Do Hospital Standardized Mortality Ratios Measure Patient Safety? HSMRs in the Winnipeg Regional Health Authority

Division of Research and Applied Learning, Winnipeg Regional Health Authority, Department of Community Health Sciences, University of Manitoba.
HealthcarePapers 02/2008; 8(4):8-24; discussion 69-75. DOI: 10.12927/hcpap.2008.19972
Source: PubMed


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. "
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    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.
    No preview · Article · Oct 2012 · Australian health review: a publication of the Australian Hospital Association
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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. "
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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. "
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