Helen Hogan

What can we learn about patient safety from information sources within an acute hospital: a step on the ladder of integrated risk management?

Objective: To assess the utility of data already existing within hospitals for monitoring patient safety. Setting: An acute hospital in southern England. Design: Mapping of data sources proposed by staff as potentially able to identify patient safety issues followed by an in-depth analysis of the content of seven key sources. Data source analysis: For each data source: scope and depth of content in relation to patient safety, number and type of patient safety incidents identified, degree of overlap with incidents identified by different sources, levels of patient harm associated with incidents. Results: A wide range of data sources existing within the hospital setting have the potential to provide information about patient safety incidents. Poor quality of coding, delays in reports reaching databases, the narrow focus of some data sources, limited data-collection periods and lack of central collation of findings were some of the barriers to making the best use of routine data sources for monitoring patient safety. An in-depth analysis of seven key data sources (Clinical Incident database, Health and Safety Incident database, Complaints database, Claims database and Inquest database, the Patient Administration System and case notes) indicated that case notes have the potential to identify the largest number of incidents and provide the richest source of information on such incidents. The seven data sources identified different types of incidents with differing levels of patient harm. There was little overlap between the incidents identified by different sources. Conclusion: Despite issues related to the quality of coding, depth of information available and accessibility, triangulating information from more than one source can identify a broader range of incidents and provide additional information related to professional groups involved, types of patients affected and important contributory factors. Such an approach can provide a focus for further work and ultimately contributes to the identification of appropriate interventions that improve patient safety.

Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis

Objectives To determine the proportion of avoidable deaths (due to acts of omission and commission) in acute hospital trusts in England and to determine the association with the trust’s hospital-wide standardised mortality ratio assessed using the two commonly used methods - the hospital standardised mortality ratio (HSMR) and the summary hospital level mortality indicator (SHMI). Design Retrospective case record review of deaths. Setting 34 English acute hospital trusts (10 in 2009 and 24 in 2012/13) randomly selected from across the spectrum of HSMR. Main outcome measures Avoidable death, defined as those with at least a 50% probability of avoidability in view of trained medical reviewers. Association of avoidable death proportion with the HSMR and the SHMI assessed using regression coefficients, to estimate the increase in avoidable death proportion for a one standard deviation increase in standardised mortality ratio. Participants 100 randomly selected hospital deaths from each trust. Results The proportion of avoidable deaths was 3.6% (95% confidence interval 3.0% to 4.3%). It was lower in 2012/13 (3.0%, 2.4% to 3.7%) than in 2009 (5.2%, 3.8% to 6.6%). This difference is subject to several factors, including reviewers’ greater awareness in 2012/13 of orders not to resuscitate, patients being perceived as sicker on admission, minor differences in review form questions, and cultural changes that might have discouraged reviewers from criticising other clinicians. There was a small but statistically non-significant association between HSMR and the proportion of avoidable deaths (regression coefficient 0.3, 95% confidence interval −0.2 to 0.7). The regression coefficient was similar for both time periods (0.1 and 0.3). This implies that a difference in HSMR of between 105 and 115 would be associated with an increase of only 0.3% (95% confidence interval −0.2% to 0.7%) in the proportion of avoidable deaths. A similar weak non-significant association was observed for SHMI (regression coefficient 0.3, 95% confidence interval −0.3 to 1.0). Conclusions The small proportion of deaths judged to be avoidable means that any metric based on mortality is unlikely to reflect the quality of a hospital. The lack of association between the proportion of avoidable deaths and hospital-wide SMRs partly reflects methodological shortcomings in both metrics. Instead, reviews of individual deaths should focus on identifying ways of improving the quality of care, whereas the use of standardised mortality ratios should be restricted to assessing the quality of care for conditions with high case fatality for which good quality clinical data exist.

The Impact of Working Beyond Traditional Retirement Ages on Mental Health: Implications for Public Health and Welfare Policy

AbstractBackground: Many people now want or need to work longer due to increased life expectancy. In some countries statutory retirement ages deny older people free access to the labour market. It has been hypothesised that exclusion from employment may have negative effects on the mental health of older people. The global financial crisis has forced some countries to propose increasing the retirement age but the implications of this for population health are unclear. This paper reviews the evidence for the mental health impacts of working beyond retirement, and discusses the implications for future public health and welfare policy. Methods: A systematic literature review was conducted of studies that examined the effect of working or volunteering beyond traditional retirement ages on mental health outcomes. Results: Of the ten studies that met the inclusion criteria, none showed a negative impact of working beyond retirement age on mental health. Four studies showed that post-retirement working has a statistically significant positive effect on a range of mental health outcomes. Discussion: This review suggests that working beyond traditional retirement ages may be beneficial for mental health in some populations. The mechanisms by which this occurs are complex but are likely to be mediated by the maintenance of productive societal roles, continued income and social support. The benefits of post-retirement employment are unlikely to be universal as such factors will have varying effects depending on individual lifestyle, self-esteem and socioeconomic status. Although our research shows that allowing older people free access to the employment market may have important health benefits, flexible retirement strategies are needed to ensure that any national policy to increase statutory retirement age does not increase health and social inequalities in the elderly.

The Evolution of Public Health Education and Training in the United Kingdom

The United Kingdom has a long and evolving history of public health education. From the initiation of formal standardised training for Medical Officers for Health in the early 1900s, to the current national public health training programme, public health education has adapted to the changing contexts of public health practice. Whilst the profession was originally only a medical specialty, subsequent recognition of the skills and contribution of the wider public health workforce has led to changes in professional specialist training for public health, which is now open to non-medical applicants. This well-established professional training scheme allows the formal accreditation of competence in a broad range of public health skills. The academic component of public health training is provided by a rapidly growing number of postgraduate courses. Once confined to the UK’s first school of public health, the London School of Hygiene and Tropical Medicine and a handful of British Universities, the current 60 or so courses across the country are found in diverse university settings. Quality and standards in higher education are monitored by the Quality Assurance Agency for Higher Education but there are no other professional accreditation schemes for postgraduate courses in public health nationally. Public health education and training continues to face challenges in the UK, notably the current government plans for major restructuring of the National Health Service (NHS) which threatens the loss of traditional NHS training placements and has created uncertainty around how professional training might be structured in the future. Whilst the long established tradition of public health education and more recent adoption of competency-based approaches to training gives some flexibility to meet these challenges, insight and innovative responses are required to ensure that public health education and training are not destabilised by these challenges. Revisions of the curricula of postgraduate courses and the competencies required for professional accreditation along with provision of experience in the new locations where public health is to be practiced in the future will be key to ensuring that public health professionals are ready to tackle the key issues that confront them.

Relationship between preventable hospital deaths and other measures of safety: an exploratory study

OBJECTIVE To explore associations between the proportion of hospital deaths that are preventable and other measures of safety. DESIGN Retrospective case record review to provide estimates of preventable death proportions. Simple monotonic correlations using Spearmans rank correlation coefficient to establish the relationship with eight other measures of patient safety. SETTING Ten English acute hospital trusts. PARTICIPANTS One thousand patients who died during 2009. RESULTS The proportion of preventable deaths varied between hospitals (3-8%) but was not statistically significant (P = 0.94). Only one of the eight measures of safety (Methicillin-resistant Staphylococcus aureus bacteraemia rate) was clinically and statistically significantly associated with preventable death proportion (r = 0.73; P < 0.02). There were no significant associations with the other measures including hospital standardized mortality ratios (r = -0.01). There was a suggestion that preventable deaths may be more strongly associated with some other measures of outcome than with process or with structure measures. CONCLUSIONS The exploratory nature of this study inevitably limited its power to provide definitive results. The observed relationships between safety measures suggest that a larger more powerful study is needed to establish the inter-relationship of different measures of safety (structure, process and outcome), in particular the widely used standardized mortality ratios.

The problem with preventable deaths

Interest in the utility of measuring preventable hospital deaths to drive improvement dates back to Florence Nightingales first intimation that variations in mortality between London hospitals might reflect differences in quality of care.1 In 1999, the US Institute of Medicines report ‘To Err is Human’ published the frequently quoted estimate of 44 000–98 000 preventable deaths annually in US hospitals, claiming that medical error represented the eighth most common cause of death in the country.2 This claim has fuelled ongoing and vigorous debate over actual numbers across many countries. Following well-publicised failures at Bristol Royal Infirmary3 and Mid Staffordshire NHS Foundation Trust,4 ,5 in England, the problem of preventable deaths has come to the wider attention of politicians and the public alike. Of late, politicians in England have developed a myopic focus on tackling preventable deaths as the key to raising performance across the NHS and look to single out discrete measures for bench-marking purposes, despite clearly not representing the complexity of modern-day hospitals.6 Acknowledgement of the existence of preventable hospital deaths is helpful in raising interest in the scale and burden of healthcare-related harm and encouraging commitment to improvement among clinicians and hospital managers. However, using preventable deaths as a comparative measure of quality between hospitals, if measures are not robust and fair, may overestimate the size of the problem and the risk to patients inducing unjustified levels of anxiety and fear and have a powerful stigmatising effect on hospitals identified as ‘high death rate’ outliers. Conversely, underestimation may lead to complacency and failure to acknowledge ongoing risks to patients. A thorough understanding of problems associated with both the concept and different approaches to measurement is needed to determine the role of preventable deaths in quality improvement. Failing to prevent an avoidable death or, worse, …

Learning from preventable deaths: exploring case record reviewers' narratives using change analysis.

Objective To determine if applying change analysis to the narrative reports made by reviewers of hospital deaths increases the utility of this information in the systematic analysis of patient harm. Design Qualitative analysis of causes and contributory factors underlying patient harm in 52 case narratives linked to preventable deaths derived from a retrospective case record review of 1000 deaths in acute National Health Service Trusts in 2009. Participants 52 preventable hospital deaths. Setting England. Main outcome measures The nature of problems in care and contributory factors underlying avoidable deaths in hospital. Results The change analysis approach enabled explicit characterisation of multiple problems in care, both across the admission and also at the boundary between primary and secondary care, and illuminated how these problems accumulate to cause harm. It demonstrated links between problems and underlying contributory factors and highlighted other threats to quality of care such as standards of end of life management. The method was straightforward to apply to multiple records and achieved good inter-rater reliability. Conclusion Analysis of case narratives using change analysis provided a richer picture of healthcare-related harm than the traditional approach, unpacking the nature of the problems, particularly by delineating omissions from acts of commission, thus facilitating more tailored responses to patient harm.

Global health: a positive addition to public health training?

Factors that influence health, both enduring and emergent, more than ever extend beyond national borders. Worldwide trade, migration, travel and communication technologies have all served to create a smaller world where notions of boundaries and nation states become less meaningful for health. No country is unaffected by the health threats posed by the global economic crisis, climate change, emerging novel diseases and increasing prevalence of chronic disease. The need to rebalance emphasis on disease-centred models and the search for technological health service-related solutions with social models of health that recognize the influence of wider determinants is evident. Those engaged in efforts to improve public health will need the knowledge and skills to deal with complex problems that bridge the gaps between biological, environmental and social sciences. Active participation in the development of innovative policies to tackle such problems will draw on explanations, methods and interventions from a range of disciplines. Effective communication of benefits, in terms of health outcomes and cost-effectiveness, to policy-makers will be required at local and global levels. Complex hierarchies created by multiple donor–recipient relationships are likely to be ineffective and inefficient. Global networks of partners collaborating on an increasingly equal basis require approaches that champion advocacy, equity, consensus and partnership underpinned by the best available evidence from research. Public Health will have to show its worth in this new environment demonstrating how a robust public health infrastructure and a trained public health workforce are paramount for economic growth and prosperity. Recognizing the growing demand for well-trained individuals to work within the field of global health many schools of public health and university faculties, including our own, have created new courses with modules covering areas such as global health politics, health diplomacy, global trade and health and global environmental change. These courses have in many cases also recognized the importance of continued exposure to established public health subjects including epidemiology, health economics, policy analysis and infectious disease control. Such courses should be considered complementary to more traditional courses on health problems that predominantly affect populations in low-income countries, which are designed to equip students with practical skills and conceptual understanding to improve health in such settings. Undertaking a postgraduate qualification is one route to acquisition of new competencies required, the experiences offered by international placements are another. Placements provide opportunities to become immersed in other cultures, to appreciate perspectives based on different value systems and to grasp the interdependencies and the possibilities for mutual learning. Experiences within complex, resource constrained healthcare settings or government structures with direct responsibility for providing care or implementing policies provide invaluable learning. The insights gained have the potential to promote a flexibility of approach needed to bring innovative solutions at whichever level the practitioner chooses to work in the future. As Nigel Crisp advocates in his book ‘Turning the World Upside Down’ such experiences have the potential to contribute to the development of public health infrastructure

To what extent are inpatient deaths preventable? The author's reply

We are pleased that findings from our Preventable Incidents, Survival and Mortality Study (PRISM) study1 are consistent with Nash and Quinns clinical experience. They raise the important point that published variation in hospital standardised mortality ratios (HSMRs) and its recent modified version, the summary hospital-level mortality indicator, between acute trusts and within individual trusts over time, is greater …

Rate of avoidable deaths in a Norwegian hospital trust as judged by retrospective chart review

Background The proportion of avoidable hospital deaths is challenging to estimate, but has great implications for quality improvement and health policy. Many studies and monitoring tools are based on selected high-risk populations, which may overestimate the proportion. Mandatory reporting systems, however, under-report. We hypothesise that a review of an unselected sample of hospital deaths will provide an estimate of avoidability in-between the estimates from these methods. Methods A retrospective case record review of an unselected population of 1000 consecutive non-psychiatric hospital deaths in a Norwegian hospital trust was conducted. Reviewers evaluated to what degree each death could have been avoided, and identified problems in care. Results We found 42 (4.2%) of deaths to be at least probably avoidable (more than 50% chance of avoidability). Life expectancy was shortened by at least 1 year among 34 of the 42 patients with an avoidable death. Patients whose death was found to be avoidable were less functionally dependent compared with patients in the non-avoidable death group. The surgical department had the greatest proportion of such deaths. Very few of the avoidable deaths were reported to the hospital’s report system. Conclusions Avoidable hospital deaths occur less frequently than estimated by the national monitoring tool, but much more frequently than reported through mandatory reporting systems. Regular reviews of an unselected sample of hospital deaths are likely to provide a better estimate of the proportion of avoidable deaths than the current methods.