The Problem: Mortality rates at Tallahassee Memorial Hospital (Tallahassee, Florida, USA) were higher than average. And not enough was known about why. Fortunately, both situations were about to change.
When the Institute of Medicine issued its groundbreaking 1999 report, To Err Is Human: Building a Safer Health System
, which estimated that as many as 98,000 patients die each year in US hospitals as a result of medical errors, hospital leaders took notice. Many began to quietly investigate the extent of their own problems. Many leaders, like those at Tallahassee Memorial Hospital found the results rather sobering.
After being selected to be part of the Pursuing Perfection
program in 2001, Tallahassee Memorial, a 770-bed acute care and extended care hospital that is part of Tallahassee Memorial HealthCare, developed a new way to address the situation. It all starts with having a more accurate picture of patient deaths.
Working with the Pursuing Perfection sites was Sir Brian Jarman, Emeritus Professor of Primary Health Care at Imperial College School of Medicine in London, UK, and an IHI Senior Fellow. While at IHI, Jarman developed a hospital standardized mortality ratio
(HSMR) for US hospitals similar to one already used in the UK.
Jarman calculated the HSMR for each of the 13 Pursuing Perfection sites. Tallahassee’s rate of 128.7 was the highest, and well above the average US mortality rate of 100.
Spurred into action, Winnie Schmeling, PhD, RN, Tallahassee Memorial’s then Vice President of Organizational Improvement and Planning and executive-in-charge of Pursuing Perfection, led the charge. “We took on the whole issue of mortality in a very intense way,” she says.
This meant looking inward — combing the records of patients who had died in search of clues and patterns that might be instructive for averting needless deaths — and looking outward, at other hospitals and to IHI for best practices in reducing mortality. Both efforts would pay off, bringing Tallahassee’s mortality rate down nearly 31 percent over the next three years.
Tallahassee staff used a chart review tool developed by IHI
to help hospitals analyze their HSMR in a way that sorts deaths into meaningful categories, highlighting problems with the system, rather than problems with individual cases. By sorting the hospital’s most recent 50 deaths into four groupings based on the type of care that was planned and the bed placement (i.e., admitted for comfort care only or not, to the ICU or not), the Tallahassee staff was able to see that patients admitted for comfort care needed more careful planning, such as being placed in hospice care or another more appropriate setting. Patients admitted for acute or critical care who subsequently died left behind important clues about system-level problems.
Within this category, Tallahassee reviewers began to see three significant patterns:
- Failure to communicate — this could mean anything from a physician whose instructions were misunderstood by either patients or staff to a patient who didn’t speak up for fear of “bothering” the nurse
- Failure to recognize when a patient’s condition was worsening and take action
- Failure to plan (including diagnosis, treatment and goals)
While failures in these areas are seldom the cause of death, they often contribute.
The Solution: To address each area, Tallahassee adopted proven strategies developed by IHI faculty:
Staff members use a specific communication framework to discuss all patients, similar to the SBAR methodology promoted by IHI. This method guides a provider who wishes to consult another to succinctly describe the patient’s S
ituation (“The patient’s respiratory rate has dropped”), B
ackground (“She has a history of heart failure”), A
ssessment (“I think she is deteriorating”), and R
ecommendation (“I think the respiratory therapist should come see her now.”). This is a useful and effective way to organize information for decision-making.
Rapid Response Teams:
Unit nurses recognize when patients’ conditions are declining, but often lack the means to mobilize a “rescue” effort before a medical crisis develops. Rapid Response Teams, available 24/7 to consult with any provider who is concerned about a patient, are typically composed of a critical care-trained nurse, a respiratory therapist, and/or an intensivist physician. Rapid Response Teams are proving to be effective at preventing medical crises and reducing patients’ risk of dying.
At Tallahassee, as use of the Rapid Response Team (or Medical Emergency Team as they call it) increased, the number of Code Blue calls (for cardiac arrest) decreased.
Tallahassee implemented multidisciplinary rounds to enhance communication and care planning. A multidisciplinary care team consists of physicians, nurses, pharmacists, therapists, and others who provide care for a patient collaboratively. This group of providers shares knowledge, observations, and expertise among themselves and with patients and families, and makes decisions jointly with patients on appropriate goals.
The Results: Between 2001 and 2004, Tallahassee Memorial Hospital reduced mortality by nearly 31 percent:
In addition, condition-specific mortality dropped between 2002 and 2004:
- 53 percent reduction in death from acute myocardial infarction (AMI)
62 percent reduction in death from heart failure
41 percent reduction in death from stroke
46 percent reduction in death from pneumonia
What The Team Members Said: “We know what the top drivers of mortality are: AMI, heart failure, stroke, and community-acquired pneumonia. But IHI taught us to look at improvement systematically rather than by diagnosis. If you fix just your AMI rate, you bring your HSMR down by only so much. If you fix the system, you’re addressing the issues more broadly. As a result, our mortality rate is down among all the leading conditions.” – Winnie Schmeling, PhD, RN, former Vice President of Organizational Improvement and Planning and executive-in-charge of Pursuing Perfection
“The best part about this whole process has been watching people get motivated to create change. They have seen dramatic improvements, and now they know not to worry about looking silly when they try something new. They know how to make small tests of change, and then spread what works. We are really improving care, and really making a difference for patients, and that’s very motivating.” – Fain Folsom, RN, BSN, MS, Manager of Performance Measurement
The Pursuing Perfection Team at Tallahassee Memorial