Investigating Poor Performance

Poorly Performing Practitioners

PHAST has wide experience of investigating poor performance and working with poorly performing practitioners in all health settings including general practice acute health trusts to ensure that they are safe to practice and to improve their performance as individuals and in teams.

Examples of our work as follows

Acute Hospital Intensive Care
PHAST was asked to support a Hospital Board because their Intensive Care Unit had a higher than expected mortality rate. A PHAST team investigated the department, analyzing the clinical data to assess whether or not there was really a problem and conducting sensitive interviews with clinical and management staff. An action plan was devised with new pathways of care, performance monitoring of clinical data. The team all had individual performance assessments and professional development plans scrutiinised. A programme of individual and team coaching and mentoring was organised. The mortality rate returned to expected levels. 

General Practitioner
PHAST investigated a Serious Untoward Incident report into the self-prescription of controlled drugs by a GP. The investigation team developed a chronology of events and collated and reviewed the evidence using root cause analysis. They also identified and made recommendations to address the fundamental causes of this incident. PHAST produced an Incident Report and an Action Plan for the PCT, outlining actions to take in order to ensure this does not happen again.

Health Protection
PHAST investigated poor coverage of MMR Immunisation in a number of PCTs and organized a catch up programme in schools and GP practices to increase the local coverage rates to protect children. They recommended using standardised systems and processes to improve uptake in the future and a monitoring system to measure performance. 

Screening
PHAST investigated a screening programme failure in which cervical screening results were delayed and in some cases lost. The programme failure was handled sensitively with all stakeholders involved. The women affected were advised to contact their GP and the GPs were advised what needed to be done to minimize the delay in rectifying the situation. Additional pathology services were used to deal with the backlog and regular meeting held to monitor progress.