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Vol 1, Issue 1, ISSN 2632-363X

Learning from Deaths: Implementing Structured Judgement Reviews across the West of England Dr Mark Juniper1, Kevin Hunter2, Melody Moxham3

Summary The West of England Academic Health Science Network has a strong patient safety portfolio. As part of our work on improving patient safety we partnered with the Royal College of Physicians in late 2016 to pilot, and be an early adopter of, their Structured Judgement Review (SJR) process. Using our experience in delivering collaborative projects, we approached all acute hospitals in the region to work together to improve the way we learn from deaths in healthcare. Our aim was to standardise the Mortality Review process, share learning, identify outcome themes and facilitate region-wide quality improvement (QI) initiatives.

Introduction The purpose of mortality review is to learn from deaths and to identify areas of practice that can be improved. Standardising this process enables organisations to compare data, to share the lessons they have learned and to establish improvement work more widely across the healthcare system. The Structured Judgement Review (SJR) methodology was developed by Professor Allen Hutchinson and validated in the Yorkshire & Humber AHSN by the Improvement Academy. The SJR process has been adopted by the Royal College of Physicians (RCP) to standardise the approach to mortality review in all hospitals under the National Mortality Case Record Review (NMCRR) programme. The West of England AHSN worked with the RCP and the Improvement Academy to roll out the SJR process across all acute hospitals in the West of England.

Methods The West of England AHSN used a collaborative approach to adopt a region-wide

SJR process. We used the Institute for Healthcare Improvement Breakthrough Series Methodology, and launched our Collaborative in September 2016. We established a network which involved senior leaders from all organisations. They initially met together and shared their established processes for mortality reviews. All organisations agreed to work together to establish SJR as a common methodology. Non-executive and Executive Directors were invited to initial meetings to ensure organisational buy-in at a senior level. All Trusts were involved from the outset, but a step-wise approach was taken with three trusts acting as early implementers, to refine the methodology, to understand some of the barriers to implementation and to gain confidence in the use of SJR. Regular contact between the leads was established in the form of a monthly telephone conference and a quarterly face-to-face meeting. Initially this involved sharing the challenges faced and how these had been best overcome.

Consultant in Respiratory and Intensive Care Medicine at The Great Western Hospital in Swindon, Clinical co-ordinator (Medicine) at National Confidential Enquiry into Patient Outcome and Death (NCEPOD) since 2012

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2

Head of Patient Safety & Programme Delivery, West of England AHSN

3

Patient Safety team, West of England AHSN

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Patient Safety Journal Vol 1, Issue 1  

This is a record of the proceedings and learning shared at the Bristol Patient Safety Conference. The Journal's purpose is to improve safety...

Patient Safety Journal Vol 1, Issue 1  

This is a record of the proceedings and learning shared at the Bristol Patient Safety Conference. The Journal's purpose is to improve safety...

Profile for munglani