1. Mortality and harm – Developing Board Assurance
6th September 2010
Mortality and harm – Developing Board Assurance
Presenters: Tim Heywood & Patrick Coyle
Tim Heywood and Patrick Coyle

2. Session objectives
Understand learning from elsewhere about Board assurance relating to mortality and harm.
Clarify the role of the Quality and Safety Committee in providing assurance to the Board on patterns of mortality and harm.
Consider what questions Quality and Safety Committees need to ask when presented with mortality and harm information.
Consider current progress in individual organisations and steps to be taken before next mini-collaborative.
Tim Heywood and Patrick Coyle

3. The value of understanding the data: The case of Bristol Royal Infirmary
“Although external action to address concerns about paediatric cardiac surgery at Bristol Royal Infirmary took place in 1998, monitoring using control charts could have provided a basis for action in 1987”
Bristol Royal Infirmary
The Lancet, February 2001
Tim Heywood and Patrick Coyle

4. The value of understanding the data: The Case of Harold Shipman
“A control chart of mortality rates for women aged 65 years and older in Thameside and Glossop, UK, during 1992–9810 shows that in 1992 and 1994, Harold Shipman’s mortality rates were within common-cause variation. However, during 1993 and 1995–98, his mortality rates indicated special-cause variation. To reduce special-cause variation, the special cause must be found and removed. Subsequent legal proceedings identified that special cause as being Shipman himself.”
The Lancet, February 2001
Tim Heywood and Patrick Coyle

5. The critical role of the Quality and Safety Committee in providing assurance..
“…a system of governance that was confused about who had responsibility, where decisions were made and how the Board got its assurances and from where.”
Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009
Tim Heywood and Patrick Coyle

6. The warning signs didn’t come from only one source..
“We accept that there is no single, perfect mechanism for assessing health care quality. We also agree that every statistical quality monitoring algorithm, including Dr Foster, should be critically examined by experts to determine its validity. However, we believe that in the case of Mid-Staffordshire, there were so many different warning flags from different entities, using different approaches, and over multiple time periods, that it would have been completely irresponsible not to aggressively investigate further.”
Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009
Tim Heywood and Patrick Coyle

7. The danger of dissing the data..
“The report contains trenchant criticism of the Trust’s approach concerning mortality rates and its reliance on an argument that these were attributable to coding deficiencies.”
We recognize that mortality alerts and HSMRs cannot be used as a direct tool for discovering failings in hospitals. What the data do[es] do... is pose the question what is the explanation for our high mortality for the particular diagnosis or procedure that has alerted that month?
Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009
Tim Heywood and Patrick Coyle

8. Posing the right questions..
Does everyone understand the importance of patient safety?
Do we really have an open and fair culture?
Are we actively encouraging reporting of incidents?
Do we get the right information?
Are we always open when things go wrong?
Do we learn from patient safety incidents?
Are we actively implementing national guidance and safety alerts?
Tim Heywood and Patrick Coyle

9. Getting the right information: What does good look like?
The organisation draws information from all sources, including:
Reported incident themes and rates
Clinical risks
Complaints and claims
Serious untoward incidents
Clinical audits (including National Audits)
Safety WalkRounds
Unexpected deaths
Mortality rates
Triggers identified in case-note reviews
Tim Heywood and Patrick Coyle

10. Pyramid model for investigating and seeking assurance re avoidable death
Questioning and investigation needs to happen at multiple levels
From 1000 Lives Plus, A guide to mortality measurement
Tim Heywood and Patrick Coyle

11. Mortality reviews – questions to ask
Are we undertaking systematic mortality reviews?
How has avoidable death been defined?
Has Global Trigger tool review been undertaken on deaths?
Are patterns of causes of avoidable death compatible with existing priority improvement activities for harm reduction?
Does this information indicate process weaknesses that should become a new focus for improvement activity?
Tim Heywood and Patrick Coyle

12. Casemix – questions to ask
Are there factors that could distort our RAMI?
If so, what might the effect be?
What is the range of RAMI by site/ Speciality/ Clinician?
Has our RAMI measure changed over time?
Is our RAMI target within process control limits?
Tim Heywood and Patrick Coyle

13. Processes of care – questions to ask
Is there any sign of process improvement at all? At first, teams should be held to account for process reliability, not outcome change.
Which interventions are having an effect and which not? This will show you where you need to revisit your improvement efforts.
How far have the interventions been spread? If you haven’t covered the majority of relevant clinical areas then you probably haven’t got enough spread to effect mortality measure. Concentrate on spreading the improvements to more areas.
Are the process changes reliably implemented? The key to getting an impact is to ensure that the improved process is definitely reliable before trying to spread. Spreading improvement too early results in patchy performance.
From 1000 Lives Plus, A guide to mortality measurement
Tim Heywood and Patrick Coyle

14. Presenting mortality and harm information to the Q & S committee
Issues that should be presented in Public part of the meeting.
Agreed procedures for mortality reviews and GTT use
Organisation-level RAMI
Themes and issues (from MR’s and GTT)
High level progress on process improvement linked to themes and issues
Issues that might be discussed in committee.
Specific incident reporting
Initial reporting on drill-down investigations from high level data.
Tim Heywood and Patrick Coyle

15. Attitude to patient safety issues at Board committee level
Pathological
The committee has no interest in patient safety information.
Reactive
The committee receives and acts on information about
Complaints and claims
Serious untoward incidents
Reported incident themes and rates
Clinical risks
Calculative
Mortality reviews
Mortality rates
Triggers identified in case-note reviews
Pro-active
The committee is assured that improvement priorities have been set and that progress is being monitored
Generative
“The high reliability organisation”.
Increasing maturity
Adapted from Manchester Patient Safety Assessment Framework
Tim Heywood and Patrick Coyle

16. Some questions for you to consider
Board level assurance (in Q&S)
What stage is your Board at now?
What do you need to do now to move to the next level?
Operational surveillance and response
Are Mortality and morbidity reviews undertaken in a consistent way?
Are escalation arrangements in place?
Tim Heywood and Patrick Coyle