The Yorkshire & Humber Academic Health Science Network’s Improvement Academy has welcomed the Department of Health’s announcement of a national mortality framework to learn from the care of patients who die.
We are also delighted that the Structured Judgement Review (SJR), which was developed and validated by Professor Allen Hutchinson from the Yorkshire & Humber AHSN’s Improvement Academy, has been recommended as one of the methodologies for a standardised approach to mortality reviews in NHS trusts.
The Yorkshire & Humber mortality programme was set up in 2014 and is entirely shaped by frontline clinicians. Twelve acute and mental health trusts in the region are now successfully using the SJR as part of their clinical governance structure to learn about both the good and not so good care in their health processes. Analysis of the reviews is used to inform and drive care quality improvement initiatives.
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.
It is important to stress that 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.
In a speech at yesterday’s Learning from Deaths event, Jeremy Hunt, Secretary of State for Health recognised the need to change the blame culture in the NHS and focus instead on learning and improvement. He also reassured health organisations that the aim of the framework was not to create a league table of avoidable deaths.
More information about this work is available here
To find out more about our Learning from Healthcare Deaths programme, please click here