Whose job is it in the NHS to reduce deaths and complications?

Recently there is an increasing concern about mortality and morbidity in the NHS. Let us for simplicity say that people are asking whether the death rates and complication rates can be reduced. People are asking if there are any avoidable components in relation to deaths and complications and whether those avoidable problems can be eliminated or at least reduced to minimum. People are also want to know who is responsible or accountable for ensuring lower death and complication rates.

NHS Directors

NHS trusts are in the business of delivering healthcare to their populations – that is the essential purpose of their existence. So it may be reasonable to assume that the directors, who are the top bosses of these trusts  and their bosses (SHA equivalent, NHS England directors) will be assessed and rewarded against clinical quality parameters of which deaths and complications are core.

Apparently not. The contract for the managers especially when it comes to pay uplifts and bonuses are very specific. I quote:

''It is an essential criterion of the performance bonus scheme that the organisation achieves its financial control target as agreed with its grand parent organisation (see paragraphs 64 and 65 below).

Where an organisation fails to do this, all its very senior managers will be treated as Category D performers and so no awards (either annual uplift or performance bonus payment) will be paid to them

The annual uplift will be applied to the basic pay being paid to the post holder (which would include any long-term RRP payment), provided that:

the organisation achieves its financial control target; and

the individual concerned is judged as performing at Category A, B or C.

Those in Categories A, B and C will receive this annual uplift to their basic pay, which will be pensionable

Those in Categories A and B will receive, in addition to the annual uplift, a non-consolidated bonus payment, provided the essential criterion is met –

i.e. that the organisation achieves its financial control target. Bonus payments will be non-pensionable, non-consolidated one-off payments

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/126865/pay-framework-vsm-strategic-and-special-has-pcts-amb-trusts-updated-july-2012.pdf.pdf ''

So it is seems the only officially contracted criteria to be eligible for a pay uplift and bonus is meeting the financial target (and something woolly about being classed as A, B or C. In any case if you don't meet the financial target it is an automatic D which means no pay uplift or bonus irrespective of how much quality is improved and mortality/morbidity is low

What do you think might be happening in a manager's mind when priority setting? Which director will be prepared to have a very low mortality and morbidity and yet be classed as a failure and given a D. If ever a CEO was prepared to do that what do you think that their directors's mind would think given the fact that various director's pay are set as a percentage of their CEO's pay. What does it tell Jo public when the Finance Director's pay is linked to and set at 75% of the CEO pay and all other directors get a lesser percentage? One lovely chain where there is clear financial incentive to reach financial targets and ensure the CEO gets a higher pay. I am sure my understanding is not perfect but it looks like a conflict of interest built into a contract - you could not make it up if you were writing fiction. Where do you think the emphasis will lie? No guess work – it is explicit – financial control target it is and nothing else.

Now do I think for a minute that any CEO or director gets to work and says 'kill patients but save money', heck no. But we have all heard about subliminals, motivation, contractual obligations playing a part in how we perform. It does not sound sweet.

REGULATORS

We then have regulators to oversee that trust bosses who are contractually only obliged to serve the financial agenda are still meeting some sort of standards that matter to a publicly funded healthcare system – i.e. clinical quality with death and complications at its core.

Lets look at some of the regulators purposes:

Monitor: Our main duty is to protect and promote the interests of patients. We do this by promoting the provision of health care services which is effective, efficient and economic, and maintains or improves the quality of services.

CQC: We make sure hospitals, care homes, dental and GP surgeries, and all other care services in England provide people with safe, effective, compassionate and high-quality care, and we encourage them to make improvements.

GMC: Our purpose is to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine.

But let us look at how it actually works out

CQC

The CQC talks about safety and quality but when you look into what they actually say there is no specific mention that organisations will be assessed against their death and/or complication rates

http://www.cqc.org.uk/public/what-are-standards/national-standards

For God's sake how else do you assess care quality if you do not start with death and complications.

MONITOR

It is the government's aim to provide independence to NHS trusts by allowing them foundation trust status. Clinical quality especially reducing mortality and morbidity is not a criteria for affording independence (though there is assessment on whether the trust is governed properly)

http://www.monitor-nhsft.gov.uk/sites/default/files/publications/An%20introduction%20to%20Monitor%27s%20role%201%20April%202013_0.pdf

With 10 out the 14 trusts under Keogh review being Foundation trusts, it is reasonable to wonder what actually the question 'well governed' means for Monitor.

BOSS' BOSS – The Grandparent Organisation is DoH

It looks like the department of health may have the overall responsibility for mortality and morbidity reduction though those are not explicitly spelt out in their website

https://www.gov.uk/government/organisations/department-of-health/about

It has taken nearly a decade and half after HSMR was introduced that DoH is making some moves to look into this. Perhaps better late than never. But as the grandparent organisation DoH is responsible for setting the contractual framework like it is in the first place.

What about doctors and nurses?

Doctors 

Doctors bonuses in the form of CEAs are based on quality of service and hopefully given to excellence. There is no requirement to demonstrate reduction of mortality or morbidity but the hope is that those two essential measures of quality will be considered explicitly when these awards are made. That is sometimes the case, sometimes that is not the case. In theory it is possible for even the highest award holders to hold the awards without ever demonstrating a decrease in mortality or morbidity.

https://www.gov.uk/government/publications/clinical-excellence-awards-2012-application-forms-and-guidance

Then of course there is the GMC who will come down on doctors who are caught out mainly due to significant single incidents which are reported. More recently the GMC due to its revalidation format demands 'quality improvement' though does not explicitly demand reduction of deaths and complications. 

Nurses

Agenda for change does not speak explicitly about improving clinical quality or reducing mortality/morbidity.

http://www.nhsemployers.org/PayAndContracts/AgendaForChange/Pages/Afc-Homepage.aspx

So who is responsible for deaths and complications in the NHS?

It is everyone's job but no one is required to do it and nobody is responsible or accountable for it.

It does not say in anyone's job description or contractual terms that 'it is your contractual duty to seek and achieve a reduction in mortality and morbidity of your patients and when it is not achieved to provide a reasonable explanation of why they have not been achieved and what you will do to achieve them'. Nobody's pay scale is linked to a reduction of mortality and morbidity. Therefore no one is responsible or accountable for deaths and complications. People do it as an optional extra, as a gesture of goodwill, from the goodness of their hearts, as a side effect of their day jobs. There are so many organisations all claiming to be working for patients' protection, quality and so on but all they do is announce diktats on what others should do; they do not hold themselves accountable on behalf of or as representatives of their members by measured reductions in avoidable deaths or complications. It is always everybody's job, somebody else's job, each one of us wants to hold somebody else to account but never us.

That is why it is so very impossible to deal with and so very difficult to get meaningful sustainable improvements. The contractual requirements, recognition and reward structures are all wrong in the sense they are not geared to look for quality improvement. Looks like this is a case where the structure and process results in just the expected poor outcome.

There are solutions – it is to use healthcare management methods to manage healthcare and not to use as we do now - business, financial, manufacturing, service industry or other management methods for healthcare. Whether there is enough interest, knowledge or expertise to do so is highly questionable.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Further Info: I am informed by an NHS FT Board Director that the NHS Board director's contract that is referred to in this blog does not apply to NHS FT Chief Exec or Board Directors.
It will be interesting to find out who it applies to.
Hemadri
15 August 2013

High Mortality Hospitals Cannot Afford To Pay

In a previous post I showed that most high mortality trusts did not pay bank holiday extra rates/wages to staff for the Queen’s diamond jubilee bank holiday, while most low mortality trusts paid higher wages. 

 

A friend of mine who is an academic wrote back to me and said he could not resist doing a chi square on the numbers and found the p=0.01. I am no don to argue or explain stats but irrespective of statistical significance it is important to probe if there might be a deeper meaning or relevance. 

 

It is important to understand why the high mortality trusts did not pay higher holiday rates. Are they ‘mean spirited’ as the Unite Union portrayed them?

In my mind the underlying reasons are very simple and here it is:

QUALITY IS INVERSELY PROPORTIONAL TO COST 

 

And a high HSMR is broadly speaking poor quality care.

Financial reasons?

It might be something as simple as they had no money left to pay. Now that would be a perfectly reasonable assumption to make. Trusts get paid for activity, things like hernia repairs, aneurysm repairs, cardiac stenting, the kinds of things that you do to make patients get better. As far as I know the NHS tariff system through which the trusts get paid does not include things like deaths or complications. 

But in-hospital deaths are very costly; in-hospital complications are very costly. There is no mechanism for payment for that. So a hospital/trust which has high deaths and complications will obviously not have money to do anything else.

Well, it therefore might turn out that their inability to pay higher wages had no a financial reason at all; it may well be a by product of poor quality. High cost, deficits, losses are all a function of poor quality. 

 

If you pushed them they will come out with something like ‘in this financial climate we would like to channel all our sparse finances directly into patient care’ and you know what, they sure do; their patient care must cost excessive amounts of money due to higher rates of standardised mortality and higher complications.

Cultural reasons?

Perhaps they were unwilling to pay higher rates; management might not have felt the need to 'reward' staff who are unable to produce high quality measured in terms of mortality. Another reason might have been that the money might be better spent in a high mortality hospital in trying to reduce the mortality rather than paying more to staff when the law does not demand that you do so. These are a part of the mental make up and cultural reasons of management. They are right, well, partly right. It is also just possible that well rewarded staff might be motivated to engage in improvement. Works both ways but always difficult to decide which one is right for the given circumstances.

Finally, here is some speculation

But, why did some high mortality hospitals pay staff bank holiday wages? Surely the above arguments apply to them as well. Why did some low mortality hospitals not pay higher bank holiday wages? 

 

Now I am moving into speculation something which I try not to do too often. My gut feeling is that the high mortality hospitals who paid a higher wage are probably going to find reduced mortality soon or at the best they may continue to stay where they without slipping and getting any worse and the low mortality hospitals who did not pay may find their mortality going up or at the best they may stay where they are without getting any better

 

My speculation is an extension of my theory about money in hospitals, the trusts who are doing clinically well might have the spare cash to spend it on staff. If that was indeed the case, the staff deserve it.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Demanding consultant delivered acute care

Who should deal with the most urgent and severe emergencies?

The following runs in every healthcare worker's mind but we usually do nothing about this. Let me describe it.

First time elective referrals at out patients for major conditions gets seen usually by consultants
First time elective major operations usually done by consultants (especially the major ones)

However,
Redo operations after complications due to first time elective surgery - quite often done by registrars or 'middle grades'
First time major emergencies in Resuscitation rooms and dire post operative emergencies in wards and ICUs are usually dealt with by registrars or 'middle grades'

Is that logical? Is that sensible?

Of course in some specialties like vascular, neonatal and a few other, the senior most persons often deal with the most dire things but I am talking about most specialties. For instance in internal medicine an elective referral for a chronic cough or chest pain will normally be seen by a consultant but a severe acid base imbalance, a pneumothorax, undiagnosed sepsis will be first seen often by very junior doctors fresh out of medical school or if the patient was extremely lucky by a registrar or middle grade.

This anomaly should be addressed. But it will not be easy to address. Clinical severity of the condition and clinical severity of any potential adverse outcomes should decide who will see/treat the patient and not mere availability, convenience, historical residual legacies and other administrative/managerial issues. This will demand consultant delivered care (not consultant 'led' care). People will rightly be concerned about the cost; it would be important to recognise that the improvement in clinical quality and the enhanced clinical accountability for outcomes could result in lower overall costs. If on the other hand there was a clear increase in quality the richer economies should accept that as the new benchmark for cost.

Success in Healthcare will depend on the proper utilisation of its very valuable human resource; the utilisation of the human resource should be exclusively based on clinical need - more severe the presenting situation - the more senior should be the primary attending human resource.

Here is where patients could play a part in improving the quality for themselves and in shifting the culture within healthcare. Patients and families could use the consent process to influence better care. Consent is a legal requirement before professionals can provide care hence any caveats in that legal process carries significant weight. Patients and families may or may not be able to define what should be done but they can define what cannot be done; for instance you cannot say you have to be given a blood transfusion but you can say that you should not be given a blood transfusion.  In the same manner I think patients probably cannot demand that only a fully trained healthcare profession should treat them but can possibly decline to accept care from anyone who is not fully trained without them being directly supervised.

For instance my living will or perhaps my consent to treatment form could say 'I, having worked hard and paid my taxes, when I am ill, expect to be treated and cared for at every stage by fully trained clinical staff; if that does not happen I will take it as having possibly received substandard care. Being a responsible citizen and supporter of NHS I am aware of the need for trainees to learn so that future specialists can be created; I will allow trainees to care for me at any time as long as their trainer is physically present and actively training the trainee in a hands-on manner. If the trainer is not physically present and actively involved (for instance if it is a surgical operation the trainer must be scrubbed up and assisting the trainee) I shall consider it as a breach of my right to have received the highest quality of healthcare that I expect and a breach of the consent that I have provided' (** Caution: Using aforesaid statement is likely to negatively affect your healthcare and risk an adverse outcome. The statement is used to make a point and not necessarily for practical use**)

It is patients' choice, let us take it seriously. If you thought this was a bit too assertive - pause for a few seconds and reflect on the day when my above sentences will be cut and pasted by every patient on to their consents and living wills. Or even better, pause and think of what you would want for your child, spouse or parent when they are facing the most dire emergency circumstances of their life perhaps after something that had already gone wrong. Would you want someone who has left medical school recently (though they are very good trainees and keen to learn) or someone for whom you have already paid upwards of £1million to become fully trained and employed to care for you, when you are facing a potentially resolvable life threatening condition? I rest my case.

©M HEMADRI

COMPLICATIONS OR HARM AND THEIR IMPACTS

COMPLICATIONS OR HARM AND THEIR IMPACTS

M HEMADRI

'Complication' is such a sanitised word. When doctors and nurses speak about complications the language is purely technical, distant and mostly third party. When the complication comes true, it is of course none of those, it is very personal; physically and emotionally hurtful with huge trauma to to the sufferers and their families, in so many ways that we can never understand or even describe.

The following is about a series of extraordinary real life happenings that relates to a normal British person from Portsmouth and his family. The words are a cut and paste from the court judgement with a few minor changes to help normal reading.

-----------------------------------begin of cut & paste----------------------------

• The patient was aged 39. His father had for several years been undergoing kidney dialysis treatment and was suffering from renal failure. The patient was anxious to give his father the opportunity of a better quality of life in his well earned retirement by donating his own right kidney, thus sparing his father further dialysis treatment. The operation was performed on 26^th February 2008. The hospital admits that the operation was performed negligently, and to a degree recklessly. There are proceedings before the General Medical Council against the surgeon in question.

• The consequences of the hospital's negligence have been catastrophic for the patient and his family: physically, psychologically, emotionally and financially. Although the patient's right kidney was successfully removed and transplanted, the patient suffered irreversible failure of the left kidney. In fact he should never have been advised to undergo the operation at all given the grave dangers involved. That negligent advice was compounded by serial mistakes during the operation itself. The patient's life was saved only after many hours on the operating table during which he received over 100 units of blood and fluid transfusions.

• During the course of the operation the patient suffered further complications which have had far reaching consequences: a minor myocardial infarction; ischaemic damage to the bundle of nerves known as the lumbo-sacral plexus, which supply the right leg and foot; a thrombosis of the inferior vena cava.

• The patient was left in total renal failure. He was in hospital for nearly two months, during which he started to receive haemodialysis. He developed a serious drug induced confusional disorder. There were further re-admissions to hospital in March and April 2008, following which he received dialysis treatment three times a week as an outpatient for a year. This treatment affected him profoundly. He became severely depressed, frequently contemplating suicide. He contracted serious infections, one of which necessitated a further admission to hospital for four days in October 2008.

• The patient's own act of altruism and family devotion in donating a kidney to his father, which cost him so dear, was reciprocated by the patient's sister. With the same outstanding altruism and family devotion she in turn donated a kidney to the patient, at very considerable psychological and emotional cost. That operation, performed on 27^th March 2009, was successful. It released the patient from an indefinite regime of dialysis. However, he lives with the constant fear that his body will reject the kidney and it is common ground that when he reaches his early sixties that kidney will require replacement. This uncertainty, and his experiences generally, have left him with an understandable obsession about his health.

• Unfortunately a recurrent infection was imported with his sister's kidney, cytomegalovirus viraemia (CMV). This is a constant source of worry. So is his blood creatinine level which, if raised, can be a sign of kidney rejection.

• The renal failure the patient suffered increases significantly the risk that he will suffer from ischaemic heart disease and a stroke. Consequently he adopts a very careful lifestyle and diet. He has had high blood pressure and high cholesterol levels which cause him constant worry. The immuno-suppressant drugs he takes, in particular to control the CMV, greatly increase the risk of his developing other debilitating and life threatening conditions. The consequence is that he has become fastidious to the point of obsessional about personal and general hygiene, which impacts upon the whole family. He can be irritable and overbearing. He is prone to bouts of weeping.

• There are further serious physical consequences. The nerve damage suffered during the negligent operation has resulted in altered sensation below the right knee. There is hyper-sensitivity, pain and loss of sensation in various parts of the right foot, and clawing of the first and second toes. He has had surgery on the first toe. Further surgery had been planned to straighten and fuse the toes but this drastic measure may be avoided by regular injection of botulinum toxin for life. The issue surrounding this problem with his foot has a bearing on his residual earning capacity. Currently he is unable to run, and walking on uneven ground and stairs presents some difficulty.

• The patient has also been much distressed by urinary difficulties. For a time self- catheterisation was attempted. He found it a dreadful experience. Urinary frequency bedevils his daily life, and results in broken nights for him and for his wife.

• The medication he takes has had unpleasant side-effects including the profuse growth of unwanted body hair, the development of skin acneiform lesions and the deposit of facial and abdominal fat. His inability to exercise has also led to undesirable weight gain. Prior to the operation, the patient was a healthy, fit and active 35 year old man. He took great pride in his health and fitness, running several kilometres each morning to set himself up for the working day. He had enormous energy. He was cheerful, optimistic and extrovert.

• Now the picture is very different. At the age of 39 his daily life revolves around his health worries. He is constantly fearful of infection or changes which may increase the risk of the kidney being rejected. Any venturing from the strictly enforced hygiene of the home is fraught with anxiety. He lives with the certain knowledge that the kidney will require replacement by the time he reaches the age of 61 and that this will be preceded by symptoms of progressive renal failure. It is agreed that his life expectancy has been reduced by 10 years.

• The patient's wife says that the patient is a shadow of his former self. He is lacking in energy. He is exhausted by 9 pm and generally has to be in bed by 10 pm. He is moody and irritable. Their marriage, though very strong, is constantly under strain. The children have been affected and distressed by their father's condition and behaviour and he has bridges to build there.

-----------------End of cut and paste------------------------------

The above example was of course extraordinary, further the issue reached the court of law otherwise we would not have heard it in such a profound and full sense. It might have reached us through the press in which case we would have discounted it for journalistic embellishment. In reality most if not every healthcare related 'complication' has impacts on patients' lives which are significant but we will never hear about it.

Perhaps it is time to start describing some of the possible known effects of complications on patient's lives should be described in a way that it really affects patients lives. Let me explain. Do you think the hospitals, doctors or nurses when explaining or consenting patients for surgery ever tell them 'if you had one of the severe complications your marriage could be constantly under strain; your children could be affected and distressed by your condition and behaviour and your may need bridges to be built with them as a result''?

For instance When we talk about surgery on blood vessels in the limb we mention 'amputation' as a possibility. Does that really describe anything to a patient who has never experienced or seen amputation before? Perhaps we ought to tell them how in the initial days even to move from side to side in a bed they would need support, their entire body will need to put in daily heroic effort to cope, they will not be able to do any sort of work for many months, if everything goes well it will hurt during wound healing, during dressing change, during physio, during limb fitting, when using the limb. When goes wrong it will hurt more, more often and for longer – if it goes wrong even more it will hurt every day of their lives (phantom limb pain). They will need to know that the pain will need strong pain killers, strong pain killers will cause constipation, constipation could cause fissure which will hurt even more. They would need to know that if the wound breaks down their raw cut bone could stick out. Well, even after these descriptions we haven’t even made a start on the long list and impacts in a proper way!! These are only physical.

Perhaps we need to tell them that they may not be able to drive a normal car; the pain could drive them to become an alcoholic if they are lucky and a drug addict if they are unlucky. Perhaps they need to know that their family and friends will provide sympathy which the patient could misinterpret and end up feeling patronised resulting in phenomenally strained relationships all around.

God help us avoid complications.

Complications are true complications only when every effort at our command is made to avoid them from happening and yet they happened, otherwise it cannot be called a complication; it is called harm. As an illustration, if a patient developed deep vein thrombosis due to omitted drug thromboprophylaxis, poor mobilisation, poor hydration or pelvic injury at surgery that DVT is healthcare caused harm; similarly if a spinal or epidural catheter was removed without regard to when chemical thromboprophylaxis was given and the patient developed spinal cord problems, that would be harm caused by heal. DVT prevention is an easy example, there are thousands of other ways that healthcare's omissions, commissions and disagreements hurt patients; they can no longer be euphemistically called complications any longer.

Here is something uncomfortable, a number of these problems happen because of us (organisation or individuals) though we are often unable to even recognise that.

Once again, the impacts of complications on peoples lives is something that healthcare professionals would not be able to even begin to understand, or describe. There are specific tried and tested methods to avoid harm or to reduce them to their minimum possible. Most healthcare providers do not have to do world beating cutting edge stuff, they only have to put in some effort to just avoid harm in healthcare. If it was done that would count as Success in Healthcare.

© HEMADRI

Follow me on twitter @HemadriTweets

Ref: http://www.judiciary.gov.uk/Resources/JCO/Documents/Judgments/xyz-judgment-14022011.pdf

HSMR

HSMR

Hospital Standardised Mortality Ratio

M HEMADRI

Preface

This is written on the basis of my understanding of the HSMR after attending a mini-course at the International Forum on Quality and Safety in Healthcare, Amsterdam 2011, taught by Sir Brian Jarman the original designer of HSMR, Paul Aylin of the Imperial College Dr Foster unit and Andre van der Veen (of de Praktijk index the Dutch collaborator of dr Foster). Their methodology and descriptions are publicly available and links are provided at the end.

Introduction

Death is a definite unarguable outcome; that includes deaths in hospitals. Though hospitals are essentially to provide care and save lives there will be some patients who will die in hospital despite the best possible care provided by the hospital and its staff. Using risk assessment models it is possible to calculate the number of patients who could be expected to die in hospital.

The number of actual patients who die in a hospital can obviously be accurately measured. The number of patients who are expected to die in the hospital can be calculated by risk assessment and risk adjustment models. These values are converted into a ratio and expressed as a value. That value would be the value of the Hospital Standardised Mortality Ratio.

In this write up, the basis of the calculation of the model is explained, some questions about the way it works are explained and the implications of the ratio are explored.

Founder/creator of HSMR

Prof Brian Jarman was an exploration geophysicist who worked at Shell and later became a doctor. He is a qualified physician, general practitioner and public health doctor. He developed the HSMR in 1999 at the Imperial College. He was a Senior Fellow at the IHI (where he looked into American HSMRs). He was a panel member of the Bristol Enquiry. He is a former president of the BMA. He is of course the author of innumerable papers, book chapters, member of various committees and boards

Calculating the HSMR

HSMR = (observed mortality/expected mortality) X 100

Observed mortality is the actual number of deaths that happen in the hospital. The expected mortality is based on a reference population. The standardisation is the risk adjustment that is taken into account for the reference population.

In England, the HSMR is based on HES (Hospital Episode Statistics) data with 14 million records and 300 fields of information. The risk adjustments are made for numerous factors including but not limited to age, sex, elective status, socio-economic status, diagnostic subgroup, procedure subgroup, some co-morbidity palliative care, source of admission, ethnicity, month, number of prior emergency admissions and so on.

Clinical risk adjustment takes into account specific biometric data some of the models are Euroscore, ASA, APACHE, POSSUM and so on. But the HSMR risk adjustment model takes into account sociological and operational data. HSMR uses the 56 diagnostic groups which contribute to 80% of in-hospital deaths in England

THE DEBATES AND ARGUMENTS

PALLIATIVE CARE CODING IS INACCURATE AND DISTORTS HSMR

The arguments about HSMR are about not including some of the preferred or favourite variables of some users. For instance, some hospitals feel that they have a palliative care/hospice ward within their premises and that could make their mortality rates high, some hospitals feel that there are no adequate hospice facilities in their area and hence more patients could come into hospital to die thus distorting their mortality rates by increasing it.

Research shows that firstly that the coding of palliative care is unreliable (more about it in an example below) and secondly that HSMR adjusted and non-adjusted for palliative care showed good correlation (i.e. no difference)

HSMR IS BASED ON HES DATA AND NOT ON SPECIFIC CLINICAL RISK DATA

Another argument is that HSMR risk adjustments are based on HES data which does not include specific clinical data on co-morbidity and hence does not account for the clinical complexity of the patients who died. Interestingly, HSMR adjusted and unadjusted for co-morbidity still has a good correlation (i.e. no difference).

In the instance of vascular society data the data showed 8462 cases whereas the HES data showed 32242 cases.

In the case of the ACPGBI (colo-rectal), the database showed 7635 cases when the HES data showed 16346 cases. The ACPGBI/NBOCAP audit was voluntary (it has since then thought to be biased due to under reporting by the latest article on bowel cancer outcomes in Gut on 11 April 2011.)

It seems that the HES data is more complete.

In the ACPGBI database 39% of patients had missing data for risk factors. It seems that the HES data is more accurate for its (HSMR) parameters. (In the same article in GUT published on 11 April 2011 where they analyse cancer survival/mortality they admit they had Duke’s classification missing in 15% of cases – to show that even within the parameters/data they set themselves clinical databases seem to have incomplete data; whereas there was incomplete post code information only in 0.25%).

Research shows that HES-drFoster is as good as or better than clinical models/databases.

COST

The cost of a clinical data base is up to £60 per patient whereas the HES general database is about £5 per patient.

THE ADMISSION DIAGNOSIS IS A POOR INDICATOR WHEN CALCULATING HSMR

Another common feeling is that admission diagnosis based coding could distort HSMR. Again interestingly in UK HES data apparently has no admission diagnosis and hence that is not taken into account in calculating HSMR.

IN SPECIALTIES WITH SMALL VOLUMES OF DEATHS THE HSMR IS NOT VERY USEFUL

Broadly speaking an increase or decrease in the HSMR in specialties with a small number of deaths may not indeed be a very useful way of understanding the issues – hospitals would be better off looking at the outcomes of specific process measures (and their compliance) within those deaths to obtain a better understanding on whether appropriate care was offered.

But for specialties with larger volumes, death as an outcome (increased or decreased deaths) is valid.

CODING IS POOR

That is certainly possible. However change of coding could result in actually increasing the HSMR (due to change in the denominators of the new code)

HSMR AND NON-NHS BEDS

One of the things we hear is mortality in private hospitals and mortality in private beds in NHS hospitals not being considered seriously.

Only 2% of bed usage in UK is non-NHS.

So obviously there is a substantial case for focussing on the NHS.

SOME INSIGHTS FROM SIR BRIAN JARMAN'S TALK

MORTALITY ALERTS & MID-STAFFS

Mid Staffs were sent mortality alerts like dr Foster would do for any other hospital.

Mid Staffs internally looked into 200 deaths and explained it as coding errors – they may well might have been – but subsequently took no notice of overall deaths or HSMR.

At the same time or thereabouts dr Foster looked into coding and found it was average.

Mid Staffs were doing regular clinical audits.

Mid Staffs palliative care coding ('not curable' categorisation) went up from 2% to 60%

CAN HOSPITALS REPORTED AS GOOD BY REGULATORS HAVE PROBLEMS?

Of all the assessments and inspections reports 96% are dependent on self-reported quality measures and only 4% are by external/independent assessment and inspection.

2/3rds of self-reported quality measures are incorrect.

WHAT CAN WE DO TO GET A START ON REDUCING MORTALITY

ADVERSE EVENT REPORTING

Hospitals with high adverse event reporting have low mortality. When hospitals start looking a mortality they start by encouraging increased adverse event reporting which then goes up by 4 times.

CARE BUNDLE APPROACH

We will all recall the hospital where trial patients developed severe organ failure. That was as a result of a private company hiring the hospital facilities for their drug trial. The NHS hospital itself at that time was doing just about okay. One of the senior nurses there took the care bundle approach to move to the hospital with the lowest mortality in England.

FINALLY AN ASIDE

Looking into mortality can be a threat to longevity.

Sir Brian says that there were assassination threats to the Bristol enquiry panel of which he was a member. Apparently there were people very upset that the panel refused to look into morbidity and stuck only to mortality investigation.

PERSONAL VIEWS

All the above is 'as heard' from the mini-course that I attended. My personal observations/views follow below from this point and hence cannot be attributed to the speakers of the course.

HSMR is a valid way of looking at mortality and is an excellent indicator of quality of healthcare provided by any healthcare organisation. Ignoring or explaining away HSMR and its related alerts have a huge underlying risk which may come back and bite very severely.

PROCESS MEASURES AND OUTCOME MEASURES

Michael Porter says measuring process is servitude and measuring outcome is liberation.

We should have a clear understanding of process measures and outcome measures. The new white paper's core theme is better outcome.

If we are achieving 4 hours, 31/62, 18 weeks, NPSA alert implementation, CQC points, Monitor requirements and so on; good for us but they are process measures.

Process measures have meaning only if they lead to improved outcome measures such as reduced mortality and reduced complications.

WHERE TO FOCUS

Hospitals that are at the higher end of the mortality ratio need to realise and accept that they do have the resources to deal with it. Having self confidence is the first and the best place to start.

That has to be followed by a very deep reflection on the activity, its explanations and results in the context of mortality.

Hospitals need to accept that the HSMR is mostly and broadly right and the alerts are relevant. When there is activity on internal validation of HSMR alerts it cannot be enough to explain coding issues/data validity; internal validation of HSMR alerts can only be accepted if they include a plan to reduce the subspecialty mortality (or risk as the case may be).

What should not be said is 'we are already doing this' or 'we are doing something even better’ when the mortality is not showing a downward trend.

If the mortality is high but regulator's ratings are good the questions to ask are about the accuracy/correctness of the internal reporting mechanisms – however uncomfortable those questions are. Similarly if care bundles are not working and the assumption should be that there is perhaps nothing wrong with the bundles or the patients, perhaps it is the way it is being done. If clinical audits are showing good results and but HSMR is increasing or procedure risk alerts are increasing that should trigger a reflection on whether the hospital is actually looking in the right direction.

A month on month continuous reduction in mortality (HSMR) should be the only acceptable proof. It looks like arguing with the data and explaining it away is no longer an option. If activity does not match the outcome data there may not be much point in attacking the data.

BY THE WAY WHAT ABOUT OTHER PROVIDERS

Dr Foster is not the only provider of analytical and comparative information; there are CHKS and others. It may or may not matter who the provider is; the point is to use the information in a way that makes a meaningful difference to the patients.


© HEMADRI

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Check out blog posts on 
Why High Mortality hospitals cannot afford to pay staff well (http://successinhealthcare.blogspot.co.uk/2012/06/any-links-between-bank-holiday-pay-and.html)
What your hospital mortality was in 1998 and if it is any different now?  http://successinhealthcare.blogspot.co.uk/2012/01/mortality-1998-now-what-can-we-learn.html

Links:

Imperial College Dr Foster Unit http://www1.imperial.ac.uk/publichealth/departments/pcph/research/drfosters/

NHS Choices: http://www.nhs.uk/NHSEngland/Hospitalmortalityrates/Documents/090424%20MS%28H%29%20-%20NHS%20Choices%20HSMR%20Publication%20-%20Presentation%20-%20Annex%20C.pdf

Brian Jarman http://www1.imperial.ac.uk/medicine/people/b.jarman/

Mid Staffs public enquiry: http://www.midstaffspublicinquiry.com/