Content, Featured, Interview

Opinion: A Clinical Outcomes and Mortality Challenge

By Orlando Agrippa, CEO, Draper and Dash

Hospital mortality continues to be a serious concern, a subject of much conversation so much so that in 2017, the Learning from Death initiative was implemented across the NHS to systematically review mortality in an effort to ensure providers were learning from the deaths of those in their care and to guarantee measures were being taken to improve the quality of care in their organisations. This initiative is being further extended with the introduction of the Medical Examiner role and the Structured Judgement Review (SJR) process due in April 2019, to further ensure providers are taking every opportunity to make improvements.As far as patient outcomes go, mortality is pretty much the worst outcome for many patient or families.

As one can imagine, hospital mortality is not a simple problem, and for me personally it is an area of focus as it was around 2010 that I was a part of an excellent task force and transformation team within a leading NHS hospital. The CEO, COO, CHAIR and the entire team were truly one of the finest I’ve had the pleasure of working with. The trust was hailed as one of the best but within months was under review for quality and specifically mortality being a key issue. This then started a cascade of events that would last years as the hospital investigated the mortality issues and different ways they could learn from their mistakes. Since then I have been focused on establishing how we support health organisations deal with the issue of hospital mortality and outcomes.

Fast forward a few years and we have seen an increase in hospitals being in the press for failings in patient care, whether it is in maternity care or the management of sepsis patients. With hundreds of patients passing through hospital doors each day with no issues, there is a significant number of patients who are admitted to hospitals for seemingly non-life-threatening illnesses and unfortunately die in the hospital from avoidable conditions. It is recognised that between 3 – 5% of all in hospital deaths could potentially be prevented. Safety problems in these patients broadly reflect those arising in the emergency pathway and in general ward care, ranging from poor clinical monitoring, insufficient response to deterioration, poor sepsis management, medication issues and a list of issues longer than my weekly grocery shopping list.However, it is important to remember that hospital death rates are also influenced by the characteristics of the hospital (e.g. if it provides specialist services), the characteristics of the patients (if they are older and more likely to die) and the availability of other provisions such as local care services, as these take pressure off hospitals and thus decrease mortality rates in hospitals. When it came to building our Clinical Outcomes Review System (CORS) platform we developed with this in mind.

Draper & Dash have worked in partnership with NHS trusts, to develop and release a Clinical Outcome Review System (CORS) platform in anticipation of the new national mortality mandate. The CORS system encompasses recommendations from the Learning from Death initiative, as well as the most recent Medical Examiner and SJR mandates, in one streamlined and easy to use platform. It also embodies our own experiences of working with partner organisations in combating hospital mortality.

The CORS is purposefully designed, as the name suggests to be an all-encompassing clinical outcomes review platform. The system includes a built-in mortality dashboard created in line with the new mortality standards as well as the ability to for organisations to commission their own app, and have access to other free apps created by other trusts, developed with the aim of promoting shared learning and best practice in managing the mortality review challenge.

Draper & Dash are committed to helping health organisations to provide exemplary patient care and our CORS platform aims to provide all trusts with an easy to use and dependable way of reviewing mortality. We believe that 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, and ultimately works to provide better patient care at all points in the patient journey.

We are already looking at how we integrate our predictive outcomes algorithms into the platform, which will allow clinical and quality leads to understand which patients might be at risk of adverse outcomes so action can be taken quickly.

For a demo and free trial of our CORS solution please contact