Lau adds that Kaiser brings in non-physician and non-nurse providers for a more disciplinary approach to inform the process. Speech therapists, nutritionists are part of the mix.
The hospital system also is experimenting with elevating the head of the bed in patients who are identified as high risk of aspiration pneumonia. This strategy is now used with ventilator-associated pneumonia patients, but is not well known for patients with aspiration pneumonia, Litman says.
So far, they've done a "deep dive" with e-Autopsy strategies on 150 deceased patients who met the criteria since 2009 in 12 Kaiser hospitals, Kanter says.
Litman, Lau, and Kanter, however, still aren't ready to talk in detail about any solutions they may have found, because they're not yet sure what they know.
"We're sort of in a learning cycle of trying different interventions and then measuring, to see whether that actually helps the patients in any way, and if it does we would continue that and expand it throughout our system," Kanter said. "And if it doesn't we'd try something else. We're in the middle of doing what we call rapid improvement of planning an intervention, and implementing it on a small scale."
And they emphasize that Kaiser already has a death rate that is far below the national average. In fact, in recent years they have reduced that rate from 80% to 60%, based on the Hospital Standardized Mortality Ratio index.
But this is about being the best they can be, and helping others find tools to improve care, they say.
Diane Jacobsen, who directs the Institute for Healthcare Improvement's Improving Flow Through Acute Care Settings and Reducing Mortality Rates (HSMR) project, says hospitals have long performed mortality reviews. But what's exciting about projects like Kaiser's e-Autopsy is "what we can learn from the death record. Rather than 'did someone do something wrong, or make a bad judgment,' it's a broader and more open discussion – what are the opportunities for learning?