Number of Quarterly Mortality Mortality & Any shortfalls Morbidity eligible reports to the Learning identified will have Group, deaths Board an action plan put in Quality reviewed, place to address Assurance including LD which will have Committee, deaths Public Board timescales included specifically. for re-audit / monitoring. 2 Quarterly Mortality Any shortfalls Mortality & Morbidity mortality reports to the Learning identified will have Group, review Board an action plan put in Quality outcomes to address which – Assurance avoidability will have timescales Committee, score Public Board included for re-audit / monitoring. Time taken Monthly Mortality Mortality & Appropriate action Morbidity to return reports to Learning as necessary by Group mortality directorates the MMG where review forms and the Trust specialties/ Mortality & directorates are Morbidity identified as not Group meeting the required timeframe for review (30 days from request). Performance Monthly IQPR Mortality Mortality & Alerts will be Morbidity against key Learning investigated Group, Trust mortality accordingly in Board metrics collaboration with the – crude death Clinical Coding rate, HSMR Team and relevant and SHMI specialties.
Number of eligible deaths reviewed, including LD deaths specifically. Quarterly reports to the Board Mortality Learning Mortality & Morbidity Group, Quality Assurance Committee, Public Board Any shortfalls identified will have an action plan put in place to address which will have timescales included for re-audit / monitoring. 2 mortality review outcomes – avoidability score Quarterly reports to the Board Mortality Learning Mortality & Morbidity Group, Quality Assurance Committee, Public Board Any shortfalls identified will have an action plan put in to address which will have timescales included for re-audit / monitoring. Time taken to return mortality review forms Monthly reports to directorates and the Trust Mortality & Morbidity Group Mortality Learning Mortality & Morbidity Group Appropriate action as necessary by the MMG where specialties/ directorates are identified as not meeting the required timeframe for review (30 days from request). Performance against key mortality metrics – crude death rate, HSMR and SHMI Monthly IQPR Mortality Learning Mortality & Morbidity Group, Trust Board Alerts will be investigated accordingly in collaboration with the Clinical Coding Team and relevant specialties.
Responding%20to%20Deaths%20Policy%20-%20POLCGR130.docx