Learning from deaths programme shortlisted

A Yorkshire & Humber Academic Health Science Network’s Improvement Academy programme designed to ensure that hospitals learn from the care of patients who die has been shortlisted for a prestigious BMJ Patient Safety Award.

The programme supports the uptake of the retrospective case record review methodology called the Structured Judgement Review (SJR). This method, developed and validated by Professor Allen Hutchinson from the Yorkshire & Humber AHSN’s Improvement Academy, allows Trusts to learn about both the good and not so good care in their health processes. Analysis of the review themes is used to inform and drive care quality improvement initiatives.

It is important to stress the majority of patients who die in hospitals have had good care. However, when a review identifies failings in the care processes, whether this led to a death or not, then systems need to be in place to recognise and learn from these issues.

The Improvement Academy has trained more than 750 reviewers from multidisciplinary teams across departments and specialities in Yorkshire and Humber. Trained reviewers include specialist nurses, consultant surgeons/physicians, senior registrars, and senior allied health professionals.

Seventeen acute and mental health trusts in the region are now successfully using the SJR as part of their clinical governance structure. Mortality leads come together quarterly to share learning, experience and challenges, thus shaping the programme bottom up. A lay subgroup involving carers and relatives has also been set up. Since 2014 approximately 7000 SJRs have been carried out in the region.

Since February 2016 the Yorkshire & Humber AHSN’s Improvement Academy has been working in partnership with the Royal College of Physicians to roll out the SJR methodology across England and Scotland for adult deaths in acute hospitals as part of the National Mortality Case Record Review programme

SJR has also been recommended as one of the methodologies for a standardised approach to mortality reviews in NHS trusts in the Learning from Death guidance announced by the Department of Health in March 2017.

Dr Usha Appalsawmy, Clinical Leadership Fellow at the Improvement Academy, said: “Our work over the past four years has demonstrated how a standardised retrospective mortality case notes review can provide a robust method for organisations to assess their care systems and identify problems.

“Our support for organisations in Yorkshire and Humber who are learning together has yielded demonstrable benefits to organisations and an improved patient experience.”

Richard Stubbs, Chief Executive Officer at the Yorkshire & Humber AHSN, commented: “This is great news and I am delighted that the team has received this recognition.

“Innovation is hard to do and is even harder to scale up. To have trained more than 750 reviewers and undertaken 7,000 reviews is an incredible achievement.

“I’m very proud that this is being rolled out nationally.”

Beverley Slater, Improvement Academy Director, added: “I am so proud that this programme has been shortlisted for a BMJ Patient Safety Award. It’s making a real difference in Trusts that are working with us.”

Winners of the awards will be announced by the BMJ at a dinner in London on May 10 2018. The full list of finalists is available here.

Further details about the programme are available here.