Lau, H., & Litman, K.C. (2011). Saving Lives by Studying Deaths: Using Standardized Mortality Reviews to Improve Inpatient Safety. The Joint Commission Journal on Quality and Patient Safety, 37(9). Retrieved from http://www.ihi.org/knowledge/Knowledge%20Center%20Assets/4672f1f5-d077-47e4-9a28-411cb688c5f1/Saving%20Lives%20by%20Studying%20Deaths-%20S2-JQPS-09-11-lau.pdf. (Note: you must create and account to access this report but it is completely free to do so.)
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.
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.
