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Explain Clinical Governance
- A framework throught which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating and environment in which excellence will flourish.
- Statuatory duty.
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PATIENT SAFETY: 2 events and 2 failures
- ADVERSE EVENT: injury caused by medical management, e.g. drug allergy.
- ACTIVE FAILURES: lead to patient harm at 'sharp end' (slips and lapses, mistake, violation)
- LATENT FAILURES: predispose to active...
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SWISS CHEESE MODEL
- hazards lead to losses
- successive layers of defenses, barriers and safeguards
- active failures and latent conditions make holes
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GUIDANCE ON QUALITY
- NICE
- NHS evidence guidelines
- Disclosure=>quality accounts
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Care Quality Commission
- Register and license providers of care services
- moniter services
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EVIDENCE BASED PRACTICE
- we should practice with the best available evidence-findings from rigorous research
- evidence of: cost effectiveness, drug efficacy etc
- systematic research is best
- critiques: (Practical): not possible for all specialities, RCT not always possible, choice of outcomes, biomedical view. (Philosophical) doesn't align with doctor's mode of reasoning, population level outcome may not work for individual
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QUALITATIVE RESEARCH
- aims to make sense of phenomena in terms of meanings people bring to them
- Observations, Interviews, Focus groups, documentary and media analysis
- Good for: Understanding the perspective
- of those in a situation, Accesssing information not
- revealed by quantitative approaches, Explaining relationships between variables
- Less good for: Finding consistent relationships between variables, Generalisability (good at
- finding range of views, need to prove is from statistically representative group)
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QUANTITATIVE RESEARCH
- collection of numerical data.
- strengths: reliability and repeatability
- e.g. questionnaires (valid and reliable)
- Good at: Describing, measuring, finding relationships, allowing comparisons, can consult large numbers, check reliability by re-testing a large number of samples.
- Cons: May force people into inappropriate categories, people can't express things properly, may not access all important info, may not effectively establish causality
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SUMMARY
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what is professional socialisation?
process of acquiring professional identities
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Regulation
- doctors trad. self regulated-bad (bristol)
- GMC: has lay and professional members-overseen by Council for Healthcare Regulatory Excellence
- Procedures of Fitness to Practice
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Screening 1: criteria of disease
- important health problem
- well understood
- have early detectable stage
- primary prevention available instead
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Screening 2: criteria of test
- simple
- safe
- precise + valid
- acceptable to population
- distribution of test values in the population must be known
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Screening 3: criteria of treatment
- effective EBP available
- advantageous to have earlier diagnosis
- agreed policy on who to treat
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Screening 4: criteria of programme
- proven effectiveness (RCT)
- quality assurance
- counselling, diagnosis and treatment facillities
- opportunity costs weighed
- benefits outweigh harm
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TEST VALIDITY 2
- Sensitivity: proportion of people with disease who test positive. high=most with disease will test +ve so test is good at finding the disease
- Specificity: proportion of people who test negative and don't have the disease. high=low numbers of false positives
- PPV: if test positive-chance of actually having disease (strongly influenced by prevalence) high=strong chance that positive test is true. (in low prevalence area, low PPV)
- NPV: if i test negative-chance of not having disease. high=strong chance that negative test=disease free
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RATIONING
- IMPLICIT: care is limited-reasoning not clearly expressed. (often due to budget constraints) leads to inequality and discrimination. open to abuse. based on social deservingness. doctors unwilling to do it.
- EXPLICIT: care limited but reasoning expressed. adv: transparent, accountable, can debate, uses EBP, equity. disadv: complex, heterogenicity of patients and illness, hostility, threat to clinical freedom, evidence of patient distress
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OPPORTUNITY COSTS
- measured as benefits foregone
- Technical: choosing most efficient way of meeting a need
- Allocative: choosing between many needs to be met
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ECONOMIC EVALUATION
- 1. Cost minimisation analysis: outcomes assumed equivalent (choose cheapest)
- 2. Cost Effectiveness analysis: outcomes vary, but can be measured in identical units-compared cost per unit to outcome
- 3. cost benefit analysis
- 4. Cost utility analysis: QALY
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INEQUALITIES
- Social class: segment of the population distinguishable from the rest because of similar labour, market position and property relations.
- can be...individual, area based, education based, income based.
- Ethnicity: shared values, beliefs, customs, traditions, language, lifestyle
- Gender: culturally appropriate behaviour for men and women
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THE BLACK REPORT
- 1. artefact explaination: inequalities due to collection of health statistics
- 2. social selection: health status -> social position. not the other way around
- 3. behavioural-cultural: ill health due to people's own choices. disadvantaged engage in more health damaging behaviours
- 4. materialist explaination: inequalities arise from differential access to material resources(low income, unemployment, work environment, low control over job, poor housing conditions) needs further research
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LAY BELIEFS
- negative definition of health: health=absence of illness
- functional: health=ability to do things (lower, no time off work)
- positive: health=state of wellbeing and fitness (affluent)
- symptom iceberg: most illnesses never get to a doctor.
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HEALTH PROMOTION
- primary: aim to prevent onset, decrease risk factors
- secondary: detect, treat early (screening)
- tertiary: minimise effects of established disease (adherance)
- Dilemmas: ethics of interfering, victim blaming, reinforce -ve stereotypes
- Prevention Paradox: population level interventions might not affect individual
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EVALUATING HEALTH PROMOTION
- WHY? need EBP, accountability, ethical obligation, programme management.
- Types: process, impact, outcome( 5 years later). timing of evaluation influences outcome due to...
- DELAY: takes time to have effect
- DECAY: effect wears off quickly
- Difficulties: design of evaluation, timing, confounders, cost
- Sociological Critiques: structural, surveillance issues, consumption
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CHRONIC ILLNESS-WORK
- Illness: symptom management
- Everyday life: tasks of daily living
- Emotional: own + other's
- Biographical and narrative: reconstruction of biography [biographical disruption]
- Identity: Stigma
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STIGMA
- Discreditable: nothing seen but if found out...
- Discredited: Physically visible/well known
- Enacted: real experience of prejudice and discrimination
- Felt: Fear of enacted stigma + shame (selective concealment)
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DISABILITY
- medical model: deviation from medical norms=>disadvantage as direct consequence. needs medical intervention. critique: no psychosocial, stereotyping/stigmatizing language
- Social model: have problems because society fails to adjust. disability=social oppression. requires political actions. Critiques: body left out, overly drawn view of society, fails to recognise corporeal reality.
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International Classification of Functions (ICF)
- measure health and disability at individual and population levels
- Key components: body structures and functions, activities undertaken by individual (+difficulties).
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PROMS AND HRQoL
- commonly used measures of health, mortality, morbidity, patient based outcomes. (wellbeing from pts point of view)
- HRQoL: measures physical function, symptoms, global judgements, psychological well being, social wellness, cognitive function, personal constructs, satisfaction with care.
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MEASURING HRQoL
- Qualitative: bad
- Quantitative:
- Generic: SF 36, EQ5D. advantages: broad range of health problems, good if no disease specific available, enable comparisons across treatments, can assess population, detect unexpected effects of intervention. disadvantages: loss of detail, not relevant, less sensitive, less acceptable to patients/
- Specific: assess disease, site, dimension. Advantages: relevant, sensitive to change, acceptable to pts. disadvantages: only for people with that disease, limited comparison, may not detect unexpected.
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PATIENT PROFESSIONAL RELATIONSHIPS
- Explanatory/Descriptive approaches
- Conflict Theory: (conflict)
- Interpretivism/Interactionism: (meanings patients ascribe to social situations.
- Aspirational (to be more cooperative)
- Patient-centred models: egalitarian. Biophyschosocial engagements. enhances prevention and promotion, mutually agree on Rx
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COMPLEMENTARY THERAPIES
- why? persistant symptoms, adverse effects, holistic, attention
- doctors perspectives: pts may see unqualified, risk missed/delayed dx, refuse conventional
- Evidence base: anecdotal/qualitative
- Challenges: resources, trial of single intervention may not reflect reality, randomisation, hard to find placebos, hard to double blind.
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