Author(s): Hortincia Williams, RN, MSN, CPHQ
Director, Quality - Harris Health System
Williams, a seasoned nurse with over two decades of experience, holds a master's degree in nursing and is a Certified Professional in Healthcare Quality (CPHQ). Her extensive background spans critical care, medical-surgical, ambulatory care, and home health settings. With over a decade of expertise in quality management and leadership roles, Williams currently holds the position of Director of Quality at Harris Health Systems Lyndon Baines Johnson Hospital in Houston, Texas. Additionally, she serves as a High Reliability Organization (HRO) trainer within the organization, delivering courses on the Plan-Do-Check-Act (PDCA) methodology and quality enhancement tools.

Arshada Hayes, DNP, RN, CPHQ
Director of Quality Programs - Ben Taub Hospital Harris Health System
Arshada L. Hayes serves as Quality Programs Director Ben Taub Hospital Harris Health System in Houston, TX. She has been a member of the National Association for Healthcare Quality (NAHQ) since 2018. She has been serving in healthcare for 17 years and a nurse since 2011. She is known for her advocacy in promoting health care equity. She has experience in emergency management, medical surgical, long-term acute care, nursing education, leadership and Quality management. I have 6 years of Quality experience working to adhere with regulatory guidelines and improving compliance in metrics such as restraints.

Competency Domain: Quality Leadership & Integration

Description: Research indicates medical errors as the third leading cause of deaths, with national estimates suggesting that 14-56% of inpatient deaths are preventable. To address this issue, the mortality review process was designed to be the driving force in identifying opportunities and driving improvement in systems, processes, and outcomes. By adopting a multidisciplinary approach, establishing a standardized review process, organizing a formal review committee, and leveraging technology, we have successfully boosted clinician responses to mortality queries, pinpoint areas for improvement, identify areas of focus, reduce our observed-to-expected (O/E) ratio, and reduce the number of decedents falling below the Vizient threshold. Problem: o Low response rate with clinician completing review so Difficulty in capturing opportunities and identify trends with paper processo No visualization of data to identify trends to drive significant improvement Measurement: In this process, the O/E (Observed/Expected) Ratio and Vizient Threshold data source was employed, ensuring accuracy and alignment with industry benchmarks. The team, in pursuit of continuous improvement, utilizes a diverse set of tools such as run charts and fishbone diagrams to analyze trends and develop meaningful process improvement solutions. Analysis: The multidisciplinary team undertook a comprehensive root cause analysis, the outcomes of which were systematically organized into a fishbone diagram to focus on key challenges. One of the prominent findings was the necessity to harness technology to enhance our ability to visualize trends. Implementation: An electronic review tool facilitated a standardized review process ensuring that all pertinent data was captured. The information derived from the electronic review tool was aggregated into a dynamic dashboard, enabling visualization of opportunities with quality of care and documentation concerns as well as highlight response rate across the organization. Results/Discussion The commitment to continuous improvement, increased engagement, and robust reporting has yielded significant advancements in our mortality review process. Our response rate has seen remarkable progress, escalating from less than 50% in 2021 to an impressive 96% in 2023. The implementation of an electronic process has also enhanced satisfaction.

Evaluation: Complete Poster Evaluation