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Mutual support amongst mortality reviewers

Melody Moxham, Project Support Officer, reflects on the collaborative and supportive work of our Mortality Reviews Steering Group.

I’ve been supporting our Mortality Reviews Steering Group since summer 2018. I think it is a fantastic example of how collaborating across our region helps to improve patient safety.

Since 2017 all of the acute trusts in the West of England region have used a standardised process for their mortality reviews – Structured Judgement Reviews (SJRs). (You can read more about how we implemented this process in the Patient Safety Journal).

The SJRs take place in each trust and the accumulated data is brought to the steering group meetings. For example, one trust might share that they had 200 deaths during the last quarter and that 70% of these qualified for an SJR. Of those, one or two were judged as having had poor care and one as having had very poor care, and that case has been escalated as a Serious Incident. The vast majority of cases identify good or excellent care. Critically, trusts also talk about their learning from the SJRs, either positive feedback or areas to improve, and how this is shared. For example in their internal newsletters or magazines, through quality improvement projects, feedback to teams or individuals, and at Board level.

During my time supporting the group I’ve noticed how the monthly meetings provide a ‘safe space’ for colleagues from six trusts to access peer support regarding the results of their SJRs. By sharing their monthly and quarterly SJR data, and more in-depth information about specific (anonymised) reviews, common themes can be identified and solutions shared; all which help to improve patient safety. I’ve been impressed at how open the group discussions have been, which really nurtures collaboration across the region.

We followed the IHI (Institute for Healthcare Improvement) Breakthrough Collaborative Series model for this project, which enabled our trust representatives to learn from each other and improve together. The clinicians in the group have shared resources, such as Board Reports and recruitment documents for specific roles to further learn from each other and replicate effective systems. This has saved work being duplicated and allows others to adopt tested solutions more efficiently.

In my role at the AHSN, I’m a few steps removed from the front line delivery of patient care, so for me this has been a fascinating window into our colleagues’ world, working in acute services. The most immediate impact that I experience is not seeing how systems and care are improved from the SJR process, but the benefits that these meetings bring to the clinicians. The support that they provide each other is clearly so beneficial, and helps to create and sustain a culture of sharing learning within our region, for the ultimate benefit of improving our patients’ safety.


Posted on September 12, 2019 by Melody Moxham, Project Support Officer, Patient Safety Collaborative, West of England AHSN

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