Morbidity & Mortality Meetings: Using safety science to drive effective discussion

Ms Yvonne Singer1,2, Ms Heather Cleland1,2,4, Ms Andy Kattula2, Dr Margaret Way3, Ms Nicole Rasmussen2

1Victorian Adult Burn Service, The Alfred, Melbourne, Australia, 2Alfred Health, Melbourne, Australia, 3Sunshine Coast Hospital and Health Service, Sunshine Coast, Australia , 4Monash University, Department of Surgery, Melbourne, Australia

Abstract:
Learning from outcomes of care is fundamental to improving patient safety but it can also be a challenging and delicate matter. There is often a focus on what happened at the “pointy end” of care, and it can be difficult to unpack the underlying system factors.

To improve patient safety at the Victorian Adult Burn Service (VABS), PROCESS SCREEN, a structured checklist based in safety and quality improvement science, and developed in the Clinical Governance Unit at Alfred Health, has been implemented to facilitate Morbidity & Mortality Meeting (M&MM) discussions.

PROCESS, the first checklist, helps identify key events in the process of care and how these unfolded to determine where in the story we could do something differently next time. It explores themes of planning & decision making, recognising & responding, outcomes, communication & coordination, escalation, staffing & supervision. These events make the cornerstones of reviewing our systems of care.

SCREEN, the second checklist, helps staff identify factors in our systems of care that influenced why those events unfolded the way they did. It explores themes of standards of care, context & culture, routines and teams, environment, experience and training, and considers what we would do differently next time.

Using an illustrative scenario developed for training, this presentation provides a summary of the PROCESS SCREEN framework and how it is used at the VABS. PROCESS SCREEN has focused our efforts on system improvements, using a structured approach to engage clinicians in M&MM discussion and drive effective outcomes.

Biography:

Yvonne was born at the Alfred and she went away for a while to go to school and came back as a Graduate Nurse in the 90s and hasn’t left.

Yvonne is the Burn Program Coordinator at the Victorian Adult Burn Service at the Alfred Hospital in Melbourne.  Yvonne has worked at the Alfred for over 25 years and has been working in the field of burns for over 15 years in various positions including Clinical Nurse Specialist, Educator and Care Coordinaor.

Yvonne is the Australian Vice President of the Australian & New Zealand Burn Association and past Chair of the ANZBA Nursing Committee. She is a member of the Steering Committee for the Burn Registry of Australia & New Zealand and a member of the ANZBA Burn Prevention Committee.

She is a 2007 Churchill Fellow and her interests include quality improvement, patient safety, registry science, clinical practice guidelines development, education, prevention and sustainable workforce planning

About ANZBA

ANZBA is a not for profit organisation and the peak body for health professionals responsible for the care of the burn injured in Australia and New Zealand. ANZBA encourages higher standards of care through education, performance monitoring and research.

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