Institute for Healthcare Improvement: Learning and Innovation Community: Reducing Hospital Mortality Rates

Available through the IMPACT network or on a direct-enroll basis, IHI’s most intensive front-line improvement work happens in Learning and Innovation Communities. These are collaborative change laboratories in which teams from a wide variety of organizations work with each other and IHI faculty to rapidly test and implement meaningful, sustainable change within a specific topic area.

Listen Listen to an informational call on Reducing Hospital Mortality Rates.

Reducing Hospital Mortality Rates is available either through membership in the IMPACT network or through direct enrollment in the Community. Learn more about IMPACT.

The Challenge

The Solution

Numerous studies have shown wide variability across both quality and safety in health care. Recent work by Sir Brian Jarman documents substantial variation among hospital death rates, as measured by the hospital standardized mortality ratio (HSMR). Even when multiple risk factors are considered, there is no clear explanation for differences in HSMR from hospital to hospital. The implication is that differences in care, rather than case mix or other patient or hospital variables, account for the differences in adjusted mortality rates.

An opportunity exists to close the gap among hospital death rates by improving hospital care. Early work on reducing mortality and review of the literature suggest three main systemic issues: failure to plan, failure to communicate, and failure to rescue. A set of high-leverage changes and a related measurement strategy have been proposed to deal with these systemic issues.

The HSMR, appropriately adjusted for multiple variables such as population characteristics and diagnoses, provides an essential starting point in improving care and reducing mortality.

Many hospital deaths could be prevented if all the factors that contribute to them were better understood. Each hospital death provides an opportunity for learning — by understanding and addressing local conditions that contribute to mortality.

As part of its effort to foster improvement in health care systems, IHI has developed an analytical tool — the Reducing Mortality Rates Diagnostic — for understanding hospital mortality rates, and an action framework designed to reduce deaths.

The Reducing Hospital Mortality Rates Learning and Innovation Community focuses on decreasing mortality rates by improving the system factors that contribute to mortality, and for which medical evidence already exists.

Areas of Focus

This Learning and Innovation Community is a continuation of learning from initial testing of an analytical framework that places hospital deaths into four categories, each of which have associated strategies for improvement. After reviewing a series of cases, deaths that fall into Box 3 and Box 4 are further analyzed to determine if there is any evidence of failure to recognize, communication failures, or planning failures. Finally, the IHI Global Trigger Tool is used to see if there is any evidence of adverse events.


	ICU	NON-ICU CARE

COMFORT CARE ONLY	Box 1 Strategy: Clarity of ICU admission/transfer criteria	Box 2 Strategies: Advanced directives Alternatives to hospital care at the end of life Palliative Care Team Infrastructure Changes: Advanced directives completed pre-hospital In-house hospice program

NOT COMFORT CARE ONLY	Box 3 Strategies: Multidisciplinary rounds and daily goals Ventilator bundle Tight glucose control Sepsis intervention Infrastructure Change: Intensivist program	Box 4 Strategies: Rapid Response Team Early Warning Systems Reduction of adverse events Communication and teamwork techniques — SBAR Infrastructure Change: Hospitalist program

Aims

Participants will aim to make measurable improvements in each of the boxes. Overall outcome measures will be emphasized to reduce overall mortality:

20-point reduction of overall HSMR or greater than 25% reduction in raw mortality
Reduction in box-specific mortality rates