This issue of Healthcare Papers examines the validity of the hospital standardized mortality ratio (HSMR) measurement tool and the implications of its use in Canadian hospitals. The lead article, titled "Do Hospital Standardized Mortality Ratios Measure Patient Safety? HSMRs in the Winnipeg Regional Health Authority," questions the tool's ease of use and whether or not it is consistent across different facilities. Authors Robert B. Penfold, Stafford Dean, Ward Flemons and Michael Moffatt note that the goal of the HSMR is to reduce "preventable" deaths - to motivate hospital administrators to examine in-hospital mortality rates and to reduce them. It discusses how, to date, a peer-reviewed study validating the HSMR as an indicator of the occurrence of adverse events does not exist.

In response, John McKinley, Debbie Gibson and Sten Ardal, in "Hospital Standardized Mortality Ratio: The Way Forward in Ontario," note the importance of reporting HSMRs to highlight the need to improve the quality of healthcare. They discuss how the HSMR debate has focused too much on the measure's shortcomings and not enough on what it brings to the healthcare field. They note that while the HSMR does not provide a specific measure of adverse events, its usefulness in tracking the impact of quality improvement initiatives over time cannot be negated. Finally, they point out the need to better educate the public to facilitate an accurate interpretation of the HSMR data.

Shauna Figler's article notes that "the rationale presented fails to address the real issue found within the Winnipeg Health Authority." She discusses how a hands-on approach to sorting through the data can reveal internal issues and create improvement in quality of care. Figler discusses that the HSMR is not meant to provide a comparison between different facilities; instead, it allows an individual facility to assess its own performance. She notes how a facility can identify areas needing performance improvement by tracking the HSMR over time.

This interesting debate continues in "CIHI's Hospital Standardized Mortality Ratio: Friend or Foe?" by Susan E. Brien and William A. Ghali. Their commentary echoes the concerns of Penfold et al. in the lead essay but also comments on the importance of the HSMR. Brien and Ghali point out that, despite its limitations, the HSMR stimulated the lead authors to probe factors that may have influenced mortality rates, which shows the merit of HSMR reporting and the types of insight and knowledge likely gained by using this or similar evaluations.

In "Hospital Standardized Mortality Ratio Is a Useful Burning Platform," Catherine Zahn, Michael Baker, John MacNaughton, Cara Flemming and Robert Bell discuss the HSMR as an important indicator of hospital performance that can be used immediately for improvements. The authors cite benefits of using the HSMR, including how it serves as a useful measure readily understood by healthcare professionals and by the public. These authors applaud the tool while agreeing that limitations exist. They note that while it is imperfect, the HSMR "serves as a compelling instrument to use in engaging staff in a culture change that will stimulate improvements in hospital safety."

Samuel B. Sheps supports the findings of Penfold et al. in "Measure for Measure? The Challenge of New Thinking about Patient Safety." Sheps agrees with points raised regarding the impact that a high number of deaths of terminally ill patients has on the HSMR measurement, as well as the variations between facility policies, specifically regarding discharge. Sheps discusses the need to rethink what it takes to achieve patient safety from a systems perspective.

In "Understanding and Using the Hospital Standardized Mortality Ratio in Canada: Challenges and Opportunities," Eugene Wen, Carolyn Sandoval, Jennifer Zelmer and Greg Webster maintain that the HSMR, despite its limitations, remains an important tool for hospitals to help focus their efforts for patient safety and quality improvement, monitor the provision of care over time and identify opportunities for improvement.

The debate over the HSMR is sure to continue - enjoy this issue's enlightening discussion as the authors examine this tool's uses and its pros and cons.

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