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Significant Event Audit

Significant Event Audit. A Guide To Starting, Sustaining & Maintaining. What is Significant Event Audit?. Defined as occurring when :

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Significant Event Audit

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  1. Significant Event Audit A Guide To Starting, Sustaining & Maintaining

  2. 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)

  3. 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

  4. Introducing Significant Event Audit (1) • Initial meeting- involve ‘stakeholders’ • Identify facilitator • 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

  5. Introducing Significant Event Audit (2) • Collect events a week 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’

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

  7. Introducing Significant Event Audit (4) • Record the key points and actions decided, and by whom • Four 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’

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

  9. Maintaining the process • A healthy and varied agenda • Monitor the overall process six monthly • Rotate the day to benefit part-timers • Defer some decisions to Practice Meeting • Summarise actions at end of meeting • Increase number of congratulations • Reconsider venue & group size

  10. The Team View • Looking after each other • Celebrating aspects of care even in worst disasters • Coming out of hierarchies • Teamscan blow their own trumpet

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