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Clinical governance

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How would you introduce change?


RAID - 4-step process:


R - Review- where are we now? Gathering information, listening to patients and staff, looking at audit, documentation and process

A - Agree - gain consensus, build teams, formulate recommendations, shape the future

I - Intervene - project management, priorities, dealing with transition, motivate and support staff, expect and deal with resistance

D - Demonstrate - project analysis, show the differences, identify lessons, plan next objectives

What is the difference between leadership and management?


Management
is:

  •  Getting things done with and through others

 

  •  Achieving goals through efficient use of resources

 

  •  Achieving objectives within a series of constraints on time, money and other resources, using a range of techniques and processes

Leadership is:

  •  The ability to envisage a new path forward and inspire others to make the vision a reality

 

  •  The skill of influencing and motivating others to work together to achieve goals

 

  •  The art of remaining true to values, ideals and achieving goals, overcoming hurdles and constraints, no matter how difficult that may be.

Leaders do the right things and the manager does things in a right way.

What are private finance initiatives?

The private finance initiative (PFI) is use of private sector funds for the design and building of new healthcare buildings. Critics say that PFI is unduly expensive and will saddle the NHS with high bills for decades to come. The government argues that PFI has allowed the most ambitious hospital building programme that the NHS has seen. PFI has allowed a massive and needed expansion of the NHS capital programme. By the 1990s, the physical fabric of many buildings was in poor condition, and there was a huge backlog in maintenance.


NHS independence: is it good?

An important question to ask is what an independent NHS body would actually do. A great deal of devolved decision making is already under way.

a. Soon the centre will no longer control the supply side, which will be made up of a diverse range of providers, who will be accountable through contracts with local commissioners.

b. Already, ministers have no significant role in relation to foundation trusts.

c. The Appointments Commission has taken over the recruitment of non-executive directors, and other departmental agencies have substantial discretion - for example, the National Institute for Health and Clinical Excellence (NICE) assesses technologies and the Healthcare Commission sets standards and inspects.

Running of the NHS involves much more than efficient management. It is riddled with value judgements. It involves balancing competing priorities and interests. So when we argue about whether a drug for Alzheimer's should or should not be prescribed on the NHS, or whether more money should be invested in health visitors in a deprived area, those are political decisions. They may currently be taken by officials or clinicians, but the framework under which they are taken is ultimately set by an accountable politician. So the NHS is highly political.

So, what responsibilities would ministers retain under an independent NHS?

i. First, everyone agrees that they must continue to determine the overall resource. There is less agreement as to who should decide allocations. Allocations are broadly based on value judgements, which makes a strong case both for transparency and political accountability.

ii. Second, most accept that government should determine in broad terms what it expects the healthcare system to achieve.

An independent board for NHS could have limited functions like;

  •  Its main task would be to translate the government's broad objectives into goals for the commissioners.
  •  It could provide a national voice, independent of government, for the healthcare system and would be held to account for its overall performance.
  •  It could monitor the performance of strategic health authorities and commissioning bodies, and set standards that would be expected in every area and monitor locally established ones.

 

We may be able to take politicians further away from day-to-day decisions, but they will need to set and be answerable for strategic direction and for the much more transparent value-based judgements that shape the system. So, NHS independence will have minimal impact.

What do you think about the impact of NHS reforms?

Since 2000, the government’s ‘system reform’ agenda for the NHS in England has aimed to create a self-improving NHS that is more responsive to patients. There are four main elements to the reforms:

  •  Incentives to reward activity and efficiency (PbR)

 

  •  Diverse providers with greater freedom to innovate

 

  •  Increased patient choice and commissioning by practices and primary care trusts

 

  •  Regulation and system management to ensure quality, equity and value for money.

Incentives

Payment by results (PbR) rewards activity and efficiency. Together with patient choice of provider, PbR ensures that money follows patients and is intended to reward hospitals for high levels of activity and quality.

Providers

The government is encouraging a greater diversity of organisations to supply healthcare services, by creating NHS foundation trusts and introducing new providers, including those from the private sector and social enterprise organisations.

Commissioning

Under ‘practice-based commissioning’, PCTs give GP practices notional budgets with which to commission care for their patients. They can keep a percentage of any surpluses they accrue, providing incentives for efficiency. It is hoped that high-quality commissioning will reduce health inequalities, preventing ill health and managing chronic conditions more effectively, such as reducing costly avoidable admissions.

Regulation

Underpinning all these elements of reform is the need for effective regulation to ensure the quality and safety of both individuals and institutions.
The benefits of each of the reforms are discussed in the relevant sections.

What are the benefits of NHS direct?

NHS Direct is the name of a 24-hour, confidential telephone, online and interactive digital TV health advice and information service provided by the NHS. The telephone service aims to triage symptomatic callers to provide guidance on which healthcare provider the caller should access. Nurses also give advice on how to manage an episode of illness at home.

The main purpose of NHS Direct is to provide 24-hour healthcare information and advice.

Critics are concerned that NHS Direct is generating increased levels of demand for NHS services from a society whose expectations of 24-hour accessibility are changing markedly.

What are the GMC good medical practice guidelines? What do you think the most important aspects of the GMC’s ‘Good medical practice’ guidelines are?

Good medical practice sets out the principles and values on which good practice is founded; these principles together describe medical professionalism in action.

GMC good medical practice (2006) guidelines

  • Make the care of your patient your first concern
  • Protect and promote the health of patients and the public
  • Provide a good standard of practice and care

 

  • Keep your professional knowledge and skills up to date

 

    • Recognise and work within the limits of your competence
    • Work with colleagues in the ways that best serve patients' interests

 

  • Treat patients as individuals and respect their dignity (Treat patients politely and considerately. Respect patients' right to confidentiality)
  • Work in partnership with patients

 

    • Listen to patients and respond to their concerns and preferences

 

    • Give patients the information they want or need in a way they can understand

 

    • Respect patients' right to reach decisions with you about their treatment and care

 

    • Support patients in caring for themselves to improve and maintain their health
  • Be honest and open and act with integrity

 

    • Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk

 

    • Never discriminate unfairly against patients or colleagues

 

    • Never abuse your patients' trust in you or the public's trust in the profession.

You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions.

What is the role of the deanery?

The deaneries are responsible for the management and delivery of postgraduate medical education and for the continuing professional development of all doctors and dentists. This includes ensuring that all training posts provide the necessary opportunities for doctors and dentists in training to realise their full potential and provide high-quality patient care. The deaneries are also responsible for trainers, educational supervisors and educational leaders, their training needs and educational development.


What is the difference between a protocol and a guideline?

A protocol is a step-by-step outline for undertaking a specific task. They normally have to be followed exactly, whereas with a guideline the recommendations need to be considered in the light of the particular patient and settings as well as the strength of the evidence base.

A guideline is 'a systematically developed statement to assist decisions about appropriate healthcare for specific circumstances.' Clinical guidelines are based on the best available evidence and provide recommendations for practice about specific clinical interventions for specific patient populations.

What constitutes a good doctor?

GMC - Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity.

What is the modernising agenda?

The main themes for modernisation, as set out in the NHS Plan, are:

  • To redesign care pathways to put children and families at the centre of the system
  • To involve service users closely in the design and operation of new services
  • To provide care in, and closer to, patients’ homes
  • To develop consultant-delivered services
  • To set up multidisciplinary teams that overcome traditional barriers between staff groups
  • To promote closer working relationships between different parts of the health and social care system.

How do you seek informed consent for the procedures that you do?

I work in close partnership with my patients. I consider consent as an important part of the process of discussion and decision making, rather than an isolated process. I explain to them their condition and treatment options in a way they can understand. The amount of information I share with them depends on their wishes. The information I share is in proportion to the nature of their condition, the complexity of the proposed investigation or treatment, and the seriousness of any potential side effects, complications or other risks. I respect their right to make decisions about their care. (GMC guidance)


What do you think of league tables – tables with hospitals and trusts, clinics and other healthcare facilities which have been assessed according to certain criteria, cleanliness, waiting lists etc?


Advantages

  • Allow public and professionals to see how well or otherwise they have performed vs targets
  • May help with choice in the future
  • Rewards the good
  • Recognises poorly performing places

Disadvantages

  • Patient preference may lead to closure of poorly performing services
  • Reduced morale in poorly performing, especially best staff

 

How would you commission specialist services?

'Commissioning' describes the processes by which healthcare is planned and paid for. This is the responsibility of Primary Care Trusts (PCTs). They receive a budget based on the size and need of their populations which, in the main, they will spend on general practitioner and hospital services to ensure that, as far as possible, the people they serve have access to the healthcare they need when they need it.

'Specialised services' are treatments for relatively rare conditions which, if they are to be provided safely and effectively, need a minimum number of patients under the care of each centre providing the particular service. Thus, they are not provided in every hospital and tend to be found only in larger ones based in big towns and cities.

'Specialised' means that the service needs to be commissioned for a large population. Thus, PCTs group together at different levels from local up to national to ensure that such services are planned and paid for at the level appropriate to the condition.

So, unlike normal services which are commissioned at PCT (local) level, specialised services need to be commissioned at regional (e.g. children’s cancer), supraregional (e.g. severe burn care) or national level (e.g. heart transplant).

The government's plan outlined in “Care closer to home” is to move more patient care into the community. Do you think this is a good thing?

Care closer to home provides more convenient and accessible services. It is thus a laudable concept, provided that high levels of quality and service are maintained.


How would you ensure quality in your unit?

Use the seven pillars of clinical governance to answer the question. So, I would ensure quality in my unit by:

  • Education and training – supporting continuing professional development of all staff to ensure that they are competent and up to date

 

  • Clinical audit - regular audits to review and improve clinical performance

 

  • Clinical effectiveness – by use of evidence-based medicine

 

  • Risk management – by ensuring robust systems are in place to understand, monitor and minimise the risks to patients, staff and the organisation and to learn from mistakes and past experience.

 

  • Research and development - by supporting research as well as ensuring that the research is implemented in patient care with a minimal time lag

 

  • Openness - promoting a blame-free culture to ensure that mistakes are reported/discussed and lessons learnt

 

  • Patient and public involvement- to ensure services are responsive to the needs and aspirations of the patient and the public.

Do you think the 2-week rule referral system is effective?

The idea behind the 2-week referral is good. However, a lot of 2-week referrals do not follow the DoH guidance. These guidelines may increase diagnostic precision if adhered to rigidly. Inappropriate referrals have extended already lengthy outpatient waiting times in many specialities. Further, the studies have shown that the cancer pick-up rate is no higher in the 2-week pathway. There is also criticism that fast-track referral prioritises the worried well at the expense of the target population. So, in summary, we need better predictors of cancer and better pathways. Reduction in NHS waiting times and implementation of the 18-week pathway are steps in the right direction.


How do you think a blame-free culture can be brought about in the NHS?

In aviation, airline staff are rewarded for reporting mistakes and failures. More importantly, they can be disciplined, if not sacked, for not reporting. That says something about the culture and the pride which airline workers have in their safety record.

What will it take to instil that sense of pride about safety in NHS staff? We recognise that there may be many barriers to creating a ‘blame-free’ culture. But we feel that many of those barriers are psychological, the fear of what someone else could do to you. Part of that process is helping NHS staff to realise that they don’t need to feel threatened or feel guilty about reporting after they’ve done so. We’ve got to look after the staff and recognise the traumas that many staff experience from being involved in adverse events.

How can we persuade the public that doctors can be trusted?

  • Strong clinical governance framework
  • Structured and streamlined training of doctors
  • Appraisals and revalidation to ensure that the public can be confident that poorly performing doctors are being identified and early action taken in order to protect patients
  • Promoting an open culture in healthcare - to ensure that mistakes and near misses are reported and discussed
  • Patient and public involvement in designing clinical services
  • Impeccable integrity and good role models
  • Increased involvement of public in the regulatory bodies like the GMC

Is the expanding role of nurses a benefit or a danger to the medical profession?

What is your view of nurse specialists?

A greater use of skill mix is needed with the implementation of EWTD. So, tasks traditionally undertaken by doctors will need to be done by other allied health professionals. I fully support this, provided that:

  • Tasks are only undertaken by individuals who are competent to perform them

 

  • Such individuals are permitted to make decisions within the scope of their professional practice but otherwise need to operate under clear protocols and accountability.

What is the trust risk register?

A trust risk register is a management tool that enables an organisation to understand its comprehensive risk profile. It is simply a log of risks of all kinds that threaten an organisation’s success in achieving its declared aims and objectives. It is a dynamic living document, which is populated through the organisation’s risk assessment and evaluation process.

Example risk register

Ref

Source/location

Date in register

Description

Lead officer

Rating

Action summary

Completion rate

1

Trust board

2/10/2007

Failure to meet waiting list targets

Chief executive

Extreme

Monitor performance against targets

Increase theatre capacity

Ongoing

 

 

Jan 2008

2

All wards

11/11/2008

Obsolete bed stock

Director of nursing

High

Capital bid for replacement

5 year programme


Give me an example of an adverse clinical incident you were directly involved in and how you handled this.

Quote a clinical incident which you were involved in or are aware of:
Steps in dealing with an adverse clinical incident: ensure the safety of the patient first, involve your seniors, thorough documentation of the incident, debrief or actions taken to prevent its recurrence in future.

The general principles of dealing with an adverse clinical incident:

  • What went wrong and why?
  • What are the systems failures?
  • What is the individual contribution in that failure?
  • What lessons can be learnt?

 You think a surgical emergency in the theatres has been mismanaged. What do you do?

  • Number 1 priority – patient safety
  • Discuss with surgeon and call for help
  • Inform theatre sister and consultant in charge
  • Careful documentation – critical incident – afterwards debrief

A nurse gives a substantially large dose of opioid to a patient. What do you do?

  • Number 1 priority: check patient safety
  • Careful documentation of the incident in the notes. Fill in an incident report form
  • Explain the incident to the patient
  • Inform the charge nurse. Discuss the likely reasons - mistake, training deficits etc.
  • Possible action - retraining, extra supervision

How would you ensure local delivery of national standards?

On an individual or team level, I will ensure delivery of national standards by:

  • Regular audits to review and improve my practice
  • Evidence-based medicine by appropriately using NICE and other national guidelines
  • Ensuring optimum resource allocation to ensure delivery of national standards
  • Regular liaison with departmental heads and PCT
  • Having procedures in place to remedy situations where practice is not in line with national standards
  • Ensuring that the team is aware of the goals and their roles in achieving it

What monitoring of standards would you undertake in your service?

  • Audit compliance with clinical national standards - for example, compliance with NICE guidance or guidance from relevant medical society
  • Compliance with NSF
  • Robust clinical governance mechanisms are in place
  • Robust risk management strategy
  • Patient and public involvement in clinical services

 How would you manage the budget?

A budget is essentially a financial plan for the short term, usually one year, allocated to each department. The budget is divided between pay or fixed (staff-related expenditure) and non-pay or variable expenditure (goods and services) to cover all the running costs of the department for the duration of the budget.

The process of managing the budget can be broken down into four stages:

  • Establish actual position: in general, the budget can be divided into monthly blocks. It is important to focus on the future position to control the budget. The calculation of out-turn (amount of spend to date/number of months to date X12 equals projected out-turn) formula will provide the year-end position for pay and non-pay expenditure.
  • Compare actual expenditure with budget totals: this will indicate whether the budget is over- or under-spent and help you to identify the spending pattern. For example, use of bank and agency staff will create potential overspending, thus careful monitoring is essential.
  • Establish reasons for variance: variance is the difference between the budgeted amount for the month and the actual amount spent. The reasons for variance must be sought. It could be due to an anticipated increase or decrease in workload and therefore be of no particular concern. However, variance may be completely unexpected and in such cases the reasons must be found.
  • Take action: variance could be due to mistakes. Items may have been wrongly attributed to a budget or miscoded and end up in the wrong division of the budget. These problems can be corrected with the help of the finance manager. The budget must be checked for every transaction and corrected where necessary.

How would you develop the current clinical service? What do you hope to achieve in the first year, if you are successful in being appointed?

How can YOU contribute to the service (more than another candidate)? 

Your pre-interview visit will come in handy here. Identify their service needs and relate it to your special skill or experience.


What could you do to improve the organisation and running of your current workplace environment?

Again, at your pre-interview visit, you may have identified a few things that need improvement. Discuss them without criticising.


What is your opinion of performance-related pay?

Performance-related pay means extra financial inducement for personnel who achieve certain targets - for example, throughput of patients/reduction in waiting lists/improvement in quality of patient care etc.

Advantages:

  • Inducements that can allow targets to be met
  • Popular with workers

Disadvantages:

  • Not evenly spread. For example, consultants/managers get inducements for ops, but not nurses, ODAs and theatre support staff
  • Potential resentment between groups and between hospitals

What research project would you develop first in the post?

This will depend on your research interests and the research set up at the Trust with which you are applying for a job.


What area of research is important for the future?

You could relate an area in your specialty or alternatively you could mention research in killer diseases like malaria (need for vaccine), improved sanitation, air pollution etc.


What do you think about links between NHS and industry?

Advantages:

  • Increase quality of care for patients
  • Mirror the use of some techniques in industry to motivate staff
  • Increased new research

Disadvantages:

  • Size of company – their influence may be “pervasive”
  • Potential conflicts of interest when clinicians are funded for study leave research grants
  • Other financial payments
  • Potential to influence PCTs

 What do you think about management issues? Do you think it’s something we should be getting involved in as clinicians?

Clinicians serve the public and the patients by using their skills to provide the best possible advice, treatment and care. But we can only do this if the money available to the NHS is used well. Failure to do so results in less care and of a lower quality. Money will only be used well if clinicians are fully engaged in managing it. Ultimately, it is clinicians who are responsible for the way in which services are delivered to individual patients and it is they who commit the necessary resources.

Improving the quality of care and providing more responsive services for patients can only be achieved by strong involvement of local clinicians in the management of the service.

This includes having the understanding, the tools and the ability to manage resources effectively and use them well to the benefit of patients. This will empower them to lead change and improve services. Without clinical involvement, the progress will be much slower and the outcomes poorer.

This is not about focusing on cost and cost alone. It is about how money can best be used to improve the quality of care, combining operational and clinical effectiveness. Efficient use of resources and good quality services go hand in hand.

AnaesthesiaUK would like to thank consultantmedicalinterview.com for allowing us to reproduce their material.

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