How to do a ward round

Till recently there were no accepted method, standard, process, protocol or parameters on how a doctor should do a ward round for in-patients. We generally turn up, see the patient, sort problems and when the patient gets better we discharge the patient. In recent times there are emerging opinions which have led to some recommendations on ward rounds.
 
I describe my personal experience of one of the best ward rounds that I had the privilege to be a part of during my training days. I describe the ward rounds of the late Mr Suresh B Desai, Consultant Surgeon, Scunthorpe General Hospital. The following is a tribute to him.

House Surgeons should come in at 8 am and had till 9 am to prepare for the ward rounds (time was defined - nothing woolly there); the job was defined:

- Get an updated list of in-patients including admissions through other consultants emergency takes, outliers and consultation requests from other consultants
- Write in the patient notes the results of investigations or have the investigation results on hand ready to be written in the notes
- Deal with any really dire emergencies where the physiology was really poor

Registrars should come in at 8.30 am and had till 9 am; their job was defined:

- Help the house surgeon deal with dire emergencies if there were any
- Talk to the nurses to identify any issues that arose overnight for the in-patients

Mr Desai would arrive at 9 am to the male ward. If there were any dire emergencies the registrar (and not anyone else) would continue to deal with it. Otherwise the whole team started the ward round. The whole team included the ward sister and the nurse who looks after the patient apart from the house surgeon, medical students if any, clinical attachment doctors if any and other healthcare staff as relevant. What I call a ward round kit followed the team - this included the notes trolley, all investigation request forms, a dictaphone, gloves, gel, stationery (continuation sheets, consultation request forms), some house surgeons used to take canulation trays as well.

Every patient was seen - well that is what a ward round is for.

But what then happened was simply brilliant. 

Everything that the patient needed as a result of the consultant visit was completed before moving on to see another patient.

If a patient needed bloods to be repeated immediately it was done right there in front of the consultant, bloods need to be repeated in the afternoon or the next day the forms were done right there, any other test requests (X-ray, CT, ECG, etc) were done then and there. Any communication with other teams/speciality's consultants/registrars they were bleeped or rung, spoken to or if they were not available a message was left with their secretaries. Letters needing dictation though this was rare was done right there. A canula that needed doing was done then and there. Every work that was generated as a result of Mr Desai's ward round was done in the presence of Mr Desai or if appropriate by Mr Desai himself as soon as it was generated before moving on to the next patient for whom again the same process applied.

This made the ward round quite long. When most other consultant ward rounds took less than an hour (which was reasonable by surgical standards), Mr Desai's ward round took all morning (his ward rounds were in the morning). It was initially frustrating. But soon junior doctors realised that there were not many 'to do lists' not many things to actually pending. We were not running like headless chicken after the ward round. We ended up having more time for the doctors mess, more time for learning, more time for everything else.

Any really abnormal results were acted upon at the earliest as anyone would. The next time the house surgeon had any serious work was at 3.30 pm to check on any changes to patient's status which were not already informed and to check on investigation results that were not direly abnormal and to act on it. Barring a late finish in theatres Mr Desai would always visit the wards and speak to the senior nurse at 5 pm every day and conducted the equivalent of a board round. Any patients that needed to come to the attention of the on-call teams were noted - Mr Desai would speak to the on-call consultant and Mr Desai's registrar would speak to the on-call registrar. 5.30 pm we were gone.

I do not know the precise results of Mr Desai's work. All I know was that everyone including me was of the impression that his work was good. It was organised, it was thorough and all elective work was directly consultant delivered or delivered in the presence of a consultant. An aside which could be a nugget as a mark of the quality of his work: all his patients who were having elective major surgery were seen by the physiotherapist with a special emphasis on chest physio - blowing balloons et al - it was no wonder we thought his patients did well.

I did not know about lean concepts in 1994. When I later became aware of lean I realised that this is a single piece flow ward round if there was ever such a thing described.

I recommend it.

© HEMADRI

 
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PS: I have heard a number of patients credit Mr Desai with commencing gastrointestinal endoscopy, vascular surgery, endo-urology and triple assessment breast clinic service at Scunthorpe; I am sure he played a major part in these. I know of a few patients who still remember him and praise him.

Skin in the Game

DO DOCTORS AND NHS MANAGERS HAVE ENOUGH SKIN IN THE GAME?

Skin in the game is a term mainly used in the financial world where it is thought that those persons who are playing the game (e.g. fund managers) should have their own money and reputation involved so that they are as rewarded or as damaged as the people on whose behalf they play the game (i.e. their customers, investors). Philosopher and author Taleb has ignited a debate on the importance of this, he points to a Hammurabic code where if a house were to collapse and kill the owner of the house then the builder will be given the death penalty - now that is some real skin. This blog has already written on how Warren Buffet would not take a fee unless he crossed a certain level of achievement for his investors (http://successinhealthcare.blogspot.co.uk/2012/01/getting-paid-for-performance-buffet.html); apparently Buffet also has his own money invested along with his investors - he has enough skin in the game.

This got me thinking on what kind of 'skin in the game' we have in the NHS. Of course that is a large one to put out in a short blog. Lets try a limited short version.

In the past when doctors were employed as consultants in the NHS there was a requirement to live within a defined distance of their hospital so that they can respond to urgent and emergency calls when they are on duty and also help their colleagues when necessary even if they were not on duty. In the past consultants had an obligation to let the hospital know if they will be out of the area (even if they were not on call or on annual leave). Doctors were paid some money as relocation expenses to facilitate the same.

This obviously meant that the doctors working in a hospital lived within the catchment area of the hospital. In the event of an urgent need for healthcare for the doctor or for their families, they are highly likely to attend the hospital where they work. The success and failure of the hospital had the potential to directly affect them. In the last decade or so, the obligation to live within the local area seems to have disappeared due to a combination of societal changes of both spouses working and the officialdom seeming to demand that the doctor be available only when rostered to do so. However a large number of permanent senior doctors still live in the catchment area of their local hospitals. By definition there is skin in the game - if your hospital mortality or morbidity or general services were bad you and your family were likely to be affected by it.

The other aspect for consultants in the NHS is many consultants expected to work for many decades in one hospital, they do not expect to move. This has seen a slight change recently but it is substantially true that you would generally not find NHS substantive consultant post holders move very often. They develop, grow skin into the game. There is of course the issue of excess skin in the game where people with too much stake take too much risk, perhaps in the case of NHS consultants it may be a case where due to their superior knowledge of local and national situation they learn to avoid personal risk while all the risks remain for their patients. The doctors have a reputation risk - this is really serious - so serious that a doctor can be struck of for damaging the risk of their profession; at a personal level the reputation is equally serious;  due to peer pressure and long service reputational damage can be devastating.

I am unable to find a historic or current requirement that states that executive directors of NHS hospitals were/are obliged to live in the catchment area of their hospitals. I know of many hospital directors who do not live in the geography covered by their local hospital. This means in reality they have not much skin the game. In contrast to NHS consultants, board directors stay in post only for a fraction of the time that a consultant stays in post - compared to consultant appointments, executive director appointments are practically musical chairs or passing the parcel. Again there is not much skin the game. Of course there is a reputational issue but with performance measurement in the NHS for managers not being so accurate as say for a financial fund manager a large gooey fudge substitutes for reputation.

I don't know how practically applicable the above thoughts are. I have already written about the fact that NHS board director contracts have no reward or punishment for anything other than financial performance (Whose job is it to reduce mortality? http://successinhealthcare.blogspot.co.uk/2013/06/whose-job-is-it-in-nhs-to-reduce-deaths.html) Modern life and employment conditions may mean that we may not be able to demand that people live where they work. However we do need to find a way to ensure the skin in the game for NHS managers and directors; increase skin in the game for doctors.

Perhaps a starting point might be to publicly declare if they live within the area of the hospital where they work and how long have they lived within the area (not asking for private addresses, just for HR to declare if they live within the area). Perhaps remuneration and penalties should be linked to quality of performance (when we get around to understanding how we can measure quality meaningfully). We must think of other ways that suit the modern world to increase skin in the game. Healthcare is person to person business, very important for healthcare professionals to remember - no skin means poor game.

©M HEMADRI 

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My Conversation with Dr Ravindran, Chairman of Aravind Eye Care

I had the privilege of meeting Dr Ravindran, Ophthalmologist and Chairman of Aravind Eye Hospitals, India, at the International Forum for Quality and Safety in Healthcare London 2013. I had a general informal conversation but it was of course an eye opener - you bet he has experience in that!

I share some of the conversation here. 

Clinicians' Selection processes at Aravind

Doctors

It is well known that Aravind has processes that are followed really well by the staff, especially doctors who work there. Protocols and processes are very important for their pathways and systems to work. It is also well known in healthcare that it is very difficult to get doctors to follow organisational protocols. I asked Dr Ravindran on how they do that.

Aravind appoints doctors after a 3 day selection process. Applicant to appointment ratio is a minimum of 3:1. Fellows and residents work and spend time with staff on those three days. Doctors then provide feedback to the appointments panel on the suitability of applicants. Anyone blackballed by existing staff are not selected. The main if not the only criteria for appointment is if the doctor is 'suitable for our culture and basic values'.

They obviously get people who are already high flyers with research credentials, publications, etc but Aravind's attitude seems to be that they want only normal average people to work with them and their system and culture will then make them do good work. (This sounds very similar to Toyota Chairman Cho's statement that they get brilliant results from average/normal people when other car manufacturers get average results from brilliant people). These high flyers, if they are not suitable for the Aravind culture are told that they are likely to be very successful outside the Aravind systems.

Chairman Ravindran says 'we want everyone to be pleasant and professional to each other. If we detect even a small amount of arrogance during the selection process, we will not appoint the person. Arrogant people can offend and upset others which will disrupt team work and increase staff turnover - we cannot have that'.

Nurses

Student Nurses are selected after a written test and an interview. The test is a hand written test where they answer a question on a social concept. Hand writing is thought to be important (if you cannot read a person's writing the value of their documentation and written communication becomes a future problem). As for the content, it is thought that if a young aspiring nurse cannot write with genuine empathy about a socially important issue they would not fit in with Aravind's culture and communication.

Now comes the interesting part of the process. While interviewing the applicants is what everyone does anyway, Aravind interviews the parents of the applicants. They see this as very important. Attitudes of parents and aspects from home have an influence on how people behave and work. This is accounted for in the interview and selection process.

Once they are selected to be nursing students, Aravind pays for their training, accommodation etc. These students after graduation get to work for Aravind.

I probed their thinking - I said that the society will have many different types of people and their organisation will/should have different type of people; including and excluding some types will not reflect the society. Dr Ravindran was very clear with his answer, he said that of course the society  will have many types of people but in his organisation they only want the type of persons who can share their basic value.

Their basic value is compassion.
 

He also said that many in the organisation including the senior people continue to engage with the staff and their lives, he said 'I know a lot about many people who work with us, what they enjoy, what problems they have at work, what issues they have outside work and in general a lot about their lives. Due to this we are able to support them very early.'

Learning

I specifically asked him about where and whom he and his organisation learns from. He says that their main learning is from within their organisation, they try to improve everyday and share it with their internal colleagues -  mutual learning within the organisation. (This blog has in a previous post stated this as the fourth fundamental condition if healthcare is to be successful http://successinhealthcare.blogspot.co.uk/2012/01/hemadris-four-fundamental-questions-for.html )

No external consultant has even been contracted. No lean specialist, no management consultant. They get regular visitors trying to learn from the Aravind system. Aravind staff do visit hospitals around the world to explore what might be suitable for adaptation.

Attitudes

When asked about how they deal with the high volume of patients Dr Ravindran said 'If we have more patients we simply start early - all of us. We do not put patients on a waiting list, we do not turn patients away'.

I asked about being lean and quick and his response was 'It is not about being quick. It is the attitude of not wasting anything. So if we don't waste time it looks like we are quick. We do not throw away anything; if a bed sheet is torn you can be sure it will re-appear in some other form to help with some other function'.

I think my commentary is not really needed as the conversation is very illuminating and self-explanatory. Their website shows that eight out of ten directors of their board are doctors - does that say something? I think we can learn a great many things from Aravind Eye Care and their practices. I wonder what we can actually adapt and use for healthcare delivery in the western world?

©M HEMADRI 

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Links

Aravind Eye Care http://www.aravind.org/

NHS in India - be aware of what it means

This blog post was originally published as a guest editorial at Soumyadeep Bhaumik's Caffeinated Works & Random Musings which is one of the largest healthcare blogs in India

(http://soumyadeepb.wordpress.com/2013/01/04/the-uk-nhs-in-india-be-aware-of-what-it-means/)
Reposted here.

I follow Indian healthcare with some interest.

I have wondered about 'why do doctors who work in India and want to continue to work in India take up exams such as FRCS, MRCS, etc?' Many of these exams are conducted in India. I suppose I should give those doctors the benefit of the doubt and think that they do it as a part of knowledge improvement and knowledge validation with an international perspective. Many though may have commercial marketing motives. I ask myself if the content and the style of these exams are suitable for non-western practice? I think not, but that is purely my view.

Now the news of NHS wanting to go to India. The NHS in UK is a government funded public service healthcare system. Is that the model the NHS will follow in India? The NHS in UK is increasingly outsourcing its activity to the private sector and inviting private sector in to the NHS. However, the NHS in its new wisdom may be choosing to go to India to provide services as a private provider. Which is the exact opposite of what the NHS does here in UK. The policy and strategy confusion seems to be immense and contradictory. The NHS currently does not have any great operational experience of purely private provision.

Why would the Indians allow the NHS to do the exact opposite of what they do in UK in terms of business model, inside India? It is a question that should be asked in the Indian parliament; I am sure it will be asked if and when trouble arose.

More relevantly, why would the NHS itself want to do this? The reasons are not that difficult to fathom. India is a growing market in general, healthcare is a really high growth market, there is a clear need for more high quality providers. The non-commercial UK NHS wants to take commercial advantage of these factors to make money for UK. It is nothing else apart from money making. Money making in itself is not such a bad thing, only to couch it in the language of healthcare improvement, helping populations, transferring expertise, spreading knowledge and other obviously superficial euphemisms reflects poor intentions. I am a believer in the primacy of intentions.

I wonder if the NHS would still go to India if it was required to provide 72% of its Indian services in rural India (that is the percentage of population that lives in rural India) to the same standard and more or less the same price that they provide in urban India? I ask because that is exactly what the NHS prides itself in UK; providing more or less the same standard of service at more or less equivalent costs all over UK. Well, if you want to be an international business thats how you begin to think; Coke and Pepsi do that, produce soft drinks, distribute it to all corners of India at almost the same price; which is exactly what they do anywhere in the world. Will the NHS do in India what their business model does in UK? Would the NHS in India treat the rich and the poor equally as they are required to do in UK?

I suspect that is not what the NHS in India will be about. I sincerely hope the NHS in India will make me eat my words as that will be a win-win for everyone.

The principles of care, content of education, models of care delivery that are needed in India are different. India is perhaps already suffering from a techno-centric, finance driven, western oriented, urban focussed, doctor obsessed healthcare system. As long as we are clear in our minds that whether it is examinations such as MRCP/FRCS/MRCOG/MRCGP which are conducted in India or a possible NHS as a provider in India are simply commercial businesses operating in India for profit making; as long as we recognise and be constantly aware of this its fine. Once we start assigning higher value, philosophical or operational, we will be doing a disservice to the Indian public by deliberately misleading them. Those of you who are highly sensitive amongst the Indians should also reflect on whether this is a form of cultural and knowledge colonialism.

I am British and work in the NHS. I am an admirer of the NHS system and I believe the NHS in UK does a great job in terms of many clinical, operational and cost parameters. It is my vested personal interest that NHS in India is successful commercially. I am of Indian origin and have family in India, hence creating awareness of potential sub-optimisations is probably my broader duty.

M. HEMADRI

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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 

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Single Visit Surgical Service

When we look at providing healthcare services we should look at it from a patient's perspective. For instance, ''how often would the patient have to travel to the hospital to obtain healthcare services?'' is not the top question in any providers mind when they design the service.

This results in the patients traveling often to secondary care services even for obviously clear problems such as hernias, varicose veins etc.

At Goole Hospital we provide a single visit general surgery service for patients who need day case and short stay surgical procedures. This may mean procedures likes superficial lumps and bumps, toe-nails, etc. This also means patients who have groin hernias including recurrent groin hernias and gall stones (needing laparoscopic cholecystectomy).  Obviously there has to be a clear cut diagnosis based on obvious findings followed by some appropriate investigations by the general practitioners. These patients visit Goole Hospital only once to obtain their surgical care. The patients are telephone pre-assessed. They come to the hospital at about 8 am and are seen by nurses, anaesthetists, surgeons and residual simple investigations are performed instantly; they are operated during the day and discharged when they meet clinical criteria often within the day. They are not offered specific follow up out patient appointments but can ring to make one if they felt they needed it.

We do inguinal hernia repairs, laparoscopic cholecystectomies and many other procedures as a part of this service. The service has been running for a good few years.

My personal calculations are that this saves money overall, especially saves on travel costs for patients and their relatives. My feeling is many of the services provided by healthcare are currently very hospital focussed. When the processes becomes patient focussed there is a good chance that quality could improve while saving on costs at the same time. It is up to us to manage our services and processes maturely - our poor design should not trouble the patients.

© HEMADRI

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Warning & Disclaimer:
We do not claim superior clinical results. We only describe our process/pathway. Not all patients with any of the conditions stated above or with other similar conditions are suitable for this service. Your GP is best placed to advice the kind of pathway that could be suitable to you. This blog/website does not give clinical/medical advice. The views expressed are my personal views and not those of my hospital or the NHS.

 

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

Follow me on twitter @HemadriTweets

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/