Learning from adverse events and consumer, family and whānau experience is one of the priority areas of the Health Quality & Safety Commission’s national five-year mental health and addiction (MHA) quality improvement programme. One of the project aims is to learn from when things go wrong and the impact it has on the consumer, their family and whānau, so we can prevent adverse events happening again.
Over 60 participants from 16 district health boards (DHBs) attended learning session three for this project. Read more about learning session one and learning session two. Due to restrictions on travel from COVID-19, the learning session was held online in July with project teams meeting together to attend and work in small groups.
The learning sessions are an opportunity for project teams to collaborate and learn new ideas for testing and implementing improvements.
Teams are focusing their improvement and testing of change ideas on two of the primary drivers of this project’s theory: ‘learning system’ and ‘consumer, family and whānau involved’. A time-limited working group has been established to focus on the ‘consistent processes’ primary driver. The working group is developing a toolkit for triaging, investigating and reporting MHA adverse events, aligned with the National Adverse Events Reporting Policy 2017.
Break-out sessions after each presentation, supported by a package of learning materials sent to project teams, helped participants to progress their project work.
The learning session was well received. Many participants appreciated hearing different ideas and approaches to adverse events management from other DHB project teams, particularly being reminded of the importance of family/whānau and cultural advisors in the project.
While participants acknowledged the limitations of an online learning session, mainly the inability to freely network with others, feedback was generally positive.
'I would like to commend the Commission for their leadership and expertise; they continue to inspire us to think not only out of the box but across all aspects of our projects. Learning from adverse events and consumer, family and whānau experience is the only approach to take for real authentic quality improvement and excellence. The 360o view and perspectives is the way forward for enhanced and meaningful workforce and community development’.
While this was to be the final learning session for the project, many teams when self-assessed using a 0–6 project assessment scale, felt they would not complete their project within the original timeframe. The Commission is currently consulting with project team leads and their sponsors about extending support for this project to the end of 2020.