Before the case discussions
- 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.
- Quiet room
- Audio or video taping facilities, or a person to record key points
- Protected time. Use locums?, MAAG money?
- 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.
- 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…
- Case notes:
- to identify what those present see as good or bad incidents in the care given, and why,
- to offer suggestions as to how things could have been done better,
- 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.
- 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.
- Facilitator provides practice written feedback listing positive points, concerns and suggestions, with space for ‘any actions taken’.
- 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.
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
|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.|
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.
- Lack of acceptable room.
- Problems with recording: too intrusive, poor quality results, time of transcription (if done).
- 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.
- Inability to recognise inadequacies of care: defensiveness.