Review of the national mortality review function
The Health Quality & Safety Commission (the Commission) has commissioned an independent review of the national mortality review function (NMRF).
Background
In September 2021, Francis Health was commissioned to undertake an independent review that looked at the ‘first principles’ of mortality review as a function. Based on these findings, a blueprint for a transformed mortality review function was developed for the Commission board to consider.
Recommendations and final report
The Commission board agreed to four key recommendations from the report that set out the structure of a transformed NMRF:
- Within the Commission, a single strategic National Mortality Review Committee will be established.
- Current mortality review committee (MRC) members will be invited to become subject matter and representative experts within the workstreams of the NMRF.
- All current secretariat staff will transition and form part of the NMRF business unit, which will support the NMRF to fulfil its purpose.
- Data will be brought together under the NMRF to ensure more integrated mortality data surveillance.
You can read the final report here.
Next steps
Over the coming months, the Commission will begin to implement the transformation of the NMRF. This will include developing key tools, such as the prioritisation framework for evaluating current and new areas of mortality review.
An interim National Mortality Review Committee will be stood up in early 2023 to provide expertise in the development of these core frameworks and identify emerging areas of mortality review.
The NMRF will continue to uphold key functions and activities of the existing MRCs, with a dual focus on reporting key mortality trends as well as assessing and prioritising areas of greatest need.
The interim National Mortality Review Committee and the Commission will work closely with the existing MRCs to transition institutional knowledge, and to ensure current members are well positioned to continue to provide an important voice as subject matter and representative experts.
Mortality review workstreams across child and youth, perinatal and maternal, and suicide will continue in the 2023/24 financial year under the transformed NMRF. A national expert group will continue to provide oversight and advice on national trends in perioperative deaths. Family violence death review will remain in place for the long term.
Beyond this, the National Mortality Review Committee will have the flexibility to focus on both current and emerging priority areas, informed by an all-mortality prioritisation process.
The Commission will work with the MRC secretariat to plan and transition its role and function into the future NMRF.
On 1 July 2023, formal statutory powers under Schedule 5 of the Pae Ora (Healthy Futures) Act 2022 will be transferred to the National Mortality Review Committee. Existing MRC members are invited to continue as subject matter and representative experts.
The first year of operations in 2023/24 under the transformed NMRF structure will see further refinements, including exploring new areas of mortality review, introducing new ways to disseminate findings and recommendations, and further deepening relationships with key health and social system entities.
Related Pages
If you have any questions about the independent review or the new NMRF, you can email: NMRFchange@hqsc.govt.nz.
Previous updates
The Health Quality & Safety Commission (the Commission) has commissioned an independent review of the national mortality review function. The review aims to reflect on whether the value and contribution that mortality review makes to system improvement in health and across government can be enhanced.
The Commission is undertaking an open procurement process for the review through the Government Electronic Tender Service (GETS) reference number GETS Rfx ID 24520951. The request for proposals (RFP) will close on Wednesday 28 July 2021.
The current national mortality review programme has made significant contributions to knowledge about key issues within the five scope areas of its mortality review committees (MRCs). The MRCs have provided valuable focus, advice, and recommendations to drive improvement and are well known within their areas of expertise.
The review is timely because it coincides with the significant health reforms underway. It will consider the context and impact of the larger health and disability system transformation and the role of the Commission in the monitoring and support of quality care and how mortality review contributes to this.
A particular focus of the review is how the national mortality review function can give true effect to the Crown’s responsibilities to Te Tiriti o Waitangi. It must ensure that the function of mortality review places equity at the centre of quality; is able to drive and facilitate significant system- and service-level improvement; and more strongly centres on consumers and whānau.
The terms of reference for the review forms the basis of the tender document. The content has been developed by a steering group made up of current MRC chairs and members of Te Rōpū Māori (the Commission’s Māori advisory group to the Board). Members have broad expertise in Māori health and development as well as experience and understanding of mortality review systems.
We will update this web page as the review progresses.
These terms of reference set out the purpose of a first principles review of the Commission's national mortality review function, its purpose, scope, approach, process, outputs and timeline. The terms of reference also include the governance and stakeholder input. View the terms of reference here.
The Health Quality & Safety Commission has awarded the contract for delivery of the ‘first principles’ review of the national mortality review function to Francis Health.
Francis Health is an internationally networked health and disability consultancy, delivering strategic planning, service design, service improvement, research and evaluation across Aotearoa New Zealand, Australia and the UK.
While the proposal was led by Francis Health, it is a collaboration of organisations and individuals who bring expertise, Māori partnership, sector relationships and successful track records relevant to delivering the review.
Rory Matthews, managing partner at Francis Health, expressed that, ‘We are excited by this opportunity to support the Commission with this work. Mortality reviews and outputs need to focus on ensuring responsibilities to Te Tiriti are embedded to reduce inequities that exist in preventable deaths; and understand the concept of death and mortality within a specific cultural context for Māori that is different to a Western view and acknowledge the sacredness and tapu of the event of death that Māori uphold.’
Francis Health aligned its proposal with the terms of reference for the review. The terms of reference were developed by a working group of current mortality review committee chairs and Te Rōpū, the Māori advisory group to the Health Quality & Safety Commission’s board.
A key focus running across the timeline of the review will be engagement with sector stakeholders through interviews and focus groups. These engagements will be designed to capture existing knowledge and gather views on current challenges and opportunities, as well as contributing to the design of a future blueprint for the mortality review function.
The initial timeline had the review being completed this calendar year, but has since been extended to 2022. We are conscious there is a considerable amount of pressure on the system at the moment and believe this extension is needed to ensure the required level of engagement, and therefore authenticity of the review report, in the context of equity for Māori and responsibilities to Te Tiriti o Waitangi.
As such, the substantive work of the mortality review committees will continue in 2022 while the review is completed and recommendations considered.
A skilled and experienced group of people have been appointed as the expert advisory group (EAG) to the review of the national mortality review function. Read more about the EAG here.
The Health Quality & Safety Commission is steadily progressing the changes to the national mortality review function, announced in October, of having a single National Mortality Review Committee (NMRC), supported by subject matter expert groups. This follows an independent review by Francis Health which indicated that changes to the current structure could enhance the overall impact of national mortality review, underpinned by a commitment to Te Tiriti and Māori.
Proposals invited for independent review of national mortality review function (July 2021)
The Health Quality & Safety Commission (the Commission) has commissioned an independent review of the national mortality review function. The review aims to reflect on whether the value and contribution that mortality review makes to system improvement in health and across government can be enhanced.
The Commission is undertaking an open procurement process for the review through the Government Electronic Tender Service (GETS) reference number GETS Rfx ID 24520951. The request for proposals (RFP) will close on Wednesday 28 July 2021.
The current national mortality review programme has made significant contributions to knowledge about key issues within the five scope areas of its mortality review committees (MRCs). The MRCs have provided valuable focus, advice, and recommendations to drive improvement and are well known within their areas of expertise.
The review is timely because it coincides with the significant health reforms underway. It will consider the context and impact of the larger health and disability system transformation and the role of the Commission in the monitoring and support of quality care and how mortality review contributes to this.
A particular focus of the review is how the national mortality review function can give true effect to the Crown’s responsibilities to Te Tiriti o Waitangi. It must ensure that the function of mortality review places equity at the centre of quality; is able to drive and facilitate significant system- and service-level improvement; and more strongly centres on consumers and whānau.
The terms of reference for the review forms the basis of the tender document. The content has been developed by a steering group made up of current MRC chairs and members of Te Rōpū Māori (the Commission’s Māori advisory group to the Board). Members have broad expertise in Māori health and development as well as experience and understanding of mortality review systems.
We will update this web page as the review progresses.
First principles review of the national mortality review function | Terms of reference (July 2021)
These terms of reference set out the purpose of a first principles review of the Commission's national mortality review function, its purpose, scope, approach, process, outputs and timeline. The terms of reference also include the governance and stakeholder input. View the terms of reference here.
Francis Health consortium contracted to deliver review of national mortality review function (September 2021)
The Health Quality & Safety Commission has awarded the contract for delivery of the ‘first principles’ review of the national mortality review function to Francis Health.
Francis Health is an internationally networked health and disability consultancy, delivering strategic planning, service design, service improvement, research and evaluation across Aotearoa New Zealand, Australia and the UK.
While the proposal was led by Francis Health, it is a collaboration of organisations and individuals who bring expertise, Māori partnership, sector relationships and successful track records relevant to delivering the review.
Rory Matthews, managing partner at Francis Health, expressed that, ‘We are excited by this opportunity to support the Commission with this work. Mortality reviews and outputs need to focus on ensuring responsibilities to Te Tiriti are embedded to reduce inequities that exist in preventable deaths; and understand the concept of death and mortality within a specific cultural context for Māori that is different to a Western view and acknowledge the sacredness and tapu of the event of death that Māori uphold.’
Francis Health aligned its proposal with the terms of reference for the review. The terms of reference were developed by a working group of current mortality review committee chairs and Te Rōpū, the Māori advisory group to the Health Quality & Safety Commission’s board.
A key focus running across the timeline of the review will be engagement with sector stakeholders through interviews and focus groups. These engagements will be designed to capture existing knowledge and gather views on current challenges and opportunities, as well as contributing to the design of a future blueprint for the mortality review function.
The initial timeline had the review being completed this calendar year, but has since been extended to 2022. We are conscious there is a considerable amount of pressure on the system at the moment and believe this extension is needed to ensure the required level of engagement, and therefore authenticity of the review report, in the context of equity for Māori and responsibilities to Te Tiriti o Waitangi.
As such, the substantive work of the mortality review committees will continue in 2022 while the review is completed and recommendations considered.
Expert advisory group appointed to guide the review (October 2021)
A skilled and experienced group of people have been appointed as the expert advisory group (EAG) to the review of the national mortality review function. Read more about the EAG here.
Change in approach to establishing new National Mortality Review Committee (December 2022)
The Health Quality & Safety Commission is steadily progressing the changes to the national mortality review function, announced in October, of having a single National Mortality Review Committee (NMRC), supported by subject matter expert groups. This follows an independent review by Francis Health which indicated that changes to the current structure could enhance the overall impact of national mortality review, underpinned by a commitment to Te Tiriti and Māori.
Last updated: 18th October, 2022
