What is your hospital standardised mortality rate and what have you done to improve it?

In the first in an online series on the relationship between good management and safety, Stephen Ramsden discusses strategies for lowering hospital mortality rates

What could be more important than life and death or, put even more starkly, how many people we are killing? It is, perhaps, one of the most important indicators of the quality of care in an acute hospital.

I firmly believe chief executives (and other senior people including clinicians) need to know their HSMR and put effort into supporting approaches to improve it.

As accountable officers we should be deeply concerned about avoidable deaths happening weekly in our own hospital. There should be nothing more important to a chief executive than saving lives and demonstrating to their staff they are interested in this.

We are now beginning to address safety more openly. A new patient safety campaign is planned for later this year and I hope this will be welcomed by all chief executives and other healthcare leaders.

Taking stock

In theUS,chief executives have for some years been publicly saying: ‘these are our death rates and this is how we intend to improve our record’. Five years ago at theLutonandDunstableHospitalour HSMR was 11 per cent worse than the national average and we had one of the highest infant mortality rates in theUK.

We gathered the data and, using the Institute for Healthcare Improvement's trigger tool, we tracked adverse events over time and included information on where people died in the hospital. One of our clinical directors presented this to his colleagues. The shock in the room was palpable as the clinicians present realised the extent of avoidable deaths occurring in our hospital.

We introduced a range of initiatives to better manage the acutely ill deteriorating patient:

  • improved observations at ward level;

  • early warning scoring systems for adults and children;

  • a new critical care outreach team.

Nurses had lost the art of taking respiratory rates, having become over reliant on technology (dynamaps are really useful but do not measure respiratory rates). It took us a year to re-educate, emphasise the importance of all observations and achieve a reliable system.

We monitored the impact of the improvements with new measurement systems such as observations, cardiac arrest rates and calls to outreach. We also reinforced the culture change with patient safety leadership walkabouts.

We are proud of what we have achieved but we still have avoidable deaths and we aim to improve further. Our cardiac arrest calls have reduced by two per week. Our HMSR is now 10 per cent better than the national average.

The role of chief executives

But what role do chief executives play? Evidence from the NHS Institute for Innovation and Improvement suggests that where individual clinicians or clinical teams have attempted to reduce avoidable mortality without the support of the chief executive, they have struggled.

They conclude that the role of the chief executive in initiating and leading change and prioritising the reduction in avoidable mortality is key. When we began this work, I wrote on my office whiteboard in large letters, ‘stop killing people’. This generated much interest and discussion from clinicians and staff when they came in for meetings.

World class leader in improvement Jim Reinertsen suggests that the role of the chief executive is to lead system-level changes. What he talks about is 'moving performance of the big measures such as mortality rate and overall institution infection rate, from one level to a significantly better level. So this is the challenge: to help leaders achieve system-level improvement, rather than just project-level results.'

The traditional approach to patient safety has often been reactive with a focus on risk management, governance, regulation and assurance. This is not enough. We must add new proactive approaches to our traditional tools. These should be transformational, use improvement science and tell patient stories to engage hearts as well as minds. What ambitious system-wide goal will you set for your organisation?