Approximately 60 participants representing 15 district health boards (DHBs) joined an online learning session for the Te ako mai i ngā pāmamaetanga me te wheako tāngata whaiora me te whānau / Learning from adverse events and consumer, family and whānau experience project. The learning session was held on Wednesday 6 May 2020 and was facilitated by project lead Jacqueline Ryan.
Learning from adverse events and consumer, family and whānau experience is one of the five priority areas of the Health Quality & Safety Commission’s national five-year mental health and addiction (MHA) quality improvement programme. One of the aims of this project is to learn from when things go wrong and the impact that has on the consumer, their family and whānau, so we can prevent these adverse events happening again.
While some teams have started to look at change ideas to test, others have not been able to progress their project as planned because of COVID-19. Each team will complete an assessment to understand where they are at with their co-design and quality improvement activities and when they are likely to finish.
MHA quality improvement programme kaumātua Wi Keelan says that whānau need to be included in discussions about adverse events.
‘Whānau need to know how and why they are being included in the adverse event review process. It is also about knowing whether recommendations have been enacted and what, if any, changes have been made that have had a positive effect. Whānau need to know that their involvement and the circumstances of the review have not been in vain.’
During the learning session some DHBs spoke about how they have successfully included whānau in the adverse event review process. The approach needs to be flexible and responsive to individual whānau needs. Engaging well with whānau was recognised as key to successful consumer and project outcomes.
Staff are also stakeholders in the adverse events review process. Having different paces and processes with whānau and staff is important and managing the different needs and expectations is complex.
MHA quality improvement programme improvement advisor Karen O’Keeffe’s presentation focused on quality improvement methodology.
‘Improvement is not always linear, sometimes we have to go back and forward,’ Karen explained.
‘The more we learn about the system, the more we need to revisit and potentially refresh our aim statement. We need to continually ask ourselves if there is a clear link between the changes we are making and the desired outcome.’
The next learning session will be held in July 2020.