Significant Event Audit

Changing the Culture in Primary Care

Jonathan Stead, Grace Sweeney & Richard Westcott

Learning outcomes of the workshop

What is Significant Event Audit? How is it done? How can it change the culture?

Web address

http://latis.ex.ac.uk/sigevent/

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)

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

Terminology

Critical…… Critical Incident Analysis Critical Incident Debrief Critical Incident Case Study

The above are reactive to an adverse event, differing substantially from SEA

Origins of Significant Event Audit (1)

Critical Incident Technique

1941 USAAF. High drop-out in

B36 flight training schedule

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

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

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 problemsN.B. You collect more events if you emphasise effective incidents

Flanagan.J. 1953

Historical Healthcare Perspective

Secondary Care- Post-mortem M&M meetings CEPOD Case studies Primary Care- Critical Incident Review Significant Event Audit

Conventional Audit Criterion based-design audit set standards data collection change management

Examples- diabetes depression X-ray requests

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

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

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’

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).

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”

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

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

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

Not resolved- a potential topic for QI

INVESTIGATION Choosing problem Formulating problem Guessing causes Gathering data Deciding real cause

SOLUTION Planning solution Implementing

change Evaluating results Closing/continuing

Øvretveit J 1999

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.

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

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?

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

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

SEA and Continuing Professional

Development

Some problems & challenges

Problems with “Traditional Learning” in Primary Care

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.

THE GAP

My Practice My Learning

Challenge for CPD, PDPs etc is to bring these together

My Practice

Sometimes, getting the work done is the priority Of course, there is a need

for some reflection away

My Learning

The Primary Care Team

GP

GP

PN

PN

HV

PM

DN

Multi-disciplinary Learning Zones

GP

GP

PN

PN

HV

PM

DN

Tissue viability

Statin prescribing

Team Learning

GP GP

PN

PN

HVPM

DN

The only way to get here is to be “patient-centred”

SEA and Continuing Professional

Development

A way forward

Significant Event Audit

Practice Learning

IndividualProfessional

Individual Professional

Team Learning

Outcomes of SEA CongratulationImmediate remedy

Life’s like thatNeed for further action

Team learning need

Conventional audit

CQI/PDSA

Small group task

Individual on behalf of team finds out more

Linking patient quality with individual/team development

Needs of patient(s)

Team learningPPDP

Team Improvement

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.

Significant Event Audit

Data Collection Form

Present:…………………………. Meeting Date:

TOPIC ACTION TO BETAKEN

KEYINDIVIDUAL(S)

DATEIMPLEMENTED

REVIEW DATE

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)

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.