Multicenter Standardized Mortality Review for Quality-of-Care Improvement: Implementing an Automated Workflow

Mortality review is a key mechanism for identifying preventable harm and improving hospital-based quality and safety. Traditional review processes are manual, often delayed, and inconsistent across services, resulting in variable completion rates and limited ability to generate improvement strategies. Structured, multidisciplinary review models have shown benefits, but many institutions continue to rely on decentralized, retrospective approaches that lack electronic integration or automation. Traditional approaches often fail to identify systemwide patterns, yielding insights with limited utility for driving meaningful, organization-level improvements. To overcome these limitations, a redesigned tiered mortality review workflow and supporting Web-based system were implemented across a multicampus academic health system.

A retrospective analysis was conducted comparing two six-month periods: the manual review process (January-June 2023) and the Web-based system (January-June 2025). The Web-based platform integrates automated case identification; structured Tier 1 reviews performed by frontline physicians, fellows, residents, advance practice providers (APPs), and nurses; and escalation to Tier 2 multidisciplinary committee review when indicated. Primary study outcomes included review completion rate, time to completion, and the number and nature of identified improvement opportunities.

During the manual review period (January-June 2023), 1,481 inpatient deaths occurred, of which 1,286 reviews were completed (86.8%). The mean time to completion was 78.4 days. Potential opportunities for improvement were identified in 63 cases (4.3%), with 3 cases (0.2%) resulting in implemented risk-reduction strategies. In the Web-based review period (January-June 2025), 1,440 inpatient deaths occurred, with 1,413 reviews completed (98.1%). The mean time to completion decreased markedly to 35.8 days. Potential improvement opportunities were identified in 165 cases (11.5%), with 72 cases (5.0%) leading to actionable risk-reduction strategies.

A redesigned tiered mortality review working and supporting Web-based system improved completion rates and capture of actionable opportunities compared with manual review, providing a scalable framework to strengthen patient safety and institutional learning.