Authors: Dr Jonathan Stead¹, Dr Grace Sweeney² & Dr Richard Westcott³

¹ Research Fellow in General Practice and Health Service Research, Research and Development Support Unit, University of Exeter
² Lecturer in Qualitative Research Methods, University of Exeter
³ Lecturer in General Practice, Institute of General Practice, University of Exeter

Summary: Significant Event Audit (SEA), increasingly popular as a clinical governance tool, represents a uniquely effective way to tackle the clinical governance agenda. We present a definition and background to SEA from our research experience, and show how SEA can satisfactorily address the five cornerstones of clinical governance as elaborated by the National Clinical Governance Support Team (CGST).

Introduction: Significant Event Audit (SEA) was defined by Pringle in 1995 as occurring when "…individual cases in which there has been a significant occurrence (not necessarily involving an undesirable outcome for the patient) 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".¹

With the introduction of clinical governance in April 1999, following the publication of "A First Class Service", growing numbers of health care teams have instituted SEA as a regular and systematic way for the team to learn from experiences- both good and not so good.^2,3 More recently, the Chief Medical Officer’s document "An Organisation with a memory" has been published, highlighting the need for systems to be introduced for ensuring that lessons are learnt from adverse incidents.⁴ We suggest that SEA meets this need.

SEA has been adopted enthusiastically in primary care, with some early experience in secondary care, social care and prison health services.⁵ Clinical governance leads both at Primary Care Group/Trust level and at practice level seem to value SEA as a focus for clinical governance activity. Evidence is emerging that SEA is a useful tool for improving quality of patient care.^6,7 What is it about SEA that makes it so powerful?

Much of the direction of development of clinical governance is emerging from the National Clinical Governance Support Team (CGST) in Leicester. The CGST approach underlines the central importance of five cornerstones of clinical governance, namely systems awareness, teamwork, communication, ownership and leadership.⁸ We suggest that SEA provides a tool for addressing each of the five cornerstones of clinical governance in a practical and straightforward way.

Systems awareness: SEA takes a "no-blame" approach, looking at "what is wrong, not who is wrong". Issues are raised during SEA meetings that are often quite complex. These cannot always be solved during the particular meeting, but a small team is identified to work through the problem and come to the next meeting with suggestions for improving the system. For example, a mistake with repeat prescribing in a general practice may lead to an overhaul of the repeat prescribing system. The small group nominated to undertake the task might include the practice manager, receptionist, doctor and possibly dispenser. They would bring back a draft proposal to be discussed, developed and supported by the larger group.

Teamwork: Patients hardly ever have an experience of health care involving only one person or profession. For example, long-term care of people with diabetes takes place for the most part in general practice. Although the practice nurse is increasingly becoming the key-worker, the general practitioner has a critical role, as does the chiropodist, dietician and diabetes specialist nurse in certain circumstances. From the patient’s viewpoint, their support team may change over time, but the practice nurse will probably remain the key point of contact. At times, the team will cross the traditional boundaries between primary and secondary care. SEA helps team members to understand more about the role of others, and to value their contribution.⁶ For many years, GPs have tried to improve their appointment systems. They only have to ask the receptionists for their input, and immediate progress is made!

Communication: Many significant events arise due to poor communication between individuals and between organisations. Getting teams into a room on a regular basis to discuss adverse events will not only highlight communication deficits, but also begin to improve the situation. Inviting visitors to contribute on certain agenda items at the SEA meeting not only helps to get more inclusive solutions, but also helps those involved to see things from the perspective of others. The elderly patient, who has been waiting for months for their appointment for the Pain Clinic, is understandably devastated when the ambulance fails to pick him up. For example, the patient and his family were ready at six o’clock in the morning in anticipation of the appointment. The consequences for the patient, the practice and the hospital clinic are immeasurable, and the ambulance staff should be involved in the discussions to prevent a similar event from happening again.

Ownership: With simpler problems, the team will be involved in generating the solution during the meeting, ensuring ownership of those present. The meetings are minuted and circulated to the whole team, but those present will have a higher level of ownership. With more complex problems, a small group will be delegated to produce draft proposals for the next meeting, when the wider team can adapt and support the recommendations. SEA meetings are often the first opportunity for people – not traditionally in positions of decision-making – to shape solutions. Early on, receptionists and secretaries appreciate this new feeling of influence. Conversely, the usual decision-makers, such as doctors and senior managers, often relish the opportunity to include others to achieve better solutions and encourage wider ownership.

Leadership: The success of SEA meetings depends on good facilitation and leadership. As SEA is taken up by more teams, there will be a need to develop the leaders. The traditional leaders are not necessarily the best facilitators of SEA. In one of our studies in a hospital unit, where a consultant started as chairman, the meeting were well attended by doctors and only a few nurses. The lead was changed to a nurse manager, and the meeting was immediately much more popular and effective. A similar switch from doctor to nurse had an identically beneficial effect on another ward. In a general practice, a newly appointed lady partner, with a quietly efficient manner proved an excellent leader of the SEA meetings in a general practice comprising a number of powerful doctor personalities, with little history of teamwork.

Discussion: As well as being a force for quality improvement, SEA is also an important part of multi-professional continuing professional development. It identifies learning needs as well as being a means of team learning, linking to individual learning portfolios and also the revalidation process. There is also the mutual support element, which is crucial at a time of rising levels of stress, encouraging a feeling of looking out for each other.

Clinical governance and SEA are both focussed on people – patients and professionals. They are both about improving care and learning together. SEA provides an important link between learning and quality improvement in a multi-professional setting. It is simple and enjoyable, which probably explains why it is being taken up so widely with such enthusiasm by teams in the health service.

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