Quality and safety in healthcare revisited: A challenge to anaesthetists

Anaesthesia

Volumn 69, Issue 6, 2014, Pages 531-536

  Jarman, B ^a  

^a IMPERIAL COLLEGE LONDON   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

ANESTHESIST; EMERGENCY PATIENT; EMPLOYMENT; HEALTH CARE POLICY; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; HEART SURGERY; HUMAN; LEADERSHIP; MORTALITY; NATIONAL HEALTH SERVICE; PATIENT CARE; PATIENT SAFETY; PEDIATRIC SURGERY; PEER REVIEW; REVIEW; SURGICAL MORTALITY; TOTAL QUALITY MANAGEMENT; WHISTLEBLOWING; WORKMAN COMPENSATION;

ANESTHESIOLOGY; HUMANS; QUALITY OF HEALTH CARE;

EID: 84900415864     PISSN: 00032409     EISSN: 13652044     Source Type: Journal    
DOI: 10.1111/anae.12685     Document Type: Review

References (44)

1. Francis R,. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013. http://www.official-documents.gov. uk/document/hc1213/hc09/0947/0947.asp (accessed 18/01/2014).
2. Bristol Royal Infirmary Inquiry (Chairman: Professor Ian Kennedy). Learning from Bristol: the Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995. London: HMSO, 2001; Ch 26, para 48. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/ Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH-4005620 (accessed 04/01/2014).
3. Francis R,. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013; para 1.78, p 76.
4. Francis R,. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013; Vol 2, Ch 8, p 735, para 8.154.
5. Bristol Royal Infirmary Inquiry (Chairman: Professor Ian Kennedy). Learning from Bristol: the Report of the Public Inquiry into Children's Heart Surgery at the Bristol Royal Infirmary 1984-1995. London: HMSO, 2001; July Transcript, Day 96, 9th February 2000, p 56, line 1. http://www. nationalarchives.gov.uk/ERORecords/JA/11/2/P2/TRANSCRIPTS/DAY96.HTM (accessed 18/01/2014).
6. Darzi A,. High Quality Care for All: NHS Next Stage Review Final Report. London: Department of Health, 2008. http://www.official-documents.gov.uk/ document/cm74/7432/7432.pdf (accessed 18/01/2014).
7. Francis R,. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office: 2013; Sir Liam Donaldson's exhibit LD27, 19 September 2011. http://www.midstaffspublicinquiry.com/sites/default/files/ evidence/Prof-Sir-Liam-Donaldson-exhibits-7-28.pdf (accessed 18/01/2014).
8. Department of Health. Reports commissioned by Ara Darzi on the NHS, 2010. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/ FreedomOfInformation/Freedomofinformationpublicationschemefeedback/FOIreleases/ DH-118548 (accessed 18/01/2014).
9. Berwick D,. A Promise to Learn-a Commitment to Act. Improving the Safety of Patients in England, 2013. https://www.gov.uk/government/uploads/system/ uploads/attachment-data/file/226703/Berwick-Report.pdf (accessed 18/01/2014).
10. Institute for Healthcare Improvement. Achieving the Vision of Excellence in Quality: Recommendations for the English NHS System of Quality Improvement. Boston: IHI, January 31, 2008: pp 1 and 16. http://webarchive.nationalarchives. gov.uk/20130107105354/http://www.dh.gov.uk/prod-consum-dh/groups/ dh-digitalassets/@dh/@en/documents/digitalasset/dh-118552.pdf (accessed 04/02/2014).
11. Leslie C,. NHS scandal: if Nicholson didn't bury the damning reports, who did? Telegraph, 8 March 2013. http://www.telegraph.co.uk/health/healthnews/ 9917031/NHS-scandal-if-Nicholson-didnt-bury-the-damning-reports-who-did.html (accessed 02/03/2014).
12. Charlotte Leslie MP,. Accountability and Transparency in the NHS, House of Commons. Hansard 14 March 2013. http://www.publications.parliament.uk/pa/ cm201213/cmhansrd/cm130314/debtext/130314-0002.htm#13031445000003 (accessed 18/01/2014).
13. Charlotte Leslie MP,. NHS Standards. Hansard 19 December 2013. http://www.publications.parliament.uk/pa/cm201314/cmhansrd/cm131219/text/ 131219w0002.htm#13121980000276 (accessed 18/01/2014).
14. Campbell D,. Healthcare leaders urge end to 'relentless' criticism of NHS. Guardian, 31 December 2013. http://www.theguardian.com/society/2013/dec/31/ healthcare-leaders-end-criticism-nhs-letter (accessed 18/01/2014).
15. Francis R,. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013; Lead Counsel's written Closing Submission on 9 December 2011, Summary of conclusions, para 271, p lxxvi. http://www.midstaffspublicinquiry.com/sites/default/files/uploads/Conclusion. pdf (accessed 18/01/2014).
16. Francis R,. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013; para 1.91, Vol 1, p 60.
17. Institute for Healthcare Improvement. Achieving the Vision of Excellence in Quality: Recommendations for the English NHS System of Quality Improvement. Boston: IHI, January 31, 2008: 16.
18. Marcia Fry, ex-head of complaints at the Healthcare Commission: 6 May 2011, Day 79, Transcripts p 130, line 7 http://www.midstaffspublicinquiry.com/ sites/default/files/transcripts/Friday-6-May-2011-transcript.pdf and Exhibit MF13 http://www.midstaffspublicinquiry.com/sites/default/files/evidence/Marcia- Fry-exhibits-1-18.pdf (accessed 18/01/2014).
19. Parliamentary Health Service Ombudsman. Moving Forward: Annual Report 2011-12. London: The Stationery Office, 2012. http://www.official-documents.gov. uk/document/hc1213/hc02/0251/0251.pdf (accessed 18/01/2014).
20. British Medical Association. Speaking up for Patients, Final report. London: BMA Health Policy and Economic Research Unit, 2009.
21. Roland M, Rao SR, Sibbald B, et al. Professional values and reported behaviours of doctors in the USA and UK: quantitative survey. BMJ Quality and Safety in Healthcare 2012; doi: 10.1136/bmjqs.2010.048173.
22. National Audit Office. Report by the Comptroller and Auditor General. The Care Quality Commission: regulating the quality and safety of adult social care. 2 December 2011. http://www.nao.org.uk/wp-content/uploads/2011/12/ 10121665.pdf (accessed 02/03/2014).
23. Francis R,. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013. Page 9, Letter to the Secretary of State, 5 January 2013. http://www.official-documents.gov.uk/document/hc1213/ hc09/0947/0947.asp (accessed 18/01/2014).
24. Mclellan A,. The nine rejected Francis recommendations. Health Service Journal, 19 November 2013. http://www.hsj.co.uk/news/the-nine-rejected-francis- recommendations/5065517.article (accessed 18/01/2014).
25. Keogh B,. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report, 16 July 2013. http://www.nhs.uk/ NHSEngland/bruce-keogh-review/Pages/Overview.aspx (accessed 18/01/2014).
26. Francis R,. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. The Stationery Office: London, 2013. Statement of Sir David Nicholson to the Mid Staffs Public Inquiry, p 99, para 317. http://www. midstaffspublicinquiry.com/sites/default/files/evidence/Sir-David-Nicholson- witness-statement.pdf (accessed 18/01/2014).
27. Trust Development Authority. Special measures successfully turning troubled hospitals around. 14 February, 2014. http://www.ntda.nhs.uk/blog/2014/ 02/14/special-measures-successfullyturning-troubled-hospitals-around/ (accessed 04/03/2014).
28. Care Quality Commission. CQC appoints Deputy Chief Inspectors of Hospitals, January 2014. http://www.cqc.org.uk/media/cqc-appoints-deputy-chief- inspectors-hospitals (accessed 18/01/2014).
29. Care Quality Commission. Deputy Chief Inspectors, 14 October 2013. http://www.hsjjobs.com/job/2564193/deputy-chief-inspectors/ (accessed 18/01/2014).
30. Care Quality Commission. Intelligent Monitoring: NHS acute hospitals. Statistical methodology, October 2013. http://www.cqc.org.uk/public/hospital- intelligent-monitoring (accessed 18/01/2014).
31. Anon. Hunt vows to tackle hospital problems. Health Service Journal, 25 October 2013. http://www.hsj.co.uk/news/hunt-vows-to-tackle-hospital-problems/ 5064659.article (accessed 18/01/2014).
32. Clwyd A, Hart T,. A review of the NHS hospitals complaints system: final report, October 2013. https://www.gov.uk/government/uploads/system/uploads/ attachment-data/file/255615/NHS-complaints-accessible.pdf (accessed 18/01/2014).
33. Parliamentary and Health Service Ombudsman. The Ombudsman's annual report and resource accounts. http://www.ombudsman.org.uk/abou-t-us/publications/ annual-reports (accessed 18/01/2014).
34. Phsothefacts. http://phsothefacts.com/join-pressure-group/ (accessed 18/01/2014).
35. Macdonald V,. How blowing the whistle cost two men their NHS careers. http://blogs.channel4.com/victoria-macdonald-on-health-and-social-care/ blowing-whistle-cost-men-nhs-careers/1580 (accessed 18/01/2014).
36. House of Commons, Health Committee, 22 October 2013, Oral evidence. Accountability hearing with the Care Quality Commission, HC 761 p 21. http://www.publications.parliament.uk/pa/cm201314/cmselect/cmhealth/699/699.pdf (accessed 18/01/2014).
37. Care Quality Commission. Whistleblowing: guidance for providers who are registered with the Care Quality Commission. London: CQC, November 2013. http://www.cqc.org.uk/sites/default/files/media/documents/20131107-100495-v5-00- whistleblowing-guidance-for-providers-registered-with-cqc.pdf (accessed 04/03/2014).
38. General Medical Council. Good medical practice (2013). http://www.gmc-uk.org/guidance/ethical-guidance/11861.asp (accessed 18/01/2014).
39. Jarman B,. Quality and safety in healthcare and the role of anaesthetists. Anaesthesia 2011; 66: 757-1.
40. Association of Anaesthetists of Great Britain and Ireland. Two bodies within one. http://www.aagbi.org/about-us/work-aagbi (accessed 03/02/2014).
41. Nicholas Timmins. Never Again? The story of the Health and Social Care Act 2012. The Kings Fund, 2012, p 74. http://www.kingsfund.org.uk/sites/files/ kf/field/field-publication-file/never-again-story-health-social-care-nicholas- timmins-jul12.pdf (accessed 18/01/2014).
42. Meikle J,. Mid Staffs NHS trust to be dissolved, Jeremy Hunt announces. Guardian, 26 February 2014. http://www.theguardian.com/society/2014/feb/26/mid- staffs-nhs-trust-dissolved-jeremy-hunt (accessed 02/03/2014)
43. Kinchen R,. David Nicholson: Yes, I hurt the NHS, but I'll patch it up. Sunday Times, 2 March 2014. http://www.thesundaytimes.co.uk/sto/newsreview/ features/article1381558.ece (accessed 02/03/2014).
44. Jarman B,. Quality of care and patient safety in the UK: the way forward after Mid Staffordshire. Lancet 2013; 382: 573-5.