How United Lincolnshire Hospitals used detailed data analyses and coding education to reduce its mortality ratio

The challenge

United Lincolnshire Hospitals NHS Trust (ULH) has worked with Dr Foster for a number of years. The trust was showing a consistently higher than expected hospital standardised mortality ratio (HSMR), and the Keogh review in 2013 prompted a radical change in how the organisation approached its mortality metrics and coding quality. Several initiatives and a close partnership with Dr Foster have seen a successful reduction in mortality.

Following a peer review in 2010, United Lincolnshire Hospitals recognised that it needed to reduce its mortality rates and formed a mortality review committee to drive this. In 2013, however, the trust was included in the Keogh Review and placed into special measures. This kickstarted a trust-wide effort to understand why high mortality was occurring and how it could tackle the issue. The trust joined forces with Dr Foster to identify areas of clinical practice where improvement was urgently needed. A Dr Foster consultant also began attending the mortality review committee to support the improvement process.

The solution

In 2015, the trust held its first patient safety conference, at which mortality data was presented by a Dr Foster consultant, to increase staff awareness of the issues. An in-depth review revealed significant disparities in coding across different sites and specialties, particularly in diagnosis groups and the language used to record notes. The trust, with the support of Dr Foster, set up clinical coding masterclasses to educate staff documentation and the impact it has on mortality ratios, income, and contracting.

Bernadine Gallen, quality and compliance lead at the trust, says: “Educating staff on documentation was highly important in our strategy to improve our HSMR. Until they attended the masterclasses, clinicians didn’t understand how the documentation was translated into codes, and the wider affect this has. We are still holding regular masterclasses to embed the importance of documentation within the trust.”

The trust has also expanded its coding team and introduced closer communication between coders and clinical staff. Bernadine explains: “The clinicians wanted to be able to meet with the coders to understand what the issues were, so now senior clinical coders will sit with clinicians on a regular basis and discuss the issues.”

Benefits

Bernadine believes that the trust owes the reduction in mortality to a combination of many different initiatives that the data instigated. As a result of a review into sepsis, for example, a sepsis task and finish group was created, closely followed by the introduction of a sepsis practitioner role. Other reviews led to improvement initiatives into palliative care and the use of care bundles.

The trust has seen an improvement in its mortality rates, with a gradual and steady reduction over the past few years. The most recent HMSR was the lowest the trust has ever seen. Bernadine says: “We are still not where we need to be, but it is definitely going in the right direction.”

The trust is still determined to push forward with improving its mortality. A monthly mortality review assurance group that was introduced in 2016 still runs, looking into any cases of concern and what can be learnt from these. More recently, the trust has rolled out mortality training for junior doctors, as well as publishing a quality safety improvement plan for mortality.

The quality of information being recorded is much higher, says Bernadine, and clinical staff are far more aware of its importance. The mortality review process is also far more robust than it was previously.

ULH will continue to work closely with Dr Foster on its mortality and data quality. Bernadine says: “We’re in such a better position now, because we’re able to get down into the details and see what needs changing. It was really important to identify what we should be doing differently. We are now in the process of developing divisional reports so that we can understand the data in even more detail.”