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Standardised mortality ratios as a user-friendly performance metric and trigger for quality improvement in a Flemish hospital network: multicentre retrospective study
  1. Wim Tambeur1,
  2. Pieter Stijnen2,
  3. Guy Vanden Boer2,
  4. Pieter Maertens2,
  5. Caroline Weltens3,
  6. Frank Rademakers1,
  7. Dirk De Ridder4,
  8. Kris Vanhaecht5,6,
  9. Luk Bruyneel5,6
  1. 1 University Hospitals Leuven, Leuven, Belgium
  2. 2 Management Information and Reporting, University Hospitals Leuven, Leuven, Belgium
  3. 3 Department of Radiation Oncology, University Hospitals Leuven, Leuven, Belgium
  4. 4 Department of Urology, University Hospitals Leuven, Leuven, Belgium
  5. 5 Leuven Insititute for Healthcare Policy, KU Leuven, Leuven, Belgium
  6. 6 Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
  1. Correspondence to Dr Wim Tambeur; wim.tambeur{at}


Objective To illustrate the development and use of standardised mortality rates (SMRs) as a trigger for quality improvement in a network of 27 hospitals.

Design This research was a retrospective observational study. The primary outcome was in-hospital mortality. SMRs were calculated for All Patient Refined—Diagnosis-Related Groups (APR-DRGs) that reflect 80% of the Flemish hospital network mortality. Hospital mortality was modelled using logistic regression. The metrics were communicated to the member hospitals using a custom-made R-Shiny web application showing results at the level of the hospital, patient groups and individual patients. Experiences with the metric and strategies for improvement were shared in chief medical officer meetings organised by the Flemish hospital network.

Setting 27 Belgian hospitals.

Participants 1 198 717 hospital admissions for registration years 2009–2016.

Results Patient gender, age, comorbidity as well as admission source and type were important predictors of mortality. Altogether the SMR models had a C-statistic of 88%, indicating good discriminatory capability. Seven out of ten APR-DRGs with the highest percentage of hospitals statistically significantly deviating from the benchmark involved malignancy. The custom-built web application and the trusted environment of the Flemish hospital network created an interoperable strategy to get to work with SMR findings. Use of the web application increased over time, with peaks before and after key discussion meetings within the Flemish hospital network. A concomitant reduction in crude mortality for the selected APR-DRGs from 6.7% in 2009 to 5.9% in 2016 was observed.

Conclusions This study reported on the phased approach for introducing SMR reporting to trigger quality improvement. Prerequisites for the successful use of quality metrics in hospital benchmarks are a collaborative approach based on trust among the participants and a reporting platform that allows stakeholders to interpret and analyse the results at multiple levels.

  • hospital mortality
  • collaborative improvement
  • statistical models
  • quality assurance
  • quality indicators

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Contributors WT, GVB, DDR, FR and CW designed the study. PS, LB and WT wrote the manuscript. PS, GVB and PM programmed the algorithms for fitting the models. PM and PS programmed the web application. DDR, KV, FR and CW reviewed the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Approval by the University Hospitals Leuven ethics committee was obtained (S61450).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.

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