Development of the new Summary Hospital-level Mortality Indicator

Independent statistical testing on the NHS Summary Hospital-level Mortality Indicator (SHMI) has taken place with the intention of the SHMI being published as an Official Statistic in October 2011.

The testing was carried out by the School Of Health and Related Research (ScHARR) at University of Sheffield, and the NHS Iinformation Centre is  building its recommendations and advice from the Hospital Standardised Mortality Ratios technical review group to finalise the SHMI specification.

It is intended that the new NHS SHMI, produced by the NHS IC, represents the consensus-led measure of hospital mortality, arising directly from the HSMR review recommended by both the National Quality Board and the first Francis Inquiry, for use across the NHS. We would encourage information providers to be clear when they are offering alternative measures.

It is recognised, though, that there will be both strengths and weaknesses in a summary-level measure of this kind. Its methodology still generates considerable debate, and therefore it is intended that the SHMI methodology will be subject to regular review and improvement.

Details of the new SHMI methodology will shortly be published by the NHS IC to ensure that all interested parties have the opportunity to see how this work is progressing.

We recognise that many independent information providers may continue to produce their own mortality measures and other indicators that help in the understanding of hospital mortality rates. While there is a risk that this might  lead to variations in the assessment of hospital mortality, we believe that the adoption of a single indicator, using open and agreed methodology, is in the interests of the NHS and the public.


In November 2008 Dr Foster published its Hospital Guide which included rankings of NHS acute trusts’ perceived relative performance with respect to patient safety. Included in the indicators used was the Hospital Standardised Mortality Indicator (HSMR). This publication sparked a debate about the validity of the approach and the National Quality Board agreed the use of such indicators, particularly the HSMR, should be reviewed to see if a wider consensus could be achieved.

A working group to review the HSMR was convened by Sir Bruce Keogh, NHS Medical Director, on behalf of the National Quality Board (NQB), and facilitated by the Department of Health and the NHS Information Centre. The group was chaired by Ian Dalton, Chief Executive of the North East Strategic Health Authority and involved key players with an interest in HSMRs, including:

  • Dr Foster Intelligence
  • Imperial College (Dr Foster Research Unit)
  • CHKS
  • National Patient Safety Agency
  • Kings Fund
  • Care Quality Commission
  • Monitor
  • Professional Association of Clinical Coders
  • University Hospitals Birmingham
  • North East Quality Observatory
  • Eastern Region Public Health Observatory

Subsequently, the original Francis Inquiry into events at Stafford Hospital also recommended that a working group should be established to investigate the methodology and use of Hospital Standardised Mortality Ratios (HSMRs). HSMRs had featured prominently in the Healthcare Commssion’s decision to mount a full investigation at Stafford Hospital.

The NQB was especially mindful of the potential for confusion arising from the use of different mortality indicators across the NHS, and therefore challenged  the working group to put forward proposals for a single summary-level mortality indicator that could be adopted uniformly across the NHS.

A report into this NQB review, published in November 2010, outlined a review of existing hospital-related mortality measures, and proposed a new measure, the NHS Summary Hospital-level Mortality Indicator (SHMI).
See report into NQB review.

A consensus statement from the group published alongside this report stated that it had agreed on a set of issues to be subjected to independent statistical testing.
See consensus statement.

It also stated that the measure should be seen as one of a number indicators that could provide important information about the quality of care that hospitals provide – but only if used as a high-level indicator corroborated by other evidence eg using other clinical and population-based indicators.

The report explained that the NHS Information Centre would ultimately produce and publish the new SHMI, and that this would happen simultaneously on their website and on NHS Choices.

More information

See National Quality Board advice and recommendations published up to August 2011.

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