Membership of the Faculty of Public Health (MFPH) Health Care Public Health and Service Evaluation Syllabus

What is the PDSA cycle in quality improvement?

Plan–Do–Study–Act: a rapid, iterative, small-scale test of change. Plan the change, Do it on a small scale, Study the results/data, Act to adopt/adapt/abandon, then repeat in successive cycles.

Name three named quality improvement methodologies/approaches.

Model for Improvement (PDSA cycles), Lean (eliminating waste/maximising value), and Six Sigma (reducing variation/defects). Others include Total Quality Management and statistical process control (SPC).

What is the aim of 'Lean' methodology?

To maximise value to the patient while eliminating waste (non-value-adding steps) in a process, improving flow and efficiency.

What is a driver diagram in quality improvement?

A structured tool that maps the relationship between an overall aim, the primary drivers (high-level factors needed to achieve it), secondary drivers, and the specific change ideas/interventions to test.

What does a statistical process control (SPC) chart distinguish?

Common-cause variation (inherent, random variation within control limits) from special-cause variation (signals of a real, assignable change), helping decide whether a change has genuinely affected a process.

In patient safety, what is the difference between an error and a violation?

An error is an unintended failure of a planned action (slip, lapse or mistake); a violation is a deliberate deviation from rules, procedures or safe practice.

Distinguish a 'slip/lapse' from a 'mistake' in human error theory (Reason).

Slips and lapses are failures of execution of a correct plan (skill-based, e.g. attention/memory failures); mistakes are failures of the plan itself (rule-based or knowledge-based errors in judgement).

Explain Reason's 'Swiss cheese model' of accident causation.

System defences are like slices of cheese with holes (latent and active failures). Accidents occur when holes in successive layers momentarily align, allowing a hazard to pass through all barriers and cause harm.

Differentiate 'active failures' from 'latent conditions' in patient safety.

Active failures are unsafe acts by frontline staff with immediate effects (errors/violations). Latent conditions are underlying systemic weaknesses (poor design, staffing, culture) lying dormant until they combine with active failures to cause harm.

What is the central principle of the 'human factors' / systems approach to safety?

That errors arise largely from systems and conditions rather than individual carelessness; the response should be to redesign systems to make errors less likely and more recoverable ('design out' error) rather than blame individuals.

What is a 'Never Event'?

A serious, largely preventable patient safety incident that should not occur if appropriate preventative measures are in place (e.g. wrong-site surgery, retained instrument), for which national guidance/barriers exist.

Outline the stages of the commissioning cycle.

Three broad phases — Assessing needs (and reviewing service provision), Planning/designing services (deciding priorities, designing services, shaping structure of supply), and Securing/procuring & monitoring services (managing demand, contracting, managing performance, reviewing outcomes) — as a continuous loop.

What is the difference between commissioning and procurement?

Commissioning is the whole strategic cycle of assessing needs, planning, securing and monitoring services to meet a population's needs. Procurement is one element within it — the specific process of purchasing/contracting services from providers.

What ethical frameworks underpin priority setting and rationing?

Utilitarianism (maximise total health gain, e.g. QALY maximisation), egalitarianism (equal access/treat equal need equally), and the 'rule of rescue' / equity considerations. Procedural justice (e.g. 'accountability for reasonableness') addresses fairness of the process.

What are the four conditions of Daniels & Sabin's 'Accountability for Reasonableness'?

Publicity (decisions and rationales are transparent), Relevance (rationales rest on evidence/reasons fair-minded people accept), Appeals/Revisability (mechanism to challenge and revise decisions), and Enforcement (regulation to ensure the first three are met).

Define explicit versus implicit rationing.

Explicit rationing = decisions made through transparent, systematic rules and criteria (e.g. NICE guidance). Implicit rationing = care limited through unstated, discretionary clinical or managerial decisions (e.g. waiting lists, dilution of care) without openly stated reasons.

What cost-effectiveness threshold does NICE conventionally use, and in what units?

Approximately £20,000–£30,000 per quality-adjusted life year (QALY) gained. Interventions below this are generally considered cost-effective; above it require stronger justification.

What is a QALY?

A Quality-Adjusted Life Year: a measure combining length and quality of life. One year of perfect health = 1 QALY; it is calculated as time in a health state multiplied by the utility (0–1) of that state. $$\text{QALYs} = \sum_i T_i \times U_i$$

State the formula for the incremental cost-effectiveness ratio (ICER).

$$\text{ICER} = \frac{C_1 - C_0}{E_1 - E_0}$$ where $C$ is cost and $E$ is effect (e.g. QALYs) of the new intervention (1) versus the comparator (0).

What is service redesign / care pathway redesign?

Restructuring how care is delivered along a patient's journey to improve quality, safety, efficiency and patient experience — e.g. shifting care settings, removing duplication, integrating steps, and using process mapping to redesign the pathway.

What is process mapping in service redesign?

A technique that visually charts every step of a patient's journey/pathway from the patient's perspective, used to identify delays, bottlenecks, duplication and waste so the pathway can be redesigned to add value.

Define horizontal and vertical equity.

Horizontal equity = equal treatment of individuals with equal need (like cases treated alike). Vertical equity = appropriately unequal treatment of those with unequal need (greater resources to those in greater need).

What is the 'inverse care law' (Tudor Hart)?

The principle that the availability of good medical care tends to vary inversely with the need of the population served — those in greatest need receive the least care, especially where care is exposed to market forces.

Distinguish equity of access from equity of outcome.

Equity of access = equal opportunity to use services for equal need (removing barriers to entry). Equity of outcome = equal health results across groups. Equal access does not guarantee equal outcome because of differences in uptake, quality and wider determinants.

What resource allocation principle aims to give NHS funds according to relative need?

Weighted capitation — allocating resources to populations based on a formula that weights crude population size for age/sex, additional need (morbidity/deprivation), and unavoidable cost differences, to enable equal access for equal need.

How is Donabedian's framework applied to service evaluation?

Evaluate Structure (inputs/resources available), Process (whether activities are carried out correctly and appropriately), and Outcome (the resulting change in health/wellbeing) to give a comprehensive picture of service quality.

Name the three main types of evaluation by focus.

Structure, process and outcome evaluation (Donabedian). Evaluation can also be classified as formative (during development, to improve) versus summative (judging overall value/impact at the end).

Differentiate formative and summative evaluation.

Formative evaluation is conducted during development/implementation to shape and improve a programme. Summative evaluation is conducted after/at completion to judge overall effectiveness, impact and worth (whether to continue, expand or stop).

What is a logic model?

A diagram showing the logical sequence of a programme: Inputs → Activities → Outputs → Outcomes (short/intermediate) → Impact (long-term), linking resources to intended results and underpinning evaluation design.

How does 'theory of change' differ from a logic model?

A theory of change explains why and how change is expected to happen, making explicit the assumptions, causal pathways and contextual conditions linking activities to outcomes. A logic model is a simpler linear depiction of inputs–activities–outputs–outcomes; theory of change is more comprehensive and assumption-focused.

Name four routine data sources used for monitoring health and services in England.

Hospital Episode Statistics (HES), mortality data / death registrations (ONS), cancer registries, communicable disease/notifiable disease surveillance, and primary care (GP/QOF) data. Census and the Quality and Outcomes Framework are also routinely used.

Give two advantages and one limitation of using routine data for service monitoring.

Advantages: readily available, inexpensive, large coverage, allows trend/time-series analysis. Limitation: collected for other purposes, so may have variable completeness, accuracy and coding quality, and may lack the specific variables or denominators needed.