Turning the Mortality Review "Blame Game" into Process Improvement


Conducting mortality reviews is one of the most common practices every hospital undertakes. The two most common methods involve a peer review or morbidity and mortality committee and tend to focus primarily on potential preventability of the death and/or the performance of the attending physician. Too often, this can become a situation of parties pointing the finger of blame at one another. Now, another method is gaining traction because it transitions the traditional blame game into an opportunity for performance improvement.

This model creates an interprofessional review committee comprised of physicians, nurses, pharmacists, respiratory therapists, administrators, ambulance and/or air medical services personnel, and maybe even the local coroner.

“There’s no one correct combination. The point is the committee must include people from many disciplines who are true ‘system thinkers,’ meaning they visualize a complete picture of care from admission to discharge,” said Kate O’Shaughnessy, performance improvement collaborative advisor at Vizient.

In this multidisciplinary, multispecialty model, the focus is on what processes may have broken down or what the care team could have done better. It is not about singling out a person for blame. It also serves to facilitate the evaluation of how processes in every step of the care experience integrate or conflict. Those patterns and trends don’t surface in a typical peer review or morbidity and mortality review, because those reviews are often limited to a department or even a subspecialty focus.

“If you’re only looking at the actions of the treating physician, you might never realize there was a problem elsewhere in the hospital,” O’Shaughnessy said. “The physician may not have done anything wrong but what did go wrong would have been missed if the hospital operated in one of the other two mortality review modes. This is why the interprofessional review process is a significantly more effective approach.”

Adopters of interprofessional approach see benefits

Vizient has seen the positive effects of this approach by several adopters. In most cases, the process improvements have been in managing ICU patient flow, hospice response protocols and sepsis identification.

Large academic medical centers typically accept a substantial number of patient transfers that arrive with few, if any, treatment options available. As a result of these transfers, the ICUs can be at maximum capacity which causes a backup that affects critical patient transfers from the ED or other areas of the hospital. A recently implemented interdisciplinary mortality review process at a Tennessee health system was the catalyst for understanding how to work smarter with transferring hospitals by initiating conversations for assessing whether to accept patients who will receive futile care. At the conclusion of the Vizient 2015-2016 mortality review member collaborative, the health system created examples of the clinical resources consumed by futile transfers – resources that could be used for those patients who cannot be served when the medical center is on diversion.

In addition to consuming scarce resources, transferring these patients incurs risks to the patient and may take them to spend their final days in a hospital much further from their homes and families. Another organization has started to require that the sending hospital document the patient and family’s goals of care when accepting the patient for transfer.

“By asking additional questions about transferred patients, the receiving hospital can determine the most appropriate placement to best care for that patient, and the next acute or critical patient is also able to get the right level of care they need,” O’Shaughnessy said. “The system thinkers on the review committee were able to see the overall dynamic and bring to the surface how futile transfers were affecting not only the ICU but the system’s ability to deliver critical care for other patients. And most importantly, charge teams to improve the process and enhance care for the next patients.”

Another example involves hospice care at a health system in Pennsylvania that was having difficulty getting patients out of the ICU and into the off-site inpatient hospice care setting. By the time they identified a patient who needed to be transitioned, often he or she was too fragile to be moved and had to stay in the ICU. The hospital established a virtual hospice unit in the hospital, where patients remain on the same unit and are co-managed by hospice staff.

The interprofessional review committee at this Pennsylvania system had noted the trend of end-of-life patients in the incorrect care setting and recommended that the hospital establish a hospice response team, bringing multiple disciplines together to quickly assess the patient, determine candidacy for hospice and have those conversations with the patient and/or family, as opposed to relying on one physician to consult. This concept, modeled after a traditional rapid response team, significantly shortened the time from evaluation to deciding to transport. Referrals to the hospice response team increased 136 percent in 10 months, and admissions to the virtual hospice unit increased 111 percent.

A third example relates to sepsis, which is one of the most deadly conditions in hospitals. After noting a trend of patient deaths with hospital-acquired sepsis, one member organization’s mortality review committee recommended a sepsis task force. This task force modified assessment timelines and protocols related to identifying a patient’s decompensation more quickly and effectively. Post-implementation, this member decreased its sepsis mortality index by almost 49 percent over three years.

Assembling a team of system thinkers

“One of the first steps to implementing this model of mortality review is to enlist physicians and clinicians who are system thinkers,” O’Shaughnessy said.  “These are people who think beyond their practice or their primary function. It could be a nurse who demonstrates the ability to see patient care throughout the system, or a physician who is seen as a thought leader.”

Leadership is critical. The committee chairperson needs to be a very strong facilitator and be able to tactfully and quickly redirect a conversation if it’s going toward blame to bring the conversation back to productive reviews.

“To many physicians, this approach to mortality review is a completely new concept,” O’Shaughnessy said. “Physicians are trained in a peer review culture. Having a very strong leader who directs them to look at the larger picture is crucial in order for process improvement recommendations to come out of the review process.”

A recommendation for igniting the learning process is to start with a manageable review size. One health system began with 100 charts simply because it was a nice round number to understand and calculate. The goal is to acquire meaningful insights on how to implement the interdisciplinary model and how to foster a culture that supports it.

Learning how to design and implement effective mortality reviews has been the subject of a Vizient-led collaborative project in 2015. The findings from this project led to the determination that hospitals can substantially increase the effectiveness of their mortality reviews by employing an interprofessional model. The findings from the ongoing project will be available as soon as it is completed.

To find out more about how you can join the PI Collaboratives program and access the findings from this work, click here.

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