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    About the framework

    We developed a framework and toolkit to guide Morbidity and Mortality (M&M) meetings. This will provide health services with a systems-based and Just Culture approach to the M&M case reviews and discussions.

    Using the framework and toolkit in M&M meetings will help health services to:

    • improve the quality and consistency of M&M meetings
    • improve staff psychological safety in meetings
    • develop stronger recommendations to improve quality and safety of care.

    Background

    There is currently no standardised format for M&M meetings in Victoria.  A structured, systems-focused review process will:

    • guide clinicians to examine complex systems interactions
    • increase the likelihood of future adverse event reporting
    • identify and theme system issues for broader organisational improvement.  

    The framework and toolkit were developed and piloted with 11 Victorian health services, ranging from small rural to metropolitan. These health services tested the framework and toolkit during their M&M meetings, providing valuable feedback to further improve their sector suitability.

    Feedback

    We encourage you to provide feedback on the M&M Framework. 

    For inquiries, access issues, or to request an accessible version, please contact The Response and Development Team at culture.capability@safercare.vic.gov.au

    Related publications

    SCV has also worked with the Department of Health to develop Regional Maternal and Perinatal Morbidity and Mortality Committees Guidelines. The guidelines were developed in consultation with the Regional Maternal and Perinatal Morbidity and Mortality Committees to support their review of maternal and perinatal mortality and selected morbidity cases with all regional and rural maternity and newborn services in Victoria. 

    The committees provide a further layer of review for all public health services in regional and rural Victoria, providing additional support and governance expertise, especially for smaller services.

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