d2 rapid fire: measurement - how do you know your change is an improvement? - j. moscovitch
TRANSCRIPT
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UsingHospital Standardized
Mortality Ratio (HSMR)
to drive quality
Quality Forum 2012March 7 – 9, 2012
Vancouver, B.C.
Judi Moscovitch Quality Improvement & Patient Safety Consultant
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Key Objectives
What is HSMR? Assessment and Planning Actions Taken Where to Start
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What is HSMR?
Hospital Standardized Mortality Ratios (HSMR) track changes in hospital mortality rate
Developed in the UK in mid-1990s by Sir Brian Jarman
Used in hospitals worldwide
Courtesy of: CIHI – June 2006
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Understanding HSMR
Observed deaths
Expected deathsHSMR = X 100
Expected deaths are based on a logistical model using 7 factors
Courtesy of: CIHI – June 2006
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The Seven Contributing Factors
1. Age2. Sex3. Transfers in4. Urgent Admit5. Comorbidities6. LOS
Courtesy of: CIHI – June 2006
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7. DiagnosisBased on diagnosis groups that
account for 80% of deaths
Does not include
palliative, perinatal,
mental health and residential
care
Courtesy of: CIHI – June 2006
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HSMR Is Easy To Interpret
Equal to 100 > National Baseline
No difference between facility’s mortality rate
and average rate
More than 100
Facility’s mortality rate is higher than the
average rate
Less than 100
Facility’s mortality rate is lower than the
average rate
Courtesy of: CIHI – June 2006
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Why Track Deaths?
Significant numbers of deaths associated with adverse events
Courtesy of: CIHI – June 2006
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HSMR Data received - July 07
Opportunities for Improvement Mortality reviews Data analysis
Strategic Alignment “Big Dot” Indicator Performance measure
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Data is Wrong! It must be Wrong…
Disbelief/Anger
The Four Stages of HSMRDonald M. Berwick, MD, MPP, Former Chief Executive Officer,
Institute for Healthcare Improvement
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Data is Right
But There is No Problem
The Four Stages of HSMRDonald M. Berwick, MD, MPP, Former Chief Executive Officer,
Institute for Healthcare Improvement
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Data is Right
It’s Someone Else’s
Problem
The Four Stages of HSMRDonald M. Berwick, MD, MPP, Former Chief Executive Officer,
Institute for Healthcare Improvement
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Data is Right
There’s a Problem
andI’m Going to
Be Part of the Solution
The Four Stages of HSMRDonald M. Berwick, MD, MPP, Former Chief Executive Officer,
Institute for Healthcare Improvement
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Assessment and Planning
Where to Start?
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Environmental Scan
Literature review of HSMR work Proactive ongoing work
Su
rgic
al S
afet
y C
olla
bo
rati
ve
Pat
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afet
y W
alka
rou
nd
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Han
d H
ygie
ne
Cam
pai
gn
Med
icat
ion
Saf
ety
Co
mm
itte
e
Fal
ls P
reve
nti
on
Pro
gra
m
Pat
ien
t S
afet
y R
evie
ws
Sta
nd
ard
ized
Cra
sh C
arts
Dai
ly iC
are
Ro
un
ds
SB
AR
in C
riti
cal S
itu
atio
ns
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Understand the Patient Journey
Decision to Audit – August 07Business Case – January 08
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Available Tools
The Institute for Healthcare Improvement (IHI) www.ihi.org
Move Your Dot The Hospital Mortality Review Tool
Reducing Hospital Mortality Rates Change Ideas
IHI Global Trigger Tool for Measuring Adverse Events
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Burnaby Hospital (BH) Operational Trigger Tool
Chart Audits – Spring/Summer 08
Medical Documentation
Healthcare Acquired Infections
Failure to Rescue
Continuum of Care
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Maintaining Will
Keep Executive Leadership Engaged #1 - What is HSMR, Audit Results Executive Director and Medical Director attend IHI #2 - Change Ideas
Engage the Managers#3 – HSMR, Audit Results, Change Ideas #4 - Senior Leader Role, Improvement Planning
Involve Staff
Data Analysis – Fall ‘08 Learning and Improvement Planning – Spring/Summer ‘09
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Goals
Right CareRight PlaceRight Time
Provide clinical expertise to patients across the continuum that best meets their identified needs and goals.
Provide service to patient in locations that best meet their identified needs.
Provide service to patients at the time that best meets their identified needs.
Finding Your Voice
Initiate timely collaborative communications to support quality patient outcomes.
A Learning Organization
Improve efficiency and effectiveness in response to patients in critical conditions.
The AIM is to reduce the mortality rates of acute care patients as measured by an HSMR score of 100 or less
in the fiscal year 2009/2010.
Burnaby Hospital HSMR
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Critically Ill
Operations
“Finding Your Voice”
Communicate
Escalation of Care Algorithm
Document Patient Journey
A Learning Organization
Care & System Issues
Approriate Emergency Response Training
Implement Standardized M&MS
Chart Audit (2 x 2 Matrix)
Acute Care
Make Communication Easy
Smooth Handoffs and Transfers
Explore Case Management
Review
Right Place,Right Care,Right Time
Timely andAppropriate Access
Acuity of Patients
Clinical Flow
Early Identification
Recognize
Coding of Charts
Palliative Patient End of Life Discussions
Code Review CommitteeEarly Warning System
Resource Equity
Burnaby Hospital HSMR Lattice
Developed by J.P. Moscovitch, OT Last Revision: September 2009 Consultant, Quality Improvement & Patient Safety Version 4.2Fraser Health Authority, B.C.
Patient PopulationsA
ctio
ns
Tak
en
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Burnaby HospitalStandardized Mortality Ratio (HSMR)
Quarterly Run Chart
111 110
124
108 110115
10198 98
91
102
8886
9487
70
80
90
100
110
120
130
140
2008
- Q
1
Q2
Q3
Q4
2009
- Q
1
Q2
Q3
Q4
2010
- Q
1
Q2
Q3
Q4
2011
- Q
1
Q2
Q3
Q4
Quarter
Rat
e o
f U
nex
pec
ted
Dea
ths
Quarterly Avg.
National Benchmark
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Fraser Health and Burnaby Hospital Standardized Mortality Ratio (HSMR)
Annual Run Chart
116111
105
86101
98
113119
93969898
8770
80
90
100
110
120
130
140
05/06 06/07 07/08 08/09 09/10 10/11 11/12YTD
Fiscal Year
Ra
te o
f U
ne
xp
ec
ted
De
ath
s
Burnaby Hospital
National Baseline
Fraser Health
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Where to Start
and the Institute for Healthcare Improvement (IHI) www.ihi.org
Canadian Institute for Health Information
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www.cihi.ca Select: Health System Performance
Select: Quality of Care and Outcomes
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What data can YOU access
to drive QUALITY? For more information
please contact
Judi Moscovitch, Consultant
Quality Improvement & Patient Safety
Fraser Health