Do Hospital Standardized Mortality Ratios Measure Patient Safety? HSMRs in the Winnipeg Regional Health Authority
ABSTRACT The Canadian Institute for Health Information began publishing hospital standardized mortality ratio (HSMR) data for select Canadian hospitals in November 2007. This paper describes the experience of the Winnipeg Regional Health Authority in assessing the validity of the HSMR through statistical analysis, coding definitions and chart audits. We found a lack of empirical evidence supporting the use of the HSMR in measuring reductions in preventable deaths. We also found that limitations in standardization as well as differences in palliative care coding and place of death make inter-facility comparisons of HSMRs invalid. The results of our chart audit show that the HSMR is not a sensitive measure of adverse events as defined by "unexpected death" in the Canadian Adverse Events Study. It should not be viewed as an important indicator of patient safety or quality of care. We discuss the cumulative sum statistic as an alternative to the HSMR in monitoring in-hospital mortality.
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- "Patient mortality is widely used, as the data are regularly available in administrative data bases. However, recent studies suggest that patient mortality, as currently used, was not a reliable indicator, largely because there was not sufficient attention paid to variations in case mix which limited standardisation (Gorton et al., 2005; Penfold et al., 2008). Preuss (2003) used hospital medication errors as the measure of quality of care, and found that increased employee knowledge directly impacted on decreasing medication errors. "
ABSTRACT: Objective: Recent health system enquiries and commissions, including the National Health and Hospital Reform Commission, have promoted clinical engagement as necessary for improving the Australian healthcare system. In fact, the Rudd Government identified clinician engagement as important for the success of the planned health system reform. Yet there is uncertainty about how clinical engagement is understood in health policy and management. This paper aims to clarify how clinical engagement is defined, measured and how it might be achieved in policy and management in Australia. Methods: We review the literature and consider clinical engagement in relation to employee engagement, a defined construct within the management literature. We consider the structure and employment relationships of the public health sector in assessing the relevance of this literature. Conclusions: Based on the evidence, we argue that clinical engagement is similar to employee engagement, but that engagement of clinicians who are employees requires a different construct to engagement of clinicians who are independent practitioners. The development of this second construct is illustrated using the case of Visiting Medical Officers in Victoria. Implications: Antecedent organisational and system conditions to clinical engagement appear to be lacking in the Australian public health system, suggesting meaningful engagement will be difficult to achieve in the short-term. This has the potential to threaten proposed reforms of the Australian healthcare system.Australian health review: a publication of the Australian Hospital Association 10/2012; 36(4). DOI:10.1071/AH11095 · 0.73 Impact Factor
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- "For studies in health care, quality of care is suggested as a relevant performance measure and has been measured as patient mortality, reduction in adverse events (most commonly impact on medication errors), patient satisfaction, and as a specific clinical outcome. Recent studies have suggested that patient mortality, as currently used, was not a reliable indicator, largely because insufficient attention is paid to variations in case mix which limited standardisation (Penfold et al., 2008, Gorton et al., 2005). Similarly hospital medication errors and other adverse events have been used as a measure of quality of care (Preuss, 2003), but studies have identified substantial underreporting of adverse events (Uribe et al., 2002), suggesting that it may not be a robust measure of quality of care. "
ABSTRACT: Studies of high-performing organisations have consistently reported a positive relationship between high performance work systems (HPWS) and performance outcomes. Although many of these studies have been conducted in manufacturing, similar findings of a positive correlation between aspects of HPWS and improved care delivery and patient outcomes have been reported in international health care studies. The purpose of this paper is to bring together the results from a series of studies conducted within Australian health care organisations. First, the authors seek to demonstrate the link found between high performance work systems and organisational performance, including the perceived quality of patient care. Second, the paper aims to show that the hospitals studied do not have the necessary aspects of HPWS in place and that there has been little consideration of HPWS in health system reform. The paper draws on a series of correlation studies using survey data from hospitals in Australia, supplemented by qualitative data collection and analysis. To demonstrate the link between HPWS and perceived quality of care delivery the authors conducted regression analysis with tests of mediation and moderation to analyse survey responses of 201 nurses in a large regional Australian health service and explored HRM and HPWS in detail in three casestudy organisations. To achieve the second aim, the authors surveyed human resource and other senior managers in all Victorian health sector organisations and reviewed policy documents related to health system reform planned for Australia. The findings suggest that there is a relationship between HPWS and the perceived quality of care that is mediated by human resource management (HRM) outcomes, such as psychological empowerment. It is also found that health care organisations in Australia generally do not have the necessary aspects of HPWS in place, creating a policy and practice gap. Although the chief executive officers of health service organisations reported high levels of strategic HRM, the human resource and other managers reported a distinct lack of HPWS from their perspectives. The authors discuss why health care organisations may have difficulty in achieving HPWS. Leaders in health care organisations should focus on ensuring human resource management systems, structures and processes that support HPWS. Policy makers need to consider HPWS as a necessary component of health system reform. There is a strong need to reorient organisational human resource management policies and procedures in public health care organisations towards high performing work systems.Journal of Health Organisation and Management 06/2011; 25(3):281-97. DOI:10.1108/14777261111143536 · 0.36 Impact Factor
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- "Indeed, the Canadian Institute for Health Information adopted HSMR analysis as recently as 2005 in order to drive their patent safety and improvement agenda.22 Certainly, the HSMR has its detractors and indeed many researchers do not consider the HSMR to be a suitable measure of, or surrogate marker for, patient safety.23 The pitfalls of HSMR analysis include the possibility for administrative errors such as miscoding and the possibility of missing data. "
ABSTRACT: NHS North West aimed to fully implement the European Working Time Directive (EWTD) 1 year ahead of the August 2009 national deadline. Significant debate has taken place concerning the implications of the EWTD for patient safety. This study aims to directly address this issue by comparing parameters of patient safety in NHS North West to those nationally prior to EWTD implementation, and during 'North West-only' EWTD implementation. Hospital standardised mortality ratio (HSMR), average length of stay (ALOS) and standardised readmission rate (SRR) in acute trusts across all specialties were calculated retrospectively throughout NHS North West for the three financial years from 2006/2007 to 2008/2009. These figures were compared to national data for the same parameters. The analysis of HSMR, ALOS and SRR reveal no significant difference in trend across three financial years when NHS North West is compared to England. HSMR and SRR within NHS North West continued to improve at a similar rate to the England average after August 2008. The ALOS analysis shows that NHS North West performed better than the national average for the majority of the study period, with no significant change in this pattern in the period following August 2008. When the HSMRs for NHS North West and England are compared against a fixed benchmark year (2005), the data shows a continuing decrease. The NHS North West figures follow the national trend closely at all times. The data presented in this study quantitatively demonstrates, for the first time, that implementation of the EWTD in NHS North West in August 2008 had no obvious adverse impact on key outcomes associated with patient safety and quality of care. Continued efforts will be required to address the challenge posed nationally by the restricted working hour's schedule.QJM: monthly journal of the Association of Physicians 12/2010; 103(12):929-40. DOI:10.1093/qjmed/hcq139 · 2.50 Impact Factor