Blackpool Teaching Hospitals
NHS Foundation 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.
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
Blackpool Teaching Hospitals NHS Foundation Trust
Context
A brief overview of the Blackpool Teaching Hospitals NHS Foundation 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:
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.
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 papers 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 data and sources used are consistent across the packs for the 14 trusts included in this review
Summary:
Blackpool Teaching Hospitals NHS Foundation Trust in the
North West services a population of 440,000, which makes the
Trust approximately the size recommended by the Royal College
of Surgeons. 3.4% of Blackpool’s population belong to non-White
ethnic minorities, particularly White and Black Caribbean, and
Other Asian. Smoking in pregnancy and violent crime are
particular health concerns for this area.
The Trust has one acute hospital site, Blackpool Victoria
Hospital. In addition, the trust has two community hospitals,
three elderly rehabilitation hospitals, and two other specialist
units. Blackpool became a Foundation Trust in 2007 and has a
total of 811 beds. It has a 69% market share of inpatient activity
within a 5 mile radius of Blackpool Victoria Hospital. However,
the Trust’s market share falls to 61% within a radius of 10 miles,
and 5% within a radius of 20 miles.
A review of ambulance response times shows that the North
West meets the 8mins national response target, but fails to meet
the 19mins target.
Finally, Blackpool’s HSMR and SHMI levels have been above the
expected level for the last 2 years and the Trust was therefore
selected for this review.
Slide 5
Trust Overview
Blackpool became a Foundation Trust in 2007. The Trust services a
population in and around Blackpool of 440,000 people and has one
acute hospital, Blackpool Victoria Hospital, as well as several
community, elderly rehabilitation, and other specialist hospitals. The
Trust has a higher bed occupancy rate than the national average, and
offers a large range of services, having treated 61,685 elective and
46,327 non-elective patients in 2012.
Blackpool Teaching Hospitals NHS Foundation Trust
Acute Hospital
Blackpool Victoria Hospital
Community Hospitals
Clifton Hospital, Fleetwood Hospital
Elderly rehabilitation
Hospitals
Wesham Hospital Rehabilitation Unit , Rossall
Hospital Rehabilitation Unit
Other Specialist Units
The National Artificial Eye Service
Blenheim House Child Development Centre
Trust Status
Foundation Trust (2007)
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
811
90.9%
86%
General and
Acute
789
90.9%
88%
Maternity
22
92.2%
59%
Source: Department of Health: Transparency Website
Inpatient/Outpatient Activity
Source: NHS Choices
Inpatient Activity
Outpatient Activity
Elective
61,685 (57%)
Non-Elective
46,327 (43%)
Total
108,012
Total
325,946
(Jan12-Dec12)
Day Case Rate:
87%
Source: Healthcare Evaluation Data (HED)
Finance Information
2011–2012 Operating Income
£284m
Departments and Services
2011–2012 Operating Expenditure
£275m
2011–2012 Operating Surplus
£10
2011–2012 Net surplus (deficit)
£3m
2012–2013 Operating Income
£368m
2012–2013 Operating Expenditure
£358m
Accident & Emergency, Breast Surgery, Cardiology, Cardiothoracic Surgery,
Children’s and Adolescent Services, Dermatology, Diagnostic Medicine,
Diagnostic Physiological Measurement, ENT, Endocrinology and Metabolic
Medicine, Gastro Intestinal and Liver Services, General Medicine, General
Surgery, Geriatric Medicine, Gynaecology, Haematology, Infectious
Diseases, Maternity Service, Older People’s Services, Ophthalmology, Oral
and Maxillofacial Surgery, Orthopaedics, Pain Management, Respiratory
Medicine, Rheumatology, Sleep Medicine, Urology, Vascular Surgery.
2012–2013 Operating Surplus
£10m
2012–2013 Net surplus (deficit)
£3m
Source: NHS Choices
Sources: Blackpool Teaching Hospitals NHS Foundation Trust Annual Reports and Accounts 2011-12; Appendix
Slide 6
Trust Overview continued...
General Medicine and
General Surgery are
the largest inpatient
specialties while
Ophthalmology and
Trauma &
Orthopaedics are the
largest for outpatients.
Outpatient Activity by Trust
300
1200
250
1000
200
150
Blackpool
108,012
100
50
Number of Outpatient
Spells (Thousands)
Blackpool 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 fourth
largest by the number
of inpatient spells.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of
Blackpool against
national trusts in
terms of inpatient and
outpatient activity.
800
Blackpool
325,946
600
400
200
0
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
15%
Rheumatology
12
Ophthalmology
12%
General Surgery
11%
Infectious Diseases
64
Trauma & Orthopaedics
12%
Ophthalmology
9%
Nursing Episode
84
Dermatology
10%
Urology
7%
Critical Care Medicine
132
Obstetrics
10%
Paediatrics
7%
Endocrinology
142
Cardiology
7%
Gastroenterology
6%
Geriatric Medicine
214
Ear, Nose & Throat
6%
Trauma & Orthopaedics
6%
Respiratory Medicine
458
General Surgery
6%
Clinical Haemotology
6%
Anaesthetics
724
Gynaecology
5%
Cardiology
5%
Rehabilitation
819
Respiratory Medicine
3%
Accident & Emergency
4%
Oral Surgery
1543
Rheumatology
3%
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
Slide 7
Blackpool Area Overview
Blackpool is one of the most deprived regions in England. Over 50s in this
region constitute a higher proportion of both male and female population,
compared to their proportion of the English population as a whole. In
Blackpool, smoking in pregnancy is more common than anywhere else in
England, while violent crime is significantly more common than in England as
a whole. The ethnic composition of the local population is less varied than in
England as whole; White and Black Caribbean, and Other Asian constitute the
largest non-White minorities.
Blackpool Area Demographics
0-9
10-19
20-29
30-39
40-49
50-59
60-69
FACT BOX
Population
440,000
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
Of 149 English unitary authorities, Blackpool
is the 6th most deprived.
Ethnic
diversity
In Blackpool, 3.4% belong to non-White
minorities, including 0.5% White and Black
Caribbean, and 0.5% Other Asian.
Rural or
Urban
Blackpool is an urban region
Smoking in
pregnancy
In Blackpool, smoking in pregnancy is more
common than anywhere else in England.
Violent
crime
Violent crime is significantly more common in
Blackpool than in England as a whole.
70-79
80+
Female/BLA
20%
15%
10%
Female/ENG
5%
0%
Male/BLA
5%
Male/ENG
10%
15%
Source: Office of National Statistics, Census 2011; IMD Source: Index of Multiple Deprivation, 2010
20%
Slide 8
Blackpool and Surrounding Areas Geographic Overview
The map on the right shows the geographic location of Blackpool.
Blackpool is an urban area located in the North West. As shown by
the map, Blackpool is located near the urban area of Preston, several
major roads, as well as the sea.
Market share analysis indicates from which GP practices the
referrals 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.
Source: © Google Maps
The wheel on the left shows the market share of Blackpool
Teaching Hospitals NHS Foundation Trust. From the wheel it can
be seen that Blackpool has a 69% market share of inpatient
activity within a 5 mile radius of the Trust.
As the size of the radius is increased, the market share falls to 61%
within 10 miles and 5% within 20 miles.
The wheel shows that the main competitors in the local area are
Lancashire Teaching Hospitals NHS Foundation Trust, and
Ramsay Health Care UK.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 9
Blackpool’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.
Deprivation by unitary authority area
Blackpool
The graph shows the level of deprivation in Blackpool compared
nationally.
The tables below outline Blackpool’s health profile information in
comparison with the rest of England. Although Blackpool only part of
the area covered by the Trust, it is believed that this is the most critical
area.
1. All community
1
indicators, except
statutory homelessness,
demonstrate that
Blackpool is
statistically below the
national average.
There are high rates of 2
violent crime.
2. Children’s and
young people’s health in
Blackpool is
statistically below the
national average on all
indicators except obese
children. It should be
noted that in Blackpool,
smoking in pregnancy
is more common than
in any other area in the
country.
Slide 10
Blackpool’s Health Profile
3. Adult health in
Blackpool shows almost
3
all indicators to be
below to the national
average. In Blackpool,
smoking is more
common and there are
a lower number of
4
physically active or
healthy eating adults.
4. Disease and poor
health indicators
highlight a number of
indicators below the
national level, these
include hospital stays 5
for self-harm, alcohol
related hospital stays,
drug misuse, diabetes
and acute sexually
transmitted infections.
5. In Blackpool, life
expectancy is lower
than the national
average and there are a
higher number of
smoking related deaths
and early deaths
caused by cancer or
heart disease.
Slide 11
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 may
increase the risk of mortality.
The graphs on the right
represent some key
performance indicators for
England’s Ambulance services.
The North West service meets
the 8min response target.
However, it 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
Western
Midlands
Ambulance
Ambulance Ambulance Service NHS
Service NHS Service NHS Foundation
Foundation
Trust
Trust
Trust
South East
East of
London
North West
Great
North East
Yorkshire East Midlands
Coast
England
Ambulance Ambulance
Western
Ambulance Ambulance Ambulance
Ambulance Ambulance Service NHS Service NHS Ambulance Service NHS Service NHS Service NHS
Service NHS Service NHS
Trust
Trust
Service NHS
Trust
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%
Source: Department of Health: Transparency Website Dec 12
Isle of Wight
NHS Trust
West
London
South East
Yorkshire
South
Great
North East North West South Central
East of
East Midlands
Midlands
Ambulance
Coast
Ambulance
Western
Western
Ambulance Ambulance Ambulance
England
Ambulance
Ambulance Service NHS Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Ambulance Service NHS
Service NHS
Trust
Service NHS
Trust
Service NHS Service NHS
Trust
Trust
Foundation Service NHS
Trust
Trust
Foundation
Foundation
Trust
Trust
Trust
Trust
Trust
Ambulance Trusts
England
Slide 12
Why was Blackpool 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.
Blackpool has been above the expected level in the
HSMR and SHMI for the last 2 years and was
therefore selected for this review.
Trust
SHMI 2011 SHMI 2012
HSMR
FY 11
HSMR
FY 12
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
111
Above expected
Tameside Hospital NHS Foundation Trust
1
1
Banding 1 – ‘higher than expected’
Source: Background to the review and role of the national advisory group Financial years 2010-11, 2011-12
Slide 13
Why was Blackpool 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.
The funnel charts for 2010/11
and 2011/12, the period when
the trusts were selected for
review, show that Blackpool’s
HSMR and SHMI are both
statistically above the expected
range. Their SHMI is the
highest of all the trusts in this
review. The time series shows
both the HSMR and SHMI
have been consistently above
the expected level, however the
HSMR recently dropped below
100.
SHMI Time Series
SHMI Funnel Chart
Blackpool
Selected trusts Outside Range
Selected trusts w/in Range
HSMR Time Series
HSMR Funnel Chart
Blackpool
Selected trusts Outside Range
Selected trusts w/in Range
Source: Healthcare Evaluation Data (HED); Apr 10-Mar12
Slide 14
Mortality
Slide 15
Mortality
Overview:
Summary:
This section of the report 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 HSMR of 111 for the period January
2012 to December 2012, meaning that the number of actual
deaths is statistically above the expected range.
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.
Further analysis of this figure demonstrates that non-elective
admissions are the primary contributing factor to this figure
with an HSMR of 112, also above the expected range. Elective
admissions are within the expected range with an HSMR of 71.
Review areas
Currently, Blackpool has a SHMI of 114, which is statistically
above the expected range. Similar to HSMR, non-elective
admissions are seen to be contributing primarily to the overall
Trust SHMI with a similar higher than expected figure of 118.
Elective admissions are within the expected range, despite a
SHMI of 123.
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
• Alerts and investigations
Data sources
• Healthcare Evaluation data (HED) – HSMR and SHMI Dec 11 to
Nov 12
• Health & Social Care Information Centre – SHMI and contextual
indicators
• Dr Foster – HSMR
Blackpool has a large number of alerts and outliers for mortality
and is the only trust to meet the selection criteria for both SHMI
and HSMR.
Patient groups alerting more than once since 2007 are ischaemic
heart disease, acute myocardial infarction, pneumonia and
unspecified acute lower respiratory infection.
The Trust identified issues around delays in senior medical
review, timeliness of antibiotic provision, clarity of coding and
documentation and fluid balance monitoring.
An AQuA review of Blackpool’s mortality rates in early 2012
resulted in a number of recommendations for the trust.
• Care Quality Commission – alerts, correspondence and findings
All data and sources used are consistent across the packs for the 14 trusts included in this review
Slide 16
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 (SHMI and HSMR)
Weekend or weekday mortality outliers
Palliative care coding issues
Outcome 1 (R17) Respecting and involving e who use services
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 17
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 18
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 are
highlighted using a Random Effects funnel plot.
Slide 19
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 20
SHMI overview
Month-on-month time series
The Trust’s SHMI level for the 12 months between Dec 11 and Nov 12
is 118, which means, as shown below, it is statistically above the
expected range and so classified as an outlier, based on the 95%
confidence interval of the Poisson distribution.
The time series show a general trend of mainly decreasing SHMI
both year-on-year and month-on-month.
SHMI funnel chart –12 months
Year-on-year time series
Blackpool
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 21
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for Blackpool.
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 70.8% of
SHMI deaths occur in
hospital at Blackpool, which
is less than the national
average of 73.3%.
Percentage of patient deaths in hospital
90%
85%
80%
Blackpool 70.8%
75%
70%
65%
60%
Trusts selected for review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 22
Gynaecology
Obstetrics
Geriatric Medicine
Paediatrics
He Rheumatology
-pat Medical Oncology
Respiratory Physiology
Thoracic Medicine
Hepatobiliary & Pancreatic Surgery
Cardiology
Intermediate Care
Rehabilitation
Haemophilia
Bone and Marrow Transplantation
Hepatology
Clinical Haematology
Endocrinology
Gastroenterology
General Medicine
Not a Treatment Function
Accident & Emergency
Thoracic Surgery
Cardiac Surgery
Cardiothoracic Surgery
Maxillo-facial Surgery
Oral surgery
Ophthalmology
Ear, Nose and Throat
Trauma & Orthopaedics
Vascular Surgery
Dermatology
Colorectal Surgery
Breast Surgery
Urology
General Surgery
-
Non
Elective
SHMI 118
The tree shows that
Blackpool Hospital NHS
Foundation Trust has a
SHMI of 118 which is
above the expected
range.
-
Midwife Episode
Gynaecology
Obstetrics
Geriatric Medicine
Well Babies
Neonatology
Paediatrics
Rheumatology
Medical Oncology
Genito-urinary Medicine
Infectious Diseases
Respiratory Physiology
Thoracic Medicine (130, 25)
Dermatology
Cardiology
Respite Care
Intermediate Care
Rehabilitation
Haemophilia
Bone and Marrow Transplantation
Diabetic Medicine
Hepatology
Clinical Haematology
Endocrinology
Gastroenterology
General Medicine (138, 363)
Community Paediatrics
Critical Care Medicine (321, 31)
Pain Management
Not a Treatment Function
Accident & Emergency
Thoracic Surgery
Cardiac Surgery
Paediatric Surgery
Cardiothoracic Surgery
Oral Surgery
Ophthalmology
Ear, Nose and Throat
Trauma & Orthopaedics
Vascular Surgery
Upper Gastrointestinal Surgery
Hepatobiliary & Pancreatic Surgery
Colorectal Surgery
Breast Surgery
Urology
General Surgery
Slide 23
Observed deaths that are higher
than the expected
SHMI
Treatment Specialties
SHMI 119
The number of observed
deaths in three specific
areas within non
elective admissions are
highlighted as being
higher than expected:
Critical Care Medicine,
General Medicine, and
Thoracic Medicine.
These are potential
areas for review.
Overall
Trust
Treatment Specialties
SHMI 86
Mortality trees provide
a breakdown of SHMI
into elective and nonelective admissions. The
SHMI score for nonelective admissions has
a greater impact on the
overall indicator due to
a higher number of
expected deaths.
Elective
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Mortality - SHMI Tree
Key
Diagnosis (100 ; 1 )
SHMI sub-tree of specialties
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
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 four more observed deaths than expected. When identifying areas to
review, it is important to consider the number of deaths as well as the SHMI.
General Medicine has the highest number of greater than expected deaths with
pneumonia (37), chronic obstructive pulmonary disease and bronchiectasis (22)
and urinary tract infections (22) seen as the main diagnostic groups contributing
to this. This is shown on this and the following slide. Those groups highlighted
below may potentially be areas to be reviewed.
Overall118.2
(118; 367)
Non-elective (119; 376)
Treatment Specialties
Critical Care Medicine ( 321, 31)
Diagnostic Groups
Acute cerebrovascular disease
(884, 4)
Pneumonia
(258, 5)
Thoracic Medicine (130, 25)
Pneumonia
Chronic obstructive pulmonary
disease and bronchiectasis
General Medicine (138, 363)
(133, 6)
(201, 9)
See full table on the next slide
Key
Diagnosis (100 ; 1 )
SHMI
Observed deaths that are higher
than the expected
Sources: Health Evaluation Data (HED) – Dec 2011 – Nov 2012; Appendix
Slide 24
SHMI sub-tree of specialties continued
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Non-elective (119; 376)
\
Treatment Specialties
General Medicine (138, 363)
Coronary atherosclerosis and other heart disease (239, 17)
Acute and unspecified renal failure
(155, 20)
Cardiac arrest and ventricular fibrillation
(134, 5)
Urinary tract infections
(155, 22)
Congestive heart failure; nonhypertensive
(132, 14)
Cancer of pancreas
(178, 4)
Acute cerebrovascular disease
(131, 8)
Cancer of bronchus; lung
(110, 5)
Peripheral and visceral atherosclerosis
Phlebitis; thrombophlebitis and
thromboembolism
Pneumonia
(319, 5)
Septicemia (except in labor)
(119, 12)
(230, 4)
(228, 4)
Acute bronchitis
Chronic obstructive pulmonary disease and
bronchiectasis
Other lower respiratory disease
(149, 13)
Other non-traumatic joint disorders
Spondylosis; intervertebral disc disorders;
other back problems
Other connective tissue disease
(135, 22)
Open wounds of head; neck; and trunk
(398, 8)
Superficial injury; contusion
(313, 10)
Other upper respiratory disease
(255, 7)
Malaise and fatigue
(226, 7)
Intestinal infection
(133, 5)
Leukemias
(233, 5)
Biliary tract disease
(220, 6)
Secondary malignancies
(127, 4)
Liver disease; alcohol-related
(169, 9)
Fluid and electrolyte disorders
(142, 5)
Gastrointestinal hemorrhage
(140, 12)
Senility and organic mental disorders
(127, 5)
Key
Noninfectious gastroenteritis
(176, 5)
Other psychoses
(247, 7)
Diagnosis (100 ; 1 )
Other gastrointestinal disorders
(275, 11)
Within General Medicine, the
diagnostic groups with the highest
numbers of observed deaths above
the expected level are pneumonia
(37), chronic obstructive pulmonary
disease and bronchiectasis (22) and
urinary tract infections (22).
Diagnostic Groups
SHMI
(125, 37)
(179, 5)
(214, 4)
(240, 6)
Observed deaths that are higher
than the expected
Sources: Health Evaluation Data (HED) – Dec 2011 – Nov 2012; 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, Blackpool FT
130
120
117
120
122
125
126
125
121
110
100
90
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 Blackpool was 121 in the year to Sept-12 (England
baseline = 100) and has been above the expected range
throughout.
Source: Health & Social Care Information Centre – SHMI
Slide 26
HSMR overview
Month-on-month time series
The Trust’s HSMR level for the 12 months between Jan 12 and Dec 12
is 111, which means, as shown below, it is above the expected range.
The time series show a highly fluctuating trend of HSMR year-onyear; however the month on month time series shows overall a slight
increase during the course of 2012.
HSMR funnel plot –12 months
Year-on-year time series
Blackpool
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 27
HSMR Statistics
The table to the right shows
Blackpool’s HSMR broken
down by admission type.
The breakdown illustrates
the overall HSMR is 111
which is above the expected
range. The table identifies
that non-elective
admissions have an HSMR
above the expected range.
Key – colour by
alert level:
HSMR
Weekend
Week
All
Elective
100
70
71
Non-elective
112
112
112
Red – Higher than
expected (above the
95% confidence
interval)
All
112
110
111
Blue – Within
expected range
Source: Health 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 represent the number of observed deaths that are
higher than the expected deaths. The larger and darker boxes
within the tree plot will highlight potential areas for further
review.
From this tree plot it is clear that the following areas have the
greatest number of above expected deaths:
•
Pneumonia (117 for HSMR, 32 observed deaths that are
higher than the expected);
•
Congestive heart failure nonhypertensive (135, 22);
•
Septicaemia except in labour (122, 17);
•
Acute cerebrovascular disease (114, 15); and
•
Chronic obstructive pulmonary disease and bronchiectasis
(132, 14).
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 29
Geriatric Medicine
Gynaecology
Medical Oncology
Ear, Nose and Throat
Ophthalmology
-
-
-
-
-
Thoracic Medicine
Respiratory Physiology
Infectious Diseases
Genito-urinary Medicine
Medical Oncology
Paediatrics
Neonatology
Midwife Episode
Dermatology
Gynaecology
Cardiology
-
Respite Care
-
Intermediate Care
Obstetrics
Rehabilitation
Geriatric Medicine
Haemophilia
-
Bone and Marrow Transplantation
-
Diabetic Medicine
Well Babies
-
-
Clinical Haematology
Accident & Emergency
Endocrinology
Thoracic Surgery
-
-
Cardiac Surgery
-
-
Cardiothoracic Surgery
Gastroenterology
-
Ophthalmology
General Medicine (128, 178)
-
Ear, Nose and Throat
-
-
Trauma & Orthopaedics
-
-
Vascular Surgery
Community Paediatrics
-
Upper Gastrointestinal Surgery
Critical Care Medicine (260, 20)
-
Colorectal Surgery
-
-
Breast Surgery
-
-
Urology
Not a Treatment Function
-
General surgery
-
-
Diagnosis (100 ; 1 )
-
Dermatology
Thoracic Medicine
Hepatobiliary & Pancreatic Surgery
-
Rehabilitation
Bone and Marrow Transplantation
Hepatology
Gastroenterology
-
General Medicine
Clinical Haematology
Accident & Emergency
-
-
Trauma & Orthopaedics
Thoracic Surgery
Vascular Surgery
-
Cardiology
Cardiac Surgery
Colorectal Surgery
-
Breast Surgery
-
Key
Cardiothoracic Surgery
Urology
Treatment Specialties
HSMR 112
Slide 30
Observed deaths that are higher
than the expected
HSMR
Treatment Specialties
HSMR 71
-
-
Elective admissions are
within the expected range,
due to relatively few
expected deaths.
General Surgery
HSMR 111
-
Non
Elective
Within non-elective
admissions General
Medicine and Critical Care
Medicine have the highest
number of observed deaths
above the expected level.
Elective
The tree shows that the
HSMR for Blackpool is 111
which is above the
expected range. When
breaking this down by
admission type, it is clear
that it is driven by non elective admissions, which
are at similar level.
Overall
Trust
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Mortality - HSMR Tree
HSMR sub-tree of specialties
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
The HSMR sub-tree indicates the specialties with a statistically higher HSMR
than expected and with diagnostic groups with at least four more observed deaths
than expected. When identifying areas to review, it is important to consider the
number of deaths as well as the HSMR.
The sub-tree indicates that General Medicine has the highest number of above
expected deaths. These are spread over numerous diagnostic groups such as
pneumonia (23) and congestive heart failure, nonhypertensive (20).
Overall118.2
(111; 135)
Non-elective (112; 145)
Treatment Specialties
Critical Care Medicine (260, 20)
Diagnostic
Groups
Acute cerebrovascular disease
(811, 4)
Pneumonia
(286, 5)
Septicemia
(435, 4)
Key
Diagnosis (100 ; 1 )
HSMR
Observed deaths that are higher
than the expected
General Medicine (128, 178)
Acute and unspecified renal failure
Acute bronchitis
Acute cerebrovascular disease
Cancer of bronchus; lung
Chronic obstructive pulmonary disease and bronchie
Congestive heart failure; nonhypertensive
Coronary atherosclerosis and other heart disease
Fluid and electrolyte disorders
Gastrointestinal hemorrhage
Liver disease; alcohol-related
Noninfectious gastroenteritis
Other gastrointestinal disorders
Other lower respiratory disease
Peripheral and visceral atherosclerosis
Pneumonia (except that caused by tuberculosis or s
Septicemia (except in labor)
Urinary tract infections
(142, 13)
(131, 6)
(125, 6)
(119, 6)
(123, 11)
(156, 20)
(196, 12)
(166, 5)
(120, 5)
(157, 7)
(205, 4)
(188, 4)
(262, 7)
(208, 5)
(118, 23)
(128, 15)
(139, 11)
Slide 31
HSMR – Dr Foster
The HSMR time series for Blackpool Teaching FT from Dr Foster
shows an above expected 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
financial year shown in the time series.
Blackpool’s latest SHMI published by the HSCIC, for Oct 11 to Sept
12, is higher than the Dr Foster HSMR for the same period.
125
Time series of HSMR, Blackpool
Teaching FT
120
115
110
108
105
100
2008/09
2009/10
95
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.
115
112
113
HSMR
I
2010/11
2011/12
I
95% Confidence interval
Com parison of m ortality m easures,
Blackpool Teaching FT
130
120
121
123
117
110
108
100
SHMI
90
SHMI adjusted
for palliative
care
SHMI in
hospital
deaths only
HSMR
80
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 32
Coding
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.
Average Diagnosis Coding Depth
Elective
6
6
5
5
4
4
3
3
2
2
1
1
0
When looking at the depth
of coding for Blackpool, it
is clear that the Trust’s
average diagnosis coding
depth has been
consistently higher than
the national average over
the time period shown.
This is evident in both
elective and non-elective
admissions
Non-elective
7
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
2012/13
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
National Average Diagnosis Coding Depth
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
Blackpool
Blackpool
2012/13
Source: Health 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.
1.4
Blackpool have had above average use of palliative care
coding on admissions (by treatment specialty or
diagnosis), but this has declined to slightly below
average over the last year or so.
0.6
Percentage of admissions with palliative
care coding
1.2
1.0
0.8
0.4
0.2
-
Oct-11
Jan-12
Apr-12
Blackpool
25
Jul-12
Oct-12
National
Jan-13
Apr-13
SHMI publication
Percentage of deaths with palliative care
coding
20
15
10
5
-
Oct-11
Jan-12
Apr-12
Blackpool
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.
Sep 11 to Aug 12
Nephrology
Respiratory medicine
Gastroenterology and hepatology
Emergency specialty groups worse than expected
Sep 11 to Aug 12
For Blackpool, there are no common themes that have arisen
across the patient groups alerting since 2007, although there
were multiple alerts for some diagnoses. Mortality for 18 to 74
year olds and 75+ year olds was much worse than expected in
the year to September 2012.
Common themes arising from Trust responses to the CQC
include delays in senior medical review, timeliness of antibiotic
provision, clarity of coding and documentation and fluid
balance monitoring.
In early 2012, Blackpool invited the Advancing Quality Alliance
(AQuA) to undertake a comprehensive review of its mortality
rates. This has resulted in a number of recommendations for
the Trust, which include the following areas:
• The relationship between clinicians and coders;
• Leadership of patient safety and mortality;
• Further improvements in clinical practice;
• Use of mortality information;
• Staffing levels in high risk areas;
• Medical records; and
• End of life care planning.
Source: Care Quality Commission – alerts, correspondence and findings
3
5
Infectious diseases
Cardiology
Neurology (but small numbers)
Dermatology (but small numbers)
Vascular
Diagnosis group alerts (2007 to date)
Alerts to CQC
13
Alerts followed up by CQC
9 (+2 known concern from recent alert)
Recent diagnosis group alerts pursued by CQC
Unspecified acute lower respiratory infection (Jun 11)
Acute cerebrovascular disease (Aug 11)
Pneumonia (Aug 11)
Acute myocardial infarction (Oct 11, Dec 11, Jul 12)
Deficiency and other anaemia (Feb 12)
Acute and unspecified renal failure (Apr 12)
Any related patient groups alerting more than once since 2007
Ischaemic heart disease
Acute myocardial infarction (however two of the AMI alerts were closed
on the basis of being a known concern)
Pneumonia
Unspecified acute lower respiratory infection
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 four diagnosis groups and no
procedure group with above expected SMRs in Blackpool
Teaching FT, which may highlight potential areas for review.
One diagnosis group had above expected mortality for weekend
admissions but not for weekday ones: Coronary atherosclerosis
and other heart disease, but this did not have a high SMR overall.
Apr 2012 to Mar 2013
Diagnosis groups
Procedure groups
SMRs above expected
4
0
CUSUM alerts
1
1
Diagnosis groups with SMRs above expected
Acute cerebrovascular disease
Chronic obstructive pulmonary disease and
bronchiectasis
Congestive heart failure, nonhypertensive
Intestinal obstruction without hernia
SMR
Obs – Exp
deaths
123
24
130
147
208
21
30
9
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, Blackpool had a CUSUM alert for congestive
heart failure, non-hypertensive, and one for a procedure group
that did not have a high SMR.
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 36
Mortality – other alerts
Blackpool has a large number of alerts and outliers for
mortality and is the only trust to meet the selection criteria for
both SHMI and HSMR.
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.
30-day mortality following specific surgery / admissions
Myocardial infarction (high and improving 9% below national rate in 2010/11).
VLAD charts with a negative SHMI trend (year to
Jun-12)
Pneumonia
Renal failure
Acute myocardial infarction
No. dips to the lower
control limit
4
3
3
Blackpool have the highest 30-day mortality following
Myocardial infarction: three times the national rate in 2010-11
(published in Feb 2013), although not risk adjusted.
Variable Life Adjusted Display (VLAD) charts are produced by
the Health & Social Care Information Centre (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.
Blackpool had such VLAD charts for three diagnosis group in
the year to June 2012: pneumonia, renal failure and acute
myocardial infarction.
In addition, Blackpool had much worse than expected mortality
for pneumonia and worse than expected for COPD on the Acute
Trust Quality Dashboard (year to Q1 2012-13). It also had high
excess deaths for pneumonia (51 deaths, 24% more than expected),
coronary atherosclerosis and other heart disease (22 deaths, 51%
more than expected), COPD and bronchiectasis (22 deaths, 28%
more than expected) and acute and unspecified renal failure (21
deaths, 48% more than expected) in the HSCIC’s SHMI to
September 2012.
Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.
Slide 37
Mortality – Deprivation
Blackpool has a relatively high proportion of patients from the
lowest deprivation quintile, which may affect expected deaths.
Deprivation is taken into account in the HSMR, whereas the
SHMI methodologists concluded that it did not add sufficient
value to the model (over and above co-morbidities), although
they show it as context.
35
Percentage of spells by deprivation quintile,
SHMI April 2013
30
25
20
15
10
CQC report that the trust expressed concerns that adjustments
for deprivation and comorbidity in standardised mortality
rate calculations may not sufficiently take account of the local
demographics and health profile of their catchment
population. The AQuA Mortality review acknowledges that
deprivation is a major concern in the Blackpool health
economy population, however it concludes that this is not in
isolation an explanation of the high SHMI or HSMR.
5
1 Most
deprived
2
Blackpool
30
3
National
4
5 Least
deprived
SHMI publication
Percentage of deaths by deprivation quintile,
SHMI April 2013
25
20
15
10
5
1 Most
deprived
Blackpool
Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR; Peoples’ Voices Summary
2
3
National
4
5 Least
deprived
SHMI publication
Slide 38
Patient Experience
Slide 39
Patient Experience
Overview:
Summary:
The following section provides an insight into the Trust’s patient
experience.
Of the 9 measures reviewed within Patient Experience and
Complaints there are three which are rated ‘red’.
Review Areas:
In the Cancer survey, 19 of the 58 questions placed the Trust in
the bottom 20%, with no questions in the top 20%. The main
concerns were around diagnostics, finding out what was wrong
and deciding on the best treatment.
To undertake a detailed analysis of the Trust’s Patient Experience
it is necessary to review the following areas:
•
Patient Experience, and
•
Complaints.
Data Sources:
•
Patient Experience Survey;
•
Cancer Patient Experience Survey;
•
People’s Voice Summary; and
•
Complaints data.
The ombudsman’s report rated the Trust as B-rated for
complaints handling, due to satisfactory remedies and low risk
of non-compliance, but observed that is was likely to be
downgraded at next review. The Trust was above average for
complaints escalating to the ombudsman and in the, top 50 for
complaints overall. There had been two cases of service failure
possibly indicating wider organisation failure.
Of comments recorded on CQC’s patient voice system, 85% were
negative, with comments focussing on understaffing, bullying,
neglect, lack of dignity, poor attitudes and inconsistent advice.
Whilst the Trust had an average score on the inpatient survey
overall, there were negative indications around information
given to patients, doctors responses to questions and delays in
discharge processes.
All data and sources used are consistent across the packs for the 14 trusts included in this review
Slide 40
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
Not applicable
Outside expected range
Within expected range
Slide 41
Inpatient Experience Survey
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
Blackpool performs above average on survey questions relating to the quality of food provided by the hospital, but below average on
those relating to coherent discharge processes, involvement in decision-making, staff communication on the purpose of medication
provided, and the clarity of doctors’ responses to patient questions.
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 42
Patient experience and patient voice
Overall patient experience score: Inpatients 2012
Inpatient Survey
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, coordination of care, information & choice, relationship with
staff and the quality of the clinical environment .
•
England Average: 76.5
•
Blackpool: 74.9 (average)
95
90
Blackpool
85
80
75
70
65
60
55
50
England
average
Cancer Survey
•
Of 58 Questions, 19 were in the ‘bottom 20%’ whilst none
were in the top 20%. The main concerns were around
diagnostics, finding out what was wrong, and deciding
on the best treatment
The quality risk profiles compiled by the Care Quality
Commission collate comments from individuals and
various sources. In the two years to 31st January 2013,
there were 66 comments on Blackpool of which 56 were
negative (85%). Comments focussed on understaffing,
bullying, neglect, lack of dignity, poor attitudes and
inconsistent advice.
National
results curve
Source :Patient Experience Survey, Cancer patient experience survey
Complaints Handling
•
Data returns to the Health and Social Care Information
Centre showed 353 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, 49% of complaints related to clinical treatment (in
line with the national average of 47%).
•
A separate report by the Ombudsman rates the Trust as
B-rated for satisfactory remedies and low risk of noncompliance, although the report notes that it may be
downgraded at next review. Above average for Trusts
escalating to the ombudsman, top 50 for complaints
overall, two cases of service failure possibly indicating
wider organisation failure.
Slide 43
Patient Voice
•
Trusts in
this review
Safety and workforce
Slide 44
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.
Blackpool is ‘red rated’ in one of the safety indicators: Clinical
negligent 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 data and sources used are consistent across the packs for the 14 trusts included in this review
The Trust has reported 449 patient safety incidents recorded as
either moderate, severe or death. They have had two ‘never
events’ between 2009 and 2012.
In recent months, Blackpool’s new pressure ulcer prevalence rate
has fallen, and has been below the national rate for all but four
of the last 12 months. It is apparent that the prevalence rate of
total pressure ulcers for Blackpool has been largely above the
national average over the last 12 months. However, the data also
shows that Blackpool has been below the average of the selected
14 trusts in this review for the majority of this time period.
Blackpool’s Clinical Negligence payments have exceeded
contributions to the ‘risk sharing scheme’ over the last 3 years.
Payouts exceeded contributions by a total of £4.6m over this
period. The Rule 43 Coroner report flagged two items to be
considered, however there were no cases directly attributed to
Blackpool NHS Trust.
The Trust was ‘red rated’ on six of the workforce indicators.
Blackpool’s medical staff and nursing staff sickness absence rate
is above the national average, and the agency staff costs, as a
percentage of total staff costs, are slightly higher than the
regional median. Blackpool has a patient spells per whole time
equivalent rate of 21, which is lower than the average capacity in
relation to the other trusts in this review and nationally. Also,
the consultant appraisal rate of Blackpool is just below 59%,
which is among the lowest of the trusts included in this review.
Slide 45
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
449
Number of ‘never events’ (2009-2012)
2
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 46
Safety Analysis
The Trust has reported fewer medication errors than
the national mean. There is no desired direction on this
indicator. However, lower reporting may be an issue.
Rate of medication errors per 1,000 bed days (October 2011 – March
2012)
Blackpool
Mean rate for all acute
6.36
7.17
Source: Acute Trust Quality Dashboard Winter 2012/13
Slide 47
Safety Incident Breakdown
Since 2009, two ‘never events’ have occurred at Blackpool, classified as such
because they are incidents that are so serious they should never happen.
The patient safety incidents reported are broken down into five levels of harm
below, ranging from ‘no harm’ to ‘death’. 32% of incidents which have been
reported at Blackpool have been classed as ‘no harm’, with 60% ‘low’, with 7%
‘moderate’, and 11 and 0 occurrences of incidents classified as ‘severe’ and
‘death,’ respectively.
Never Events Breakdown (2009-2012)
Wrong site surgery
2
Total
2
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 Blackpool are in ‘patient accident’ and ‘medication’.
Breakdown of patient
incidents by degree of harm
4000
Breakdown of patient
incidents by incident type
3699
Implementation of care and ongoing…
3500
3000
2500
2000
135
Consent, communication, confidentiality
1976
1500
Medical device / equipment
169
All others categories
213
Clinical assessment
238
Infrastructure
279
Treatment, procedure
297
358
Documentation
1000
484
Access, admission, transfer, discharge
438
500
11
0
Severe
Death
0
157
621
Medication
3173
Patient accident
No Harm
Low
Moderate
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
0
500
1000
1500
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
2000
2500
3000
3500
Slide 48
Pressure ulcers
New pressure ulcers prevalence
This slide outlines the total
1.8%
number of pressure ulcers and the 35
1.7%
1.6%
number of new pressure ulcers
1.5%
30
1.4%
1.3%
broken down by category for the
25
1.2%
last 12 months. Due to the effects
1.0%
20
0.9%
of seasonality on hospital
0.7%
0.7%
0.6%
acquired pressure ulcer rates, the 15
10
national rate has been included
which allows a comparison that
5
takes this in to account. This
provides a comparison against
the national rate as well as the 14
trusts selected for the review.
In recent months, Blackpool’s new
Category 2
Category 3
pressure ulcer prevalence rate
has fallen from 1.3% to 0.6%.
Throughout the last 12 months,
New pressure ulcer analysis
Blackpool has been below the
Apr-12
national average on all but 4
Number of records submitted
738
months.
Trust new pressure ulcers
Category 4
140
2.0%
1.8%
1.6%
1.4%
1.2%
1.0%
0.8%
0.6%
0.4%
0.2%
0.0%
120
6.7%
5.7%
100
80
9.0%
7.7%
8.0%
5.8%
7.0%
5.9%5.8%
5.2%5.3%
5.1% 6.0%
6.2%6.2%
5.0%
3.8%
4.0%
60
3.0%
40
2.0%
20
1.0%
-
0.0%
Category 2
Rate
Category 3
Category 4
Rate
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
758
1547
1645
1714
1734
1772
1765
1686
1721
1781
1806
14
21
12
From the data, it is apparent that Trust new pressure ulcer rate
1.6%
1.8%
1.4%
Selected 14 Trusts new pressure
the prevalence rate of total
ulcer rate
1.4%
1.5%
1.4%
pressure ulcers for Blackpool has
National new presseure ulcer rate
1.7%
1.7%
1.5%
been largely above the national
average over the last 12 months.
Total pressure ulcer prevalence percentage
However, the data also shows
Apr-12
May-12
Jun-12
that Blackpool has been below the
738
758
1547
average of the selected 14 trusts Number of records submitted
Trust total pressure ulcers
28
43
103
in this review for the majority of
Trust total pressure ulcer rate
3.8%
5.7%
6.7%
this time period.
An understanding of specific case
mix should be reviewed in
parallel to understand any root
causes.
Total pressure ulcers prevalence
25
29
16
18
13
11
23
21
11
1.5%
1.7%
0.9%
1.0%
0.7%
0.7%
1.3%
1.2%
0.6%
1.5%
1.5%
0.9%
1.0%
1.1%
0.9%
1.1%
1.0%
1.2%
1.5%
1.4%
1.3%
1.2%
1.2%
1.2%
1.3%
1.3%
1.3%
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
1645
1714
1734
1772
1765
1686
1721
1781
1806
127
106
107
93
93
97
101
103
93
7.7%
6.2%
6.2%
5.2%
5.3%
5.8%
5.9%
5.8%
5.1%
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 49
Litigation and Coroner
Clinical negligence payments
Clinical negligence scheme analysis.
2009/10
Blackpool’s Clinical Negligence payments have exceeded
contributions to the ‘risk sharing scheme’ over the last 3
years. Payouts exceeded contributions by a total of £4.6m
over this period.
Coroner’s Rule 43 Report
2010/11
2011/12
Payouts (£000s)
4,090
3,967
7,799
Contributions (£000s)
3,303
3,871
4,119
Variance between
payouts and contributions
(£000s)
-787
-96
-3,680
Coroners rule 43 reports flagged two items:
•
•
Royal Preston Hospital to consider a review of
staffing provision and the location within wards of
patients with special nursing needs; and
To consider a review of the use of bladed trocars in
operations using the open technique.
However, there were no cases directly attributed to
Blackpool NHS Trust.
Source :Litigation Authority Reports
Slide 50
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
2.06
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
2.21
Vacancies –medical
Sickness
absence
-Nursing
staff
Staff to Total Staff Ratio
Outcome
1 (R17)
Respecting
and involving eNon-clinical
who u
Vacancies - Non-medical
Consultant appraisal rates
Agency spend
Response Rate from National Staff
Survey 2012
Staff Engagement from NSS 2012
Training Doctors – “undermining”
indicator
se services
0.31
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days) 617.21
Staff leaving rates
Nurse Hours per Patient Bed Day
10.15
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 51
General Medical Council (GMC) National Training Scheme Survey 2012
Emergency 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
Endocrinology and diabetes
mellitus
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 52
General Medical Council (GMC) National Training Scheme Survey 2012 continued
Gastroenterology
The GMC Survey results continue as follows:
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Ophthalmology
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 53
General Medical Council (GMC) National Training Scheme Survey 2012 continued
Respiratory Medicine
The GMC Survey results continue as follows:
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
The specialties listed below have the following as green outliers:
•
Cardiology - access to educational resources;
•
General (internal) medicine - handover;
•
General psychiatry - local teaching;
•
Geriatric medicine - handover and access to educational resources;
•
Haematology - clinical supervision, feedback and local teaching;
•
Otolaryngology - access to educational resources;
•
Paediatrics - feedback; and
•
Trauma and orthopaedic surgery - study leave.
Green outlier
Within expected range
Red outlier
Slide 54
Workforce Analysis
Number of FTEs (Dec
11-Nov 12 average)
The agency staff costs, as a percentage of total staff costs, are slightly
higher than the median within the region. The data also illustrates that the
Trust has more staff joining compared to the SHA median and fewer staff
leaving compared to the SHA median. This stability rate is significantly
higher than the median in the region.
Agency Staff (2011/12)
Blackpool has a patient spells per whole time equivalent rate of 21, which is
lower than the average capacity in relation to the other trusts in this review
and nationally.
WTE nurses per bed day December 2012
National Average
2.38
1.96
Percentage of
Total Staff
Costs
Median within
Region
£6.6m
3.9%
3.5%
Blackpool
Median within Region
5.5%
1.1%
(Sep 11 – Sep 12)
Staff Turnover
Spells per WTE for Acute Trusts
50
45
Blackpool
North West SHA
Median
Joining Rate
10.5%
6.8%
Leaving Rate
5.0%
5.7%
Consultant appraisal rate 2011/12
40
Spells per WTE
Blackpool
Expenditure
Staff Stability (Joining Rate – Leaving Rate)
Trust should target a higher number (Oct 2011/12)
The consultant appraisal rate of Blackpool is 58.8% and is among the
lowest of the trusts under review.
Blackpool
5,184
100%
35
Blackpool:
21
30
25
20
Blackpool
(58.8%)
80%
60%
15
10
40%
5
20%
0
0%
Trusts covered by review
All Trusts
Trusts covered by review
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
All other trusts
Slide 55
Workforce Analysis continued…
Blackpool’s total sickness absence rate is lower
than the North West Strategic Health Authority
average and the national average. However, at a
more granular level, the Trust’s sickness absence
rates for medical and nursing staff both exceed
the national averages for their respective
categories, although Blackpool’s rate for other
staff is below the average figure for all trusts in
England.
Blackpool has medical staff to consultant, and
nurse staff to qualified staff, ratios that are below
the national average. Additionally, Blackpool’s
registered nurse hours to patient day ratio is
lower than the average figure for all English
trusts.
The Trust’s consultant productivity is above the
national average.
Sickness Absence Rates
All Staff
(2011-2012)
Blackpool
North West SHA
Average
National Average
3.41%
4.52%
4.12%
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
Blackpool
National Average
Medical Staff
2.2%
1.3%
Nursing Staff
5.0%
4.8%
Other Staff
4.4%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
Blackpool
National Average
Medical Staff to Consultant Ratio
2.06
2.59
Nurse Staff to Qualified Staff Ratio
2.21
2.50
Non-Clinical Staff to Total Staff
Ratio
0.31
0.34
Registered Nurse Hours to Patient
Day Ratio *
10.15
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) April 13
Blackpool
National Average
617
492
Slide 56
Deanery
The trust is not currently subject to enhanced monitoring. While doctors in training at the trust reported more concerns about
patient safety than the average, we did not receive any concerning information from the Deanery or the National Training Survey.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Ophthalmology and F1 trainees in Emergency Medicine were the programme groups with the most below outliers between 2011 and
2012 (there were no outliers for 2010). F1 trainees in Surgery received the most above outliers during the same period. There were
slightly more outliers in 2012 than 2011, but no indicator had programme level outliers across both years.
NTS 2012 Patient Safety Comments
10 doctors in training commented, representing 5.8% 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:
•
Poor staffing levels, particularly at night;
•
Staff Grade doctors of variable ability;
•
Lack of cross-team working;
•
Doctors in training managing patients without appropriate supervision; and
•
Patients on trolleys due to lack of beds.
Source: GMC evidence to Review 2013
Slide 57
Deanery Reports
The Deanery returns for 2011 and 2012 did not identify any concerns, with the 2012 return identifying one item of good practice –
the development of internal quality control processes which have further enhanced the ability of the Trust to respond to concerns
raised by GP trainees.
Monitored under the response to concerns process?
Undermining
No, the Trust is not subject to increased monitoring at the time of
the report. The Trust has not been visited as part of our Education
Quality Assurance programme.
For doctors which are undertaking their training at Blackpool, the
Trust has a score of 93% which is below the national average of
94%.
Mean Score on 'Undermining'
105
100
Blackpool
95
90
85
80
Trusts covered by review
Source: National Training Survey 2012
All other non specialist trusts
Slide 58
Clinical and operational
effectiveness
Slide 59
Clinical and Operational Effectiveness
Overview:
The following section provides an insight into the Trust’s clinical
and operational performance based on nationally recognised key
performance indicators.
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 data and sources used are consistent across the packs for the 14 trusts included in this review
Summary:
In the National Clinical Audits, Royal Lancaster Infirmary, used
by the Trust, and Blackpool Victoria Hospital, belonging to the
Trust, are outliers.
With 94% of A&E patients seen within 4 hours, which is below
the 95% target level, Blackpool has one of the lower percentages
from the selected trusts in this review. However, the percentage
of patients seen within 4 hours is rising slightly. 94.1% of
patients are seen within the 18 week target time (RTT) which is
above the target level and places the Trust in the top half among
the trusts being reviewed.
The Trust’s crude readmission rate is among the higher
readmission rates of the trusts in the review as well as
nationally, at 13.4%. The standardised readmission rate shows
Blackpool is within the expected range with an average length of
stay of 5.37 days, which is slightly higher than the national
mean of 5.2 days.
The PROMs dashboard shows that Blackpool was a relatively
poor performer in general. Blackpool had three instances when
it was classified as a negative outlier below the 99.8% control
limit. It had a further four occasions when one of the measures
returned a score between two standard deviations (95%) and
three standard deviations (99.8%) below the average score for
England.
Slide 60
Outside expected range
Clinical and Operational Effectiveness
Within expected range
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.
Neonatal – women receiving steroids
Coronary angioplasty
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
Elective Surgery
Cancelled Operations
Emergency readmissions
PbR Coding Audit
Operational
Effectivenes
s
RTT Waiting Times
Cancer Waits
PROMs
Dashboard
Hip Replacement EQ-5D
National
Cancer peer
review
A&E Waits
Aspects of good practice
3
Immediate risks
2
Serious concerns
2
Knee Replacement EQ-5D
Hip Replacement OHS
Outcome 1 (R17)
and involving
people who use services
KneeRespecting
Replacement
OKS
Varicose Vein EQ-5D
Groin Hernia EQ-5D
Concerns
8
Outcome 1 (R17) Respecting and
Slide 61
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 considered as part of this review.
Clinical Audit
Safety Measure
Clinical Audit
Effectiveness Measures
Diabetes
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
Elective Surgery
Peripheral vascular surgery
Adult Critical Care (ICNARC
CMPD)
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 62
Clinical effectiveness: Clinical Audits
Proportion of patients referred for cardiology follow
up post discharge
In the National Clinical Audit for Heart Failure
(NICOR), a key measure of effectiveness is the rate of
referral for cardiology appointment following
discharge.
110%
On this measure, Blackpool Victoria Hospital appears
to be an outlier, having both a large number of cases
and a low rate of referral for cardiology follow up.
80%
100%
90%
70%
60%
50%
40%
30%
Blackpool
Victoria
Hospital
20%
0
Slide 63
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
Blackpool sees 94% of
A&E patients within 4
hours which is below
the 95% target level.
In addition to this, the
percentage of patients
seen within 4 hours
remained relatively
consistent over the
last 6 months.
Local data including
the co-located Urgent
Care Centre indicates
the Trust achieved the
95% standard for
2012/13.
94.1% of the patients
are seen within the 18
week target time,
which is above the
target level. In
addition, the time
series shows that
Blackpool has been
consistently above the
target rate.
A&E Percentage of Patients Seen
within 4 Hours
105%
Blackpool
94.0%
100%
95%
90%
85%
80%
Blackpool 4 Hour A&E Waits
Attendances (Thousands)
A&E wait times and
RTT times may
indicate the
effectiveness with
which demand is
managed.
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
8
7
6
5
4
3
2
1
0
75%
70%
Patients Seen
Trusts Covered by Review
All Trusts
A&E Target 95%
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Seen within 4 hours (%)
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Referral to Treatment (Admitted)
Blackpool Referral to Treatment
Performance
105%
100%
95%
Patients Not Seen
98%
Blackpool
94.1%
96%
94%
92%
90%
90%
85%
88%
86%
80%
75%
Trusts Covered by Review
All Trusts
Source: Department of Health. Feb 13
RTT Target 90%
Referral to Treatment Rate
RTT Target 90%
Source: Department of Health. Apr 12 – Feb 13
Slide 64
Operational Effectiveness – Emergency Re-admissions and Length of Stay
Blackpool sees 94% of A&E
patients within 4 hours
which is below the 95%
target level. In addition to
this, the percentage of
patients seen within 4 hours
remained relatively
consistent over the last 6
months.
25%
20%
15%
Blackpool
13.4%
10%
5%
0%
Trusts Covered by Review
All Trusts
Blackpool
Selected trusts Outside
Selected trusts w/in Range
Local data including the colocated Urgent Care Centre
indicates the Trust achieved
the 95% standard for
2012/13.
Average Length of Stay by Trust
10
9
Spell Duration (Days)
94.1% of the patients are
seen within the 18 week
target time, which is above
the target level. In addition,
the time series shows that
Blackpool has been
consistently above the
target rate.
Standardised 30-day Readmission
Rate
Crude Readmission Rate by Trust
Crude Readmission Rate
A&E wait times and RTT
times may indicate the
effectiveness with which
demand is managed.
8
7
6
Blackpool
5.37
5
4
3
2
1
0
Trusts Covered by Review
Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12
All Trusts
Slide 65
Hip Replacement EQ-5D
PROMs Dashboard
Dashboard Analysis
0.6
England Average
0.4
Blackpool
0.3
Upper Control Limit
0.2
0.1
Lower Control Limit
2
20
11
/1
20
10
/1
1
0
0
However, the Trust did show some improvement in
2011-12, being just inside the control limit for two
measures related to hip replacement, and close to the
average for other measures in the dashboard.
0.5
20
09
/1
The PROMs dashboard shows that Blackpool was a
relatively poor performer in general. Blackpool had
three instances when it was classified as a negative
outlier below the 99.8% control limit. It had a further
four occasions when one of the measures returned a
score between two standard deviations (95%) and
three standard deviations (99.8%) below the average
score for England.
Hip Replacement OHS
25
England Average
20
15
Blackpool
10
Upper Control Limit
5
Lower Control Limit
2
20
11
/1
1
20
10
/1
Source: PROMs Dashboard and NHS Litigation Authority
20
09
/1
0
0
Slide 66
National Cancer peer review
A peer review was conducted of Blackpool’s head and neck multi-disciplinary team (MDT) in May, 2013. They found the following:
Good Practice/Significant Achievements:
•
The neck lump clinic is a multiprofessional, one stop clinic with access to imaging in clinic and cytology within 24 hours.
•
The joint CNS/SLT clinic, with the intention to include the dietician when appointed.
•
Lack of complications for microvascular flaps.
Immediate risks:
•
The team is operating on upper aero-digestive tract cancers when the Blackpool Victoria Hospital is not a designated surgical hospital.
•
The number of laryngectomies and other major surgical procedures undertaken in Blackpool is too low to assure maintenance of
competence for surgical and nursing staff.
Serious Concerns:
•
The number of UAT cancers managed by the service is significantly short of that required for IOG compliance for an MDT, however the
LST is acting in many ways as an aspirant MDT and as if it were a designated surgical centre.
•
There is a lack of integration with both the MDT at Preston and the OMFS team that leads to inequalities in care.
Source: National Cancer Peer Review, 2013
Slide 67
National Cancer peer review continued...
Concerns:
•
No oncologist in clinic when the post holder has planned or unplanned absence leading to patients being delayed or seen elsewhere;
•
No cover for planned and unplanned absence of the CNS;
•
No cover for planned or unplanned absence of the speech and language therapist;
•
AHP staff at Blackpool do not benefit from the interaction and other advantages that accrue from being part of a larger head and neck
team;
•
The aspiration to be a stand alone MDT against the intention of the IOG to centralise services;
•
Despite the Cancer Network and the Director of NCAT having highlighted disquiet about the volume of surgical activity of the team,
Trust senior management have apparently not undertaken its own analysis of activity or consequently taken any action;
•
Diversity of staff involved in the valve replacement service that will see patients infrequently; and
•
Lack of input of data into DAHNO meaning that the Trust is not benefiting from having robust information on which to benchmark
and improve the service.
Source: National Cancer Peer Review, 2013
Slide 68
Leadership and
governance
Slide 69
Leadership and governance
Overview:
Summary:
This section provides an indication of the Trust’s governance
procedures.
There has been significant turnover at Board level in the past 12
months. The Chairman and Medical Director took post in April
2012, the CEO left in November 2012 and his successor took post
in April 2013. The acting CEO, who was Director of Finance, left
in March 2013 as did the Director of Human Resources &
Organisation Development; there are acting Directors currently
in those two posts. Also the non-executive Chair of Audit
Committee is to retire in May 2013.
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 data and sources used are consistent across the packs for the 14 trusts included in this review
A new Board Committee Structure was agreed by the Board in
January 2013 and the Sub-Board Committees have been
streamlined. Quality Governance arrangements are scrutinized
through a number of standing sub-board Committees, in
particular a Healthcare Governance Committee which is chaired
by the Chief Executive.
A recent CQC inspection at Blackpool Victoria Hospital has
found the Trust to be compliant with all outcomes reviewed.
The Trust has identified its highest risks to quality as being
mortality, demography and primary care services, medical and
nursing workforce, infrastructure and capacity, admission
pressures and the Lancashire & Cumbria System Impact
reviews.
Slide 70
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.
Leadership and
governance
Monitor governance risk rating
Monitor finance rating
CQC Outcomes
3
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 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 71
Leadership and governance
Trust Board
There has been significant turnover at Board level in the past 12 months. The Chairman and Medical Director took post in April
2012, the CEO left in November 2012 and his successor took post in April 2013. The acting CEO, who was Director of Finance,
left in March 2013 as did the Director of Human Resources & Organisation Development; there are acting Directors currently in
those two posts. Also the non-executive Chair of Audit Committee is to retire in May 2013.
Governance and clinical structures
A new Board Committee Structure was agreed by the Board in January 2013 and the Sub-Board Committees have been
streamlined. Quality Governance arrangements are scrutinized through a number of standing sub-board Committees, in
particular a Healthcare Governance Committee which is chaired by the Chief Executive.
In addition the Trust has three Governance Committees which report into the Healthcare Governance Committee. These are the
Quality Governance Committee, Health, Safety and Environmental Governance Committee which are chaired by the Medical
Director and the Health Informatics Committee which is chaired by the Director of Facilities. A number of reporting
Committees feed into the relevant Governance Committees.
In April 2012 the acute Trust merged with the local community services provided by two PCTs. There has been a process to
harmonise management structures, documentation and procedures over the past year. The Trust have restructured their
Divisions to: Scheduled Care, Unscheduled Care, Adult Community Services/Long Term Conditions, and Families.
Quality priorities
Improved hospital mortality rates
Conformance to best practice
Reducing avoidable harms
Improving the patient experience
Slide 72
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust, and other potential risks to quality
identified through review of Trust Board papers.
Trust identified risks
Trust response
Mortality
As is known to the visiting team the Trust has had a high reported standardised mortality (SMR) as measured
by HSMR and/or SHMI for the past two years. This has been recognised by the Trust Board and a number of
steps have been taken, including:
• Improving the process of consultant sign-off for coding of deaths.
• Improved documentation processes to ensure safer handover of clinical care and ensure information is
available to attribute accurate clinical codes
• Engagement with Northwest AQUA (Advancing Quality Alliance) team to develop a definitive action plan for
mortality improvement
• Development of enhanced informatics tools (HED tool from UH Birmingham) for early identification of
mortality issues
• Initiated a review of the compliance with agreed care pathways and care bundles
• Detailed review of all mortality indicators with Chief Executive involvement
• The Trust Mortality Board meets monthly
• The Medical Director, Mortality reduction Lead, and Associate Director for Clinical Informatics meet weekly to
review mortality data and lead actions upon these.
• The Medical Director meets with the local Director for Public Health and other colleagues at CCGs to discuss
in hospital mortality.
Demography and
primary care services
Blackpool has the worst male and third worst female life expectancy in the country. There are high levels of
alcohol and substance abuse, and teenage pregnancy. Bloomfield electoral ward is the most deprived in the
country. Blackpool PCT was in the bottom 30 in the country for GP provision per head of population. The area
is in the bottom quintile for persons dying in their place of residence.
Slide 73
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust, and other potential risks to quality
identified through review of Trust Board papers.
Trust identified risks
Trust response
Medical Workforce
The Trust has historically had a doctor: bed ratio lower than the national average and below the average for
Trusts in the North West. The Trust faces challenges in recruitment in relation to medical staff. We are at the
northern extreme of the North West Deanery: because of this trainees centred on Manchester and its environs
are sometimes reluctant to travel to Blackpool (even though those who do come report high satisfaction with
training opportunities and training delivered). This in turn results in a continuing reliance upon locum medical
staff, which can impact on continuity/consistency, and also means we are less well placed than some Trusts to
recruit trainees into substantive consultant posts.
Nursing Workforce
Achieving appropriate nurse staffing levels particularly in the Unscheduled Care Division is a challenge that the
Trust is focused on. Historically the Trust has had issues in recruiting nurses to work in a coastal hospital and
had been very dependent on the use of temporary staffing. In 2009 a significant project to improve nurse
staffing recruitment and retention was launched by the Board. The main outcomes of the project were closure
of the nurse bank and re-investment of £1.8 million to recruit nurses for the medical wards, a targeted
recruitment campaign to establish the Trust as an attractive employer for nurses in the region, improved support
for newly registered nurses, reduction in sickness and absence and the introduction of supervisory status for
band 7 ward managers. Nursing Turnover is 10.66 % (rolling 12 months) and sickness is 4.28%. The Board has
continued to monitor nurse staffing levels and further investment of £1.5 million (52 WTE) has been agreed to
further enhance the establishments in 13/14. The Trust has recently recruited nurses from Portugal and Ireland
in order to achieve full establishment.
Slide 74
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust, and other potential risks to quality
identified through review of Trust Board papers.
Trust identified risks
Trust response
Infrastructure and
Capacity
The Trust has made major investments into building stock in recent years including a new A&E department,
critical care areas, and medical wards; a new cardiothoracic centre; a new surgical block and a newly
refurbished women’s and children’s unit. We currently face a challenge to replace some of our medical
equipment and our IT infrastructure. The Trust has a range of medical equipment that needs to be replaced on a
phased basis across the forthcoming years with an emphasis on a large number of assets to be replaced
immediately. A range of options for equipment replacement are currently being considered by the Trust. The
Trust has approved a programme of IT equipment replacement which will support our ‘Vision’ project to create
an electronic patient record. This will enhance patient safety through the implementation of care pathways and
easier audit. We are currently working to review our plans to implement our Vision project in the light of lessons
to date.
Admission pressures
The Trust, like all of our neighbouring Trusts, has experienced significant levels of activity growth, with particular
pressures during the winter. Despite putting a wide range of measures in place, both internally and working with
health/social care partners, there has been a lengthening of waiting times for patients in our A&E department.
Lancashire/Cumbria
system impact/reviews
We are part of a wider healthcare system and both impact on, and are impacted on, by changes elsewhere.
One of our neighbouring Trusts has recently experienced financial and clinical governance issues and we are
already experiencing an increase in women from outside our catchment area attending for antenatal and
perinatal care. Whilst this increase has been accommodated so far unplanned further increases in maternity
and/or other clinical services may place a strain upon our ability to offer a high quality service. We are also
dependant on other providers for some of our specialist cancer work. The level of activity pressure within other
economies has led to the cancellation of some elective activity, which has lengthened waiting times for cancer
patients referred from Blackpool. We have raised the issue with our commissioners and we are monitoring the
situation very closely. The ongoing review of vascular services in Cumbria and Lancashire has recommended
the provision of three specialist centres to serve the population. None of these will be situated in Blackpool
despite the fact that we host the regional Cardiothoracic centre. This reconfiguration may impact upon our ability
to recruit high the highest calibre surgical and radiological consultants in future.
Slide 75
Leadership and governance
External reviews
Last year the Trust had an Invited Review by the Royal College of Surgeons of its Cardiothoracic Service. This was prompted
by concerns raised from within the trust about the practice of one surgeon. The Review found no serious cause for clinical
concern and no reason to suggest any restriction of the surgeon’s practice. It did however note that the relationships within the
department are less than ideal. An external company has been commissioned to facilitate team working within the department.
The Care Quality Commission reviewed care at Blackpool Victoria Hospital in March 2013 (report published in May 2013). This
review found the hospital to be compliant with all outcomes reviewed (respecting and involving people who use services,
meeting nutritional needs, and records).
Mortality
In 2012 the Trust commissioned a report from AQUA on the mortality situation. After the report they constructed a Mortality
Reduction Action Plan which AQUA has endorsed. This plan is a live document owned by and reported to the Mortality Board
and to the Trust Board.
The Trust continues to be part of a North West Collaborative Programme for mortality reduction and has implemented
programmes specifically around the care of patients with pneumonia and patients with severe sepsis. In addition to this work
the Trust has implemented harm reduction strategies including reduction in hospital acquired infections, progress on reducing
Venous Thrombo-Embolism (VTE), and strict adherence to quality measures as part of the North West Advancing Quality
initiative.
Slide 76
Appendix
Slide 77
Trust Map
Slide 78
Source: http://emergencyeyetreatment.org.uk
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 79
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 80
Appendix
Interim Director of
HR
Jackie Bates
Source: http://www.bfwh.nhs.uk/about/board.asp
Slide 81
Appendix
Source: Trust submission: Item 7 – board committee structure April 2013
Slide 82
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 83
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 84
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
192 - Critical care medicine
Acute myocardial infarction
Non-elective
192 - Critical care medicine
Other circulatory disease
Non-elective
192 - Critical care medicine
Phlebitis; thrombophlebitis and thromboembolism
Non-elective
192 - Critical care medicine
Acute bronchitis
Non-elective
192 - Critical care medicine
Non-elective
Observed Deaths that
are higher than the
expected
SHMI
692.48
3
2549.73
1
4697.3
1
3313.67
1
Respiratory failure; insufficiency; arrest (adult)
181.25
1
192 - Critical care medicine
Liver disease; alcohol-related
261.89
1
Non-elective
192 - Critical care medicine
Pancreatic disorders (not diabetes)
4790
2
Non-elective
192 - Critical care medicine
Gastrointestinal hemorrhage
938.61
2
Non-elective
192 - Critical care medicine
Other gastrointestinal disorders
3706.94
2
Non-elective
192 - Critical care medicine
Acute and unspecified renal failure
318.4
2
Non-elective
192 - Critical care medicine
Septicemia (except in labor)
359.79
3
Non-elective
192 - Critical care medicine
Intracranial injury
642.91
2
Non-elective
192 - Critical care medicine
Bacterial infection; unspecified site
945.24
1
Non-elective
192 - Critical care medicine
Leukemias
548.26
1
Non-elective
192 - Critical care medicine
Secondary malignancies
367.41
1
Non-elective
192 - Critical care medicine
Diabetes mellitus with complications
823
1
Non-elective
192 - Critical care medicine
Coma; stupor; and brain damage
509.19
2
Non-elective
300 - General medicine
Acute myocardial infarction
111.1
2
Non-elective
300 - General medicine
Nonspecific chest pain
171.06
2
Non-elective
300 - General medicine
Pulmonary heart disease
123.92
1
Non-elective
300 - General medicine
Conduction disorders
217.83
1
Non-elective
300 - General medicine
Cardiac dysrhythmias
113.8
1
Non-elective
300 - General medicine
Cancer of head and neck
242.9
1
Non-elective
300 - General medicine
Aortic; peripheral; and visceral artery aneurysms
242.09
1
Non-elective
300 - General medicine
Aortic and peripheral arterial embolism or thrombosis
8469.71
1
Slide 85
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
300 - General medicine
Other circulatory disease
Non-elective
300 - General medicine
Cancer of esophagus
Non-elective
300 - General medicine
Asthma
Non-elective
300 - General medicine
Non-elective
Observed Deaths that are
higher than the expected
SHMI
143.8
1
122.05
2
165.2
1
Cancer of colon
188.28
2
300 - General medicine
Appendicitis and other appendiceal conditions
267.66
1
Non-elective
300 - General medicine
Intestinal obstruction without hernia
291.16
3
Non-elective
300 - General medicine
Diverticulosis and diverticulitis
754.27
1
Non-elective
300 - General medicine
Peritonitis and intestinal abscess
5422.35
1
Non-elective
300 - General medicine
Cancer of rectum and anus
201.19
3
Non-elective
300 - General medicine
Nephritis; nephrosis; renal sclerosis
354.2
1
Non-elective
300 - General medicine
Cancer of liver and intrahepatic bile duct
139.53
1
Non-elective
300 - General medicine
Hyperplasia of prostate
3047.97
1
Non-elective
300 - General medicine
Other male genital disorders
12370.83
2
Non-elective
300 - General medicine
Nonmalignant breast conditions
616.02
1
Non-elective
300 - General medicine
Cancer of other GI organs; peritoneum
318.74
3
Non-elective
300 - General medicine
Skin and subcutaneous tissue infections
146.37
3
Non-elective
300 - General medicine
Chronic ulcer of skin
155.76
2
Non-elective
300 - General medicine
Other skin disorders
216.11
1
Non-elective
300 - General medicine
Osteoarthritis
786.53
2
Non-elective
300 - General medicine
Cancer of bone and connective tissue
347.05
1
Non-elective
300 - General medicine
Melanomas of skin
329.19
2
Non-elective
300 - General medicine
Skull and face fractures
276.12
1
Non-elective
300 - General medicine
Fracture of upper limb
218.21
3
Non-elective
300 - General medicine
Fracture of lower limb
162.53
1
Non-elective
300 - General medicine
Intracranial injury
128.34
1
Slide 86
SHMI Appendix
Observed Deaths that are
higher than the expected
Admission Methodaria
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General medicine
Cancer of breast
127.57
1
Non-elective
300 - General medicine
Poisoning by psychotropic agents
213.23
2
Non-elective
300 - General medicine
Syncope
116.24
1
Non-elective
300 - General medicine
Cancer of uterus
241.93
2
Non-elective
300 - General medicine
Abdominal pain
185.54
1
Non-elective
300 - General medicine
Rehabilitation care; fitting of prostheses; and adjustment of devices
283.61
1
Non-elective
300 - General medicine
Residual codes; unclassified
143.9
2
Non-elective
300 - General medicine
Cancer of ovary
230.92
2
Non-elective
300 - General medicine
Cancer of bladder
303.41
2
Non-elective
300 - General medicine
Cancer of kidney and renal pelvis
273.99
1
Non-elective
300 - General medicine
Cancer of other urinary organs
265
1
Non-elective
300 - General medicine
Cancer of thyroid
365.71
1
Non-elective
300 - General medicine
Hodgkin`s disease
2457.94
1
Non-elective
300 - General medicine
Malignant neoplasm without specification of site
143.69
1
Non-elective
300 - General medicine
Neoplasms of unspecified nature or uncertain behavior
171.06
1
Non-elective
300 - General medicine
Other endocrine disorders
140.81
2
Non-elective
300 - General medicine
Deficiency and other anemia
120.77
2
Non-elective
300 - General medicine
Coagulation and hemorrhagic disorders
332.49
1
Non-elective
300 - General medicine
Anxiety; somatoform; dissociative; and personality disorders
1055.31
2
Non-elective
300 - General medicine
Blindness and vision defects
1261.79
1
Non-elective
300 - General medicine
Other nervous system disorders
123.5
1
Non-elective
300 - General medicine
Heart valve disorders
137.39
1
Non-elective
340 - Thoracic medicine
Congestive heart failure; nonhypertensive
188.28
3
Non-elective
340 - Thoracic medicine
Acute cerebrovascular disease
198.39
2
Non-elective
340 - Thoracic medicine
Acute bronchitis
127.73
1
Slide 87
SHMI Appendix
Observed Deaths that are
higher than the expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
340 - Thoracic medicine
Liver disease; alcohol-related
332.54
1
Non-elective
340 - Thoracic medicine
Other liver diseases
416.27
1
Non-elective
340 - Thoracic medicine
Pancreatic disorders (not diabetes)
403.64
1
Non-elective
340 - Thoracic medicine
Septicemia (except in labor)
122.85
1
Non-elective
340 - Thoracic medicine
Intracranial injury
948.01
1
Non-elective
340 - Thoracic medicine
Open wounds of extremities
6080.84
1
Non-elective
340 - Thoracic medicine
Cancer of breast
207.12
1
Non-elective
340 - Thoracic medicine
Poisoning by psychotropic agents
2449.18
1
Non-elective
340 - Thoracic medicine
Non-Hodgkin`s lymphoma
409.19
1
Non-elective
340 - Thoracic medicine
Leukemias
507.05
1
Non-elective
340 - Thoracic medicine
Neoplasms of unspecified nature or uncertain behavior
329.9
1
Non-elective
340 - Thoracic medicine
Diabetes mellitus with complications
1165.44
1
Non-elective
340 - Thoracic medicine
Other nutritional; endocrine; and metabolic disorders
320.34
1
Non-elective
340 - Thoracic medicine
Deficiency and other anemia
547.35
1
Non-elective
340 - Thoracic medicine
Senility and organic mental disorders
459.76
1
Non-elective
340 - Thoracic medicine
Coma; stupor; and brain damage
504.21
2
Non-elective
340 - Thoracic medicine
246.51
1
Non-elective
340 - Thoracic medicine
Heart valve disorders
Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by tuberculosis
or sexually transmitted disease)
647.44
3
Slide 88
HSMR Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
192 - Critical care medicine (also known as intensive care medicine)
Acute and unspecified renal failure
Non-elective
192 - Critical care medicine (also known as intensive care medicine)
Acute myocardial infarction
Non-elective
192 - Critical care medicine (also known as intensive care medicine)
Gastrointestinal hemorrhage
Non-elective
192 - Critical care medicine (also known as intensive care medicine)
Intracranial injury
Non-elective
192 - Critical care medicine (also known as intensive care medicine)
Leukemias
Non-elective
192 - Critical care medicine (also known as intensive care medicine)
Liver disease; alcohol-related
Non-elective
192 - Critical care medicine (also known as intensive care medicine)
Non-elective
Observed Deaths that
are higher than the
expected
HSMR
210
1
672.4
1
1530.2
1
737.4
2
265
1
337.3
1
Other circulatory disease
8886.2
1
192 - Critical care medicine (also known as intensive care medicine)
Other gastrointestinal disorders
5057.5
2
Non-elective
192 - Critical care medicine (also known as intensive care medicine)
Respiratory failure; insufficiency; arrest (adult)
269.4
1
Non-elective
300 - General medicine
Acute myocardial infarction
110
2
Non-elective
300 - General medicine
Aortic; peripheral; and visceral artery aneurysms
250.5
1
Non-elective
300 - General medicine
Aspiration pneumonitis; food/vomitus
106.7
2
Non-elective
300 - General medicine
Biliary tract disease
170.1
3
Non-elective
300 - General medicine
Cancer of bladder
288.8
1
Non-elective
300 - General medicine
Cancer of breast
116
1
Non-elective
300 - General medicine
Cancer of pancreas
118.8
1
Non-elective
300 - General medicine
Cancer of prostate
208
1
Non-elective
300 - General medicine
Cancer of stomach
365.1
2
Non-elective
300 - General medicine
Cardiac arrest and ventricular fibrillation
120.3
3
Non-elective
300 - General medicine
Chronic ulcer of skin
151.1
2
Non-elective
300 - General medicine
Deficiency and other anemia
139.4
2
Non-elective
300 - General medicine
Fracture of neck of femur (hip)
157.6
1
Non-elective
300 - General medicine
Intestinal obstruction without hernia
223.2
2
Non-elective
300 - General medicine
Intracranial injury
122.7
1
Non-elective
300 - General medicine
Leukemias
232.9
3
Slide 89
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
HSMR
Non-elective
300 - General medicine
Other circulatory disease
145.9
1
Non-elective
300 - General medicine
Other upper respiratory disease
186.5
2
Non-elective
300 - General medicine
Peritonitis and intestinal abscess
1159.5
1
Non-elective
300 - General medicine
Pulmonary heart disease
130.2
1
Non-elective
300 - General medicine
Senility and organic mental disorders
120.6
2
Slide 90
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Elective)
Treatment Specialty
HSMR
SHMI
N/A
Slide 91
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Nonelective)
Treatment Specialty
HSMR
SHMI
General medicine
X
X
Critical care medicine
X
X
Thoracic medicine
X
Slide 92