CG in ophthalmology

Clinical Governance in Ophthalmology: 

Clinical Governance in Ophthalmology M. Jabir 27 November 2003

Introduction: 

Introduction RCOphth charter : maintain proper standards in the practice of ophthalmology for the benefit of the public

Definition: 

Definition A framework through which the NHS organisations are accountable for continually improving the quality of their services & safeguarding high standard of care by creating an environment in which excellence in clinical care flourish

Clinical Governance Pillars: 

Clinical Governance Pillars Strategic capacity in the trust Resources & processes Clinical Audit Clinical Risk Management Education, Training, CPD Patient Consultation & Involvement Research & Effectiveness Staffing & Staff management Use of information to support CG & health care delivery Patients experience Trust context: activity, finances

Purpose of the Session: 

Purpose of the Session Clinical Governance issues & arrangements specific to ophthalmology

Outline: 

Outline Clinical governance links National quality standards in ophthalmology Facilities Clinical outcomes Delivering & monitoring standards Audits Critical Incidents Complaints Improving standards

CG Links: 

CG Links RCOphth NICE CHAI DOH Private sector ? Trust management Boards :Annual reports on clinical quality by eye units

Slide8: 

GMC Appraisal & Revalidation CME & CPD EBM & research

Slide9: 

National quality standards

Slide10: 

1 Facilities

OPD: 

OPD Elective, A & E, DCS high volume children or elderly & many relatives Equipment's : FFP, photos, B scan, laser, optometry, orthoptic, VF, minor ops & pre-op assessments Room for the visually impaired & wheelchairs , well signpost Well lit waiting area & kids facilities

Slide12: 

Consulting rooms : test chart, trial lens set, slit lamp with tonometry, direct & indirect ophthalmoscopes, lenses & reclining chair CLs, focimeter, perimetry , B scan & biometry Minor operation facilities Orthoptic rooms with Hess charts Fundus photography & FFP Lasers both yag & posterior segment

Slide13: 

Workload : 1 pt / 15 min + booking space for emergencies & ward discharge Consultant’s list : 5-6 new + 6-7 returns Total number of pts / Dr no more than 15 Consideration for presence of medical students & trainees Adequate administrative, secretarial & clerical support.

Inpatients: 

Inpatients Eye pts should be looked after by ophthalmic nurses Whether in ophthalmic ward or dedicated ophthalmic beds in a mixed ward will be determined by the No of pts & turnover Equipped examination room Children should be admitted to wards where they are attended by staff trained in paediatric & ophthalmic care with access to a consultant paediatrician.

Theatres: 

Theatres Dedicated ophthalmic theatre without any absolute restrictions on other non infected surgery being undertaken in the ophthalmic theatre Microscope with coaxial illumination, binocular assistant’s eyepieces Phacoemulsifier and vitrectomy machines

Slide16: 

High standard of microsurgical instrumentation with training in care & handling Information technology : recording data about pt, surgeon, procedure & co-morbidity Anaesthetic facilities according to their college’s guidelines A video camera, a video & a monitor

Day case: 

Day case All pts should have access to DCS preferably in a day case unit or a ward with DC facilities Provision of general & ophthalmic pre- op assessment DC theatres should have same standards Provision of a bed if necessary Resuscitation facility & trained staff

Staffing levels: 

Staffing levels 1 consultant / 70000 population provided there is support from trainees, middle grades, nurse practitioners, orthoptists & other ophthalmic assistants In teaching hospitals 1 / 50000 Some juniors tasks can be delegated to non medical staff

Slide19: 

No unit should be staffed by one consultant Locum consultants should be restricted to 6 months only, further 6 after college approval Effective link with Medical staff in other specialities

Service design: 

Service design Hub & spoke : unit amalgamation Clinical networks : several hubs at a supra-regional level Ophthalmic emergencies : 24 hr cover by ophthalmic staff , first on call by SHO or years 1 & 2 SPRs or staff grades Consultants should not be first on call

Slide21: 

2 Measurement of clinical outcomes

Slide22: 

Data collection on outcomes in a way that allows it’s quality to be measured which is easier in surgical specialities College’s national audits can set standards Allowance for co-morbidity & case mix Chronic diseases as D.R., OAG, ARMD outcomes may not be apparent for years

Slide23: 

Blind registration statistics may be used as an indicator of medicine or NHS status in general & not the individual doctor or the trust’s performance IT or A4 paper with tick boxes for data The next few tables are the proposed indicators of clinical quality in ophthalmology

Slide26: 

Delivering & monitoring standards

Bodies responsible: 

Bodies responsible Locally Trusts Clinical Effectiveness departments Clinical Governance committees Trust Boards Health Authorities Nationally CHAI

Audit: 

Audit Utilise current procedures, role of clinicians , unwise to rely on clerical staff alone Collection of data and comparing with national outcomes ( benchmarking) Two separate sets of data : *Combined results of a unit ( CHAI ) *Individual clinicians detailed data

Critical Incident AnalysisTrigger List: 

Critical Incident Analysis Trigger List Operating on the wrong eye Wrong operation on the correct eye Missing case notes at surgery Globe perforation during local anaesthesia Expulsive Haemorrhage during surgery Patient’s collapse Death Endophthalmitis

Slide30: 

Open category for incidents: Unplanned return to theatre within 28d Unplanned admission to an eye unit within 28 d Unplanned transfer to another eye unit within 28 d Stories of success are also part of CIA

Complaints monitoring: 

Complaints monitoring Regular monitoring and auditing of complaints Litigation monitoring

College Inspections: 

College Inspections Juniors training Monitoring service provision & facilities In non training units if requested to assess quality

Continuing Professional Development: 

Continuing Professional Development GMC : clinicians should be up to date Personal development plans CME / CPD Voluntary system now, will be obligatory soon

Revalidation: 

Revalidation GMC document : Regular demonstration by all registered doctors that they remain fit to practise in their chosen field is best be assured by a link with registration Portfolio files Five yearly Linked with appraisal

Slide35: 

Improving standards

Slide36: 

Improving standards through local audits & CME / CPD NICE & RCOphth EBM standards to compare with Local failing trust involving college investigating dept

Conclusions: 

Conclusions Patient welfare is the core objective Clinicians & units should have CG impeded in their practice Continuous auditing of outcomes Trigger lists of Incidents in all units Fair Vs No blame culture Benefits from clinical governance Teams should be Up to date Evidence based practice No harm comes to patients

References: 

References BMJ V 317 19-26 December 1998 BMJ V 317 4 July 1998 BMJ V 313 & September 1996 RCOphth guidance for clinical governance April 1999 GMC good medical practice July 1998 A first class service 1998 The national cataract audit 1998-1999 RCOphth CME 1998 The national DR audit Eye 1998 12: 77-84 Cataract surgery 1995 Clinical governance 1999 CHI report