The gains that have been made during the Safer Every Day 90 day initiative have laid the foundation for improving quality and safety in Saskatoon Health Region. And while it may be too early to see what the long term results of these improvements will be, it’s anticipated that the work of these teams will help improve the Region’s overall hospital standardized mortality ratio (HSMR).

The hospital standardized mortality ratio is an overall measure of actual deaths compared with expected deaths that occur in-hospital. The HSMR provides a starting point to assess mortality rates and indicates how successful hospitals and health regions have been in reducing inpatient deaths — which demonstrates improved patient care. This week, the Canadian Institute for Health Information (CIHI) will be releasing the 2014-2015 stats on hospital standardized mortality ratio (HSMR).

The last numbers that CIHI released are from March 31, 2013 to March 31, 2014 and placed the Region above the national average for in-hospital deaths. The 2014-2015 HSMR report being released on December 16 will have additional data up to March 2015.

“We are anticipating that the numbers are similar to last year’s results, based on the previous year’s data and from our own review of in-hospital deaths,” said Petrina McGrath, vice president of People, Practice and Quality. “However, we know that whatever this year’s results are, we have to take into account that these numbers probably do not reflect the improvement work we’ve undertaken since these HSMR numbers were last released. Our improvement work will take some time to show a change in the HSMR results.” McGrath added the work has only just begun, but there is a strong commitment to enhancing safety, which is the Region’s number one priority.

After the last HSMR results, the Region did a review of 108 consecutive deaths. This review showed us that our opportunities for improving patient care and safety fell into three categories: failure to communicate, failure to rescue and failure to plan. “These themes were relevant to some of the work we’ve done with Safer Every Day,” says McGrath.

For example, the Clinical Process Improvement team, as part of the Safer Every Day initiative, has been doing work around diagnosing and treating sepsis. Sepsis was the top diagnostic group where the number of actual deaths was above expected deaths, and it was identified as a key area that the Region needed to improve in terms of rescue. However, sepsis can also be tricky to diagnose and early diagnosis and treatment are key in fighting sepsis.

“We began using a tool for sepsis identification and initial response,” explains Dr. Mark James, co-lead for the Clinical Process Improvement team. “Our initial audits on this tool have indicated that there is 75 per cent compliance for us meeting the target time of one hour from when a patient is first identified as having severe sepsis to when the first dose of antibiotic is given.”

As well, in St. Paul’s Hospital emergency department, the percent of patients receiving an intravenous antibiotic within three hours once sepsis has been suspected has increased from 50 per cent to 82.35 per cent in three weeks. Gathering this data has been labour intensive because it involves completing a daily chart review on the patient care units.

Similarly, the Team Communication and Performance team has been using an evidence based teamwork system, called TeamSTEPPS, aimed at optimizing patient care by improving communication and teamwork skills among healthcare professionals. STEPPS stands for Strategies and Tools to Enhance Patient and Performance Safety.

“Medical literature and our own review of data indicate that in up to 70 per cent of adverse events, communication breakdown is a contributing factor. The TeamSTEPPS work has been very successful in Acute Care Pediatrics where it is being trialed,” explains McGrath. “Although Pediatrics is not a part of the HSMR results, improved communication is a theme identified within the HSMR as an opportunity to improve.” The Region will be taking the learnings, tools and approaches the Team Communication and Performance team have found successful and incorporate them with other teams across the system, to further support the work on HSMR in other clinical areas.

The Safer Every Day work also included designing and testing a new process to review all inpatient deaths.

“Since October 19, we’ve reviewed close to 80 deaths at St. Paul’s Hospital in real time,” says Janet Harding, lead on the mortality review work. “Knowing exactly why someone died while they were a patient under our care is key to learning about safety issues within our acute care facilities.”

The HSMR data has identified themes for improving safety in specific areas of care where the Region’s HSMR rates were higher than the national average.

“Our deeper analysis of the data and the themes of rescue, communication and planning are showing us that we have similar issues affecting the care we provide across the system,” says McGrath.

Safety is the Region’s largest priority and prioritizing improvement work, such as sepsis identification and response, is all part of our commitment to improving safety throughout the Region.

“We know that any improvements we are working on must be spread systemically. We have started this work with Safer Every Day and we will continue this work beyond these 90 days. We understand from other healthcare organizations which have been in similar situations, that turning these numbers around can typically take up to two years,” says McGrath. “This is tough and complex work and we’ve really just begun to scratch the surface of it, but we will keep at it. We will not lose focus until this issues is solved.”

While the 90 day Safer Every Day initiative is officially over, follow-on plans to continue the teams’ progress are in development. The teams will be reporting out on this work on Tuesday January 12.