The Reducing Hospital Mortality “Diagnostic”
The Mortality “Diagnostic” is emerging content developed through the work of IHI’s
Reducing Hospital Mortality Rates Learning and Innovation Community. The purpose of
the Mortality Diagnostic is to get a clearer understanding of local conditions that
contribute to mortality.
The Mortality Diagnostic consists of four components:
1. Analyze the most recent 50 consecutive deaths and place them in a two by
two table:
a. the 2x2 table provides a framework for organizations to focus on changes that
may reduce mortality.
b. the 2x2 table is constructed based on the following questions:
- On admission: was the patient admitted for comfort care? (Y/N)
- On admission: was the patient placed into an intensive care unit (ICU)? (Y/N)
Box 1:
Box 2:
Box 3:
Box 4:
YES admitted to the ICU; YES admitted for comfort care
NO admitted to the ICU; YES admitted for comfort care
YES admitted to the ICU; NO admitted for comfort care
NO admitted to the ICU; NO admitted for comfort care
ICU Admission
No ICU Admission
Comfort
Care
Box 1
Box 2
Non
Comfort
Care
Box 3
Box 4
The number/proportion of deaths that occur should be reflected in each of the
respective boxes. Hospitals should focus their work initially on boxes that have at
least 20% of your mortality. Changes related to each of the boxes are included in
Appendix 3.
2. Review the deaths in Box 3 and Box 4 to determine if there was evidence of
failure to recognize, plan, communicate during the entire hospitalization:
- failure to recognize: any situation in which a patient has died and there was
evidence that an intervention could have been made anytime prior to the patient’s
death (in this hospitalization) that potentially would have impacted the patient’s
outcome.
Example criteria that could be considered in reviewing the medical record
include: staff was worried, change in heart rate, change in respiratory rate, change
in blood pressure, change in O2 saturation or change in consciousness or
neurological status that was not responded to.
- failure to plan, such as: diagnosis, treatment, or calling a rescue team
- failure to communicate: Patient to staff, clinician to clinician, inadequate
documentation, inadequate supervisor, leadership (no quarterback for the team),
etc.
3. Evaluate the first 20 deaths in Box 3 and Box 4 to determine if there is any
evidence of adverse events, using the Global Trigger Tool.
4. Evaluate ALL deaths in Box 3 and Box 4 to assess the estimated impact of our
care on mortality:
*As you review the deaths in Box 3 and 4, ask yourself the questions honestly
(focusing on learning, not judgment):

Was perfect care rendered?
 If perfect care wasn’t rendered, could the outcome of death have been
prevented if the care had been better?
- What number of deaths could have been prevented?
Institute for Healthcare Improvement
Reducing Hospital Mortality Rates Learning and Innovation Community:
The Mortality “Diagnostic” (updated August 2006)
2
Appendix 1: Initial Screening Tool – Mortality Analysis
INITIAL SCREENING TOOL
MORTALITY ANALYSIS


BOX
Patient ID
Med Record #
Admitting Unit
Admit Date
Unit When Death Occurred
Discharge Date
Patient admitted from:



Home
Skilled Care
  
Transferring hospital
Other




Admitting Diagnosis (without looking at discharge diagnosis)
Principal ICD-9 Code and Diagnosis at Discharge
Did the admission and discharge diagnosis match?
Yes
No
Was patient admitted for “comfort care”?
Yes
No
Was patient admitted to the ICU?
Yes
No
Was the patient transferred to a higher level of care?
(at any point during their stay)
Yes
No
Institute for Healthcare Improvement
Reducing Hospital Mortality Rates Learning and Innovation Community:
The Mortality “Diagnostic” (updated August 2006)
3
Appendix 2: Mortality Analysis Tool
MORTALITY ANALYSIS
In the work on mortality, we have encouraged all hospitals to develop
measurement/learning systems for mortality analysis. All hospitals have a peer review
system that looks at mortality but those systems have focused on measurement for
judgment. To be successful, you need to have something more. We have looked at the
work of a variety of organization, the work of Charles Vincent and our own work and
have come up with a list of the main categories that should be considered in a mortality
analysis.
The following worksheet should be completed for each death in Box 3 and Box 4 to
determine if there is evidence of: Failure to recognize, plan and/or communicate. The
goal of this tool is not to provide an exercise in categorization but an opportunity for you
to more fully understand your own hospital.
Failure to Recognize: any situation in which a patient has died and there was
evidence that an intervention could have been made anytime prior to the patient’s
death (in this hospitalization) that potentially would have impacted the patient’s
outcome.
Example criteria that could be considered in reviewing the medical record include:
staff was worried, change in heart rate, change in respiratory rate, change in blood
pressure, change in O2 saturation or change in consciousness or neurological status
that was not responded to.
Failure to Plan, such as: diagnosis, treatment, or calling a rescue team
Failure to Communicate, such as: Patient to staff, clinician to clinician, inadequate
documentation, inadequate supervisor, leadership (no quarterback for the team), etc.
 Failure to Recognize
Comments:
 Failure to Plan
Comments:
 Failure to Communicate
Comments:
Institute for Healthcare Improvement
Reducing Hospital Mortality Rates Learning and Innovation Community:
The Mortality “Diagnostic” (updated August 2006)
4
Appendix 3: Changes related to the 2 x 2 table
Hospitals should focus their work initially on boxes that have at least 20% of your
mortality.
COMFORT CARE
ONLY
Box 1 changes:
 Clarity of ICU
admission/transfer criteria
Box 2 changes:




NOT COMFORT
CARE ONLY
Box 3 changes:







Glycemic Control
Sepsis Intervention
Ventilator Bundle
Multidisciplinary rounds in the
ICU/Shared Goal Sheet
Communication & Handoffs
Central Line Bundle
Appropriate tidal volume for
ARDS patients*
Advanced Directives
Alternatives to hospital care at
the end of life
Palliative Care Team
Community outreach for
Advanced Directives
Box 4 changes:







Rapid Response Team
Communication & Handoffs
(tools, such as SBAR)
Early Warning System
Multidisciplinary rounds outside
the ICU
Glycemic Control outside the
ICU
Central line bundle outside the
ICU
Advanced training for Rapid
Response Team – incorporating
Sepsis & early warning*
* Change ideas marked with * are still consider early work.
Institute for Healthcare Improvement
Reducing Hospital Mortality Rates Learning and Innovation Community:
The Mortality “Diagnostic” (updated August 2006)
5