About the project
Subsequent to the publication of the national report on compliance with all 12 national clinical standards for neurosurgery in 2013, the Network audited selected criteria from individual clinical standards, choosing the standards in response to concerns or pressures within the service. Within the 12 standards there are 83 auditable criteria.
This project focuses on two criteria from Standard 10 Quality of Care – evidence based:
10.2 Regular mortality and morbidity (M&M) meetings will take place and clinical staff will have sufficient time to prepare for and attend these meetings
10.3 Where there are national programmes for audit, all centres will participate.
Aims
- To promote a governance framework that ensures lessons are learned by the multidisciplinary team and there is commitment to ongoing evidence-based improvement in clinical care.
How do we achieve this?
Morbidity and mortality (M&M) meetings are a key learning tool for doctors and the wider multidisciplinary team. A recognised challenge is how to ensure learning from adverse events is shared with the wider team and steps are taken to ensure risk is reduced. The MSN has shared Healthcare Improvement Scotland methodology with the four centres and offered our support to adopt the governance components that will ensure M&M meetings result in meaningful change.
An audit of compliance with the HIS recommendations was undertaken in April/May 2018. The 2018 audit provides a baseline for improvement work.
Outcome
We reported on the results of the audit in October 2018. NHS Tayside and NHS Grampian demonstrated robust governance processes in relation to their adult M&M processes which are supported by the MSN team. Areas for improvement were identified in both NHS Lothian and NHS GG&C and the MSN will work with both units to support their respective processes.