Morbidity and Mortality Review audit and continual development monitoring and action monitoring

Quality Improvement Poster Download

Background & Problem

M and M audit and sign off was delegated to registrars, due to work load and demand. M and M notes and Sign off were not reviewed and completed. Minimal management in respect to monitoring data.

Aim

• To review all Endoscopy M and M cases within a one month period 80% SQL review and sign off.
• Continual review and actions taken
• Was endoscopy needed – justified procedure
• Continual and up to date review and analysis of data.

Method

Outcome

• The link to a High ASA score and mortality
• Percentage of procedures unsuitable – Endoscopy should not have been carried out
• Percentage rate of SQL sign off compared to previous months.
• Number of Presentations for governance.

Process Measures

• Documented ASA score for each M and M case.
• Documented and presented all non-appropriate procedures
• Export SQL report sign off

Balancing measures

• Time Constraints
• MDT availability
• Clinical notes availability due to the change in IT system.

Results

• SQL sign off prior to QI – 6 Months prior GRH 43: cases 0% SQL signed off/ CGH: 35 – 17.1% SQL sign off.
• Following QI – 99 cases of M and M CGH: 39 cases 71.8% SQL sign off, GRH: 60 cases 83.4% SQL sign off. 3 presentations for December Governance. (perforation times two/ suitability of colonoscopy)
• 2 M and M meetings with Clinical leads.
• Community death’s being explored (data request from GP)
• 100% ASA score documentation
• Direct link with ASA score and mortality – 100% of deaths within 30 days had an ASA score of 3 and above.

Implications

• Notes Request: Since the launch of track-care clinical notes retrieval is lengthy.
• Upload request and phone calls still required to receive medical notes.
• Notes can take over 8 weeks to be received – patient safety issue.
• Time for M and M meetings with essential stakeholders, overcome by emails and one to one meetings.
• Motivation from team members: From current meetings and discussions clinical leads happy with the new process and documentation of M and M.
• Patient safety and quality assurance discussions assists in compliance with meetings and participation. And linking this to local and national standards and the drive for a safe and transparent service.