Buckinghamshire Healthcare
NHS Trust
Data Pack
9th July, 2013
Overview
Sources of Information
On 6th February the Prime Minister asked Professor Sir Bruce
Keogh to review the quality of the care and treatment being
provided by those hospital trusts in England that have been
persistent outliers on mortality statistics. The 14 trusts which fall
within the scope of this review were selected on the basis that they
have been outliers for the last two consecutive years on either the
Summary Hospital Mortality Index or the Hospital Standardised
Mortality Ratio.
Document review
Trust information
submission for
review
These two measures are being used as a ‘smoke alarm’ for
identifying potential quality problems which warrant further
review. No judgement about the actual quality of care being
provided to patients is being made at this stage, or should be
reached by looking at these measures in isolation.
The review will follow a three stage process:
Stage 1 – Information gathering and analysis
Stage 2 – Rapid Responsive Review
Benchmarking
analysis
Information shared
by key national
bodies including
the CQC
Stage 3 – Risk summit
This data pack forms one of the sources within the information
gathering and analysis stage.
Information and data held across the NHS and other public bodies
has been gathered and analysed and will be used to develop the Key
Lines of Enquiry (KLOEs) for the individual reviews of each Trust.
This analysis has included examining data relating to clinical
quality and outcomes as well as patient and staff views and
feedback. A full list of evidence sources can be found in the
Appendix.
Given the breadth and depth of information reviewed, this pack is
intended to highlight only the exceptions noted within the evidence
reviewed in order to inform Key Lines of Enquiry.
Slide 2
Buckinghamshire Healthcare NHS Trust
Context
A brief overview of the Buckinghamshire area and Buckinghamshire Healthcare NHS Trust. This section provides a profile of the area,
outlines performance of local healthcare providers and gives a brief introduction to the Trust.
Mortality
An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the Trust
which are outliers.
Patient Experience
A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient experience
surveys.
Safety and Workforce
A summary of the Trust’s safety record and workforce profile.
Clinical and Operational Effectiveness
A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This section
compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures (PROMs).
Leadership and Governance
An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership, current
top risks to quality and outcomes from external reviews.
Slide 3
Context
Slide 4
Context
Overview:
Summary:
This section provides an introduction to the Trust, providing an
overview, health profile and an understanding of why the Trust
has been chosen for this review.
Buckinghamshire Healthcare NHS Trust in the South Central of
England services a population of about 500,000, which places
the Trust within the higher range of the size recommended by
the Royal College of Surgeons.
Review Areas:
To provide an overview of the Trust, the following areas have
been reviewed:
•
Local area and market share;
•
Health profile;
•
Service overview; and
•
Initial mortality analysis.
Data Sources:
•
Trust’s Board of Directors meeting 29th May, 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, 2010;
•
© 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.
Buckinghamshire is one of the least deprived areas in the
country as of 149 English unitary authorities, Buckinghamshire
is the 142nd most deprived. 14% of Buckinghamshire’s
population belong to non-White ethnic minorities. Incidents of
malignant melanoma, violent crime and infant death are
significantly higher than the national average in parts of
Buckinghamshire.
The Trust has two acute hospital sites: Stoke Mandeville
Hospital and Wycombe Hospital. In addition, the Trust provides
services at five community hospitals. Buckinghamshire is not a
Foundation Trust. The Trust has a total of 739 beds. It has a 74%
market share of inpatient elective activity within a 5 mile radius
of the Trust’s acute hospitals. However, the Trust’s market share
falls to 48% within a radius of 10 miles, and 15% within a radius
of 20 miles.
A review of ambulance response times shows that the South
Central Ambulance Trust meets the national 8min response
target, but not the 19min response target.
Finally, Buckinghamshire’s HSMR level has been above the
expected level for the last 2 years and the Trust was therefore
selected for this review.
Slide 5
Trust Overview
Buckinghamshire is not currently a Foundation Trust. The Trust serves
a population in South Central England of about 500,000 people and has
seven hospitals, two acute hospitals (Stoke Mandeville, and Wycombe),
and five community hospitals. The Trust is integrated and therefore also
provides the full range of adult and child community services. The Trust
has a higher bed occupancy rate than the national average, offering a
large range of services, in 2012 serving 94,116 inpatients and 476,074
outpatients.
Buckinghamshire Healthcare NHS Trust
Trust Status
Not currently a Foundation Trust
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
739
87.9%
86%
General and
Acute
682
89.7%
88%
Maternity
57
66.9%
59%
Source: Department of Health: Transparency Website
Acute Hospitals
Stoke Mandeville Hospital, Wycombe Hospital
Community Hospitals
Amersham Hospital, Buckingham Community
Hospital, Chalfont and Gerrards Cross Community
Hospital, Marlow Community Hospital, Thame
Community Hospital,
Inpatient Activity
Elective
47,896 (51%)
Source: NHS Choices
Outpatient Activity
Finance Information
(Jan12-Dec12)
Inpatient/Outpatient Activity
Non Elective
46,220 (49%)
Total
94,116
Total
476.074
Day Case Rate:
85%
Source: Healthcare Evaluation Data (HED)
Apr 2012– Feb 2013 Income
£321m
Departments and Services
Apr 2012– Feb 2013 Expenditure
£295m
2012–2013 EBITDA
£26m
2012–2013 Net surplus (deficit)
£0m
2013-2014 Budgeted Income
£335m
2013-2014 Budgeted Expenditure
£300m
2013-2014 Budgeted EBITDA
£35m
Accident & Emergency, Cardiology, Children’s & Adolescent
Services, Community Nursing, Dental and Medicine Specialties,
Dentistry and Orthodontics, Dermatology, Diabetic Medicine, ENT,
Endocrinology and Metabolic Medicine, Gastrointestinal and Liver
Services, General Surgery, Geriatric Medicine, Gynaecology,
Haematology, Maternity Service, Neurology, Ophthalmology, Oral
and Maxillofacial Surgery, Orthopaedics, Pain Management, Plastic
Surgery, Respiratory Medicine, Rheumatology, Therapy Services for
adults and children, Urgent Care, Urology, Vascular Surgery
2013-2014 Budgeted Net surplus (deficit)
£5m
Source: NHS Choices
Source: Buckinghamshire Healthcare NHS Trust, papers for public board meeting, 29.05.2013,
and papers for public board meeting, 27.03.2013
A map of Stoke Mandeville Hospital is included in the Appendix
Slide 6
Trust Overview continued...
General Medicine and
Paediatrics are the
largest inpatient
specialties while
Nursing Episodes and
Ophthalmology are the
largest for outpatients.
Outpatient Activity by Trust
300
1200
250
200
150
Buckinghamshire
94,116
100
50
Number of Outpatient Spells
(Thousands)
Buckinghamshire is a
medium sized trust for
inpatient activity,
relative to both the 14
trusts selected for this
review and the rest of
England. However, the
Trust is in the upper
quartile of all those
nationally for
outpatient activity.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of
Buckinghamshire
against national trusts
in terms of inpatient
and outpatient
activity.
0
1000
800
600
Buckinghamshire
476,074
400
200
0
Trusts
Trusts Covered by Review
Trusts
National Inpatient Activity Curve
Top 10 Inpatient Main Specialties as a
% of Total Inpatient Activity
Trusts Covered by Review
Bottom 10 Inpatient Main Specialties
and Spells
National Outpatient Activity Curve
Top 10 Outpatient Main Specialties as
a % of Total Outpatient Activity
General Medicine
18%
Haematology
9
Nursing Episode
30%
Paediatrics
12%
Rehabilitation
25
Ophthalmology
12%
Gynaecology
11%
Allied Health Professional Episode
38
Trauma and Orthopaedics
7%
General Surgery
9%
General Medical Practice
154
General Medicine
7%
Urology
7%
Nursing Episode
239
Dermatology
6%
Trauma and Orthopaedics
6%
Palliative Medicine
348
Gynaecology
5%
Ophthalmology
5%
Medical Oncology
407
General Surgery
5%
Clinical Oncology
5%
Respiratory Medicine
536
Clinical Haemotology
4%
Midwifery
5%
Rheumatology
652
Plastic Surgery
4%
Plastic Surgery
4%
Neurology
906
Paediatrics
3%
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
Slide 7
Buckinghamshire Area Overview
Buckinghamshire, in South East England, is one of the least deprived areas in
the country. The age distribution in Buckinghamshire is largely similar to that
of England as a whole; however, Buckinghamshire has significantly fewer
women and men in their 20’s. Incidents of malignant melanoma and infant
death are particular health concerns in parts of Buckinghamshire compared to
the country as a whole. 14% of Buckinghamshire’s population belong to nonWhite minorities.
Buckinghamshire Area Demographics
0-9
FACT BOX
Population
The Royal College of Surgeons recommend that the
"...catchment population size...for an acute general hospital
providing the full range of facilities, specialist staff and
expertise for both elective and emergency medical and
surgical care would be 450,000 - 500,000."
IMD
Of 149 English unitary authorities,
Buckinghamshire is the 142nd most
deprived.
Ethnic diversity
In Buckinghamshire, 13.6% belong to
non-White minorities, including 4.2%
Pakistani.
Rural or Urban
Buckinghamshire is a rural-urban region.
Incidence of
malignant
melanoma
In parts of Buckinghamshire, and
particularly in Aylesbury Vale, incidents of
malignant melanomas are significantly
more common that in the country as a
whole.
Road injuries
and death
In parts of Buckinghamshire, and
particularly in South Bucks, road injuries
and death are significantly more common
than in the country as a whole.
10-19
20-29
500,000
30-39
40-49
50-59
60-69
70-79
80+
Female/BUC
20%
15%
10%
Female/ENG
5%
Male/BUC
0%
5%
Male/ENG
10%
15%
20%
Source: Buckinghamshire Healthcare NHS Trust; Index of Multiple Deprivation 2010; ONS Census 2011
Slide 8
Buckinghamshire Area Geographic Overview
The map on the right shows the location of the main sites belonging
to Buckinghamshire Healthcare Trust located in the South Central of
England. As shown on the map, Buckinghamshire is a rural-urban
area and located in proximity to London as well as to some major
roads.
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 elective market share of
Buckinghamshire Healthcare NHS Trust. From the wheel it can be
seen that Buckinghamshire has a 74% 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 48%
within 10 miles and 15% within 20 miles.
The wheel shows that the main competitors in the local area are
Oxford University Hospitals NHS Trust, Heatherwood and
Wexham Park Hospitals NHS Foundation Trust, and Milton
Keynes Hospital NHS Foundation Trust.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 9
Buckinghamshire Market Share analysis continued...
The wheel on the right shows the non-elective market share of
Buckinghamshire Healthcare NHS Trust. From the wheel it can be
seen that Buckinghamshire has an 85% 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 40%
within 10 miles and 13% within 20 miles.
The wheel shows that the main competitors in the local area are
Oxford University Hospitals NHS Trust, Heatherwood and
Wexham Park Hospitals NHS Foundation Trust, West
Hertfordshire Hospitals NHS Trust and Milton Keynes Hospital
NHS Foundation Trust.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 10
Buckinghamshire’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
Aylesbury Vale,
Chiltern &
Wycombe
The graph shows the level of deprivation in Aylesbury Vale, Chiltern
and Wycombe compared nationally.
The tables below outline Aylesbury Vale, Chiltern and Wycombe’s
health profile information in comparison with the rest of England.
1.
All three areas are
performing above
the national
average on almost
all indicators
within the
community
indicators. Only
Wycombe is
performing below
the national
average for violent
crime.
1
Source: Public Health Observatories – area health profiles
Slide 11
Buckinghamshire’s Health Profile
2. Aylesbury Vale,
Chiltern and
Wycombe are
above the national
average on all
indicators
relating to
children and
young people’s
health.
3. For adults’ health
and lifestyle, all
indicators are
within the
expected range.
However, it
should be noted
that all areas are
below the national
average for
higher risk
drinking and in
Chiltern there are
a fewer number of
physically active
adults than the
national average.
However, as
noted above, these
are still within the
expected levels.
2
3
Source: Public Health Observatories – area health profiles
Slide 12
Buckinghamshire’s Health Profile
4. In Aylesbury Vale
the rate of
malignant
melanoma is
significantly
higher than the
national average.
Also, Chiltern is
slightly outside of
the national
average. Other
disease and poor
health indicators
suggest all areas
are above the
national average
but show that hip
fracture in over
65s are more
common in
Aylesbury Vale
than the national
average. Once
again, the rate is
not significantly
different from the
national average.
4
Source: Public Health Observatories – area health profiles
Slide 13
Buckinghamshire’s Health Profile
5. Excess winter
deaths are below
average in
Aylesbury Vale,
Chiltern and
Wycombe. They
are all below the
national average
but there is no
significant
difference
compared to the
national average.
The life
expectancy and
cause of death
indicators also
highlight a high
number of infant
deaths in
Aylesbury Vale
compared to the
national average.
5
Source: Public Health Observatories – area health profiles
Slide 14
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 South Central Ambulance
Trust meets the 8min response
target. However, the Ambulance
Trust 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 15
Why was Buckinghamshire 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.
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 reviews of these five 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.
Buckinghamshire has been above the expected
level for HSMR over 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 16
Why was Buckinghamshire chosen for this review?
The way that levels of observed
deaths that are higher than
expected deaths can be
understood is by using HSMR
and SHMI. Both compare the
number of observed deaths to
the number of expected deaths.
This is different to avoidable
deaths. An HSMR and SHMI of
100 means that there is exactly
the same number of deaths as
expected. This is very unlikely
so there is a range within
which the variance between
observed and expected deaths
is statistically insignificant. On
the Poisson distribution,
appearing above and below the
dotted red and green lines
(95% confidence intervals),
respectively, means that there
is a statistically significant
variance for the trust in
question.
SHMI Time Series
SHMI Funnel Chart
Buckinghamshire
Selected trusts Outside Range
Selected trusts w/in Range
HSMR Time Series
HSMR Funnel Chart
Buckinghamshire
Selected trusts Outside Range
Selected trusts w/in Range
The funnel charts for 2010/11
and 2011/12, the period when
the trusts were selected for
review, show that
Buckinghamshire’s SHMI and
HSMR are statistically above
the expected range. This is
supported by the time series for
both SHMI and HSMR as they
are above the expected level for
the majority of the period.
Source: Healthcare Evaluation Data (HED); Apr 10-Mar12
Slide 17
Mortality
Slide 18
Mortality
Overview:
This section focuses upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The measures identified are being used as a ‘smoke alarm’ for
highlighting potential quality issues. No judgement about the actual
quality of care being provided to patients is being made at this stage,
nor should it be reached by looking at these measures in isolation.
Review areas
To undertake a detailed analysis of the trust’s mortality, it is
necessary to look at the following areas:
• Differences between the HSMR and SHMI;
• Elective and non-elective mortality;
• Specialty and Diagnostic groups; and
• Alerts and investigations.
Data sources
• Healthcare Evaluation Data (HED);
• Health & Social Care Information Centre – SHMI and contextual
indicators;
• Dr Foster – HSMR; and
• Care Quality Commission – alerts, correspondence and findings.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Summary:
The Trust has an overall HSMR of 117 for the period January
2012 to December 2012, meaning that the number of actual
deaths is higher than the expected level. This is statistically
above the expected range.
Deeper analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure,
with an HSMR of 117, also above the expected range. Elective
admissions are within the expected range, with an HSMR of 90.
Currently, Buckinghamshire 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, both with a
figure of 114, which is above the expected range. Elective
admissions are within the expected range.
Buckinghamshire was selected on the basis of its HSMR, but its
SHMI has been statistically higher than expected for 4 of the last
12 months. Its HSMR has been higher than expected for 3-4
years.
Mortality concerns appear to be focused within respiratory
medicine/elderly care, strongly associated with a mortality
outlier alert for patients admitted with pneumonia. The Trust
raised issues around clinical coding as well as process actions
around the emergency care pathway for patients with
pneumonia.
Buckinghamshire report above average activity associated with
palliative care.
Slide 19
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 20
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 21
SHMI Definition
What is the Summary Hospital-level Mortality Indicator?
The Summary Hospital-level Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department
of Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a
nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice.
How does SHMI work?
1.
2.
3.
4.
Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
The Indicator will utilise 5 factors to adjust mortality rates by
a.
The primary admitting diagnosis;
b.
The type of admission;
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities);
d.
Age; and
e.
Sex.
All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are
highlighted using a Random Effects funnel plot.
Slide 22
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 23
SHMI overview
Month-on-month time series
The Trust’s SHMI level for the 12 months from Dec11 to Nov12 is 114,
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 decreasing SHMI month-onmonth, and an initial decrease leading to a stable trend year-onyear.
SHMI funnel chart –12 months
Year-on-year time series
Buckinghamshire
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 24
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for
Buckinghamshire.
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.
Percentage of patient deaths in hospital
90%
85%
80%
Buckinghamshire 78.0%
75%
70%
65%
60%
Trusts selected for review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The data shows that 78.0% of
SHMI deaths occur in
hospital at Buckinghamshire,
which is higher than the
national average of 73.3%
and is the second highest of
all of the trusts selected for
review.
Slide 25
Treatment Specialties
SHMI 113
-
-
-
-
Gynaecological oncology
Midwife Episode
Clinical oncology
Interventional Radiology
-
-
-
-
Gynaecology
Gynaecological Oncology
Midwife Episode
Clinical Oncology
Interventional Radiology
Rheumatology
Obstetrics
Neurology
-
Medical Oncology
-
Thoracic Medicine
Gynaecology
Dermatology
-
Spinal Injuries
Geriatric Medicine
Cardiology
Paediatrics
Palliative Medicine (218; 76)
-
Rehabilitation
Well Babies
Diabetic Medicine
-
Clinical Haematology
Neonatology
Endocrinology
-
Gastroenterology
-
General Medicine (119; 159)
Rheumatology
Community Paediatrics
-
-
Paediatric Dermatology
Paediatrics
-
Paediatric Opthamology
Neurology
-
Critical Care Medicine (259; 62)
-
Rehabilitation
-
Pain Management
-
Clinical Haematology
-
Accident & Emergency (A&E)
Medical Oncology
Gastroenterology
-
Burns Care
-
General medicine
-
Plastic Surgery
Thoracic Medicine
Critical care medicine
-
Oral surgery
-
Pain Management
-
Ophthalmology
Dermatology
Burns Care
-
Ear, Nose and Throat (ENT)
-
Plastic Surgery
-
Trauma & Orthopaedics
Spinal Injuries
Oral Surgery
-
Vascular Surgery
-
Ophthalmology
-
Urology
Cardiology
Ear, Nose and Throat (ENT)
-
-
Trauma & Orthopaedics
Palliative medicine (465; 12)
Vascular Surgery
Treatment Specialties
SHMI 114
-
Urology
-
General Surgery
Key
Diagnosis (100 ; 1 )
-
The tree shows that
Buckinghamshire has a
SHMI of 114 which is
above the expected
range.
General Surgery
SHMI 114
-
-
Observed deaths that are higher
than the expected
SHMI
Non
Elective
The number of observed
deaths are highlighted
as being above the
expected level in
Palliative Medicine for
elective and non –
elective admissions, and
in Critical Care
Medicine, General
Medicine for nonelective admissions.
These are potential
areas for review.
Elective
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.
Overall
Trust
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Mortality - SHMI Tree
Slide 26
SHMI sub-tree of specialties
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.
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
General medicine has the highest number of greater than expected deaths. Acute and unspecified renal
failure (22) and pneumonia (45) are seen as the main diagnostic groups contributing to this.
Overall (114; 226)
Elective (113; 4)
Non-elective (114; 222)
Treatment Specialties
Critical Care Medicine (259; 62)
Acute cerebrovascular disease
Acute myocardial infarction
Pneumonia (except that
caused by tuberculosis or
sexually transmitted disease)
Septicemia (except in labor)
Key
Diagnosis (100 ; 1 )
SHMI
Observed deaths that are higher
than the expected
(684; 9)
(944; 7)
(226; 7)
(295; 6)
\
Diagnostic Groups
\
\
Palliative Medicine (465; 12)
118.2
General Medicine (119; 159)
Acute and unspecified renal failure
Acute bronchitis
Acute cerebrovascular disease
Acute myocardial infarction
Cancer of bladder
Cancer of breast
Cancer of bronchus; lung
Congestive heart failure;
nonhypertensive
Gastrointestinal hemorrhage
Liver disease; alcohol-related
Pneumonia (except that caused by
tuberculosis or sexually transmitted
disease)
Secondary malignancies
Urinary tract infections
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Palliative Medicine (218; 76)
(149; 22)
(121; 4)
(106; 6)
(184; 6)
(324; 6)
(234; 5)
(119; 5)
Cancer of bronchus; lung
Cancer of colon
Cancer of head and neck
Cancer of prostate
Secondary malignancies
(170; 7)
(217; 5)
(439; 4)
(192; 5)
(228; 14)
(134; 12)
(139; 5)
(179; 6)
(128; 45)
(115; 5)
(136; 14)
Slide 27
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, Buckingham shire
120
115
110
112
112
111
113
112
111
115
105
100
95
90
85
80
Mar-11
Jun-11
Sep-11
Dec-11
Mar-12
Jun-12
Sep-12
Rolling 12 months ending
Lower limit
Upper limit
SHMI
The SHMI for Buckinghamshire was 115 in the year to Sept-12
(England baseline = 100) and has been above the expected range
in the latest two periods (but within the expected range prior to
that).
The Trust was selected on the basis of its HSMR, but its SHMI
has been significantly higher than expected since June-12. It’s
HSMR has been higher than expected for three years.
Buckinghamshire have a fairly low percentage of out of hospital
deaths, so the SHMI may be as expected when the HSMR is high.
Source: Health & Social Care Information Centre – SHMI
Slide 28
HSMR overview
Month-on-month time series
The Trust’s HSMR for the 12 months from Jan 12 to Dec 12 is 117, which
means, as shown below, it is above the expected range and so is
classified as an outlier.
The time series show no real trend for HSMR year-on-year and monthon-month time series shows no real trend. Further to this, the month-onmonth time series fluctuates between extremes of 103 and 135, and the
year-on-year time series shows a large increase of 87 to 113 from 2008
to 2009 but a relatively stable trend following this.
HSMR funnel plot –12 months
Buckinghamshire
Selected trusts Outside Range
Selected trusts w/in Range
Year-on-year time series
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 29
HSMR Statistics
The table to the right shows
Buckinghamshire’s HSMR
broken down by admission
type.
The breakdown illustrates
the overall HSMR is 117
which is above the expected
range. The table identifies
that elective admissions
have an HSMR within the
expected range.
Both week and weekend
non-elective admissions
have an HSMR higher than
expected.
Key – colour by
alert level:
HSMR
Weekend
Week
All
Elective
0
95
90
Non-elective
130
113
117
Red – Higher than
expected (above the
95% confidence
interval)
All
130
112
117
Blue – Within
expected range
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Green – Lower than
expected (below the
95th confidence
interval)
The high non-elective
admissions contribute to the
weekend and week
admissions HSMR being
above the expected range.
Slide 30
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 (HSMR of 128, and 53 observed deaths that
are higher than the expected);
•
Acute cerebrovascular disease(122; 30);
•
Acute and unspecified renal failure (138; 21);
•
Congestive heart failure; nonhypertensive (121; 12) and
•
Secondary malignancies (126; 12)
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 31
-
-
-
Gynaecological Oncology
Clinical Oncology
Interventional Radiology
-
-
-
-
-
-
Geriatric Medicine
Obstetrics
Gynaecology
Gynaecological Oncology
Clinical Oncology
Interventional Radiology
Well Babies
Gynaecology
Neurology
-
Paediatrics
Medical Oncology
-
Medical Oncology
Thoracic Medicine
-
Thoracic Medicine
Dermatology
Stroke Medicine
Dermatology
Spinal Injuries
-
-
Spinal Injuries
Cardiology
-
Cardiology
Palliative Medicine (149; 31)
-
Palliative Medicine
Rehabilitation
-
Rehabilitation
Diabetic Medicine
Clinical Haematology
Clinical Haematology
Endocrinology
-
-
Gastroenterology
Gastroenterology
-
General Medicine (124; 142)
General Medicine
-
Community Paediatrics
-
-
Paediatric Diabetic Medicine
Critical Care Medicine
-
Paediatric Dermatology
-
-
Critical Care Medicine (268; 49)
Plastic Surgery
-
Pain Management
-
-
Accident & Emergency (A&E)
Ophthalmology
-
Burns Care
-
-
Plastic Surgery
Ear, Nose and Throat (ENT)
-
Ophthalmology
-
-
Ear, Nose and Throat (ENT)
Trauma & Orthopaedics
-
Trauma & Orthopaedics
-
-
Vascular Surgery
Urology
-
Urology
-
-
General Surgery
General Surgery
HSMR 117
-
-
Observed deaths that are higher
than the expected
HSMR
Non
Elective
Key
Diagnosis (100 ; 1 )
Treatment Specialties
HSMR 117
Within non-elective
admissions Critical Care
Medicine, General
Medicine and Palliative
Medicine have the highest
number of observed deaths
above the expected level
and so each have an HSMR
above the expected level.
Elective
Treatment Specialties
HSMR 90
The tree shows that the
HSMR for
Buckinghamshire is 117
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 the same level.
Elective admissions are
within the expected range.
Overall
Trust
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Mortality - HSMR Tree
Slide 32
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 several diagnostic groups with
pneumonia (42), acute cerebrovascualr disease (17), and acute and unspecified
renal failure (15) having the highest number of above expected deaths.
Overall118.2
(117; 184)
Non-elective (117; 184)
Treatment Specialties
Critical Care Medicine (268; 49)
General Medicine (124; 142)
Palliative Medicine (149; 31)
Diagnostic Groups
Acute cerebrovascular disease
(611; 10)
Acute myocardial infarction
(602; 6)
Pneumonia (except that caused by
tuberculosis or sexually transmitted
disease)
(306; 8)
Septicemia (except in labor)
Key
Diagnosis (100 ; 1 )
HSMR
Observed deaths that are higher
than the expected
(395; 6)
Acute and unspecified renal
failure
(137; 15)
Acute cerebrovascular disease
Aspiration pneumonitis;
food/vomitus
Congestive heart failure;
nonhypertensive
(118; 17)
Gastrointestinal hemorrhage
(186; 8)
Liver disease; alcohol-related
Pneumonia (except that caused
by tuberculosis or sexually
transmitted disease)
(167; 6)
Urinary tract infections
(134; 9)
Secondary malignancies
(224; 14)
(131; 5)
(141; 13)
(131; 42)
Slide 33
HSMR – Dr Foster
The HSMR time series for Buckinghamshire NHS Trust 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 all
financial years since 2008/09.
Buckinghamshire’s latest SHMI published by the HSCIC, for Oct
11 to Sept 12, is slightly higher than the Dr Foster HSMR for the
same period, which may be due to a number of factors.
Dr Foster have made the following adjustments to show
differences explained by these factors:
• 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.
Time series of HSMR,
Buckinghamshire
130
125
120
118
115
110
112
113
110
105
100
95
2008/09
2009/10
HSMR
I
2011/12
95% Confidence interval
Com parison of m ortality m easures,
Buckingham shire
130
122
120
The 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.
2010/11
115
111
110
107
100
SHMI
90
SHMI
adjusted for
palliative care
SHMI in
hospital
deaths only
HSMR
80
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 34
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.
The diagnosis coding depth
of elective patients at
Buckinghamshire was
performing below the
national average and the
average of the 14 trusts.
However, more recently, the
Trust has risen above the
national average and is
currently just above the
national average.
For non-elective patients,
Buckinghamshire’s average
coding depth has been
consistently below the
national average in the time
period shown.
Average Diagnosis Coding Depth
Elective
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Non-elective
6
5
4
3
2
1
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
Buckinghamshire
Buckinghamshire
2012/13
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 35
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.
1.8
1.6
1.4
1.2
1.0
0.8
0.6
0.4
0.2
-
Buckinghamshire ranks 17 out of 142 Acute trusts for use
of palliative care codes on admissions and 9 out of 142 for
the percentage of deaths with palliative care codes (Apr 13
SHMI contextual indicators). Although the majority of
palliative care is reported through diagnoses,
Buckinghamshire also use the palliative treatment
specialty, with around 11 palliative care inpatient beds in
Florence Nightingale Hospice and Stoke Mandeville.
Analysis of palliative care coding suggested that
Buckinghamshire’s SHMI would reduce by around 3% if
the treatment specialty use were accounted for in the
model (report by HSCIC, Feb 13). However, the report
found that the benefit of adjusting for the palliative care
treatment specialty was diminished by lack of consistent
coding between trusts.
Percentage of admissions with palliative
care coding
Oct-11
Jan-12
Apr-12
Buckinghamshire
35
Jul-12
Oct-12
National
Jan-13
Apr-13
u
SHMI publication
Percentage of deaths with palliative care
coding
30
25
20
15
10
5
-
Oct-11
Jan-12
Apr-12
Buckinghamshire
Jul-12
National
Oct-12
Jan-13
Apr-13
u
SHMI publication
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 36
Care Quality Commission findings
The 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.
Emergency specialty groups much worse than expected
Sep 11 to Aug 12
0
Emergency specialty groups worse than expected
Sep 11 to Aug 12
1
Respiratory medicine
Diagnosis group alerts (2007 to date)
For Buckinghamshire, the common theme that has arisen
across the patient groups alerting since 2007 is
Respiratory medicine, with reference also to Elderly Care.
Alerts to CQC
7
Alerts followed up by CQC
4
No common themes arise from responses to the CQC from
the Trust.
Mortality concerns appear to be focused within
respiratory medicine/elderly care, strongly associated
with the mortality outlier alert for patients admitted to
hospital with pneumonia. The Trust raised issues around
clinical coding as well as process actions around the
emergency care pathway for patients with pneumonia.
Recent diagnosis group alerts pursued by CQC
Pneumonia (Aug 11)
Any related patient groups alerting more than once since 2007
Pneumonia
Acute bronchitis
Other upper respiratory disease
Source: Care Quality Commission – alerts, correspondence and findings
Slide 37
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 five diagnosis groups and
no procedure groups with above expected SMRs in
Buckinghamshire, which may highlight potential areas for
review. One of these diagnosis groups, Pneumonia, had above
expected mortality for weekend admissions but not for
weekday ones.
Apr 2012 to Mar 2013
Diagnosis groups
Procedure groups
SMRs above expected
5
0
CUSUM alerts
5
1
Diagnosis groups with SMRs above expected
Acute and unspecified renal failure
Acute myocardial infarction
Congestive heart failure, nonhypertensive
Pneumonia
Secondary malignancies
SMR
132
150
132
121
144
Obs – Exp
deaths
16
11
18
37
18
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, Buckinghamshire had a CUSUM alert for
pneumonia. It also had four alerts for other diagnostic groups
and one for a procedure group that did not have a high SMR.
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 38
Mortality – other alerts
Variable Life Adjusted Display (VLAD) charts are produced by the
Health and Social Care Information Centre 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.
VLAD charts with a negative SHMI trend
(year to Jun-12)
•
•
No. dips to the
lower control limit
Cancer of bronchus/lung
Pneumonia
45
40
35
30
25
20
15
10
5
Buckinghamshire had such VLAD charts for two diagnosis groups in
the year to June 2012: Cancer of bronchus/lung and Pneumonia (see
table).
Buckinghamshire had a high proportion of deaths higher than
expected for Pneumonia (38 deaths, 18% more than expected) in the
HSCIC’s SHMI to September 2012.
2
2
Percentage of spells by deprivation quintile,
SHMI April 2013
1 Most
deprived
The Trust was selected on the basis of its HSMR, but its SHMI has
been higher than expected for 6 months or so. Its HSMR has been
higher than expected for 3-4 years. Buckinghamshire has a fairly
low percentage of out of hospital deaths, so the SHMI may be as
expected when the HSMR is high.
2
Buckinghamshire
60
3
National
4
5 Least
deprived
SHMI publication
Percentage of deaths by deprivation quintile,
SHMI April 2013
50
Dr Foster’s 2012 HSMR found Buckinghamshire above expected
mortality for weekend admissions but not for weekday ones. This is
different from the findings of HED (Jan 12– Dec 12) which sees both
as being above the expected range.
40
30
20
10
As shown by the graphs, Buckinghamshire serves one of the least
deprived patient populations nationally, reflected in the percentage
of both spells and deaths in the lowest quintile. This tends to reduce
expected deaths in the HSMR, although it is not taken account of in
the SHMI (methodologists concluded that it did not add sufficient
value to the model, but they show it as context).
Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.
1 Most
deprived
2
Buckinghamshire
3
National
4
5 Least
deprived
SHMI publication
Slide 39
Patient Experience
Slide 40
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 the Trust was rated ‘red’ on two measures: The
inpatient survey and a report from the complaints ombudsman.
Review Areas:
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; and
•
Cancer Patient Experience Survey.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
On the inpatient survey, the Trust was below the national
average overall, with poor scores on delays allocating patients
to a ward, poor information given to discharged patients, poor
communication on medication side effects, poor cleanliness, poor
hospital food and noise at night from other patients.
A separate report by the Ombudsman rates the Trust as C-rated
for satisfactory remedies of complaints and risk of noncompliance. This is the lowest category rating. The Trust has a
high number of nurse complaints, and is above average for
‘inadequate personal remedy’.
Slide 41
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 42
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
Inpatient Experience Survey
Buckinghamshire performs above average on survey questions relating to gaining admission to the hospital on the planned date, but
below average on a range of questions, including those relating to the length of time required to be allocated a bed on a ward,
information provided on post-discharge danger signals and medication side-effects, and hospital cleanliness.
Overall
Length of time spent on waiting list
Alteration of admission date by hospital
Length of time to be allocated a bed on a
ward
Overall
Delay of patient discharge
Consistency of staff communication
Information provided on post-discharge
danger signals
Overall
Staff communication on purpose of
medication provided
Patient involvement in decision-making
Staff communication on medication
side-effects
Overall
Clarity of doctors’ responses to
important questions
Language used by doctors in front of
patients
Clarity of nurses’ responses to
important questions
Language used by nurses in front of
patients
Overall
Hospital food
Patient noise levels at night
Degree of privacy provided
Staff noise levels at night
Level of respect shown by staff
Hospital/ward cleanliness
Overall staff effort to ease pain
Above expected range
Source: Patient Experience Survey 2012/13
Within expected range
Below expected range
Slide 43
Patient experience and patient voice
Inpatient
Overall patient experience score: Inpatients 2012
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
•
Buckinghamshire: 73.9 (two standard deviations
below average)
95
85
80
75
70
65
60
55
50
England
average
Cancer Survey
Of 58 Questions, 14 were in the ‘top 20%’ whilst 2 were in
the ‘bottom 20%’.
•
Patient Voice
PEAT results
•
Scores from patient environment action teams report a
number of ratings of ‘acceptable’ for environment at
Stoke Mandeville and Wycombe. Recent results are rated
‘good’.
Trusts in
this review
National
results curve
Source :Patient Experience Survey, Cancer patient experience survey
Complaints Handling
•
Data returns to the Health and Social Care Information
Centre showed 553 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, 46% of complaints related to clinical treatment, in
line with the national average of 47%.
•
A separate report by the Ombudsman rates the Trust as
C-rated for satisfactory remedies and low-risk of noncompliance. This is the lowest category. The Trust has a
high number of nurse complaints, and above average for
‘inadequate personal remedy’.
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 47 comments on Buckinghamshire, of which
30 were positive.
•
Buckinghamshire
90
Slide 44
Safety and workforce
Slide 45
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.
Buckinghamshire is ‘green rated’ in all of the safety indicators.
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 – Mar 2013;
•
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 recorded 932 incidents reported as either moderate,
severe or death between April 2011 and March 2012. Since 2009,
five ‘never events’ have occurred at Buckinghamshire, classified
as that because they are incidents that are so serious they should
never happen.
Throughout the last 12 months, the new pressure ulcer rate at
Buckinghamshire has been below the national average.
However, the Trust has a higher total pressure ulcer rate than
the national average and has been above the national average in
seven out of the last eight months.
Buckinghamshire is a net contributor to the Clinical Negligence
Scheme for Trusts. Contributions to the scheme have exceeded
payouts to litigants in each of the last 3 years, and in total by
£10.7m. There were 2 items flagged in the Rule 43 Coroner’s
reports.
Buckinghamshire is ‘red rated’ in 12 of the workforce indicators.
It notably has sickness absence rates for medical, nursing and
other staff above the national mean rate and has a higher staff
leaving rate and lower staff joining rate than the median within
the region. For training of its doctors, it has a lower score on
‘undermining’ than the national average. In addition, it is being
monitored by the GMC’s ‘response to concerns’ process.
Slide 46
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
932
Number of ‘never events’ (2009-2012)
5
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 47
Safety Analysis
The Trust has reported at the median level for patient
safety incidents in similar trusts. Buckinghamshire has
a rate of 6.7 for its patient safety incident reporting per
100 admissions.
Rate of reported patient safety incidents per 100 admissions (April –
September 2012)
Buckinghamshire
Median rate for medium acutes
6.7
6.7
Source: Incidents occurring between 1 April 2012 to 30 September
2012 and reported to the National Reporting and Learning System
Slide 48
Safety Incident Breakdown
Since 2009, five ‘never events’ have occurred at Buckinghamshire, classified as
that 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’. 54% of incidents which have been
reported at Buckinghamshire have been classed as ‘no harm’, with 30% ‘low’,
14% ‘moderate’, 1% ‘severe’ and seven occurrences classified as ‘death’.
When broken down by category, the most regular occurrences of patient
incident at Buckinghamshire are in ‘patient accident’ and ‘treatment,
procedure’.
Breakdown of patient
incidents by degree of harm
3500
Surgical Error
2
Other
1
Wrong site surgery
1
Unexpected Death of Inpatient
1
Total
5
Source: Freedom of information request, BBC http://www.bbc.co.uk/news/health-22466496
Breakdown of patient incidents by incident type
Consent, communication,…
3185
3000
2500
2000
Never Events Breakdown (2009-2012)
1753
Medical device / equipment
143
Documentation
172
Clinical assessment
236
Infrastructure
256
All others categories
297
Access, admission, transfer,…
1500
Implementation of care and…
851
1000
83
333
446
Medication
596
Treatment, procedure
500
74
7
Severe
Death
0
No Harm
Low
Moderate
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
A definition of serious harm is given in the Appendix.
1455
Patient accident
1853
0
500
1000
1500
2000
Source: National Patient Safety Agency (NPSA) . Apr 11 – Mar 12
Slide 49
Pressure ulcers
New pressure ulcers prevalence
35
This slide outlines the total
number of pressure ulcers and
the number of new pressure
ulcers broken down by
category for the last 12 months.
Due to the effects of seasonality
on hospital acquired pressure
ulcer rates, the national rate
has been included which allows
a comparison that takes this in
to account. This provides a
comparison against the
national rate as well as the 14
trusts selected for the review.
Throughout the last 12 months,
the new pressure ulcer rate at
Buckinghamshire has been
below the national average.
However, the Trust has a
higher total pressure ulcer rate
than the national average and
has been above the national
average in seven out of the last
eight months. This may
highlight an area for review.
An understanding of specific
case mix should be reviewed in
parallel to understand any root
causes.
Total pressure ulcers prevalence
1.7%
30
140
2.0%
1.8% 120
1.6%
1.2% 1.4% 100
1.2%
80
1.0%
0.8% 60
0.6%
0.4% 40
0.2%
20
0.0%
1.4%
1.4%
25
1.0%
0.9%
1.0%
20
15
0.6%
10
5
7.3%
1.7%
0.0%0.0%0.0%
-
5.9%
8.0%
7.3%
6.6%
7.0%
5.3%
5.9%
5.5%
5.4% 6.0%
5.0%
3.4%
4.0%
2.9%
3.0%
2.1%
2.0%
1.0%
0.0%
-
Category 2
Category 3
Category 4
Rate
0.0%
Category 2
Category 3
Category 4
Rate
New pressure ulcer analysis
Number of records submitted
Trust new pressure ulcers
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
48
29
0
1891
1758
1648
1589
1390
1553
1372
1321
1343
0
0
0
33
25
10
16
20
16
13
23
16
Trust new pressure ulcer rate
Selected 14 Trusts new pressure
ulcer rate
0.0%
0.0%
0.0%
1.7%
1.4%
0.6%
1.0%
1.4%
1.0%
0.9%
1.7%
1.2%
1.4%
1.5%
1.4%
1.5%
1.5%
0.9%
1.0%
1.1%
0.9%
1.1%
1.0%
1.2%
National new presseure ulcer rate
1.7%
1.7%
1.5%
1.5%
1.4%
1.3%
1.2%
1.2%
1.2%
1.3%
1.3%
1.3%
Total pressure ulcer prevalence percentage
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
48
29
0
1891
1758
1648
1589
1390
1553
1372
1321
1343
1
1
0
112
128
48
94
77
83
90
96
72
Trust total pressure ulcer rate
Selected 14 Trusts total pressure
ulcer rate
2.1%
3.4%
0.0%
5.9%
7.3%
2.9%
5.9%
5.5%
5.3%
6.6%
7.3%
5.4%
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%
Number of records submitted
Trust total pressure ulcers
Source: Safety Thermometer Apr 12 to Mar 13
Slide 50
Litigation and Coroner
Clinical negligence payments
Clinical negligence scheme analysis:
2009/10
Buckinghamshire is a net contributor to the Clinical
Negligence Scheme for Trusts. Contributions to the scheme
have exceeded payouts to litigants in each of the last 3 years,
and in total by £10.7m.
Coroners rule 43 reports flagged 2 separate items, to
consider the following:
i)
ii)
2010/11
2011/12
Payouts (£000s)
3,791
2,087
2,751
Contributions (£000s)
5,684
6,613
7,041
Excess of Payouts over
Contributions (£000s)
1,893
4,526
4,290
a review of the Trust's intubation training, procedures
and equipment in obstetric theatres
reviewing communication channels between medical
disciplines and the arrangements for handover of
patients.
Source :Litigation Authority Reports
Slide 51
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
2.83
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
2.39
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
0.29
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days) 459
Staff leaving rates
Nurse Hours per Patient Bed Day
9.44
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 52
General Medical Council (GMC) National Training Scheme Survey 2012
Cardiology
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
Dermatology
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…
Emergency 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
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 54
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
Geriatric 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
Rehabilitation medicine
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 55
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
Trauma and orthopaedic
surgery
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 Trust also had green outliers for the following:
•
Haematology – overall satisfaction;
•
Plastic surgery – handover and access to educational resources;
•
Respiratory medicine – overall satisfaction and adequate experience; and
•
Rheumatology – workload and access to educational resources.
Green outlier
Within expected range
Red outlier
Slide 56
Workforce Analysis
The Trust has a patient spell per whole time equivalent rate of 20, which is
the lowest of all the trusts in this review and below average capacity in
relation to nationally.
Number of FTEs (Dec 11-Nov 12 average)
4,779
Agency Staff (2011/12)
The consultant appraisal rate of Buckinghamshire is 55.9% which is the
second lowest of the trusts under review.
Buckinghamshire’s staff leaving rate is 8.8% which is higher than the
regional median average of 8.1%. The joining rate of 9.6% is lower than the
regional average.
Buckinghamshire
Expenditure
Percentage of
Total Staff Costs
Median within
Region
£7.7m
3.7%
3.8%
The data shows that the agency staff cost, as a percentage of total staff costs,
is just below the median within the region.
WTE nurses per bed day December 2012
Buckinghamshire
National Average
2.15
1.96
(Sep 11 – Sep 12)
Staff Turnover
Buckinghamshire
South Central SHA
Median
Joining Rate
9.6%
10.7%
Leaving Rate
8.8%
8.1%
Source: Health and Social Care Information Centre (HSCIC)
Consultant appraisal rate, 2011/12
Source: Acute Trust Quality Dashboard, Methods Insight
Spells per WTE for Acute Trusts
100%
50
80%
45
Buckinghamshire
Spells per WTE
40
60%
35
Buckinghamshire
40%
20
30
25
20
20%
15
10
0%
5
0
Trusts covered by review
Trusts covered by review
All other trusts
Buckinghamshire
All Trusts
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
Data based on the appraisal year from April 2011 to March 2012
Slide 57
Workforce Analysis continued…
Buckinghamshire’s total sickness absence rate is
higher than the South Central Strategic Health
Authority average but below the national
average. Despite being below the national
average at an overall level, for each of the more
granular categories investigated (medical,
nursing, and other staff), Buckinghamshire’s rate
was higher than the national average absence
rate.
Buckinghamshire has a medical staff to
consultant ratio above the average for all English
trusts, although its nurse staff to qualified staff
and non-clinical staff to total staff ratios are both
below their respective national averages. The
Trust’s registered nurse hours to patient day ratio
is also below the national mean.
The Trust’s consultant productivity rate is below
the national average.
Sickness Absence Rates
(2011-2012)
Buckinghamshire
South Central
SHA Average
National Average
3.82%
3.75%
4.12%
All Staff
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
Buckinghamshire
National Average
Medical Staff
1.6%
1.3%
Nursing Staff
5.1%
4.8%
Other Staff
4.9%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
Buckinghamshire
National Average
Medical Staff to Consultant Ratio
2.83
2.59
Nurse Staff to Qualified Staff Ratio
2.39
2.50
Non-Clinical Staff to Total Staff
Ratio
0.29
0.34
Registered Nurse Hours to Patient
Day Ratio *
9.44
8.57
Source: Electronic Staff Record (ESR), Apr 13
*Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Source: The Health and Social Care Information Centre Non-Medical
Workforce Census (Sept 2009), Vacancies Survey March 2010
Workforce indicator calculations are listed in the Appendix.
Consultant Productivity
(Spells/FTE)
Buckinghamshire
National Average
459
492
Source: Electronic Staff Record (ESR) April 13
Slide 58
Workforce Analysis continued…
National Staff Survey results
Buckinghamshire’s response rate to the
staff survey is higher than the average
and has risen in 2012. The staff
engagement score is in the lowest 1/5th
when compared with trusts of a similar
type, although it improved in 2012.
Buckinghamshire is significantly below
the national average on all three
organisational questions although all
have improved in 2012.
Buckinghamshire
2011
Average for all
trusts
2011
Buckinghamshire
2012
Average for all
trusts
2012
Response rate
50%
50%
52%
50%
Overall staff engagement
3.56
3.62
3.59
3.69
Care of patients/service
users in my organisation’s
top priority
49%
69%
54%
63%
I would recommend my
organisation a place to work
39%
52%
44%
55%
If a friend or relative needed
treatment, I would be happy
with the standard of care
provided by this organisation
51%
62%
53%
60%
Source: National Staff Survey 2011, 2012
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Source: GMC evidence to Review 2013
Data based on the appraisal year from April 2011 to March 2012
Slide 59
Deanery
The trust has been subject to enhanced monitoring since 2008, as a result of patient safety concerns. Doctors in training were
removed by the Deanery from one site at the trust and a number of visits have taken place to investigate the concerns. Whilst the
Deanery considers many of the concerns resolved, the trust is still being monitored under the response to concerns process.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
F2s in Emergency Medicine recorded the most below outliers between 2011 and 2012 (there were no outliers for 2010). F2s in
Surgery recorded the most above outliers in the same period. The indicators Induction, Adequate Experience and Overall Satisfaction
were all above outliers in 2011 and 2012 among Foundation Year 2s in surgery.
NTS 2012 Patient Safety Comments
6 doctors in training commented, representing 2.20% of respondents. This was less than half 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 senior cover, including at night;
•
A lack of continuity of care and appropriate team leadership;
•
Poor stocks of fluids in Paediatrics Emergency Medicine; and
•
Ward designed for fast patient turnover, but has problems coping with longer term patients.
Source: GMC evidence to Review 2013
Slide 60
Deanery Reports
Oxford Deanery reported concerns in the Buckinghamshire Healthcare NHS Trust in its 2011 annual report, and further concerns
were raised in 2012. Issues relating to supervision and understaffing were reported in both years. Concerns in Trauma and
Orthopaedic Surgery were also raised in both years - a 2011 survey negative outlier for clinical supervision was identified in F2Trauma and Orthopaedic Surgery, a concern around patient safety (caused by the lack of leadership) among F1 doctors in training
in Trauma and Orthopaedics was raised in 2012.
Monitored under the response to concerns process?
Yes, Buckinghamshire Healthcare NHS Trust has been monitored through the response to concerns process since November 2008,
when it was identified that clearer mechanisms needed to be in place for monitoring patient safety at Stoke Mandeville and
Wycombe Hospitals. A lack of middle grade Anaesthetics doctors created supervision issues, the location of Intensive Therapy Unit
(ITU) was too far away from operating theatres and doctors in training were working unsupervised remotely in Ophthalmic block.
A Deanery visit in June 2012 to Amersham and Stoke Mandeville Hospitals indicated that Dermatology doctors in training were
undertaking clinics without supervision. They reported excessive workloads, and excessive use of locum doctors which was having a
detrimental effect on training.
Deanery Action
Stoke Mandeville and Wycombe Hospitals:
Seven conditions were set during a deanery visit to the Anaesthetics programme, and action plans were set and agreed. A School of
Anaesthetics report sent in 29 January 2010 provided an update of conditions and an action plan; improvement was apparent and
the Deanery confirmed that all requirements had been met.
2010 survey indicated no negative outliers for the programme, with a positive outlier for handover. Clinical supervision scores for
anaesthetics across the Deanery were highest at another hospital in Trust. Deanery rated the programme as ‘satisfactory’ and
reported no further issues.
2011 survey results indicated a number of below outliers and the Dean reported a number of issues with supervision in ITU at High
Wycombe due to reduction in consultant numbers due to retirement and leave. The GMC supported the Deanery on a visit 2 March
2012, which confirmed the issues. The Deanery stopped placing new doctors in training in ITU at High Wycombe from August 2012,
and remaining doctors in training were moved by November 2012.
The Deanery confirmed that issues around trainee accommodation, accurate recording of hours/rota compliance, and lack of
consultants on the neonatal ward round have been fully resolved and the Deanery considers the issues to be 'closed‘.
Slide 61
Deanery Reports continued…
Deanery Action continued….
Amersham and Stoke Mandeville Hospitals:
The Deanery is working with the Trust to ensure additional Dermatology consultants are appointed. Short term plans include
training locum and SAS doctors to provide supervision. Plans are now in place to appoint additional consultants, and the Deanery
is closely monitoring supervision in the meantime.
A follow up visit took place on 21/11/12, which confirmed improvement around level of supervision, but there were remaining issues
with the levels of education.
The Deanery has set a number of requirements for the Trust and the department, and will be carrying out a Deanery-wide review of
the specialty.
The Deanery will closely monitor the Trust action plans and supervision arrangements. It has been asked to report to the GMC in
April 2013.
GMC Action
Deanery Reports and Trust action plans closely monitored.
To continue to support and feed back to the Deanery in a coordinated way, and involve our Response to Concerns Assessment Team
if improvement is not forthcoming.
Undermining
For doctors undertaking training at Buckinghamshire,
the trust has a score on the National Training Survey on
undermining of 92.7 which is below the national average
of 94. It is in the bottom 1/6 of the distribution across all
training organisations
Slide 62
Clinical and operational
effectiveness
Slide 63
Clinical and Operational Effectiveness
Overview:
The following section provides an insight in to 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:
Buckinghamshire is at the lower end of the distribution for the
percentage of diabetic patients receiving a foot risk assessment
due to low scores at both Stoke Mandeville and Amersham
Hospitals. A key measure of clinical effectiveness is the
percentage of discharged patients who are prescribed beta
blockers and Stoke Mandeville was outside the control limits and
is therefore an outlier on this measure.
The Trust sees 92% of A&E patients within 4 hours which is
below the 95% target level. The percentage of patients seen
within 4 hours generally decreases during 2012. 93.7% of
patients start treatment within the 18 week target time which is
above the target level. This has been a consistent trend from
April 2012 to March 2013.
Buckinghamshire’s crude readmission rate is among the lower
readmission rates of the trusts in the review as well as
nationally, at 9.2%. The Trust’s standardised readmission rate
shows a level of performance that is statistically within what is
expected. The Trust’s average length of stay is shorter than that
of the national average, at 4.92 days.
The PROMs dashboard shows that Buckinghamshire was a
consistent performer overall. None of the indicators fell outside
of the control limits for the 3 years shown in the dashboard.
Slide 64
Clinical and Operational Effectiveness
Clinical
effectiveness
This page shows the Clinical and Operational Effectiveness measures which are considered to be the most pertinent for this review.
Further analysis, where relevant, is detailed in the following pages.
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
A&E Waits
Hip Replacement EQ-5D
Knee Replacement EQ-5D
Varicose Vein EQ-5D
Hip Replacement OHS
Outcome 1 (R17)
and involving
people who use services
KneeRespecting
Replacement
OKS
Groin Hernia EQ-5D
Not applicable
Outside expected range
Within expected range
Slide 65
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
Diabetes
Elective Surgery
Safety Measure
Clinical Audit
Proportion with medication
error
Proportion experiencing
severe hypoglycaemic
episode
Neonatal intensive and special care
(NNAP)
Proportion of women receiving antenatal steroids
Diabetes
Proportion foot risk assessment
Adult Critical Care
Standardised hospital mortality ratio
Proportion of patient reported
post-operative complications
Coronary angioplasty
Acute Myocardial Infarction
Proportion receiving primary PCI
within 90 mins
Elective abdominal aortic aneurysm
post-op mortality
Proportion having surgery within 14
days of referral
Proportion discharged on beta-blocker
Acute Stroke
Proportion compliant with 12 indicators
Heart Failure
Proportion referred for cardiology
follow up
90 day post-op mortality
Peripheral vascular surgery
Adult Critical Care (ICNARC
CMPD)
Effectiveness Measures
Proportion of night-time
discharges
Carotid interventions
Bowel cancer
Hip Fracture
Elective surgery (PROMS)
Severe Trauma
Hip, knee and ankle
Lung Cancer
Source: Clinical Audit Data Trust, CQC Data Submission.
30 day mortality
Proportion operations within 36 hrs
Mean adjusted post-operative score
Proportion surviving to hospital
discharge
Standardised revision ratio
Proportion small cell patients receiving
chemotherapy
Slide 66
Clinical effectiveness: Clinical Audits
StokeMandeville
Mandeville Hospital:
Hospital:
Stoke
Received a foot risk assessment during the
hospital stay 2012
Received a foot risk assessment during the hospital stay 2012
The National Diabetes Inpatient Audit for 2012 found
relatively low scores for the percentage of diabetic patients
receiving a foot risk assessment at Stoke Mandeville and also
at Amersham Hospital.
100%
80%
Each graph ranks the percentage of patients with diabetes at
each hospital that reported that they received a foot risk
assessment during their stay.
60%
The red line in each graph shows where this specific hospital
ranks.
20%
40%
0%
Amersham
Hospital:
Amersham
Hospital:
Received a foot risk assessment during the
hospital stay 2012
Received a foot risk assessment during the hospital stay 2012
100%
80%
60%
40%
20%
0%
Source: http://www.hscic.gov.uk/catalogue/PUB10506/nati-diab-inp-audi-12-comp.xlsx
Note: Caution should be taken when looking at the data for some sites in these summaries as they may be based on a small sample of inpatients with diabetes. This
Slide 67
means that a small variation would have a substantial impact on the indicators presented.
Clinical effectiveness: Clinical Audits
In the National Clinical Audit for Acute Myocardial
Infarction, a key measure of effectiveness is the percentage
of discharged patients who are prescribed beta blockers.
Stoke Mandeville was outside the control limits and is
therefore an outlier.
Percentage of patients prescribed beta blockers on
discharge by hospital in England, plotted against total
number of discharges, 2011/12
100%
95%
90%
85%
80%
75%
Stoke
StokeMandeville
Mandeville
70%
65%
60%
0
200
400
600
800
1000
1200
1400
1600
Source: National Institute for Cardiovascular Outcomes Research (NICOR)
Slide 68
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
A&E Percentage of Patients Seen
within 4 Hours
Buckinghamshire
92%
105%
100%
95%
90%
Buckinghamshire sees
92% of A&E patients
within 4 hours which is
below the 95% target
level. The time series
graph reflects this as
there has been a
generally decreasing
trend from January
2012.
93.7% of patients are
seen within the 18 week
target time which is
above the target level.
In addition, the time
series shows that
Buckinghamshire has
been consistently
performing above the
target rate.
85%
80%
Buckinghamshire 4 Hour A&E Waits
Attendances (Thousands)
A&E wait times and
RTT times may
indicate the
effectiveness with
which demand is
managed.
12
100%
10
95%
8
90%
6
85%
4
2
80%
0
75%
75%
70%
Trusts Covered by Review
All Trusts
Number of patients seen within 4 hours
A&E Target 95%
Patients Not Seen
Seen within 4 hours (%)
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Referral to Treatment (Admitted)
Buckinghamshire Referral to Treatment
Performance
105%
100%
Buckinghamshire
93.7%
95%
94%
93%
95%
92%
90%
91%
90%
85%
89%
80%
88%
87%
75%
Trusts Covered by Review
RTT Target 90%
Source: Department of Health. Feb 13
All Trusts
Referral to Treatment Rate
Source: Department of Health. Apr 12 – Feb 13
RTT Target 90%
Slide 69
Operational Effectiveness – Emergency Re-admissions and Length of Stay
Buckinghamshire’s crude
readmission rate is among
the lower readmission rates
of the trusts in the review as
well as nationally, at 9.2%.
25%
20%
Buckinghamshire
9.2%
15%
10%
5%
0%
The standardised
readmission rate, most
importantly, accounts for
the trust’s case mix and
shows Buckinghamshire is
statistically within the
expected range.
Trusts Covered by Review
Buckinghamshire
Selected trusts Outside
Selected trusts w/in Range
All Trusts
Average Length of Stay by Trust
10
9
Spell Duration (Days)
Buckinghamshire’s average
length of stay is 4.92 days,
which is shorter than the
national mean average of
5.2 days.
Standardised 30-day Readmission
Rate
Crude Readmission Rate by Trust
Crude Readmission Rate
Readmission rates may
indicate the
appropriateness of
treatment offered, whilst
average length of stay may
indicate the efficiency of
treatment.
8
7
6
Buckinghamshire
4.92
5
4
3
2
1
0
Trusts Covered by Review
Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12
All Trusts
Slide 70
PROMs Dashboard
PROMs Dashboard Analysis
The PROMs dashboard shows that Buckinghamshire is
a consistent performer, close to the national average
on all measures for all years.
Knee Replacement OKS
20
15
England Average
Buckinghamshire
10
Upper Control Limit
5
Lower Control Limit
2
20
11
/1
1
20
10
/1
20
09
/1
0
0
Source: PROMs Dashboard and NHS Litigation Authority
Slide 71
Leadership and
governance
Slide 72
Leadership and governance
Overview:
Summary:
This section provides an indication of the Trust’s governance
procedures.
The Trust Board is relatively stable with two recent changes at
Board level: the Chair joined the Trust in September 2012 and
the Chief Operating Officer joined the Trust in Feb 2013. The
Director of Human Resources (non-voting, in post since Jan
2013) is an interim post but all the other executive positions are
substantive.
Review Areas:
To provide this indication of the Trust’s leadership and
governance procedures, the following areas have been reviewed:
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Healthcare Governance Committee is chaired by a non
executive (Keith Gilchrist) and reports directly to the Trust
Board. The Trust has also established a Mortality Task Force.
A review of quality governance was performed by KPMG in
October 2012. This review compared the governance
arrangements in the Trust against Monitor’s Quality
Governance Framework. KPMG scored the Trust 3.0 (trusts
must achieve a score below 4 to be authorised as a foundation
trust).
Key risks identified by the Trust relate to Accident & Emergency,
staffing, the National Spinal Injuries Centre, theatres and Care
of Older People.
Slide 73
Leadership and governance
Leadership and
governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in
the following pages.
Monitor governance risk rating
n/a
Monitor finance rating
n/a
Governance risk rating
Red - Likely or actual significant breach of terms of authorisation
Amber-red - Material concerns surrounding terms of authorisation
Amber-green - Limited concerns surrounding terms of authorisation
Green - No material concerns
CQC Outcomes
CQC Concerns
Red – Major concern
Amber – Minor or Moderate concern
Green – No concerns
Financial risk rating
rated 1-5, where 1 represents the highest risk and 5 the lowest
Slide 74
Leadership and governance
Trust Board
The Trust Board is relatively stable with two recent changes at Board level: the Chair joined the Trust in September 2012 and the Chief
Operating Officer joined the Trust in Feb 2013. The Director of Human Resources (non-voting, in post since Jan 2013) is an interim post but
all the other executive positions are substantive. There are five executive posts: Chief Executive, Director of Finance, Chief Operating
Officer, Medical Director and Chief Nurse & Director of Patient Care Standards.
Governance and clinical structures
In November 2012 the Trust undertook a wide scale reconfiguration called Better Healthcare in Buckinghamshire. This reconfiguration led
to consolidation of specialist clinical services on specific sites. Each of the three clinical divisions (Integrated Medicine, Surgery and Critical
Care and Specialist Services) is clinically led by a divisional chair; presently within the Trust Divisional Chairs are doctors. Divisional
chairs report to the chief operating officer. Responsibility for the operational running and governance of each division is shared with an
associate chief nurse and an assistant chief operating officer. The Divisional Boards also report to the Trust Management Committee where
quality and organisational operational business is discussed.
There are a number of Board sub-committees, including the Healthcare Governance Committee, Audit Committee and Trust Management
Committee. The Healthcare Governance Committee, the forum for discussion of clinical governance matters ,reports directly to the Trust
Board. The Healthcare Governance Committee is chaired by a non executive director (Keith Gilchrist). The Healthcare Governance
Committee has several sub-committees including the Risk Monitoring Group and Infection Control Committee.
The Trust has established a Mortality Task Force, chaired by the Medical Director, which has a special remit to review patient care, the
patient experience and clinical coding.
The Trust committee structure and board members are shown in the Appendix.
External reviews
Details of these are given overleaf.
Slide 75
Top risks to quality
The table includes the top risks and significant challenges identified by the Trust.
Trust identified risks
Trust response
Accident and Emergency:
Post reconfiguration the performance of the four hour A&E
access targets had dropped (93.6% for 2012/13). This has led to
a diminution in patient experience as patients are in A&E for an
unacceptable time. Also it is recognised that whilst work has
been ongoing to improve the A&E environment, until this is
complete it is not the ideal care environment for patients.
Sir Jonathan Ashridge undertook a review of the service following
which he produced a report highlighting his concerns and made
recommendations. An action plan was produced to mitigate the risk.
The report also included the need to move to one site which was
undertaken as described above.
In February of this year the new COO invited in the national
Emergency Care Intense Support Team (ECIST) to review the A&E at
Stoke Mandeville. A report has been received in April and an action
plan is being developed around the findings.
Staffing:
The Trust recognises that in 2012/13 there was a need to reduce
the number off temporary staff and it is acknowledged that this
can have an impact on quality of care.
The Trust has aimed to mitigate the risk to the quality of care relating
to bank and agency staff by reviewing aspects of their role, for
example, restricting the administration of intravenous medicines to
Trust employed staff only who have undergone the relevant training.
There is also e-rostering in place with a new bank partner to help
manage and monitor our temporary staffing and importantly there is
an escalation process in place for the use of temporary staff.
A recent CQC inspection has raised concerns around staffing
and some supervision issues and declared these as moderate
concern although it did not have a concern around patient care.
Slide 76
Top risks to quality
The table includes the top risks and significant challenges identified by the Trust.
Trust identified risks
Trust response
National Spinal Injuries Centre:
In 2011 a number of clinical incidents relating to the NSIC were
highlighted to the Trust executive. These incidents had been
reported by junior doctors through a Deanery visit and had not
been reported through other mechanisms. The issues related to
some staff not working within procedures and policies of the
treatment of the acute spinal patients.
The Deanery informed the executive and prompt action was taken.
The ward in question was closed to new patients and a review of the
area was undertaken and actions put in place.
There was also a recent case where a patient had not received the
correct level of ventilation support again by individuals not following
procedures. There has been a robust plan around this including a
review of staff numbers and staff training in this area.
The risk now lies at a lower level on the risk register however this
continues to be monitored to ensure that changes are embedded in
the unit and have a long term impact.
Theatres:
Over the last three years there have been six never events in
theatres; two occurring in 2012/13.
In addition there were concerns that theatres had an unhealthy
culture of behaviours and leadership issues.
Each of these has been reported and investigated as a Serious Event
and a root cause analysis investigation undertaken and which was
presented to the Serious Event Review Group. In each case actions
have completed to reduce the risk of occurrence of such incidents.
The Trust invited an external team from North West London NHS
Trust to review theatres. An active performance management process
and the historical concerns continue to be closely monitored.
Care of Older People:
The Trust is aware that nationally there is a rightful focus on the
care of older people using NHS services, and the Trust takes the
care of this vulnerable group of patients very seriously.
The recent Health Overview and Scrutiny Committee reports evidence
of good practice and the Trust want to see best practice consistently
applied across the whole organisation
Slide 77
Leadership and governance – other areas for further review
External reviews
The CQC April 2013 report of an inspection carried in Mar 2013 indicates the following:
There is an Enforcement Action in place for Stoke Mandeville Hospital for Outcome 14 (Staff should be properly trained and supervised,
and have the chance to develop and improve their skills)
Improvements are required for Outcome 13 at Stoke Mandeville Hospital (There should be enough members of staff to keep people safe and
meet their health and welfare needs)
Improvements are required for Outcome 13 at Amersham Hospital(There should be enough members of staff to keep people safe and meet
their health and welfare needs)
The August 2012 CQC report of Wycombe Hospital indicated that all standards are being met.
A Quality Governance Review was conducted by KPMG in October 2012. The Trust’s position was assessed and scored using Monitor’s
scoring methodology as detailed in “Applying for NHS Foundation Trust Status-Guide for Applicants” (July 2010). Each area of the 10
questions was scored. The findings identified no Red areas, no Amber/Red areas, 6 Amber/Green areas and 4 Green areas. The Trust’s
overall score was calculated as being 3.0. This assumes that the Trust continues to implement identified actions and that the new systems
and processes recently implemented become embedded in the Trust, in particular, the new divisional structure. From the review, it was
noted quality impact assessments are in place for cost improvement programmes(CIPs), but the monitoring of the impact of CIPs on quality
could be better enhanced by understanding the pre-implementation performance.
Postgraduate Dean’s annual visit to Buckinghamshire Healthcare NHS Trust in June 2012 reported that although the Deanery focused on
two main areas of concern (Anaesthetics/ICM and Dermatology), overall, the visiting team’s impression of the Trust was very positive.
Who Cares? A report into the Care of Older People in Hospital Wards by Buckinghamshire County Council Health Overview & Scrutiny
Committee Task and Finish Group, dated October 2012: The report makes a number of recommendations to the BHT Board, which are
considered will raise both the standard of care, and consistency of care across its wards. The report recommendations therefore apply to
all wards and not just those specialising in care for older patients.
Cost Improvement Programme
There was an overall £800k shortfall in the CIP target for 2012/13.
The efficiency plans for the clinical divisions for 2013/14 include:
Surgery: £3,499k (31.78 WTEs)
Integrated medicine: £3,960k (35.97 WTEs)
Specialist services: £4,980k (45.24 WTEs)
Slide 78
Appendix
Slide 79
Trust Map – Stoke Mandeville Hospital
Source: www.medical-architecture.com
Slide 80
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 81
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
FTE whose job role is ‘Consultant’
Denominator
FTE in ‘Medical and Dental’ Staff Group
Numerator
FTE in ‘Nursing & Midwifery Registered’ Staff Group
Denominator
FTE of Additional Clinical Services – 85% of bands 2, 3 and 4
Numerator
FTE not in ‘Nursing and Midwifery Registered’, ‘Additional Clinical
Services,’ ‘Allied Health Professionals’ or ‘Medical and Dental’ staff
groups
Denominator
Sum of FTE for all staff groups
Numerator
Consultant FTE’s
Denominator
Total Bed Days
Numerator
Nurse FTE’s 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
(FTE/Bed Days)
Nurse hours per patient day
HED
ESR
ESR
ESR
ESR
ESR
ESR
HED
Note: ESR Data only includes substantive staff.
Slide 82
Board of Directors
Source: Management_structure_chart_28.02.13.pdf" - Trust submission folder 6
Slide 83
Overall governance structure chart
TRUST BOARD
Monthly
ASSURANCE
HEALTHCARE
GOVERNANCE
AUDIT
Bi-monthly
Bi-Monthly
STATUTORY
Nominations
and
Remuneration
Committee
As and when
necessary
Source: MASTER-Governance structures Vs 7 August 2012.ppt" - Trust submission folder 7
CHARITABLE
FUNDS
OPERATIONAL
TRUST
MANAGEMENT
COMMITTEE
Quarterly
Monthly
Slide 84
Integrated governance assurance committees
Trust Board
Healthcare Governance
Committee
Divisional Boards
Integrated Medicine
Risk
Monitoring
Group
Audit Committee
Infection
Control
Committee
Drug and
Therapeutics
Committee
Organ &Tissue
Donation
Committee
Surgery and Critical Care
Specialist Services
Footnote: this depicts risk and assurance process, not operational
management
Source: MASTER-Governance structures Vs 7 August 2012.ppt" - Trust submission folder 7
Slide 85
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 86
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 87
SHMI Appendix
Diagnostic Group
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
SHMI
Elective
315 – Palliative Medicine
Cancer of esophagus
1476
1
Elective
315 – Palliative Medicine
Cancer of colon
3995
1
Elective
315 – Palliative Medicine
Cancer of rectum and anus
1587
1
Elective
315 – Palliative Medicine
Cancer of bronchus; lung
1832
1
Elective
315 – Palliative Medicine
Cancer of prostate
980
3
Elective
315 – Palliative Medicine
Non-Hodgkin`s lymphoma
1583
1
Elective
315 – Palliative Medicine
Multiple myeloma
891
1
Elective
315 – Palliative Medicine
Secondary malignancies
814
2
Elective
315 – Palliative Medicine
Deficiency and other anemia
4285
2
Elective
315 – Palliative Medicine
Pleurisy; pneumothorax; pulmonary collapse
671
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Cancer of bronchus; lung
220
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Non-Hodgkin`s lymphoma
2368
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Leukemias
740
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Coma; stupor; and brain damage
309
2
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Coronary atherosclerosis and other heart disease
6489
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Pulmonary heart disease
1299
2
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Cardiac arrest and ventricular fibrillation
111
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
7522
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Phlebitis; thrombophlebitis and thromboembolism
Chronic obstructive pulmonary disease and
bronchiectasis
782
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Asthma
3541
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Pleurisy; pneumothorax; pulmonary collapse
292
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Esophageal disorders
2480
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Abdominal hernia
521
2
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Diverticulosis and diverticulitis
1052
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Peritonitis and intestinal abscess
331
1
Slide 88
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Liver disease; alcohol-related
306
3
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Other liver diseases
294
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Pancreatic disorders (not diabetes)
1170
2
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Gastrointestinal hemorrhage
595
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Other gastrointestinal disorders
1239
3
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Acute and unspecified renal failure
173
2
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Urinary tract infections
497
2
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Other connective tissue disease
979
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Other fractures
763
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Intracranial injury
329
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Complications of surgical procedures or medical care
725
2
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Poisoning by psychotropic agents
989
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Poisoning by other medications and drugs
1718
2
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Poisoning by nonmedicinal substances
5305
1
Non-elective
192 - Critical Care Medicine (also known as intensive care medicine)
Other injuries and conditions due to external causes
1946
1
Non-elective
300 - General medicine
Tuberculosis
779
1
Non-elective
300 - General medicine
Bacterial infection; unspecified site
364
1
Non-elective
300 - General medicine
Cancer of esophagus
160
3
Non-elective
300 - General medicine
Cancer of stomach
171
2
Non-elective
300 - General medicine
Cancer of colon
205
3
Non-elective
300 - General medicine
Cancer of rectum and anus
164
2
Non-elective
300 - General medicine
Cancer of liver and intrahepatic bile duct
184
1
Non-elective
300 - General medicine
Cancer of pancreas
123
2
Non-elective
300 - General medicine
Cancer of bone and connective tissue
155
1
Non-elective
300 - General medicine
Cancer of uterus
219
2
Slide 89
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General medicine
Cancer of cervix
229
1
Non-elective
300 - General medicine
Cancer of other male genital organs
488
1
Non-elective
300 - General medicine
Cancer of kidney and renal pelvis
164
1
Non-elective
300 - General medicine
Leukemias
172
2
Non-elective
300 - General medicine
Multiple myeloma
235
1
Non-elective
300 - General medicine
Malignant neoplasm without specification of site
141
2
Non-elective
300 - General medicine
Neoplasms of unspecified nature or uncertain behavior
176
1
Non-elective
300 - General medicine
Diabetes mellitus without complication
231
1
Non-elective
300 - General medicine
Diabetes mellitus with complications
139
1
Non-elective
300 - General medicine
Other CNS infection and poliomyelitis
218
1
Non-elective
300 - General medicine
Other hereditary and degenerative nervous system conditions
246
2
Non-elective
300 - General medicine
Epilepsy; convulsions
135
2
Non-elective
300 - General medicine
3123
1
Non-elective
300 - General medicine
1751
1
Non-elective
300 - General medicine
Retinal detachments; defects; vascular occlusion; and retinopathy
Inflammation; infection of eye (except that caused by tuberculosis or sexually
transmitted disease)
Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by tuberculosis
or sexually transmitted disease)
137
1
Non-elective
300 - General medicine
Hypertension with complications and secondary hypertension
275
1
Non-elective
300 - General medicine
Coronary atherosclerosis and other heart disease
229
2
Non-elective
300 - General medicine
Other and ill-defined cerebrovascular disease
1091
3
Non-elective
300 - General medicine
Peripheral and visceral atherosclerosis
141
1
Non-elective
300 - General medicine
Aortic; peripheral; and visceral artery aneurysms
134
1
Non-elective
300 - General medicine
Asthma
284
2
Non-elective
300 - General medicine
Aspiration pneumonitis; food/vomitus
119
3
Non-elective
300 - General medicine
Other lower respiratory disease
125
1
Non-elective
300 - General medicine
Appendicitis and other appendiceal conditions
337
1
Non-elective
300 - General medicine
Regional enteritis and ulcerative colitis
264
1
Slide 90
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General medicine
Intestinal obstruction without hernia
144
1
Non-elective
300 - General medicine
Diverticulosis and diverticulitis
202
1
Non-elective
300 - General medicine
Peritonitis and intestinal abscess
790
3
Non-elective
300 - General medicine
Biliary tract disease
181
2
Non-elective
300 - General medicine
Other liver diseases
113
1
Non-elective
300 - General medicine
Chronic renal failure
249
2
Non-elective
300 - General medicine
Other diseases of kidney and ureters
413
1
Non-elective
300 - General medicine
Genitourinary symptoms and ill-defined conditions
212
1
Non-elective
300 - General medicine
Skin and subcutaneous tissue infections
128
2
Non-elective
300 - General medicine
Chronic ulcer of skin
197
2
Non-elective
300 - General medicine
Other non-traumatic joint disorders
236
1
Non-elective
300 - General medicine
Spondylosis; intervertebral disc disorders; other back problems
151
1
Non-elective
300 - General medicine
Pathological fracture
282
1
Non-elective
300 - General medicine
Fracture of neck of femur (hip)
348
1
Non-elective
300 - General medicine
Fracture of upper limb
189
1
Non-elective
300 - General medicine
Other fractures
181
1
Non-elective
300 - General medicine
Intracranial injury
120
1
Non-elective
300 - General medicine
Crushing injury or internal injury
330
1
Non-elective
300 - General medicine
Syncope
124
1
Non-elective
300 - General medicine
Shock
310
1
Non-elective
315 – Palliative Medicine
Abdominal pain
201
1
Non-elective
315 – Palliative Medicine
Cancer of esophagus
178
2
Non-elective
315 – Palliative Medicine
Cancer of stomach
246
3
Non-elective
315 – Palliative Medicine
Cancer of rectum and anus
345
2
Non-elective
315 – Palliative Medicine
Cancer of liver and intrahepatic bile duct
161
1
Slide 91
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
315 – Palliative Medicine
Cancer of pancreas
132
1
Non-elective
315 – Palliative Medicine
Cancer of other GI organs; peritoneum
250
1
Non-elective
315 – Palliative Medicine
Cancer; other respiratory and intrathoracic
356
1
Non-elective
315 – Palliative Medicine
Cancer of bone and connective tissue
168
1
Non-elective
315 – Palliative Medicine
Cancer of breast
181
3
Non-elective
315 – Palliative Medicine
Cancer of uterus
159
1
Non-elective
315 – Palliative Medicine
Cancer of cervix
413
1
Non-elective
315 – Palliative Medicine
Cancer of ovary
222
2
Non-elective
315 – Palliative Medicine
Cancer of brain and nervous system
277
1
Non-elective
315 – Palliative Medicine
Leukemias
243
1
Non-elective
315 – Palliative Medicine
Multiple myeloma
561
1
Non-elective
315 – Palliative Medicine
Cancer; other and unspecified primary
263
2
Non-elective
315 – Palliative Medicine
Malignant neoplasm without specification of site
162
2
Non-elective
315 – Palliative Medicine
Other hereditary and degenerative nervous system conditions
688
1
Non-elective
315 – Palliative Medicine
1198
1
Non-elective
315 – Palliative Medicine
Other nervous system disorders
Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by tuberculosis
or sexually transmitted disease)
7867
1
Non-elective
315 – Palliative Medicine
Congestive heart failure; nonhypertensive
423
2
Non-elective
315 – Palliative Medicine
Pneumonia (except that caused by tuberculosis or sexually transmitted disease)
388
3
Non-elective
315 – Palliative Medicine
Acute bronchitis
347
1
Non-elective
315 – Palliative Medicine
Pleurisy; pneumothorax; pulmonary collapse
425
1
Non-elective
315 – Palliative Medicine
Lung disease due to external agents
319
1
Non-elective
315 – Palliative Medicine
Intestinal infection
382
1
Non-elective
315 – Palliative Medicine
Other disorders of stomach and duodenum
2710
1
Non-elective
315 – Palliative Medicine
Intestinal obstruction without hernia
601
1
Non-elective
315 – Palliative Medicine
Urinary tract infections
635
2
Slide 92
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
315 – Palliative Medicine
Other connective tissue disease
Non-elective
315 – Palliative Medicine
231 - Other fractures
Observed Deaths that
are higher than the
expected
SHMI
3368
3
669
1
Slide 93
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
HSMR
Non-elective
192 - Critical care medicine
Acute and unspecified renal failure
174
2
Non-elective
192 - Critical care medicine
Cancer of bronchus; lung
411
1
Non-elective
192 - Critical care medicine
Chronic obstructive pulmonary disease and bronchie
1153
1
Non-elective
192 - Critical care medicine
Coronary atherosclerosis and other heart disease
9759
1
Non-elective
192 - Critical care medicine
Gastrointestinal hemorrhage
192
1
Non-elective
192 - Critical care medicine
Intracranial injury
283
1
Non-elective
192 - Critical care medicine
Leukemias
709
1
Non-elective
192 - Critical care medicine
Liver disease; alcohol-related
435
3
Non-elective
192 - Critical care medicine
Non-Hodgkin`s lymphoma
859
1
Non-elective
192 - Critical care medicine
Other fractures
715
1
Non-elective
192 - Critical care medicine
Other gastrointestinal disorders
1640
2
Non-elective
192 - Critical care medicine
Other liver diseases
214
1
Non-elective
192 - Critical care medicine
Peritonitis and intestinal abscess
196
1
Non-elective
192 - Critical care medicine
Pleurisy; pneumothorax; pulmonary collapse
531
1
Non-elective
192 - Critical care medicine
Pulmonary heart disease
3005
2
Non-elective
192 - Critical care medicine
Secondary malignancies
649
1
Non-elective
192 - Critical care medicine
Urinary tract infections
747
2
Non-elective
300 - General medicine
Acute bronchitis
127
3
Non-elective
300 - General medicine
Acute myocardial infarction
154
3
Non-elective
300 - General medicine
Aortic; peripheral; and visceral artery aneurysms
147
1
Non-elective
300 - General medicine
Biliary tract disease
189
2
Non-elective
300 - General medicine
Cancer of bladder
177
3
Non-elective
300 - General medicine
Cancer of breast
190
2
Non-elective
300 - General medicine
Cancer of bronchus; lung
106
1
Non-elective
300 - General medicine
Cancer of esophagus
154
2
Slide 94
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
HSMR
Non-elective
300 - General medicine
Cancer of pancreas
138
3
Non-elective
300 - General medicine
Cancer of rectum and anus
152
1
Non-elective
300 - General medicine
Cancer of stomach
214
1
Non-elective
300 - General medicine
Chronic obstructive pulmonary disease and bronchie
102
1
Non-elective
300 - General medicine
Chronic renal failure
148
1
Non-elective
300 - General medicine
Coronary atherosclerosis and other heart disease
162
1
Non-elective
300 - General medicine
Fracture of neck of femur (hip)
395
1
Non-elective
300 - General medicine
Intestinal obstruction without hernia
165
2
Non-elective
300 - General medicine
Leukemias
169
2
Non-elective
300 - General medicine
Malignant neoplasm without specification of site
151
2
Non-elective
300 - General medicine
Other circulatory disease
279
2
Non-elective
300 - General medicine
Other liver diseases
145
2
Non-elective
300 - General medicine
Other lower respiratory disease
121
1
Non-elective
300 - General medicine
Peripheral and visceral atherosclerosis
128
1
Non-elective
300 - General medicine
Peritonitis and intestinal abscess
416
2
Non-elective
300 - General medicine
Senility and organic mental disorders
128
2
Non-elective
300 - General medicine
Syncope
161
1
Non-elective
315 - Palliative medicine
Cancer of breast
129
1
Non-elective
315 - Palliative medicine
Cancer of bronchus; lung
133
3
Non-elective
315 - Palliative medicine
Cancer of esophagus
125
1
Non-elective
315 - Palliative medicine
Cancer of ovary
143
1
Non-elective
315 - Palliative medicine
Cancer of pancreas
134
1
Non-elective
315 - Palliative medicine
Cancer of prostate
129
3
Non-elective
315 - Palliative medicine
Cancer of rectum and anus
323
2
Non-elective
315 - Palliative medicine
Cancer of stomach
188
2
Slide 95
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
HSMR
Non-elective
315 - Palliative medicine
Intestinal obstruction without hernia
417
1
Non-elective
315 - Palliative medicine
Other fractures
208
1
Non-elective
315 - Palliative medicine
Pleurisy; pneumothorax; pulmonary collapse
205
1
Non-elective
315 - Palliative medicine
Pneumonia (except that caused by tuberculosis or s
182
2
Non-elective
315 - Palliative medicine
Urinary tract infections
214
1
Slide 96
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Elective)
Treatment Specialty
Palliative medicine
HSMR
SHMI
X
Slide 97
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Non-elective)
Treatment Specialty
HSMR
SHMI
Critical care medicine
X
X
General medicine
X
X
Palliative medicine
X
X
Slide 98