Role Of Quality Assurance With Emphasis On Significant Event Auditing

Quality assurance in the National Health Service (NHS) is made up of three components: patient safety, patient experience and clinical effectiveness. Patient safety is top priority for all health care systems but human error can always occur (NHS Corby Clinical Commissioning Group, 2015). In 2016, approximately 24% of all deaths in the UK were considered avoidable (141,101 deaths out of 597,206) (Office for National Statistics, 2016). With a good quality assurance system in place and the development of tools used to assess quality of care avoidable death percentages should fall. Over 10 years ago the Department of Health made the recommendation that health care organisations should systematically reflect from their patient safety incidents, and that system-wide safety interventions were a necessary part of collective learning and the improvement process (Department of Health, 2000). Significant event auditing/analysis (SEA) is one measure used for quality assurance, aiming to improve quality of patient care from lessons learnt from critical events. In practice, team members should focus on particular incidents they considered significant.

These significant events (defined as ‘Any event thought by anyone in the team to be significant in the care of patients or the conduct of the practice’ (Bradley, 1995)) from individual cases are analysed in a qualitative, detailed, systematic way to determine if anything can be learnt about the overall quality of care and indicate if something needs to change or can be improved for the future. This can reflect good practice as well as bad practice (Henderson, 2014). From a structured dissection of events, centralised around crucial questions such as: what happened and why? How could things have been different? What can we learn from what happened and what needs to change? SEA objectives are to help identify good and bad practice, promote team building and support in light of stressful events, promote a culture of openness and not individual blame, to promote reflective learning and to be a tool for professional development (Henderson, 2014). In 2008, a review of current evidence base for SEA was published on the perceived advantages and disadvantages associated with SEA. It was a comprehensive search of electronic databases and peer reviewed journals in which they explored or measured perceptions or attitudes in relation to SEA or assessed its impact on health care quality were included. It should be noted however that this study was limited by the number of available published research studies (Bowie, 2008). A strength of the study was that the inclusion criteria was highly specific and from a total of 27 studies the perceived benefits included: improved communication, enhanced team‐working and awareness of others' contributions. Disadvantages included: concerns about litigation, reprisal, embarrassment and confidentiality. The study concluded that SEA did have some merit as a team‐based educational tool, however, it may not be a reliable technique for investigating serious or complex safety issues in general practice. Furthermore the 27 studies were each examined independently by two authors, which may have introduced some bias in interpreting and judging (Bowie, 2008). In a first attempt to include all members of the primary care team, a further comparative study focusing on the knowledge, process and attitudes in primary care of SEAs was published in 2011. This study benefited from using a random selection process but only received a response rate of 53%.

General practice team members from 111 practices of the National Health Service of Greater Glasgow anonymously completed a postal questionnaire survey aimed at determining: the awareness, degree of analysis and perceived risk of recurrence of a recent significant event, types of discussion forums, staff groups' participation and perceived barriers. They were asked whether they could recall a recent significant event in the workplace that was subsequently highlighted, analysed and discussed by the primary care team. They were also asked to indicate if the key stages (which are thought to be relevant to a structured analysis) had been undertaken. The fact that participants could reply anonymously would make for more honest answers (Bowie, 2011). Comparisons were made with a 2003 survey and significant changes were described (Bowie, 2004). Although this study is limited by response and self-report bias, the results showed that a vast majority of team members were aware of a recent significant event, 29% reported not implementing a change and 23% perceived the risk of recurrence as moderate to high. Furthermore administrative and community‐based staff were infrequently involved in meetings and dedicated significant event meetings remained uncommon. Perceptions had improved since 2003, but lack of time to dedicate to SEA remained an issue (Bowie, 2011).

Clearly from the studies referenced above, as with any method utilised to improve the quality of care there is always room for improvement and it seems the SEA is no exception. It has been reported that learning from routine SEAs is a rarity or appropriately acted upon in both practices and regional healthcare organisations (Bowie, 2008). There are some aspects of safety and hazard incident types that are not easily detected and as a result the majority of these incidents remain undetected and if they are detected they are rarely shared within practice teams, not formally reported and rarely lead to further action (Brennan, 2002). In a recent cross-sectional structured review of random samples of electronic records of ‘high risk’ patient groups conducted twice per year by 274 general practices in two regions of Scotland, a re-design and testing of a trigger review method (TRM) for general practice offered one approach to identifying previously undetected events (Bowie, 2009). There was high level engagement from practices participating. It provided these practices with opportunities to reflect and therefore act in the light of events and thus strongly emphasising their importance as change catalysts. However, data was self-reported and therefore subject to bias as there was no means to externally verify data quality (Black, 2016). By using the TRM to systematically review their clinical records of their own patients for incidents and hazards, provided the care teams with a personal perspective of the safety of their care and provided valuable opportunities that were relevant to their practices to take pre-emptive action before harm could occur.

The majority of clinician reviewers ‘successfully’ applied the trigger review method, which uncovered important but previously undetected patient safety incidents which prompted the care teams to take action during and after the trigger reviews, suggesting the TRM has potential as a feasible, pragmatic approach to improving primary care safety and quality (Black, 2016). In an article published in the Primary Health Care journal, advanced nurse practitioner Bridget Coutts describes the complex decision making needed in SEA, she concluded that SEA allowed her to reflect that her decision regarding a patient “was possibly based more on luck than judgement, and that future care and treatment will be rooted in the five domains of advanced clinical practice” (Coutts, 2014). Although SEA has some well documented flaws, indicating it may not be a reliable technique for investigating serious or complex safety issues in general practice and the fact that time restraints are an issue, it is still a vital tool for health care professionals, such as Bridget Coutts, for improving quality assurance and therefore improving the quality of care patients receive. More research and improvements, such as the TRM are welcomed for the future.