National Mortality Case Record Review Programme to be delivered by Yorkshire & Humber AHSN

Left to Right: Clare Wade, Programme Manager, RCP, Dr Michael McCooe, ASSO Clinical Director, Improvement Academy, Beverley Slater, Director, Improvement Academy, Dr Usha Appalsawmy, Programme Manager, Improvement Academy, Prof Allen Hutchinson, Emeritus Professor, University of Sheffield, Dr Andrew Gibson, Clinical Lead, RCP & Kevin Stewart, Clinical Director, RCP.

The Yorkshire & Humber Academic Health Science Network (AHSN) will be working in partnership with the Royal College of Physicians (RCP) to deliver a national Mortality Case Record Review Programme over the next 3 years.

The RCP will deliver the programme in partnership with researchers at the Yorkshire & Humber AHSN and our Improvement Academy who have already developed, tested and implemented a qualitative methodology for mortality review across 12 Trusts in Yorkshire.

Based on work from Professor Allen Hutchinson and his colleagues at the Yorkshire & Humber Academic Health Science Network (AHSN), the programme has already been tested in six sites across other parts of the country.

The pioneering programme will help hospitals in England and Scotland standardise the way they review adult deaths in hospital. The National Mortality Case Record Review Programme has the full backing of the NHS in both England and Scotland, funded by NHS Improvement and commissioned by HQIP in England, and directly funded by NHS Scotland*.

The focus will be on investigating in detail adult deaths in hospitals admitting very ill patients, to understand where the weaknesses might be in particular systems, and identify areas for quality improvement. Done well, this approach has the potential to make a real difference to the quality of patient care, and avoids the pitfalls of analysing numerical statistics only.

The aim of the project is to replace the varied systems currently used with a single, standardised, national, evidence based method for mortality review in every acute hospital to maximise the potential for learning and improvement.

The programme is now being rolled out across the NHS, and the RCP is seeking 30-40 hospitals to become early adopters and start using the new approach from January 2017. The official launch will take place on 21 November at the Science of Improvement Conference in Harrogate. Volunteer sites will be asked to integrate this work into existing mortality, clinical governance and quality improvement work and to ensure that they have sufficient clinicians from a range of disciplines who are available to be trained as reviewers.

Richard Stubbs, Interim Managing Director of the Yorkshire & Humber AHSN said: This exciting news is a further demonstration of the excellent work our Improvement Academy is delivering across the Yorkshire and Humber region. We are delighted to be working with the RCP in an area that is so important for patients and clinical professionals alike. It is at the heart of our strategic objective to support members in continually improve safety and quality of care and as a result, reduce operational costs.

Dr Michael McCooe, Associate Clinical Director of the Improvement Academy said: Prior to 2014, regionally, mortality reviews varied widely. Now, 90% of the Acute Trusts in the Yorkshire and Humber region use the validated systematic Judgement Review (SJR) methodology for retrospective mortality reviews.This methodology allows us to assess good aspects of care processes but also find out where improvement is needed.

Dr Usha Appalsawmy, Leadership Fellow at the Improvement Academy said: This pioneering programme was entirely shaped bottom-up by the clinicians in the region with the support of the AHSN Improvement Academy. We are very proud to have this programme now being commissioned nationally across England and Scotland by HQIP and delivered by the RCP in partnership with the Improvement Academy.

The RCP is working in collaboration with patient and professional organisations to deliver this work including: the Yorkshire and Humber AHSN, Action against Medical Accidents (AvMA), the Royal College of Physicians of Edinburgh (RCPE), Faculty of Medical Leadership and Management (FMLM), the Academy of Medical Royal Colleges (AoMRC), the Royal College of Nurses (RCN), Healthcare Improvement Scotland, and Datix UK, as well as aligning with the medical examiner’s office.

*The programme is funded by NHS Improvement and is part of the NHS Improvement Patient Safety team’s work to support continuous improvement in patient safety.

To learn more about our Mortality Case Note Review Programme click here

To learn more about the Improvement Academy click here

To read the RCP press release, please  click here