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 problems
N.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.