Background
Structured Judgement Reviews (SJRs) are commonly used in acute hospitals, community trusts and ambulance services to review deaths, identify learning and improve patient care. Since 2017, many NHS organisations have been required to carry out these reviews, but hospices and community palliative care services have not. With around 25,000 people dying in hospices in England each year, representing around half of hospice admissions, there is a significant opportunity to learn from patient deaths and use this information to improve care. Increased focus on patient safety, learning from deaths and the introduction of the Medical Examiner system have led to growing interest in applying SJRs within hospice and community palliative care settings.
Aims and Objectives
The project aims to support learning from deaths in hospice and community palliative care services by adapting and implementing Structured Judgement Reviews for these settings.
The objectives are to:
- Adapt the Royal College of Physicians’ Structured Judgement Review methodology for hospice and community palliative care services.
- Develop practical tools and training packages to support implementation.
- Help organisations identify learning from patient deaths and use this to improve care quality, patient safety and family experience.
- Promote cross-organisational learning and reduce duplication of improvement activity across hospice services.
- Recognise and celebrate examples of excellent care to support staff wellbeing and retention.
Methods
The project adapted the Royal College of Physicians’ Structured Judgement Review tool to create two new versions tailored specifically for:
- Inpatient hospice care.
- Community palliative care services.
To support implementation, the team developed:
- A hospice-specific SJR training programme.
- A three-hour workshop that can be delivered face-to-face or virtually.
- A flexible virtual training option including a recorded presentation, self-directed SJR completion and facilitated feedback session.
- Hospice-specific case studies and training materials.
Further Information
- Theme: Implementation and Improvement Science.
- Study duration: August 2023 onwards.
- Key outputs already available include:
- Adapted hospice and community palliative care SJR tools.
- Training workshops and implementation support.
- Ongoing advice and troubleshooting from the Improvement Academy.
Potential benefits include:
- Improved patient care and safety in hospice and community palliative care settings.
- Better patient and family experiences.
- Increased staff wellbeing through recognition of excellent care.
- Learning and improvement across organisations.
- Identification of health inequalities and opportunities to improve care for underserved groups.
- Organisational assurance and evidence for regulators such as the Care Quality Commission (CQC).
The learning from this project could be applied across approximately 200 hospices in England and has potential relevance internationally.