Eastern Tales of the HSMR

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Eastern Tales of the HSMR
Pursuing Quality Safety Improvement

• 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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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

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HSMR Work Plan

• Coding and Data Analysis
• Medical Practice
• Quality and Safety Practices
• Patient Flow
• Coding
• Documentation Recommendations
• Clinical Recommendations

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HSMR
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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

• 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

• 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

• Hospital Staff (managers, flow coordinators,
  patient care coordinators) in the Medicine and
  Surgery Health Services (n39)
• Active staff physicians of in the Departments of
  Medicine (n40) and Surgery (n49)

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Knowledge Translation Intervention

• 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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Educational toolkit Mortality Matters

• HSMR - What is it?
• 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

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Pre-Intervention Questionnaire

• 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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Ranking the top 10 CMG-based opportunities for
improving the HSMR
 
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Monthly Physician Documentation Audits (Months 3
to 12)

• 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
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Pre-Intervention Months
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Unexpected Mortality

• 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
Outreach team cases, Inpatient code blues and
calculated unexpected mortality index for
2007-2008 year
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HSMR definition calculation including the
definition of the palliative care (or comfort
care)
 
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Awareness of locally available interventions to
improve the hospital HSMR
 
Intervention
 
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Conclusions

• 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 Ian M. Fraser, MD,
FRCPC Physician-in-Chief, Department of
Medicine Program Medical Director, Medicine
Health Service ifras_at_tegh.on.ca
Above all, we care.