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Published on: November 4, 2025
Standardised mortality ratios as a user-friendly performance metric and trigger for quality improvement in a Flemish
Wim Tambeur1, Pieter Stijnen2, Guy Vanden Boer2
1University Hospitals Leuven, Leuven, Belgium wim.tambeur@uzleuven.be.
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.
Insights
Standardised mortality rates (SMRs) were developed and used to drive quality improvement across 27 hospitals. A web application and collaborative approach facilitated SMR interpretation, leading to reduced crude mortality rates.
Area of Science:
- Healthcare quality improvement
- Hospital performance metrics
- Public health surveillance
Background:
- Hospitals require effective tools to monitor and improve patient outcomes.
- Standardised mortality rates (SMRs) offer a benchmark for comparing hospital performance.
- Quality improvement initiatives necessitate reliable data and collaborative frameworks.
Purpose of the Study:
- To develop and implement standardised mortality rates (SMRs) as a quality improvement trigger within a hospital network.
- To assess the utility of a custom web application for disseminating and analyzing SMRs.
- To foster a collaborative environment for discussing and acting upon quality metrics.
Main Methods:
- A retrospective observational study was conducted across 27 Belgian hospitals.
- In-hospital mortality was analyzed using logistic regression for All Patient Refined-Diagnosis-Related Groups (APR-DRGs).
- A custom R-Shiny web application was developed for data visualization and communication.
Main Results:
- SMR models demonstrated good discriminatory capability (C-statistic of 88%).
- Malignancy-related APR-DRGs frequently showed significant deviations from benchmarks.
- Web application usage increased, correlating with collaborative meetings, and crude mortality decreased from 6.7% to 5.9%.
Conclusions:
- A phased approach to SMR reporting can effectively trigger quality improvement.
- A collaborative approach built on trust is essential for successful implementation of quality metrics.
- An accessible reporting platform enabling multi-level analysis is crucial for stakeholders.
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