Abstract
Background: Comprehensive Stroke Centers (CSC) are required by The Joint Commission to have an interdisciplinary peer review process. Most hospitals structure their peer review programs, also known as morbidity and mortality meetings, by specialty and not by Centers of Excellence. Often these meetings are closed, with minimal information sharing for making program-wide improvements. Purpose: To develop and implement a process for conducting morbidity and mortality reviews for a CSC based on best practices to foster improved clinical outcomes. Methods: A literature review was performed to establish best practices for such reviews. An interdisciplinary team including key stakeholders was developed for a non-biased comprehensive chart review. All deaths within 30-days, sentinel events, serious incidents, adverse events, close calls, stroke mimics treated with alteplase, delays in care, complications, and major complaints were reviewed. Cases were captured by formal and informal processes (see diagram). Outcomes and trends are monitored. Recommendations are made for changes in clinical processes. Results: Between January 2016 - June 2018, 853 charts were reviewed for the criteria discussed above. A total of 89 charts were referred to the committee for further chart review, of which, 3 were identified for department peer review. Of those 3 cases, all were determined to be outliers, and no trends have been identified . While there were no blatant opportunities identified for improvement, the review process provides helpful information regarding the quality of the program. Members of the interdisciplinary team feel that the process is robust and valuable. Conclusion: Establishing a succinct process for chart evaluation and interdisciplinary team review has proven effective in identifying cases for referral to peer review. These data have been helpful in improving performance and monitoring patient-centered outcomes.
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