CARRYING OUT SIGNIFICANT EVENT AUDITING & LEARNING FROM COMPLAINTS

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

2. 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

3. What is a significant event?

4. 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.

5. 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 Is there potential for learning or change? SEA!

6. 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

7. Question What examples of significant events can you think of?

8. 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

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

10. 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

11. 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

12. Question • What are the benefits of significant event auditing?

13. 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

14. Question • What are the risks?

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

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

17. 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?

18. 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

19. 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?

20. 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

21. 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

22. Practical Exercise

23. HANDLING COMPLAINTS

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

25. 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

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

27. 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.

28. 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

29. Avoiding Complaints • Good communication skills • Accurate & complete record keeping

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

31. 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

32. 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

33. 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

34. 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?

35. 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

36. Practical Exercise

37. Finally What have we learnt? Evaluations