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 Audit What it is….. n Inter-professional team activity n Regular meeting to discuss events (both good and not so good) n Focus on system improvement rather than individuals n Development of a ‘no blame’ culture

4. Introducing Significant Event Audit (1) n Initial meeting- involve ‘stakeholders’ n Identify facilitator n Meet monthly- substitution not more n Collect events as they occur n Record events using forms/books kept in strategic places n If event described in letter from another organisation, record details

5. Introducing Significant Event Audit (2) n Collect events a week prior to the meeting n 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) n Circulate agenda 48 hours before meeting n 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) n Record the key points and actions decided, and by whom n 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 n Key part of Clinical Governance n Focus on patient outcomes n Promotes self-esteem and self value n Identifies communication opportunities n Comprehensive nature of SEA n Fulfils team potential n Personal, professional and service development in active way

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

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