Describe the assessment of quality of care and the principles of patient safety.

Quality of Care and Patient Safety

• The six dimensions of quality — care should be effective (based on evidence and producing benefit); safe (avoiding harm); patient-centred (respecting preferences and values); timely (reducing harmful delay); efficient (avoiding waste); and equitable (not varying by personal characteristics)
• The donabedian framework is the standard way to assess quality, and should be given with an example of each:
• Structure — the settings and resources: building, equipment, drugs, staff numbers and qualifications. Easy to measure, but a poor predictor of outcome
• Process — what is actually done: whether blood pressure was measured, the correct drug given, hands washed, the partograph used
• Outcome — the result: mortality, complications, functional status, satisfaction
• The practical point about the three — structure is what is usually measured because it is easiest to count, yet it guarantees nothing; a facility can possess every item on the checklist and deliver poor care
• Process measures are the most useful for improvement, since they are directly actionable and attributable to the provider
• Outcomes are what matter but are affected by case mix and by factors outside the provider’s control, so comparing raw outcomes between facilities can penalise those treating the sickest patients and requires risk adjustment
• Patient safety and its vocabulary:
• An adverse event is an injury caused by medical management rather than by the underlying disease; a preventable adverse event is one that need not have occurred; a near miss is an error that did not reach the patient; and a sentinel event is an unexpected occurrence involving death or serious harm
• The common safety problems — medication errors, which are the commonest; health care-associated infection; surgical errors, including wrong site and retained instruments; diagnostic error, which is the most under-recognised; falls and pressure ulcers; unsafe injection practice and blood transfusion; and failures of handover and communication
• Communication failure is the most frequently identified root cause of serious events, particularly at handover, on transfer between units, and where a junior member of staff does not feel able to raise a concern
• The systems approach to error is the central concept and should be argued explicitly:
• The person approach blames the individual and demands greater care; the systems approach asks why the system allowed the error to reach the patient
• Reason’S SWISS cheese model holds that defences have holes, and harm occurs only when the holes in successive layers align
• The conclusion is that harm results from multiple small failures rather than one careless person, and that adding layers of defence prevents more harm than exhorting individuals to be careful
• The practical argument for the systems approach is that a blame culture produces concealment — errors and near-misses are not reported, so the system never learns and the same error recurs
• A just culture is the refinement — distinguishing human error, which requires system change and support; AT-risk behaviour, which requires coaching; and reckless behaviour, which does warrant accountability
• The practical safety interventions with the best evidence — hand hygiene and the five moments; the WHO surgical safety checklist, with its sign-in, time-out and sign-out, which reduces mortality and complications; correct patient identification using two identifiers; attention to look-alike and sound-alike drugs and to concentrated electrolytes; structured handover using a defined format such as SBAR; medication reconciliation at transitions of care; care bundles for catheter and ventilator-associated infection; and incident reporting with root cause analysis
• The checklist works not because surgeons forget the steps but because it creates a moment at which anyone in the room may speak, which addresses the hierarchy that otherwise silences a nurse who has noticed something
• Quality improvement methods — the plan-DO-study-act cycle; clinical audit, which compares practice against a standard, implements change and RE-AUDITS; root cause analysis; and accreditation
• The RE-audit is what makes an audit worthwhile, and is the step most often omitted, leaving a cycle that was never closed
• The INDIAN mechanisms — the national quality assurance standards (NQAS); kayakalp for cleanliness and hygiene; LaQshya for labour room and maternity operation theatre quality; MUSQAN for child-friendly services; NABH accreditation; and the Clinical Establishments Act
• A blame culture produces concealment, and a system that hears nothing learns nothing and repeats the same error
• The checklist creates a moment when anyone may speak, which defeats the hierarchy that silences a nurse who noticed something
• Structure is easiest to count and guarantees nothing, since a facility can have every item and deliver poor care
• Process measures are the most useful for improvement, being directly actionable and attributable
• Comparing raw outcomes penalises the sickest caseload, which is why risk adjustment is necessary before ranking anyone
• Communication failure is the commonest root cause, particularly at handover and between units
• Holes must align for harm to occur, which is why adding layers beats exhorting individuals to be careful
• A just culture separates error from recklessness, supporting the first and holding the second to account
• Diagnostic error is the most under-recognised, since it leaves no obvious trace and is rarely reported
• Re-audit is what makes an audit worthwhile, and is the step most often omitted, leaving the cycle unclosed
• Use two identifiers to confirm a patient, which prevents a large share of wrong-patient errors at trivial cost