Significant Event Audit (ePub)

Nobody does their job perfectly and no system of care gives ideal out- comes. We need to recognise and remember the continuum of quality, from poor care to "e;best"e; care that in reality means "e;better than the aver- age"e;. Everybody can improve; some need to improve more than others. If clinical governance is to be effective in improving care for all people who use the health service, it must have tools that engage clinicians, man- agers, and teams at all points on the continuum. There will be many tools, including monitoring and feedback, conventional auditing, academic detailing, continuing professional development and risk management. One methodology is emerging as being effective in many teams and in uniting all the disparate elements of clinical governance - significant event auditing. It includes all team members - doctors, nurses, managers, allied health professionals and receptionists - in the pursuit of quality. It is non-judgemental, but rigorous. It works with the existing culture. And most importantly is enjoyable. The real strength of significant event auditing lies in harnessing the emotional content of cases, through a structured process, to achieve real changes. In my general practice we regularly audited the number of people with diabetes who had had their retina examined in the past year. The numbers hung around the 50% mark year after year and at each audit discussion we vowed to do better. When we discussed the case of an elderly woman living alone who had been diagnosed with advanced diabetic retinopathy, it all came to life for us. The commitment to retinal screen- ing was hugely enhanced. Those teams that have not taken up significant event auditing, and those primary care groups or trusts that are not encouraging it, need practical guidance. This book is exactly the guidance they seek. It explains the background, evidence and context. And it gives practical support to those interested in establishing it where they work.