3 Auditing deaths that occur at the health-care facility This chapter provides an overview of considerations for initiating a system for reviewing stillbirths and neonatal deaths that occur at a health-care facility, and the process required to walk through each of the steps of an in-house mortality audit cycle at the health-care facility level.
3.1 Setting up the system In many health-care facilities, local in-house mortality reviews are conducted as standard clinical practice and risk management. This is not always the case, however, even in facilities where there are large, multidisciplinary teams operating in well-resourced settings; but often some form of review is part of an ongoing quality improvement processes. A good principle is to review what already exists, start small and scale up gradually. A phased approach to scaling up may be applied: following introduction and institutionalization in one or a few facilities, expand the audit system to other locations, moving towards greater coverage (Figure 3.1). This chapter describes the process of introducing the mortality audit approach at an individual health-care facility, while the process of scaling up to a regionalor national-level system is described in Chapter 6. A positive enabling environment at the national and/or regional level will make it easier to move through the various phases of the mortality audit process, but it is possible for an inhouse process to start and thrive without initial external support from authorities at that level. In the pre-implementation phase, the right stakeholders need to be involved to establish the programme and raise awareness about it. In some settings, audits may be linked to existing quality improvement initiatives. If a quality improvement committee is already in place, it can be engaged to support the formation of a facility-level steering committee that will prepare cases for review and rotate facilitation of the audit meetings (Annex 5). This committee could be combined with an existing maternal death review committee, or just closely linked to it (Box 3.1), but either way, the committee should be well institutionalized within the system. The steering committee’s role includes the overall responsibility for operationalizing the audit policy, providing technical assistance for the implementation of audit systems, and monitoring recommendations and follow-through. Midwives and obstetricians are in a natural position to lead the audit process, given their knowledge of the burden of intrapartum deaths. In South Africa, midwives drive the national mortality audit process, called the Perinatal Problem Identification Programme (PPIP) (41). However, recording the details of first-day and later neonatal deaths also requires crossover with other departments and specialities such as paediatrics, neonatal nursing, emergency, outpatients and pharmacy. In Brazil, for example, paediatricians hold leadership positions on perinatal review committees. In Uganda, stillbirth and neonatal death review has been successfully initiated and sustained by midwives and community representatives (42). A facility-based mortality audit committee should include representatives of various departments, and stakeholders from among the facility’s management team and the district medical office as well as a community liaison, if applicable. In some settings, the range of committee participants may be even further expanded (43). In the United States, multi-agency child death review involves coroners, law enforcement officers, child protective services and health-care providers (44), and in England, each local authority has established a multidisciplinary child death overview panel to review all child deaths (from birth to age 18) in their area (45). However, such a wide stakeholder group is not essential. Involving the legal system, in particular, can undermine a collaborative environment in which shortcomings in care are openly discussed. While accountability is needed, the mortality audit process should focus on the ability of health professionals to identify opportunities to improve the health system, not assign blame. MAKING EVERY BABY COUNT: AUDIT AND REVIEW OF STILLBIRTHS AND NEONATAL DEATHS 29
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