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HSMR FAQ

Questions & Answers – Ineligible Hospitals

1. What is HSMR?

The Canadian Institute for Health Information (CIHI) has calculated the HSMR for eligible acute care hospitals in Canada (excluding Quebec). HSMR is a “Big Dot” indicator and measurement tool that compares a hospitals’ mortality rate with the overall average rate. It has been used by hospitals in many jurisdictions to assess and analyze mortality, and to identify areas for improvement.

2. Why didn’t your hospital make its HSMR result publicly available?

CIHI has made HSMR results public only for “eligible” hospitals – those with more than 2,500 HSMR cases. It has not released results for hospitals, like ours, with less than 2,500 HSMR cases because the low numbers make the results less stable and, therefore, less reliable.

Ontario’s hospitals are among the most accountable anywhere, and our hospital takes a great deal of pride in how open and transparent we are to the people we serve. The purpose of HSMR is to show statistically stable and reliable information.

We encourage the public to refer to the LHIN-level result, which can give you an indication of performance on this particular indicator in this region.

3. Although your HSMR is not being publicly reported, are you still monitoring it?

Yes, we receive our HSMR data from CIHI. We use HSMR and other indicators internally to help our hospital inspire performance improvement and enhance patient safety.

Analysis of HSMR are also geared towards system-level improvements, and we look forward to working with our health professionals to make those kinds of improvements.

4. Is HSMR more or less valuable than other quality indicators?

It is neither. HSMR is a “Big Dot” indicator and measurement tool that compares a hospital’s mortality rate with the overall average rate. Like other indicators, such as those included in the OHA’s Hospital Report series, HSMR gives hospital administrators and health providers a snapshot of a hospital’s performance at a given time – areas where it is performing well and areas where it could improve. As such, HSMR results must be viewed in context with other indicators.

That said, the analysis of HSMR, when coupled with system-level improvements based on that analysis, have led to significant performance and quality improvements in other jurisdictions.

We look forward to working with our health professionals to make those kinds of improvements.

5. Does a high HSMR result mean that a hospital has a high number of adverse events, or is unsafe?

No. HSMR is an indicator that provides a snapshot or screening tool of what has happened with respect to one aspect of care – mortality – in a hospital/LHIN/Regional Health Authority over a certain period of time. We must also remember that not all deaths are preventable. The purpose of the HSMR is to provide useful data to support hospitals in their ongoing efforts in improving hospital performance.

A higher than average HSMR result does not necessarily mean that a hospital is “unsafe;” a lower than average HSMR does not necessarily mean a hospital is “safe.” That is why it is vital that HSMR results be viewed in the context of other performance indicators.

That said, the analysis of HSMR, when coupled with system-level improvements based on that analysis, have led to significant performance and quality improvements in other jurisdictions.

6. What factors influence HSMR scores?

HSMR scores can be influenced by a number of factors, some of which are beyond a hospital’s control. These include:
Structural factors: the availability of physicians, long-term care facilities, hospice, screening facilities, and public health programs may influence how and where patients are treated, and how and where patients die.

Population characteristics: the incidence of specific illnesses in the population a hospital serves, as well as the communities in which patients live, can influence their health status and health outcomes.

7. Did you receive HSMR results for the individual physicians and nurses who work in your hospitals?

No. The HSMR results provided by CIHI were a hospital-level snapshot of activity. HSMR is a “Big Dot” indicator and a measurement tool that compares a hospital’s mortality rate with the overall average rate. It is not available at a provider-specific level.

Like other indicators, such as those included in the OHA’s Hospital Report series, HSMR gives hospital administrators and health providers a snapshot of a hospital’s performance at a given time – areas where it is performing well and areas where it could improve. As such, HSMR results must be viewed in context with other indicators.

8. Who in your hospital will see these results?

The results will be shared with our hospital’s trustees and management team so that we can determine what our next steps should be in terms of system-level process improvements.                                                     

9. What performance indicators, other than HSMR, does your hospital use?

Our hospital examines a number of patient safety and quality indicators in its standard quality improvement efforts.

These indicators (from the OHA Hospital Report series) include:

  • Use of Clinical Information Technology: The degree to which clinical information is available electronically to care providers inside and outside the hospital.
  • Use of Data for Decision-Making: The degree to which organizations are disseminating and utilizing both clinical and administrative data.
  • Use of Standardized Protocols: The degree to which hospitals are developing and using standardized protocols for the diagnosis and treatment of a broad range of relatively common clinical conditions and procedures.
  • Community Involvement and Coordination of Care: The degree of coordination, both internally and externally, with other care providers and the community.

Ontario hospitals are also publicly reporting on a host of other patient safety indicators to inspire improved performance, enhance patient safety and strengthen the public’s confidence in Ontario’s hospitals. The Ministry of Health and Long-Term Care passed a regulation in June 2008, requiring all Ontario hospitals to report on a variety of patient safety indicators, including

  • Clostridium difficile (C. difficile), beginning September 30, 2008
  • Methicillin-resistant Staphylococcus aureus (MRSA), beginning December 31, 2008
  • Vancomycin-resistant Enterococci (VRE), beginning December 31, 2008
  • Rates of ventilator-associated pneumonia, beginning April 30, 2009
  • Rates of central line infections, beginning April 30, 2009
  • Rates of surgical site infections, beginning April 30, 2009
  • Hand hygiene compliance among health care workers, beginning April 30, 2009

10. What action does your hospital intend to take to improve your HSMR result?

Our hospital intends to carefully review the CIHI report and our HSMR results, and then work with health professionals to identify and implement system-level improvements – as we do when we receive reports on other safety and quality indicators, such as those in the OHA’s Hospital Report, or in the course of our standard quality improvement programs.

11. Are HSMR results grouped by peer hospital?

There are no peer groups involved in the publicly reported HSMR results. Please e-mail hsmr@cihi.ca if there are further questions related to this.

12. Why isn’t the number of expected deaths calculated by hospital category (i.e. teaching, community)?

The current method of calculating the number of expected deaths in acute care hospitals in Canada (excluding Quebec) adjusts for several variables that may affect in-hospital mortality (i.e. age, sex, length of stay, admission category, diagnosis group, other). This method provides for simplicity in reporting and a more stable platform to observe trends over time. This is the overall goal of HSMR. Please contact hsmr@cihi.ca if there are further questions related to this.

13. Can hospitals compare their HSMR results against other organizations?

The HSMR tool is not intended to serve as a measure for hospitals to compare themselves against other organizations, or for the public to use as a measure of choosing where to seek care.

The HSMR should be used as a tool by hospitals to help follow their own progress over time, and make quality improvements based on the results.

14. Why is the HSMR Excluding Palliative Care (PC) not being reported this year?

Last year, CIHI reported two HSMR results.  Last year, CIHI also reported a second result, the HSMR Excluding PC, which excluded all palliative care cases from the calculation. This result does not reflect mortality trends for a growing number of organizations as there have been changes over time in the identification of palliative care patients. These changes in PC coding are in line with the CIHI palliative care coding guideline and subsequent standard and have been implemented by hospitals. Accordingly, the HSMR Excluding PC result is not used this year because the trend has been broken.