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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.
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
- Disclosure=>quality accounts
Care Quality Commission
- Register and license providers of care services
- moniter 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
- well understood
- 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)
- quality assurance
- 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
- Allocative: choosing between many needs to be met
- 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
- 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
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
- Sociological Critiques: structural, surveillance issues, consumption
- Illness: symptom management
- Everyday life: tasks of daily living
- Emotional: own + other's
- Biographical and narrative: reconstruction of biography [biographical disruption]
- Identity: 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)
- 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.
- Qualitative: bad
- 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
- Explanatory/Descriptive approaches
- 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
- 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.