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. 2023 May 30;12(2):e002230. doi: 10.1136/bmjoq-2022-002230

Table 1.

Project plan for 12-week engagement between MC and SSMC

Implementation Content
Introduction
(weeks 1–3)

  • Organisational overview of SSMC.

  • Introduction to SSMC core engagement partners.

  • MC Global Quality Consulting Team:

    • Key objectives, scope and deliverables.

    • Engagement timeline.

    • Allocated resources.

    • Assessment of organisational structure before MC CRP implementation.

  • Current SSMC mortality review activities: strengths, weaknesses, opportunities and threats analysis.

  • SSMC-associated key performance indicator metric review and regulatory requirements.

  • Access to SSMC electronic health record (legal/technical considerations).

  • High-level overview of education/training approach.

  • MC CRP in detail: principles, cadence, output and goals.
Huddle review and comprehensive review
(weeks 4–6)

  • Purpose and value:

    • How the MC CRP work intersects with the clinical practice, patient safety, risk management and committees.

  • Composition, frequency and logistics:

    • Clinician and nurse perspective.

  • Key review elements, template use, and documentation.

  • Use of MC standardised opportunity taxonomy (mortality indicators):

    • Establish SSMC’s review indicators via consensus and definition.

  • Case review and outcome tracking.

  • Use case demonstration.

  • Multireview opportunities.
Mortality review subcommittee
(week 7)

  • Purpose and value:

    • Fostering a fair and just culture.

  • Composition (multidisciplinary), frequency and logistics.

  • Case review discussion and mortality indicator validation process:

    • Review consensus ‘indicators’ (ie, a taxonomy for categorising opportunities for improvement consistently across cases and reviewers).

  • Determination of performance improvement opportunities or organisational escalation of issues (eg, root cause analysis, peer review):

    • How MC CRP complements other clinical care reviews.

  • Case discussion and outcome tracking.
Closing the loop
(week 8)

  • Purpose and value.

  • Multiple practice communication methods.

  • Accountability: use of practice quality improvement champions.

  • Use of single-case and multi-case learning for organisational improvement of clinical care:

    • Closing the loop: converting analysis into improvement action and dissemination of learning.

  • Organisational sharing of best practices.
SSMC use cases
(weeks 9–11)

  • Coaching with cases reviewed by both MC and SSMC personnel:

    • Discuss the value of multidisciplinary reviews (eg, medical specialties, pharmacy).

    • Review of indicators and selection rationale.

    • Discuss next steps with opportunities for improvement.

  • Readiness assessment:

    • Comfort of SSMC with conducting reviews.
Conclusion
(week 12)

  • Review of engagement key objectives and deliverables.

  • Plans for ‘train the trainer’ MC CRP approach at SSMC.

  • Lessons learnt.

  • Monitoring plan.

  • MC CRP future capabilities.

  • Plan for a 1-month touchpoint meeting and subsequent meetings as needed.
Touchpoint meetings
(weeks 16 and 20)

  • Evaluate the CRP at SSMC, answer questions regarding implementation.

  • Review examples of closing the loop letters and closing the loop process.

  • Engagement closure.

CRP, Care Review Process; MC, Mayo Clinic; SSMC, Sheikh Shakhbout Medical City.