Chaning Culture

7/29/2019 Chaning Culture

1/42

Significant Event Audit

Changing the Culture

in Primary Care

Jonathan Stead, Grace Sweeney & Richard Westcott


2/42

Learning outcomes of the

workshop

What is Significant Event Audit?

How is it done?

How can it change the culture?


3/42

Web address

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


4/42

What is

Significant Event Audit?Defined as occurring when :

..individual episodes in which there has

been a significant occurrence (eitherbeneficial or deleterious) are analysed

in a systematic and detailed way to

ascertain what can be learnt about theoverall quality of care and to indicatechanges that might lead to future

improvements. (after Pringle 1995)


5/42


What it is..

Inter-professional team activity

Regular meeting to discuss events

(both good and not so good)

Focus on system improvement ratherthan individuals

Development of a no blame culture


6/42

Terminology

Critical

Critical Incident Analysis

Critical Incident Debrief

Critical Incident Case Study

The above are reactive to an adverseevent, differing substantially from SEA


7/42

Origins of

Significant Event Audit (1)

Critical Incident Technique


8/42

1941 USAAF. High drop-out in

B36 flight training schedule


9/42

1944 effective & ineffective

incidents in combat leadershipWickert.F. Army Air Forces Aviation Psychology

Program Research Reports


10/42

Origins of

Significant Event Audit (2) 1947 Critical Incident methodology

formally developed by

American Institute of Researchfor use with specific

occupational groups

1947 Commercial airline pilotsAir traffic controllers

1949 General Motors/Westinghouse

Dentists -seeking patient views


11/42


Early 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


12/42

Historical Healthcare Perspective

Secondary Care- Post-mortem

M&M meetings

CEPOD

Case studies

Primary Care- Critical Incident ReviewSignificant Event Audit


13/42

Conventional Audit

Criterion based-design audit

set standards

data collectionchange management

Examples- diabetes

depression

X-ray requests


14/42

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


15/42

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 keptin strategic places

If event described in letter from another

organisation, record details


16/42

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


17/42

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).


18/42

Introducing

Significant Event Audit (4) 4 possible outcomes:

CONGRATULATION

IMMEDIATE ACTION

NOT RESOLVED- a potential

topic for quality Improvement

NO ACTION (lifes like that)-

but I feel better for talking

about it


19/42

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


20/42

Immediate Action

It is clear during the discussion at the

meeting what needs to be done.

The course of action is approved by theteam.

The discussion does not dominate the

meeting and make the agendaunachievable


21/42

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 teams time.

The task may be a quality improvement

project, production (or adaptation) of

guidelines etc


22/42

Not resolved-

a potential topic for QIINVESTIGATION

Choosing problem

Formulating problem Guessing causes

Gathering data

Deciding real cause

SOLUTION

Planning solution

Implementingchange

Evaluating results

Closing/continuing

vretveit J 1999


23/42

No Action Required

Lifes 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.


24/42

Group work (1) 15 mins

Just do it

Discuss one event - either a success ora mild failure that has happened in the

last fortnight

Feedback


25/42

Group Work (2) 10 mins

What do you feel are the benefits of

SEA?

So how can SEA contribute to theprocess of cultural change?


26/42

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


27/42

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


28/42

SEA and

Continuing Professional

Development

Some problems & challenges


29/42

Problems with Traditional

Learning in Primary Care

Work Learning

Everyday practice

get on with itNo 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 dont work here.

THE

GAP


30/42

My Practice My Learning


31/42

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


32/42

The Primary Care Team

GP

GP

PN

PN

HV

PM

DN


33/42

Multi-disciplinary Learning

Zones

GP

GP

PN

PN

HV

PM

DN

Tissue viability

Statin prescribing


34/42

Team Learning

GP GP

PN

PN

HVPM

DN

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


35/42

SEA and

Continuing Professional

Development

A way forward


36/42


Practice Learning

Individual

ProfessionalIndividual

Professional

Team Learning


37/42

Outcomes of SEA CongratulationImmediate remedy

Lifes like that

Need for further action

Team learning need

Conventional audit

CQI/PDSA

Small group task

Individual on behalf of

team finds out more


38/42

Linking patient quality with

individual/team development

Needs of patient(s)

Team learning

PPDP

TeamImprovement


39/42

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 teams annual clinical governance

report, and indicate that the team isresponsive to, as well as learns from,

events both good and bad.


40/42


Data Collection Form

Present:. Meeting Date:

TOPIC ACTION TO BE

TAKEN

KEY

INDIVIDUAL(S)

DATE

IMPLEMENTED

REVIEW DATE


41/42

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)


42/42

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 studyof case-based auditing in primary medical care.Occasional Paper. R Coll Gen Pract. (BPU) (70).

vretveit J. (1999). A team quality sequence for

complex problems. Quality in Health Care. 8:239-246.

Chaning Culture

Documents

Transcript of Chaning Culture