You are either dead or alive..hold on, let me just adjust that

I’ve recently had the privilege of two hours with Sir Brian Jarman, GP, previous president of the BMA, statistician, geophysicist, senior IHI Fellow, founding member of Dr Foster and yes, architect of the HSMR – Hospital Standardised Mortality Ratio.

His story is fascinating – a selfless commitment to improvement, transparency and the development of balanced data.

HSMR measures an adjustment in patient mortality while the sister measure, Summary Hospital-level Mortality Indicator, measures 30 day mortality post discharge. SHMI excludes patients coded as palliative so discharging a terminal patient to die at home doesn’t count.

We’ve all heard criticism of the HSMR. Indeed it would appear at times that only patients are interested in a 25% increased probability of dying in Hospital A versus Hospital B – but then why wouldn’t they? After all they are the patients and death is kind of an all or none event.

HSMR was initially developed by Sir Brian as a means of seeing if it could be used in the formula for redistributing resources to hospitals. The square root of the SMR of an area  was used to calculate the allocation to the geographical area  e.g. SMR 1.21, Square root 1.1, the area gets 10% more on adjusted allocation.

When it comes to quality assurance, the first response as clinicians when faced with comparative data is to claim that our patients are actually the illest or the data is invalid. In the Bristol inquiry a higher proportion of Downs Syndrome babies was used for this excuse, only for the research to prove the opposite. Multivariate analysis with regression modelling is not manipulation of the data, its adjustment to a meaningful scale. The simplest example of readjustment is a ratio. If hospital A and hospital B both have 50 deaths a month but hospital A has 500 admissions and B 625 admissions then we can all work out which is the ‘safer’ of the two. Similar principles but more complex methods adjust for multiple parameters in turn thus putting the multiple variables back in context. These variables include:

  • Sex
  • Age on admission (in five-year bands up to 90+)
  • Admission method (emergency or elective)
  • Socio-economic deprivation quintile of area of residence of patient
  • Co-morbidities
  • Financial year of discharge
  • Primary diagnosis

In fact the HSMR is the ratio of the actual number of acute in-hospital deaths to the expected number of in-hospital deaths, for conditions accounting for 80% of inpatient mortality.In England the baseline is reset to 100 each year.

For the full monty here is an excellent summary from the man himself.

The dark reality is that greater attention to the HSMR could have prevented the need for the Mid-Staffs and Bristol inquiries where HSMR had been steadily climbing for the decade before. It was not only ignored but claimed, by David Nicholson among others, that the data was not available. Organisations in the West Midlands SHA logged on to their mortality alerts 69,000 times in the period covered by the Mid Staffs Inquiry (Jan 2005 to Mar 2009).

Revised HSMR for Mid-Staffs 2003-2008


In fact in the name of transparency Dr Foster is now putting more and more data in the public domain. Go on, check out your local.


Still, understanding the data and nuances is crucial for sound judgement. So what does Jarman say when challenged about the use of HSMR? He’s pretty clear:

1. HSMR is a trigger, not the end of the story

2. If someone can improve on the clinical and statistical aspects then he welcomes their input. Unlike other companies the method is clear.

3. Use in league tables has never been suggested, but use for individual improvement has.

4. HSMR should not be used to generate figures on ‘preventable deaths’ or ‘avoidable mortality’. This use in the media has likely contributed to its criticism.

However, far more dangerous than a statistic that carries a probability of being incorrect 0.1% of the time is the attitude of explaining away difficult data, hiding it or denying it. The quality triangle includes quality planning, assurance and most importantly improvement. We’ve been infected with quality denial but we have a real opportunity for treatment and cure.

Becoming an improvement organisation, which the NHS needs to become, requires a commitment to understand where we are at. If we don’t measure, we can’t tell we have improved. In addition a cyclical system of learning is required as the engine for change.

I’ve heard people say “there will be another Mid Staffs, you can’t stop it happening”. True, if things stay the same. There’s another way though.

Despite Bristol Infirmary getting a clean bill of health from the Royal College of Surgeons (twice) prior to the uncovering of the reality, real changes happened post inquiry. It wasn’t a wonder cure but simple process improvements and getting the basics right. Resource allocations were dealt with (for instance having 3 paediatric cardiac surgeons/ million vs 40/million in Northern Europe). Re-training occurred, system flaws (such as having the recovery area on a different level to the theatre) were dealt with.

The mortality rate for paediatric cardiac surgery fell from 24% to 10% then 3%. Cause for celebration? Those involved should be congratulated.

Let’s not wait for an inspection nor concentrate one’s effort on the coding department but take the stats on the chin and be resolute about making our health system safer.


Joy at work? You can’t be serious…

Who are the most important people for your organisation?

According to Johann Krieger, the general manager of the Gaylord hotel in Orlando it’s not the’s the staff. Maybe surprising, but he knows all too well that in a service industry, that they are the key to success.

I helped to man the desk at the IHI staff retreat yesterday. (Hey, it was only next door to the office but you did get breakfast, lunch and tea). It was Jeff Selbergs last day. He is the COO and moving  to a new job in New York. It got pretty emotional – in a fun way plus the odd staff shed a tear.  Standing ovation, HUGE cake, Red Sox shirt (which should ensure he is beaten up on the NY tube), life size poster and a few personal jokes. Hey – he only did 3 years! Maybe this guy was just amazing, maybe it’s just American’s but it felt like the right thing to do and it made you proud to share in the success. Time was set aside to facilitate people in forming their personal goals (from spiritual to loved ones, physical fitness, professional etc) and your 4Es to discuss with your manager for this year: What do you want to achieve regarding experience, exposure, . At the end of the day there was some compulsory dancing to loosen up which developed into a conga, all of which seemed perfectly natural of course. IHI give each employee $750 in professional development AND $750 for personal development. It still requires a signature but gym membership counts. Then there’s the ‘ministry of fun’, a wellbeing blog, sponsored health checks. One starts to realise that investment in staff isn’t just a random occurrence.


The guys at EA sports also seem to be onto something – gyms at work, chill zones…and yet when staff are required to put in the 14 hour day there’s no come back. Sure, there are times that they will shoot a few baskets at lunch but making the next FIFA 2014 for X-box doesn’t happen by just fiddling your thumbs (or maybe it does, I’m not a big gamer anyhow).

Richard Sheridan takes it one step further. Joy, Inc.: How We Built a Workplace People Love is getting quite a bit of attention. Sheridan runs Menlo innovations – a software company in Michigan, which to me is a flat, cold and therefore non-joyful place.

To be fair, (at least at some point) he had his feet firmly on the ground:

“Joy is a pie-in-the-sky, cymbals-clanging,music-playing, radical dream. Joy is a word that carries connotations of love, happiness, health, purpose, and values. Joy might work at home, or at church, or with a hobby – but not at the office. It’s a concept that has no place in the corporate world. It certainly does not sound profitable.

BUT Deep down you know that there is a better way to run a business, a team, a company, a department. You’ve always known it…” (of if you don’t you would like to work there anyway)

Menlo has tripled in size three times. Maybe they just are competitive, but there must be some reason why thousands of people, (who have no interest in software) go and visit each year. “Sheridan and his team changed everything about how the company was run. They established a shared belief system that supports working in pairs and embraces making mistakes, all while fostering dignity for the team”.

joy inc

Well, you know, it’s okay for these namby pamby companies who don’t have a ‘serious’ job to do – but real healthcare? No – it’s just not possible. I mean, the hours, the suffering, the complexity, the political pressures. Plus in a National Health Service, we are servants of the state, we are accountable for every penny.

For some reason though things haven’t turned out quite they way they should. It’s got to a point now where we give students in healthcare courses in resilience before they graduate (seriously, I’ve run one). Wouldn’t it be a better idea to train them at least how to improve the system, increase efficiency and gain time to at least do a thorough job?

You know, sometimes I wonder what has caused a system designed to help people enjoy life, lead to so much burnout, low morale, moaning and perpetual grind. So for the purpose of ‘reality’ let’s down grade our expectations to mere ‘staff satisfaction’.

And yet here is the crux…the public (via politicians) do not support rewarding hard working NHS staff with little more than a Christmas letter of thanks from the Health Minister. Celebrating success? It’s just not on the contract.


(surely this guy must be posing, bit harsh of his mate to take a shot on the iphone)

A typical article: “NHS managers spend £100,000 on staff events”. Of course, this was the sum of Primary Care Trust events across the entire country. The biggest culprit was Berkshire Primary Care Trust who lashed an incredible £8 ($13) per staff over a whole year on thanking them for their hard work and celebrating success. Wow, I estimate that’s 0.03% or less of the staff operating budget. (In the name of transparency, could the telegraph please publish how much it spent on staff per head – oh, and please include free coffees and tea over the last financial year too please, given that is also considered wasting tax payers money and beyond the NHS budget)

Rant over – but is it possible?

Take a look at the the CareerBliss 2013 Top 50 companies in the US. This survey is in it’s third year and assesses 100,000 independent employers.

The first observation is that there is no, one sector, industry or company type. The second observation is that Kaiser Permanente, a health system covering 8 million Americans, is in the top 20 for two years running. Sure, it’s not hard to find a review of someone who thinks there issues but surely making the top 0.02% isn’t to bad? Of interest KP are adding another 1 million Americans this year without any expansion in infrastrusture, such has been the ‘space created’ by good practice. So maybe it is possible for a health system with salaried staff that covers all areas of care and drives a tough improvement agenda to actually have happy staff?

The business case for this is pretty clear.

Staff satisfaction is inversely proportional to sick leave and staff turnover – two very expensive measures every organization should be tracking.

  • Staff are a healthcare systems most expensive asset
  • The UK NHS spends 2.5 billion GPB on agency staff (on top of the staff who are not there doing the job anyway)
  • On average 4% of staff are off at any one time (highest in support, ambulance and nursing staff)
  • Staff turnover varies between 4-18% of total staff a year between NHS trusts, a greater than 4 fold variation. Each post involves cost on advertisement, interviewing, recruitment and often a gap between filling the post
  • And the cost of a staff appreciation program? Back fill for one nurse for a month

I sure felt like going the extra mile when I worked at places where the boss took the effort to thank you (and generally out of their own pocket): Wine at Christmas from Dr Rodrigues for all at Aintree cardiology, registrars meal with partners at St Georges Medical Centre, Clive Shaw picking up the tab on a work night out (hey if I didn’t thank you back, please accept my humblest electronic cheers).

Now, before hiring your local foot massager, it’s important to take in a few principles.

  1. It doesn’t happen by itself: All the organisations mentioned above have a strategy to increase staff engagement and support staff actively in a positive way (as opposed to waiting until an issue occurs).
  2. It doesn’t have to be costly to create a culture of gratitude, but it does need to be regular: Words don’t cost anything and a few hundred quid a year to gain appreciated staff just requires the addition of creativity and fun.
  3. As with everything, leaders need to lead by example: Leaders shape culture, for good or bad, knowingly or not knowingly.
  4. When it comes down to money, its still worth it: Locum fees are 50-100% more than regular salaried staff costs. Loss of organizational memory can be crippling and people who don’t want to be there are less likely to put the required effort in to see the organisation succeed.
  5. A culture of psychological safety is a key building block: Few fancy touches won’t cut it if staff don’t feel comfortable to speak up in a trusted environment
  6. It’s likely going to require changes in team structure and function for a sustainable difference

So, what’s your next step to retaining your best employees, reducing stress related time off and the agency staff bill? Probably go and have a chat and find out how things really are underneath the employee bonnet – because joy at work may by more than a pipe dream.

My Dad used to buy Rovers until one blew up…

My Dad always used to buy Rovers – then one at only 18 months old blew up on holiday. Stranded with family, reliability suddenly took center stage. Ever since then every car has been a Toyota or Honda. As a result Rover went bust (well a contributing factor at least!).

UK Car manufacturer reliability index (2012)

1. Daihatsu
2. Honda
3. Suzuki
4. Toyota
5. Chevrolet
6. Hyundai
7. Lexus
8. Ford
9. Mazda
10. Skoda

+ 29 others!


It’s no surprise that 6/10 top brands are Japanese – but what’s the secret?

A few months ago Eiji Toyoda died after 60 years in service at the helm of Toyota. Things were not always great. The CEO went home humbled after trying to get a Toyota over the Rockies in a US PR stunt  Toyoda was the guy who turned this mediocre car company that manufactured just 2000 crumby cars a year in 1950 into a global powerhouse.

So what happened?

The first step was they acknowledged who and where they were in the quality stakes then looked outside the box for assistance and help. Enter Edward Deming, sent by the US to assist post war Japan. The improvement scientist taught a new leadership and systems approach in Japan that involved 1) empowered front line staff, 2) a systems approach, 3) live statistical variance analysis and most importantly 4) continuous incremental improvement (termed kaizen by the Japanese). His methods meshed perfectly with the Japanese tireless effort to eliminate waste and a lean society. The highest medal for manufacturing in Japan is indeed the Deming award while Toyoda developed the Toyota Production System.

How do we define a perfect process? For Toyota its one where every step is:

  • Valuable
  • Capable
  • Available
  • Adequate
  • Flexible
  • Linked by continuous flow

The main focus of all this is to eliminate waste (or muda) in its widest sense:

  • Overproduction
  • Waiting
  • Transporting
  • Processing time
  • Excess inventory
  • Excess motion
  • Correction of defects

At this point it’s important to note that one cannot simply apply the ideas of lean manufacturing to get the results. Leadership create the culture on which to build the learning system. Staff then use the tools effectively as part of a standardized process.


So what does a lean culture look like? Maybe reflect on where your organisation is at.

‘Traditional Culture’

‘Lean Culture’

Functions in silos Integrated interdisciplinary teams
Managers direct Managers enable
Benchmarking justifies ‘just as good’ Seek ultimate performance, absence of waste
Blame people Root cause analysis & system diagnostics
Rewards individuals Rewards groups
Supplier is enemy Supplier is ally
Guard information Share information
Volume lowers cost Removing waste lowers cost
Internal focus Customer focus
Expert driven Process driven

Here’s a few examples of how it plays out on the production line:

  1. Quality at Source: A worker sees something that has the potential of going wrong. One pull and the whole production line slows, another and it stops and a senior technician is there is 30 seconds
  2. Pull systems ensure the correct inventory is drawn to the line, ‘just in time’
  3. Middle managers on the line – no offices remote.
  4. Worker empowerment: Workers provide 1.5 million suggestions a year – over 90% are tested practically
  5. Suppliers are seen as integral part of the system, involved in the system diagnostics and trained alongside
  6. Reduced set up times as new kit is prepared in parallel and process improved to slot into the flow

toyota-production line

Now the first observation everyone makes is that patients are not cars and so it really doesn’t apply. (before that they said this system could only work in Japan, only on cars and all kinds of other rubbish). Healthcare is incredibly complex and involves all kinds of processes, flow, equipment, knowledge, timing to produce the desired effects. (Hey cars are pretty complex too, with on average 30,000 parts). Categories of ‘waste’ are certainly present wherever there is a process and thus the principles apply, but the specifics need translation.

For instance, imagine the above were translated into healthcare:

nhs staff

  1. Everyone including the HCA or cleaner is comfortable enough to interject and call a time out regarding a patient safety concern
  2. Key assessments, equipment, investigations and treatments are facilitated by triggers drawing patients through the system / restock is automated ensuring key equipment is always in place.
  3. Middle managers are in amongst the work for the majority of the time and execs do the rounds, engaging with staff and patients.
  4. There are no work-arounds or putting up with inconvenience as staff suggestions are actively encouraged and systematically incorporated into the improvement machine
  5. Different departments, even sectors train each other at the fringe of their interactions, all having an appreciation of one another’s flow and challenges
  6. Patients don’t wait for staff to set up for procedures, they enter the room and it’s a seamless flow of progress

virginia mason

These are just some of the aspects of ‘lean care’ at Virginia Mason, a small healthcare system with 5000 employees in Seattle. Back in 1990s it too was a mediocre outfit, losing money and quality was poor. They too humbly accepted the data and looked outside of themselves for solutions. The clinical leaders visited the heart of Toyota, observing the shop floor, culture and processes. A Toyota manager who visited the hospital to assist was shocked to see so may rooms with no apparent function. “Those are waiting rooms” they said. “Are you not ashamed” he asked?

Using the LEAN principles of Toyota, Virginia Mason produced startling results after just 2 years with no layoffs:

–          Nursing time with patients 30% > 90%

–          Productivity:  Free up 150 WTE – reinvestment in increasing capacity and capability

–          Inventory down $1.3m

–          $7m saved in cancelled building projects not required

–          Waiting times down 44%

–          Floor space down 41%


The translation to healthcare was the Virginia Mason Production System. So how does it work day to day, month to month?


–          Every Tuesday all projects are presented to the executive and clinical directors (on average 20 projects at one time)

–          Execs do regular floor rounds with staff and patients

–          Mandatory training with regular site visits for all execs (including to Toyota)

Staff training:

–          40 full time improvement experts support and guide the workforce ‘masters level’

–          400 clinicians trained to ‘experts’

–          All staff receive basic training

Process change

–          3P Production preparation process: 5 day event bringing dedicated and diverse stakeholders to design a new plant, unit or product

–          Rapid process Improvement Workshops:

4 weeks of system diagnostics by the lean team e.g. value stream mapping, spaghetti diagrams

5 days when about 5 key personnel offline who don vests and engage on the front line to apply multiple PDSAs. Report out at end of week and 4 weeks to translate the concepts.

–          Everyday lean idea system: Formal method to capture staff ideas

It may seem quite overwhelming to try and achieve what another health system has managed over now 10 years of development. However, we can all start thinking – what are the processes around me? Where is the waste and key areas to focus? How can I work with my colleagues to plant the seed of a leaner system?

There’s a storm coming – better get prepared

Happy new year everyone! It’s lovely blue skies here in Boston and the sun is shining.

The issue is that some people who are into predictive modelling say there’s a storm coming.

They call them ‘nor-easters’ which basically means a good lashing off Greenland. Ok, so it’s not the next superstorm Sandy but -17 oC, 45 mph gusts and 14″ of snow should bring out the rosy cheeks if nothing else. Last year there was a three day power cut and leaking through the windows in this place so it’s essential to get prepared:

  • Snow gear
  • 10 gallons water
  • Candles and torches
  • 3 days of tinned and dried food
  • Radio
  • Phone numbers of hotels
  • Spare clothes
  • Financial stuff together
  • Tarpaulin
  • Car ready
  • Getaway plan

Walmart have been here before and don’t leave a business opportunity to chance. Once they have wind of a significant storm (no pun intended)  the central nerve center triggers an series of automatic series of events ensuring just the right increase in water, torches and yes, beer stocks are at the optimum level within hours.

Baden Powell was into this kind of stuff. ‘Be prepared’ he told the young lads on Brownsea island whose pen knives never left their pockets. Discerning the weather from pattern recognition is nothing new. Jesus berated the religious leaders for being able to discern the weather patterns but not the signs of the times. Meteorologists of course take things a bit further using thousands of data points across whole continents in complex computer modelling. Enough data and you can confidently predict a number of variables.

Receiving APT from NOAA-18 weather satellite

Receiving APT from NOAA-18 weather satellite (Photo credit: csete


What’s this got to do with anything in healthcare you may ask?

Well in healthcare we generally use pattern recognition to predict, inform and ultimately intervene. This improves with experience but the risk of inexperience, my experience being different from yours plus our subjective interpretation can lead to a wide variety of care and potential variance in quality. In addition it can be difficult to weigh multiple factors within a short time frame whilst juggling multiple other issues. Being prepared is all about knowing what is coming your way
– on a system, team and individual patient level. Equipping health care professionals with the penknife/tools should provide the ability to take cases from what appear to be unexpected to the expected and with that timely intervention.

Insurers, meteorologists, finance markets, even travel companies are all using predictive modelling so what’s the issue with using the mathematics in medicine? Some people find that attaching numbers to patients can depersonalize the medicine. Patients are people, not a collection of data points. Its challenging for the meteorologists to predict down to the very local level too which is why ‘local knowledge’ of the patient will always be necessary.

It’s taken a while for predictive modelling to get its foot through the door but believe me it’s going to force it wide open as big data meets innovative patient specific analytics in real time. Actuaries are decent proof that there’s money to be made in risk and prediction and that’s because getting it right (or wrong) has such huge consequences.

The Framingham heart study kicked us off in 1948. Epidemiologists at Boston University used regular statistics to give us the Framingham score and we’ve set relative levels of risk for interventions in the name of prevention and essentially preparedness ever since(2). Risk prediction doesn’t need to be complex though. On a simple level a Medical Early Warning Score quite accurately predicts the deterioration of a patient and need for critical care (3) Wells score for DVT, CHADs2VASC for AF, LACE for readmission and so the list continues…

Prevention really is better than cure. However, getting ahead of the curve can prove difficult. Key factors to a successful predictive modelling include

  1. Data (and ideally lots of it)
  2. The ability to interrogate that data in a confidential manner
  3. A mathematical model that produces the goods in a
  4. Timely manner
  5. An actual intervention that makes a difference.

One missing link in the chain and it’s not really worth the while.
Specialist models are understandably more specific than generalist models. In addition generally the higher risk a patient is, the greater the positive predictive value of the tool. For example the Welsh Model for unplanned admissions the PPV for a patient with a score of 80 is about 80%.  That drops  to 45% for a score of less than 50/100 . Of course, such patients may be obvious to the clinician but what if a predictive model identifies 20% of those overseen by the clinician or simply prompts in amongst the noise and nonsense. Preventing a deterioration is going to be pretty crucial for those individuals.

About 75% of stalls at the IHI conference were health IT related, a significant number advertising risk modelling.  However, there’s a way to go before we get up to the level of the meteorologists in using maths to guide our practice – and guide being the prerogative. As clinicians however we should be prepared to engage with the data geeks developing models that buy us precious time to get ahead of the curve.

I’m pretty confident those weather geeks have got it right, it’s getting chilly out there and I can see a pattern forming.

References & Resources:

1.Choosing a predictive risk model: a guide for commissioners in England, Nuffield Trust – an easy read and great summary of what makes a good tool from a generic perspective

2. P.W., Wilson; D’Agostino, R.B., Levy, D., Belanger, A.M., Silbershatz, H., Kannel, W.B. (12 May 1998). “Prediction of coronary heart disease using risk factor categories.”. Circulation 97 (18): 1837–1847

3. Subbe CP, Kruger M, Rutherford P, Gemmel L: Validation of a modified Early Warning Score in medical admissions. QJM 2001, 94:521-526.

4. Welsh Model