The Hospital Manager’s Association
Top Secret – Eyes Only
The Hospital Manager’s Guide to Massaging HSMRs
Members will be aggrieved to hear that the Doctor Foster Intelligence Unit and its lottery hospital standardised mortality ratios (HSMRs) are here to stay, despite several recent papers showing the methodology to be unsound.
Members will appreciate that they supply the raw data used by Dr Foster, thus providing opportunities to ‘cook’ the figures before they are passed to Dr Foster. The Association does not condone directly tampering with the data; however, faced with the intractable use of flawed statistics, the Association does believe members are entitled to ‘game’ the system to their advantage.
Members will further recall that the HSMR is the ratio of observed deaths to expected deaths, conventionally multiplied by 100. The secret of successful gaming is not only to reduce observed deaths, but also to arrange matters so as to increase the number of expected deaths. This can simply be achieved by weighting matters in such a way as to favour adjustment factors – such as age and co-morbidities – that increase expected mortality.
The Association has researched options for members, and recommends any or all of the following:
1. Get rid of dying patients. Nothing boosts HSMRs more than dead patients – so dump them before they die. It doesn’t matter where you dump them – just get them off the ward before they die. Try tapping into the nostalgia for dying at home – start a campaign through your local paper.
2. Shift dying patients that can’t be dumped into ‘unseen groups’. Remember, Dr Foster only includes only 56 diagnostic groups that account for 80% of in-patient deaths. If a patient’s diagnostic group falls outside the 56 that are included, the death won’t be ‘seen’ by Dr Foster.
3. Rack up those co-morbidities. HSMRs are heavily adjusted for case-mix (concurrent illnesses), so the more co-morbidities the better. Consider taking on extra clerical staff to review case notes for missed co-morbidities.
4. Admit as many old but not expected to die patients as possible – so called ‘Golden Oldies’. It may make the wards smell a bit more than usual, but it does wonders for lowering HSMRs.
5. Avoid elective admissions like the plague. Maintain bed occupancy as 110% so as to force cancellation of elective admissions. Discretely facilitate bed-blocking with old (but not moribund) patients. Liase with local Social Services to ensure that discharge arrangements are slow and complicated.
6. Dr Foster now adjusts for palliative care. Open a large palliative care unit and admit as many dying patients as possible to it. A large high profile palliative care unit has the added bonus of making your hospital appear trendy and caring.
Finally, always bear in mind the most enthusiastic gaming can fail, and a high HSMR result. In such circumstances, the only option is to discredit the Dr Foster methodology. Have ready at all times a briefing pack explaining why Dr Foster HSMRs are not to be trusted. Useful background papers include:
Lilford R, Pronovost P. Using hospital mortality rates to judge hospital performance: a bad idea that just won’t go away. BMJ 2010;340:c2016. [link]
Black N. Assessing the quality of hospitals: hospital standardised mortality ratios should be abandoned. BMJ 2010;340:c2066. [link]
Mohammed MA, Deeks JJ, Girling A, Rudge G, Carmalt M, Stevens AJ, et al. Evidence of methodological bias in hospital standardised mortality ratios: retrospective database study of English hospitals. BMJ 2009;338:b780. [link]
I’m just curious as to when (or possibly whether) this blog will be updated anytime soon. I always worries that my favourite medical bloggers have been rounded up in some sort of midnight raid and sent to the Siberian Salt mines for defamation of the status quo.
Dr No is not in a salt mine (yet). He is bidng his time.
DN
Waiting for you.
Anon – rest assured – DN is alive and well. He has just been enjoying a holiday he couldn’t refuse. But – he’ll be back! Soon!
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How strangely prophetic your article is, Dr. No.
Seems to be a description of the entire NHS ‘end of life care pathway’. This : http://www.ncpc.org.uk/sites/default/files/AandE.pdf advice was issued by the Coalition to the new nhs commissioners who take over in April 2013…it advises them to code up more or less the same patient groups for’end of life care’ your scheme does…and is specifically to avoid hospital admissions.
Page 4 reads:
“For the purposes of this guidance people are‘approaching the end of life’ when they are likely to die within the next 12 months.
This includes people whose death is imminent (expected within a few hours or days) and
those with:
(a) advanced, progressive, incurable conditions
(b) general frailty and co-existing conditions that mean
they are expected to die within 12 months
(c) existing conditions if they are at risk of dying from a
sudden acute crisis in their condition
(d) life-threatening acute conditions caused by
sudden catastrophic events.
http://www.ncpc.org.uk/sites/default/files/AandE.pdf
…that covers just about EVERYONE in the known frigging universe.
The profits have spoken. By the way, there’s a secret gematric code in the Book of Revelations, and what God meant is that on the Day of Judgement, everyone who can’t afford BUPA cover should be palliatively sedated in a Marie Curie (TM) unit – ‘have a good death’ as they say in Hospiceland!
Gematria Consultant: Julia ‘Rabbi’ Neuberger
..oh, and I guess the fact the Coalition planned their ENTIRE NHS budget savings (£20 million by 2014) on the ‘bed days saved’ with the End of Life Care pathway, which leaves people to die of treatable conditions at home (whether they want to or not!) is entirely coincidental to Messrs. Hunt & Lamb refusing to hold a Public Inquiry into the Liverpool Care Pathway ??? The tastefully named ‘Omega Report’ proves the wheels are coming off that one …
What annoys me is, I have seen almost everything mentioned here happen at Leighton hospital, yet despite these venal efforts, they STILL come bottom in the mortality figures.
Best maternity unit in the North West my arse! They “cook” those figures by showboating the unit during parent education classes and give you a survey to fill in there and then. They don’t wait until after patients have actually USED or endured those so-called “facilities” to carry one out!
It’s bloody dangerous in there, I was lucky to get relatives out alive, and violent staff-patient conflict is higher than average. I wonder why?