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Clinical Audit Session 1 22 nd Feb 2016

Clinical Audit Session 1 22 nd Feb 2016. USSKAR Practice and Communication of Science Dr Viv Rolfe BSc PhD (intestinal physiology) Associate Head of Department of BBAS National Teaching Fellow Principal Fellow of the Higher Education Academy. Learning Outcomes.

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Clinical Audit Session 1 22 nd Feb 2016

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  1. Clinical AuditSession 1 22nd Feb 2016 USSKAR Practice and Communication of Science Dr Viv RolfeBSc PhD (intestinal physiology) Associate Head of Department of BBAS National Teaching Fellow Principal Fellow of the Higher Education Academy

  2. Learning Outcomes • By the end of these sessions you will understand: • What clinical governance and clinical audit is. • Why they are important and the cultural challenges facing the NHS and other large organisations. • What is audit and what is research? • Go and perform your own mini-audit! (optional) • The audit cycle. • How audit is important in medicine and the growing professions around clinical auditor. • Some audit case studies and the cycle of improvement.

  3. http://www.bbc.co.uk/programmes/b05y16mv BBC Radio 4 “From the Cockpit to the Operating Theatre” Available: 3 mins – 1977 Tenerife crash

  4. 1989 Kegworth air disaster – air hostesses noticed the captain shutdown the wrong engine but were powerless to say anything. 6.22 and 22.30 mins – change of NHS culture toward openness?

  5. Aviation industry moved quickly. • Accepted there were human errors, deference to authority, poor communication. • Made reporting of minor errors OK and NOT a blame culture. • Problems with authority gradients – captains and air hostesses, like doctors/surgeons and nurses. • Introduced reporting, audits and clear communication.

  6. NHS has been slower to change. But 2001 and 2012 events in Bristol were ‘game changing’

  7. Public inquiry with 200 recommendations. • Inquiry into children receiving complex cardiac surgical services at the Bristol Royal Infirmary between 1984 and 1995. • Mortality rate from infant cardiac surgery was double elsewhere in the UK and worsening. • The overall mortality rate by one consultant was 13.6% compared with 5.9% for his colleagues. “Learning from Bristol” 2001.

  8. It is an account of people who cared greatly about human suffering, and were dedicated and well-motivated. Sadly, some lacked insight and their behaviour was flawed. Many failed to communicate with each other, and to work together effectively for the interests of their patients. There was a lack of leadership, and of teamwork. It is an account of a time when there was no agreed means of assessing the quality of care. There were no standards for evaluating performance. There was confusion throughout the NHS as to who was responsible for monitoring the quality of care. It is an account of a hospital where there was a ‘club culture’; an imbalance of power, with too much control in the hands of a few individuals. This old-style paternalism is evident in the adherence to the idea of hierarchy…It is assumed that a doctor’s view is inevitably superior and that nurses are there to carry out a doctor’s orders. “Learning from Bristol” 2001.

  9. Winterbourne was highlighted by BBC Panorama in 2011 and not by any quality or care process. A vile culture of cruelty around 2005 in which 11 care staff were jailed. 7.31 We have heard deep concerns about over-use of antipsychotic and anti- depressant medicines. Services should have systems and policies in place to ensure that this is done safely and in a timely manner and should carry out regular audits of medication prescribing and management, involving pharmacists, doctors and nurses. “A national response to WinterbourneView Hospital” 2012.

  10. The Rise of Clinical Governance “The system through which NHS organisations are accountable for continuously improving quality of their services and safeguarding high standards of care, by creating an environment in which clinical excellence will flourish” (Scally and Donaldson 1998).

  11. Timeline 1984-1995 Bristol medical and 2005 – 2007 Bristol care atrocities (plus others e.g. Beverley Allitt and Harold Shipman serial killers) 1989 “Working for Patients” NHS White Paper (policy document proposing legislation) 1993 Move from the term “medical audit” to “clinical audit” 1998 Scally and Donaldson define clinical governance 2001 “Learning from Bristol review of medical care”. Public inquiry 2012 “Winterbourne View Hospital review of social care”. Report 2012 “Health and Social Care” Act (law) 2015 National Institute for Health and Care Excellence (NICE) Parliament Glossary (2016).

  12. Clinical Governance for Managing Risk Internal • Having appropriate policies/procedures • Adequate training • Risk identification/reporting • Regular audits • Incident reports • Open working culture? External • Professional bodies - GMC, NMC, HCPC • Accreditation by external bodies UKAS (clinical laboratories), Care Quality Commission (hospitals, dentists, care homes) • NICE guidelines • Data openness and availability • Legislation

  13. Risk of Mortality per Exposure Sport parachuting Motoring Rock climbing Scheduled Airlines Motorbikes & Cycles Bungee Jumping Railways Scuba Diving Manned Space Shuttle Hospital Admissionsat Weekend Nuclear Power Hospital Admissions Dangerous Acceptable RiskSafe Ultra Safe

  14. Openness and availability of medical data. Mortality is 20% higher for patients admitted to NHS hospitals for emergency treatment at weekends (Dr Foster Intelligence 2016)

  15. Quiz • What is the overarching term by which patient safety and quality in healthcare is now managed? • What do we call the authority imbalance between nurses/doctors, airhostesses/pilots? • List two of the big failings that resulted in the Bristol Royal Infirmary inquiry? • What was the 2012 Act introduced partly as a result of the Bristol Care Home atrocity? • What year was the NICE organisation updated to include ‘health and care’ excellence?

  16. Answers • What is the overarching term by which patient safety and quality in healthcare is now managed? (Clinical governance) • What do we call the authority imbalance between nurses/doctors, airhostesses/pilots? (Authority gradient) • List two of the big failings that resulted in the Bristol Royal Infirmary inquiry? (paternalism, lack of communication, authority gradients, poor leadership). • What was the 2012 Act introduced partly as a result of the Bristol Care Home atrocity? (Health and Social Care Act)? • What year was the NICE organisation updated to include ‘health and care’ excellence? (2015).

  17. Clinical Audit Clinical Audit • Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. • Measuring patient care / laboratory / any parameter against benchmarks / criteria / standards to the implementation of an audit cycle (see next week). • Audits don’t just occur within healthcare.

  18. Education Audits! • Think about your student journey and all the places where we gather feedback and information from you?

  19. What is Research and what is Audit?

  20. Audit or Research?

  21. Simple Audit • Question? How many people have brought drink/food into lecture theatre? • Measure? 1) Retrospective? Items in here already? 2) Prospective? Number of people? Items of food? Items of drink? • Findings?

  22. Audit Task (optional but fun  ) • Maybe in small groups, think about something you can audit on campus. Email Viv your results to share next week. • vivien.rolfe@uwe.ac.uk

  23. Listening • BBC Radio 4 (2015). From the Cockpit to the Operating Theatre. Available:http://www.bbc.co.uk/programmes/b05y16mv

  24. Reading • Care, T (2012). A national response to Winterbourne View Hospital. Availablehttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213215/final-report.pdf • Dr Foster Intelligence (2016). Available: http://myhospitalguide.drfosterintelligence.co.uk/#/weekend-care • http://www.heart-resources.org/wp-content/uploads/2012/10/Clinical-governance-in-the-UK-NHS.pdf • Learning from Bristol (2001). The Report of the Public Inquiry Into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995: July 2001. Stationery Office, 2001. Available: http://webarchive.nationalarchives.gov.uk/20090811143745/http:/www.bristol-inquiry.org.uk/final_report/the_report.pdf • Parliament Glossary (2016). Available at: http://www.parliament.uk/site-information/glossary/ • Scally, G and Donaldson, L J (1998). Clinical governance and the drive for quality improvement in the new NHS in England. British Medical Journal, 317(7150), p61. • Zahir K (2001). Clinical governance in the NHS. Available: http://www.heart-resources.org/wp-content/uploads/2012/10/Clinical-governance-in-the-UK-NHS.pdf

  25. Next Time • We’ll be discussing the audit cycle and some clinical and medical cases. Have a look at this video by medical student Libor Hurt who has kindly shared with us his experiences of learning about audit at Swansea University. • https://www.youtube.com/watch?v=CbeN8ztcIb8&feature=youtu.be

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