5Schedule

5 Schedule

The quality assurance activity described in the Schedule to this Declaration is, to the extent that the quality assurance activity relates to health services provided in Australia, declared to be a quality assurance activity to which Part VC of the Health Insurance Act 1973 applies.

Schedule 1— Description of quality assurance activity

1 Name of activity:

Alice Springs Public Hospital Morbidity and Mortality Program

2 Description of activity:

This declaration applies to the Alice Springs Public Hospital - Morbidity and Mortality Program (Activity). The Activity involves regular morbidity and mortality (M&M) meetings in which the care pathway resulting in a complication or death is discussed by the team(s) involved in the patient’s care. The meetings provide a forum for the sharing of clinical cases in an open non-punitive environment with the primary goals of learning and the improvement of patient safety.

Key components of the Activity include:

(a) introduction of a consistent and standardised reporting method for M&M meetings;
(b) standardisation of M&M meetings to include three key features, namely the event, the complications and the outcomes and recommendations;

(c) identification of clinical and systems factors that contribute to patient M&M;

(d) hospital wide discussion with input from a variety of clinical departments and subspecialties
(e) clear identification of a senior clinician and department who take responsibility for following up on recommendations recorded in the hospital recommendations register;
(f) recording of recommendations in the Alice Springs Public Hospital recommendations register, which is overseen by the clinical governance committee; and
(g) publication, in the Central Australian Health Service (CAHS) Annual Report, of information relating to:
(i) the number of M&M meetings held in the previous 12 months;
(ii) the number of cases discussed in M&M meetings;
(iii) a summary of themes that contribute to morbidity and mortality;
(iv) the number of recommendations made and the number of recommendations accepted by the CAHS; and
(v) a description of issues raised during M&M meetings and any recommendations that arise from assessing safety and quality systems at the Alice Springs Hospital.

Access to identifying information is limited to the Quality Assurance coordinator, the Executive Director of Medical and Clinical Services and Northern Territory Department of Health Legal Services.