CARRYING OUT SIGNIFICANT EVENT AUDITING & LEARNING FROM COMPLAINTS Dr Sarah Hands

Workshop Objectives To know what a Significant Event is & how to undertake a Significant Event Audit To practice carrying out a significant event audit To understand what factors may lead to complaints & how to handle them appropriately To practice preparing an ideal response to a complaint

What is a significant event?

A Significant Event Is An event thought by anyone in a clinical team to be significant to the care of patients or the conduct of the practice Usually an event where something has gone wrong, or could have gone wrong Can also be applied where something has gone extremely well and the practice can learn from this to enhance the patient experience.

Was this a Significant Event? Was the event out of the ordinary? Better or worse than usual? Does anyone in the team feel this should be discussed? Was anyone upset or harmed by the event? Yes Yes Yes This flowchart helps people we’re training to think about what is a significant event and what isn’t. We start off with “was this a significant event”. Was the event you’re thinking of out of the ordinary? Was there a better or worse outcome than usual? Both are SEAs. Does anyone in the team feel that the event should be discussed – be guided by your team, who may pick up good opportunities for learning. Was anyone upset or harmed by the event – and I don’t mean the Practice goldfish dying, unless it died of an nasty electric shock from the tank filter! If any of the above is the case, the next question to ask is: Is there the potential for learning or change. If there is, then you are ready to do a significant event analysis! Is there potential for learning or change? SEA! 5

Terminology Critical Incident - A critical incident is any event or circumstance that caused or could have caused (referred to as a near miss) unplanned harm, suffering, loss or damage. Adverse event - The NPSA calls adverse events "patient safety incidents" Near miss - near misses "prevented patient safety incidents” Significant Event Audit – Also known as significant event analysis or learning event audit

Question What examples of significant events can you think of?

S.E. examples: Good & Bad Drug reactions Theft of prescription pad Wrong notes on home visit Managing flu epidemic Successful flu campaign Successful management of a crisis Under-age pregnancy Coping with staff illness Drug errors Complaints and compliments Breaches of confidentiality

Questions What is a significant event audit? Have you been involved and was it a useful experience?

A Significant Event Audit is: “a process in which individual episodes (cases) 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”. Professor Mike Pringle, 1995

What does SEA involve? Learning from what has happened & sharing it Analysis of events from start to finish Normally an inter-professional team activity A way of identifying problems Shows differences in which different people manage the same situation A regular meeting to discuss events (Both good and bad) Focusing on system improvement Celebrating success

Question What are the benefits of significant event auditing?

Benefits of SEA Encourages systematic approach to problems Fosters development of a learning organisation particularly if includes successes as well as problems Emphasises a patient focus Leads to rapid change Improves quality of Practice Opportunity for shared learning Improves team working & communication Requires only small amount of preparation Reduces likelihood of complaints & litigation Useful for highlighting individual learning needs

Question What are the risks?

Risks of SEA Unsettling to those involved Can be emotionally charged Demoralising Potential for victimisation Frustrating if no action can be taken

Minimising the risks Must be supportive Yet structured & rigorous Not blame seeking but quality orientated

Questions How often should you hold SEA meetings ? How soon after the event has occurred? How much investigation should you undertake before the meeting? Who do you involve? When should you review your SEA?

SEA Process Record event - contemporaneously using standard form & lodge it (good & bad) Prepare report - collect all relevant information leading up to event, what happened, who was involved, witness statements (brief), relevant protocols, the consequence Conduct an analysis - Organise a meeting, preferably including those involved analyse & agree on an outcome Write it up – include action plan & communicate findings & own personal review (anonymised) for revalidation Implement the action & arrange a review date Carry out a review

Areas to cover in SEA discussion What was the root cause? What existing processes are in place & do they need changing? What are the existing safety nets? What actually went wrong? What could have been done differently? What would need to be in place to encourage a different action/behaviour? What is the outcome? What are the main learning points?

Possible outcomes of discussion Congratulations Immediate action to be taken Further work called for - a potential topic for quality improvement No action (‘life’s like that’) but I feel better for talking

Areas to cover in the report What actually happened? Issues arising from incident & discussion Positive points Concerns Suggestions Actions to be taken Follow up & review

Practical Exercise

HANDLING COMPLAINTS

Questions How does receiving a complaint make you the doctor feel? How do you think the patient complaining might feel?

Impact of a complaint ‘Learning experience’ Shock Feelings of being out of control Doubts about clinical competence Conflicts with family and colleagues Depression Decision to leave GP Suicide

Questions Why are complaints on the increase? Why do they occur – what factors are involved? How might you avoid them?

Why the increase? Gap between patient expectations + what can be delivered Reduced fear of complaining Increased number of medical interactions NOT overall slipping of standards.

Factors possibly playing a part Communication Misunderstanding Clinical Delayed Diagnosis/Correspondence Learning points Changes to practice Rudeness Appointment issues Private Grievances Failure to diagnose serious condition Prescribing Error

Avoiding Complaints Good communication skills Accurate & complete record keeping

Questions How are complaints dealt with in your practice? Have you seen the practice complaints procedure?

Nationally Agreed Criteria Practice-based procedures owned and managed entirely by the practice Everyone in the practice should understands how system works + owns it One person nominated to administer the procedure Practice makes procedure public Procedure sets out how and to whom a complaint should be lodged and How to gain access to health authority complaints procedures Complaints should be acknowledged in 2 working days Explanation should provided within 10 working days

On receiving a complaint….. Follow the NHS complaints procedure Give a full factual account to your educational supervisor/consultant Early careful, systematic and sensitive handling reduces risk of escalation Notify your defense organisation early on Avoid taking criticism personally & focus on improvement + prevention Offer an apology, offer to meet Obtain consent if complaint made by 3rd party Dealing with verbal complaints

Writing a Response Acknowledge voicing concerns appreciated Acknowledge the distress & person’s experience Say what has been done to investigate complaint State what has been done/could be done to address concerns Mention any changes of action taken or being considered as result of complaint Offer opportunity to discuss further with choice of options (meeting, telephone, written) Reassure person can receive further service as needed without any concern about having made the complaint

Questions Have you had a complaint you are willing to discuss? What factors do you think were at play? How did you deal with it?

Remember ‘’Complaints are jewels to be treasured” - Quote from a former Secretary of State for Health because they give the NHS vital feedback on ways of improving the service

Practical Exercise

Finally What have we learnt? Evaluations