Session 1 - Quality And Safety Flashcards
Define Equity:
Everyone with the same need gets the same care.
What are the seven principles that define healthcare quality?
Safe - no needless deaths
Effective - no needless pain or suffering
Timely - no unwanted waiting
Efficient - no waste
Equitable - no one left out
Patient-centred - no helplessness in those served or serving
Define an adverse event:
An adverse event is an injury caused by medical management (rather than the disease) that prolongs hospitalisation, produces a disability or both.
Define a preventable event:
An adverse event that could have been prevented in the current state of medical knowledge.
Why is healthcare not as safe as it could be?
There are poorly designed systems that do not take into account human factors.
Over reliance on individual responsibility
Most errors result from the system: lack of training, long hours, ampoules look the same.
What are some of the steps involved in implemented human factors thinking?
Avoid reliance on memory Make things visible Review and simplify processes Standardise common processes and procedures Routinely use checklists Decrease the reliance on vigilance.
What are the two types of conditions in the James Reasons framework of error and explain what they mean.
Later conditions - predisposing conditions that make error more likely to occur e.g. Poor or lack of training, long hours
Active failures - acts that lead to patients getting hurt
What is the definition of clinical governance?
A framework through which NHS services are accountable 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.
Give some examples of NHS quality improvement measures?
Standard setting - NICE Commissioning Financial Incentives Disclosure Regulation - registration and inspection - Care Quality Commission Data gathering and feedback Clinical audit - local and national
What are quality and outcome frameworks?
These are used in primary care as a financial incentive to generate income for practices.
What is a clinical audit?
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care and the implementation of change.
What are the component parts of a clinical audit?
Settings standards Measuring current practice Comparing results with criteria Changing practice Re-auditing to see if changes have improved the system.
