better information --> better decisions --> better health1 ScotPHO Training Day Hospital Standardised Mortality Ratios Richard Dobbie Gavin MacColl (ISD Quality Improvement Programme)

Quality Improvement Programme Hospital Standardised Mortality Ratios (HSMR’s) Surgical / Medical Profiles Scottish Arthroplasty Project Complaints Incident Reporting Pilot ‘Better Together’ Inpatient Survey National Audits SICSAG / Stroke / STAG-Sepsis / Renal Registry Routine Linked Data Quality Strategy – Patient Centred Clinical Engagement

better information --> better decisions --> better health3 What is an HSMR? Observed Deaths Predicted Deaths HSMR =  Observed Deaths =Deaths  Predicted Deaths =Predicted Probabilities

better information --> better decisions --> better health4 Data source - SMR01/GRO linked data Outcome - 30 day mortality Patient indexing – Quarterly (CIS) Explanatory variables Age, sex, deprivation Type of admission (elective / non-elective) Inpatient / day case Place admitted from Number of previous emergency admissions Primary diagnosis Prior morbidity – 1 and 5 years Surgical / non-surgical specialty HSMR Methodology

better information --> better decisions --> better health5 Patient Record Sets HSMR’sSAPProfiles

better information --> better decisions --> better health6 Primary diagnosis group 30 day mortality ratePrimary diagnosis group 30 day mortality rate Cerebrovascular112.4 (8.3 – 13.8)Malignancy316.6 (14.7 – 30.3) Cerebrovascular224.3 (19.3 – 40.1)Metabolic3.2 (0.9 – 8.7) CVS12.3 (1.3 – 7.2)Miscellaneous11.0 (0 – 2.83) CVS211.0 (8.2 – 13.5)Miscellaneous25.6 (3.7 – 18.2) CVS315.9 (13.7 – 31.3)Mortality93.0 (92.9 – 100.0) CVS468.0 (62.5 – 70.8)Neurological11.1 (0.6 – 2.9) Gastrointestinal11.4 (0.7 – 4.1)Neurological24.5 (2.5 – 17.4) Gastrointestinal26.5 (5.0 – 15.7)Renal17.8 (8.3 – 22.2) Gastrointestinal313.4 (10.1 – 23.4)Respiratory12.5 (0.7 – 4.3) Haematology2.7 (1.5 – 6.1)Respiratory26.6 (3.2 – 9.0) Low risk0.2 (0 – 0.6)Respiratory326.1 (8.9 – 47.8) Malignancy13.9 (1.5 – 7.4)Trauma11.2 (0.7 – 3.0) Malignancy211.4 (8.1 – 14.2)Trauma26.3 (3.1 – 16.7) Primary Diagnostic Groupings

better information --> better decisions --> better health7 ConditionWeight (1=least severe, 6=most severe) Acute myocardial infarction1 Congestive heart failure1 Peripheral vascular disease1 Cerebral vascular accident1 Dementia1 Pulmonary disease1 Connective tissue disorder1 Peptic ulcer1 Liver disease1 Diabetes1 Diabetes complications2 Paraplegia2 Renal disease2 Cancer2 Metastatic cancer3 Severe liver disease3 HIV6 Prior Morbidity

better information --> better decisions --> better health8 Scottish Case-Mix Model (selected pathways in model)

better information --> better decisions --> better health9 Timeline of HSMR Development March 08 QIP starts development Surgical Profile May 08 Learning Session 2 Progress reported to senior NHS leaders Recommendation to establish design group Aligned to an extent with Dr Foster December 08 First Results Released Admissions: October 2006 to September 2007 Communication: SPSA to Chief Executives No outliers on the funnel plot January 09 Learning Session 3 Methods and results of validation presented

better information --> better decisions --> better health10 Timeline of HSMR Development May 09 Updated Analysis Admissions: October 2007 to September 2008 Data passed to the SPSA No data circulated to Chief Executives May 09 Learning Session 4 Sep – Dec 09 Model adapted for quarterly reporting November 09 Learning Session 5 Quarterly Model explained December 09 Quarterly HSMR’s Released Time series per hospital showing observed and expected deaths Communication: ISD Director to CEOs and MDs Password protected area on ISD Website

better information --> better decisions --> better health11 Quarterly Release

better information --> better decisions --> better health12 Quarterly Release

better information --> better decisions --> better health13 Quarterly Release Baseline

better information --> better decisions --> better health14 Jul – Sep 10Oct – Dec 10Jan – Mar 11Apr – Jun 11 4 Months3 Months Jan – Mar 09Apr – Jun 09Jul – Sep 09Oct – Dec 09 9 Months Addressing Timeliness

better information --> better decisions --> better health15 Timetable DatePre-release Access to Boards or into Public Domain Reporting Final Data to:Provisional Results Tues. 27 th Jul 2010Pre-release31 st Dec 2009N/A Tues. 31 st Aug 2010Public31 st Dec 2009N/A Tues. 26 th Oct 2010Pre-release31 st Mar 2010Apr–Jun 2010 Tues. 30 th Nov 2010Public31 st Mar 2010Apr–Jun 2010 Tues. 25 th Jan 2011Pre-release30 th Jun 2010Jul-Sep 2010 Tues. 22 nd Feb 2011Public Release30 th Jun 2010Jul-Sep 2010 Tues. 26 th Apr 2011Pre-release30 th Sep 2010Oct-Dec 2010 Tues. 31 st May 2011Public Release30 th Sep 2010Oct-Dec 2010 Tues. 26 th Jul 2011Pre-release31 st Dec 2010Jan-March 2011 Tues. 30 th Aug 2011Public Release31 st Dec 2010Jan-March 2011 Tues. 25 th Oct 2011Pre-release31 st Mar 2011Apr–Jun 2011 Tues. 29 th Nov 2011Public Release31 st Mar 2011Apr–Jun 2011 Tues. 31 st Jan 2012Pre-release30 th Jun 2011Jul-Sep 2011 Tues. 28 th Feb 2012Public Release30 th Jun 2011Jul-Sep 2011 Tues. 24 th Apr 2012Pre-release30 th Sep 2011Oct-Dec 2011 Tues. 29 th May 2012Public Release30 th Sep 2011Oct-Dec 2011 Tues. 31 st Jul 2012Pre-release31 st Dec 2011Jan-March 2012 Tues. 28 th Aug 2012Public Release31 st Dec 2011Jan-March 2012

better information --> better decisions --> better health16

better information --> better decisions --> better health17 What is a High HSMR? A high HSMR where variation greater than +3SDs above Scotland HSMR –Also where HSMR >Scot HSMR but within control limits; Where HSMR is increasing or is steady over time Distribution of variation shown on a funnel plot In addition to published data, HSMR used as part of an internal process to highlight hospitals with exceptional variation (variation outwith norm) Data variability on a funnel plot is not published – risk of league tables Escalation protocol for potential quality/safety concerns flagged up by data – instigated by QIS (HIS) and ISD

better information --> better decisions --> better health18 HSMR Funnel Plot Scot HSMR Hospitals HSMR Control Limits Upper & Lower CL+2SD CL+3SD CL-2SD CL-3SD Unusual HSMR above CL(+3SD)

better information --> better decisions --> better health19 Information Support to Boards 1 Provide data to support further investigation into high HSMR HSMR trend over time and control limits

better information --> better decisions --> better health20 Information Support to Boards 2 HSMR within control limits over time Scot HSMR HSMR within Control limits

better information --> better decisions --> better health21 Information Support to Boards 2 HSMR reaching control limits Scot HSMR Unusual HSMR above CL(+3SD)

better information --> better decisions --> better health22 Information Support to Boards 2 Provide data to support further investigation into high HSMR HSMR trend over time and control limits HSMR stratified : Elective / non elective admissions, age group, specialty, diagnostic grouping

better information --> better decisions --> better health23 Information Support to Boards 2 Elective / non elective, age group, specialty, diagnostic grouping Example HSMR elective / non elective, age group, specialty, diagnostic grouping

better information --> better decisions --> better health24 Information Support to Boards 2 Scot HSMR HSMR Elective / non elective, age group, specialty, diagnostic grouping Indicator of where to start to look Indicate where Scot HSMR < lower 95% CI HSMR

better information --> better decisions --> better health25 Information Support to Boards 3 Case Listing Deaths 30-Day Survivors

better information --> better decisions --> better health26 Information Support to Boards 3 Case Listing Unlikeliest Death According to Model Unlikeliest Survivor According to Model

better information --> better decisions --> better health27 Information Support to Boards 3 Value of Case Listing Review of the patient journey Review of clinical records ICD 10 coding vs SMR01 linked file HSMR catalyst for improvement(s) in SMR01 coding accuracy

better information --> better decisions --> better health28 Three funnel plots Effect of Coding

better information --> better decisions --> better health29 Regression – Scotland, Crosshouse The 15% ‘Target’

better information --> better decisions --> better health30 Importance of Robust Clinical Coding –Individual probabilities of death based on ICD-10 coding Supporting Users –Developing data pack (case listings, aggregations etc) –Working (proactively with stakeholders locally to avoid surprises –Main contacts (Patient Safety Leads, Clinical Governance) –Refer to existing resources (Navigator, Surgical / Medical Profile, ACaDMe) Data Timeliness –SMR01 and GRO data submissions –30-day Follow-up –Reduced lag Issues

If you would like to contact us: Richard Dobbie Gavin MacColl Website address: Thank you very much for listening

better information --> better decisions --> better health32 Any Questions?