Western Australian Review of Mortality

7/31/2019 Western Australian Review of Mortality

1/18


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.


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.


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



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.



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.



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.



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);



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.



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.



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).



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.



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



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;



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:


16/18



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


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


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


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.


18/18

Date post:	05-Apr-2018
Category:	Documents
Upload:	siusiuwidyanto
View:	219 times
Download:	0 times

Western Australian Review of Mortality

Documents