Hospital Standardized Mortality Ratio
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Why it is important for hospitals to track HSMR
HSMR is one of a number of important quality and safety measures designed to improve patient care. Many hospitals use measures like HSMR to develop action plans to monitor performance and identify improvement opportunities.
Niagara Health System’s HSMR Results for 2008-09
For 2008-09, Niagara Health System (NHS) showed improvement with an HSMR of 109 compared to 114 in 2007/08 and 127 for 2006/07.
How HSMR is measured
HSMR is the ratio of the actual number of deaths, compared to the “expected” number of deaths, times 100. A score of 100 would mean that the number of actual and expected deaths is the same as the national average.
A score over 100 indicates there are more actual deaths than what was expected, and less than 100 shows there are fewer deaths than expected. The HSMR is based on specific diagnosis groups (this includes diagnosis groups such as pneumonia, chronic obstructive pulmonary disease and heart attack), which account for 80% of all in-hospital deaths.
What HSMR is NOT
It needs to be stressed that HSMR is NOT intended to serve as a measure for individual hospitals to compare themselves against other hospitals or for members of the public to use as a measure of choosing where to seek care.
HSMR is only one of a number of performance and quality indicators, and like other indicators, is not perfect or without critics. Hospital care is complicated and depends on many factors, not all of which are reflected or accounted for by HSMR.
Many indicators must be examined in combination to get a full and accurate sense of how hospitals are performing. To judge performance on only one indicator is misleading.
Factors influencing NHS HSMR results
Various factors influence HSMR results. The major factors influencing our HSMR continue to be:
- Population Characteristics: Incidence of specific illnesses in the population our hospital serves can influence their health status and health outcome. With the high prevalence of chronic disease, heart disease, cancer and kidney disease in Niagara, the poor socio-economic status of the region and the significant shortage of family practitioners, the NHS is seeing more and more patients coming into hospital at advanced stages in their illness with little opportunity to change the patients’ outcome.
- Population Served: Hospitals often serve different segments of the population with different health needs. In the case of NHS, high HSMR results reflect the significant numbers of palliative and oncology patients being cared for.
- Shortages of Health Professionals: The ongoing shortage of health professionals, specifically family doctors in the community and shortages of nursing professionals in hospital contributed to the HSMR result. Niagara continues to struggle with shortages in family physicians. Progress has been made in the last two years, but the region is still short 67 family physicians. This shortfall and therefore lack of primary care continues to be evident in the ongoing higher use of NHS Emergency Departments. Evidence shows that patients being admitted into NHS hospitals through its Emergency Departments are coming into hospital at more advanced stages of illness.
- Alternate Level of Care Patients in Hospital: The ongoing effect of alternate level of care patients residing in hospitals due to the lack of available long-term care and rehabilitation facilities in the community also contributes to a higher HSMR.
Why we improved
HSMR is a big dot measure intended to guide investigation and efforts towards quality improvement and that is exactly how we have used this measure to guide NHS initiatives in the last year. This past year, a number of factors positively influenced our improvement in HSMR, and we are extremely proud of the exceptional work done by all towards this result. Improving HSMR is truly a team effort.
Under the leadership and guidance of the Quality Committee of the Board of Trustees, we continue to implement our five-point action plan to help improve HSMR results and profile the importance of patient safety across our hospital. The action plan includes:
- Continuing to implement priorities and action plans within our comprehensive Patient Safety Plan developed to improve our patient safety culture and address areas requiring improvement. This has included an increased focus on reporting adverse events and “good catches” as well as education on patient safety concepts, tools, and related policies and procedures. Most notably this past year we saw the implementation of:
- Patient Safety Leadership Walkarounds
- Principles of a Fair and Just Culture
- Targeted Communication, Education and Resource Materials for front-line staff and patients regarding key patient safety issues
- A new Corporate Patient Safety Committee
- Ongoing review and monitoring of our results on key patient safety projects including Safer Healthcare Now (SHN) and Institute of Health Improvement (IHI) initiatives such as the prevention of Central Line Associated Infections; prevention of Surgical Site Infection; prevention of Ventilator Associated Pneumonia; medication reconciliation; the falls prevention program; and implementation of Patient Safety Required Organizational Practices (as defined by Accreditation Canada)
- Ongoing analysis and monitoring of HSMR results and formula
- HSMR and Morbidity and Mortality chart review process
- Follow up on items arising from all conducted death reviews completed previously
Along with the action plan items, the introduction of a “closed” ICU at St. Catharines General Site continues to contribute to the improvement in HSMR. With this new model, patients from across Niagara requiring the most intensive critical care services receive their care at the St. Catharines ICU, where they remain under the care of a dedicated Intensivist physician, who is a specialist in critical care. Numerous medical studies show that this type of model improves patient outcomes.
Palliative Care a Major Influence on NHS’s HSMR
Another major influence on our HSMR results is the full-year effect of the opening of Hospice Niagara in September 2007. Hospice Niagara provides an invaluable service to area residents requiring a more appropriate setting for end-of-life care than in a hospital. When CIHI excludes in-hospital palliative care cases from our HSMR results, our HSMR significantly drops to 55. This underscores the profound lack of community resources in end-of-life care in Niagara. While Hospice Niagara has bridged a major gap in palliative care services in Niagara, it cannot and does not address the full demand for residential end-of-life care in our region, leaving many end-of-life patients to die in hospital.
HSMR does not include deaths that occur in Emergency Departments
Like all other hospitals, our HSMR results are comprised of in-hospital deaths that occur after the patient has been admitted into hospital. HSMR results do not include out-patient deaths that occur in the Emergency Department prior to any physician order to admit the patient into hospital.
The Year to Come
While significant efforts have been put into the analysis and follow up on our previously received HSMR results, the NHS continues to strive for improvement. Those items designed to improve our HSMR that are targeted for implementation this coming year are:
- Introduction regarding the Early Warning System across all sites and programs
- Ongoing death and adverse event review procedures completed by Risk Management and Patient Safety in collaboration with the programs
- Introduction of a corporate-wide electronic incident reporting system for adverse events and near misses
We are hopeful that these system-wide patient safety initiatives will reap further benefits and contribute to continued improvement in the overall HSMR and quality of care being provided to our patients.