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While there is debate about the extent to which patients are harmed when they are cared for in hospital, it is clear that admission as an inpatient is not without risk. This paper presents works on the progress to date with identifying what these risks are and quantifying the likelihood and severity of the risk. The clinical risk profiling tool that has been developed as part of this exercise has assisted with the identification and prioritisation of clinical risks and is the first step in risk reduction and elimination.

Adverse event monitoring is a problem‐oriented approach to clinical audit and health‐care quality improvement, which was developed and has been widely used in the USA. Briefly explores the technique itself and its evolution. Presents experience gained from the widespread use of the approach in a British acute hospital, and results from one specialty – ophthalmology. Suggests that the study of adverse events in patient care can produce significant improvements in patients’ care, that it is particularly suited to some specialties, and that it should be used alongside other techniques in hospital clinical audit programmes. Concludes that, as the demand for quality‐monitoring information from purchasers and within providers grows, adverse event monitoring may become one of the key techniques for quality assessment and improvement.

Clinical audit has a pivotal role to play in improving the quality of patient care. As part of the programme for co‐ordinating clinical audit across the trust each clinical area has a nominated doctor to lead and co‐ordinate the audit programme in their specialty. This qualitative survey reviews the effectiveness of having specialty audit leads and reviews the progress that specialties have made in developing their audit programme. The semi‐structured interviews with 30 clinical audit leads identified an uneven level of development of clinical audit across the trust, and demonstrated that dedicated time would be needed to make these posts more universally successful. Although one size will not fit all, the interviews highlighted some recurring themes – seeds of success – in functioning audit programmes.

The national tariff system for clinical processes and procedures aims to put a discrete unit cost on clinical activity. Calculating such costs can be subject to a great deal of local variation and interpretation. Given the rising costs of diabetes the purpose of this paper is to ask the question what does a diabetes outpatient appointment in the UK NHS actually cost? This is important in a time of financial austerity and healthcare rationing because it can be difficult to decipher the attribution of costs within the acute hospital setting.

Exploring this question, the author considers the present cost model and analyse in terms of the language of unit model cost; the basic tariff system and how it works in diabetes and looking at internal cost information the author attempts to unbundle the cost to provide a more accurate value for the cost object.

One major finding is that costs and overheads are divided arbitrarily as opposed to being distributed on the basis of measured relative consumption. Alternative costing methods are appraised to demonstrate that a patient level episodic costing approach such as patient level information and costing system (PLICS) which incorporates aspects of activity-based costing (ABC) would be far more appropriate. Using time driven ABC (TDABC), a new patient appointment costs £162 for 30 minutes and a follow-up appointment costs £81 for 15 minutes.

PLICS has the added benefit of greater financial and clinical transparency and this goes some way towards the holy grail of greater engagement with the doctors delivering clinical care.

It would appear that there are different purposes of different costing systems. One can argue that a costing system is there to both contain costs and divide overheads and demonstrate activity. Depending on how data are interpreted costing information can be an agent of enlightenment and behavioural modification for healthcare professionals to show them their direct and indirect costs, their capacity and productivity.

Clinicians and health service managers can see from this practical example how the distribution of costs and resources are unfair and can impede the delivery of a service. By using alternative costing methodologies such as ABC not only do the author gets a better reflection of the true cost of the finished consultant episode but is also able to engage clinicians in understanding how costs are generated.

In the UK, obstetric surgery is commonly performed with the patient awake and her partner present. Patient expectations are high. Even under high quality regional anaesthesia, non‐painful sensation may occur. This and other contentious issues must be discussed before surgery. Legal proceedings against obstetric anaesthetists are rare, but may arise many months later. Accurate contemporaneous notes are essential. The quality of notekeeping was audited for 50 Caesarean sections. A redesigned anaesthetic chart with prompts for key information was introduced and the audit repeated. There were significant improvements in documenting the pre‐operative discussion of: intra‐operative sensation; conversion to general anaesthesia; post‐dural puncture headache; suppositories; neuraxial opiate‐induced itch. Records of pain free operations; the presence or absence of nerve root pain; and the timing of events leading to delivery were significantly increased. This audit suggests that an anaesthetic chart with specific prompts improves the documentation of medico‐legally relevant information.

The purpose of this study is to document the experience and impact of implementing lean thinking (LT) in an Indian healthcare institution.

A detailed review of literature documenting the experience of implementing LT in healthcare institutions is carried out. Review revealed that there is a dearth of documentation on implementation of LT in Indian healthcare institutions. To address this gap, the experience of implementing LT in an Indian case hospital is documented by adopting a single case study research methodology.

Lean practices adopted by the Indian case hospital are documented. Performance measures before and after implementation of lean practices in the case hospital are compared. Based on this experience, a framework for implementing LT is proposed for healthcare institutions.

The current study documents the experience of an Indian case hospital, which is only at its initial stages of LT implementation. Future studies can be undertaken to assess the long-term impact of implementing LT in a healthcare institution. Similarly, the proposed framework for implementing LT can be validated by using the same in different healthcare institutions.

Review of lean principles, practices and performance measures discussed in the literature on implementing LT in healthcare institutions can act as a ready reckoner for practitioners. Framework proposed based on the experience of the case hospital is expected to guide healthcare practitioners in their lean journey.

This study is unique, as it documents the experience of implementing LT in an Indian healthcare institution and proposes a framework for implementing LT for future validation.

CASPE Research and Brighton Health Authority have been working together to test a series of approaches to quality assurance in healthcare. In this paper, they give an account of the results of the quality assurance techniques used; discuss the key requirements for successful quality assurance in the NHS environment; and consider the need for systematic evaluation of quality assurance programmes.

South East Thames Regional Health Authority (SETRHA), in conjunction with the Brighton Health Authority, have negotiated a prospective contract for the provision of NICU services by Brighton Health Authority to district health authorities in the South West Thames Region.

Aarhus Kommunes Biblioteker (Teknisk Bibliotek), Ingerslevs Plads 7, Aarhus, Denmark. Representative: V. NEDERGAARD PEDERSEN (Librarian).