush and make mistakes that are tolerated
What are active failures?
Acts that lead directly to a pt being harmed e.g. prescribing overdose
What is a latent condition?
Any aspect of a clinical context that means active failures are more likely e.g. poor training, too few staff
What do latent conditions require to prevent active failures from occurring?
Defences that trap or mitigate error
What is the Swiss Cheese model of harm in healthcare?
A successive layer of defences, barriers and safeguards is breached as holes caused by active failures and latent conditions align
What are the 6 components of human factors thinking that avoid loss of situational awareness?
Avoid reliance on memory, make things visible, review and simplify processes, standardise common processes and procedures, routinely use checklists and decrease reliance on vigilance
What happens when situational awareness is lost?
Bigger picture and timescale are lost and there is persistence with the wrong course of action
What system factors impact safety in healthcare?
Pt characteristics, task factors, individual practitioner, team factors, work environment etc
What is clinical governance?
Framework through which NHS organisations are accountable for continuously improving quality and safeguarding high standards of care by creating an environment in which excellence will flourish
How is clinical governance achieved?
Health and Social care act 2012 with regard to quality standards prepared by NICE
What are NICE quality standards?
Markers of high quality and cost effective pt care across a pathway
How are NICE quality standards derived?
From NICE accredited resources and in collaboration with stakeholders
What is comissioning in NHs quality improvement?
200 CCGs specify expectations of service in contracts to drive quality of service for their local population
How is the Quality and Outcome Framework used?
Primary care settings score points according to performance against national indicators to work out practice payments
How does the Commissioning for Quality and Innovation (CQUIN) drive quality improvement?
1.5% of provider trust income depends on achieving measurable goals in safety, effectiveness and pt experience
How does the national tariff drive quality improvement?
Hospital treats pt --> diagnosis and Tx recorded and coded --> HRG assigned --> tariff paid therefore efficient trusts make profit and inefficient trusts make losses
Are national tariffs paid if an 'never event' occurs?
How does disclosure lead to quality improvement?
All trusts are required to annually publish and make public ally available quality accounts focusing on safety, effectiveness and pt experience
What can the CQC do to improve quality of healthcare?
Impose conditions of registration (which all NHS trusts must be), make unannounced visits, request information, issue warning notices or fines or prosecution, restrictions in activities or close practices
What is the process of a clinical audit?
Choose topic --> research evidence of criteria and standards --> 1st evaluation to measure current practice and compare with standards --> implement change --> 2nd evaluation --> continue cycle
Describe the act-plan-do-study cycle of systematic effort to make change.
Act:plan next cycle and decide if change can be implemented
Plan: define objective, questions and predictions and plan data collection
Do: carry out plan, collect data and begin analysis
Study: complete analysis, compare data to predictions and summarise learning