Recommended Guidelines for Conducting and ... - …

1 Recommended Guidelines for Conducting and reporting mortality and morbidity / clinical Review Meetings October 2016 Recommended Guidelines for Conducting & reporting clinical Review / mortality & morbidity Meetings: Page 2 All rights are reserved. In keeping with the NSW Government's commitment to encouraging the availability, dissemination and exchange of information (and subject to the operation of the Copyright Act 1968), you are welcome to reproduce the information which appears in this publication, as long as the user of the information agrees to.

2 Use the document for information only save or print a single copy for personal use only and not to reproduce any major extract or the entire document except as permitted under Copyright Act 1968 (as amended) without the prior written permission of the State of New South Wales acknowledge the source of any selected passage, table diagram or other extract reproduced not make any charge for providing the Information to another person or organisation without the prior written consent of the State of New South Wales and payment of an agreed copyright fee not modify the Information without the express prior written permission of the State of New South Wales include this copyright notice in any copy made.

3 - Copyright clinical Excellence Commission for and on behalf of the Crown in right of the State of New South Wales. SHPN: (CEC) 140052 Suggested citation clinical Excellence Commission. 2016. Guidelines for Conducting and reporting mortality & morbidity / clinical Review meetings. Sydney: clinical Excellence Commission. clinical Excellence Commission Board Chair: A/Prof Brian McCaughan, AM Chief Executive Officer: Ms Carrie Marr Any enquiries about or comments on this publication should be directed to: clinical Excellence Commission Locked Bag A4062 Sydney South NSW 1235 Phone: (02) 9269 5500 Email: ABN.

4 79 172 068 820 Document Modifications Version Description of Change Created/Modified By Date Initial document Bernadette King / Dr Charles Pain November 2009 Document review Dr Maree Bellamy 2012 Change of version Bernadette King / Marghie Murgo October 2016 Recommended Guidelines for Conducting & reporting mortality & morbidity / clinical Review Meetings: Page 3 1. Introduction Effectively run clinical audit and peer review processes, incorporating analysis of mortality and morbidity (M&M), contribute to improved patient safety.

5 This guide aims to provide practical advice to clinical departments on establishing and running M&M/ clinical review meetings. It is recognised that different departments will have different requirements and aims in relation to M&M/ clinical review meetings. Some services may choose to apply another title to their M&M/ clinical review meeting, such as case review however the purpose, outcomes, principles and documentation are the same. 2. Purpose and Scope This document describes a comprehensive list of functions for M&M/ clinical review meetings, and individual departments will need to decide how to apply these most effectively in their circumstances.

6 3. Related Legislation, NSW Health Circulars, Area Policies, Other Documents These Guidelines draw upon a number of NSW Health documents: clinical Excellence Commission, 2016. Clinician s Guide to Quality & Safety NSW Health Incident Management Policy PD2014_004 NSW Health Complaint or Concern about a Clinician PD2006-007 NSW Health Patient Safety & clinical Quality Program PD2005-608 National Safety and Quality Health Service (NSQHS) Standard 1 Governance and Quality in Health Service Organisations 4.

7 Principles Although M&M/ clinical review meetings have the very important function of providing education and an opportunity for reflection that may result in individual clinicians resolving to adopt different approaches with the next similar patient, it is important to recognise that M&M/ clinical review meetings also form an important part of the institutional and state-wide opportunity for system improvement. If issues are recognised at an M&M/ clinical review meeting that may have lessons for other Departments or other institutions, these should be reported promptly at the Patient Safety and Quality forum, or to the Director of Medical Services (DMS) in more urgent circumstances.

8 All clinical departments are expected to adhere to the following principles: M&M/ clinical review meetings should be held on a regular, scheduled basis. Meetings should be multidisciplinary, including clinicians from nursing, medical and allied health. Meetings should be used to critically analyse the circumstances surrounding outcomes of care. These outcomes should include selected deaths, serious morbidity and significant aspects of regular clinical practice. Recommended Guidelines for Conducting & reporting mortality & morbidity / clinical Review Meetings: Page 4 The focus of these meetings should be on the systems and processes of care and not on individual performance.

9 Recommendations arising from individual cases should focus on measures that can prevent similar outcomes or adverse incidents, or that will improve the processes of care provided to this group of patients. These recommendations should not apportion blame to individuals. Actions to implement the recommendations should be initiated and it is the responsibility of the Chair of the meeting to oversee progress in their implementation. Outcomes and decisions of these meetings should be documented in a brief meeting report.

10 Recommended Guidelines for Conducting & reporting mortality & morbidity / clinical Review Meetings: Page 5 5. Meeting Guidelines Responsibility Participation in morbidity and mortality meetings should be considered a core activity for all clinicians. The responsibility for ensuring this occurs resides with the duly appointed clinical department head. Oversight of this activity will occur through the appropriate Facility Manager and the Facility Patient Safety and Quality Committee. Organisation and Conduct Meetings should be held on a regular basis.