A new programme from the Royal College of Physicians 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*.
Most people who die in hospital have had good care, but research shows that between 10% and 15% have some sort of problem in their care, and around 3% of deaths might have been avoided.
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 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.
Based on work from Professor Allen Hutchinson and his colleagues at the Yorkshire and Humber Academic Health Science Network (AHSN), the programme has already been tested in hospitals in Yorkshire and the Humber, and in six sites in other parts of the country.
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. Information letters are being sent out in the week beginning 7 November ahead of the official launch on 21 November. 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.
Dr Kevin Stewart, clinical director of the RCP’s Clinical Effectiveness and Evaluation Unit (CEEU), said:
When things go wrong in healthcare, what patients and their families want more than anything else is that we will learn and improve our systems as a result, so reducing risk for future patients. They also expect that we will learn from and spread good practice.
By moving beyond the controversies surrounding numerical mortality measures this programme gives hospitals a real opportunity to take a systemic approach to mortality review so they can learn and improve.
Dr Mike Durkin, NHS national director of patient safety, said:
We commissioned this work because evidence shows that careful, considered review of the care provided to people who have died is a powerful tool for learning and improvement. Hospitals told us they wanted a standardised way of doing this, demonstrating their commitment to improvement.
