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Pursuing Quality & Safety Improvement. Eastern Tales of the HSMR. Ian M. Fraser, MD, FRCPC Physician-in-Chief, Department of Medicine Program Medical Director, Medicine Health Service Toronto East General Hospital. 2008 HSMR Highlights. Concurrent Mortality Review HSMR Work Plan

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Eastern tales of the hsmr l.jpg

Pursuing Quality & Safety Improvement

Eastern Talesof the HSMR

Ian M. Fraser, MD, FRCPC

Physician-in-Chief, Department of Medicine

Program Medical Director, Medicine Health Service

Toronto East General Hospital


2008 hsmr highlights l.jpg
2008 HSMR Highlights

  • Concurrent Mortality Review

  • HSMR Work Plan

  • HSMR Grand Rounds

  • MPSQ Committee Monitoring

  • Geriatrics Review

  • Knowledge Translation Project

  • Sepsis Resuscitation Order Set

  • Targeted Performance Feedback


Hsmr work plan l.jpg

Coding and Data Analysis

Medical Practice

Quality and Safety Practices

Patient Flow

Coding

Documentation Recommendations

Clinical Recommendations

HSMR Work Plan



Targeted knowledge transfer to reduce community hospital mortality hsmr l.jpg
Targeted Knowledge Transfer to Reduce Community Hospital Mortality (HSMR)

Interim Report

August 31, 2008

Reema Shah, BSc

M.D. Candidate 2011, University of Toronto

Ian M. Fraser, MD, FRCPC

Physician-in-Chief, Department of Medicine

Program Medical Director, Medicine Health Service

Toronto East General Hospital


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Design Mortality (HSMR)

  • Before-and-after interventional knowledge translation study

  • Targeted group of hospital staff and physicians

  • Baseline HSMR knowledge assessment

  • Primary Outcomes

    • Improvement in HSMR knowledge gaps

    • Changes in hospital HSMR over three year period

  • Secondary Outcomes

    • Improvements in local best physician documentation performance (defined by peer physician practices)

    • Unexpected adult inpatient mortality outside of a monitored care unit


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HSMR Knowledge Questionnaire Mortality (HSMR)

  • 6 questions

  • HSMR definition & calculation including the definition of the palliative care (or comfort care) designation

  • Ranking the top 10 CMG-based opportunities for improving the HSMR

  • Awareness of locally available interventions to improve the hospital HSMR

  • A free, online survey tool, SurveyMonkey, was used to collect survey responses


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Intervention Group Mortality (HSMR)

  • Hospital Staff (managers, flow coordinators, & patient care coordinators) in the Medicine and Surgery Health Services (n=39)

  • Active staff physicians of in the Departments of Medicine (n=40) and Surgery (n=49)


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Knowledge Translation Intervention Mortality (HSMR)

  • Educational toolkit-“Mortality Matters”

    • e-mail, posters, intranet, meeting agenda

  • Monthly Physician Documentation Audits (Months 3 to 12)

  • Quarterly Unexpected Mortality Index

  • Quarterly hospital HSMR Results


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HSMR - What is it? Mortality (HSMR)

Top 10 CMG-based opportunities for improving HSMR

Best Practices for Physician Documentation

Near Miss Program

Surviving Sepsis Campaign

Unexpected Mortality Index Monitoring

Myocardial Infarction

Central Line-associated Infection Prevention

Medication Reconciliation To Prevent Adverse Drug Events

Outreach Team

Surgical Site Infection Prevention

Ventilator-Associated Pneumonia Prevention

MRSA Prevention Guidelines

Venous Thromboembolism Thromboprophylaxis

Computerized Provider Order Entry

Educational toolkit“Mortality Matters”


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Pre-Intervention Questionnaire Mortality (HSMR)

  • Response rate was 50.4% (65 out of 129 possible respondents)

    • HS staff ( 28/39) = 71.8 %

    • Physician group (37/89) = 41.6%


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CMG Ranking Responses Mortality (HSMR)

HS Staff

Physicians

Top 5

Bottom 5

Top 5

Bottom 5

Actual

Rank

Top 5

4

1

3

2

Bottom 5

1

4

2

3

Ranking the top 10 CMG-based opportunities for improving the HSMR


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Monthly Physician Documentation Audits (Months 3 to 12) Mortality (HSMR)

  • A single day monthly audit of all non-short stay patients admitted to the Medicine and Surgery Health Services

  • Reported by in-patient service group or division

  • Percentage best practice score was calculated for mandatory (every patient) and situational (e.g. palliative care designation) best practice associated with patient admission and discharge


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Pre-Intervention Months Mortality (HSMR)


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Pre-Intervention Months Mortality (HSMR)


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Unexpected Mortality Mortality (HSMR)

  • An admitted adult patient, expiring outside a monitored unit (e.g. ER, ICU, CCU, Telemetry) without the designation of comfort care (i.e. palliative care)

    • Discharge Abstract Database was used to extract all deaths , over 17 years old, with a Discharge unit of B2, ACC, CCU, ICU, MCCU, SCN, SICU, ER being and cases with a most responsible diagnosis of Z51.5 (palliative care) being excluded.


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Unexpected Mortality Index Mortality (HSMR)

Outreach team cases, Inpatient code blues and calculated unexpected mortality index for 2007-2008 year


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HS Staff Mortality (HSMR)

Physicians

Total Correct Answers

71.3%

73.2%

HSMR definition & calculation including the definition of the palliative care (or comfort care)


Awareness of locally available interventions to improve the hospital hsmr l.jpg

HS Staff Mortality (HSMR)

Physicians

%

Aware

n

Total

% Aware

n

Total

Surviving Sepsis Campaign

37.00%

10

27

47.10%

16

34

Near Miss Program

85.20%

23

27

17.60%

6

34

Best Practices MD Documentation

55.60%

15

27

75.00%

27

36

Unexpected Mortality Index Monitoring

40.00%

10

25

52.80%

19

36

Total Awareness

77.7%

73.0%

Awareness of locally available interventions to improve the hospital HSMR

Intervention


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Conclusions Mortality (HSMR)

  • HSMR can focus local Quality & Safety Initiatives

  • Easy to develop & distribute

    • educational toolkit describing interventions to reduce HSMR

    • feedback of an unexpected mortality index, physician documentation in comparison to local best practices and quarterly hospital HSMR

  • Follow-up surveys and the hospital HSMR over the next two years will test feasibility of closing identified knowledge gaps and improving patient survival

  • Soft signs of a cultural shift are appearing


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For more information: Mortality (HSMR)

Ian M. Fraser, MD, FRCPC

Physician-in-Chief, Department of Medicine

Program Medical Director, Medicine Health Service

ifras@tegh.on.ca

  • Above all, we care.