d2 rapid fire: measurement - how do you know your change is an improvement? - j. moscovitch

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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

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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

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Tak

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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

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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

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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

judi.moscovitch@fraserhealth.ca