1
Q
Why is quality and safety important?
A
- evidence patient are being harmed and receiving sub standard care
- variations in healthcare e.g. Postcode lottery
- direct costs and legal bills
2
Q
Sections in defining healthcare quality
A
SEPTEE Safe Effective Patient centred Timely Efficient Equitable
3
Q
Three principles NHS was built on
A
- free to point of access
- meets needs of everyone
- based on clinical need, not ability to pay
4
Q
Define
- adverse effect
- preventable adverse effect
- never event
A
Adverse effect
- injury caused by medical management that prolongs hospitalisation, produces disability or both
- common and many unavoidable e.g. Chemo hair loss, streptokinase may cause haemorrhage but not in everyone
Preventable adverse effect
- adverse effect that should have been prevented given current state of medical knowledge e.g. Op on wrong body part
Never events - many occur in surgery - they are preventable adverse effects which have evidence so clear that they should not happen
5
Q
James Reason’s framework of error
A
Active failures
- acts that directly harm the patient
Latent conditions
- predisposing conditions that make active failures more likely to occur
E.g. Poor training, few staff, poor design of syringes, over reliance on individual responsibility
6
Q
Reason’s model of Swiss Cheese
A
Holes in the Swiss cheese - some due to active failures and others due to latent conditions
Errors occur when the holes line up so barriers to those failures not working
7
Q
Define clinical governance
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 clinical care can flourish
8
Q
Name the 6 NHS quality improvement mechanisms
A
SCC DR F
Standard setting
- NICE sets standards based on best quality evidence to define what high quality of care should look like
Commissioning
- CCGs using budgets to meet needs of local population
Clinical audit and quality improvement
- clinical audit: quality improvement process that aims to improve patient care and outcomes through systematic review of are against criteria and implementation of change
- quality improvement is more continual so you are constantly improving care
Disclosure
- disclosing information about performance to patients and public
Registration and inspection
- organisations must be registered with quality care commission
Financial incentives
- QOF (quality and outcomes framework) - primary care GPs score points relative to indicators
- CQUIN (commissioning for quality and innovation) - trusts achieving measurable goals
- National tariff (healthcare resource groups)
9
Q
Define evidence based practice
A
Integration of individual clinical exposure with best available external clinical evidence from systematic research
10
Q
Why are systematic reviews needed?
A
- traditional literature may be biased and subjective
- quality of studies sometimes poor
- can highlight gaps in research
- can help address clinical uncertainty
They are useful as saves clinicians time, reduces delay between findings and implementation, help prevent bias decisions
11
Q
Practical and philosophical criticisms around evidence based practice
A
Practical criticisms
- impossible to create and maintain systematic reviews across all specialities
- RCTs not always feasible/necessary/desirable
Philosophical criticisms
- If works at population level does not mean it will work at individual level
- potential of EBM to create unreflective rule followers
- when does professional autonomy and responsibility overtake EBM?
- does not align with doctors mode of reasoning
12
Q
Why is there a gap between evidence and implementation?
A
- Evidence exists but Drs do not know about it
- Doctors know about it but do not use it e.g. Do not agree
- Resources not available to implement change
- Commissioning decisions reflect different priorities
13
Q
Quantitative research methods
A
Reliable and repeatable
Use questionnaires
- should be valid (measure what they are supposed to measure) and reliable (measure things consistently)
- published questionnaires already tested for validity and reliability
14
Q
Qualitative research methods
A
Makes sense of phenomena in terms of meanings people bring to them
- Observation and ethnography
- Interviews
- Focus groups
- Document and media analysis
15
Q
Pros and cons of qualitative research
A
Good as
- understand perspectives
- access info not in quantitative research
- explain relationships between variables
Not good at
- finding consistent relationships between variables
- generalisability
16
Q
What classification is used do to measure health of people in different socioeconomic positions?
A
NS-SEC
National Statistics Socio-Economic Classification
Calculated via Census data
17
Q
6 explanations for inequalities in Health
A
BAMS (Black Report) PI
Behavioural cultural
- ill health is due to people’s choices and decisions (does not consider adverse conditions and social processes)
Artefact
- health inequalities are evident due to the way statistics are collected
Materialistic
- inequalities in health arise from differential access to material resources e.g. Housing conditions, income, employment
Social selection
- Health determines class/ position through social mobility
Psychosocial
- psychosocial pathways act in addition to direct effects of absolute material living standards e.g. Stressors
Income distribution
- countries with greater income inequalities have greater health inequalities
- increased income inequality, increased social-evaluative threat, increased stress, decreased health
18
Q
Define
- inequality
- inequity
A
Inequality - when things are different
Inequity - inequalities that are unfair and avoidable
Can have inequality without inequity
E.g. Different gps offering different services to meet needs of region. But if region had as,e needs then it would be an inequity
19
Q
Why do people in deprived areas have higher rates of GP/ emergency services and use less preventative services?
A
- Manage health as series of crises
- Normalisation of ill health
- Use more accessible services
- Reflects lack of cultural alignment between health services and lower socio-economic groups
20
Q
Define health promotion
A
Enabling people to increase control over and improve their health
Public Health England has duty to protect and improve nation’s health and wellbeing and reduce health inequalities
21
Q
Sociological perspectives on health promotion
A
- focuses on individual responsibility - victim blaming
- way of monitoring and regulating population - encourages self surveillance
- health promotion privileges certain lifestyles and those wealthier - widens inequalities
22
Q
5 approaches to health promotion
A
- medical/ prevention e.g. Smoking
- behaviour change
- educational
- empowerment - client centred approach
- social change e.g. Smoking ban
23
Q
Levels of prevention
A
Primary prevention
- prevent onset of the disease by reducing exposure to risk factors e.g. Immunisations
Secondary prevention
- detect and treat disease at early stage to prevent progression/ further complications e.g. Screening
Tertiary prevention
- minimise the effects of an established disease
24
Q
Health promotion dilemmas
A
- Ethics of interfering with peoples lives
- Victim blaming
- Fallacy of empowerment (information does not give people power)
- Reinforcement of negative stereotypes
- Unequal distribution of responsibility
- Prevention paradox (interventions that make a difference at population level may not make much of a difference at individual level)
25
Types of health promotion evaluation
Process evaluation
- assesses process of programme implementation so how the programme was put into place and how it is being delivered/received
Impact evaluation
- assesses immediate effects of the programme
- baseline data needed before and after intervention
Outcome evaluation
- measures long term consequences
(delay: some interventions take a long time to have an effect)
(Decay: some interventions wear off rapidly)
26
What are lay beliefs?
How people understand and make sense of health
| Constructed by people with no specialised knowledge
27
Perceptions of health
- negative definition
- functional definition
- positive definition
Negative definition - health is absence of illness (common in lower socioeconomic group)
Functional definition- health is the ability to do certain things so do what is important to you (lower socioeconomic group and elderly)
Positive definition - health is a state of wellbeing and fitness
28
What is the interplay between lay and medical beliefs?
As lay people engage with professional concepts and are exposed to new concepts, the way they understand them and embed them in everything they know is a process of understanding and refinement
29
Define
- illness behaviour
- sick role behaviour
Illness behaviour is the activity of an ill person to define illness and seek solution so what people do when they have symptoms e.g. Advice from lay people. Internet
Sick role behaviour is the formal response to symptoms so the step after illness behaviour where someone seeks formal help.
30
Symptom / iceberg illness
The iceberg are all the symptoms people experience but those above the he water fare thoe hsymptoms atare of opeople who seek mdical help.
Under water do nothing or self treat.
31
Name some factors that influence illness behaviour?
Illness behaviour - behaviour of person with symptoms e.g. Lay people opinions
- culture
- visibility of symptoms
- extent to which symptoms disrupt life
- tolerance threshold
32
Lay referral system
Chain of advice seeking contacts the sick makes with other lay people prior to/ or instead of seeking help from HCPs
33
What is symptom evaluation?
Relates to the fact that when patients often have explanations for their symptoms but wen they are not able to it usually prompts consultation
34
Three groups relating to adherence
- deniers and distancers
- acceptors
- pragmatists
Deniers and distancers
- deny they have the condition and so do not take the medication etc
Acceptors
- accept the diagnosis and doctor's advice
- normal life having controlled symptoms through medication
Pragmatists
- do not use preventative medication for condition unless it was aggravated
- accept condition but see as mild illness
35
What is a chronic illness?
Encompasses a wide range of conditions which are
- long term
- have profound influence on live of sufferer
- often co-morbid conditions
36
What is an illness narrative?
Refers to story telling and accounting of the practices that occurred in the face of the illness
37
Types of work related to chronic illness
I BEE I
```
Illness work
- getting diagnosis
- managing symptoms
- self management
Biographical work
- loss of self (plans in future etc)
Emotional work
- protect emotional being of others and self
- impact on role and dependency
Everyday life work
- coping and strategy
- normalisation
Identity work
- stigma
- not treated the same
```
38
Types of stigma:
- Discreditable
- Discredited
- Enacted
- Felt
Discreditable
- nothing can be visibly seen but if found people would have different view
Discredited
- physically visible characteristic or well know stigma sets person apart
Enacted
- real experience of prejudice, discrimination and disadvantage due to condition
Felt
- fear of enacted stigma so fear that if someone knew they would be treated differently
39
Medical v social disability
Medical disability
- disability is deviation from medical Norms
- need medical intervention to help
(Lacks recognition of social and psychological factors)
Social disability
- Problems due to product of the environment and failure of the environment to adjust not due to abnormalities of the pele
40
Three commonly used measures of health
Mortality
Morbidity
Patient based outcomes
41
What are patient based outcomes?
Used to assed the well being of patients from their point of view
Focuses on patient concerns
Patient recorded outcome measures are good as
- improves clinical management of patients
- comparison of providers e.g. Hospitals
42
What is health related quality of life?
Functional effect of an illness and its consequent therapy upon a patient, as perceived by the patient
- psychological well being
- social wellbeing
43
Quantitative v qualitative methods of measuring HRQoL
Quantitative methods use instruments or scales
- reliable and valid (measures what it intends to measures)
- published instruments tested for reliability and validity, can be used to compare across different groups
Qualitative methods good to initially look at dimensions of HRQoL
44
Generic quality of life measures advantages and disadvantages
Generic instruments
- can be used with any population and covers general health
+ used for broad range of health problems
enables comparisons across treatment groups
can detect unexpected positive and negative effects of interventions
- generic so less detailed
Les sensitive to changes that occur due to an intervention
Loss of relevance as too general
45
Specific quantitative instruments to measure HRQoL
Specific instruments evaluates health dimensions specific to a disease, site or dimension
SF-36 (Short form 36)
- 4 week recall period
- 36 items into 8 dimensions
- responses scored so scores for each dimension added (0-100) but cannot add up all dimension scores to give overall score
EuroQol EQ-5D
- generates single index value for health status
- full health 1, death 0
- 5 dimensions and 3 levels for each
- also draw s line for where you feel your health is
46
What type of specific instruments are there for measuring HRQoL?
Disease specific
Dimension specific
Site specific
+ relevant, sensitive to change, acceptance to patients
- cannot use with people who do not have the disease, may not detect unexpected effects as focused on one condition
47
What should you consider when picking an instrument for measuring HRQoL?
- are there studies showing established reliability and validity
- have there been published studies showing the instrument was used successfully
- is it suitable for your area of interest
- is it sensitive to change
- is it acceptable to patients
48
Spontaneous presentation v Opportunistic case finding
Spontaneous presentation is when a patient presents themselves with symptoms e.g. GP
Opportunistic case finding is when person presents with symptoms related to a disease or problem and then by chance something else is found
49
Define screening
Systematic attempt to detect an unrecognised condition by the application of rapid tests to distinguish apparently well people into those who probably do and do not have the disease
Purpose of screening
- give a better outcome compared with finding something in the usual way so if the treatment can wait there is no point screening
50
Five criteria from U.K. National screening committee for assessing screening
CTISI
Condition - needs to be important
Test - simple, save, acceptable to population, sensitivity, specificity, PPV, NPV
Intervention - what to do to people when diagnosed with condition, need evidence that intervention at pre symptomatic phase is better than usual care
Screening programme - proven effectiveness in reducing mortality and morbidity
Implementing - management and monitoring
51
Features of the test in screening
- sensitivity
- specificity
- positive predictive value
- negative predictive value
Sensitivity
- first column
- out of all the people with the disease, how many were detected positive in the test
Specificity
- second column
- out of all the people without the disease, how many were detected negative in the test
Specificity and sensitivity are characteristics of the test so they do not change even if the population characteristics change
PPV
- first row
- out of all the people who test positive, how many actually have the disease
NPV
- second row
- out of all the people who test negative, how many people do or actually have the disease
These change with population characteristics
52
It can be difficult to evaluate screening programmes due to
- lead time bias
- length time bias
- selection bias
- lead time bias
Early diagnosis falsely appears to prolong survival
Patient lives the same amount of time but longer knowing they had the disease so looks like they lived longer as they found out about the disease earlier
- length time bias
Screening better at picking up slow growing unthreatening cases than aggressive fast ones so diseases that are detectable through screening are more likely to be favourable prognosis anyway
- selection bias
Studies of screening often skewed due to healthy volunteer effect
53
Sociological critiques of screening
Victim blaming
Feminist critiques
Moral obligation to screening
54
Compared to previously what has changed in the structure in the NHS
- increasing role of managers
- increasing marketisation of provision
- change in NHS structure
55
Role of Secretary of State
Accountable for NHS
Responsible for promoting healthcare
Leads department of health
56
Role of department of health
Sets national standards that commissioners and providers have to follow
Sets national tariff
57
Role of NHS England
Authorises CCGs
| Commissions primary care services and specialist services
58
What are CCGs
Clinical commissioning groups
| Brings together GPS, nurses, public health, patients etc and responsible for flow of money in NHS budget
59
All clinicians should have the opportunity to become
- partner
- leader
Partner
- takes responsibility for management of finite resources
Leader
- works with other clinicians and managers to change systems where it will benefit patients
60
What is a
- clinical director
- medical director
Clinical director
- each directorate (speciality) is led by a clinical director
- has to implement audits, continue medical education and training for staff, design and implement policies on junior doctor work etc
Medical director
- above clinical directors
- most senior doctor in organisation that sits on board of NHS trust
- responsible for quality of medical care
- communicates between board and medical staff
- approves job descriptions, involved in disciplinary hearings
61
Define profession
Type of occupation able to make distinctive claims about its work practices and status
62
Define professionalisation
Process of an occupation becoming a profession
Involves three elements
- asserting an exclusive claim over a body of knowledge
- establishing control over market and exclusion of competitors
- establishing control over professional work practice
(Remember GMC now has lay members so medicine no longer as much of a profession compared to previously)
63
Define socialisation
Process by which professionals learn during their education and training the attitudes and behaviour necessary for their professional role
This occurs through the interaction with others. The formal curriculum refers to knowledge/ tested in exams while the informal curriculum are the attitudes and beliefs acquired but not formally examined
64
What are some critiques of professions?
- protected monopolies
| - seek to optimise own interested and not their clients
65
What services are fitness to practice concerns reported to?
Medical Practitioners Tribunal Services (MPTS)
- this group's sits above the GMC and decides if someone is struck off or not
- so GMC still says what doctors can/can't do but if someone falls short, they investigate the person and if there is a question of their FTP they hand the decision to MPTS.
66
What does revalidation involve?
Local evaluation of doctor's practice through annual appraisals
67
Implicit v explicit rationing
Implicit rationing
- care is limited but neither the decisions or the basis of the decisions are clearly expressed
- so allocation of resources through individual clinical decisions without criteria for those decisions being explicit
- can lead to inequalities and discrimination, decisions based on social deservingness, patients not aware of all options
Explicit rationing
- clearly set out procedures are followed to make decisions of who gets treatment etc
- care is limited but decisions are explicit
- transparent and accountable decisions, more equity in decision making, more clearly evidenced based however heterogeneity of patients and illnesses, impact on clinical freedom, complex
68
Define opportunity cost
When spending resources on one thing/treatment, these resources now cannot be used in other treatments
Measured in benefits foregone
69
Technical v allocative efficiency
Technical efficiency
- you have decided the bets outcome but are finding the best way to do it
Allocative efficiency
- you are choosing between the many needs to be met
70
What is an economic analysis?
```
Compares inputs (resources) and outputs (benefits and value attached to them) of alternative interventions
Allows for better decisions to be made about which interventions represent best value for investment
```
71
Four types of economic evaluation
MEBU
- cost minimisation analysis
Outcomes assumed to be equivalent so focus is on cost
- cost effectiveness analysis
Comparing drugs or interventions that have a common health outcome by comparing cost per unit outcome
- cost benefit analysis
All inputs and outputs have monetary terms so think about how much money is given to healthcare and other services e.g. Education
- cost utility analysis
Type of cost effectiveness analysis that measures quality of adjusted life years (QALY)
72
What is a QALY?
They adjust life expectancy for quality of life
| 1 QALY is one perfect year of health or = 10 years with 0.1 quality of life
73
Criticisms of QALYS
- controversy about the values that they embody (quantity v quality of life)
- may disadvantage common conditions
- technical problems with their calculations
- do not assess impact on carers and family
74
Define complementary therapies
The practice of complementary and alternative medicine involves any medical system based on a theory of disease or
method of treatment other than the orthodox science taught in medical school
75
Why might people turn to complementary therapies?
- preference for a holistic approach
- feel they receive more time and attention from practitioner
- persistent symptoms not relieved by conventional treatment
- concern about real or perceived adverse effects of conventional treatment
76
Concerns over complementary therapies
- safety and competence of practitioners
- social factors
- costs
- guilt for spending money
- denial
77
For and against NICE evaluating complementary therapies
For
- high public interest
- half GPS provide access
- should apply same standards to everything
- address inequalities in access
Against
- money limited in NHS
- poor quality evidence
- NICE has higher priorities
78
Challenges in conducting trials to look at complementary therapies
- who will fund it
- trial of single intervention may not reflect reality
- finding placebos is challenging
- difficult to double blind
79
EBM and complementary therapy issues
- to what extent is EBM relevant and applicable to complementary medicine
- whose evidence counts
- validity to EBM principles
80
Why are we interested in patient's views related to healthcare?
Evidence that patient satisfaction is important outcome
Ethical views
Increased external regulation of health services
Means of securing funding
81
What is healthwatch England?
Healthwatch England is the national consumer champion in health and care
Ensure voice of consumer strengthened and heard by commissioners
82
What are PALs
Trust based patient advice and liaison services
They offer confidential advice, support and information on health related matters
83
What is the parliamentary and health service Ombudsman?
Ombudsman sits above all different healthcare organisations and undertakes independent investigation into complains that NHS in England has not acted upon properly or fairly
You can either complain initially to local CCG or hospital and then if not sorted properly then goes to Ombudsman
84
Disadvantages of using locally developed DIY instruments to get patients views on healthcare
May not comply to basic standards for questionnaire design
May not have proven reliability and validity
Lack comparability
Tend to find higher levels of satisfaction rather than published instruments
85
Challenges in responding to dissatisfaction to healthcare experience
Views may not be reasonable or rational
How much resource should be diverted to satisfy issues from complaints
How should patients concerns about someone's clinical competence and/or fitness to practice be viewed?
86
Sociological approaches to patient professional relationship
PIFc
Functionalism
- argues doctor patient relationship based on a set of socially prescribed roles for Dr and patients
- sick role associated with rights to be excused from obligations and seek medical attention, want to get well, not to abuse role
- Dr role includes work in interest of patients, be objective, non discriminatory, autonomy and status
- roles important as imbalance of power in relationship so for relationship to work doctors and patients must trust each other and work together
Conflict theory
- Dr holds power and patient has little choice but to accept dominance of Dr
- lay ideas are being marginalised
- medicalisation of everything
Interactionist approach
- Interested in patterns of interaction between doctor and patient
Patient centred model
- aspiration that relationship less hierarchal and more cooperative
- patient views taken into account, holistic care
- shared decision making
Kelog Med
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