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Mortality monitoring: where are we now?

Dr Helen Hogan Clinical Lecturer in UK Public Health/Course Director London School of Hygiene and Tropical Medicine delivers a presentation on mortality monitoring: where are we now?  Helen discussed

  • should hospital-wide mortality ratios be avoided?

  • looking forward: new ways to look at harm, mortality and avoidable deaths

  • engaging clinicians in assessing the safety of their care to stimulate improvement

  • the national annual review of avoidable deaths

In her presentation Dr Hogan made the following comments;

"The profile of this topic is very media driven eg Bristol, Staffs.  ‘2,500 die at horror hospital’ headlines.  It ignores the complexity of issues – hospitals become Stigmatised, patients lose confidence.

"There are limitations of avoidable deaths as a measure of quality – very small numbers in most hospitals, complexity of situations."

“We should focus not just on problems we can see, we need to look ‘upstream’ to origins of problems” e.g. good palliative care in community reduces deaths in hospitals

“As a measure, it has difficulties” (subjective view of a clinician as to whether it was avoidable)

Dr Hogan discussed the PRISM 1 Study 2011 – first British study to establish baseline for avoidable deaths and national standard approach to local mortality review, “will ensure robust process”.  Trained retired docs to do the reviews.  75% good or excellent care.  5.2% deaths probably avoidable over 10 Trusts studied.  Majority of these were in people with short life expectancy i.e. were likely to die anyway within 12 months.

PRISM 2 2014, extended to further 24 trusts.  Low variation between trusts, all fairly similar levels.

Total combined result from PRISM 1&2 was 3.6% of deaths were probably avoidable.

Dr Hogan concluded; "don’t use avoidable deaths to compare between trusts.  Use a coherent set of indicators known to be associated with quality e.g. hospital acquired infections.  Develop indicators that reflect integrated care/quality of care across health systems."

Abstract of Helen’s presentation:

Public and policy interest in hospital death rates has risen sharply, particularly following the recent investigation into the Mid Staffordshire NHS Trust and the investigation into 14 other acute Trusts around the country (Keogh Review).

There are a range of information sources on deaths in NHS hospitals, all of which have advantages and disadvantages to their use. The Department of Health (DH) has advocated the use of hospital-wide measures of mortality such as HSMR and SHMI to provide an early warning system of quality and safety problems within hospitals and to compare performance across hospitals. However, intense debate surrounds whether the "excess deaths" detected by these measures are a valid indicator of the safety of a hospital and actually represent “avoidable deaths”. Many factors beyond patient safety impact on these measures including how well coded patient diagnoses are within hospital administration systems or whether there is adequate provision of alternative facilities and services to care for those approaching death in the geographical area to avoid terminally ill patients dying in hospital. These factors can lead to higher scores for some hospitals which may not be accounted for by poorer quality and safety standards.

Mortality review using retrospective case record review (RCRR) is becoming widespread across the NHS as an approach for identifying quality and safety issues including estimation of the proportion of avoidable deaths. This talk will explore some the lessons learnt from the PRISM studies of a 3400 deaths across English hospitals as to the strengths and weaknesses of the approach and the strength of the relationship between avoidable deaths identified by RCRR and HSMR/SHMI. The future direction for both local and national mortality review will be reviewed.

Helen Hogan’s Biography:

I trained as a GP before undertaking specialty training in public health. Since joining LSHTM in September 2006 my main research interest has been patient safety in acute care and I have undertaken a number of studies in collaboration with colleagues from the Centre for Patient Safety and Service Quality at Imperial College and the former National Patient Safety Agency. I was chief investigator for the Preventable Incidents, Survival and Mortality studies (PRISM 1 and 2), retrospective case record reviews of 3400 adult deaths across 34 English Hospitals. The approach and findings from these studies are informing the design of a national mortality review programme. Ongoing studies are looking at the measurement of healthcare-related severe harm and the effectiveness of interventions to prevent patient deterioration in the ward setting.

Also of interest:

Delivering a 7 Day Health Service
Monday 9 November 2015, Hallam Conference Centre, London


Clinical Audit Masterclass
Tuesday 10 November 2015, Hallam Conference Centre, London


National PROMs Summit 2015
Tuesday 1 December 2015, Colmore Gate, Birmingham


Data Quality and Clinical Coding for Improvement
Thursday 3 December 2015, Manchester Conference Centre, Manchester


Download: Helen Hogan full presentation

8 October 2015


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