1. Changing the Narrative of Safety Reviews in Healthcare
Healthcare Improvement Scotland Scottish Mortality and Morbidity Programme.
Could this Work Across Health and Social Care?
Manoj Kumar Manoj_K_Kumar
Brian Robson

2. “How Safe Is Our Care?”

4. TRAINING Patient Safety DoC TIME MONEY/RESOURCE MEDICO LEGAL
Joy in Work
Realistic Medicine QI
MONEY/RESOURCE
Mortality /Case Note Reviews
Human Factors/Ergonomics
COMPLAINTS
National Audits
Patient Safety
Fatal Accident Inquiry
Adverse Event
DoC
MEDICO LEGAL
WMTY .
TIME
PERSONAL REFLECTION
TRAINING
TEAM REFLECTION

5. -
WORK AS IMAGINED
WORK AS DONE

6. Courtesy: Neil Patel

7. Courtesy: Neil Patel

8. >50% Learning - Infrequent/ Rare/ Never
SMMP National Survey
88.1%
M&M or similar peer review meeting
>50% Learning - Infrequent/ Rare/ Never
Significant variation
Output
?Culture
? £££

9. EFFECTIVE REVIEWS
SYSTEMS THINKING
SHARED LEARNING
IMPROVEMENT THROUGH COLLABORATION
EFFECTIVE GOVERNANCE

10. System/ IT/ Logistics Knowledge/ Training Shared Learning
Scottish M&M Program
System/ IT/ Logistics
Designing effective systems
to support the process
Human Factors
Quality Improvement
Knowledge/ Training
Shared Learning
Embedding
skill set
Learning
for Improvement

11. care and compassion
dignity and respect
openness, honesty and responsibility
quality and teamwork

13. Guidance/ Tools/
Framework
SMMP Workshop

14. Undergraduate Professional Practice Block
A new generation of NHS Scotland workforce
Safety reviews
Human Factors QI

15. Poor Design Poor Engagement Poor Outcome
Responsive
User friendly
‘Memory’
Links to simulation/ training
Supports Learning & Improvement

16. Systems- Based Framework for Safety Review (M&M) Analysis
Seek multiple perspectives
Consider Work Conditions
Analyse Interactions and Work Flow
Understand Why Decisions Make Sense at the Time
Learning Value of Case
HF/E
Safety 2 QI
Just Culture
Psychological Safety

17. “You can’t change the culture” M&M Meetings – ‘Toxic’
“The M&M Process can be non-judgemental, fair and a genuine learning and improvement process” (Trainee)
“…. positive effect on trainees/ trainers..”.
“....process has allowed trainees/ staff to to confidently raise concerns ...feel reassured that they will be addressed in a learning environment.”
... .We have had some fantastic learning opportunities so here's hoping the process can go from strength to strength. (Senior Charge Nurse)
“We feel that the overt linkage between Datix and the QI (M&M) meetings is a particular strength"  (Scottish Deanery)

18. “Doctors/ Staff do not engage/ poor at reporting” ?

19. Improve reporting by improving available systems
Integrated Incident Reporting System with M&M meetings

22. Coming together is a beginning Staying together is progress and working together is success
Henry Ford