Eastern Tales of the HSMR

1. 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

2. 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

3. Coding and Data Analysis Medical Practice Quality and Safety Practices Patient Flow Coding Documentation Recommendations Clinical Recommendations HSMR Work Plan

4. HSMR

5. 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

6. 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

7. 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

8. Intervention Group • 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)

9. 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

10. 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 Educational toolkit“Mortality Matters”

12. 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%

13. CMG Ranking Responses 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

14. 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

16. Pre-Intervention Months

17. Pre-Intervention Months

18. 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.

19. Unexpected Mortality Index Outreach team cases, Inpatient code blues and calculated unexpected mortality index for 2007-2008 year

21. HS Staff Physicians Total Correct Answers 71.3% 73.2% HSMR definition & calculation including the definition of the palliative care (or comfort care)

22. HS Staff 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

25. 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

26. For more information: 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.