Session 1 Flashcards
(24 cards)
How do we know that quality in the NHS is not optimal?
Because there are variations in the medical care provided throughout the country
What is Equity?
Every patient with the same needs get the same care
What is an adverse event?
An injury caused by medical management (Instead of the underlying disease) that prolongs hospitalisation, produces a disability, or both
What is a preventable adverse event?
An adverse event that could be prevented given the current state of medical knowledge
What is a ‘never event’?
An event that should not ever happen in healthcare due to the regulations put in place to prevent it
What is an example of an adverse event that is unavoidable?
A drug reaction in a patient who has been prescribed a drug for the first time eg antibiotics
What is an example of a preventable adverse event?
Retained objects after surgery. It could have been prevented by counting the objects in and out of surgery.
Give some examples of never events
Operations performed on the wrong part of the body
Operating on the wrong patient
Wrong route administration of chemotherapy
Why do things go wrong?
The systems are poorly designed to not incorporate human factors
Culture & behaviour
Is it more often humans or systems who are at fault?
Systems. Usually there are multiple contributions or not enough or the right defences built in
What is the WHO’s human factors thinking list?
- Avoid reliance on memory
- Make things visible
- Review & simplify processes
- Standardise common processes & procedures
- Routinely use checklists
- Decrease the reliance on vigilance
What is the Swiss cheese model of accident causation?
Has successive layers of defences, barriers and safeguards
BUT each layer has holes in it due to either active failures or latent conditions.
When all the holes line up, an accident occurs
What are active failures?
Acts that lead directly to the patient being harmed
Occur at the ‘sharp end’ of practice (Closest to the patient)
What are latent conditions?
Predisposing conditions. Any aspect of a situation/context that means active failures are more likely to occur
Can be stopped with defences
What is 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 excellence in clinical care will flourish
What are the NHS quality improvement mechanisms?
Standard setting Commissioning Financial incentives Disclosure Regulation (Registration & Inspection) Data gathering & Feedback Clinical audit (Local & National)
What are the 5 domains that have national outcome goals and indicators?
- Prevention of premature death
- Enhanced quality of life for people with long term conditions
- Help people recover from episodes of ill health/injury
- Ensure people have a positive experience of care
- Treat & care for people in a safe environment and protect from avoidable harm
What is QOF?
Quality and outcomes framework. Used by GPs, give points that generates income for them
What is CQUIN?
Commissioning for Quality and Innovation. Used by hospital trusts
What are Best practice tariffs?
A list of things that must be done in each clinical case to get extra money.
What are Quality accounts?
Trusts are required to publish them
They relate to safety, effectiveness and experience of patients
Who has to be registered with the Care Quality commission?
NHS Trusts
GPs
Dentists
What is a clinical audit?
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against criteria and the implementation of change
What are the parts of a clinical audit?
Set standards Measure current practice Compare results with standards Change practice Re-audit to ensure practice has improved
