Using Literature Review and Structured Hybrid Electronic/ Manual Mortality Review to Identify System-Level Improvement Opportunities to Reduce Colorectal Cancer Mortality.

BACKGROUND: Despite colorectal cancer (CRC) screening and survival rates exceeding national averages in the United States, Kaiser Permanente Southern California (KPSC) aimed to identify system-level improvement opportunities to further reduce mortality from CRC. METHODS: To examine modifiable factors contributing to CRC mortality, a structured hybrid electronic/manual mor- tality review was used to examine 50 randomly selected cases among 524 individuals aged 25-75 years diagnosed with stage II, III, or IV CRC after July 2008 who subsequently died. Physicians conducted chart reviews using a standardized data extraction tool based on evidence-based best practices. RESULTS: Eighty-six percent (43) of the 50 decedents were initially diagnosed with stage III or IV CRC; two cases of appendiceal cancer were excluded. Thirty-one percent (15) of the remaining 48 cases presented with no history of screening; 15% (7) had documented iron deficiency anemia and abdominal pain or rectal bleeding; and 6% (3) had no follow-up colonoscopy after positive screening. Eleven (52%) of the 21 patients with initial stage II-III CRC received appropriate surveillance after curative surgery; 57% (12) developed metastases. Adjuvant chemotherapy was offered to 88% (14/16) of patients with stage III (node-positive) CRC; chemotherapy initiation was delayed in 6 patients. Missed opportunities for surgical oncology evaluation occurred among 61% (11/18) of patients with liver metastases at diagnosis. Failure to report clinically significant features on pathology occurred in 2 patients; they received appropriate treatment for other reasons. CONCLUSIONS: Improvement opportunities existed at multiple stages of care, including screening, evaluation of symp toms, timeliness of care, use of adjuvant chemotherapy, and surgical oncology practices.

Saving lives by studying deaths: using standardized mortality reviews to improve inpatient safety.

BACKGROUND: Despite extensive ongoing quality improvement (QI) efforts, substantial variation existed in hospital standardized mortality ratios (HSMRs) across hospitals in Kaiser Permanente, an integrated health care delivery system. In 2008, Kaiser Permanente developed an efficient and effective method for investigating hospital-level mortality to identify patterns of potential harm. METHODS: The standardized multidisciplinary mortality review process incorporates the Institute for Healthcare Improvement Global Trigger Tools and 2x2 Mortality Matrix, elements of the United Kingdom's National Health Service (NHS) 3x2 matrix, and two groups of questions to "deep dive" into issues of preventable harm and the use of appropriate care settings. Between April 2008 and November 2009, multidisciplinary teams conducted mortality reviews of the 50 most recent inpatient deaths at 11 hospitals in Kaiser Permanente's Southern California region. An electronic chart abstraction tool facilitated rapid analysis of data. De-identified patient narratives portrayed trends and issues from a patient-centered perspective. RESULTS: Ten categories of harm in inpatient deaths were identified, including failure to rescue, to plan, and to communicate; harm that occurred before hospitalization; medication-related events; surgical or procedural-related harm; hospital-acquired infection and pressure ulcers; falls; and "other." Senior leaders at the study hospitals identified 36 quality improvement goals in response. CONCLUSIONS: The mortality review process, which included quantitative data from structured chart abstraction and qualitative description of harm events, efficiently gathered important information on patterns of mortality that was not otherwise available, enabling hospitals to identify trends and focus improvement efforts.