Guidelines for facilitating case discussions

Before the case discussions

The Group

  • Decide who will be in the group. Include ancillary staff, receptionists in primary health care team?
  • Aim for consistent membership.
  • May be helpful if group already meets on a regular basis eg for team meetings.
  • Choose internal or external facilitators.

Equipment

  • Quiet room
  • Audio or video taping facilities, or a person to record key points
  • Protected time. Use locums?, MAAG money?

The process

  1. Explain aims:
    • to improve the quality of patient care by learning from good and bad aspects of previous care,
    • to avoid attributing individual blame,
    • to develop guidelines for good practice.
  2. Explain process:
    • to talk through a specific case in (eg) half an hour,
    • to have available a summary of the case and the patient’s…
  3. Case notes:
    1. to identify what those present see as good or bad incidents in the care given, and why,
    2. to offer suggestions as to how things could have been done better,
    3. to develop practice protocols where appropriate.

Establish ground rules for the group, eg confidentiality, speaking for self (using ‘1’ not ‘we’), allowing people to speak uninterrupted.

The facilitator

  • Explain role of facilitator:
    • to structure discussion including timekeeping,
    • to encourage contributions from all participants and ensure a well balanced discussion,
    • to encourage suggestions for improvement where areas of concern arise,
    • to encourage participants to accept responsibility for suggestions made in the discussion and to be prepared to initiate change.

The case discussions

Discussing the case

  • Person who knew patient best starts by giving brief summary of their recollections of patient’s past history, final illness if applicable and death.
  • Other members of the primary health care team asked to contribute.
  • Ascertain positive aspects of care and areas of concern that the team might have.
  • Facilitator summarises positive points and concerns; asks for suggestions for ways of doing it differently.

Feedback

  • Facilitator provides practice written feedback listing positive points, concerns and suggestions, with space for ‘any actions taken’.

Review

  • Facilitator presents summary of positive points, concerns and suggestions for all the cases discussed to date.
    • ‘Have suggestions been turned into actions?’
    • ‘Who will take responsibility?’
  • Have further reviews after additional cases. Keep checking on concerns and suggestions, keep a feedback spiral.

Facilitators

Rules for facilitators

  • Stay separate from the group; avoid identifying with them.
  • Concentrate on what they are saying rather than thinking of own opinions.
  • Encourage everyone to participate: structure to increase equality of contributions.
  • Recognise emotion: acknowledge it and allow appropriate offloading.
  • Give clarification and summaries at frequent intervals.
  • Encourage acceptance of responsibility within the discussion and work towards decisions on actions.
  • Facilitators need to offload their feelings.

Pros and cons of external facilitators

Pros  Cons
Leaves everyone in the team free to contribute. If facilitator is someone from another practice, could be threatening – try MAAG facilitator.
Not involved in any internal ‘games’ can keep boundaries better. Likely to be more expensive.
Safer if there are nay feelings of distrust in the PHCT. Internal facilitators might be more flexible eg use different people on different occasions
Someone to off load distress onto.
Takes responsibility for keeping it going.
External facilitators can get support for themselves more easily.

Problems

The group (PHCT)

  • Barriers of hierarchies.
  • Fear of exposure/blame/being humiliated.
  • Existing tensions such as innovators vs laggards, personality clashes.
  • People “too busy” to commit themselves.
  • Worry about medical litigation.

Environment

  • Lack of acceptable room.
  • Problems with recording: too intrusive, poor quality results, time of transcription (if done).

Discussions

  • Dealing with emotions: anger, guilt, sadness.
  • Peer support may not be forthcoming.
  • Reluctance to express ‘failure’ in front of other professionals in the group eg GPs in front of nurses.
  • Collusion.
  • Inability to recognise inadequacies of care: defensiveness.
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