Reviewing Deaths to Improve Quality of Care

Mortality Review is a system-wide program designed and developed by the Johns Hopkins Technology Innovation Center (TIC) to review patient deaths and improve clinical care.

The TIC developed the Mortality Review program with the Armstrong Institute to facilitate review of all Johns Hopkins Health System (JHHS) patient deaths. Every time a patient in any of the six JHHS hospitals dies, a case is opened. The program automatically emails the front-line team that took care of the deceased patient and provides a link to a questionnaire. This team (usually the attending, discharge provider, and nurses) accesses the Mortality Review program to answer multiple choice and free-response questions to provide feedback about the patient’s death. Did they think it was preventable? Were there any system issues? Are there other people involved in the patient’s care who should be surveyed?

If no concerns are raised, further review is not indicated. However, if the front-line team raises any concerns, the quality improvement and risk management teams further investigate the case (Level 2) and determine if a wider multidisciplinary review (Level 3) is indicated. The review teams look at all areas of concern to try and improve quality in the future.

Prior to this program’s development, patient deaths were reviewed on an ad hoc basis. Some departments conducted very robust review processes while others did not. The Health System averages about 2000 patient deaths per year across all six hospitals.

“There was no general repository for any of the death-related information and therefore, no one could see any trending across the Health System. Whether there were areas where a group was doing well related to a particular issue, or whether a system-wide workgroup was needed to tackle an issue, we had no way
of knowing.”
— Jody Bigley, Senior Quality & Innovation Project Administrator,
Armstrong Institute

“One of the goals of this program is to look at all deaths and explore them as a broader group instead of small areas finding an issue and trying to fix it locally, but not doing anything across the Health System.”
— Dr. Elliott Haut, a trauma surgeon who was part of the Mortality Review program development team

This project began before the pandemic without the TIC’s assistance. Once the TIC became involved, they were able to quickly turn this product around in a few short months. Dr. Amy Knight, a hospitalist at Johns Hopkins Bayview who also helped develop the program said the TIC “was responsive, creative, and honest about what could and couldn’t be done.”

The first level of the Mortality Review program was recently upgraded and small tweaks and changes are ongoing.