Learn more about a systems engineering, multidisciplinary, multi-specialty approach with onsite or web sessions

Diagnostic Case Reviews

Give us 100 Cases to Review and we will help you to identify Opportunities for Improvement


We will coach you to be a system thinker that supports transparency for system learning

Jeanne Huddleston, MD Presenting How to Move Beyond Mortality Review and Create the Next Generation Safety Learning System

Philosophical Approach: Safety Learning System™

Call us today to join a session to discuss the impetus for the Safety Learning System™ and its multidisciplinary, multi-specialty review process approach. Hear Dr. Huddleston share lessons learned through its development and evolution.

Fundamentals: Safety Learning System™

  • A systems engineering approach to solving complex problems
  • Multidisciplinary, multispecialty collaboration
  • Runs under Chatham House Rule
  • Is a process of System and process of care review – NOT peer review (Not related to preventability or causality)

Impetus to Safety Learning System

Case Review Basics

Multidisciplinary/specialty Approach Key to Patient Experience Improvement

Recent F2F Training:

ML8: The Future of Mortality Review, IHI National Forum

Monday, December 11, 2017, 8:00AM-11:30AM

Representatives from our collaborative of more than 50 hospitals will guide you through the implementation of a safety learning system — not only learning from every death, but also learning from the living. Using a real-time audience response system, participants will: 1) identify opportunities for improvement in care delivered to simulated patient journeys; 2) quantify barriers to implementing a reliable learning system; and 3) prioritize opportunities for improvement. You will walk away with actionable insights.

After this presentation, you will be able to:
1. Implement a learning system that embodies principles of high reliability — specifically, deference to expertise
2. Move beyond the medical model of peer review to a process of interprofessional learning that leads to actionable information and change
3. Define the largest safety problems facing health care today: acts of omission, not commission.

Speakers: Hanan Foley, Jeanne Huddleston, Patty Atkins, Vicki Nolen, Valerie Craig, Lacey Hart

Tenets of a Safety Learning System

1.Multidisciplinary reviews

  • Nurses have equal voice
  • Multiple perspectives on patient journey
  • Identification of “contributing factors” (HF nomenclature)

2.Practicing providers & Deference to expertise

  • Omissions provide bigger opportunities
  • Increases physician involvement

3.Multispecialty, multidisciplinary case discussions

4.Actionable Information and Influence

  • Case-based teaching with patient stories
  • Six Sigma structure and analytics
  • Leading “up” and influencing change

Why does the structure work?

  • Moves away from insular peer review
  • Promotes culture change
  • It’s NOT about adverse events
  • Identifying process of care and system failures
  • Identifying opportunities for improvement
  • Inspiring action through stories
  • Right size quality improvement initiatives

Online Webinar Recordings:

Learn from Mortality Review AND the Living: Next Generation Safety Learning System™
Patient safety events are increasingly recognized as the 3rd leading cause of death including the typical adverse events we count and measure in patient safety. These existing measurement systems do not identify actionable opportunities for improvement nor provide obvious direction for next steps. The information Dr. Huddleston will share will help us understand areas of critical importance that will compliment what we do in prevention of adverse events.

Learning Objectives:

  • Awareness: Participants will understand and be able to communicate the know how learned from collaborators on Mortality Reviews.
  • Accountability: Participants will understand who is accountable for responding to, and prioritizing, the opportunities for improvement identified through Mortality Reviews.
  • Ability: Participants will learn what they must be able to do in order to join a collaborative program on mortality review.
  • Action: Participants will learn what actions they may need to take in order to consider or adopt an approach to collaborating on Mortality Review programs.

The following webinars are available for viewing on demand courtesy of Texas Medical Institute of Technology (TMIT):

Saving Lives Putting Mortality Reviews to Work – It does pay off!  
Overview: Dr. Jeanne Huddleston from the Mayo Clinic generated one of the strongest positive reactions we have ever had in our nearly 100 monthly sequential webinars for her work in mortality reviews. She will now show how such information can be used to save lives.
Duration: 90 Minutes
View Here

Learn from Mortality Review AND the Living: Next Generation Safety Learning System  
Overview: Dr. Jeanne Huddleston and her colleagues at the Mayo Clinic have undertaken breakthrough work that can have enormous impact on the patient safety of healthcare institutions. She will share learnings on their journey to analyze the stories of all patient deaths. She will share the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System. Patient safety events are increasingly recognized as the 3rd leading cause of death including the typical adverse events we count and measure in patient safety.
Duration: 90 Minutes
View Here

Learn from Mortality Review AND the Living: Part 2 – A Deeper Dive  
Overview In response to the overwhelmingly positive evaluations of our webinar last month addressing Learning from Mortality Reviews, we have asked Dr. Jeanne Huddleston to take a deeper dive into what can be learned from mortality reviews and how participants can start a program and learn from others.
Duration: 90 Minutes
View Here

Learning from Mayo Clinic Mortality Reviews: Next Generation of Patient Safety
Overview: Dr. Jeanne Huddleston of the Mayo Clinic shares the 13 year journey of learnings and cultural change processes experienced as an organization to move to a next generation approach to patient safety.
Duration: 75 Minutes
View Here (courtesy of CareUniversity)

Learning from Collaboration on Mortality Reviews: The Journey  
Overview: In response to the overwhelmingly positive evaluations of our webinars on Learning from Mortality Reviews by Dr. Jeanne Huddleston of the Mayo Clinic, we have engaged leading organizations who have joined the collaborative efforts. Hanan Foley, MSN, RN, CPHQ, the Director of Quality and Safety at MedStar Georgetown University Hospital, will share their experience on the journey.
Duration: 90 Minutes
View Here

Mortality Reviews: Great Learning from Our Early Journey  
Overview: Patty Atkins, RN, MS, CNS, CPPS, is responsible for Quality, Patient Safety and Lean Six Sigma for Sharp HealthCare, the largest healthcare system in San Diego, CA. She will share the terrific learning her organization has gleaned from mortality reviews, having worked with Dr. Jeanne Huddleston. Following Patty's presentation, a reactor panel will discuss how the insights can be applied to frontline care.
Duration: 90 Minutes
View Here