Structured mortality review can help identify care issues and focus quality efforts, but existing methods have limitations. In the Department of Medicine at UCLA, we developed a novel in-person, near real-time, interdisciplinary rapid mortality review (RMR) process to capture the insight of frontline providers and improve care. In this study, we compare the yield of RMR debriefings with that of electronic provider surveys.
Over four years, we conducted over 500 RMR meetings. As part of the standardized review facilitated by a quality lead, the physician and nursing team assesses whether the death was potentially preventable and discusses opportunities for improvement in care. The quality lead categorizes the issues discussed, and any quality action items are tracked in our mortality database. When an in-person meeting cannot be arranged, an electronic survey with the same questions posed in the in-person review is sent to the attending physician. Here, we compare the yield of the in-person debriefings and surveys using chi-squared or Fisher’s exact tests.
Overall, 5.3% of deaths were deemed potentially preventable, 52.8% had quality issues identified, and 25% inspired quality action items. The most prevalent categories of issues identified were advance care planning/palliative care (22.6% of cases), communication/teamwork (15.1%), systems issues (13.8%), delays in recognition and treatment of deterioration (11.5%) and medical error (4.2%).
501 cases were reviewed with in-person debriefings and 88 with surveys only. There was no difference between review methods in the percent of cases providers deemed potentially preventable (5.2% vs. 5.7%, p=0.8). However, the in-person debriefings identified quality issues in a significantly higher proportion of cases than the electronic surveys (55.5% vs. 37.5%, p=0.003). All categories of issues were identified in a higher percentage of cases in the in-person debriefings; however this difference only reached statistical significance for communication/teamwork (17.4% vs. 2.3%, p<0.001) and near-significance for systems issues (15% vs. 6.8%, p=0.06).
In-person debriefings were more likely to inspire quality action items (28% vs. 8%, P<0.001), with a similar proportion completed or in progress (71% vs. 67%, p=0.726).
In our experience, near real-time debriefing of interdisciplinary frontline providers reveals more quality opportunities than electronic provider surveys. Advantages may include the quality-trained facilitator who can prompt the participants to look beyond individual to team and system factors and potential solutions, as well as the presence and discussion amongst multiple providers with different perspectives on the case. Transforming mortality review can lead to better identification of actionable quality opportunities to eliminate preventable deaths and improve end of life care.