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 

Follow me on twitter @HemadriTweets

Keogh Review

KEOGH REVIEW OR KEYHOLE REVIEW? TIME WILL TELL

The Keogh review team visited my work place. I volunteered to meet them. Twice. Once as a part of a group discussion. Again on what was supposed to be a one-to-one drop in session.

The group session was very interesting - individuals and as a group there was a delicate balance on many fronts. The one I found really intriguing was the pride we felt about our work place when faced with these external bodies which had to be balanced with the view that if we were really worthy of the pride we felt those external bodies would not be in our hospitals in the first place. Difficult emotions to cope with.

The group session was supposed to be for people who had signed-in before but eventually allowed people who had not registered. The advantage of a free discussion was probably cancelled out by poor management of 'air time'. There were some highly placed persons whose attendance might have dampened the sessions but I cannot be sure about that. The one-to-one drop in session turned out not to be one-to-one at all, I was invited in to sit as a previous person was talking to the Keogh people and a person who followed me was invited in to join as I was speaking. Of course we were asked if that was okay with us, what is the point of asking if it fundamentally changes the nature of the session. In my case the person before me and after me have a history of thinking on similar lines so I did not feel constrained and the person who followed me mentioned no feeling of constraint (in a private conversation later)

The Keogh people have promised that this will be a very open and transparent enquiry. So I am not going to put out what I said or did not say, as obviously without the bigger picture context in place I cannot make sense. In any case, if the promised transparency turns out to be true everything that we said (though anonymised, I think) would be available to everyone when the review is published.

I took the opportunity to ask them some questions. I wanted to know who exactly will write the report for my trust and whether that person or persons were actually present in the premises as a part of the visit. They were not sure about that.

I asked how the success of the Keogh review will be measured. They were unsure about that as well. 

There was an assurance that there will be all the support needed for the 14 trusts to deal with their problems. I am particularly keen that Keogh review should only be called a success if the 14 trusts under review were no longer outliers two years from now and remained so for a further four or five years. Having commissioned a review on high mortality, in my mind the obvious end point will be the reduction of mortality for which Keogh and DoH should take joint responsibility from now. To publish a report, however well informed it is, to provide support however intensive it is, will be meaningless unless our mortality gets low and remains low. Having lent his name, Sir Bruce should have no choice but to link his success to ours.

We discussed my motivation for meeting them. It was very simple - I live and work in the area, if I had a problem by default I will end up in my hospital's bed. If my hospital's mortality statistics are bad, it will be foolish of me to think I might escape from its clutches. So I want to see it get better.

We will have to wait and see if at the end of it all Keogh review will give us the keys we need to get out of this hole or will simply become a keyhole review. My healthcare, my life, my family's healthcare and my family's livers, my neighbours' healthcare and lives, my friends' healthcare and lives are at stake - so there is no other option than to get this right.

©M HEMADRI 

Follow me on twitter @HemadriTweets

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

Scheduled airlines are safe, just like out patient clinics

There are constant comparisons between aviation and healthcare especially in terms of how safe aviation is.  There is no doubt that aviation in general has a low mortality rate for passengers. I have already written about the need to learn from how aviation achieved it, I have also pointed out to the limitations of the comparisons (http://successinhealthcare.blogspot.co.uk/2012/04/healthcare-not-similar-to-aviation-but.html). The term aviation or air transport in my view, includes many things, which starts from the booking process, airport formalities, baggage, catering, flying, etc. It also includes transportation of animals and goods.

In general, the whole of aviation is considered arguably to be better than healthcare. What is not arguable is that commercial scheduled airlines have a very low mortality rate for passengers. Here is my problem, death is not one of the eventual natural outcomes of transportation when transporting essentially healthy persons from one place to another; quite rightly in aviation is mortality is unacceptable. Hospitals on the other hand are not in the business of transporting passengers, people come in with illnesses and diseases many of which are really serious; mortality is one of the eventual outcomes of serious illness and disease. In other words healthcare routinely battles against death and sometimes death wins.

To compare error rates could be valid as error is often a measurable part of process failure but to compare the impact of those errors is probably a false comparison. In aviation all mortality is avoidable mortality, in healthcare it is not. So to put it in context the comparison if we must is between all mortality in aviation and avoidable mortality in healthcare (i.e. the result of process failure). That is what I mean by impact. The impact of errors that result 'morbidity' is of course hugely different like losing a bag vs losing a leg. Hence let us not compare impacts of errors such as mortality morbidity between aviation and healthcare which skews the public discourse. Let us look at error rates and see what we can learn.

Variation the enemy of quality

People talk about variation of care across hospitals and locations; it is true that there is wide variation and reducing the variation will improve outcomes.

Aviation which is often looked upon as a beacon of safety also has variation. Looking at 2004 accident rates for North American airlines Delta scored 0.30 and Value Jet/Air Tran scored 5.88 – well, you work out the how wide the variation is even in an ultra safe industry. If you start looking at international comparisons the variations are of course much worse. (http://www.airdisaster.com/statistics/) There is also a five times variation of fatalilties per million flight hours with scheduled airlines being lowest compared with general aviation.

When there is human to machine interaction as in aviation, there is such a large degree of variation. Healthcare is human to human interaction so it is hardly surprising that variation exists and could be expected to be more than other industries. Looks like variation in performance is not a problem exclusive to healthcare industry; variation is a human problem or to put it better, variation is a function of human performance.

That does not mean we must accept variation especially when it causes harm, we should work very hard to reduce it to ensure safe healthcare.

Fatalities in Aviation

The human fatality rate is very low indeed in the scheduled airlines part of the aviation industry. The air transport of animals, however has suffered bad press. Airlines are apparently not even required to report animal deaths. The mortality rate of animals in air transport is thought to be 0.2%.(http://www.dailymail.co.uk/news/article-2102733/More-HALF-pets-died-airline-travel-year-flew-Delta.html)

The post surgical 30 day mortality for day case surgery in humans which is about 0.01%. In-hospital mortality for day cases is probably as low as the scheduled commercial aviation segment.

CRM and Simulation are of course extremely valuable tools and has a lot to teach us in healthcare. The number of air accidents and the number of fatal air accidents have remarkably decreased over the past few decades. That is truly fantastic. What is interesting though, is that the pilot error rate has been at about 50% since the 1950s to the 2000s, percentage of accidents attributed to pilot errors has not shown a significant decrease. The proportions of various reasons for crashes have also remained more or less the same. This is in a way a tribute to the aviation industry, since the planes have become technologically very superior it would not be surprising if pilot/human error played a bigger part and it has not, that is creditable. However, I wonder if it would be valid to argue that if CRM and simulation were indeed really powerful should the pilot error rates be falling?

Survival rates of passengers in aircrafts involved in fatal accidents has not improved (and averages about 25% since the 1930s to 2000s) (http://planecrashinfo.com/cause.htm) Military aircraft, fighter planes, aircraft engaged in warfare and private planes are thought to have much higher accident and fatality rate.

Some Aspects of Aviation are Safer than Others; Some Aspects of Healthcare are Safer than Others

I suppose in clinical healthcare delivery terms, scheduled airlines are possibly the equivalent of out patient care – not many patients die in out patient clinics. The risk to life is also very low for elective investigations, day case surgery and obviously the risk increases with emergencies and trauma.

In healthcare we talk about morbidity as well. Airlines perhaps should take into consideration DVTs, respiratory illnesses, musculo-skeletal problems and other health issues that happen after a flight. Non-health related morbidity for aviation perhaps include lost baggage, wrong meals............... no let me stop there before it gets silly. Hold on, why not, non-flying errors are also errors and results in 'airline industry morbidity' to passengers, perhaps not that silly.

What has to be said is in healthcare there is clearly much avoidable mortality - that is unacceptable. In healthcare the error rates in day to day activities are simply too high, that is again unacceptable. That is where learning meaningfully from other industries will help.

There is a fundamental problem with my writing here. I am not comparing like for like, I am comparing apples to pears. In my defense, I did not start that comparison. Comparing aviation to healthcare was not my original idea. There is a second problem with this manner of writing, it may sound like I am being defensive of healthcare and its practices, I am certainly not defending any poor healthcare practice or result. I acknowledge the superior results that aviation has had as a result of dedicated persistent efforts in the field of human transportation in scheduled airlines. I recognise the need for healthcare to learn from every source possible including commercial scheduled airlines. All I am saying is, let us stop comparisons and let us focus on learning. Let us look for clinical adaptations of these techniques rather than attempted direct transfer of airline techniques. Let us recognise the uniqueness and the intimacy of human to human interaction that healthcare involves.

A word of warning: This is not a 'hate aviation' piece of writing, this is not aviation versus healthcare writing. This is a plea to learn the lessons in a way that is appropriate to healthcare - clinicians and patients.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Any links between bank holiday pay and mortality?

The Queen's diamond jubilee celebrations are going on right now. The government declared a 'bank holiday' on Tuesday 5 June 2012 (http://www.direct.gov.uk/en/Nl1/Newsroom/DG_183806). Some of us will still be working over the celebration period to keep essential and emergency services going. This includes NHS staff. Individual NHS organisations can decide on whether they will treat this extra holiday as 'bank holiday' or 'public holiday'; they do not have to follow the government declaration of a 'bank holiday'. 'Bank holiday' attracts a higher rate of pay for those who work on that day along with some other terms advantageous to the employees. 'Public holiday' does not attract a higher rate of pay.

Unite Union surveyed their members and found that 113 NHS organisations were treating this as a 'public holiday' and hence no extra pay for staff. (http://www.unitetheunion.org/news__events/latest_news/_named-and-shamed__-_nhs_emplo.aspx) They have called this 'mean-spirited' and called their publication 'named and shamed'.

My interest includes hospital mortality and I wanted to find out what the high mortality hospitals and low mortality hospitals did in terms of the bank/public holiday pay arrangements. I took the list of 21 low mortality hospitals and 19 high mortality hospital from drFoster's hospital guide and then cross checked with Unite's named and shamed list. The findings are interesting to put it mildly.

My findings are:

7 OUT OF 21 LOW MORTALITY HOSPITALS ARE IN UNITE'S LIST (suggesting that they are not pay bank holiday rates)

14 OUT OF 21 LOW MORTALITY HOSPITALS ARE NOT IN UNITE'S LIST (suggesting that they are paying bank holiday rates)

14 OUT OF 19 HIGH MORTALITY HOSPITALS ARE IN UNITE'S LIST (suggesting that they are not paying bank holiday rates)

5 OUT OF 19 HIGH MORTALITY HOSPITALS NOT IN UNITE'S LIST (suggesting that they are paying bank holiday rates)

Low Mortality Hospitals (as per dr Foster)	Unite's named-and-shamed list
Barnet and Chase Farm Hospitals NHS Trust	In Unites' list
Barts and the London NHS Trust	In Unites' list
Cambridge University Hospitals NHS	In Unites' list
Chelsea and Westminster Hospital NHS	Not in Unite list
Epsom and St Helier University Hospitals	Not in Unite list
Frimley Park Hospital NHS Foundation Trust	Not in Unite list
Guy’s and St Thomas’ NHS Foundation Trust	Not in Unite list
Imperial College Healthcare NHS Trust†	Not in Unite list
King’s College Hospital NHS	In Unites' list
Kingston Hospital NHS Trust†	Not in Unite list
Newham University Hospital NHS Trust†	Not in Unite list
North West London Hospitals NHS Trust	Not in Unite list
Royal Devon and Exeter	Not in Unite list
Royal Free Hampstead NHS Trust	Not in Unite list
Sheffield Teaching Hospitals NHS	In Unites' list
South London Healthcare NHS Trust†	Not in Unite list
St George’s Healthcare NHS Trust	Not in Unite list
The Whittington Hospital NHS Trust†	In Unites' list
University College London Hospitals	Not in Unite list
University Hospitals Bristol	In Unites' list
West Suffolk Hospitals NHS Trust	Not in Unite list
High mortality hospitals (as per dr Foster)	Unite's named-and-shamed list
Blackpool Teaching Hospitals NHS	Not in Unite list
Buckinghamshire Healthcare NHS Trust	Not in Unite list
Burton Hospitals NHS Foundation Trust	Not in Unite list
Dartford and Gravesham NHS Trust	In Unites' list
George Eliot Hospital NHS Trust	Not in Unite list
Hull and East Yorkshire Hospitals NHS Trust	In Unites' list
Isle of Wight NHS Primary Care Trust	Not in Unite list
Medway NHS Foundation Trust	In Unites' list
Mid Cheshire Hospitals	In Unites' list
North Cumbria University Hospitals	In Unites' list
Northampton General Hospital NHS Trust	In Unites' list
Northern Lincolnshire and Goole Hospitals	In Unites' list
Shrewsbury and Telford Hospital	In Unites' list
The Dudley Group of Hospitals	In Unites' list
The Royal Wolverhampton	In Unites' list
United Lincolnshire Hospitals	In Unites' list
University Hospitals of Morecambe Bay	In Unites' list
Worcestershire Acute Hospitals	In Unites' list
York Teaching Hospital	In Unites' list

Caution: This is a write up based on information that is publicly available so far. This analysis may not be accurate. We can find out the correct situation only when either NHS employers or individual trusts tell us whether they have paid extra treating it as a bank holiday or not paid extra treating it as a public holiday. So further enquiry and analysis would be needed to validate this. What is presented here is a mere observation and does not suggest cause and effect.

On the basis of current information (this may change when we have accurate information) it seems like there may be attitudes and cultures of organisations, management and staff, playing a bigger part in mortality and morbidity than we previously have assumed.

Please let me know if there are any factual errors in the above and I am only too willing to correct them.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Know when mortality increases and try to prevent it

When junior doctor changes over (in UK it is usually February, August and a couple of other months), there is a higher mortality.
Weekends have a higher mortality.
Major operations on a Friday have a higher mortality.
Winter has a higher mortality.

There are other mortality peaks as well. The question is not what the 'evidence' is around this topic. The question is 'Does it happen in your hospital?'. Do you know? If you don't know - should you know? If you know that you have such a peak in mortality, what are you doing about it? What can be done about it? (If you know you do not have such a peak - do you know how you managed to avoid it?)

These types of mortality cannot be made better by 'better coding' and by 'building hospices'. But can certainly be dealt with by taking specific preventative upstream action.

Take care. Take preventative upstream action.

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/