Beyond Learning from Deaths: Supporting Clinical Teams Across the NHS in Progressing Digital Aims Around Clinical Outcomes

It is arguably more crucial now, more than ever, that public health takes stock of its pandemic learnings as we continue to navigate the biggest crisis the NHS has faced. It continues to become more and more clear that we need to learn from in-hospital mortalities, and apply these findings into future care delivery to support clinical and medical teams in managing demand and preventing as many in-hospital deaths as possible.

To actualise this endeavour, healthcare professionals have recently joined forces in sharing crucial learnings from the pandemic. Under the guidance of Draper & Dash, top health executives have armed themselves with critical knowledge and evidence to enhance their learning from death initiatives. 

Draper & Dash’s Learning from Deaths and Clinical Outcomes Workshop united multiple NHS teams, who shared best practices and approaches to incorporating learning from deaths across clinical care. With Royal Berkshire’s NHS FT Associate Director of IT, and Midlands regional NHS Medical Examiner presenting on their local approaches to the topics at hand, the workshop attendees worked together to address questions such as how in hospital mortality learnings can help us to pre-empt patient pathways and risk in an intelligent manner; specifically, the workshop focused on the available tools that healthcare executives could use to support local support and review teams. 

The Workshop Community

In discussion with Draper & Dash’s Orlando Agrippa, as well as Eghosa Bazuaye, RBFT’s Associate Director of IT, workshop attendees learned how digital tools can support learning from death processes. Specifically, they engaged with RBFT’s digital approach, as supported by Draper & Dash’s Clinical Outcome Review System.

Regarding the session, Orlando Agrippa praised the conversations spurred by his esteemed colleagues:

“The Draper & Dash team was delighted by the vivacity and breadth of discussions upheld by our colleagues during the Learning from Deaths and Clinical Outcomes workshop. Through consistent communication and the implementation of digital tools such as CORS, clinical teams across the country are working in unison to progress local frameworks to support MEs, and will most certainly improve and progress their practices, particularly with digital support.”

To bolster their gained understanding of data-driven mortality review solutions, the attendees interacted with Midlands Regional NHS Medical Examiner Benjamin Lobo. Lobo facilitated a open forum workshop, supporting medical and clinical teams across the NHS in their aims to progress on internal learning from deaths and clinical outcomes priorities. In sharing their approaches in these areas, the attendees reviewed successes and bottlenecks they have seen in their positions within their Trusts, with perspectives and approaches

shared from individuals across a range of roles and departments, such as Medical Director, Learning from Deaths Lead, Patient Safety Lead and Consultant.

‘It was great to understand where other teams were at in the process of implementing digital approaches. From a community Trust perspective, it was really useful for our team to consider the next steps in improving ME services after the pandemic, particularly with regard to optimised data management’

Addressing Real Life Challenges

In breakout sessions, the workshop attendees analysed a number of real-life questions, based on the specific priorities highlighted by attendees in a pre-workshop survey, and discussed the different approaches Trusts have had to specific situations around clinical outcomes. They surveyed learning from deaths measures that health teams could incorporate back into clinical care, as well as how these findings could be effectively reported to the board. The attendees then gathered feedback, commented on valuable discoveries and critiqued challenges they encountered throughout the process. 

Some of the issues discussed included the current approaches and processes Trusts use in their Learning and Deaths framework. Within their operations, the attendees and facilitators worked together to identify constrictions and better alternatives in tracking progress, successes and key learning outcomes from in-hospital mortalities. Much of these opportunities for optimisation were gathered in challenging traditional ways of documenting process from ME scrutiny through to SJR; and many agreed that data-driven capabilities could enhance advancements in this area. 

‘The discussions on challenges, actions and solutions in implementing the CORS tool was valuable to us all. In terms of addressing core issues, the CORS tool and its functionality certainly provide a way for ME teams to gain better insights into the digital involvement within mortality reviews and opened up a number of learning opportunities to support us in making pre-emptive changes in our clinical care.’

Furthermore, the attendees noted on the various improvements and changes they have seen since The Learning from Deaths framework was introduced over three years ago. With regards to novel approaches to information collection, reports, and data learning, the general consensus was that digital capabilities improved clinical care overall and that Trusts as a whole required more support in setting up local frameworks and processes in these areas.

The CORS Solution

Core findings from Draper & Dash’s Learning from Deaths Clinical Outcomes Workshop covered multiple issues and solutions. Attendees, facilitators and the Draper & Dash team identified how the increased emphasis on avoidance, rather than structured reviews of care proved detrimental to quality review delivery. Further, they noted how several logistical challenges, such as temporary care notes, revealed a great need for digital tools and overall support. 

These hindrances manifested a critical need for solutions like Draper & Dash’s CORS platform, which could address: the reduction mortality review forms submitted, reduction in ME office, significant backlogs of required reviews, and limited resources. Tools like CORS are necessary in supporting reduced elective activity, late presentation and difficulty in analysing mortality data. 

Draper & Dash’s CORS was developed with the aim of providing all Trusts with an easy to use and dependable way of reviewing mortality. Equipping hospitals and health systems with the tools to properly review clinical processes and outcomes is key to ensuring the same mistakes are not made again. By ensuring that healthcare providers can easily access necessary analytics pipelines, CORS can help health teams improve patient outcomes and, ultimately quality of care. 

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