Describes how the implementation of thromboembolic prophylaxis in patients undergoing oral and maxillofacial surgical procedures was audited. In 1997, four oral and maxillofacial units were asked about their practice of prophylaxis for thromboembolic disease (TED). Proformas were sent to each unit to assess 45 patients retrospectively. These patients were chosen at random from within defined groups of surgery. The audit was repeated in 1998, after presentation and discussion of initial findings. Of 117 patients at low risk of TED, 72 (62 per cent) and 50 (81 per cent) of 62 patients at moderate risk received prophylaxis. In the second run of the audit, there was a 7 per cent increase in the number of patients at moderate risk receiving prophylaxis. Patients admitted for trauma surgery were the most likely to have TED prophylaxis omitted. Concludes that there was an improvement between the first and second run of the audit, but some patients were still not being treated appropriately.
The aim of this study was to devise a simple proforma for reporting staging CT scans of the thorax, to ensure that all essential information is included on the report, in a logical manner, and that a TNM classification and tumour stage is given. Once the design of the proforma had been agreed, its utilisation and effectiveness was audited. In an initial six month period, every proforma filled in had resulted in a TNM classification being given, although in only 20 out of 40 (50 per cent) had a tumour stage been given. In a subsequent six month period, 39 out of 44 patients (89 per cent) with lung cancer undergoing a staging CT scan had proformas completed, and a TNM classification and tumour stage given (95 per cent CI is (0.75, 0.96)). Therefore, a proforma can be a useful aid to reporting staging scans, and is an effective method of ensuring that tumours are staged as fully as possible, radiologically. In addition, relevant information is presented in a clear format that allows accurate collection of data for audit purposes.
Describes and analyses the factors limiting the success of implementation of guidelines on management of heart failure using content analysis of structured interviews with nine general practitioners in Wakefield District, validated from hospital records, to generate within‐case displays. Discusses the results and conclusions.
A study was carried out to determine the nature of medical prescribing errors identified by pharmacists in an NHS Hospital Trust. From the 587 errors detected in a one‐month period, eight were potentially grave, 151 were potentially very serious, 351 were potentially moderately serious and 77 were comparatively minor. This extrapolated to 7,044 prescribing problems a year and an estimated detected prescribing error rate of approximately 0.35 to 0.7 per cent. Pharmacists detected 63 per cent of these errors while working on wards and 36 per cent while in dispensaries. The main causes of errors were failure to obtain an accurate medication history, oversight and prescribing uncertainty. In the absence of guidelines, there was a tendency for the isolated hard‐pressed prescriber to guess or prescribe on a “that looks about right somehow” basis. This study has made medical staff more aware of the areas where they are most vulnerable to making prescribing errors. In addition, greater support is now being offered to junior doctors in checking medication histories and in creating prescribing guidelines.
A survey of cardiac patients, their relatives and friends and local GPs was conducted to establish whether there is a need for an online patient support system. In November 2000, 859 patients, 360 relatives and 160 friends attending cardiac out‐patients completed a questionnaire, 159 GPs were contacted by postal survey. Participants were asked if they use e‐mail and the World Wide Web and if obtaining relevant health information via an online support system would be beneficial. Participants were also asked to select preferred subject options. The survey showed clear interest in the provision of a Web‐based support service for cardiac patients and a pilot would be pursued.
The structures for inspecting and monitoring health care are changing, and the Commission for Health Improvement (CHI’s) work in involving patients and the public in assessing the delivery of medical care will evolve. Involving patients, encouraging better systems within trusts and the independent sector to deliver a high standard of care, fostering self‐assessment and a willingness to change and improve will continue to be at the centre of audit and inspection work within the Health Service.
Describes a process of adopting a set of review criteria for use in a regional project to improve heart failure management in general practice. Published guideline review criteria were assessed using a protocol examining indicator relevance, practicality and the clinical evidence on which indicators were based. An expert panel with experience in general practice, cardiology and general internal medicine, ethics, and research methodology was used to evaluate the indicators. Good overall agreement was observed with the review criteria. Areas of disagreement related to poor wording of the criteria, the need to incorporate more up‐to‐date evidence and criteria based on weak evidence. A need exists for greater training of health practitioners about how regional indicators can be used as screening tools for quality improvement. Nationally endorsed sets of regularly updated review criteria for common and important conditions would be helpful in guiding similar quality improvement projects.
National Health Service trust boards are constantly challenged to achieve a balance between their resources and meeting the needs of the communities they serve. In addition, the scientific, technological, political and economic factors, which influence health and social care, are driving change more rapidly than ever before in the Health Service. As part of its function to support NHS organisations with the implementation of clinical governance, the NHS Clinical Governance Support Team (CGST) has developed a strategic development programme for trust boards. The aim of the programme is to develop the board’s capability to meet its responsibilities for governance and the delivery of safe, high quality patient care.
Facilitating user involvement is regarded as a significant factor in advancing the overall quality of health care provision. The wish to develop user involvement is present in White Papers, government reports and policy guidance. The reform of cancer services consequent on the implementation of the Calman Hine Report creates opportunities for meaningful user involvement in cancer care. Draws on research conducted in the Trent Region of the NHS and examines how far user groups have been involved, which groups may be excluded and what remains to be done to elevate user views in planning and evaluation of cancer services. Many commissioners and providers of health care are currently establishing the infrastructure to encourage the development of user involvement. Suggests the experience in relation to cancer can offer a model for others.
This qualitative study examined the views of clinical governance leads in South West England on the development of clinical governance, and its relationship to education in primary care. Information was obtained from semi‐structured interviews with clinical governance leads, and supplementary methods were used to confirm key findings. Four principal themes emerged: education, support, barriers, and evolution. Education is central to achieving the clinical governance agenda. There is a range of educational needs within primary care and these must be integrated into practice professional development plans, which will be shaped by national and local priorities. A need for PCG clinical governance tutors to support this process emerged. A range of supporting mechanisms was identified, as were barriers: principally inadequate resources and a rigid agenda imposed from above. Existing educationalists will need to change their role within the new structures, and this should be an evolutionary rather than a revolutionary process.
There is strong evidence for the use of HMG Co‐A reductase inhibitors (statins) for secondary prevention after myocardial infarction. Previous surveys suggest sub‐optimal use of such secondary prevention measures. The national service framework (NSF) for coronary heart disease (CHD) has now set new standards for preventing and treating CHD. In our audit of 182 survivors of myocardial infarction in 1999, 86.2 per cent had cholesterols measured on admission, but only 39 per cent had statins prescribed on discharge. Our data provide information about base‐line practice for the year immediately preceding the publication of the NSF and indicate that the average district general hospital may have a long way to go to meet the target set by the NSF.
A structured sticker for examination of women in labour was introduced at Arrowe Park Hospital in 1998 to improve documentation of examination findings. This study was undertaken to assess whether the use of the sticker improved documentation of examination findings and second, compliance of sticker use. A retrospective analysis was performed on 64 cases randomised by random number generated on Arcus Quickstat from 470 women who were induced by prostaglandin during 1 January 1998 to 31 December 1998 at Arrowe Park Hospital. Women were induced by prostaglandin were chosen as the study population to obtain data from early labour. A total of 229 examinations were performed in these areas. Statistical analysis was undertaken on Arcus Quickstat, and χ2 and Fisher’s exact tests were applied to check for statistical significance.
Twenty‐four hour pH monitoring is an expensive, time‐consuming and uncomfortable investigation only necessary in a small proportion of patients with gastro‐oesophageal reflux disease. Guidelines have been published by the British Society of Gastroenterology, in order to clarify those patients likely to benefit. Aims to assess whether these guidelines are being followed in a large teaching hospital. A random selection of the notes of all patients referred for 24‐hour pH monitoring at the Queens Medical Centre were assessed for the appropriateness of referral. A total of 114 patients were referred for pH monitoring, and the notes of 77 of them reviewed. This audit shows that in the majority of cases guidelines are being followed. Referrals from non‐gastrointestinal specialties accounted for 50 per cent of cases where they were not. In addition, 40 per cent of all referrals from non‐gastrointestinal specialties failed to follow guidelines, suggesting that this group is either educated further as to their contents, or that all patients referred for 24‐hour pH monitoring see a medical or surgical gastroenterologist prior to the investigation.
This review and discussion outline domains and a research agenda leading to improvements in the quality of transitions of care between health‐care settings. Over the past two decades changes in health care financing have restructured the organization and delivery of health care. Health‐care plans and insurers have shifted to provision of health care in less expensive settings and growing concerns about the quality of health care have arisen – continuity may be lost, errors may occur, and patients may end up deeply dissatisfied. To improve the quality across the continuum of care, providers will need to reconceptualize from an intra‐organizational to an inter‐organizational viewpoint and will have to focus on transitions of care across settings. Services, such as case management, must effectively bridge gaps in the continuity of care. Improved measurement of outcomes, such as satisfaction with the transition, will be necessary.
Nomenclature is of fundamental importance in healthcare. Different professionals interpret different terms in different ways. This has implications for measurement, clinical governance, risk management and any comparative studies where clear definitions are not predetermined. A project to determine how aseptic dispensing activity in pharmacies and clinical areas should be measured found this to be the case, primarily between nurses and pharmacists. It was essential to have consistently used terms and definitions for the purposes of the project. A preliminary list was audited with senior staff in clinical areas to ascertain local views and practices. Commonly used alternatives and other relevant terms were identified. The results were validated by a multidisciplinary workshop to determine a final list. Evaluation of these and wider examples highlights the many implications and the need for the issue to be directly addressed, particularly in a multi‐professional environment.
Reports on a study that focuses on the specific roles of the nurse within the interdisciplinary team as an example of how nursing contributes to developing clinical effectiveness in wound healing. The multidisciplinary team approach used here builds on recommendations by Edmonds as the most effective method of delivering care to patients with diabetic foot ulceration. In particular, monitors the evolution of the service provided and patient outcomes by measuring the number of ulcers treated, the level of service provided, record keeping and patient outcome. The contribution of the wound care nurse includes the assessment of the status and progress of ulcers presented at the clinic. Argues that, as research in wound care has evolved, so the contribution of the nurse has grown (in line with NHS recommendations) with a broader range of wound features assessed and documented. In evaluating improvements in recording information, three indicators were used. Ulcer size and type were recorded in 1993 on 2.2 per cent and 17.8 per cent of occasions respectively. By 1999 these had progressed to being recorded on 100 per cent of occasions. Assessments of ulcer edge also showed an improvement, being recorded on 11.1 per cent of occasions in 1993 and 50.6 per cent of occasions in 1999. The detail of record keeping allowed the data collection.
The implementation of effective frameworks which support the clinical governance agenda is proving to be a significant challenge for management teams across the NHS. Since there is no recognised ideal model or gold standard for such frameworks, it is not surprising that many organisations remain in a state of “trial and error” with their clinical governance arrangements. This article provides an insight into the ongoing developments of the clinical governance “infrastructure” at Southampton University Hospitals NHS Trust. A model of delivery for clinical governance within a large acute teaching hospital is proposed and it is hoped that it may prove useful to colleagues across the country, who may well be facing difficulties in their structural arrangements to deliver the clinical governance agenda.
The case for involving the users of health services in the NHS decision‐making process is clearly identified in a range of Government policy and guidance documents. A gradual shift from seeing users as passive recipients of care to active consumers of care has led to a belief that the opinions and views of users must be heard in particular in relation to clinical audit. Alongside this shift is the increasing recognition that the views of children and young people should be sought in decisions which affect their lives. Highlights the case for involving children and young people in clinical audit. Examines the background to user involvement in general, reviews the arguments for involving children and young people and identifies some of the barriers to that involvement. Introduces briefly new research being carried out with children and young people to explore ways of involving them in clinical audit.
Responding to a commitment made in the NHS plan, the Department of Health produced a series of documents (not yet widely distributed and discussed) during 2001 aimed at improving the process of obtaining consent in the NHS and aiming for consistent practice across the NHS, so that patients and health care professionals will be familiar with the process as they are looked after by or work for different organisations. Trusts have a very tight timescale for the introduction and use of the new style consent forms and the implementation of the model policy. While the basics are there, feels debate is necessary within each organisation as to how best these forms should be used. Discusses these issues, and claims the new standards currently are not achievable within an under‐resourced service. Concludes that those agencies established to assess the quality of health care need to be mindful of the severe constraints that exist in attempting to push forward this initiative by the end of 2002, before criticising trusts for their failure to do so.
The protracted and multidisciplinary nature of paediatric cochlear implantation presents particular challenges in addressing issues of clinical governance. The implantation process is one that involves many disciplines in acute and community settings over several years. Reviews the difficulties presented by a protracted, multidisciplinary intervention for addressing issues of clinical governance within the context of paediatric cochlear implantation. Discusses the activities of the Nottingham Paediatric Cochlear Implant Programme in tackling these problems and gives some details of its progress and success in these areas.
