This guide is for reviewers undertaking Structured Judgement Reviews (SJR's). A SJR is usually undertaken by an individual reviewing a patient’s death and mainly comprises two specific aspects: explicit judgement comments being made about the care quality and care quality scores being applied. These aspects are applied to both specific phases of care and to the overall care received.
The phases of care are:
admission and initial care – first 24 hours
care during a procedure
end-of-life care (or discharge care)
assessment of care overall.
While the principle phase descriptors are noted above, dependent on the type of care or service the patient received not all phase descriptors may be relevant or utilised in a review.
Four key themes were identified in the study:
context of exposure
fear of punitive action
On the one hand, students recognised there was a professional obligation bestowed upon them to raise concerns if they witnessed sub-optimal practice; however, their willingness to do so was influenced by intrinsic and extrinsic factors. Students have to navigate their moral compass, taking cognisance of their own social identity and the identity of the organisations in which they are placed.
The use of artificial intelligence (AI) in patient care can offer significant benefits. However, there is a lack of independent evaluation considering AI in use. This paper from Sujan et al., published in BMJ Health & Care Informatics, argues that consideration should be given to how AI will be incorporated into clinical processes and services. Human factors challenges that are likely to arise at this level include cognitive aspects (automation bias and human performance), handover and communication between clinicians and AI systems, situation awareness and the impact on the interaction with patients. Human factors research should accompany the development of AI from the outset.
Summary of findings and recommendations
People living in the poorest neighbourhoods in England will on average die seven years earlier than people living in the richest neighbourhoods.
People living in poorer areas not only die sooner, but spend more of their lives with disability – an average total difference of 17 years.
The Review highlights the social gradient of health inequalities - put simply, the lower one's social and economic status, the poorer one's health is likely to be.
Health inequalities arise from a complex interaction of many factors – housing, income, education, social isolation, disability - all of which are strongly affected by one's economic and social status.
Health inequalities are largely preventable. Not only is there a strong social justice case for addressing health inequalities, there is also a pressing economic case. It is estimated that the annual cost of health inequalities is between £36 billion to £40 billion through lost taxes, welfare payments and costs to the NHS.
Action on health inequalities requires action across all the social determinants of health, including education, occupation, income, home and community.
Central Manchester University Hospitals NHS Foundation Trust
Case study: Improving management of deteriorating acutely ill patients
Improve compliance with an Early Warning Score protocol
A flowchart for the escalation of deteriorating patients
Western Sussex NHS Foundation Trust
Case study: Using electronic bedside observation to target support to deteriorating patients and facilitate research and development of new triaging and scoring systems
University Hospitals Bristol NHS Foundation Trust
Case study: Empowering a clinical champion to ensure effective use of the World Health Organization surgical safety checklist
The findings from this study, published in BMC Nursing show that advanced education and familiarity with current diabetes guidelines was related to adequate evaluations on essential areas of patient safety culture in nursing homes.
Key learning points
An abnormal antenatal cardiotocograph (CTG) may represent chronic fetal hypoxia.
Consideration should be given to the use of an antenatal CTG classification system (see example CTG sticker) and/or computerised cCTG.
Intrapartum CTG classification may not be appropriate in women who are not in established labour.
Where there are CTG concerns and fetal well-being cannot be further assessed, obtain senior review and consider expediting the birth.
Clear communication with the woman giving birth, birth partner(s) and maternity team is an essential part of good clinical care.
This editorial by Dr Michael Farquhar, published in Anaesthesia, explains the importance of taking breaks while on shift and ensuring a good sleep between shifts and the inextricable link between sleep and patient safety.
In this series of case studies, CQC highlight what providers have done to take a flexible approach to staffing. The case studies show different ways of organising services. They focus on the quality of care, patient safety, and efficiency, rather than just numbers and ratios of staff. They illustrate how providers have redesigned services to make the best use of the available range of skills and discipline or they found new ways to work with others in the local health and care system.
Safe, effective staffing is about having enough people with the right skills, in the right place, at the right time. It's about team work, not silo working. It's about developing staff to support each other in new roles - making sure patients follow the smoothest possible journey on their care pathway.