Many of the arguments in the piece by Richard Lilford and Peter Pronovost and the editorial by Nick Black have been discussed in previous articles and correspondence and add nothing new to this debate.[1 2 3] We would recommend Section G and Appendix 9 from the Francis Inquiry report on Mid Staffordshire for an independent review of some of these issues.[4] We therefore do not propose to go over them again. However, we would like to make a few specific comments.
The Health Care Commission (HCC) investigation preceded the Department of Health Inquiry,[4] as did reports by George Alberti [5] and David Colin-Thomé.[6] These were not public inquiries that ‘take on a life of [their] own’, but serious investigations of what were found to be very poor standards of hospital care. Sometimes the inspections by the Care Quality Commission, the successor to the Healthcare Commission, find problems and at other times they do not: finding problems is not a “self fulfilling prophecy.”
Without the HCC investigation into Mid Staffordshire,[7] prompted by mortality alerts, it is likely that the unacceptable situation in the trust would have continued unchecked and unrecognised by the HCC’s self assessment system based mainly on process measures.[8] Under this system, two thirds of the standards of compliance were subsequently discovered to be wrong for hospitals considered “at risk” by the HCC.[9] Interestingly, Lilford himself found no sign of any problems with Mid Staffordshire in his own analysis of process indicators.[10] As an example for stroke care, he notes that Mid Staffordshire “scores consistently highly in the acute care (<_48 hours="hours" despite="despite" having="having" a="a" high="high" overall="overall" hsmr="hsmr" and="and" relatively="relatively" small="small" proportion="proportion" of="of" patients="patients" staying="staying" in="in" stroke="stroke" unit.="unit." while="while" these="these" facts="facts" themselves="themselves" do="do" not="not" necessarily="necessarily" validate="validate" the="the" use="use" mortality="mortality" statistics="statistics" monitoring="monitoring" quality="quality" care="care" they="they" suggest="suggest" need="need" for="for" more="more" than="than" simple="simple" process="process" indicators.="indicators." p="p"/>
We believe that an intelligent approach to monitoring quality of care is called for, making use of both outcome (including mortality indicators) and process information. We call for an end to the evangelical pursuit of one or the other, and in the light of cases like Mid Staffordshire, a renewed focus on systematic monitoring of whatever reliable and relevant information is available to ensure such tragedies do not occur again.
Brian Jarman, Emeritus Professor
Paul Aylin, Clinical Reader in Epidemiology and Public Health
Alex Bottle, Lecturer in Medical Statistics
Dr Foster Unit at Imperial, Dept. Primary Care and Public Health, School of Public Health Imperial College London, Jarvis House, 12 Smithfield St, London EC1A 9LA
[1] Aylin P, Bottle A, Jarman B. Monitoring mortality. BMJ 2009;338:b1745
[2] Mohammed MA, Deeks JJ, Girling A, Rudge G, Carmalt M, Stevens AJ, Lilford RJ. Evidence of methodological bias in hospital standardised mortality ratios: retrospective database study of English hospitals. BMJ
[3] Aylin P, Bottle A, Jarman B. Monitoring hospital mortality, A response to the University of Birmingham report on HSMRs. http://bit.ly/W6S7f
[5] Alberti G. Mid Staffordshire NHS Foundation Trust: a review of the procedures for emergency admissions and treatment, and progress against the recommendation of the March Healthcare Commission report. Department of Health, 2009
[6] Dr David Colin Thomé “Mid Staffordshire NHS Foundation Trust: A review of lessons learnt for commissioners and performance managers following the Healthcare Commission investigation.” 29 April 2009.
[9] Joint Commission International. “Quality Oversight in England – Findings, Observations, and recommendations for a New Model.” Submitted to Department of Health, 30 January 2008 www.policyexchange.org.uk/assets/JCI_report.pdf
[10] Mohammed M, Lilford R. Probing Variations in Hospital Standardised Mortality Ratios in the West Midlands.2008
Competing interests:
The authors are employed in the Dr Foster Unit at Imperial. The Dr Foster Unit at Imperial College London is funded by a grant from Dr Foster Intelligence (an independent health service research organisation)
Competing interests:
No competing interests
09 May 2010
Brian Jarman
Emeritus Professor
Imperial College, Jarvis House, London EC1A 9LA
Dr Foster Unit at Imperial, Department of Primary Care and Public Health, School of Puiblic Health
Rapid Response:
A plea for reason
Many of the arguments in the piece by Richard Lilford and Peter Pronovost and the editorial by Nick Black have been discussed in previous articles and correspondence and add nothing new to this debate.[1 2 3] We would recommend Section G and Appendix 9 from the Francis Inquiry report on Mid Staffordshire for an independent review of some of these issues.[4] We therefore do not propose to go over them again. However, we would like to make a few specific comments.
The Health Care Commission (HCC) investigation preceded the Department of Health Inquiry,[4] as did reports by George Alberti [5] and David Colin-Thomé.[6] These were not public inquiries that ‘take on a life of [their] own’, but serious investigations of what were found to be very poor standards of hospital care. Sometimes the inspections by the Care Quality Commission, the successor to the Healthcare Commission, find problems and at other times they do not: finding problems is not a “self fulfilling prophecy.”
Without the HCC investigation into Mid Staffordshire,[7] prompted by mortality alerts, it is likely that the unacceptable situation in the trust would have continued unchecked and unrecognised by the HCC’s self assessment system based mainly on process measures.[8] Under this system, two thirds of the standards of compliance were subsequently discovered to be wrong for hospitals considered “at risk” by the HCC.[9] Interestingly, Lilford himself found no sign of any problems with Mid Staffordshire in his own analysis of process indicators.[10] As an example for stroke care, he notes that Mid Staffordshire “scores consistently highly in the acute care (<_48 hours="hours" despite="despite" having="having" a="a" high="high" overall="overall" hsmr="hsmr" and="and" relatively="relatively" small="small" proportion="proportion" of="of" patients="patients" staying="staying" in="in" stroke="stroke" unit.="unit." while="while" these="these" facts="facts" themselves="themselves" do="do" not="not" necessarily="necessarily" validate="validate" the="the" use="use" mortality="mortality" statistics="statistics" monitoring="monitoring" quality="quality" care="care" they="they" suggest="suggest" need="need" for="for" more="more" than="than" simple="simple" process="process" indicators.="indicators." p="p"/>
We believe that an intelligent approach to monitoring quality of care is called for, making use of both outcome (including mortality indicators) and process information. We call for an end to the evangelical pursuit of one or the other, and in the light of cases like Mid Staffordshire, a renewed focus on systematic monitoring of whatever reliable and relevant information is available to ensure such tragedies do not occur again.
Brian Jarman, Emeritus Professor
Paul Aylin, Clinical Reader in Epidemiology and Public Health
Alex Bottle, Lecturer in Medical Statistics
Dr Foster Unit at Imperial, Dept. Primary Care and Public Health, School of Public Health Imperial College London, Jarvis House, 12 Smithfield St, London EC1A 9LA
Correspondence to b.jarman@imperial.ac.uk
References
[1] Aylin P, Bottle A, Jarman B. Monitoring mortality. BMJ 2009;338:b1745
[2] Mohammed MA, Deeks JJ, Girling A, Rudge G, Carmalt M, Stevens AJ, Lilford RJ. Evidence of methodological bias in hospital standardised mortality ratios: retrospective database study of English hospitals. BMJ
[3] Aylin P, Bottle A, Jarman B. Monitoring hospital mortality, A response to the University of Birmingham report on HSMRs. http://bit.ly/W6S7f
[4] Department of Health. Robert Francis Inquiry report into Mid-Staffordshire NHS Foundation Trust. 2010.http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...
[5] Alberti G. Mid Staffordshire NHS Foundation Trust: a review of the procedures for emergency admissions and treatment, and progress against the recommendation of the March Healthcare Commission report. Department of Health, 2009
[6] Dr David Colin Thomé “Mid Staffordshire NHS Foundation Trust: A review of lessons learnt for commissioners and performance managers following the Healthcare Commission investigation.” 29 April 2009.
[7] Healthcare Commission. Investigation into Mid Staffordshire NHS Foundation Trust. 2009. www.cqc.org.uk/_db/_documents/Investigation_into_Mid_Staffordshire_NHS_F...
[8] Health Committee – Sixth Report - Patient Safety, 18 June 2009 (para 235).
http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/151/...
[9] Joint Commission International. “Quality Oversight in England – Findings, Observations, and recommendations for a New Model.” Submitted to Department of Health, 30 January 2008
www.policyexchange.org.uk/assets/JCI_report.pdf
[10] Mohammed M, Lilford R. Probing Variations in Hospital Standardised Mortality Ratios in the West Midlands.2008
Competing interests:
The authors are employed in the Dr Foster Unit at Imperial. The Dr Foster Unit at Imperial College London is funded by a grant from Dr Foster Intelligence (an independent health service research organisation)
Competing interests: No competing interests