Significant event audit (or analysis [SEA]) has been an integral part of contractual and appraisal requirements in general practice for nearly a decade. Undertaking SEA can have a wide range of benefits for participants such as enhancing team-based learning and communication, improving patient safety and highlighting good practice. To benefit fully from SEA it is important that it is undertaken using a structured format in a blame-free environment with the aim of maximising learning for all relevant individuals.
From this a meaningful plan for change and improvement should be implemented, where necessary, to minimise the risk of any adverse event occurring in the future – particularly important if patient safety is the issue.
The early diagnosis of cancer is a key area of concern for clinicians, patients and their families. When such a diagnosis is made, it provides an excellent opportunity for the primary care team to reflect on the potential factors that informed the decision pathways to investigation, referral and diagnosis. The SEA technique is ideally suited to maximise the educational gain from this reflection.
Cancer SEA pilot project
To help maximise the learning opportunities associated with undertaking a ‘new cancer diagnosis’ analysis, an SEA pilot project is now available. This is a joint initiative between the RCGP, the National Cancer Action Team (NCAT) and Macmillan Cancer Support that provides GPs within participating Cancer Networks the opportunity to have their reports anonymously peer reviewed. The peer reviewers are nominated Network Cancer leads who have undergone a quality assured training process. This model of feedback has been shown to enhance clinicians’ understanding of the SEA process as well as augmenting reflection and learning. It also provides powerful evidence to appraisers of engagement with, and commitment to, quality improvement.
Two examples of the content of SEA reports submitted on the cancer diagnosis proforma are given via the links below. For both reports feedback would be offered in relation to the individual sections of the report and the overall analysis. Examples of issues that could be highlighted for each analysis are given below:
The ‘What happened’ section: Consider giving more background information so that the event can be placed in context – such as who saw the patient on each occasion? Were there any relevant negative findings? Did clinicians exclude red flags in earlier consultations?
The ‘Why did it happen?’ section highlights that a prompt referral had taken place. Justify in more detail why this was the case. For example, at the consultation on 14/9 – was this an opportunity for baseline investigations? Was appropriate safety netting carried out?
The section ‘What have you learned?’ documents confirmation of existing good practice. A full analysis should offer evidence of reflection and discussion in a team meeting. Were the other clinicians in agreement that there were not missed opportunities?
The section ‘What has been changed?’ details no change to be implemented. Are there any learning needs around investigation of ‘tiredness’ symptoms that could be implemented?
What was effective about this SEA? The analysis narrative describes a good quality of care. Consider the ‘opportunity–cost’ of the analysis. There is sparse information to ascertain the quality of care delivered, and whether the underlying reasons for the event happening have been considered.
The ‘What happened’ section gives a clear description of the events with the active participants identified. It could also discuss the potential impact of the event – for example a delayed diagnosis and the possible effect on the doctor-patient relationship.
The ‘Why did it happen?’ section gives insight into the thought processes at the time of the consultations. Further considerations for potential underlying reasons could include: Why was Dr a reassured by an X-ray from two years previous? Did the practice follow current guidelines for investigation for cough? Was the receptionist trained in how to action urgent results?
In the section ‘What have you learned?’ The author presents an honest reflection highlighting positive and negative aspects of the event.
In the section ‘What has been changed?’ the practice has identified specific and measurable actions to be taken. We can see that the results system has been changed.
What was effective about this SEA? The author has identified relevant points with good practice celebrated by the team. For an ideal analysis all changes would be actioned and where actions have been identified responsible individuals also identified and timescales given.
Many feedback points will be generic to the majority of SEA reports undertaken in primary care. Where good care is demonstrated this should be embedded in the practice. Where less than ideal care has taken place practices should ask – will the change(s) implemented stop the chance of an event recurring in the future?
- Dr McKay is Associate Adviser, NHS Education for Scotland and RCGP Cancer SEA Pilot Steering Group Member