Significant Event Audit

1. Significant Event Audit Changing the Culture in Primary Care Jonathan Stead, Grace Sweeney & Richard Westcott

2. Learning outcomes of the workshop • What is Significant Event Audit? • How is it done? • How can it change the culture?

3. Web address http://latis.ex.ac.uk/sigevent/

4. What is Significant Event Audit? Defined as occurring when : “..individual episodes in which there has been a significant occurrence (either beneficial or deleterious) are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care and to indicate changes that might lead to future improvements.” (after Pringle 1995)

5. Significant Event AuditWhat it is….. • Inter-professional team activity • Regular meeting to discuss events (both good and not so good) • Focus on system improvement rather than individuals • Development of a ‘no blame’ culture

6. Terminology • Critical…… • Critical Incident Analysis • Critical Incident Debrief • Critical Incident Case Study The above are reactive to an adverse event, differing substantially from SEA

7. Origins of Significant Event Audit (1) Critical Incident Technique

8. 1941 USAAF. High drop-out in B36 flight training schedule

9. 1944 effective & ineffective incidents in combat leadership Wickert.F. Army Air Forces Aviation Psychology Program Research Reports

10. Origins of Significant Event Audit (2) • 1947 Critical Incident methodology formally developed by American Institute of Research for use with specific occupational groups • 1947 Commercial airline pilots Air traffic controllers • 1949 General Motors/Westinghouse Dentists -seeking patient views

11. Significant Event AuditEarly Evidence • Leads to change rapidly • Built in to the fabric of the organisation • Systematic approach • Encourages a user/patient focus • Includes successes as well as problems N.B. You collect more events if you emphasise effective incidents Flanagan.J. 1953

12. Historical Healthcare Perspective • Secondary Care- Post-mortem M&M meetings CEPOD Case studies • Primary Care- Critical Incident Review Significant Event Audit

13. Conventional Audit • Criterion based-design audit set standards data collection change management • Examples- diabetes depression X-ray requests

14. Examples of Significant Events • Successful management of a crisis • Managing the flu epidemic • Under-age pregnancy • Coping with staff illness • Drug errors & drug reactions • Complaints and compliments • Breaches of confidentiality

15. Introducing Significant Event Audit (1) • Initial meeting- involve ‘stakeholders’ • Identify chairman/manager • Meet monthly- substitution not more • Collect events as they occur • Record events using forms/books kept in strategic places • If event described in letter from another organisation, record details

16. Introducing Significant Event Audit (2) • Collect events prior to the meeting • Create agenda, recognising: -priority of topics -availability of personnel -involvement of team members -sensitivity of topic -flexibility to add ‘hot topics’

17. Introducing Significant Event Audit (3) • Circulate agenda 48 hours before meeting • At the meeting: -run through minutes of last meeting, in particular action points. -each topic presented by key person, followed by discussion (praise before criticism).

18. Introducing Significant Event Audit (4) • 4 possible outcomes: CONGRATULATION IMMEDIATE ACTION NOT RESOLVED- a potential topic for quality Improvement NO ACTION (‘life’s like that’)- “but I feel better for talking about it”

19. Congratulations • Not enough of it about • No history in the NHS- just individual blame • There is usually some part of an adverse event, which is well managed and should be acknowledged

20. Immediate Action • It is clear during the discussion at the meeting what needs to be done. • The course of action is approved by the team. • The discussion does not dominate the meeting and make the agenda unachievable

21. Not resolved- a potential topic for QI • Discussion identifies a piece of work which needs to be done by two or three members of the team. • The work will take place before the next meeting, but tackling the task during the SEA meeting would not be a good use of the team’s time. • The task may be a quality improvement project, production (or adaptation) of guidelines etc

22. INVESTIGATION Choosing problem Formulating problem Guessing causes Gathering data Deciding real cause SOLUTION Planning solution Implementing change Evaluating results Closing/continuing Øvretveit J 1999 Not resolved- a potential topic for QI

23. No Action Required • Life’s like that. • It is sometimes necessary to accept that such an event will sometimes happen and there is not much we can do about it.

24. Group work (1) 15 mins • “Just do it” • Discuss one event - either a success or a mild failure that has happened in the last fortnight • Feedback

25. Group Work (2) 10 mins • What do you feel are the benefits of SEA? • So how can SEA contribute to the process of cultural change?

26. Benefits of Significant Event Audit (1) • Risk management • Clinical negligence • Positive approach to complaints • Identifies learning needs • Identifies audit & research topics • Helps understanding of others’ roles • Builds and develops skills of teams

27. Benefits of Significant Event Audit (2) • Focus on individual experience • Promotes self-esteem and self value • Identifies communication opportunities • Comprehensive nature of SEA • Fulfils team potential • Personal, professional and service development in active way • Key part of Clinical Governance

28. SEA and Continuing Professional Development Some problems & challenges

29. Problems with “Traditional Learning” in Primary Care THE GAP Work Learning Everyday practice “get on with it” No time for learning when you are at work Library resources- they are somewhere else. Go away to study on a course. People who really know are the specialists = teachers. They don’t work here.

30. My Learning My Practice

31. Challenge for CPD, PDPs etc is to bring these together My Practice My Learning Sometimes, getting the work done is the priority Of course, there is a need for some reflection away

32. The Primary Care Team PM GP PN GP PN DN HV

33. Multi-disciplinary Learning Zones PN DN PN GP GP Tissue viability PM Statin prescribing HV

34. Team Learning PM PN HV PN GP GP DN The only way to get here is to be “patient-centred”

35. SEA and Continuing Professional Development A way forward

36. Significant Event Audit Practice Learning Individual Professional Individual Professional Team Learning

37. Outcomes of SEA Congratulation Immediate remedy Life’s like that Need for further action Conventional audit CQI/PDSA Team learning need Small group task Individual on behalf of team finds out more

38. Linking patient quality with individual/team development Needs of patient(s) Team learning PPDP TeamImprovement

39. Reporting framework • List events discussed, the type of outcome, the specific action and the date of implementation. • This documentation will be a key part of a team’s annual clinical governance report, and indicate that the team is responsive to, as well as learns from, events both good and bad.

41. SEA and culture change • Values people • Local ownership and destiny • Encourages openness • Facilitates reflective practice • Systems aware - not blame • Addresses leadership in primary care • Links people and processes of CG • Leads to improvement (fast)

42. References • Flanagan JC. (1954). The Critical Incident Technique. Psychological Bulletin. 51:327-58. • Pringle M, Bradley CP, Carmichael CM, Wallis H, Moore A. (1995). Significant Event Auditing, a study of case-based auditing in primary medical care. Occasional Paper. R Coll Gen Pract. (BPU) (70). • Øvretveit J. (1999). A team quality sequence for complex problems. Quality in Health Care. 8:239-246.