Ep 13 - The NCEPOD with CEO Dr. Marisa Mason
Watch the full video podcast on YouTube: https://youtu.be/wDgv5gnRDX8?si=T6jKII0V5-QI9cTs
Show Notes
The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) is an independent UK charity and company that started in 1988 that reviews medical and surgical care in the UK to improve care for patients
Started with anesthetists focused on post-operative outcomes, in response to post operative deaths eventually adopted by surgeons, and finally into all medical practices
Periodically release reports on key topics related to quality of care
Consists of a small team of non-clinical staff, clinicians, and a board of trustees
Funding comes from the NHS England directed through departments of Health and Social Care.
According to Dr. Mason, the mandate of the NCEPOD is to “use clinicians to highlight where they think they can improve care."
NCEPOD reports, while not being formal academic research, can act as the initial bridge to new safety interventions; the NCEPOD process attempts to identify common issues in different care environments and works on reports to provide recommendations; it exists somewhere between an audit and a Quality improvement body
The process of the NCEPOD (roughly two years) includes
An open call for topics,
An audit of potential projects,
Discussion with relevant professional bodies,
A final discussion with the Healthcare Quality Improvement Partnership for funding of a topic
Following this, the NCEPOD advised by the Royal Colleges, professional organizations, patients, caregivers, and charities
Creates surveys to go out to clinicians and patients for case series
Clinicians then independently, voluntarily, and confidentially review cases
The data is pooled, and narrative recommendations are created
The recommendations are reviewed by all stakeholders prior to publishing
In England, every hospital has internal designated NCEPOD “local reporters” who serve as intermediaries and repositories of adverse events/NCEPOD relevant issues and liaise with the NCEPOD
The NCEPOD looks at a large number of incidents and institutions to assess quality of care, and shortcomings broadly, whereas the Health Services Safety Investigations Body (HSSIB) investigates individual cases to identify broader issues related to patient safety.
The NCEPOD is similar to a deductive approach
HSSIB uses an inductive approach
Both branches may use multiple cases to draw a conclusion about patient care but have different starting points and philosophies and may refer to each other as appropriate
Examples of NCEPOD work include the introduction of NCEPOD “Theatres,”dedicated emergency operative rooms as opposed to emergency procedures bumping elective operating room slates into the evening or night.
Dr. Mason is particularly proud of the NCEPOD for its part in
Providing clinical voice for clinicians who want to make a difference
Having a formal process for reviewing individual cases that occasionally lead to specific patients having an improved outcome
Changes to trauma care in the UK to an organized service centred around major trauma centres. Trauma: Who Cares? (2007)
Similar to the Transportation Safety Board (for aviation) watchlist, the NCEPOD has a list of “Common Themes” which highlight key themes in quality of patient care
Dr. Mason’s key suggestions in advocating for the creation of something similar to NCEPOD in Canada:
Highlight how the work is directly relevant to patients while engaging clinicians as opposed to punishing them.
Acts as a protective mechanism for the healthcare institution.
Emphasizes clinicians volunteering their time to reflect on cases of other clinicians and generate insights into how care could have been improved
Safety Intervention Worth Mentioning:
NCEPOD Reports – see below.
NCEPOD Audit Tools for various hospital departments.
Random Recommendations
Dr. Mason: “Try to find the lightheartedness where you can.”
Adam: Watch the World Cup. Look for something to bring us all together.
Amir: Podcast Search Engine.
Other Resources