Upload
siusiuwidyanto
View
220
Download
0
Embed Size (px)
Citation preview
7/31/2019 Western Australian Review of Mortality
1/18
7/31/2019 Western Australian Review of Mortality
2/18
acknowledgents
The Ofce o Sety nd Qulity in Helth Cre cknowledges nd pprecites the input o ll
individuls nd groups who hve contributed to the developent o this docuent. In prticulr we
recognise the guidnce provided by indi vidul clinicins, the edicl directors o helth services, nd
the Helth Consuers Council o Western austrli or their dvice nd constructive eedbck.
The Western austrlin Council or Sety nd Qulity in Helth Cre together with the Ofce o
Sety nd Qulity in Helth Cre will provide ledership role in onitoring nd evluting the
ipleenttion o this policy by hospitls nd helth services cross the Western austrlin helth
syste, thus prooting the delivery o consuer ocused, se, qulity helth cre in Western
austrli.
7/31/2019 Western Australian Review of Mortality
3/181Policy and Guidelines for Reviewing Inpatient Deaths
Foreword
Western Australians enjoy excellent health care. To ensure the ongoing delivery o sae, quality
care the Western Australian Council or Saety and Quality in Health Care, in consultation with
clinicians, developed the Strategic Plan for Safety and Quality in Health Care in Western Australia
2003/04 to 2007/08. This strategic document sets the agenda or continuous improvement o
health care across the State. It is built around our important interlined strategic areas o clinical
governance: consumer-ocused health care, clinical practice improvement, ris management, and
system improvement and accountability. Central to clinical practice improvement is the clinical audit
process.
The clinical audit o patients who have died under medical care is undamental to improving saety
and quality or uture generations o patients. This document promotes a standardised process or
health services to review and audit deaths with the ultimate aim o improving the complex systems
and processes intrinsic to the delivery o health care.
This policy should be read in conjunction with other relevant policies and guidelines, including the:
Clinical Incident Management Policy or WA Health Services using the Advanced Incident
Management System (AIMS);
Sentinel Event Policy;
Open Disclosure Policy; and
Qualied Privilege Guidelines.
All o the above are available on the Oce o Saety and Quality in Health Care website. Hard copies
may be obtained by contacting the Oce o Saety and Quality on 9222 4080.
As the saety and quality eld is dynamic and rapidly changing, updates o this policy will be
available on the Oce o Saety and Quality in Health Care website (http://www.health.wa.gov.
au/saetyandquality/publications).
I encourage all health service sta to read these policies and participate in the continuous drive to
improve the saety o health care.
7/31/2019 Western Australian Review of Mortality
4/182 Western Australian Review o Mortality
Table o Contents
1. Purpose o Policy 3
2. Scope o Policy 3
3. Other Obligations and Requirements 3
3.1 Proessional obligations 3
3.2 Statutory requirements 3
3.3 Mandated requirements 4
4. Denitions okey Terms 4
5. Mortality Review Process 4
5.1 Mortality review teams 5
5.2 Categorising death 5
5.3 Detailed clinical review 6
5.4 Timerame or review 6
5.5 Reporting 6
6. Qualied Privilege 7
7. Disclosure o Inormation 8
8. Perormance Indicators 8
9. Updates and Review o Policy 9
Appendix 1: Western Australian Audit o Surgical Mortality 10
Appendix 2: Flow Chart 11
Appendix 3: Individual Death Review Documentation Sample Proorma 12
Appendix 4: Department Quarterly Report Sample Proorma 14
Appendix 5: Proposed Perormance Indicators 15
7/31/2019 Western Australian Review of Mortality
5/183Policy and Guidelines for Reviewing Inpatient Deaths
1. Purpose o Policy
This document provides guidance or establishing a consistent approach to the classication and
review o deaths as part o a clinical audit process. It aims to reduce preventable deaths by ensuring
all inpatient deaths are systematically reviewed and that recommendations or improvement arising
out o mortality (death) reviews are considered regularly or implementation.
2. Scope o Policy
This policy applies to:
all deaths occurring in public hospitals and licensed private health care acilities that provide
services or public patients in Western Australia; andall health service employees and contract sta, including salaried and non-salaried visiting
medical practitioners. Participation in the mortality review process in accordance with this
policy is a designated quality improvement activity (see Section 3.1).
For the purpose o this policy, hospitals and health services are not obliged to conduct the mortality
review process on sentinel events or deaths reported to WA Audit o Surgical Mortality (WAASM).
Clinical Governance committees or equivalent should be notied o inpatient deaths reviewed solely
by the WAASM process in order to ensure they ull specic requirements as detailed in Appendix 1.
All other inpatient deaths should be reviewed in accordance with this policy.
3. Other Obligations and Requirements
An inpatient death can give rise to many reporting requirements including proessional obligations
to the amily and/or carer(s) o the deceased, statutory reporting requirements and mandatory
reporting requirements as per Department o Health (WA) policy. Some o these are outlined below.
It should be noted that regardless o these other requirements, this policy applies to all deaths as
dened in the scope unless otherwise specied in the document.
3.1 Professional obligations
Communication with the amily and/or carer o the deceased. Please see Operational Circular
2050/06 regarding Patient Condentiality and the Open Disclosure Policy.
Participation in the WA Audit o Surgical Mortality. For urther inormation please see
Appendix 1.
Participation in quality improvement activities under the Terms and Conditions o Indemnity
or Salaried Medical Ocers and Terms and Conditions o Indemnity or Non-Salaried Medical
Ocers, available at http://www.health.wa.gov.au/indemnity/indemnity
3.2 Statutory requirements
Maternal deaths must be reported to the Executive Director, Public Health. Reer to Health
Act 1911, s336, and Operational Circular 1453/01.
Perinatal and inant deaths must be reported to the Executive Director, Public Health. Reer
to Health Act 1911, s336A and Operational Circular 1454/01.
7/31/2019 Western Australian Review of Mortality
6/184 Western Australian Review o Mortality
Deaths o persons under anaesthesia must be reported to the Executive Director, Public
Health. Reer to Health Act 1911, s336B, and Operational Circular 1197/99.
Deaths which require notication to the Coroner. Reer to Coroners Act 1996 and Operational
Circular 2066/06.
Certication o death. Reer to Births, Deaths and Marriages Registration Act 1998, s44, and
Operational Circular 1652/03.
Death as a result o suspected child abuse. Reer to Operational Circular 2051/06.
3.3 Mandated requirements as per Department of Health (WA) Policy
Deaths classied as sentinel events must be reported to the Chie Medical Ocer. For urther
inormation see the Sentinel Event Policy which is available at http://www.health.wa.gov.au/saetyandquality/publications.
Under the Mental Health Act 1996, the Chie Psychiatrist has responsibility or the medical
care and welare o all involuntary patients. In respect o other patients, the Chie
Psychiatrist is required to monitor the standards o psychiatric care provided throughout
the state. Consequently, serious incidents and deaths that occur in mental health services
throughout Western Australia must be reported to the Chie Psychiatrist. Reer to Operational
Circular 2061/06.
Serious adverse events that result in a medico-legal claim, or have the potential to result in a
medico-legal claim, must be reported to the appropriate bodies. Reer to Operational Circular
1850/04: Non-salaried medical practitioners - protocol or notiying and managing medicaltreatment liability claims/potential claims (non-teaching hospitals).
4. Denitions o key Terms
Clinical audit means a quality improvement process that sees to improve patient care and
outcomes through systematic review o care against explicit criteria (National Institute or Health
and Clinical Excellence, 2002, Principles for best practice in clinical audit).
Mortality review means a two-stage process which involves the categorisation o death ollowed
by a detailed investigation and review o selected patients with the aim o identiying deciencies o
care in the clinical setting and maing recommendations or change.
Mortality review team means a committee o a clinical department, which reports to the
organisational committee responsible or clinical governance. The mortality review team conducts
inpatient death reviews in accordance with this policy.
5. Mortality Review Process
The implementation o the Mortality Review process should be managed at the Area Health Service
level and refect local structures, reporting and governance.
7/31/2019 Western Australian Review of Mortality
7/185Policy and Guidelines for Reviewing Inpatient Deaths
Prior to the mortality review process occurring, the appropriate personnel must determine the
ollowing: i the death is a sentinel event and reported to the Chie Medical Ocer; and/or
i the death can be reported to the WA Audit o Surgical Mortality.
I the death is a sentinel event and/or can be investigated by the WA Audit o Surgical Mortality (in
accordance with this policy, reer to Appendix 1) the mortality review process as outlined in this
document need not be undertaen.
For all other inpatient deaths a review must be conducted. Reer to Appendix 2 or a fow chart o
the mortality review process.
5.1 Mortality review teamsIn a department with registrars, the mortality review team should include the ollowing:
the consultant responsible or managing or supervising the case;
the registrar responsible or managing or supervising the case;
one or more consultants with relevant sills or experience who were not directly involved in
the care o the patient; and
one or more registrars who were not directly involved in the care o the patient.
In a department without registrars, the mortality review team should include the ollowing:
the doctor responsible or managing or supervising the case; and
two or more doctors with relevant sills or experience who were not directly involved in the
care o the patient.
This mortality review team structure represents a minimum requirement. However, as deaths occur
under dierent teams in multidisciplinary settings, departments are encouraged to include additional
senior medical sta as well as nursing and allied health sta as additional members o a mortality
review team.
5.2 Categorising death
All inpatient deaths should be categorised on the basis o the Health Round Table criteria (Death
Audits: 2001, The Health Round Table).
Category 1: Anticipated death
1a) due to terminal illness (anticipated by clinicians and amily); and/or
1b) ollowing cardiac or respiratory arrest beore arriving at the hospital.
Category 2: Not unexpected death, which occurred despite the health service taing preventative
measures.
Category 3: Unexpected death which was not reasonably preventable with medical intervention.
Category 4: Preventable death where steps may not have been taen to prevent it.
Category 5: Unexpected death resulting rom a medical intervention.
7/31/2019 Western Australian Review of Mortality
8/186 Western Australian Review o Mortality
In addition to categorising the death as per the Health Round Table Criteria, the mortality review
should also consider any statutory or mandated reporting requirements as outlined in 3.2 and 3.3.
I the mortality review team determines the death is a sentinel event it must be reported to the
Chie Medical Ocer and investigated in accordance with the Sentinel Event Policy which can be
ound at http://www.health.wa.gov.au/saetyandquality/publications.
In the case o a missed potential organ donor, the death should also be reported to the Head o the
Intensive Care Unit o the relevant hospital and the Medical Director o DonateWest. DonateWest
may be contacted by email on [email protected].
5.3 Detailed clinical reviewInpatient deaths categorised as a level 4 or a level 5 and are not sentinel events must undergo a
detailed clinical review by the mortality review team to mae recommendations or improvements
where appropriate. Deaths categorised as a level 1, 2, or 3 may also undergo a detailed clinical
review at the discretion o the mortality review team.
A detailed clinical review o an inpatient death should involve a comprehensive and systematic
analysis o the acts to identiy contributing actors and develop recommendations or local and/or
system change. These changes can help prevent similar events occurring in the uture.
For the 06/07 year and until policy review, a minimum standard has not been specied or how a
detailed clinical review should be conducted. In practice, mortality review teams are encouraged toollow evidence-based principles with respect to the assessment o the standard o care.
Hospitals/Health Services can reer to the Clinical Incident Investigation Standard, which can be
ound at http://www.health.wa.gov.au/saetyandquality/publications.
5.4 Timeframe for review
The review o level 4 or 5 deaths should be completed within three months o the date o death. This
is to ensure that recommendations or improvement are relevant and contemporaneous.
5.5 ReportingThe aim o reporting is to ensure that:
all deaths undergo an appropriate level o review;
where a detailed review identies an adverse event, that these are managed appropriately as
per local protocols;
where changes are recommended, they are implemented in a timely manner as per local Area
Health Service policies; and
system-level recommendations are given appropriate consideration.
The Head o Department is responsible or ensuring that the mortality review team provides a
quarterly written report on its activities to the hospital or health services Clinical GovernanceCommittee or equivalent. The quarterly reports should include the ollowing inormation:
patient identication (or code assigned by the mortality review team);
7/31/2019 Western Australian Review of Mortality
9/187Policy and Guidelines for Reviewing Inpatient Deaths
date o death;
date o review;
categorisation level;
type o investigation used (e.g. root cause analysis);
date o completion;
recommendations or system change; and
implementation status o recommendations.
The patient identication eld does not need to contain patient details, but rather a patient ID or
code that is assigned by the mortality review team to distinguish between deaths. See Appendices 3
and 4 or sample proormas or recording and reporting the outcomes o the process or an individualdeath and quarterly summaries.
Following the review process the Clinical Governance Committee or equivalent is responsible or
proposing relevant recommendations or system-level change to the organisations Executive.
Area Health Services are required to report the ollowing to the Chie Medical Ocer via the Oce
o Saety and Quality on a quarterly basis:
the number o deaths categorised as level 4 or level 5;
or each o the reviewed deaths, a report containing a brie description o the event/
circumstances o the death (de-identied), a brie summary o the outcome o the review,
and any relevant recommendations and comments that may have statewide relevance.
The template or reporting recommendations arising rom sentinel events may be used as a guide to
satisy this reporting requirement.
6. Qualied Privilege
Qualied privilege reers to the provision o saeguards to protect certain inormation rom disclosure
and to protect persons involved in the quality assurance/quality improvement activity rom civil
liability. Some hospitals and health services currently conduct quality improvement activities
(including the investigation o sentinel events) using qualied privilege.
There are two types o qualied privilege schemes that a mortality review team can access.
1. The State qualied privilege scheme via the Health Services (Quality Improvement) Act
1994. The object o the Health Services (Quality Improvement) Act 1994 is to encourage
and promote the establishment o ormal quality improvement committees to review, assess
and monitor health services with a view to improving the standard o health care in Western
Australia.
2. The Commonwealth qualied privilege scheme via the Health Insurance Act 1973. The
investigation and analysis o clinical incidents reported to the Advanced Incident Management
System (AIMS) is protected under the Health Insurance Act 1973.
It should be noted that a mortality review team can undertae an inpatient death review without
qualied privilege, in which case all documents generated via the investigation process are not
necessarily protected and may be available under the Freedom of Information Act 1992 (WA) or by
discovery in legal proceedings.
7/31/2019 Western Australian Review of Mortality
10/188 Western Australian Review o Mortality
The decision about the most appropriate qualied privilege option or an individual organisation
should continue to be made at an organisational level. It should also be recognised that reviewsor investigations in some cases may also be conducted with the protection o legal proessional
privilege. When maing a decision about qualied privilege it should be noted that or investigations
carried out under privilege there are restrictions on the disclosure o inormation arising rom the
investigation. This includes inormation protected rom disclosure by statutory prohibitions and
condential patient inormation.
For inormation on:
the State qualied privilege scheme, including the disclosure o inormation, reer to the
Qualied Privilege Guidelines, available at:
http://www.health.wa.gov.au/saetyandquality/publications
the protection o the investigation and analysis o clinical incidents reported to AIMS,
reer to the Clinical Incident Management Policy or WA Health Services using the AIMS
available at: http://www.health.wa.gov.au/saetyandquality/publications
For urther inormation on qualied privilege please contact the Oce o Saety and Quality by
phone on 08 9222 4080.
7. Disclosure o Inormation
Inormation arising out o reviews or investigations is subject to restrictions with respect to what
can be disclosed to the carer or nominated relative. For urther inormation please reer to the
Department o Health policy on Open Disclosure Policy available at: http://www.health.wa.gov.
au/saetyandquality/publications
Health proessionals also have a duty o condentiality to the deceased patient and inormation must
not be disclosed where there would be a breach o condentiality. Reer to Operational Circular
2050/06 or urther details.
Public hospitals and health services are advised to reer any drat correspondence to the patients
carer or nominated relative or review by their medico-legal departments or the Department o
Healths Legal and Legislative Services Division to ensure that disclosure o the inormation is
appropriate.
8. Perormance Indicators
An organisations incidence o death is liely to depend upon a number o variables including patient
type and presentation. However, the incidence o preventable deaths can be lined with quality
improvement activities and thus may be used as an outcome perormance measure.
Perormance indicators can be used as tools to trac progress and provide a basis or the health
system to evaluate and improve perormance with respect to reducing preventable deaths.
Hospitals and Area Health Services should begin to assess and report on their perormance using
the perormance indicators provided (see Appendix 5). It is anticipated that ater the collection o
baseline data, the health system will be in a position to report on its perormance against reducing
preventable deaths.
7/31/2019 Western Australian Review of Mortality
11/189Policy and Guidelines for Reviewing Inpatient Deaths
9. Updates and Review o Policy
This policy may be updated rom time to time. The latest version o the policy can be ound on the
policies and publications page o the Oce o Saety and Quality in Health Care website at http://
www.health.wa.gov.au/saetyandquality/publications
This policy will be reviewed between January-June 2008. Particular items or review will include the:
reporting timerame;
role o the WA Audit o Surgical Mortality and other audits in relation to mortality review;
need to mandate nursing sta and/or allied health sta on mortality review teams;
minimum standards or Mortality Review;
development o thresholds and targets or a reduction o category 4 and 5 deaths; and
Mortality Review o recently discharged patients and patients on community care programs
(e.g. Hospital In The Home).
7/31/2019 Western Australian Review of Mortality
12/1810 Western Australian Review o Mortality
Appendix 1 Western Australian Audit of Surgical Mortality
The WA Audit o Surgical Mortality (WAASM) is an external, independent peer review o deaths o
patients under the care o a surgeon (whether or not a procedure has taen place). The process is
voluntary and involves two stages o condential reviews by anonymous, independent surgeons.
The rst-line review is to determine whether deciencies o care may have occurred and whether
there are useul lessons to be learnt to improve uture health care. Where a more detailed review
is required, a second-line review is undertaen by one or more dierent surgeons to identiy those
associated deciencies or lessons.
Many surgeons already participate in WAASM, which provides eedbac in the ollowing ways:
individual surgeons receive eedbac rom rst- and/or second-line assessors on their cases;
all surgeons receive summaries o second-line reviews, newsletters and copies o annual
reports;
participating hospitals receive reports on aggregated anonymous data that relate specically
to their hospital; and
annual WAASM reports that summarise the latest results are made available on the WAASM
website (www.surgeons.org). Inormation is aggregated and anonymous.
The WAASM process is limited to peer review without routine access to other team participants or
inormation, so there is a ris that any potential team, system or organisational contributors to the
death will be missed.
By being based on a oundation o system improvement, the Mortality Review Process is
complementary to the WAASM. A mortality review has the capacity to involve all team members
in the death review and to identiy any contributors to the death arising rom the team,
clinical environment or organisation. The structure o the Mortality Review Process allows or
recommendations or change to be made at the team, departmental or organisational level and then
implemented. Further, regular reporting o incidents and associated recommendations at the State
level will allow or analysis to occur across and between departments and organisations.
However, in recognition o the benets o the WAASM process and the potential or expansion o the
WAASM process to include ey elements o the Mortality Review as outlined above, it is proposed or
2006/07 that health services will determine whether or not WAASM is an acceptable audit processor each organisation. I health services consider that participation in WAASM is an acceptable audit
process then the Clinical Governance Committee must be able to:
identiy which deaths have been ully reviewed through WAASM; and
demonstrate application o WAASM recommendations.
The role o WAASM in relation to the Mortality Review will be reviewed ollowing implementation in
2006/07 to assess the practicality, the leaage rates (audits not completed), timeliness and potential
impact on patient saety.
7/31/2019 Western Australian Review of Mortality
13/1811Policy and Guidelines for Reviewing Inpatient Deaths
Appendix 2: Flow Chart
PROMOTE SYSTEM CHANGE
Recommendations or system wide attentionreported to the Chie Medical Ocer
via the Oce o Saety and Quality
Clinical Governance Units
Mortality ReviewTeam report to
Discretiono theMortalityReviewTeam
Investigationreport to
DetailedClinicalReview
Mandatory
I SE identied
Hospital/Health System
Death occurs
LOCAL CHANGES
No Yes
WA Audit oSurgical Mortality
Notication,investigation and
reporting as per SEpolicy
Death Categorisation
1 2 3 4 5
Is the death a Sentinel
Event (SE) or a death
referred to WAASM?
SYSTEM CHANGES
7/31/2019 Western Australian Review of Mortality
14/1812 Western Australian Review o Mortality
Appendix 3: Individual Death Review Documentation Sample
ProformaFor use by Mortality Review Teams
Hospital/Health Service
Clinical Department
Head o Department
Patient and medical team details:
Patient ID/code Date of Death Medical team
Mortality Review Team
Name Role
First-Stage Review Categorisation Date:
A. Is the death a nown reported Sentinel Event or a case reported to WAASM in accordance with
this policy?
Yes No urther review by the mortality review team required.
No Proceed to Part B.
B. The Mortality Review Team should categorise the death using the ollowing categories:
1. Anticipated death due to terminal illness (anticipated by clinicians and amily) and/or
ollowing cardiac or respiratory arrest beore arriving at the hospital;
2. Not unexpected death, which occurred despite the health service taing preventativemeasures;
3. Unexpected death, which was not reasonably preventable with medical intervention;
7/31/2019 Western Australian Review of Mortality
15/1813Policy and Guidelines for Reviewing Inpatient Deaths
4. Preventable death where steps may not have been taen to prevent it;
5. Unexpected death resulting rom medical intervention.
Proceed to Part C.
C. Is the case a potential missed organ donor?
Yes Report death to Head o Intensive Care Unit and Medical Director o
Donate West
D. Is the death an unreported Sentinel Event?
Yes Reer death or Sentinel Event investigation. No urther review by the mortality
review team required.
No Proceed to Part E.
E. Is death a category 4 or a category 5?
Yes Progress to second-stage review.
No Will a second-stage review be undertaen?
Yes
No
Second-Stage Review Recommendations Date:
The Mortality Review Team undertaes a methodological review and develops recommendations or
quality improvement.
Recommendations:
7/31/2019 Western Australian Review of Mortality
16/18
7/31/2019 Western Australian Review of Mortality
17/1815Policy and Guidelines for Reviewing Inpatient Deaths
Appendix 5: Proposed Performance Indicators (PI)
Mortality Review PI 1:
Numerator:
Denominator:
Multiplier:
Percentage o hospitals in an Area Health Service with a Mortality
Review process in place.
Number o hospitals in Area Health Service with a Mortality Review
process as dened by this policy.
Total number o hospitals in Area Health Service
100
Target 2006/07: 100%
Responsibility: Area Health Service level
Mortality Review PI 2:
Numerator:
Denominator:
Multiplier:
Percentage o deaths reviewed
Number o hospital inpatient deaths reviewed* within 3 months o death
occurring.
Total number o inpatient deaths in hospital.
100
Target 2006/07 = 80%
Responsibility: Hospital level
Mortality Review PI 3:
Numerator:
Denominator:
Percentage o deaths in category 4 and 5 deaths
Number o inpatient deaths categorised as category 4 or 5 within Area
Health Service.
Total number o inpatient deaths in Area Health Service
Baseline data collection only
Mortality Review PI 4:
Numerator:
Denominator:
Proportion o recommendations (arising rom category 4/5 deaths)
progressed toward implementation.
Number o recommendations being progressed.
Total number o recommendations endorsed or local implementation.
* For death, classied as categories 4 and 5, reviews must be completed within 3 months in order to meet the PI.
7/31/2019 Western Australian Review of Mortality
18/18