North Cumbria University
Hospitals NHS Trust
Data Pack
9th July, 2013
Overview
Sources of Information
On 6th February the Prime Minister asked Professor Sir Bruce
Keogh to review the quality of the care and treatment being
provided by those hospital trusts in England that have been
persistent outliers on mortality statistics. The 14 trusts which fall
within the scope of this review were selected on the basis that they
have been outliers for the last two consecutive years on either the
Summary Hospital Mortality Index or the Hospital Standardised
Mortality Ratio.
Document review
Trust information
submission for
review
These two measures are being used as a ‘smoke alarm’ for
identifying potential quality problems which warrant further
review. No judgement about the actual quality of care being
provided to patients is being made at this stage, or should be
reached by looking at these measures in isolation.
The review will follow a three stage process:
Stage 1 – Information gathering and analysis
Stage 2 – Rapid Responsive Review
Benchmarking
analysis
Information shared
by key national
bodies including
the CQC
Stage 3 – Risk summit
This data pack forms one of the sources within the information
gathering and analysis stage.
Information and data held across the NHS and other public bodies
has been gathered and analysed and will be used to develop the Key
Lines of Enquiry (KLOEs) for the individual reviews of each Trust.
This analysis has included examining data relating to clinical
quality and outcomes as well as patient and staff views and
feedback. A full list of evidence sources can be found in the
Appendix.
Given the breadth and depth of information reviewed, this pack is
intended to highlight only the exceptions noted within the evidence
reviewed in order to inform Key Lines of Enquiry.
Slide 2
North Cumbria University Hospitals NHS Trust
Context
A brief overview of the North Cumbria area and the North Cumbria University Hospitals NHS Trust. This section provides a profile of
the area, outlines performance of local healthcare providers and gives a brief introduction to the Trust.
Mortality
An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the
Trust which are outliers.
Patient Experience
A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient
experience surveys.
Safety and Workforce
A summary of the Trust’s safety record and workforce profile.
Clinical and Operational Effectiveness
A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This
section compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures
(PROMs).
Leadership and Governance
An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership,
current top risks to quality and outcomes from external reviews.
Slide 3
Context
Slide 4
Context
Overview:
Summary:
This section provides an introduction to the Trust, providing an
overview, health profile and an understanding of why the Trust
has been chosen for this review.
North Cumbria has a population of 340,000 with 14% of it
belonging to non-White ethnic minorities. Homelessness and
youth drinking is significantly more common than in the rest of
England.
Review Areas:
To provide an overview of the Trust, we have reviewed the
following areas:
•
Local area and market share;
•
Health profile;
•
Service overview; and
•
Initial mortality analysis.
Data Sources:
•
Trust’s Board of Directors meeting 30th Jan, 2013;
•
Department of Health: Transparency Website, Dec 12;
•
Healthcare Evaluation Data (HED);
•
NHS Choices;
•
Office of National Statistics, 2011 Census data;
•
Index of Multiple Deprivation, 2011;
•
© Google Maps;
•
Public Health Observatories – Area health profiles; and
•
Background to the review and role of the national
advisory group.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
North Cumbria’s health profile also outlines that there are a
number of aspects for which children’s and young people’s and
adult’s health is significantly lower than the national average. It
also shows that the life expectancy is lower than the national
average.
The Trust has two hospital sites, Cumberland Infirmary and
West Cumberland Hospital. The Trust has a total of 589 beds
and has an 81% market share of inpatient activity within a 20
mile radius of the Trust. However, as the size of the radius is
increased, the market share falls to 44% within 30 miles and
19% within 40 miles.
To give an informed view it was necessary to review the local
health economy. This included an indication of ambulance
response times and showed that the North West ambulance
services were slightly slower than the national average.
The Trust has been selected for this review as a result of its
HSMR for 2011 and 2012. For both years it was statistically
above the national average and is therefore within scope of this
review.
.
Slide 5
Trust Overview
North Cumbria University Hospitals NHS Trust serves a population of
340,000 people. The Trust was created in 2001 through the merger of
Carlisle Hospitals NHS Trust and West Cumbria Healthcare NHS Trust.
The Trust manages two hospitals: the Cumberland Infirmary in Carlisle
and the West Cumberland Hospital in Whitehaven. The Trust provides a
midwifery-led service at Penrith Community Hospital as well as
providing secondary health care services.
Trust Status
Not currently a Foundation Trust
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
589
87%
86%
General and
Acute
557
88%
88%
Maternity
32
73%
59%
Source: Department of Health: Transparency Website
(Jan12-Dec12)
Inpatient/Outpatient Activity
North Cumbria University Hospitals NHS Trust
Acute Hospitals
Inpatient Activity
Cumberland Infirmary
West Cumberland Hospital
Source: NHS Choices
Outpatient Activity
Elective
49,775 (57%)
Non-Elective
36,848 (43%)
Total
86,623
Total
294,099
Day Case Rate:
85%
Source: Healthcare Evaluation Data (HED)
Finance Information
2012-13 Budgeted Income
£228m
2012-13 Budgeted Expenditure
£212m
2012-13 Budgeted EBITDA
£17m
2012-13 Budgeted Net Surplus (deficit)
£1m
2013-14 Budgeted Income
£237m
2013-14 Budgeted Expenditure
£220m
2013-14 Budgeted EBITDA
£17m
2013-14 Budgeted Net surplus (deficit)
£1m
Source: North Cumbria University Hospitals NHS Trust , Statement of Comprehensive Income,
February 2013; April 2013.
A map of Cumberland Infirmary is included in the Appendix.
Departments and Services
Accident & Emergency, Breast Surgery, Cardiology, Children’s and
Adolescent Services, Dermatology, ENT, Endocrinology and
Metabolic Medicine, Gastro Intestinal And Liver Services,
Gynaecology, General Surgery, Geriatric Medicine, Maternity
Service, Minor Injuries Unit, Nephrology, Ophthalmology,
Orthopaedics, Oral and Maxillofacial Surgery, Pain Management,
Rehabilitation, Respiratory Medicine, Rheumatology, Urology,
Vascular Surgery.
Source: NHS Choices
Slide 6
Trust Overview continued...
General Medicine and
General Surgery are
the largest inpatient
specialties whilst
Trauma &
Orthopaedics and
Ophthalmology are the
largest specialties for
outpatients.
Outpatient Activity by Trust
300
1200
250
1000
200
North Cumbria
86,623
150
100
50
0
Number of Outpatient
Spells (Thousands)
North Cumbria is a
medium sized trust for
both measures of
activity, relative to the
rest of England. Of the
14 trusts selected for
this review, it is the
ninth largest by the
number of inpatient
spells.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of North
Cumbria against
national trusts in
terms of inpatient and
outpatient activity.
800
North Cumbria
294.099
600
400
200
0
Trusts
Trusts Covered by Review
Trusts
National Inpatient Activity Curve
Top 10 Inpatient Main Specialties as a
% of Total Inpatient Activity
Trusts Covered by Review
Bottom 10 Inpatient Main Specialties
and Spells
National Outpatient Activity Curve
Top 10 Outpatient Main Specialties as
a % of Total Outpatient Activity
General Medicine
23%
Neurology
30
Trauma & Orthopaedics
13%
General Surgery
14%
Paediatric Surgery
38
Ophthalmology
13%
Nephrology
11%
Rehabilitation
157
General Surgery
8%
Paediatrics
10%
Accident & Emergency
199
Dermatology
6%
Trauma & Orthopaedics
7%
Respiratory Medicine
305
Ear, Nose & Throat
5%
Ophthalmology
4%
Rheumatology
360
Gynaecology
5%
Clinical Oncology
4%
Geriatric Medicine
578
Cardiology
5%
Obstetrics
4%
Midwifery
823
Obstetrics
5%
Gynaecology
4%
Oral Surgery
992
Allied Health Professional Episode
4%
Urology
3%
Anaesthetics
1258
Rheumatology
4%
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
Slide 7
North Cumbria Area Overview
North Cumbria University Hospitals NHS Trust covers a relatively small
population. Cumbria, as a rural community, is not particularly deprived and
has very little ethnic diversity. However, youth drinking and related hospital
stays is far more common than in England as a whole, while homelessness is
also more widespread. Finally, over 65’s constitute a larger proportion of the
population in Cumbria than they do in the rest of the country.
North Cumbria Area Demographics
FACT BOX
Population
The Royal College of Surgeons recommend that the
"...catchment population size...for an acute general hospital
providing the full range of facilities, specialist staff and
expertise for both elective and emergency medical and
surgical care would be 450,000 - 500,000."
IMD
Cumbria is the 85th most deprived
unitary authority in England (of 149
unitary authorities)
Ethnic diversity
Only 1.4% of the population in Cumbria
belong to non-white ethnic minorities.
Of these, Chinese constitute the largest
ethnic group, with only 0.2% of the
population.
Rural or Urban
Cumbria is mainly a rural community
Youth drinking
Alcohol-related hospital stays for people
under 18 are much more common in
North Cumbria than elsewhere in
England. The problem is particularly
pronounced in Allerdale.
Homelessness
Statutory homelessness is significantly
more common in North Cumbria than in
England as a whole.
0-9
10-19
20-29
30-39
40-49
50-59
340,000
60-69
70-79
80+
20%
15%
10%
5%
0%
5%
10%
Male/CUM
Male/ENG
Female/CUM
Female/ENG
15%
Source: Office of National Statistics, Census 2011; IMD Source: Index of Multiple Deprivation, 2010
20%
Slide 8
North Cumbria Geographic Overview
The map on the right shows the location of North Cumbria
geographically. North Cumbria is a rural area located in the North
West. As shown by the map, the Trust is located in an area served by
a major A road.
Market share analysis indicates from which GP practices the
referral s that are being provided for by the Trust originate. High
mortality may affect public confidence in a Trust, resulting in a
reduced market share as patients may be referred to alternative
providers.
Market Share: Proportion of Elective Inpatient Referrals by Distance from Trust
North Cumbria
University
Hospitals Trust
North Cumbria
19%
18%
8%
1%
2%
University Hospitals
of Morecambe Bay
Cumberland
Infirmary
Northumbria
Healthcare
6%
21%
Other
1%
10%
44%
81%
11%
Proportion of
Referrals to
Competitor Trusts
West
Cumberland
Hospital
The Newcastle upon
Tyne Hospitals
16%
62%
Proportion of Elective
Inpatient Referrals to
Trust
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Source: © Google Maps
The wheel on the left shows the market share of the North
Cumbria University Hospitals NHS Trust. The wheel
shows that the Trust has an 81% market share within a 20
mile radius of the Trust. However, it is clear that the
market share falls as the radius is increased. Within 30
miles, the market share is 44% whereas within a 40 mile
radius, the market share is only 19%.
The wheel shows the competitors in the local area, these
were identified as The Newcastle-upon-Tyne Hospitals
NHS Foundation Trust, The University Hospitals Of
Morecambe Bay NHS Foundation Trust and
Northumbria Healthcare NHS Foundation Trust.
Slide 9
North Cumbria’s Health Profile
Health Profiles, depicted on this slide and the following, are designed
to help local government and health services identify problems in their
areas and decide how to tackle these issues. They provide a snapshot of
the overall health of the local population and highlight potential
differences against regional and national averages.
The graph shows the level of deprivation in Carlisle and Copeland, the
areas served by the Trust, compared nationally.
Deprivation by unitary authority area
Carlisle
Copeland
The tables below outline Carlisle and Copeland’s health profile
information in comparison with the rest of England.
1. North Cumbria’s
population has a
slightly higher
number of homeless
people than the
national average.
Additionally, GCSE
results are statistically
lower than national
average, especially in
Copeland.
1
2
2. Almost all
indicators in children’s
and young people’s
health are statistically
lower than the
national average.
Source: Public health observatories-area health profiles
Slide 10
North Cumbria’s Health Profile
3. Adults’ Health in 3
these areas is within
the expect range in
most cases.
4. Self harm levels
are statistically
higher than average
as are alcohol-related
harm hospital stays.
Finally, diabetes
diagnosis is
4
statistically higher
than the national
average in Copeland.
Source: Public health observatories-area health profiles
Slide 11
North Cumbria’s Health Profile
5. Life expectancy
indicators are
generally statistically
lower than the
national average.
5
Source: Public health observatories-area health profiles
Slide 12
Performance of Local Healthcare Providers
To give an informed view of the
Trust’s performance it is
important to consider the service
levels of non-acute local
providers. For example, slow
ambulance response times will
greatly increase the risk of
mortality.
The graphs on the right represent
some key performance indicators
for England’s Ambulance services.
The North West Ambulance
Service meets the 8min response
target, but fails to meet the 19min
response target.
Proportion of calls responded to within 8 minutes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Isle of Wight
NHS Trust
South
West
South Central South East
East of
London
North West Great Western North East
Yorkshire East Midlands
Western
Midlands
Ambulance
Coast
England
Ambulance Ambulance Ambulance Ambulance Ambulance Ambulance
Ambulance Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Service NHS Service NHS Service NHS
Service NHS Service NHS Foundation Service NHS Service NHS
Trust
Trust
Trust
Trust
Trust
Trust
Foundation
Trust
Trust
Foundation
Trust
Trust
Trust
Ambulance Trust
England
Proportion of calls responded to within 19 minutes
100%
98%
96%
94%
92%
90%
88%
86%
84%
Isle of Wight West Midlands
London
NHS Trust
Ambulance
Ambulance
Service NHS Service NHS
Trust
Trust
South East
Coast
Ambulance
Service NHS
Foundation
Trust
Yorkshire South Western Great Western North East
Ambulance
Ambulance
Ambulance
Ambulance
Service NHS Service NHS Service NHS Service NHS
Trust
Foundation
Trust
Trust
Trust
Ambulance Trusts
Source: Department of Health: Transparency Website Dec 12
North West South Central
East of
East Midlands
Ambulance
Ambulance
England
Ambulance
Service NHS Service NHS Ambulance Service NHS
Trust
Foundation Service NHS
Trust
Trust
Trust
England
Slide 13
Why was North Cumbria chosen for this review?
Based on the Summary Hospital level Mortality
Indicator (SHMI) and Hospital Standardised
Mortality Ratio (HSMR), 14 trusts were selected for
this review. The table includes information on
which trusts were selected. An explanation of each
of these indicators is provided in the Mortality
section. Where it does not include the SHMI for a
trust, it is because the trust was selected due to a
high HSMR as opposed to its SHMI. The SHMI for
all 14 trusts can be found in the following pages.
Initially, five hospital trusts were announced as
falling within the scope of this investigation based
on the fact that they had been outliers on SHMI for
the last two years (SHMI data has only been
published for the last two years).
Subsequent to these five hospital trusts being
announced, Professor Sir Bruce Keogh took the
decision that those hospital trusts that had also been
outliers for the last two consecutive years on HSMR
should also fall within the scope of his review. The
rationale for this was that it had been HSMR that
had provided the trigger for the Healthcare
Commission’s initial investigation into the quality of
care provided at Mid Staffordshire Hospitals NHS
Foundation Trust.
The HSMR shows North Cumbria has been above
the expected range for the last two years and was
therefore selected for this review.
Trust
SHMI 2011 SHMI 2012
HSMR
FY 11
HSMR
FY12
Within
Expected?
Basildon and Thurrock University Hospitals NHS
Foundation Trust
1
1
98
102
Within expected
Blackpool Teaching Hospitals NHS Foundation Trust
1
1
112
114
Above expected
Buckinghamshire Healthcare NHS Trust
112
110
Above expected
Burton Hospitals NHS Foundation Trust
112
112
Above expected
Colchester Hospital University NHS Foundation Trust
1
1
107
102
Within expected
East Lancashire Hospitals NHS Trust
1
1
108
103
Within expected
George Eliot Hospital NHS Trust
117
120
Above expected
Medway NHS Foundation Trust
115
112
Above expected
North Cumbria University Hospitals NHS Trust
118
118
Above expected
Northern Lincolnshire And Goole Hospitals NHS
Foundation Trust
116
118
Above expected
Sherwood Forest Hospitals NHS Foundation Trust
114
113
Above expected
101
102
Within expected
The Dudley Group Of Hospitals NHS Foundation Trust
116
111
Above expected
United Lincolnshire Hospitals NHS Trust
113
Tameside Hospital NHS Foundation Trust
1
1
111
Above expected
Banding 1 – ‘higher than expected’
Source: Background to the review & role of the national advisory group
Slide 14
Why was North Cumbria chosen for this review?
The way that levels of observed
deaths that are higher than
expected deaths can be understood
is by using HSMR and SHMI. Both
compare the number of observed
deaths to the number of expected
deaths. This is different to
avoidable deaths. An HSMR and
SHMI of 100 means that there is
exactly the same number of deaths
as expected. This is very unlikely so
there is a range within which the
variance between observed and
expected deaths is statistically
insignificant. On the Poisson
distribution, appearing above and
below the dotted red and green
lines (95% confidence intervals),
respectively, means that there is a
statistically significant variance
for the trust in question.
SHMI Time Series
SHMI Funnel Chart
North Cumbria
Selected
trusts Outside Range
North Cumbria
Selected
trusts
w/in
RangeRange
Selected
trusts
Outside
Selected trusts w/in Range
HSMR Time Series
HSMR Funnel Chart
North Cumbria
Selected trusts Outside Range
Selected trusts w/in Range
The funnel charts for 2010/11 and
2011/12, the period when the trusts
were selected for review, show
North Cumbria’s SHMI and HSMR
are statistically above the expected
range. This is supported by the
time series which shows the SHMI
and HMSR consistently higher
than expected.
Source: Healthcare Evaluation Data (HED); Apr 10 – Mar 12
Slide 15
Mortality
Slide 16
Mortality
Overview:
Summary:
This section focuses upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The Trust has an overall SHMI of 110 for the last 12 months.
The measures identified are being used as a ‘smoke alarm’ for
highlighting potential quality issues. No judgement about the actual
quality of care being provided to patients is being made at this stage,
nor should it be reached by looking at these measures in isolation.
Review areas
To undertake a detailed analysis of the trust’s mortality, it is
necessary to look at the following areas:
• Differences between the HSMR and SHMI;
• Elective and non-elective mortality;
• Specialty and Diagnostic groups; and
• Alerts and investigations.
Data sources
• Healthcare Evaluation Data (HED);
• Health & Social Care Information Centre – SHMI and contextual
indicators;
Deeper analysis of this demonstrates that non-elective
admissions are the primary contributing factor to a SHMI of
110, compared to 93 for elective admissions.
The Trust has an overall HSMR of 116, which is above the
expected level, however still within the expected range.
Similar to SHMI, non-elective admissions are seen to be
contributing primarily to the overall Trust HSMR of 117,
compared to 70 for elective admissions.
Since 2007, North Cumbria has had 4 diagnosis group alerts to
the CQC, of which 3 have been followed up. The most recent of
these are: Intermediate mouth or throat procedures (Apr-11);
Deficiency and other anaemia (Dec-11); Septicaemia except in
labour (Mar-12).
Septicaemia except in labour (Mar-12) is the one patient group
which has alerted more than once since 2007.
North Cumbria had three rates improving substantially below
the national average in the data to 2010-11 (published in Feb
2013): Stroke, Myocardial infarction and Non-elective surgery.
• Dr Foster – HSMR; and
• Care Quality Commission – alerts, correspondence and findings.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Slide 17
Mortality Overview
Mortality
The following overview provides a summary of the Trust’s key mortality areas:
Overall HSMR
Elective mortality (SHMI and HSMR)
Overall SHMI*
Non-elective mortality
Weekend / weekday mortality distinction
Palliative care coding issues
Emergency specialty groups much worse than expected
30-day mortality following specific surgery / admissions
Emergency specialty groups worse than expected
Mortality among patients with diabetes
Diagnosis group alerts to CQC
Diagnosis group alerts followed up by CQC
SHMI*
Outside expected range of the HSCIC for Mar 11 – Sep 12
Outside expected range
Outside expected range based on Poisson distribution for Dec 11 – Nov 12
Within expected range
Within expected range
*The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model,
which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14
trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the
purposes of this review.
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR,
Care Quality Commission – alerts, correspondence and findings
Slide 18
HSMR Definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a
hospital is higher or lower than you would expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it
cannot be said for certain that this reflects failings in the care provided by the hospital. However, it can be a warning sign that things are
going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of inhospital deaths (multiplied by 100) for 56 specific CCS groups in a specified patient group. The expected deaths are calculated from
logistical regression models taking into account and adjusting for a case-mix of: age band, sex, deprivation, interaction between age band
and co-morbidities, month of admission, admission method, source of admission, the presence of palliative care, number of previous
emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected
number in order to identify if variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to
calculate 95% and 99.9% confidence intervals and only when these have been crossed is performance classed as higher or lower than
expected.
Slide 19
SHMI Definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of
Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a
nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice.
How does SHMI work?
1.
2.
3.
4.
Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
The Indicator will utilise 5 factors to adjust mortality rates by
a.
The primary admitting diagnosis;
b.
The type of admission;
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities);
d.
Age; and
e.
Sex.
All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are
highlighted using a Random Effects funnel plot.
Slide 20
Some key differences between SHMI and HSMR
Indicator
HSMR
SHMI
Are all hospital deaths included?
No, around 80% of in hospital deaths are
included, which varies significantly
dependent upon the services provided by
each hospital
If a patient is transferred between hospitals
within 2 days the death is counted multiple
times
Yes all deaths are included
Does the use of the palliative care code
reduce the relative impact of a death on the
indicator?
Yes
No
Does the indicator consider where deaths
occur?
Only considers in-hospital deaths
Considers in-hospital deaths but also those
up to 30 days post discharge anywhere too.
Is this applied to all health care providers?
Yes
No, does not apply to specialist hospitals
When a patient dies how many times is this
counted?
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
Slide 21
Month-on–month time series
SHMI overview
The Trust’s SHMI for the 12 months from Dec 11 to Nov 12 is 110, this is
an outlier based on the 95% confidence interval of the Poisson
distribution.
The time series show SHMI has fallen since 2009/10, although a recent
increase is apparent since August, 2012.
SHMI funnel chart – 12 months
Year-on-year time series
North Cumbria
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 22
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for North
Cumbria.
As SHMI includes mortalities
that occur within the hospital
and outside of it for up to 30
days following discharge, it is
imperative to understand the
percentage of deaths which
happen inside the hospital
compared to outside. This
may contribute to differences
in HSMR and SHMI
outcomes.
The data shows that 70.5% of
SHMI deaths occur in
hospital, which is below the
national average of 73.3%.
Percentage of patient deaths in hospital
90%
80%
North Cumbria
70.5%
70%
60%
Trusts Covered by Review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 23
Treatment Specialties
SHMI 93
Clinical Oncology
Midwife Episode
Dermatology
Thoracic Medicine
Rehabilitation
Cardiology
Thoracic Medicine
Nephrology
Slide 24
Clinical Oncology
Gynaecology
Gynaecology
Obstetrics
Geriatric Medicine
Well babies
Neonatology
Cardiology
Paediatrics
Rehabilitation
Trauma and Orthopaedics
Ear, Nose and Throat (ENT)
Ophthalmology
Oral Surgery
Paediatric Surgery
Accident & Emergency (A&E)
Not a Treatment Function
Pain Management
Paediatric Urology
Paediatric T&O
Paediatric ENT
Paediatric Ophthalmology
Paediatric Maxilla-facial Surgery
Paediatric Gastroenterology
Paediatric Dermatology
Paediatric Respiratory Medicine
Paediatric Nephrology
General Medicine (298)
Gastroenterology
Clinical Haematology
Ear, Nose and Throat (ENT)
Ophthalmology
Oral Surgery
Paediatric Surgery
Pain Management
Paediatric Urology
Paediatric T&O
Paediatric ENT
Paediatric Ophthalmology
Paediatric Maxilla-facial Surgery
Paediatric Dermatology
Paediatric Nephrology
General Medicine
Gastroenterology
Endocrinology
Clinical Haematology
Nephrology
Paediatrics
Neonatology
Well Babies
Geriatric medicine
Treatment Specialties
SHMI 110
Lower than expected (below the
95th confidence interval)
Elective
SHMI 110
Trauma and Orthopaedics
Vascular Surgery
Colorectal Surgery
Breast Surgery
Urology
General Surgery
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Vascular Surgery
Colorectal Surgery
Breast Surgery
Urology
General Surgery
Non
Elective
The tree shows that
North Cumbria
University Hospitals
NHS Trust has a SHMI
of 110 which is higher
than expected. This is
due to greater than
expected deaths in nonelective admissions.
Mortality is significantly
higher than would be
expected within General
Medicine. This is a
potential area for
review.
Within expected range
Overall
Trust
This slide provides a
breakdown of SHMI into
elective and non-elective
admissions. The SHMI
score for non-elective
admissions has a
greater impact on the
overall indicator due to
a higher number of
expected deaths.
Higher than expected (above
the 95th confidence interval)
Mortality - SHMI Tree
SHMI sub-tree of specialties
Higher than expected (above
the 95th confidence interval)
The SHMI sub-tree
highlights the specialties
for non-elective
admissions with a
statistically higher SHMI
than expected and
highlights the diagnostic
groups with at least 4
more observed deaths
than expected. When
identifying areas to
review, it is important to
consider the number of
deaths as well as the
SHMI.
The sub-tree highlights
that General Medicine
has the highest number of
above expected deaths
for non-elective
admissions. Within this
treatment speciality
there are a number of
diagnostic groups with
above expected deaths,
including 39 in
pneumonia (excluding
that caused by
tuberculosis or sexually
transmitted disease) and
18 in congestive heart
failure; nonhypertensive.
Within expected range
Lower than expected (below the
95th confidence interval)
Treatment Specialties
Diagnostic Groups
Key
Diagnosis (100 ; 1 )
SHMI
observed deaths greater
than expected
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Slide 25
HSCIC SHMI overview
The Health and Social Care Information Centre (HSCIC) publish
the SHMI quarterly. This official statistic covers a rolling 12
month reporting period using a model based on a 3-year dataset
refreshed quarterly. The earliest publication was in October
2011, for the period from April 2010 to March 2011.
The HSCIC produce two sets of upper and lower limits. One set
uses 99.8% control limits from an exact Poisson distribution
based on the number of expected deaths. The other set uses a
Random effects model applying a 10% trim for over-dispersion,
based on the standardised Pearson residual for each provider
excluding the top and bottom 10% of scores. This latter set is
broader than the Poisson and is the one against which the
HSCIC report whether the SHMI is within, below or above the
expected range.
SHMI published by HSCIC, North Cum bria
120
115
110
112
114
113
112
111
111
110
105
100
95
90
85
80
Mar-11
Jun-11
Sep-11
Dec-11
Mar-12
Jun-12
Sep-12
Rolling 12 months ending
Lower limit
Upper limit
SHMI
The SHMI for North Cumbria was 110 in the year to Sept-12
(England baseline = 100) and on this basis has been within the
expected range for all but one of the time periods to date.
(although above the Poisson-based upper limit).
Source: Health & Social Care Information Centre – SHMI
Slide 26
HSMR overview
Month-on –month time series
The Trust’s HSMR for the 12 months from Jan 12 to Dec 12 is 116,
which means that it is statistically above the expected range and
therefore an outlier.
The time series show significant variations since 2007/08 with an
overall increase from 106 to 114. Variation is also shown month-onmonth over the past 12 months.
HSMR funnel chart–12 months
Year-on-year time series
North Cumbria
Selected trusts Outside Range
Selected trusts w/in Range
Source: Healthcare Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 27
HSMR Statistics
The table to the right shows
North Cumbria’s HSMR
broken down by admission
type.
North Cumbria has an
HSMR of 116 which is above
the expected range. From the
table, it can be seen that the
mortality rate for nonelective admissions is higher
and drives the Trust’s overall
HSMR up. This is mainly a
result of the weekend
admissions. These may,
therefore, be areas for
further review.
Key – colour by
alert level:
HSMR
Weekend
Week
All
Elective
n/a
77
74
Non-elective
122
115
117
Red – Higher than
expected (above the
95% confidence
interval)
All
122
114
116
Blue – Within
expected range
Source: Healthcare Evaluation Data (HED) – Jan 2012 – Dec 2012
Green – Lower than
expected (below the
95th confidence
interval)
Slide 28
HSMR CCS Diagnostic Group Overview
The darker colour boxes have the highest HSMR while the size
of the boxes represents the number of observed deaths that are
higher than the expected. The larger and darker boxes within
the tree plot will highlight areas for investigation by the Trust.
From this tree plot it is clear that the following areas could
potentially be reviewed:
•
Pneumonia (HSMR: 130; observed Deaths that are higher
than the expected Deaths: 53);
•
Congestive heart failure; non-hypertensive (150; 24);
•
Urinary tract infections (162; 20);
•
Acute cerebrovascular disease (117; 18);
•
Gastrointestinal haemorrhage (146; 11);
•
Chronic obstructive pulmonary disease and bronchiectasis
(121; 9);
•
Other lower respiratory disease (172; 7); and
•
Other fractures (187; 6)
Source: Healthcare Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 29
Mortality - HSMR Tree
Treatment Specialties
Lower than expected (below the
95th confidence interval)
Clinical Oncology
Gynaecology
Geriatric Medicine
Neonatology
Paediatrics
Nephrology
Thoracic Medicine
Cardiology
Rehabilitation
Clinical Haematology
Gastroenterology
General Medicine
Paediatric Nephrology
Paediatric ENT
Paediatric Surgery
Oral Surgery
Ophthalmology
Ear, Nose and Throat
T&O
Vascular Surgery
Colorectal Surgery
Breast Surgery
HSMR 116
Urology
Overall
Trust
Non Elective
Treatment Specialties
HSMR 117
Slide 30
Clinical Oncology
Gynaecology
Obstetrics
Geriatric Medicine
Well Babies
Neonatology
Paediatrics (5)
Nephrology
Thoracic Medicine
Cardiology
Rehabilitation
Clinical Haematology (1)
Gastroenterology
General Medicine (218)
Paediatric Nephrology
Paediatric ENT
Paediatric T&O
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Pain Management
Accident &Emergency (A&E)
Paediatric Surgery
Oral Surgery
Ophthalmology
ENT
T&O (10)
Vascular Surgery
Colorectal Surgery
Breast Surgery
Urology
Within non-elective
admissions, General
Medicine, T&O, and
Paediatrics have the
highest number of
observed Deaths that are
higher than the expected
deaths.
HSMR 70
General Surgery
The tree shows that the
HSMR for North
Cumbria is 116 which is
statistically higher than
expected. When breaking
this down by admission
type, it is clear that this
driven by non-elective
admissions.
Within expected range
Elective
General Surgery
This slide provides a
breakdown of HSMR into
elective and non-elective
admissions. The HSMR
for non-elective
admissions has a greater
impact on the overall
indicator due to a higher
number of expected
deaths.
Higher than expected (above
the 95th confidence interval)
HSMR sub-tree of specialties
Higher than expected (above
the 95th confidence interval)
Within expected range
The HSMR sub-tree indicates
the specialties with a
statistically higher HSMR
than expected and with
diagnostic groups with more
than 4 observed deaths that
are higher than the expected
Treatment Specialties
deaths. When identifying
areas to review, it is
important to consider the
number of observed Deaths
that are higher than the
expected deaths as well as the
HSMR
The sub-tree indicates that
General Medicine has the
highest number of observed
Deaths that are higher than
the expected deaths. These
are spread over numerous
diagnostic groups such as
pneumonia (49) and
congestive heart failure; nonhypertensive (23).
Lower than expected (below the
95th confidence interval)
Diagnostic Groups
Key
Diagnosis (100 ; 1 )
HSMR
Observed Deaths that are
higher than expected
Source: Healthcare Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 31
HSMR – Dr Foster
The HSMR time series for North Cumbria Trust from Dr Foster
shows a rise in the HSMR since 2008/09. This measures the
observed in-hospital death rate against an expected value
based on all the data for that year. An HSMR (or SHMI) of 100
means that there is exactly the same number of deaths as
expected. The HSMR is classified as above expected if the lower
95% confidence limit exceeds 100, which was the case in each
year except 2009/10.
North Cumbria’s latest SHMI published by the HSCIC, for Oct
11 to Sept 12, is similar to the Dr Foster HSMR for the same
period (and above expected using a 95% confidence interval).
Dr Foster have made the following adjustments to show the
impact of factors that can affect this comparison:
• Adjustment for palliative care: used the SHMI observed
deaths but changed expected deaths to take account of
palliative care.
• Adjustment for in-hospital deaths:
• Removed out-of-hospital deaths from the observed
figure, and
• Reduced expected deaths to only those in-hospital.
Any remaining variances are largely due to:
• The scope of deaths included (SHMI covers all deaths
whereas HSMR covers clinical areas accounting for an
average of around 80% of deaths), and
• The definition of spells, which includes those provider(s) the
death attributes to.
Time series of HSMR, North Cumbria
130
125
120
118
118
115
110
105
105
107
100
95
2008/09
2009/10
90
HSMR
125
I
2010/11
2011/12
95% Confidence interval
Com parison of m ortality m easures,
North Cum bria
120
115
113
110
112
110
105
104
100
95
90
SHMI
SHMI adjusted
for palliative
care
SHMI in
hospital
deaths only
HSMR
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 32
Coding
6
Elective
5
5
4
4
3
2
1
0
2008/09
2009/10
2010/11
2011/12 2012/13
Non Elective
3
2
1
0
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
When looking at the depth of
coding for the Trust, it is
clear that the Trust’s average
diagnosis coding depth has,
until recently, been lower
than the national average.
Since Q4 2011/12, the
average diagnosis coding
depth has risen to slightly
above national average for
both elective and non-elective
admissions.
Average Diagnosis Coding Depth
Q1
Admission type
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Diagnosis coding depth has
an impact on the expected
number of deaths. A higher
than average diagnosis
coding depth is more likely to
collect co-morbidity which
will influence the expected
mortality calculation.
2008/09
2009/10
2010/11
2011/12 2012/13
National Average Diagnosis Coding Depth
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
North Cumbria
North Cumbria
Source: Healthcare Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 33
Palliative care
Accurate coding of palliative care is important for
contextualising SHMI and HSMR. HSMR takes into
account that a patient is receiving palliative care, but
SHMI does not.
North Cumbria have below average palliative care coding
on both admissions and deaths, but not significantly so.
1.2
Percentage of admissions with palliative
care coding
1.0
0.8
0.6
0.4
0.2
-
Oct-11
Jan-12
Apr-12
North Cumbria
20
Jul-12
Oct-12
National
Jan-13
Apr-13
SHMI publication
Percentage of deaths with palliative care
coding
15
10
5
Oct-11
Jan-12
Apr-12
North Cumbria
Jul-12
National
Oct-12
Jan-13
Apr-13
SHMI publication
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 34
Care Quality Commission findings
Emergency specialty groups much worse than expected
Care Quality Commission (CQC) review mortality alerts for
each trust on an ongoing basis. These alerts, which
indicate observed deaths significantly above expected for
specialties or diagnoses, come from different sources based
on either HSMR or SHMI. Where these appear
unexplained, CQC correspond with the trust to agree any
appropriate action.
For North Cumbria, the common themes that have arisen
across the patient groups alerting since 2007 are Sepsis,
Elderly Care and Emergency care.
Sep 11 to Aug 12
1
Respiratory medicine
Emergency specialty groups worse than expected
Sep 11 to Aug 12
0
Diagnosis group alerts (2007 to date)
Alerts to CQC
4
Alerts followed up by CQC
3
Source: Care Quality Commission – alerts, correspondence and findings
The themes common to responses to the CQC are
• Patient monitoring, specifically recording of
observations and correct escalation of elevated Modified
Early Warning Scores (MEWS); and
• A need for improved compliance with the sepsis care
bundle.
The management of sepsis has been highlighted as an issue
in the Trust, but there has been delay in the implementation
of some of the agreed actions.
Recent diagnosis group alerts pursued by CQC
Intermediate mouth or throat procedures (Apr-11)
Deficiency and other anaemia (Dec-11)
Septicaemia except in labour (Mar-12)
Any related patient groups alerting more than once since 2007
Septicaemia except in labour (Mar-12)
Source: Care Quality Commission – alerts, correspondence and findings
Slide 35
SMRs for Diagnostic and Procedure groups – Dr Foster
The standardised mortality ratio (SMR) is used to calculate the
mortality rate for diagnosis and procedure groups. This is
available for the 56 diagnosis groups that are included in the
HSMR and the 96 procedure groups that are part of the Real
Time Monitoring system.
SMRs are not yet remodelled for the year but are projected,
rebased estimates. SMRs are classified as above expected if their
lower 95% confidence limit exceeds 100 (excluding those with
fewer than four more observed deaths than expected).
From Apr 12 to Mar 13, there were two diagnosis groups and one
procedure group with above expected SMRs in North Cumbria,
which may highlight potential areas for review. One diagnosis
group had above expected mortality for weekend admissions but
not for weekday ones: Senility and organic mental disorders, but
this did not have a high SMR overall.
Apr 2012 to Mar 2013
Diagnosis groups
Procedure groups
SMRs above expected
2
1
CUSUM alerts
2
8
Diagnosis groups with SMRs above expected
Pneumonia
Urinary tract infections
Procedure groups with SMRs above expected
Puncture of joint
SMR
122
168
SMR
357
Obs – Exp
deaths
40
26
Obs – Exp
deaths
4
CUSUM alerts show how many early warning flags arose within
the diagnosis and procedure groups during the year. These are
based on cumulative sum statistical process control charts with
99% thresholds that trigger alerts once breached. The same
groups may alert multiple times.
During the year, North Cumbria had a CUSUM alert for urinary
tract infections and one for puncture of joint. It also had another
diagnostic group alert and seven for procedure groups that did
not have a high SMR.
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 36
Mortality – other alerts
The Health and Social Care Information Centre publish 30day mortality rates following certain types of surgery or
admission to hospital. These are not casemix adjusted, but
the rates may be compared over time.
North Cumbria had three rates improving substantially
below the national average in the data to 2010-11
(published in Feb 2013).
Variable Life Adjusted Display (VLAD) charts are produced
by the HSCIC to visualise the cumulative number of
“statistical lives gained” over a period. A downward trend
indicates a run of more deaths than expected compared to
the national baseline and one with a sustained downward
trend and multiple dips to the lower control limit may
warrant further investigation.
30-day mortality following specific surgery / admissions
•
•
•
Stroke (average but improving 14% below national rate in 2010/11)
Myocardial infarction (improving - 7% below national rate in
2010/11),
Non-elective surgery (in the highest quintile (although not risk
adjusted) and improving - 7% below national rate in 2010/11)
VLAD charts with a negative SHMI trend
(year to Jun-12)
Pneumonia
No. dips to the
lower control limit
3
North Cumbria had such a VLAD chart for one diagnosis
group in the year to June 2012.
In addition, North Cumbria had worse than expected
mortality for Pneumonia on the Acute Trust Quality
Dashboard. It also had high above expected deaths for
Pneumonia (47 deaths, 23% more than expected) and
Congestive heart failure non-hypertensive (28 deaths, 49%
more than expected) in the HSCIC’s SHMI to June 2012.
Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.
Slide 37
Patient Experience
Slide 38
Patient Experience
Overview:
Summary:
The following section provides an insight into the Trust’s patient
experience.
Review Areas:
Of the 9 measures reviewed within Patient Experience and
Complaints there are three which are rated ‘red’: cancer
survey, patient voice comments, and complaints about clinical
aspects.
To undertake a detailed analysis of the Trust’s Patient Experience
it is necessary to review the following areas:
A particular area of concern from the cancer survey was,
“support of people with cancer”.
•
Patient Experience, and
•
Complaints.
Data Sources:
•
Patient Experience Survey;
•
Cancer Patient Experience Survey;
•
Peoples’ Voice Summary; and
•
Complaints data.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Of 61 individual comments from patients and public as part of
the Patient Voice, 21 were negative (34%).
The Trust is B-rated by the Ombudsman for satisfactory
remedies and low-risk of non-compliance but is above average
for ‘poor explanation’ and ‘unnecessary delay’.
Slide 39
Patient Experience
Patient Experience
This page shows the patient experience measures which are considered to be the most pertinent for this review. Further analysis,
where relevant, is detailed in the following pages.
Inpatient
PEAT : environment
Cancer survey
PEAT : food
PEAT : privacy and dignity
Friends and family test
Complaints about clinical aspects
Patient voice comments
Ombudsman’s rating
Outside expected range
Within expected range
Slide 40
Inpatient Experience Survey
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
North Cumbria scores above average on survey questions relating to coherent discharge processes and the appropriateness of
language used by nurses in front of patients, but below average on ward cleanliness.
Overall
Length of time spent on waiting list
Alteration of admission date by hospital
Length of time to be allocated a bed on a
ward
Overall
Delay of patient discharge
Consistency of staff communication
Information provided on post-discharge
danger signals
Overall
Staff communication on purpose of
medication provided
Patient involvement in decision-making
Staff communication on medication
side-effects
Overall
Clarity of doctors’ responses to
important questions
Language used by doctors in front of
patients
Clarity of nurses’ responses to
important questions
Language used by nurses in front of
patients
Overall
Hospital food
Patient noise levels at night
Degree of privacy provided
Staff noise levels at night
Level of respect shown by staff
Hospital/ward cleanliness
Overall staff effort to ease pain
Above expected range
Source: Patient Experience Survey 2012/13
Within expected range
Below expected range
Slide 41
Patient experience and patient voice
Overall patient experience score: Inpatients 2012
Inpatient Survey
95
The national inpatient survey 2012 measures a wide range
of aspects of patient experience. A composite ‘overall
measure’ is calculated for use in the Outcomes Framework.
This measure uses a pre-defined selection of 20 survey
questions to rate the Trust on aspects including access to
services, co-ordination of care, information & choice,
relationship with staff and the quality of the clinical
environment.
90
North Cumbria
85
80
75
70
65
60
•
England Average: 76.5
55
•
North Cumbria: 76.5 (Average)
50
England
average
Cancer Survey
•
Of 58 questions, four were in the ‘top 20%’ and 19 were in
the ‘bottom 20%’. A particular areas of concern was
“Support of people with cancer” (bottom 20% on all three
questions).
The quality risk profiles compiled by the Care Quality
Commission collate comments from individuals from
various sources. In the two years to 31 January 2013,
there were 61 comments on North Cumbria of which 21
were negative (34%). Key themes include poor
complaints procedures, poor reputation locally, low staff
morale linking to poor staff attitudes, lack of
professionalism amongst staff (particularly nurses),
poor arrangements of appointments.
National
results curve
Source: Patient Experience Survey, Patients Voice Summary, PROMs Dashboard, Litigation Authority
Reports
Complaints Handling
•
Data returns to the Health and Social Care Information Centre
showed 364 written complaints in 2011-12. The number of
complaints is not always a good indicator, because stronger
trusts encourage comments from patients. However, central
returns are categorised by subject matter against a list of 25
headings. For this Trust, the proportion of complaints relating to
clinical treatment was in line with the national average (51%
compared to a national average of 47%).
•
A separate report by the Ombudsman shows the trust as B-rated
for satisfactory remedies and low-risk of non-compliance. It was
ranked above average for ‘poor explanation’ and ‘unnecessary
delay.’
Patient Voice
•
Trusts in this
review
Slide 42
Safety and workforce
Slide 43
Safety and Workforce
Overview:
Summary:
The following section provides an insight into the Trust’s
workforce profile and safety record. This section outlines whether
the Trust is adequately staffed and is safely operated.
North Cumbria is ‘red rated’ in four of the safety indicators:
reporting of patient safety incidents, “harm” for all four Safety
Thermometer indicators, pressure ulcers, and clinical negligence
scheme payments.
Review Areas:
To undertake a detailed analysis of the Trust’s Safety and
Workforce it is necessary to review the following areas:
•
General Safety;
•
Staffing;
•
Staff Survey;
•
Litigation and Coroner; and
•
Analysis of patient safety incident reporting.
Data Sources:
•
Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;
•
Safety Thermometer, Apr 12 – Mar 13;
•
Litigation Authority Reports;
•
GMC Evidence to Review 2013;
•
National Staff Survey 2011, 2012;
•
2011/12 Organisational Readiness Self-Assessment (ORSA);
•
National Training Survey, 2012; and
•
NHS Hospital & Community Health Service (HCHS), monthly
workforce statistics.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Trust may be recognising and reporting patient safety
incidents less fully and completely than similar trusts. It
recorded 500 incidents reported as either moderate, severe or
death between April 2011 and March 2012. However, no ‘never
events’ have been reported as occurring at the Trust between
2009 and 2012. Throughout the last 12 months, North Cumbria
has been consistently above the national rate, as well that of the
14 trusts selected for this review, for new pressure ulcers, falling
below the national average just twice.
North Cumbria’s Clinical Negligence payments have exceeded
contributions to the ‘risk sharing scheme’ over the last five years,
with the bulk of the variance attributable to a high level of
payouts in 2011/12.
The Trust is ‘red rated’ in 17 of the workforce indicators.
Notably, its staff engagement is in the bottom 1/5th of all trusts
for both years considered. The Trust also has sickness absence
rates above the national mean and spends a greater percentage
of its total expenditure on agency staff than the regional median.
Slide 44
Safety
This page shows the safety measures which are considered to be the most pertinent for this review. Further analysis, where relevant,
is detailed in the following pages.
Litigation and
Coroner
Specific
Safety
Measures
General
Reporting of patient safety incidents
Number of harm incidents reported as ‘moderate, severe or death’ from April ’11 to March ’12
500
Number of ‘never events’ (2009-2012)
0
Medication error
x
Pressure ulcers
MRSA
“Harm” for all four Safety Thermometer Indicators
C diff
Clinical negligence scheme payments
Rule 43 coroner reports
Outcome 1 (R17) Respecting and involving people who use services
Outside expected range
Within expected range
Slide 45
Safety Analysis
The Trust has reported fewer patient safety incidents
than similar trusts. Organisations that report fewer
incidents may have a weaker and less effective safety
culture. North Cumbria has a rate of 5.2 for its patient
safety incident reporting per 100 admissions.
The rate of medication errors for North Cumbria is
2.53, which is lower than the mean rate of 7.17 for all
acute trusts.
Rate of reported patient safety incidents per 100 admissions (April –
September 2012)
North Cumbria
Median rate for medium acutes
5.2
6.7
Source: incidents occurring between 1 April 2012 to 30 September
2012 and reported to the National Reporting and Learning System
Rate of medication errors per 1,000 bed days (October 2011 – March
2012)
North Cumbria
Mean rate for all acute
2.53
7.17
Source: Acute Trust Quality Dashboard Winter 2012/13
Slide 46
Safety Incident Breakdown
Since 2009, no ‘never events’, classified as that because they are incidents that
are so serious they should never happen, have occurred at North Cumbria.
Never Events Breakdown (2009-2012)
Total
The patient safety incidents reported are broken down into five levels of harm
below, ranging from ‘no harm’ to ‘death’. 66% of incidents which have been
reported at Colchester have been classed as ‘no harm’, with 18% ‘low’, 15%
‘moderate’, 0.4% ‘severe’ and three occurrences classified as ‘death’.
0
Source: Freedom of information request, BBC http://www.bbc.co.uk/news/health-22466496
When broken down by category, the most regular occurrences of patient
incident at Colchester are in ‘patient accident’ and ‘treatment, procedure’.
Breakdown of patient
incidents by degree of harm
Breakdown of patient incidents by incident type
Clinical assessment
2500
46
Consent, communication,…
2152
Infrastructure
2000
91
Documentation
127
All others categories
1500
1000
590
500
69
158
Medication
185
Medical device / equipment
186
Implementation of care and…
270
Access, admission, transfer,…
485
395
Treatment, procedure
12
3
Severe
Death
0
No Harm
Low
Moderate
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
A definition of serious harm is given in the Appendix.
586
Patient accident
1129
0
200
400
600
800
1000
1200
Source: National Patient Safety Agency (NPSA) . Apr 11 – Mar 12
Slide 47
Pressure Ulcers
This slide outlines the total
number of pressure ulcers
and the number of new
pressure ulcers broken down
by category for the last 12
months. Due to the effects of
seasonality on hospital
acquired pressured ulcer
rates, the national rate has
been included which allows a
comparison that takes this in
to account. This provides a
comparison against the
national rate as well as the
14 trusts selected for the
review.
During the 12 months
shown, North Cumbria fell
below the national new
pressure ulcer rate twice.
Although this was in the 2
most recent months, this
may highlight an area for
review.
When looking at the total
pressure ulcer prevalence
rate, the Trust’s prevalence
rate has been lower than the
national average for the
majority of the 12 months
shown.
New pressure ulcers prevalence
Total pressure ulcers prevalence
40
20
18
16
14
12
10
8
6
4
2
-
3.5%
2.7%
2.6%
1.8%
1.6%
1.4%1.3%
1.3%
3.0%
30
2.5%
25
2.0%
1.2% 1.5%
1.0%
1.0%
20
0.5%
0.0%
Category 2
Category 3
35
Category 4
9.0%
8.1%
4.0%
3.5%
3.3%
2.9%
6.5%
6.7%
8.0%
6.6%
7.0%
5.5%
5.0%
5.7%
4.8%
6.0%
4.8%
5.0%
4.1%
3.5%
4.0%
2.9%
15
3.0%
10
2.0%
5
1.0%
-
0.0%
Rate
Category 2
Category 3
Category 4
Rate
New pressure ulcer analysis
Number of records submitted
Trust new pressure ulcers
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
60
102
499
455
436
478
515
476
479
509
515
504
2
3
9
12
6
6
8
6
13
18
5
6
Trust new pressure ulcer rate
3.3%
2.9%
1.8%
2.6%
1.4%
1.3%
1.6%
1.3%
2.7%
3.5%
1.0%
1.2%
Selected 14 trusts new pressure
ulcer rate
1.4%
1.5%
1.4%
1.5%
1.5%
0.9%
1.0%
1.1%
0.9%
1.1%
1.0%
1.2%
National new pressure ulcer rate
1.7%
1.7%
1.5%
1.5%
1.4%
1.3%
1.2%
1.2%
1.2%
1.3%
1.3%
1.3%
Total pressure ulcer prevalence percentage
Number of records submitted
Trust total pressure ulcers
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
60
102
499
455
436
478
515
476
479
509
515
504
4
3
33
37
24
24
18
23
31
29
21
24
Trust total pressure ulcer rate
6.7%
2.9%
6.6%
8.1%
5.5%
5.0%
3.5%
4.8%
6.5%
5.7%
4.1%
4.8%
Selected 14 trusts total pressure
ulcer rate
6.4%
6.2%
6.5%
7.0%
6.3%
5.5%
5.4%
5.9%
5.8%
6.0%
5.7%
6.2%
National total pressure ulcer rate
6.8%
6.7%
6.6%
6.1%
6.0%
5.5%
5.4%
5.3%
5.2%
5.4%
5.6%
5.3%
Source: Safety Thermometer Apr 12 to Mar 13
Slide 48
Litigation and Coroner
Clinical negligence scheme analysis
Clinical Negligence payments in the last 5 years have exceeded
contributions to the ‘risk sharing scheme’, with the bulk of the
difference being due to a high level of payouts in 2011/12.
Coroners’ Rule
Coroners’ rule 43 reports flagged one item (not high):
•
Clinical negligence payments
2009/10
2010/11
2011/12
Payouts (£000s)
2,387
2,088
10,748
Contributions
(£000s)
3,854
4,025
4,723
Variance between
payouts and
contributions (£000s)
1,467
1,937
-6,025
To consider a written protocol to deal with patients
suffering alcohol withdrawal, amend resuscitation
policies to require blood sample after cardiorespiratory arrest.
Source: Litigation Authority Reports
Slide 49
Workforce
Staff Surveys and
Deanery
Workforce Indicators
This page shows the workforce measures which are considered to be the most pertinent for this review. Further analysis, where
relevant, is detailed in the following pages.
WTE nurses per bed day
Sickness absence- Overall
Medical Staff to Consultant Ratio
2.07
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
2.65
Vacancies –medical
Sickness
absence
-Nursing
staff
Staff to Total Staff Ratio
Outcome
1 (R17)
Respecting
and involving eNon-clinical
who u
Vacancies - Non-medical
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days) 702
Staff leaving rates
Nurse Hours per Patient Bed Day
Consultant appraisal rates
Agency spend
Response Rate from National Staff
Survey 2012
Staff Engagement from NSS 2012
Training Doctors – “undermining”
indicator
se services
0.33
8.69
Staff joining rates
Overall Rate of Patient
Safety Concerns
x
Care of patients / service users is my organisation’s top priority
I would recommend my organisation as a place to work
If a friend or relative needed treatment: I would be happy
with the standard of care provided by this organisation
GMC monitoring under “response
to concerns process”
Outside expected range
Within expected range
Slide 50
General Medical Council (GMC) National Training Scheme Survey 2012
Acute Internal Medicine
The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results Given the volume
of data only specialties with red outliers are noted below (where those specialties also have green outliers, they are included).
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Anaesthetics
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
In addition to the outliers displayed, Gastroenterology has one green outlier for regional teaching; Obstetrics and Gynaecology has one
green outlier for workload; Ophthalmology has one green outlier for workload; Otolaryngology has four green outliers for overall
satisfaction, clinical supervision, workload, and induction; and Paediatrics has two green outliers for local teaching and regional teaching.
Green outlier
Within expected range
Red outlier
Slide 51
Workforce Analysis
North Cumbria has a patient spells per whole time equivalent rate of 29,
which is above average capacity in relation to the other trusts in this review
and nationally.
The data shows that the Trust’s agency staff costs, as a percentage of total
staff costs, are higher than the median within the region. The data also
illustrates that the Trust has a lower staff joining rate than the regional
median but also a lower leaving rate than the equivalent regional figure.
Number of FTEs (Dec 11-Nov 12 average)
Agency Staff (2011/12)
North Cumbria
Expenditure
Percentage of
Total Staff Costs
Median within
Region
£5.8m
4.2%
3.5%
(Sep 11 – Sep 12)
Staff Turnover
North Cumbria has a consultant appraisal rate of 69%.
North Cumbria
North West SHA
Median
Joining Rate
5.1%
6.8%
Leaving Rate
5.0%
5.7%
WTE nurses per bed day December 2012
North Cumbria
National Average
1.80
1.96
2,984
Source: Health and Social Care Information Centre (HSCIC)
Source: Acute Trust Quality Dashboard, Methods Insight
Consultant
appraisal rate
2011/12
Consultant
appraisal
rate
2011/12
Spells per WTE for Acute Trusts
50
45
Spells per WTE
40
35
30
100%
North
Cumbria:
29
Northern Lincolnshire
North
69%
and Cumbria
Goole: 71.5%
North Cumbria
80%
60%
25
20
40%
15
10
20%
5
0
0%
Trusts covered by review
All Trusts
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
Trusts covered by review
All other trusts
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Data based on the appraisal year from April 2011 to March 2012
North Cumbria
Slide 52
Workforce Analysis continued…
North Cumbria’s total sickness absence rate is
higher than the North West Strategic Health
Authority average and the national average. This
pattern of exceeding the national average is
replicated in the more granular medical, nursing,
and other staff categories.
The Trust has a nurse staff to qualified staff ratio
above the national average, while its medical staff
to consultant ratio is significantly below the
average for all English trusts. North Cumbria’s
registered nurse hours to patient day ratio is also
below the national mean.
The Trust’s consultant productivity rate is above
the national average.
North Cumbria’s medical staff vacancy rate is 11
times the national average.
3 month Vacancy Rates by
Staff Category
North
Cumbria
(March 2010)
National
Average
Medical Staff
15.8%
1.4%
Non-medial Staff
0.0%
0.4%
Source: The Health and Social Care Information Centre Non-Medical
Workforce Census (Sept 2009), Vacancies Survey March 2010
Workforce indicator calculations are listed in the Appendix.
Sickness Absence Rates
All Staff
(2011-2012)
North Cumbria
North West SHA
Average
National Average
4.58%
4.52%
4.12%
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
North Cumbria
National Average
Medical Staff
2.4%
1.3%
Nursing Staff
6.7%
4.8%
Other Staff
5.3%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
North Cumbria
National Average
Medical Staff to Consultant Ratio
2.07
2.59
Nurse Staff to Qualified Staff Ratio
2.65
2.50
Non-Clinical Staff to Total Staff
Ratio
0.33
0.34
Registered Nurse Hours to Patient
Day Ratio *
8.69
8.57
Source: Electronic Staff Record (ESR), Apr 13
*Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Consultant Productivity
(Spells/FTE)
Source: Electronic Staff Record (ESR), Apr 13
North Cumbria
National Average
702
492
Slide 53
Workforce Analysis continued…
National Staff Survey results
North Cumbria’s staff engagement is in
the bottom 1/5th of the distribution for
all trusts for both years. Staff opinion
on all the three organisational
questions are nearly half of National
average (and are in the bottom 1/5th )
The score fell since 2011 for the third
question.
North Cumbria
2011
Average for all
trusts
2011
North Cumbria
2012
Average for all
trusts
2012
Response rate
58%
50%
51%
50%
Overall staff engagement
3.28
3.62
3.30
3.69
Care of patients/service
users is my organisation’s
top priority
28%
59%
35%
63%
I would recommend my
organisation a place to work
20%
52%
26%
55%
If a friend or relative needed
treatment, I would be happy
with the standard of care
provided by this organisation
39%
62%
35%
60%
Source: National Staff Survey 2011, 2012
Slide 54
Deanery
The Trust has been subject to enhanced monitoring since 2011, as a result of an anonymous letter received by the Deanery. Concerns
in the letter included the support and supervision of Foundation doctors in Emergency Medicine posts. The Deanery immediately
visited the Trust, and F2s were removed from the out of hours rota in the Emergency Department. A number of patient safety
concerns were raised by doctors in training, which were shared with the Deanery.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Anaesthetics and Obstetrics and Gynaecology were the programmes with the most below outliers between 2010 and 2012. General
Surgery was the programme with the most above outliers during the same period. Doctors in training in Anaesthetics rated the
number of hours education poorly in both 2010 and 2011. Doctors in training in Obstetrics and Gynaecology rated their workload
heavy in both 2010 and 2012.
NTS 2012 Patient Safety Comments
11 doctors in training commented, representing 7.70% of respondents. This was higher than the national average of 4.7%. Their
concerns, which were raised in relation to specific training posts, and may apply to a single or multiple departments, related to:
•
Lack of medical and nursing staff, especially out of hours;
•
Lack of senior supervision; and
•
Poor handover.
Source: GMC evidence to Review 2013
Slide 55
Deanery Reports
Northern Deanery reported concerns about the North Cumbria University Hospitals NHS Trust in its 2012 report. Nine of the
concerns came from patient safety issues raised from the 2012 survey. An urgent visit was carried out to investigate the educational
experience of doctors in training as well as patient safety, resulting in the concern detailed below.
Monitored under the response to concerns process?
GMC Action
North Cumbria University Hospitals NHS Trust has been
monitored through the response to concerns process since
November 2011, when the Northern Deanery alerted the General
Medical Council to issues at West Cumberland Hospital.
GMC visited the Trust as part of the Quality Assurance of
Foundation Programme in 2009 and continues to monitor.
Deanery Action
For doctors undertaking training at North Cumbria, the Trust has a
score on the National Training Survey on undermining of 92.3
which is below the national average of 94. It is in the bottom 1/6 of
the distribution across all training organisations.
The Deanery visited the Trust immediately after the issues were
identified, and verified issues around the support and supervision
of Foundation Doctors in Medical and Emergency Medicine posts,
as well as more general issues around communication between
departments, with inappropriate levels of locum cover of
inconsistent quality.
F2 doctors were withdrawn from all Emergency Department out
of hours rotas.
Other actions included the immediate revision of rotas, induction,
and handover, which resulted in combining the acute and
emergency departments to ensure adequate cover and
supervision, and appropriate supervision of core and GP doctors
in training.
Further Deanery visits in February and June 2012 confirmed
implementation of the action plan, and a Deanery report dated
October 2012 indicated that issues had not re-appeared.
The Deanery is monitoring the status of training closely.
Source: GMC evidence to Review 2013
Undermining
Mean Score on 'Undermining'
105
100
North
Cumbria
95
90
85
80
Trusts covered by review
All other non specialist trusts
North Cumbria
Source: National Training Survey 2012
Slide 56
Clinical and operational
effectiveness
Slide 57
Clinical and Operational Effectiveness
Overview:
Summary:
The following section provides an insight in to the Trust’s clinical
and operational performance based on nationally recognised key
performance indicators.
As only 85% of women receive ante-natal steroids, North
Cumbria is below the national median. For diabetics, data shows
that North Cumbria performs below the national median on
several indicators. On bowel cancer North Cumbria is a clear
outlier compared to the national median with 15% mortality.
Review Areas:
To undertake a detailed analysis of the Trust’s clinical and
operational performance it is necessary to review the following
areas:
•
Clinical Effectiveness;
•
Operational Effectiveness; and
•
Patient Reported Outcome Measures (PROMs) for the review
areas.
Data Sources:
•
Clinical Audit Data Trust, CQC Data Submission;
•
Healthcare Evaluation Data (HED), Jan – Dec 2012;
•
Department of Health;
•
Cancer Waits Database, Q3, 2012-13; and
•
PROMs Dashboard.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
With 95.0% of A&E patients seen within 4 hours, which is at the
target level, North Cumbria has the sixth-lowest percentage of
the trusts in the review. However, the percentage of patients
seen within 4 hours is falling. Similarly, a recent downturn
means that only 81% of patients are seen within the 18 week
target time (RTT), which is lower than the target level and
places them lowest amongst the trusts being reviewed.
When looking at North Cumbria’s crude readmission rate, it can
be seen that the Trust has the seventh-lowest readmission rate of
the trusts in the review at 11.0%, which is above the national
median. Also, the standardised readmission rate shows that
North Cumbria is statistically lower than expected with the third
lowest standardised readmission rate of the trusts in this
review. Finally, North Cumbria has an average length of stay of
4.2 days, which is shorter than the national average.
The PROMs dashboard shows that North Cumbria is an average
performer and within control limits. The EQ-5D reported scores
for Groin Hernia show a fall from above average in 2009/10 to
below average in 2011/12, while remaining in the control zone.
A wide band for the limits suggests low volumes of activity for
Groin Hernia.
Slide 58
Clinical and Operational Effectiveness
PROMs
Dashboard
Neonatal -women receiving steroids
Coronary angioplasty
x
Heart failure
Adult Critical care
Peripheral vascular surgery
Lung cancer
Diabetes safety/ effectiveness
Carotid interventions
Bowel cancer
PROMS safety/ effectiveness
Acute MI
Hip fracture - mortality
Joints – revision ratio
Acute stroke
Severe trauma
RTT Waiting Times
Cancelled operationsx
Cancer Waits
PbR Audit
A&E Waits
Emergency readmissions
Hip Replacement EQ-5D
Hip Replacement OHS
Knee Replacement EQ-5D
Varicose Vein EQ-5D
u
Operational
Effectiveness
Clinical effectiveness
This page shows the Clinical and Operational Effectiveness measures which are considered to be the most pertinent for this review.
Further analysis, where relevant, is detailed in the following pages.
Knee Replacement OKS
Outcome 1 (R17) Respecting and involving people who use services
Groin Hernia EQ-5D
Outside expected range
Within expected range
Slide 59
Clinical Effectiveness: National Clinical Audits
The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the
clinical audit results we have considered as part of this review.
Clinical Audit
Diabetes
Elective Surgery
Safety Measure
Clinical Audit
Proportion with medication
error
Proportion experiencing
severe hypoglycaemic
episode
Neonatal intensive and special care
(NNAP)
Proportion of women receiving antenatal steroids
Diabetes
Proportion foot risk assessment
Adult Critical Care
Standardised hospital mortality ratio
Proportion of patient reported
post-operative complications
Coronary angioplasty
Acute Myocardial Infarction
Proportion receiving primary PCI
within 90 mins
Elective abdominal aortic aneurysm
post-op mortality
Proportion having surgery within 14
days of referral
Proportion discharged on beta-blocker
Acute Stroke
Proportion compliant with 12 indicators
Heart Failure
Proportion referred for cardiology
follow up
90 day post-op mortality
Peripheral vascular surgery
Adult Critical Care (ICNARC
CMPD)
Effectiveness Measures
Proportion of night-time
discharges
Carotid interventions
Bowel cancer
Hip Fracture
Elective surgery (PROMS)
Severe Trauma
Hip, knee and ankle
Lung Cancer
Source: Clinical Audit Data Trust, CQC Data Submission.
30 day mortality
Proportion operations within 36 hrs
Mean adjusted post-operative score
Proportion surviving to hospital
discharge
Standardised revision ratio
Proportion small cell patients receiving
chemotherapy
Slide 60
Clinical Effectiveness: Clinical Audits
In the Neonatal Intensive and Special Care National
Audit, a key measure of effectiveness is the proportion
of women receiving ante-natal steroids.
National Neonatal Audit Programme
Proportion of women receiving ante-natal steroids
(level 1)
On this measure, North Cumbria is at the lower end of
the distribution and some way short of the 85%
national standard.
North
Cumbria
North Cumbria
Source: Clinical Audit Data Trust, CQC Data Submission
Slide 61
Clinical Effectiveness: Clinical Audit – Diabetes Care – Cumberland Infirmary
On results from the National Adult Diabetes Audit, North
Cumbria is an outlier at two separate treatment sites. Results
from this slide relate to Cumberland Infirmary.
Received a foot risk assessment during the hospital
stay 2012
Each graph ranks the percentage of patients with diabetes at
each hospital that reported that they:
- received a foot risk assessment during their stay;
- experienced a severe hypoglycaemic episode (<3mmol/L);
- experienced at least one medication error.
The red line in each graph shows where this specific hospital
ranks nationally.
100%
80%
60%
40%
20%
0%
Medication Error 2012
Severe Hypoglycaemic Episode 2012
70%
60%
50%
40%
30%
20%
10%
0%
-10%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: Clinical Audit Data Trust, CQC Data Submission, http://www.hscic.gov.uk/catalogue/PUB10506/nati-diab-inp-audi-12-comp.xlsx
Note: Caution should be borne when looking at the data for some sites in these summaries as they may be based on a small sample of inpatients with diabetes. This means that a small variation
would have a substantial impact on the indicators presented.
Slide 62
Clinical Effectiveness: Clinical Audit – Diabetes Care – West Cumberland Hospital
Received a foot risk assessment during the hospital
stay 2012
On results from the National Adult Diabetes Audit, North
Cumbria is an outlier at two separate treatment sites. Results
from this slide relate to West Cumberland Hospital.
Each graph ranks the percentage of patients with diabetes at
each hospital that reported that they:
- received a foot risk assessment during their stay;
- experienced a severe hypoglycaemic episode (<3mmol/L);
- experienced at least one medication error.
The red line in each graph shows where this specific hospital
ranks nationally.
100%
80%
60%
40%
20%
0%
Medication Error 2012
Severe Hypoglycaemic Episode 2012
70%
60%
50%
40%
30%
20%
10%
0%
-10%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Source: Clinical Audit Data Trust, CQC Data Submission, http://www.hscic.gov.uk/catalogue/PUB10506/nati-diab-inp-audi-12-comp.xlsx
Note: Caution should be borne when looking at the data for some sites in these summaries as they may be based on a small sample of inpatients with diabetes. This means that a small variation
would have a substantial impact on the indicators presented.
Slide 63
Clinical Effectiveness: Clinical Audit – Cancer
90 day post-operative mortality for bowel cancer
The key measure on bowel cancer is
post-operative mortality (at 90 days).
North Cumbria (108 patients, 15.0% mortality)
North Cumbria (108 patients, 15.0% mortality)
On this measure, North Cumbria is a
clear outlier.
The review noted also that data from
the Lung Cancer Audit suggests that
the proportion of small cell patients
receiving chemotherapy was zero –
this appears to be missing data.
Source: Clinical Audit Data Trust, CQC Data Submission
Slide 64
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
North Cumbria sees 95.0%
of A&E patients within 4
hours which is at the
target level. North
Cumbria are the sixth
lowest of the selected
trusts in the review.
A&E Percentage of Patients Seen
within 4 Hours
North
Cumbria
95.00%
100%
North Cumbria 4 Hour A&E Waits
Attendances
(Thousands)
A&E wait times and RTT
times may indicate the
effectiveness with which is
demand is managed.
95%
90%
85%
80%
North Cumbria’s referral
to treatment time is at
81%, lower than the 90%
target level. In addition to
this, their percentage
achieved is the lowest
amongst the trusts being
reviewed. From the time
series, it is apparent that
North Cumbria have been
performing below the
target 95% level for the
last four months.
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
75%
70%
The time series shows that
the percentage of patients
seen within 4 hours is
falling, which may
highlight an area for
review.
8
7
6
5
4
3
2
1
0
Patients Seen
Trusts Covered by Review
All Trusts
A&E Target 95%
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
North Cumbria Referral to Treatment
Performance
Referral to Treatment (Admitted)
North
Cumbria
81.4%
95%
Patients Not Seen
Seen within 4 hours (%)
95%
90%
85%
85%
80%
75%
75%
65%
Trusts Covered by Review
Source: Department of Health. Feb 13
All Trusts
RTT Target 90%
Referral to Treatment Rate
RTT Target 90%
Source: Department of Health. Apr 12 – Jan 13
Slide 65
Operational Effectiveness – Emergency Readmissions and Length of Stay
The standardised
readmission rate, most
importantly, accounts for
the Trust’s case mix and
shows that North Cumbria
is statistically lower than
expected with the third
lowest standardised
readmission rate of the 14
selected trusts.
North Cumbria has an
average length of stay of 4.2
days, which is shorter the
national average of 5.2.
Standardised 30-day Readmission Rate
25%
Crude Readmission Rate
North Cumbria’s crude
readmission rate is 11.0%,
which sees the Trust
operating above the
national median.
Crude Readmission Rate by Trust
20%
North
Cumbria
11.0%
15%
10%
5%
0%
Trusts Covered by Review
North Cumbria
Selected trusts Outside
Selected trusts w/in Range
All Trusts
Average Length of Stay by Trust
10
Spell Duration (Days)
Readmission rates may
indicate the
appropriateness of
treatment offered, whilst
average length of stay
suggests efficiency of the
treatment.
8
6
North Cumbria
4.2
4
2
0
Trusts Covered by Review
All Trusts
Source: Healthcare Evaluation Data (HED). Jan 12 – Dec 12
Slide 66
PROMs Dashboard
The PROMs dashboard shows that North Cumbria is an average performer
on PROMs, and within control limits.
EQ-5D reported scores for Groin Hernia showed a fall from above average
2009/10 to below average 2011/12 while remaining in the control zone. A
wide band for the limits suggests low volumes of activity for Groin Hernia.
Groin
Hernia
EQ-5D
Groin
Hernia
EQ-5D
0.3
England
Average
0.25
North
Cumbria
0.2
0.15
Upper
Control
Limit
0.1
0.05
Lower
Control
Limit
2
20
11
/1
1
20
10
/1
20
09
/1
0
0
Source: Patient Experience Survey, Patient Voice Summary, PROMs
Dashboard, Litigation Authority Reports
Slide 67
Leadership and
governance
Slide 68
Leadership and governance
Overview:
Summary:
This section provides an indication of the Trust’s governance
procedures.
The Chairman, CEO and Director of Finance roles are interim,
whilst the Director of Nursing position is an ‘acting’ role. The
interim CEO joined the Trust in September, 2012 from
Northumbria Healthcare NHS Foundation Trust (where she was
Chief Operating Officer), which is currently the preferred bidder
to acquire the Trust.
Review Areas:
To provide this indication of the Trust’s leadership and
governance procedures we have reviewed the following areas:
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The governance structures within the Trust are four fold: the
Governance and Quality Committee (GQC) chaired by Professor
Vicki Bruce (NED), having four divisions (Surgery, Medicine,
Paediatrics and Cancer Services), led by a clinical Business Unit
Director and Deputy Director, the Mortality Review Group
(MRG) which oversees the implementation of the Trust’s
Mortality & Reducing Harm Framework and the Clinical Policy
Group led by the Medical Director.
The review has also sought to identify the risks to quality and
these have been identified in staffing, finance, clinical
leadership, education & training, clinical information, staff
experience, patient flow and the mode l of services.
There have also been a large number of external reviews
conducted at the Trust in the last two years, including those by
the CQC, TDA, IST and AQuA.
Slide 69
Leadership and governance
Leadership and
governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in
the following pages.
Monitor governance risk rating
n/a
Monitor finance rating
n/a
Governance risk rating
Red - Likely or actual significant breach of terms of authorisation
Amber-red - Material concerns surrounding terms of authorisation
Amber-green - Limited concerns surrounding terms of authorisation
Green - No material concerns
CQC Outcomes
CQC Concerns
Red – Major concern
Amber – Minor or Moderate concern
Green – No concerns
Financial risk rating
rated 1-5, where 1 represents the highest risk and 5 the lowest
Slide 70
Leadership and governance
Trust Board
The executive team structure is set out in Appendix A. The Chairman, CEO and Director of Finance roles are interim, whilst the Director of
Nursing position is an ‘acting’ role.
The interim CEO joined the Trust in Sep 2012 from Northumbria Healthcare NHS Foundation Trust (where she was Chief Operating
Officer), which is currently preferred bidder to acquire the Trust.
Strategy
The Trust’s strategy is to provide outstanding integrated healthcare to improve the health and wellbeing of the people in its communities. A
summary of the Trust’s strategy is set out in Appendix B. We have reviewed a risk register which links each risk to a strategic aim,
however, these aims do not tie through to the strategy in Appendix B.
Governance and clinical structures
The governance structures within the Trust include:
•
The Governance and Quality Committee (GQC) which is the Board subcommittee dedicated to quality. This committee is chaired by
Professor Vicki Bruce (NED).
•
The Trust has three divisions (Surgery, Medicine, Paediatrics and Cancer Services), led by a clinical business unit director and deputy
director.
•
The Mortality Review Group (MRG) oversee the implementation of the Trust’s Mortality & Reducing Harm Framework, which
comprises four improvement strands (clinical care, leadership & reporting culture, improved use of clinical information, and improved
identification & care for dying patients). Each specialty conducts mortality and morbidity reviews on a regular basis.
•
The Trust also has a Clinical Policy Group led by the Medical Director.
External reviews
There have been a large number of external reviews conducted at the Trust in the last two years, including those by the CQC, TDA, IST and
AQuA. The key findings are set out overleaf.
A diagram of executive director structure can be found in the Appendix.
Slide 71
Top Risks to Quality
Trust identified risks
Trust actions and mitigation
Staffing: The Trust does not have sufficient
permanent staff, and is over reliant on locums, in
particular at consultant and middle grades.
Since September 2012 a safety quality priority commitment was made to increase
the number of permanent consultants to 95% within 2 years. The emphasis is on
the recruitment of consultants to more innovative models of care and this has
resulted in one consultant recruited a month since September 2012.
Finance: The Trust’s financial challenges have
limited its ability to make investments to improve
patient care.
A better contract position has been negotiated this year with the commissioners
and a CIP has been agreed by the Board in March for the first time and is being
delivered but this still leaves the Trust with a substantial gap hence the need for
the acquisition to take place this year to close the recurring deficit within 2 years
of the acquisition.
Clinical leadership: Issues with staffing at consultant
level means there is limited clinical leadership in
many specialties (e.g. the Emergency Care post has
been vacant for 2-3 years).
A key characteristic of Northumbria's success is the Clinical Business Unit
Director Model . This was established from December 2012 and Clinical Directors
are now all in post from April 2013. This gives the Trust a better foundation for
moving forward.
Education & training: Financial issues and a lack of
permanent senior staff has resulted in a poor
provision of training and supervision for junior
doctors.
An Interim Director for Education and Training was seconded from Northumbria in
December 2012 to start to address the serious concerns. A meeting with the
Deanery is taking place on the 8th and 9th May to demonstrate the Trust’s
commitment and its plan in order to secure headroom to retain the junior doctors.
Slide 72
Top Risks to Quality
Trust identified risks
Trust’s response (actions and mitigation)
Clinical information: The electronic record system
was poorly implemented; records are not completed
adequately and documentation is not standardised.
This features strongly in the Trust’s action plan to reduce mortality and reduce
harm and is being led by the Director of Clinical Transformation who is on
secondment from Northumbria.
Staff experience: Staff morale is low as there has not
been a clear message that there is financial
commitment to long term quality and safety of care.
Since September a key message by the Interim Chief Executive and the Director
of Clinical Transformation is that the Institute of Healthcare Improvement Model
for Quality places an equal emphasis on safety effectiveness, patient experience
and money. All of these are key to the Trust’s success and they are mindful that
one should not dominate the other. Decisions are taken based on this equal
criteria.
Patient flow: Patient flow is slow, and sometimes
blocked, impacted A&E, RTT and delayed transfers
of care.
There is a recognition that traditional models of care were evident in emergency
care flows. This followed a visit by the Intensive Support Team in the winter of
11/12. Whilst some improvements were made at this time, since November 2012
there has been more change and at a rapid pace to deliver the successful model
of emergency care and standards.
Model of services: The Trust has two sites, both
small, not coordinated and in competition with each
other.
Care Closer to Home in 2009 recognised the need for the two hospitals to act as
one hospital in the sense of consistent pathways and one team. For a range of
reasons this was not implemented. Since December 2012 the Interim Chief
Executive has emphasised that implementation should be the Trust’s key
concern to derive better outcomes and better patient experience. Clinical teams
have worked on this and are delivering changes to services from May 2013 in
both emergency care, trauma and orthopaedic and vascular surgery.
Slide 73
Top Risks to Quality
Additional identified risks
Source and further information
Never events: The Trust has recorded four never
events in 2012/13, three of which occurred in January
and February 2013.
These never events related to two retained items, one incorrect procedure and
one incident which is currently under investigation by the police.
This information is reflected in the Board’s Serious Complaints, Incidents and
Claims Report, presented to the private Board in March 2013.
Incidents: The number of incidents reported year to
date in 2012/13 has increased by 76% on 2010/11
rates. However, the number of incidents with a major
or catastrophic impact has increased by 333% in the
same period.
There were 2581 incidents in 2010/11, increasing to 4535 in 2012/13 (to
February). However, the number of incidents with a major or catastrophic impact
has increased from 9 in 2010/11 to 39 in 2012/13 (to February).
The Trust has reported 29 SUIs in 2012/13 to February, compared to 8 in
2011/13. Of these, 16 relating to fractured neck of femur from patient falls. This is
listed as a priority for improvement in Board papers but no further details are
provided.
This information is reflected in the Board’s Safety, Quality and Patient Experience
Report, presented to the public Board in March 2013.
Infection control: The Trust has breached both its C
difficile and its MRSA target for 2012/13.
The Trust has had 50 (listed as 51 in some Board papers) cases of C difficile in
2012/13 to February 2013 against a full year target of 40. Severn deaths at the
Trust included C difficile on part one or part two of the death certificate in
2012/13.
The Trust has had one case of MRSA in 2012/13 to March 2013 against a full year
target of nil.
Beech Ward A: Beech Ward A has been raised in the
Board papers as an area of concern, being described
as “dirty, dark and cluttered”.
This issue was identified in a Board walk-around, and reported to the Board in
both the private and public sessions of the February Board.
Slide 74
Leadership and governance – other areas for further review
External reviews
Care quality commission
Inspections for West Cumberland Hospital (August 2012) and Cumberland Infirmary emergency department (January 2013) found the
Trust compliant in all areas. Previously, a number of concerns had been raised by the CQC about the Cumberland Infirmary emergency
department. The Trust had established an action plan to address these.
Trust development Authority (C difficile)
Review in April 2013 identified a number of issues, including:
•
•
•
•
•
A lack of medical involvement at the Infection Prevention & Control (IP&C) Committee;
Environmental issues (dusty and cluttered). Actions from a previous audit in this area had not been implemented;
Poor staff compliance with IP&C policies;
Insufficient isolation facilities; and
Out of date policies & procedures.
National cancer action team
Review in December 2012 raised serious concerns about the storage of chemotherapy drugs, a lack of lead chemotherapy nurse and issues
in the development of an acute oncology service. No action plan was provided in the documents submitted by the Trust.
Intensive support team for Emergency Care
A review of both sites in January 2012 identified key themes including inappropriate variation in working practices between teams, higher
than expected length of stay, issues with patient flow and poor consultant job planning. No action plan was provided in the documents
submitted by the Trust.
AQuA mortality review
A review in August and September 2012 identified a need to adopt care bundles more widely, to review staffing levels, to strengthen
leadership and governance of mortality reduction, linking it more closely to other quality initiatives. The Trust is implementing these
changes through the Mortality & Reducing Harm Framework referred to above.
Slide 75
Appendix
Slide 76
Trust Map
Slide 77
Serious harm definition
A serious incident requiring investigation is defined as an incident that occurred in relation to NHS-funded services and care resulting in
one of the following:
•
Unexpected or avoidable death of one or more patients, staff, visitors or members of the public;
•
Serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention,
major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological
harm (this includes incidents graded under the NPSA definition of severe harm);
•
A scenario that prevents or threatens to prevent a provider organisation's ability to continue to deliver healthcare services, for
example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT
failure;
•
Allegations of abuse;
•
Adverse media coverage or public concern about the organisation or the wider NHS; and
•
One of the core set of "Never Events" as updated on an annual basis.
Source: UK National Screening Committee
Slide 78
Workforce Indicator Calculations
Indicator
WTE nurses per bed day
Spells per WTE staff
Medical Staff to Consultant
Ratio
Nurse Staff to Qualified Staff
Ratio
Numerator /
Denominator
Calculation
Source
Numerator
Nurses FTE’s
Denominator
Total number of Bed Days
Acute
Quality
Dashboard
Numerator
Total Number of Spells
Denominator
Total number of WTE’s
Numerator
FTEs whose job role is ‘Consultant’
Denominator
FTEs in ‘Medical and Dental’ Staff Group
Numerator
FTEs in ‘Nursing & Midwifery Registered’ Staff Group
Denominator
FTEs of Additional Clinical Services – 85% of bands 2, 3 and 4
Numerator
FTEs not in ‘Nursing and Midwifery Registered’, ‘Additional Clinical
Services,’ ‘Allied Health Professionals’ or ‘Medical and Dental’ staff
groups
Denominator
Sum of FTEs for all staff groups
Numerator
Number of Inpatient Spells
Denominator
FTEs whose job role is ‘Consultant’
Numerator
Nurse FTEs multiplied by 1522 (calculated number of hours per year
which takes into account annual leave and sickness rates)
Denominator
Total Bed Days
Non-clinical Staff to Total Staff
Ratio
Consultant Productivity
(Spells/FTE)
Nurse hours per patient day
HED
ESR
ESR
ESR
ESR
HED
ESR
ESR
HED
Note: ESR Data only includes substantive staff.
Slide 79
Executive director structure
Slide 80
Trust Strategy
Slide 81
Data Sources
No.
Data Source name
1 3 years CDI extended
2 3 years MRSA
3 Acute Trust Quality Dashboard
4 NQD alerts for 14
5 PbR review data
6 QRP time series
7 Healthcare Evaluation Data
GMC Annex - GMC summary of Education Evidence - trusts with high
8 mortality rates
9 1 Buckinghamshire Healthcare Quality Accounts
10 Burton Quality Account
11 CHUFT Annual Report 2012
12 Quality Report 2011-12
13 Annual Report 2011-12_final
14 NLG. Quality Account 2011-12
15 Annual Report 2012
16 Litigation covering email
17 Litigation summary sheet
18 Rule 43 reports by Trust
19 Rule 43 reports MOJ
20 Governance and Finance
21 MOR Board reports
22 Board papers
23 CQC data submissions
24 Evidence Chronology B&T
25 Hospital Sites within Trust
26 NHS LA Factsheet
27 NHSLA comment on five
Steering Group Agenda and Papers incl Governance Structure and
28 Timetable
29 List of products
30 Provider Site details from QRP
31 Annual Report 2011-12
32 SHMI Summary
33 Diabetes Mortality Outliers
34 Mortality among inpatient with diabetes
35 supplementary analysis of HES mortality data
36 VLAD summary
37 Mor Dr Foster HSMR
38 Outliers Elective Non elective split
39 Presentation to DH Analysts about Mid-staffs
40 CQC mortality outlier summaries
41 SHMI Materials
42 Dr Foster HSMR
43 AQuA material
44 Mortality Outlier Review
45 Original Analysis Identifying Mortality Outliers
46 Original Analysis of HSMR-2010-12
47 High-level Methodology and Timetable
48 Analytical Distribution of Work_extended table
Type
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Area
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
General
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Analysis
Analysis
General
General
General
General
General
General
General
General
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Data
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
No. Data Source name
49 Outline Timetable - Mortality Outlier Review
50 CQC review of Mortality data and alerts -Blackpool NHSFT
51 Peoples Voice QRP v4.7
52 Mortality outlier review -PE score
53 CPES Review
54 Pat experience quick wins from dh tool
55 PEAT 2008-2012 for KATE
56 PROMs Dashboard and Data for 14 trusts
57 PROMS for stage 1 review
58 NHS written complaints, mortality outlier review
59 Summary of Monitor SHA Evidence
60 Suggested KLOI CQC
61 Various debate and discussion thread
62 People Voice Summaries
63 Litigation Authority Reports
64 PROMs Dashboard
65 Rule 43 reports
66 Data from NHS Litigation Authority
67 Annual Sickness rates by org
68 Evidence from staff survey
69 Monthly HCSC Workforce Oct 2012 Quarterly tables turnover
70 Monthly HCSC Workforce Oct 2012 Annual time series turnover
71 Mortality outlier review -education and training KLOI
72 Staff in post
73 Staff survey score in Org
74 Agency and turnover
75 GMC ANNEX -GMC summary of education
76 Analysis of most recent Pat safety incident data for 14
77 Safety Thermometer for non spec
78 Acute Trust Quality Dashboard v1.1
79 Initial Findings on NHS written complaints 2011_12
80 Quality accounts First Cut Summary
81 Monitor SHA evidence
82 Care and compassion - analysis and evidence
83 United Linc never events
84 QRP Materials
85 QRP Guidance
86 QRP User Feedback
87 QRP List of 16 Outcome areas
88 Monitor Briefing on FTs
89 Acute Trust Quality Dashboard v1.1
90 Safety Thermometer
91 Agency and Turnover - output
92 Quality Account 2011-12
93 Annual Sickness Absence rates by org
94 Evidence from Staff Survey
95 Monthly HCHS Workforce October 2012 QTT
96 Monthly HCHS Workforce October 2012 ATT
Source: Freedom of information request, BBC 97 http://www.bbc.co.uk/news/health-22466496
Type
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Data
Area
Mortality
Mortality
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Data
Data
Data
Data
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Data
Safety and Workforce
Slide 82
Data Sources
No.
Data Source Name
Health and Social Care Information Centre (HSCIC) monthly workforce
98 statistics
99 National Staff Survey, 2011, 2012
100 GMC evidence to review, 2013
101 2011/12 Organisational Readiness Self-Assessment (ORSA)
102 National Training Survey, 2012
103 National Patient Safety Agency (NPSA) Apr 11 – Mar 12
Type
Area
Data
Data
Analysis
Data
Data
Data
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Slide 83
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
General Medicine
Acute myocardial infarction
104
2
Non-elective
General Medicine
Pulmonary heart disease
106
1
Non-elective
General Medicine
Cancer of head and neck
179
1
Non-elective
General Medicine
Other and ill-defined cerebrovascular disease
815
2
Non-elective
General Medicine
Peripheral and visceral atherosclerosis
140
1
Non-elective
General Medicine
Aortic; peripheral; and visceral artery aneurisms
129
2
Non-elective
General Medicine
Aortic and peripheral arterial embolism or thrombosis
139
1
Non-elective
General Medicine
Cancer of esophagus
109
1
Non-elective
General Medicine
Influenza
2,325
2
Non-elective
General Medicine
Asthma
268
2
Non-elective
General Medicine
Cancer of stomach
129
1
Non-elective
General Medicine
Pleurisy; pneumothorax; pulmonary collapse
107
1
Non-elective
General Medicine
Other upper respiratory disease
130
1
Non-elective
General Medicine
Esophageal disorders
164
2
Non-elective
General Medicine
Gastritis and duodenitis
217
1
Non-elective
General Medicine
Intestinal obstruction without hernia
208
2
Non-elective
General Medicine
Diverticulosis and diverticulitis
111
1
Non-elective
General Medicine
Peritonitis and intestinal abscess
156
1
Non-elective
General Medicine
Biliary tract disease
153
2
Non-elective
General Medicine
Cancer of rectum and anus
219
3
Non-elective
General Medicine
Pancreatic disorders (not diabetes)
166
1
Non-elective
General Medicine
Noninfectious gastroenteritis
141
2
Non-elective
General Medicine
Other gastrointestinal disorders
142
2
Non-elective
General Medicine
Cancer of liver and intrahepatic bile duct
155
2
Slide 84
SHMI Appendix
Observed Deaths that
are higher than the
expected Deaths
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
General Medicine
Menstrual disorders
889
1
Non-elective
General Medicine
Cancer of other GI organs; peritoneum
138
1
Non-elective
General Medicine
Skin and subcutaneous tissue infections
108
1
Non-elective
General Medicine
Chronic ulcer of skin
176
1
Non-elective
General Medicine
Other non-traumatic joint disorders
199
1
Non-elective
General Medicine
Pathological fracture
127
1
Non-elective
General Medicine
Cancer of bone and connective tissue
122
1
Non-elective
General Medicine
Other connective tissue disease
161
2
Non-elective
General Medicine
Other congenital anomalies
491
2
Non-elective
General Medicine
Melanomas of skin
132
1
Non-elective
General Medicine
Fracture of neck of femur (hip)
238
3
Non-elective
General Medicine
Fracture of upper limb
193
1
Non-elective
General Medicine
Sprains and strains
247
1
Non-elective
General Medicine
Intracranial injury
126
1
Non-elective
General Medicine
Crushing injury or internal injury
196
2
Non-elective
General Medicine
Open wounds of head; neck; and trunk
290
3
Non-elective
General Medicine
Open wounds of extremities
416
2
Non-elective
General Medicine
Complication of device; implant or graft
134
1
Non-elective
General Medicine
Complications of surgical procedures or medical care
211
1
Non-elective
General Medicine
Poisoning by psychotropic agents
190
1
Non-elective
General Medicine
Poisoning by other medications and drugs
278
3
Non-elective
General Medicine
Fever of unknown origin
434
1
Non-elective
General Medicine
Cancer of uterus
246
1
Non-elective
General Medicine
Nausea and vomiting
189
1
Slide 85
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
General Medicine
Abdominal pain
139
1
Non-elective
General Medicine
Rehabilitation care; fitting of prostheses; and adjustment of devices
291
2
Non-elective
General Medicine
Residual codes; unclassified
199
2
Non-elective
General Medicine
Cancer of bladder
112
1
Non-elective
General Medicine
Cancer of kidney and renal pelvis
104
1
Non-elective
General Medicine
Cancer of brain and nervous system
125
1
Non-elective
General Medicine
Hodgkin`s disease
1,383
1
Non-elective
General Medicine
Leukemias
162
3
Non-elective
General Medicine
Multiple myeloma
147
1
Non-elective
General Medicine
Secondary malignancies
104
1
Non-elective
General Medicine
Malignant neoplasm without specification of site
105
1
Non-elective
General Medicine
Neoplasms of unspecified nature or uncertain behavior
151
1
Non-elective
General Medicine
Other and unspecified benign neoplasm
282
1
Non-elective
General Medicine
Thyroid disorders
349
1
Non-elective
General Medicine
Diabetes mellitus with complications
183
2
Non-elective
General Medicine
Other endocrine disorders
109
1
Non-elective
General Medicine
Deficiency and other anemia
145
3
Non-elective
General Medicine
Hepatitis
578
1
Non-elective
General Medicine
Coagulation and hemorrhagic disorders
236
1
Non-elective
General Medicine
Encephalitis (except that caused by tuberculosis or sexually transmitted disease) 189
1
Non-elective
General Medicine
Other infections; including parasitic
352
1
Non-elective
General Medicine
Other hereditary and degenerative nervous system conditions
147
1
Non-elective
General Medicine
Paralysis
132
1
Non-elective
General Medicine
Blindness and vision defects
827
1
Slide 86
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
General Medicine
Other nervous system disorders
131
1
Non-elective
General Medicine
Heart valve disorders
184
1
Non-elective
General Medicine
Hypertension with complications and secondary hypertension
293
2
Slide 87
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
T&O
Congestive heart failure, non-hypertensive
730
1
Non-elective
T&O
Fracture of neck of femur (hip)
111
3
Non-elective
T&O
Other fractures
174
2
Non-elective
T&O
Acute and unspecified renal failure
140
1
Non-elective
T&O
Pneumonia
301
1
Non-elective
T&O
Intracranial injury
104
1
Non-elective
T&O
Acute cerebrovascular disease
540
1
Non-elective
General Medicine
Cancer of bladder
154
1
Non-elective
General Medicine
Cancer of breast
113
1
Non-elective
General Medicine
Cancer of bronchus; lung
111
3
Non-elective
General Medicine
Cancer of ovary
115
1
Non-elective
General Medicine
Cardiac Dysrhythmias
140
3
Non-elective
General Medicine
Deficiency and other anemia
175
2
Non-elective
General Medicine
Fluid and electrolyte disorders
131
3
Non-elective
General Medicine
Fracture of neck of femur (hip)
248
2
Non-elective
General Medicine
Malignant neoplasm without specification of site
105
1
Non-elective
General Medicine
Noninfectious gastroenteritis
170
2
Non-elective
General Medicine
Pleurisy; pneumothorax; pulmonary collapse
130
3
Non-elective
General Medicine
Secondary malignancies
111
1
Non-elective
General Medicine
Biliary tract disease
122
1
Non-elective
General Medicine
Abdominal pain
106
1
Non-elective
General Medicine
Cancer of rectum and anus
142
1
Non-elective
General Medicine
Peripheral and visceral atherosclerosis
114
1
Non-elective
General Medicine
Other gastrointestinal disorders
152
2
Slide 88
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
General Medicine
Aortic; peripheral; and visceral artery aneurysms
118
1
Non-elective
General Medicine
Septicemia (except in labor)
102
1
Non-elective
General Medicine
Intestinal obstruction without hernia
214
1
Non-elective
General Medicine
Acute and unspecified renal failure
111
3
Non-elective
General Medicine
Chronic ulcer of skin
310
3
Non-elective
General Medicine
Cancer of stomach
184
2
Non-elective
General Medicine
Cancer of pancreas
112
1
Non-elective
General Medicine
Skin and subcutaneous tissue infections
149
3
Non-elective
General Medicine
Other liver diseases
137
1
Non-elective
Clinical Haematology
Leukemias
558
1
Non-elective
Paediatrics
Other lower respiratory disease
1,107
1
Slide 89
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Non-elective)
Treatment Specialty
HSMR
SHMI
General Medicine
X
T&O
X
Clinical Haematology
X
Paediatrics
X
X
Slide 90