The Mortality Review Committee is a standing hospital committee responsible, through its chairman, to the Hospital apex committee. It is a policy recommending committee who provides instruction and guidance to the medical staff and administration of the hospital on various issues pertaining to Mortality Cases.

Scope

Applicable for all medical staff and administration of the hospital

Constitution of the committee

• Surgical Oncologist
• Medical Oncologist
• Anesthetist
• Radiation oncologist
• Clinical assistant
• Nursing HOD
• Nursing Supervisor
• Quality manager

The chairman shall have the authority to invite any non-member to attend the meeting if it is deemed fit in relation to any matter being/ or to be deliberated by the committee.

Quorum

The minimum quorum for passing any resolution in the committee is more than 50%.

Following members to be mandatorily present in the committee to pass a resolution
– Chairman

Frequency of meeting

Members of the committee meet once in two months.

Selection of members

1. Chairperson – Selected by the chairman of Apex Committee
2. Secretary – Selected by the chairperson, he or she is also a member of the committee
3. Members – Selected by the chairperson

Responsibilities

• All death cases are sent to the concerned department consultants for review along with the review form by the committee secretary
• Each death case is reviewed at least by 2 consultants
• Based on the review, consultants put their impression in the review form and mention whether the case needs to be discussed or not
• As per the review made by the consultants, cases that need discussion is picked for discussion during the meeting
• The death summaries are obtained from the MRD and they are analyzed with the case sheets by the committee
• Those issues that needed explanation or rectification is looked into detail by the committee
• The committee shall also follow up with the departments concerned for the corrective action taken based on the issue and also give their recommendation and suggestion for the nonoccurrence of those kinds of incidents
• Any such recommendations and suggestions and corrective action done of the previous meeting shall be discussed first and then proceed with the present affairs
• To develop strategic plans and methodologies that are designed to reduce mortality and that are relevant to the Committee’s functions

Role of Chairperson

Acts as a liaison between the Mortality Review Committee members and the apex committee chairperson
Receives all the information pertaining to the Mortality Review Committee and initiate necessary action as required
Keep oneself abreast with the recent developments in the field

Role of secretary (Member Secretary)

• Prepare the agenda for the next meeting
• Submission for approval of agenda by the chairperson
• Inform the committee members regarding the next meeting at least 2 days before the meeting
• The minutes of the meeting shall be prepared by the secretary
• Get the approval of minutes by the chairperson
• Circulate the agenda approved by the chairperson to the members and the concerned persons
• To maintain all records ( as per list) related to the committee
• Submission of a copy of the agenda and the minutes of the meeting to the quality department after getting a signature from all the concerned members

Agenda

Agendas for the meeting shall be prepared by the secretary in consultation with the chair person and signed by the chair. Then it is sent to all committee members and other experts. The agenda shall be sent to all at least 2 days before the scheduled meeting.

A meeting shall be called even by an oral / telephone communication in case of an emergency meeting. A justification for the emergency meeting has to be given.

Minutes

• Shall be prepared by the secretary
• MoM is sent to the chairperson for the approval within three days of the meeting
• After the approval of the minutes by the chairperson, the approved minutes are circulated within 2 days of the meeting to all the committee members and the person concerned for implementation
• A copy of the agenda and minutes of every meeting shall be sent to the quality manager by the member secretary

Decision making

A thorough discussion of the agenda shall be done by the committee members and based on their suggestion and recommendations the issue shall be weighed. Also as and when needed any kind of trial study may be performed and based on the outcome of it the committee will decide on that issue.

The decision of the committee will be finally taken by a majority vote and that shall be implemented.

Records to be maintained

1. List and details of all members
2. The TOR of the committee
3. Copy of all agendas, minutes of all meeting
4. Attendance sheet
5. Copy of any other correspondence to the committee members or non-members
6. Copy of any study conducted for the sake of the committee