Aims to identify awareness of and involvement in risk assessments, training, incident reporting, information giving and consenting in an acute health care context. Explores how nurse managers perceived risk management as a concept and if they saw advanced neonatal nurse practitioners having a role to play in this activity. The method used was a postal survey of 62 nurse managers or clinical specialists responsible for neonatal nursing care services within NHS Trusts in the UK. Results show that while the nurse managers studies understood the definition of risk management in general, they were more vague about certain aspects of that definition. The nurse managers appeared to be passive in their dissemination and taking forward of risk management strategies, rather than proactively "promoting and helping them forward" as may be expected in facilitative managerial behaviour. Concludes that the challenges of clinical governance demand more proactive approaches to effect and demonstrate change, and support ongoing clinical quality improvements.
Clinical governance requires three main types of information--guidelines, policies and treatment options for clinicians and patients; information about the care given; and information about how the systems work. There are other key issues which impact on the above--legal issues, national standards, sophisticated analytical tools and packages and the requisite training and development of staff.
This report presents outcome data from 3,176 consecutive prospective patients referred to physiotherapy for the treatment of soft tissue injuries. The results detailed here are part of a larger study collecting data from different NHS trusts in a benchmarking study. The Therapy Outcome Measure was used to collect data on each patient in four domains: Impairment, Disability/activity, Handicap/participation, and Distress/wellbeing on the entry and the exit from physiotherapy. The study concludes that patients do not have equal opportunity of accessing therapy for their specific condition according to their abilities and needs. Therapy provided in the Trusts did not produce similar changes in the patients' abilities and some dimensions appeared to improve more significantly in some locations. Furthermore this study would suggest that there are no common criteria for discharge of patients with similar conditions from physiotherapy across the Trusts as measured by the Therapy Outcome Measure.
This article from the NHS Clinical Governance Support Team (NCGST) outlines the development of quality concerns since the NHS was founded in 1948. It traces the development of clinical governance as a means of achieving continuous quality improvement and describes what the implementation of clinical governance means for patients and professionals. It analyses features of the cultural shift necessary to underpin quality improvement initiatives and describes with practical examples the constituents of the culture necessary for successful clinical governance. Future articles in this series will address other issues around clinical governance and will explain the model being followed by delegates to the NCGST's Clinical Governance Development Programme as they implement clinical governance "on the ground".
In our previous article we looked at the history of quality development and discussed how the implementation of clinical governance provides the opportunity to begin the cultural shift necessary to underpin quality in the modern NHS. This article begins an explanation of the model of quality improvement followed by delegates to the Clinical Governance Development Programme by looking at the service review process delegate teams undertake.
Aims to establish a mechanism to determine prospectively the health status at two years of babies who weighed less than 1.5 kg at birth, born and receiving neonatal intensive care in North Wales. Maternal and neonatal data on all babies discharged from each of the three units in North Wales meeting this criteria were collated by the study coordinator. A mechanism for review of the health status at two years, corrected for gestational age, was established using the data set recommended by a working group convened by the National Perinatal Epidemiology Unit and Oxford Regional Health Authority. The procedures developed and the outcome data, for a two year cohort of babies born in 1995 and 1996, are reported. Concludes that prevalence of severe disability was similar to that found in other studies, with a considerable number exhibiting impaired growth and delay in speech development.
OBJECTIVE:To assess the reasons behind the widespread use of X-ray in the management of nasal trauma despite the fact that it has no useful purpose, comparing the responses of doctors in Accident and Emergency (A&E) departments between the District General Hospitals (DGH) and the Teaching Hospitals.METHOD:A multiple-choice questionnaire was sent to all doctors in Accidents and Emergency departments in the North-West Region of England.RESULT:212 questionnaires were sent out and 159 were returned. Amongst the 92 (57.9 per cent) doctors who use nasal radiographs, the overall most common reason is medico-legal in 48 (52.1 per cent). A high proportion of DGH doctors use radiographs for diagnostic purposes and 35 (28.9 per cent) will refer patients based on X-ray demonstration of nasal bone fracture. Other stated reasons included detection of unsuspected facial fracture, diagnosis of compound nasal fracture and foreign body detection.CONCLUSION:Doctors need to be better informed that nasal radiography has no useful value. A clear clinical guideline should be set up nationwide to protect patients from unnecessary exposure to radiation. This will also save the time of the doctors, radiographers and patients. It will prevent inappropriate referrals. Money and other resources will therefore be better utilized.
This paper describes the implementation of a clinical guideline across three acute Trusts. A Clinical Effectiveness Steering Group identified prevention of venous thromboembolism as a health priority. A local guideline development group adapted the recommendations of an existing review and produced a local guideline. Then, a multidisciplinary implementation group developed the practical aspects of implementing guidelines into routine daily practice. They identified appropriate staff to carry out risk assessment and to administer appropriate prophylaxis, as necessary. They also produced a "guideline pack" containing a training resource manual and implementation aids. Following this a multiple strategy implementation programme was used to introduce the guidelines, and an evaluation was carried out eight to ten months after the introduction of the guidelines. The evaluation identified a number of areas for improving current practice. Guideline implementation is a complex, time-consuming process.
Patients visit emergency rooms for urgent and non-urgent care. Because emergency room visits are more costly than visits to primary care clinics and are less likely to involve preventive care, third party payers and institutions have always tried to shift patients away from the emergency room and towards primary care clinics where appropriate. Hypothesizes that an intervention based in an adult primary care clinic might enable this, especially if it involved patients who used both the clinic and the emergency room. Surveys patients to determine why they used the emergency room and to identify barriers to using the primary care clinic instead. Based on the survey results, an intervention was developed to facilitate use of the primary care clinic. Discusses the methodology used in the survey and analyses results. Concludes that it is difficult to change patient behaviour to fit the demands of the health care system. Possibly, it would be better to change the system to fit the behaviour patterns of the patients.
Maintaining good standards of clinical documentation remains a problem in the health service despite continued and consistent advice from protection organisations and professional bodies over many years. This article discusses some of the issues that arise from poor quality note keeping and the need for improvement and the establishment of basic minimum standards for all health records. Requirements are now being placed on NHS bodies to ensure that effective and robust systems are in place to ensure that record management meets Controls Assurance Standards and CNST standards. This article stresses the need to put the current house in order before we lose any opportunities to influence those aspects of electronic systems where appropriate risk management should help reduce the potential for documentation error.
An audit was undertaken to assess the compliance to British Thoracic Society guidelines (1997) in the prescription of long-term oxygen treatment (LTOT) in Bassetlaw District General Hospital. A total of 34 patients were prescribed LTOT in our hospital between March 1993 and October 1998. The average age of patients was 71 years, 31 patients had COPD and three had chronic asthma. Only ten patients were clinically stable at the time of assessment. None of the measurements were repeated after a period of three weeks before prescribing LTOT. Adherence to guidelines in the prescription of LTOT was poor in our audit.
As part of the Trust's clinical governance arrangements and to facilitate a systematic approach to clinical governance a risk assessment was conducted. This assessment identified that falls were a significant risk of patients, both during episodes of in-patient care and in their own homes. There is little evidence nationally to guide good practice; therefore a multidisciplinary steering group was set up to develop a comprehensive approach to falls prevention. This resulted in the development of evidence based falls prediction tools, Trust policy and guidelines and extensive staff training programmes. Information leaflets have been provided to patients and additional services such as falls groups have been developed.
Clinical trials have shown that highly active antiretroviral therapy (HAART) reduces plasma HIV RNA below the detection level in up to 90 per cent of patients. To assess the independent predictors that are associated with achieving undetectable plasma HIV RNA in the daily clinical practice, we carried out a retrospective study. Among 106 HIV-infected patients treated with HAART, 63 (59 per cent) achieved undetectable plasma HIV RNA (less than 400 copies/ml) at their last visit. Adherence with HAART (greater than 80 per cent of prescribed dose) was self-reported by 81 patients (76 per cent). Independent predictors of achieving undetectable plasma HIV RNA were: self-reported adherence to therapy (Odds ratio [OR] 11.79, 95 per cent Confidence intervals [CI]: 3.55-33.17, p = 0.0001) and lack of previous antiretroviral therapy (OR: 3.12, 95 per cent CI: 1.09-8.96, p = 0.03). The efficacy of antiretroviral therapy observed in the daily clinical practice was noticeably lower than that reported in clinical trials. Patient adherence with prescribed HAART and lack of previous antiretroviral therapy are important factors related to successful therapy in the real world.
The article discusses some of the clinical negligence problems and risk management issues arising from training of health professionals (predominantly junior hospital doctors) in practical procedures. There continue to be incidents, claims and complaints in the NHS arising from the clinical practice of doctors or other health professionals who are not perceived to be competent in some of the practical skills they are undertaking. This article addresses some aspects of this training, where it should best be started and who should have responsibility for ensuring that doctors, in particular, continue to work under appropriate supervision. Also acknowledges the current problems facing NHS trusts in trying to ensure that risk management standards are met for training health professionals in the use of medical equipment--a task that has not previously needed to be documented or accounted for on a formal basis. There are considerable resource implications attached to the introduction of systems that can assess and monitor the training provided in the use of medical equipment but the introduction of a baseline assessment is an essential part of sound clinical governance and risk management. It is suggested that risk management exercises of this nature are worthwhile in reducing the potential for harm to patients.
The pre-operative anaesthetic records of 195 patients were analysed for the presence of 12 agreed core items of pre-operative assessment. This study showed that anaesthetists recorded 26.8 per cent of this information. In up to one-third of patients the following were recorded: smoking history, family history, gastro-oesophageal reflux, airway assessment, dental assessment, chest examination, heart-sounds and blood pressure. Previous anaesthesia, drug history and allergies were recorded in one to two-thirds of patients. Past medical history was recorded in over two-thirds of patients. With a view to improving the level of record-keeping, a formatted, pre-printed pre-operative assessment record was introduced into practice and two months later the audit was repeated. A small but non-significant improvement in record keeping was observed. An argument is made for the introduction of an interdisciplinary, unified anaesthetic pre-operative record.
Leaflets are a useful resource for information provision. Many otolaryngology patients have poor reading skills, and may have difficulty understanding medical jargon. The aim of this project was to produce a patient information leaflet on otitis media with effusion whose content is based on the best available research evidence, and which is presented in a clear format with simple language. Patients were involved at the planning stage, and in testing the final draft. The leaflet was preferred by the majority compared to existing information material and was felt to be more informative and easier to understand. The leaflet has been given the Crystal Mark for clarity of language by the Plain English Campaign. This study shows that existing guidelines can be used to improve the quality of written information provision.
Obtaining appropriate and informed consent from patients is an integral part of provision of quality health care. Doctors are bound to obtain consent in a manner that is legally and ethically acceptable. The methods employed to train junior doctors in these principles vary from organisation to organisation and the knowledge base of both senior and junior clinicians is far from consistent. This paper raises some of the issues in relation to current practice and teaching and suggests ways in which the process can be improved--largely by introducing some basic standards that should be built on as expertise and skill develop. The author discusses the need for dissemination of information with regard to current national claims experience and the possibility of introducing the subject of consent into postgraduate examinations in a more widespread way.
The use of clinical performance data is increasing rapidly. Yet, substantial variation exists across indicators designed to measure the same clinical event. We compared indicators from several indicator measurement systems to determine the consistency of results. Five measurement systems with well-defined indicators were selected. They were applied to 24 hospitals. Indicators for mortality from coronary artery bypass graft surgery and mortality in the perioperative period were chosen from these measurement systems. Analyses results and concludes that it is faulty to assume that clinical indicators derived from different measurement systems will give the same rank order. Widespread demand for external release of outcome data from hospitals must be balanced by an educational effort about the factors that influence and potentially confound reported rates.
