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News and updates from today's Hospital Mortality Summit

Following the chair's welcome and introduction, Prof Steve Powis Medical Director Royal Free Hampstead NHS Trust opens the conference with a session on 'Early identification of care problems to reduce mortality', covering:

• how do we ensure rapid identification of unsafe care?
• what did we learn from the Keogh mortality reviews?
• understanding the reasons for outliers and engaging clinicians
• the link between mortality and quality
• how do we ensure early identification of problems to reduce mortality

In his presentation Professor Powis stated that: 

'Improvement is the main aim of mortality reviewing'

‘The relative risk of mortality is significantly lower at the Royal Free Hospital Site when compared to hospital Trusts nationally and taking into account case mix and comorbidities’

Conference chair, Dr Martin Farrier Clinical Director for Quality & Consultant Paediatrician Wrightington, Wigan and Leigh NHS Foundation Trust, continues the morning sessions with a focus on 'Developing the role of mortality audits, internal inspection and mortality reviews to answer the question “did a problem in care contribute to the death?”', covering:

• implementing a weekly mortality audit, and generating learning and systematic
 quality improvements from the problems identified
• identifying and focussing on priority areas for meaningful improvement
• using mortality review to engage clinicians in quality improvement
• feeding back the results to clinicians to change practice

In his presentation Martin stated:

'5% of deaths might be preventable, is that going to visible to us if we take the number of deaths on any one day?

'Most deaths (95%) are not amenable to healthcare'

'95% of deaths are unavoidable'

'Unexpected death rates should be published'

'No statistical significant association between hospital SMRs and the proportion of avoidable deaths'

'the future is looking a little different, we thought we would carry on with what we were doing, the start of the next story will invove how we manage frail and elderly people, if we dont we'll be in a very bad place'

'we have been on a fascinating journey around mortality, our mortality rate is going to go up significantly in the next year, thats the start of the next story......'

Chris Dew Clinical Indicators Programme Manager The Health and Social Care Information Centre, opens the afternoon with a session on 'Estimating the risk of mortality in hospital patients', looking at:

• this estimation underpins the calculation of the Summary Hospital level Mortality Indicator (SHMI), which is published quarterly by the HSCIC and is used to identify whether the number of deaths which have occurred among hospital patients is more or less than expected.
• using this information to reduce mortality rates

Chris stated 'Metrics, whether based on physical instruments or questionnaires, need rigorous testing and calibration plus precision in use'

In his presentation Chris discussed NHS Digital and Clinical Indicators?

•NHS Digital is the national provider of information, data and IT systems for commissioners, analysts and clinicians in health and social care
•Clinical Indicators programme is responsible for:
–Development of methodologies;
–Technical construction;
–Assurance; and
–Dissemination of indicators

Also of interest:

Measuring & Monitoring Patient Safety: Patient Safety Surveillance in Real Time
Friday 10 March 2017 
De Vere West One Conference Centre, London

Investigation of Deaths in NHS Trusts: Implementing the CQC Recommendations
Monday 8 May 2017 
De Vere West One Conference Centre, London

Reducing Medication Errors in Hospitals National Summit 2017
Friday 19 May 2017 
De Vere Conference Centre, London


22 February 2017


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