Membership of the Royal College of Surgeons (MRCS) Professionalism, Ethics and Surgical Governance Syllabus

Define 'clinical governance'.

Clinical governance is the framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish (Scally & Donaldson, 1998).

Name the commonly taught pillars of clinical governance.

The seven pillars: (1) Clinical effectiveness & research, (2) Audit, (3) Risk management, (4) Education & training, (5) Patient & public involvement, (6) Using information & IT, and (7) Staffing & staff management.

What is the clinical audit cycle?

A quality improvement cycle: (1) Identify a problem/topic and set standards/criteria, (2) Collect data on current practice, (3) Compare performance against the standard, (4) Implement change, (5) Re-audit (close the loop) to confirm improvement.

What is the difference between clinical audit and research?

Research aims to discover the right thing to do (generate new generalisable knowledge, often hypothesis-driven, may use randomisation/placebo, requires ethics approval). Audit measures whether you are doing the agreed right thing against an existing standard, and does not require ethics committee approval.

Define 'evidence-based medicine' (EBM).

The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients, integrating individual clinical expertise with the best available external clinical evidence and the patient's values.

List the traditional hierarchy of evidence from strongest to weakest.

Systematic reviews/meta-analyses of RCTs > Randomised controlled trials > Cohort studies > Case-control studies > Case series/case reports > Expert opinion/anecdote.

What is a 'never event' in NHS patient safety?

A serious, largely preventable patient safety incident that should not occur if available preventative measures are implemented (e.g. wrong-site surgery, retained foreign object post-procedure, wrong implant/prosthesis). They are defined nationally and require investigation.

What is the difference between an 'error' and a 'violation' in human factors terms?

An error is an unintended failure to carry out an action as intended (slips/lapses) or a failure of planning (mistakes). A violation is a deliberate deviation from rules, procedures or safe practice, though usually not intended to cause harm.

In James Reason's classification, what is the difference between a slip, a lapse and a mistake?

Slip = an action not carried out as intended (an execution failure of attention). Lapse = a memory failure (e.g. forgetting a step). Mistake = a planning/knowledge failure where the intended action is wrong (rule-based or knowledge-based).

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

System defences are layers (slices of cheese) each with weaknesses (holes). Accidents occur when holes in successive layers momentarily align, allowing a hazard to pass through all defences. It distinguishes active failures (at the sharp end) from latent conditions (organisational weaknesses).

What is the difference between an 'active failure' and a 'latent condition'?

Active failures are unsafe acts committed by people in direct contact with the patient/system (slips, lapses, violations) with immediate effects. Latent conditions are underlying organisational/system weaknesses (poor design, understaffing, fatigue) that lie dormant and predispose to active failures.

What are 'human factors' (ergonomics) in healthcare?

The study of the interrelationship between humans, the tools/equipment they use, and the environment in which they work, in order to optimise human wellbeing and overall system performance and reduce error. It focuses on designing systems resilient to human limitations.

What does the 'WHO Surgical Safety Checklist' comprise and what are its three phases?

A team checklist to reduce surgical harm with three phases: Sign In (before induction of anaesthesia), Time Out (before skin incision), and Sign Out (before the patient leaves theatre). It improves communication and verifies identity, site, procedure and equipment.

Define 'risk' in the context of clinical risk management (qualitative formula).

Risk is a function of the probability (likelihood) of an adverse event and the severity (consequence/impact) of that event: $\text{Risk} = \text{Likelihood} \times \text{Consequence}$.

What is a 'risk matrix' and how is a risk score derived?

A risk matrix is a grid plotting likelihood against consequence/severity (commonly 5x5). The risk score is the product of the likelihood rating and the consequence rating, $\text{Score} = L \times C$, categorising risks as low, moderate, high or extreme to prioritise action.

What are the four broad strategies for managing a clinical risk (the '4 Ts')?

Treat (reduce/control the risk), Tolerate (accept it), Transfer (e.g. insurance), or Terminate (avoid/stop the activity).

What is 'Root Cause Analysis' (RCA)?

A structured, systematic method of investigating an incident (retrospectively) to identify the underlying system causes rather than blaming individuals, in order to learn and prevent recurrence. Tools include the '5 Whys' and fishbone (Ishikawa) diagrams.

What is the difference between a reactive and a proactive approach to risk management? Give an example of each.

Reactive risk management responds after an incident occurs (e.g. incident reporting, root cause analysis, significant event analysis). Proactive risk management anticipates and prevents harm before it occurs (e.g. Failure Modes and Effects Analysis, checklists, audit, risk assessment).

What is 'Failure Modes and Effects Analysis' (FMEA)?

A proactive, prospective risk assessment technique that systematically examines a process to identify potential failure modes, their causes and effects, and prioritises them (often by a Risk Priority Number = severity x occurrence x detectability) to prevent failures before they happen.

What is the statutory 'Duty of Candour' and when is it triggered?

A legal and professional duty to be open and honest with patients (or their families) when something goes wrong with their care that has caused, or could cause, harm. It is triggered for notifiable safety incidents meeting a harm threshold (e.g. moderate harm, severe harm, prolonged psychological harm, or death) and requires an apology and explanation.

What is the difference between professional and statutory (organisational) duty of candour?

The professional duty of candour (GMC/NMC) applies to individual clinicians for any harm or distress and has no harm threshold. The statutory duty of candour (CQC regulation) applies to the organisation and is triggered only when a 'notifiable safety incident' reaches a defined harm threshold.

According to GMC 'Good Medical Practice', what are the broad domains of a good doctor's duties?

The four domains: (1) Knowledge, skills and performance; (2) Safety and quality; (3) Communication, partnership and teamwork; and (4) Maintaining trust.

What are the requirements for a doctor to remain on the GMC register (revalidation)?

Revalidation every 5 years, based on annual appraisal supported by a portfolio of supporting information across the four domains (including CPD, quality improvement activity, significant events, feedback from colleagues and patients, and complaints/compliments), with a recommendation from a Responsible Officer.

What is the duty regarding confidentiality, and name circumstances where breaching it is justified.

Doctors have a duty to keep patient information confidential. Disclosure without consent is justified when: required by law (e.g. notifiable diseases, court order), or in the public interest (e.g. risk of serious harm to others, such as informing the DVLA, or safeguarding concerns).

What is 'whistleblowing' and what legislation protects whistleblowers in the UK?

Whistleblowing is raising a concern about wrongdoing, risk or malpractice (a 'protected disclosure') that harms others/patients. Whistleblowers are protected from detriment/dismissal by the Public Interest Disclosure Act 1998 (PIDA).

What are Tuckman's stages of team development?

Forming, Storming, Norming, Performing (and later Adjourning/Mourning). They describe how teams progress from initial orientation, through conflict, to establishing norms, to effective high performance.

What are the components of effective teamworking and non-technical skills relevant to surgery (NOTSS framework)?

The Non-Technical Skills for Surgeons (NOTSS) categories are: Situation Awareness, Decision Making, Communication & Teamwork, and Leadership. They are the cognitive and social skills underpinning safe surgical performance.

Compare 'transformational' and 'transactional' leadership styles.

Transactional leadership motivates through rewards and penalties for performance (exchange-based, maintains status quo). Transformational leadership inspires and motivates followers towards a shared vision, encouraging innovation, growth and change beyond self-interest.

What is 'SBAR' and why is it used?

SBAR is a structured communication tool: Situation, Background, Assessment, Recommendation. It standardises handover and escalation of clinical concerns, reducing communication errors which are a leading cause of patient safety incidents.