Shared Clinical Review Across Four Rural Health Services

A project to implement a shared mortality and morbidity clinical review process across four small rural health services  in northeast Victoria. The project includes development of standardised tools and the formation of a collaborative clinical review forum to help address the common risks experienced by patients in care at small rural health services in the region.


By 1 July 2018, the four small rural health services of Beechworth Health Service, Tallangatta Health Service, Corryong Health and Alpine Health will have implemented a standardised and shared mortality and morbidity clinical review process.


  • Identification of common problems and deficits in patient care to prevent recurrence.
  • Monitoring for the early recognition of regional adverse trends in care if they arise.
  • Shared information about the patient journey across services to improve understanding of issues faced by counter-party services.
  • A standardised review process for clinical staff.
  • Benchmarking between services to encourage quality improvement.
  • Reduction in unnecessary patient transfer between services.
  • Improvement in response to deteriorating patient at small rural health services.


In recent years, there have been several instances in Australia and other countries, of failure to recognise clusters of adverse events when they occur in mainstream healthcare services. Analyses of these instances have pointed largely to a failure of clinical governance systems responsible for the ongoing monitoring of patient care.

In response to this concern, there have been a number of reviews conducted with recommendations for improvement. In Great Britain, the Kings Fund Review into Clinical Governance of the NHS, (2015), recommended alignment of clinical governance measures between the larger networks and local services.1 In Australia, the Travis Report (2015) into increasing hospital capacity recommended that health services of the Hume region in Victoria ally to better provide integrated regional and rural responses.2 Most recently the Targeting Zero Report of Hospital Safety and Quality Assurance in Victoria (2016) recommended that all smaller hospitals demonstrate that they have negotiated formal agreements to involve external specialists in clinical governance processes for each of their main areas of activity including morbidity and mortality review.3 This shared mortality and morbidity clinical review process is seen as an important step to address the recommendations and ensure safe care for the communities of the region.


  1. Assessed the current processes by visiting each of the participating organisations and reviewing their current process and documentation. This also enabled us to determine who were the key contact and operational personnel in each of the organisations.
  2. Established a local team comprised of staff from the quality department, clinical staff, and medical records staff, to undertake analysis of the findings of Step 1. From these findings a fit-for-common-purpose policy, tools and other documentation were created to standardise the process across participating organisations.
  3. Revision of the policy, tools and reports (the kit) was undertaken with involvement from key personnel at each organisation.
  4. Testing of the process, tools and reports was then carried out by each of the organisations to determine the appropriateness of the workload distribution that the process would create. The testing results led to further refinement of the process to resolve any workload imbalance.
  5. A workshop was held to discuss the changes and receive feedback for any further refinement. The workshop included members of the participating organisations as well as the governance team. Final minor amendments to the process and tools were made following this workshop.
  6. Regular reporting to the governance group, including presentation of the final draft kit. The governance group then endorsed the policy and associated tools and processes, and all member organisations agreed to undertake local approval of the policy in accordance with their local policy endorsement procedures.


Implementation – The project is ready for implementation or is currently being implemented, piloted or tested.

Key dates

July 2017

  • Planning
  • Formation of Governance Group

September  2017

  • Assessment of previous and existing clinical review processes
  • Best practice research for mortality and morbidity inclusion events

December 2017

  • Testing revision and expansion of inclusion events with governing group
  • Formation of draft process flowchart inclusive of external cross-facility compliance testing
  • Development of generic policy

January 2018

  • Development of process tools including event capturing tools, screening & clinical review tools, measurement and reporting templates

March 2018

  • Facility testing of process and tools
  • Revision of process based on testing

June 2018

  • Workshop step-through testing of flowchart and tools

July 2018

  • Agreement to adopt generic process into facility policy systems
  • Agreement to pursue measurement and benchmarking measures

Implementation sites

  • Beechworth Health Service
  • Corryong health Service
  • Tallangatta Health Service
  • Alpine Health Service


  • Rural Health Academic Network


  • By 1 July 2018 all four health services had agreed to implement and had introduced the policy into their approval systems for adoption.
  • Agreed to formally start reviewing patient files by 1 August 2018
  • The project focus has moved to developing the terms of reference, the meeting schedule, and agenda template for the regional common review forum, which will further embed the clinical review process into practice.
  • The participating organisations have also discussed introducing benchmarking tools and agreed to adopt a common sharing of data.

Lessons learnt

  • Important to have governing group support (CEOs)
  • Small rural health services are more likely to encounter perceived conflict of interest where clinical staff who have cared for patients are also called upon to conduct the review process. Need to have alternative trained personnel available to screen and/or review files as required.


  1. Ham C, Raleigh V, Foot C, et al. Measuring the performance of local health systems: a review for the Department of Health. London: The King’s Fund. 2015.
  2. Travis, DG. Travis Review: Increasing the capacity of the Victorian public hospital system for better patient outcomes. Melbourne: Doculink. 2015.
  3. Duckett S, Cuddihy M, Newnham H. Targeting zero: Supporting the Victorian hospital system to eliminate avoidable harm and strengthen quality of care: Report of the Review of Hospital Safety and Quality Assurance in Victoria. Melbourne: Victorian Government. 2016.

Further reading

  • Ben-Tovin D, Woodman R, Harrison J, et al. Measuring and reporting mortality in hospital patients. Canberra: Australian Institute of Health and Welfare March 2009.
  • Shaw, C. Principles for Best Practice in Clinical Audit. In Health Information Management Journal. 37(2):9-18. NHS Institute for Clinical Excellence, Radcliffe Medical Press.


Shell Morphy
Director of Excellence & Innovation
Beechworth Health Service
Phone: 0357 280 252


Fill in our feedback form to find out more about this project or get in touch with the project manager.

Is this your project?

Fill in our feedback form to update your story or contact details.

Browse similar projects

Unwarranted clinical variationEfficiencyAlbury Wodonga HealthRural and regionalClinical Leadership Program
Back to top