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.
PATIENT SAFETY: 2 events and 2 failures
ADVERSE EVENT: injury caused by medical management, e.g. drug allergy.
PREVENTABLE EVENT: adverse event that could have been prevented given current medical knowledge
ACTIVE FAILURES: lead to patient harm at 'sharp end' (slips and lapses, mistake, violation)
LATENT FAILURES: predispose to active...
SWISS CHEESE MODEL
hazards lead to losses
successive layers of defenses, barriers and safeguards
active failures and latent conditions make holes
GUIDANCE ON QUALITY
NHS evidence guidelines
Care Quality Commission
Register and license providers of care services
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
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)
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
what is professional socialisation?
process of acquiring professional identities
doctors trad. self regulated-bad (bristol)
GMC: has lay and professional members-overseen by Council for Healthcare Regulatory Excellence
Procedures of Fitness to Practice
Screening 1: criteria of disease
important health problem
have early detectable stage
primary prevention available instead
Screening 2: criteria of test
precise + valid
acceptable to population
distribution of test values in the population must be known
Screening 3: criteria of treatment
effective EBP available
advantageous to have earlier diagnosis
agreed policy on who to treat
Screening 4: criteria of programme
proven effectiveness (RCT)
counselling, diagnosis and treatment facillities
opportunity costs weighed
benefits outweigh harm
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
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
measured as benefits foregone
Technical: choosing most efficient way of meeting a need
Gender: culturally appropriate behaviour for men and women
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
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.
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
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
Biographical and narrative: reconstruction of biography [biographical disruption]
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)
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.
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).
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.
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.
PATIENT PROFESSIONAL RELATIONSHIPS
Functionalism: (concensus and reciprocity)
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