Heartbeat: How mortality indicators support improvements in care

April 12, 2022

As a healthcare organisation we have a responsibility to monitor and understand why people have died whilst in our care.

In many cases, some patients are expected to do die. This could be due to the severity of their condition and whether medical interventions are no longer working. However, there are cases too, where some people die unexpectedly. SWB reports all incidents of death to a national register using what is called – the mortality indicators.

We caught up with Deputy Medical Director Dr Chizo Agwu, and asked her just how the mortality indicators work.

She said: “Mortality is reported using two main indicators. Deaths that have occurred whilst at the Trust use a measure called the Hospital Standardised Mortality Ratio (HSMR) or if a patient dies up to 30 days post-discharge an indicator called Standardised Hospital Mortality Indicator (SMHI) is used. The measures report mortality performance in a way that can be compared and contrasted with other hospitals.

“Typically, elevated mortality rates should act as an alert and prompt further investigations. Quality of care and treatment of patients and clinical pathways are carefully reviewed to ensure that care quality is not compromised and potentially predisposing to avoidable harm, whilst other contributing factors such as data clinical coding, severity of illnesses, admission pathway, end of life care provision, and local population characteristics are also taken into consideration when scoring the mortality indicators. Ultimately the indicators highlight the number of expected deaths per trust per month, compared with the number of actual deaths.”

SWB has a strategy designed to ensure high standards of care and learning are supported through a strong mortality governance framework. As part of the framework, a review was undertaken to examine the Trust’s mortality indices. This identified several aspects around data quality that is resulting in higher than expected mortality ratios, including how we record admissions, primary diagnosis and comorbidities.

Dr Agwu added: “As a result I am leading a project involving colleagues from clinical groups, clinical coding, informatics, communications, operational leads and the improvement team which will oversee a plan to improve the current mortality indices rates.”

One key step has been the appointment of a new Clinical Digital Fellow, Dr Aveen Mahmood who will be supporting reviews of mortality data but also providing additional education sessions. Aveen told Heartbeat: “I am working with the medical director’s team and the improvement team to enhance our patient outcomes. My experience in quality improvement projects and in reviewing mortality data during my foundation training has guided me in my role here. I will be focussed on the acute medical units, where I will work alongside the teams, aiming to optimise our use of Unity and to improve our clinical documentation, ensuring it is in line with the clinical coding standards.

“I am also working closely with the clinical coding team to review our mortality data and ensure it is accurate and representative of our practice. I am excited to be involved in the brilliant work to make positive changes to practice across the Trust.”

So, what can teams do to improve clinical coding?

Aveen said: “We are striving to improve the quality of our documentation, ensuring it is representative of the care we are providing. A key issue in documentation is the use of ambiguous terminology that cannot be recognised and coded, with terms such as ‘impression’ and ‘likely’ for diagnoses. We are also focussing on documenting the highest level of specificity to improve accuracy and depth of clinical coding.

“We are encouraging clinical staff to use alternative terminology, for example ‘treated as’, ‘probable diagnosis’ and ‘diagnosis,’ as per the nationally-set standards. This terminology better reflects the inpatient care received. By structuring our documentation with most clinically important diagnoses first, we can give greater clarity on patient care. We can safely maintain patient records by appropriately documenting patient comorbidities on Unity. These simple updates to our daily practice will give greater clarity about patient care, and will have a significant impact on Trust data. We will also be sharing posters, stickers, screensavers and Connect banners to help keep this message in colleague’s mind.”