Cross-Division Surgical Group Conducts Quarterly Review as Supplement to Traditional Department-Specific Morbidity and Mortality Reviews, Leading to Lower Mortality Rates | AHRQ Innovations Exchange

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Cross-Division Surgical Group Conducts Quarterly Review as Supplement to Traditional Department-Specific Morbidity and Mortality Reviews, Leading to Lower Mortality Rates | AHRQ Innovations Exchange





September 24, 2014 Issue
Innovations in Surgical Care

This issue includes

Innovations:

• Cross-Division Surgical Group Supplements Traditional Morbidity and Mortality Reviews

Cross-Division Surgical Group Conducts Quarterly Review as Supplement to Traditional Department-Specific Morbidity and Mortality Reviews, Leading to Lower Mortality Rates

Martin J. Heslin, MD, MSHA, FACS

Summary As an adjunct to traditional division-specific morbidity and mortality reviews, the University of Alabama at Birmingham Hospital created a "surgical quality group" made up of representatives from across its 11 surgical divisions. The group meets quarterly to review mortality-related data and discuss trends, problems, and opportunities for systematic improvement across divisions. In both types of reviews, physicians make use of accurate and concise case reports created by coding specialists based on data provided by physicians. The addition of the cross-division quarterly reviews reduced mortality rates and improved the hospital's relative performance on a composite quality score versus other academic medical centers. Evidence Rating (What is this?) Moderate: The evidence consists of pre- and post-implementation comparisons of the hospital's observed-to-expected mortality ratio and its relative performance on a composite inpatient quality score versus that of other academic medical centers. Developing Organizations University of Alabama at Birmingham Hospital and Comprehensive Cancer Center Date First Implemented 2012