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08.11.16

New programme aims to standardise hospital death reviews

Hospitals are being encouraged to adopt a new scheme, developed by the Royal College of Physicians (RCP), to contribute to a national standard for learning lessons from patient deaths.

The National Mortality Case Record Review Programme (NMCRRP) aims to replace the various mortality reviews currently used with one standardised, national, evidence-based method, to be adopted in every acute hospital.

Trusts are currently receiving information letters about the programme before its official launch on 21 November. The RCP is seeking 30-40 hospitals to become early adopter sites from January 2017.

Dr Kevin Stewart, clinical director of the RCP’s clinical effectiveness and evaluation unit, said: “When things go wrong in healthcare, what patients and their families want more than anything else is that we will learn and improve our systems as a result, so reducing risk for future patients. They also expect that we will learn from and spread good practice.

He added that by moving beyond the controversies surrounding numerical mortality measures “this programme gives hospitals a real opportunity to take a systemic approach to mortality review so they can learn and improve”.

The NMCRRP focuses on investigating the deaths of very ill adult patients who died after they were admitted to hospital. It is thought that 10-15% of people who die in hospital had flaws in their care, with 3% of deaths being avoidable.

The standardised programme is intended to be better than numerical statistics as a means of helping providers identify problems and improve care quality.

Volunteer sites who adopt it will be asked to integrate it into existing mortality, clinical governance and quality improvement work and will need to ensure that they have sufficient clinicians from a range of disciplines who can be trained as reviewers.

In England, the NMCRRP is commissioned by the Healthcare Quality Improvement Partnership and funded by NHS Improvement. In Scotland, it is directly funded by NHS Scotland. It is based on work by Professor Allen Hutchinson and his colleagues at the Yorkshire and Humber Academic Health Science Network (AHSN) and has already been tested in hospitals in Yorkshire and the Humber, and in six sites in other parts of the country.

For more information on the NMCRRP, click here.

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