1. Mortality review Brian Bjørn, M.D. International Forum on Quality Improvement in Health Care Paris – April 9, 2014 Danish Society for Patient Safety

2. Overview Background and context –Why? –How ? IHI’s approach to mortality review –and how we tweaked it Danish experiences

3. Why measure mortality? Death is a definite and unique event Deaths are recorded by law Death rates are easily understood –also by the public Traditional outcome measure in biomedical research

5. IHI: Move your dot Plot your dot Examine your dot Evaluate your dot Understand your dot Test changes

6. Plot your dot 1 Hospital Standardized Mortality Ratio, by quarter

7. Plot your dot 2 No. of in-hospital deaths, by quarter, only deaths included in HSMR

8. Plot your dot 3

9. Plot your dot HSMR, raw mortality, crash call numbers Examine your dot Mortality review Evaluate your dot Mortality review Understand your dot Mortality review Test changes Model for Improvement

10. Mortality review Records from 50 consecutive deaths Multidisciplinary team Consensus process

11. Resources Availability of palliative care Mortality reduction Quality improvements

12. Box A Admission to ICU Comfort care only Overuse of ICU beds?

13. Box B Admission to non-ICU beds Comfort care only Inadequate hospice or other end-of-life care resources in the community?

14. Box C Admission to ICU Active treatment Quality improvement and mortality reduction –VAP –CLABSI –etc.

15. Box D Admission to non-ICU beds Active treatment Quality improvement and mortality reduction –Early Warning Score –Rapid response team –Sepsis bundle –Etc.

16. Danish experiences Limited benefit of using 2x2 matrix –Comfort care only in ICU bed a very rare event Desire to evaluate preventability –Consensus decision –Did the patient have to die in this shift?

17. Example: 14 preventable deaths ThemeNumber Hospital acquired pneumonia3 Delayed treatment3 Opioid overdose2 EWS algorithm not followed2 Delayed/wrong diagnosis2 Anti-thrombotics not used1 Unclear management plan1

18. Hospital acquired pneumonia 76-years old Admitted for episodic hyperglycemia. Antibiotics are not prescribed until two days after pneumonia is diagnosed. Patient discharged before first dose is administered. Readmission day after, dies unexpectedly Clearly preventable death due to hospital acquired pneumonia

19. Delayed treatment 80-years old Transferred after long stay at another hospital. Immunosuppressed due to ’prolonged’ corticosteroid treatment. Clinical signs of sepsis, antibiotics delayed by 8 hours. Preventability undetermined.

20. Plot your dot

21. Evaluate/understand your dot

23. ?