Colchester Hospital University
NHS Foundation Trust
Data Pack
9th July, 2013
Overview
Sources of Information
On 6th February the Prime Minister asked Professor Sir Bruce
Keogh to review the quality of the care and treatment being
provided by those hospital trusts in England that have been
persistent outliers on mortality statistics. The 14 trusts which fall
within the scope of this review were selected on the basis that they
have been outliers for the last two consecutive years on either the
Summary Hospital Mortality Index or the Hospital Standardised
Mortality Ratio.
Document review
Trust information
submission for
review
These two measures are being used as a ‘smoke alarm’ for
identifying potential quality problems which warrant further
review. No judgement about the actual quality of care being
provided to patients is being made at this stage, or should be
reached by looking at these measures in isolation.
The review will follow a three stage process:
Stage 1 – Information gathering and analysis
Stage 2 – Rapid Responsive Review
Benchmarking
analysis
Information shared
by key national
bodies including
the CQC
Stage 3 – Risk summit
This data pack forms one of the sources within the information
gathering and analysis stage.
Information and data held across the NHS and other public bodies
has been gathered and analysed and will be used to develop the Key
Lines of Enquiry (KLOEs) for the individual reviews of each Trust.
This analysis has included examining data relating to clinical
quality and outcomes as well as patient and staff views and
feedback. 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
Colchester Hospital University NHS Foundation Trust
Context
A brief overview of the Colchester and Tendring areas and Colchester Hospital University NHS Foundation Trust. This section
provides a profile of the area, outlines performance of local healthcare providers and gives a brief introduction to the Trust.
Mortality
An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the
Trust which are outliers.
Patient Experience
A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient
experience surveys.
Safety and Workforce
A summary of the Trust’s safety record and workforce profile.
Clinical and Operational Effectiveness
A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This
section compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures
(PROMs).
Leadership and Governance
An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership,
current top risks to quality and outcomes from external reviews.
Slide 3
Context
Slide 4
Context
Overview:
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.
Colchester Hospital University NHS Foundation Trust in Essex
services a population of 508,000 across both Colchester and
Tendring, which makes the Trust slightly larger than the size
recommended by the Royal College of Surgeons. 8% of
Colchester’s population belong to non-White ethnic minorities,
particularly Chinese and other Asians, while only 2.5% of
Tendring’s population belong to the same category. Smoking in
pregnancy and a high rate of statutory homelessness are among
the most prominent health and social problems in Colchester. In
Tendring, adult physical education is significantly below the
national average as is the proportion of the population
achieving 5 Cs or better in their GCSEs.
Review Areas:
To provide an overview of the Trust, we have reviewed the
following areas:
•
Local area and market share;
•
Health profile;
•
Service overview; and
•
Initial mortality analysis.
Data Sources:
•
Trust’s Board of Directors meeting 30th Jan, 2013;
•
Department of Health: Transparency Website, Dec 12;
•
Healthcare Evaluation Data (HED);
•
NHS Choices;
•
Office of National Statistics, 2011 Census data;
•
Index of Multiple Deprivation, 2011;
•
© Google Maps;
•
Public Health Observatories – Area health profiles; and
•
Background to the review and role of the national
advisory group.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
The Trust has two main hospital sites, Colchester General
Hospital and Essex County Hospital. In addition, the Trust
provides services at three community hospitals. Colchester
became a Foundation Trust in 2008 and has a total of 644 beds.
It has a 76% market share of inpatient activity within a 5 mile
radius of the Trust sites. However, the Trust’s market share falls
to 72% within a radius of 10 miles, and 45% within a radius of
20 miles.
A review of ambulance response times shows that the East of
England Trusts meet the national 8min response target, but not
the 19min response target.
Finally, Colchester’s SHMI 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
Colchester became a Foundation Trust in 2008. The Trust provides core
services for the population of North East Essex with a population of
approximately 370,000 people. The Trust also provides specialist
services for oncology/radiotherapy for the population of Mid Essex and
hosts inpatient vascular services for the population of Suffolk. The Trust
owns two hospital sites (Colchester General Hospital and Essex County
Hospital) and provides outreach services in three community hospitals
(Clacton, Harwich, and Halstead). These community hospital sites are
owned and run by the local community providers. The Trust has a lower
bed occupancy than the national average. It offers a substantial range
of services, and in 2012, the Trust saw 495,731 Outpatient attendances
and 94,812 Inpatient attendances.
Colchester Hospitals NHS Foundation Trust
Acute Hospital
Colchester General Hospital
Outpatient Hospital
Essex County Hospital
Outreach services to
Community Hospitals
Clacton Hospital, Harwich Hospital,
Halstead Hospital
Trust Status
Foundation Trust (2008)
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
644
81.1%
86%
General and
Acute
597
83.5%
88%
Maternity
47
49.8%
59%
Source: Department of Health: Transparency Website
Inpatient/Outpatient Activity
Inpatient Activity
Elective
50,699 (53%)
Outpatient Activity
Non Elective
44,113 (47%)
Total
94,812
Total
495,731
(Jan12-Dec12)
Day Case Rate:
84%
Source: Healthcare Evaluation Data (HED)
Source: NHS Choices
Departments and Services
Finance Information
2012–2013 Income
£258m
2012–2013 Expenditure
£236m
2012–2013 EBITDA
£22m
2012–2013 Net surplus (deficit)
£9m
2013-14 Budgeted Income
N/A
2013-14 Budgeted Expenditure
N/A
2013-14 Budgeted EBITDA
N/A
2013-14 Budgeted Net surplus (deficit)
N/A
Source: Colchester Hospital University NHS Foundation Trust, Board of Directors’ Meeting,
9 May 2013, Quarter 4 Performance Report 2012/13
A map of Colchester General Hospital is included in the Appendix.
Accident & Emergency, Breast Surgery, Cardiology, Children’s &
Adolescent Services, Dermatology, Diabetic Medicine, Diagnostic
Pathology, Diagnostic Physiological Measurement, Dietetics, ENT,
Endocrinology and Metabolic Medicine, Gastro Intestinal and Liver
Services, General Medicine, General Surgery, Geriatric Medicine,
Gynaecology, Haematology, Maternity Service, Neurology,
Nephrology, Ophthalmology, Oral and Maxillofacial Surgery,
Orthopaedics, Pain Management, Physiotherapy, Plastic Surgery,
Respiratory Medicine, Rheumatology, Urology, Vascular Surgery
Source: NHS Choices
Slide 6
Trust Overview continued...
General Surgery and
Clinical Oncology are
the largest inpatient
specialties while Allied
Health Professional
Episodes and Nursing
Episodes are the
largest for outpatients.
Outpatient Activity by Trust
300
1200
250
1000
200
Colchester
94,812
150
100
Number of Outpatient
Spells (Thousands)
Colchester 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
Colchester against
national trusts in
terms of inpatient and
outpatient activity.
50
800
Colchester
495,731
600
400
200
0
0
Trusts
Trusts Covered by Review
Trusts
National Inpatient Activity Curve
Top 10 Inpatient Main Specialties as a
% of Total Inpatient Activity
Trusts Covered by Review
Bottom 10 Inpatient Main Specialties
and Spells
National Outpatient Activity Curve
Top 10 Outpatient Main Specialties as
a % of Total Outpatient Activity
General Surgery
13%
Nursing Episode
24
Allied Health Professional Episode
26%
Clinical Oncology
9%
Rheumatology
217
Nursing Episode
10%
Paediatrics
8%
Neurology
259
Midwifery
9%
General Medicine
8%
Radiology
352
Trauma & Orthopaedics
8%
Gastroenterology
7%
Plastic Surgery
502
Ophthalmology
7%
Gynaecology
7%
Dental Medicine
644
Gynaecology
5%
Urology
7%
Anaesthetics
912
General Surgery
4%
Trauma & Orthopaedics
7%
Dermatology
1157
Ear, Nose & Throat (ENT)
3%
Geriatric Medicine
5%
Nephrology
1200
Clinical Oncology
3%
Clinical Haemotology
5%
Allied Health Professional Episode
1263
Paediatrics
3%
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
Slide 7
Colchester Area Overview
Essex, in which Colchester is situated, is not a particularly deprived region of
England. The age distribution in Colchester is largely similar to that of
England as a whole; however, Colchester has significantly more women and
men in their 20s. Smoking in pregnancy is a particular health concern in this
region, where statutory homelessness is also much more common than in
England as a whole. 8% of Colchester’s population belong to non-White
minorities, particularly including Chinese and other Asians.
Colchester Area Demographics
0-9
10-19
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,
Essex is the 119th most deprived.
Ethnic
diversity
In Colchester, 8.0% belong to nonWhite minorities, including 1.4%
Other Asian and 1.0% Chinese.
Rural or
Urban
Colchester is a rural-urban region.
Smoking in
pregnancy
In Colchester, smoking in pregnancy
is significantly more common than in
the country as a whole.
Statutory
homelessness
Statutory homelessness is
significantly more common in
Colchester than in the country as a
whole.
20-29
30-39
40-49
50-59
370,000
60-69
70-79
80+
Female/COL
20%
15%
10%
Female/ENG
5%
Male/COL
0%
5%
Male/ENG
10%
15%
Source: Colchester Hospital University NHS Foundation Trust website; Office of National Statistics,
Census 2011; IMD Source: Index of Multiple Deprivation, 2010
20%
Slide 8
Tendring Area Overview
The district of Tendring in Essex is a slightly deprived local authority of
England. The population of Tendring is old compared to the population of
England as a whole and has a significantly larger proportion of people aged
60 and above. Lack of adult physical activity is a particular health concern in
Tendring, where education levels are also relatively low compared to England
as a whole. 2.5% of Tendring’s population belongs to non-White ethnic
minorities, with the largest minority of 0.4% being White and Black
Caribbean.
Tendring Area Demographics
0-9
10-19
FACT BOX
Population
138,000
IMD
Of 326 English local authorities,
Tendring is the 86th most deprived.
Ethnic
diversity
In Tendring, 2.5% belong to nonWhite minorities, including 0.4%
White and Black Caribbean.
Rural or
Urban
Tendring is a rural-urban district.
Adult physical
activity
In Tendring, adult physical activity is
significantly below the national
average.
Education
In Tendring, the proportion of the
population achieving 5 Cs or better in
their GCSEs is significantly below the
national average.
20-29
30-39
40-49
50-59
60-69
70-79
80+
Female/TEN
20%
15%
10%
Female/ENG
5%
Male/TEN
0%
5%
Male/ENG
10%
15%
20%
Source: Office of National Statistics, Census 2011; IMD Source: Index of Multiple Deprivation, 2010
Slide 9
Colchester and Surrounding Areas Geographic Overview
The map on the right shows the location of Colchester
geographically within Essex, a rural-urban area located in the East
of England. As shown on the map, Colchester is located near several
larger roads, and in-between the urban areas of Chelmsford and
Ipswich.
Market share analysis indicates from which GP practices the
referrals that are being provided for by the Trust originate. High
mortality may affect public confidence in a Trust, resulting in a
reduced market share as patients may be referred to alternative
providers.
Source: © Google Maps
The wheel on the left shows the market share of Colchester
Hospital University NHS Foundation Trust. From the wheel it can
be seen that Colchester has a 76% 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 72%
within 10 miles and 45% within 20 miles.
The wheel shows that the main competitors in the local area are
Ramsay Healthcare UK Operations Ltd and Mid Essex Hospital
Services NHS Trust.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 10
Colchester’s Health Profile
Health Profiles, depicted on this slide and the following, are designed to
help local government and health services identify problems in their
areas, and decide how to tackle these issues. They provide a snapshot of
the overall health of the local population, and highlight potential
differences against regional and national averages.
The graph shows the level of deprivation in Colchester and Tendring
compared nationally.
Deprivation by unitary authority area
Tendring
Colchester
The tables below outline Colchester and Tendring’s health profile
information in comparison to the rest of England.
1. Colchester are
performing better than 1
the national average on
all community indicators
apart from Statutory
homelessness. Tendring
have higher rates of
children in poverty and
unemployment than the
national average.
2. Children’s and
2
young people’s health
indicators highlight that
smoking in pregnancy is
higher than the average
in Colchester and
Tendring. Tendring also
has a higher number of
obese children.
Slide 11
Colchester’s Health Profile
3. Adult health in
Colchester shows all
indicators to be close
to the national
average. Increasing
and higher risk
drinking is below the
national average but
is still within the
expected range. In
Tendring, there are
fewer physically
active adults than the
national average.
3
4
4. Disease and poor
health indicators
highlight acute
sexually transmitted
infections as being
above the national
average. Tendring
has a high number of
people diagnosed with
diabetes and is above
the national average.
5. The number of
excess winter deaths
and road injuries and
deaths are higher than
the national average
in Colchester but
within the expected
range.
Slide 12
Colchester’s Health Profile
3. The number of
excess winter deaths
and road injuries and 5
deaths are higher than
the national average
in Colchester but
within the expected
range. Tendring also
has a higher number
of road injuries and
deaths than the
national average but
is not significantly
higher than the
national average.
Slide 13
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 East of England 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 14
Why was Colchester chosen for this review?
Based on the Summary Hospital level Mortality
Indicator (SHMI) and Hospital Standardised
Mortality Ratio (HSMR), 14 trusts were selected
for this review. The table includes information on
which trusts were selected. An explanation of
each of these indicators is provided in the
Mortality section. Where it does not include the
SHMI for a trust, it is because the trust was
selected due to a high HSMR as opposed to its
SHMI. The SHMI for all 14 trusts can be found in
the following pages.
Initially, five hospital trusts were announced as
falling within the scope of this investigation based
on the fact that they had been outliers on SHMI
for the last two years (SHMI data has only been
published for the last two years).
Subsequent to these five hospital trusts being
announced, Professor Sir Bruce Keogh took the
decision that those hospital trusts that had also
been outliers for the last two consecutive years on
HSMR should also fall within the scope of his
review. The rationale for this was that it had been
HSMR that had provided the trigger for the
Healthcare Commission’s initial investigation
into the quality of care provided at Mid
Staffordshire Hospitals NHS Foundation Trust.
Colchester has been above the expected level for
SHMI 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 15
Why was Colchester chosen for this review?
The way that levels of observed
deaths that are higher than
expected deaths can be
understood is by using HSMR
and SHMI. Both compare the
number of observed deaths to
the number of expected deaths.
This is different to avoidable
deaths. An HSMR and SHMI of
100 means that there is exactly
the same number of deaths as
expected. This is very unlikely
so there is a range within
which the variance between
observed and expected deaths
is statistically insignificant. On
the Poisson distribution,
appearing above and below the
dotted red and green lines
(95% confidence intervals),
respectively, means that there
is a statistically significant
variance for the trust in
question.
The funnel charts for 2010/11
and 2011/12, the period when
the trusts were selected for
review, show that Colchester’s
SHMI is statistically above the
expected range, supported by
the time series which shows the
SHMI being consistently
higher than the expected.
Colchester’s HSMR is within
the expected range, and the
time series shows the HSMR
has recently risen back above
the expected level.
SHMI Time Series
SHMI Funnel Chart
Colchester
Selected trusts Outside Range
Selected trusts w/in Range
HSMR Time Series
HSMR Funnel Chart
Colchester
Selected trusts Outside Range
Selected trusts w/in Range
Source: Healthcare Evaluation Data (HED); Apr 10-Mar12
Slide 16
Mortality
Slide 17
Mortality
Overview:
Summary:
This section focuses upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The Trust has an overall HSMR of 106 for the period January
2012 to December 2012, meaning that the number of actual
deaths is higher than the expected level. However, this is
statistically within the expected range.
The measures identified are being used as a ‘smoke alarm’ for
highlighting potential quality issues. No judgement about the actual
quality of care being provided to patients is being made at this stage,
nor should it be reached by looking at these measures in isolation.
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 data and sources used are consistent across the packs for the 14 trusts included in this review.
Further analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure,
with a similar HSMR of 107, also within the expected range.
Elective admissions are within the expected range also, at 93
Currently, Colchester has a SHMI of 118, which is statistically
above the expected range.
Similar to HSMR, non-elective admissions are seen to be
contributing primarily to the overall Trust SHMI, with a similar
figure of 118. Elective admissions are within the expected range,
with a SHMI of 123.
Colchester has had three high mortality alerts for diagnostic
groups since 2007.
A common theme has arisen around Elderly Care, with much
higher than expected mortality for patients aged 75+. The Trust
has an initiative to reduce the number of avoidable admissions
for patients at end of life, possibly reflected in its high but
declining use of palliative care codes.
Other areas previously identified for improvement action
include earlier recognition and escalation of the deteriorating
patient, the quality of documentation such as the ceiling of care
and clinical coding.
Slide 18
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 19
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 20
SHMI Definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of
Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a
nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice.
How does SHMI work?
1.
2.
3.
4.
Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
The Indicator will utilise 5 factors to adjust mortality rates by
a.
The primary admitting diagnosis;
b.
The type of admission;
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities);
d.
Age; and
e.
Sex.
All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are
highlighted using a Random Effects funnel plot.
Slide 21
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 22
SHMI overview
Month-on-month time series
The Trust’s SHMI level for the past 12 months (Dec11-Nov12) is 118,
which means, as shown below, it is statistically above the expected
range and so classified as an outlier, based on the 95% confidence
interval of the Poisson distribution.
The time series show a very slight general trend of increasing SHMI
month-on-month, and a stable trend year-on-year.
SHMI funnel chart –12 months
Year-on-year time series
Colchester
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 23
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for Colchester.
As SHMI includes mortalities
that occur within the hospital
and outside of it for up to 30
days following discharge, it is
imperative to understand the
percentage of deaths which
happen inside the hospital
compared to outside. This
may contribute to differences
in HSMR and SHMI
outcomes.
The data shows that 70.2% of
SHMI deaths occur in
hospital at Colchester, which
is less than the national
average of 73.3%.
Percentage of patient deaths in hospital
90%
85%
80%
Colchester 70.2%
75%
70%
65%
60%
Trusts selected for review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 24
Treatment Specialties
SHMI 123
-
-
-
-
Gynaecology
Podiatry
Clinical oncology (265, 7)
Interventional Radiology
-
-
Orthoptics
Clinical Oncology
Interventional Radiology
-
-
Geriatric Medicine
Dental medicine
Obstetrics
-
-
Geriatric Medicine (123, 50)
Obstetrics (1846, 6)
Gynaecology
Paediatrics
Clinical Neurophysiology
Neonatology (402, 14)
Neurology
-
Nephrology
Paediatrics
Thoracic Medicine
-
Dermatology
Rheumatology
Cardiology
-
Diabetic Medicine
Clinical Neurophysiology
Clinical Haematology
-
Endocrinology
Neurology
Gastroenterology
-
General Medicine (124, 252)
Nephrology
Paediatric Nephrology
-
-
Critical Care Medicine
Thoracic Medicine
-
Not a Treatment Function
-
Pain Management
-
Accident & Emergency (A&E)
Dermatology
Plastic Surgery
-
Oral surgery
-
Oral surgery
-
Ophthalmology
Cardiology
Ophthalmology
-
Ear, Nose and Throat (ENT)
-
Ear, Nose and Throat (ENT)
-
Trauma & Orthopaedics
Clinical Haematology
Trauma & Orthopaedics
-
Vascular Surgery
-
Vascular Surgery
-
Colorectal Surgery
Gastroenterology
Breast Surgery
-
Breast Surgery
-
Treatment Specialties
SHMI 118
Slide 25
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
-
-
Urology
Diagnosis (100 ; 1 )
Urology
-
General Surgery
Key
-
The tree shows that
Colchester has a SHMI
of 118 which is above the
expected range.
General Surgery
SHMI 118
-
-
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
Clinical Oncology for
elective admissions, and
in General medicine,
Neonatology, Geriatric
Medicine and Obstetrics
for non-elective
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
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, shown on the next slide. Within
Geriatric medicine, Acute cerebrovascular disease (8) and Urinary tract infections (9) are seen as the main
diagnostic groups contributing to this. Obstetrics and Neonatology both have one diagnostics group with
four or more observed deaths above the expected level.
Overall (118; 337)
Elective (123; 9)
Other perinatal
conditions
( 14980 5)
Geriatric Medicine (123, 50)
Acute cerebrovascular
disease
Acute and unspecified
renal failure
Urinary tract infections
( 116 8 )
Neonatology (402, 14)
Short gestation; low birth weight;
and fetal growth retardation
( 285
\
Obstetrics (1846, 6)
\
\
Diagnostic Groups
Non-elective (118; 328)
Treatment Specialties
\
Clinical Oncology (265, 7)
118.2
General Medicine (124, 252)
6)
(Full table shown
on the next slide)
( 144 4 )
( 190 9 )
Key
Diagnosis (100 ; 1 )
SHMI
Observed deaths that are higher
than the expected
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Slide 26
SHMI sub-tree of specialties continued
Non-elective (118; 328)
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
\
Treatment Specialties
General Medicine (124, 252)
Within General medicine, the
diagnostic groups with the highest
numbers of observed deaths above
the expected level are pneumonia
(28), acute cerebrovascular disease
(16) and urinary tract infections (15).
Diagnostic Groups
Key
Diagnosis (100 ; 1 )
SHMI
Observed deaths that are higher
than the expected
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Acute bronchitis
Acute cerebrovascular disease
Aspiration pneumonitis; food/vomitus
Cancer of bladder
Cancer of bronchus; lung
Chronic obstructive pulmonary disease and bronchiectasis
Chronic ulcer of skin
Congestive heart failure; nonhypertensive
Coronary atherosclerosis and other heart disease
Diabetes mellitus with complications
Gastrointestinal hemorrhage
Intestinal infection
Leukemias
Malignant neoplasm without specification of site
Non-Hodgkin`s lymphoma
Open wounds of head; neck; and trunk
Other gastrointestinal disorders
Other injuries and conditions due to external causes
Other lower respiratory disease
Other upper respiratory disease
Peripheral and visceral atherosclerosis
Pneumonia
Residual codes; unclassified
Secondary malignancies
Senility and organic mental disorders
Septicemia (except in labor)
Skin and subcutaneous tissue infections
Spondylosis; intervertebral disc disorders; other back problems
Urinary tract infections
( 134, 9)
( 128, 16)
( 125, 5)
( 205, 4)
( 127, 8)
( 124, 10)
( 208, 5)
( 114, 9)
( 149, 4)
( 274, 4)
( 141,9)
( 124, 4)
( 164, 4)
( 169, 4)
( 227, 4)
( 194, 4)
( 159, 7)
( 290, 6)
( 139, 5)
( 260, 6)
( 190, 4)
( 115,28)
( 205, 6)
( 142, 6)
( 142, 7)
( 114, 4)
( 163, 7)
( 200, 4)
( 131, 15)
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, Colchester FT
120
115
110
113
115
117
118
118
116
117
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 Colchester was 117 in the year to Sept-12
(England baseline = 100) and has been above the expected range
in all but the earliest period.
Source: Health & Social Care Information Centre – SHMI
Slide 28
HSMR overview
Month-on-month time series
The Trust’s HSMR for the past 12 months (Jan 12-Dec 12) is 106,
which means, as shown below, although it is above 100, it is within
the expected range and so not classified as an outlier.
The time series show no real trend for HSMR year-on-year and
month-on-month time series shows no real trend. Further to this, the
month-on-month time series fluctuates between extremes of 93 and
126.
HSMR funnel plot –12 months
Colchester
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
Colchester’s HSMR broken
down by admission type.
The breakdown illustrates
the overall HSMR is 106
which is within the expected
range. The table identifies
that both elective and nonelective admissions have an
HSMR within the expected
range.
Mortality from weekend
admissions are highlighted
as being above the expected
level, due to the high nonelective admissions.
Key – colour by
alert level:
HSMR
Weekend
Week
All
Elective
160
91
93
Non-elective
121
102
107
Red – Higher than
expected (above the
95% confidence
interval)
All
121
102
106
Blue – Within
expected range
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Green – Lower than
expected (below the
95th confidence
interval)
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 111, and 25 observed deaths that are
higher than the expected);
•
Chronic obstructive pulmonary disease and bronchiectasis
(132, 14);
•
Urinary tract infections (117, 9);
•
Skin and subcutaneous tissue infections (159, 8);
•
Intestinal obstruction without hernia (154, 8); and
•
Acute bronchitis (130, 8).
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 31
Mortality - HSMR Tree
Elective
HSMR 93
Interventional Radiology
Gynaecology
-
-
Geriatric Medicine
Clinical Oncology
-
Paediatrics
-
-
Thoracic Medicine
Nephrology
-
Cardiology
-
-
Clinical Haematology
Ear, Nose and Throat (ENT)
-
-
Trauma & Orthopaedics
Gastroenterology
-
Vascular Surgery
HSMR 107
-
-
Breast Surgery
Non
Elective
Treatment Specialties
-
-
-
-
-
-
-
-
-
Neurology
Clinical Neurophysiology
Paediatrics
Neonatology
Geriatric Medicine
Obstetrics (2090, 13)
Gynaecology
Clinical Oncology
Interventional Radiology
Endocrinology
Nephrology
-
Gastroenterology
-
-
General Medicine (116, 117)
Thoracic Medicine
-
Critical Care Medicine
-
-
Not a Treatment Function
Dermatology
-
Ophthalmology
-
-
Ear, Nose and Throat (ENT)
Cardiology
-
Trauma & Orthopaedics
-
-
Vascular Surgery
Diabetic Medicine
-
Breast Surgery
-
-
Urology
Clinical Haematology
-
General Surgery
-
-
*Obstetrics was not
highlighted as an outlier
on HED, however with
HSMR of 2090 and with 13
observed deaths above the
expected level, it is an area
for potential review.
-
Within non-elective
admissions General
Medicine and Obstetrics
have the highest number of
observed deaths above the
expected level.
Urology
General Surgery
HSMR 106
Treatment Specialties
-
Overall
Trust
-
The tree shows that the
HSMR for Colchester is
106 which is within the
expected range. When
breaking this down by
admission type, it is clear
that it is driven by non
elective admissions, which
are at similar level,
however both admission
types are within the
expected range.
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Key
Diagnosis (100 ; 1 )
HSMR
Source: Healthcare Evaluation Data (HED). Jan 12 – Dec 12
Observed deaths that are higher
than the expected
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 numerous diagnostic groups such as
pneumonia (27) and chronic obstructive pulmonary disease and bronchiectasis
(10).Within Obstetrics, other perinatal conditions has the highest number of
above expected deaths (13).
Overall118.2
(106, 78)
Non-elective (107; 79)
Treatment Specialties
Obstetrics* (2090, 13)
Other perinatal conditions
General Medicine (116, 117)
(2099, 13)
Diagnostic Groups
Key
Diagnosis (100 ; 1 )
HSMR
Observed deaths that are higher
than the expected
*Obstetrics was not highlighted as an outlier on HED,
however with HSMR of 2090 and with 13 observed
deaths compared to an expected level of 0.3, it is an
area for potential review.
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Acute bronchitis
(144, 9)
Acute cerebrovascular disease
(107, 4)
Aspiration pneumonitis; food/vomitus
(125, 5)
Cancer of bronchus; lung
(128, 6)
Chronic obstructive pulmonary disease and bronchie
(127, 10)
Congestive heart failure; nonhypertensive
(110, 5)
Deficiency and other anemia
(216, 5)
Gastrointestinal hemorrhage
(132, 5)
Other lower respiratory disease
(183, 7)
Pneumonia (except that caused by tuberculosis or s
(115, 27)
Septicemia (except in labor)
(113, 4)
Skin and subcutaneous tissue infections
(166, 6)
Urinary tract infections
(113, 5)
Slide 33
HSMR – Dr Foster
The HSMR time series for Colchester from Dr Foster shows
variation in the HSMR since 2008/09. This measures the observed
in-hospital death rate against an expected value based on all the
data for that year. An HSMR (or SHMI) of 100 means that there is
exactly the same number of deaths as expected. The HSMR is
classified as above expected if the lower 95% confidence limit
exceeds 100, which was the case in each year from 2008/09.
Colchester FT’s latest SHMI published by the HSCIC, for Oct 11 to
Sept 12, is 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, Colchester FT
120
115
110
107
105
102
100
98
95
90
2008/09
2009/10
HSMR
I
I
2010/11
2011/12
95% Confidence interval
Com parison of m ortality m easures,
Colchester FT
125
120
115
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.
112
117
115
112
110
105
101
100
95
90
85
SHMI
SHMI adjusted
for palliative
care
SHMI in
hospital
deaths only
HSMR
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.
When looking at the depth
of coding for Colchester, it is
apparent that for elective
admissions, the Trust has
been consistently
performing below the
national average. However,
it should be noted that the
Q2/Q3 average diagnosis
coding depth is close to the
national average. The
average diagnosis coding
depth for non-elective
admissions has also been
close to the national
average and the most recent
quarter shows the trust is
above the national average
and the average of the 14
trusts in this review.
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
Colchester
Colchester
2012/13
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 35
Palliative care
Percentage of admissions with palliative care
coding
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.
2.5
Colchester’s percentage of admissions with palliative care
coding is consistently above the national average.
However, there has been a recent reduction. This may
relate to an initiative at the Trust, due for completion by
April 2013, to reduce the number of avoidable admissions
for patients at end of life.
1.0
2.0
1.5
0.5
Oct-11
Jan-12
Apr-12
Colchester
35
Jul-12
Oct-12
National
Jan-13
Apr-13
SHMI publication
Percentage of deaths with palliative care
coding
30
25
20
15
10
5
-
Oct-11
Jan-12
Apr-12
Colchester
Jul-12
National
Oct-12
Jan-13
Apr-13
SHMI publication
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 36
Care Quality Commission findings
Emergency specialty groups much worse than expected
Care Quality Commission (CQC) review mortality alerts
for each Trust on an ongoing basis. These alerts, which
indicate observed deaths significantly above expected for
specialties or diagnoses, come from different sources
based on either HSMR or SHMI. Where these appear
unexplained, CQC correspond with the Trust to agree any
appropriate action.
For Colchester, the common theme that has arisen across
the patient groups alerting since 2007 is Elderly Care,
with much higher than expected mortality for patients
aged 75+.
Sep 11 to Aug 12
3
Respiratory medicine
Neurology (but small numbers)
Dermatology
Emergency specialty groups worse than expected
Sep 11 to Aug 12
2
Other injuries due to external causes
Nephrology
Diagnosis group alerts (2007 to date)
Alerts to CQC
3
There are common themes arising from responses to the
CQC from the Trust around deteriorating patients at end
of life stage, clinical coding of co-morbidities and clinical
pathways and ceiling of care.
Alerts followed up by CQC
3
Colchester appear to have been active in monitoring and
investigating mortality concerns. In addition to reducing
avoidable end of life admissions, areas previously
identified for improvement action include earlier
recognition and escalation of the deteriorating patient,
the quality of documentation such as the ceiling of care
and clinical coding.
Complex elderly with a respiratory system primary diagnosis (Nov 10)
Intestinal obstruction without hernia (Nov 11)
Diabetes mellitus with complications (Sep 12)
Recent diagnosis group alerts pursued by CQC
Any related patient groups alerting more than once since 2007
None
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 three diagnosis groups and
no procedure groups with above expected SMRs in Colchester,
which may highlight potential areas for review. Two diagnosis
groups had evidence of above expected mortality for weekend
admissions but not for weekday ones. One of these, deficiency
and other anaemia, had a high SMR overall, although the
other, senility and organic mental disorders, did not.
Apr 2012 to Mar 2013
Diagnosis groups
Procedure groups
SMRs above expected
3
0
CUSUM alerts
3
0
Diagnosis groups with SMRs above expected
Deficiency and other anaemia
Other upper respiratory disease
Pneumonia
SMR
230
210
117
Obs – Exp
deaths
10
6
40
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, Colchester had a CUSUM alert for deficiency
and other anaemia. It also had alerts for two other diagnostic
groups 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 & Social Care Information Centre (HSCIC) to
visualise the cumulative number of “statistical lives gained”
over a period. A downward trend indicates a run of more
deaths than expected compared to the national baseline and
one with a sustained downward trend and multiple dips to the
lower control limit may warrant further investigation.
VLAD charts with a negative SHMI trend
(year to Jun-12)
Acute cerebrovascular disease
No. dips to the
lower control limit
4
On a review of the data it was apparent that although there
was not only one area with a negative trend, there was only
one area with a significant negative trend and several dips to
the lower control limit in the year to June 2012: acute
cerebrovascular disease.
Colchester had high observed deaths above the expected for
ccute cerebrovascular disease (37 deaths, 33% more than
expected) and pneumonia (32 deaths, 14% more than expected)
in the HSCIC’s SHMI to September 2012.
Source: Health & Social Care Information Centre (HSCIC) – SHMI and contextual indicators, Dr Foster – HSMR.
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, Colchester is rated ‘red’ on just one: The
Ombudsman’s rating of their complaints processes, where the
Trust is C-rated (the lowest category).
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;
•
Cancer Patient Experience Survey;
•
Peoples’ Voice Summary; and
•
Complaints data.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
There is an above average rate of escalation for complaints
becoming complaints to the Ombudsman, high average
compensation payments and one case of service failure
indicating wider organisation failure.
The Trust scores reasonably well on patient surveys, with some
concerns about consistency of information provided by staff, the
quality of hospital food, information provided on post-discharge
danger signals, and waiting times.
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
Outside expected range
Within expected range
Slide 42
Inpatient Experience Survey
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
Colchester scores above average on survey questions relating to coherent discharge processes and the appropriateness of language
used by doctors in front of patients, but below average on those relating to the length of time spent on waiting lists, the consistency of
staff communication, the degree of information provided on post-discharge danger signals, and the quality of hospital food.
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 Survey
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
•
Colchester: 75.3 (average)
90
85
80
75
70
65
60
55
50
Cancer Survey
•
Of 58 questions, 10 were in the ‘top 20%’ and 6 were in
the ‘bottom 20%’ (including two questions about
treatment as a day case or outpatient)
Patient Voice
•
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 126 comments on Colchester of which 42 were
negative (33%). Negative comments highlighted
communication from staff, lack of clear information,
responsiveness of staff, as well as some concerns about
waiting times and discharge processes.
Friends and Family Test (FFT)
•
In the Midlands & East FFT, Colchester has consistently
scored in the top quartile.
Colchester
75.3
95
England
average
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 551 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, 48% 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 worst rating. There is an above
average rate of escalation of complaints to the
Ombudsman, high average compensation payments and
one case of service failure indicating wider organisation
failure.
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.
Colchester is ‘red rated’ in three of the safety indicators:
reporting of patient safety incidents, medication errors and
clinical negligence scheme payments.
Review Areas:
The Trust may be recognising and reporting patient safety
incidents less fully and completely than similar trusts. It
recorded 158 incidents reported as either moderate, severe or
death between April 2011 and March 2012. Since 2009, two
‘never events’ have occurred at Colchester, classified as that
because they are incidents that are so serious they should never
happen. Similarly, Colchester has a rate of medication errors of
8.14, that is higher than the mean rate of 7.17 for all acute trusts.
To undertake a detailed analysis of the Trust’s Safety and
Workforce it is necessary to review the following areas:
•
General Safety;
•
Staffing;
•
Staff Survey;
•
Litigation and Coroner; and
•
Analysis of patient safety incident reporting.
Data Sources:
•
Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;
•
Safety Thermometer, Apr 12 – Mar 13;
•
Litigation Authority Reports;
•
GMC Evidence to Review 2013;
•
National Staff Survey 2011, 2012;
•
2011/12 Organisational Readiness Self-Assessment (ORSA);
•
National Training Survey, 2012; and
•
NHS Hospital & Community Health Service (HCHS), monthly
workforce statistics.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Throughout the last 12 months, Colchester has been consistently
below the national rate for new pressure ulcers, though it has
breached this figure on two occasions. The prevalence rate of
total pressure ulcers for Colchester is also below the national
average and below the average of the selected 14 trusts in this
review.
The Trust’s Clinical Negligence payments have exceeded
contributions to the ‘risk sharing scheme’ over the last two years,
and flagged once in Rule 43 Coroner’s reports.
Colchester is ‘red rated’ in ten of the workforce indicators. It
notably has a sickness absence rate for medical staff above the
national mean rate and spends more on agency staff than the
median within the region. For training of its doctors, it has a
lower score on ‘undermining’ than the national average. In
addition, Colchester has a joining rate double the national
average whilst the leaving rate is below the national average.
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
158
Number of ‘never events’ (2009-2012)
2
Medication error
x
Pressure ulcers
MRSA
“Harm” for all four Safety Thermometer Indicators
C diff
Clinical negligence scheme payments
Rule 43 coroner reports
Outcome 1 (R17) Respecting and involving people who use services
Outside expected range
Within expected range
Slide 47
Safety Analysis
The Trust has reported fewer patient safety incidents
than similar trusts. Organisations that report fewer
incidents may have a weaker and less effective safety
culture. Colchester has a rate of 5.3 for its patient
safety incident reporting per 100 admissions.
The rate of medication errors for Colchester is 8.14,
which is higher than the mean rate of 7.17 for all acute
trusts.
Rate of reported patient safety incidents per 100 admissions (April –
September 2012)
Colchester
Median rate for medium acutes
5.3
6.7
Source: incidents occurring between 1 April 2012 to 30 September
2012 and reported to the National Reporting and Learning System
Rate of medication errors per 1,000 bed days (October 2011 – March
2012)
Colchester
Mean rate for all acute
8.14
7.17
Source: Acute Trust Quality Dashboard Winter 2012/13
Slide 48
Safety Incident Breakdown
Since 2009, two ‘never events’ have occurred at Colchester, classified as that
because they are incidents that are so serious they should never happen.
Never Events Breakdown (2009-2012)
The patient safety incidents reported are broken down into five levels of harm
below, ranging from ‘no harm’ to ‘death’. 78% of incidents which have been
reported at Colchester have been classed as ‘no harm’, with 19% ‘low’, 3%
‘moderate’, 0.4% ‘severe’ and no occurrences classified as ‘death’. However, the
Trust is aware of a maternal death for this period.
Retained foreign object post-operation
2
Total
2
Source: Freedom of information request, BBC http://www.bbc.co.uk/news/health-22466496
When broken down by category, the most regular occurrences of patient
incident at Colchester are in ‘patient accident’ and ‘medication’.
Breakdown of patient
incidents by degree of harm
3500
Breakdown of patient incidents by incident type
Access, admission, transfer, discharge
3250
3000
2500
66
Medical device / equipment
182
Consent, communication, confidentiality
195
Documentation
211
Clinical assessment
225
2000
Implementation of care and ongoing…
1500
1000
257
Treatment, procedure
332
Infrastructure
339
774
All others categories
500
143
Medication
15
0
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.
Patient accident
363
641
1371
0
200 400 600 800 1000 1200 1400 1600
Source: National Patient Safety Agency (NPSA) . Apr 11 – Mar 12
Slide 49
Pressure ulcers
1.9%
12
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,
Colchester has been
consistently below the national
rate for new pressure ulcers,
though it has breached this
figure on two occasions.
From the data, it is apparent
that the prevalence rate of total
pressure ulcers for Colchester is
also below the national average
and below the average of the
selected 14 trusts in this review.
The data shows that the total
pressure ulcer rate has been
below the national average in
all but four months over the
previous year.
Total pressure ulcers prevalence
New pressure ulcers prevalence
1.5%
10
8
1.0%
6
4
0.5%
0.3%
2
-
Category 2
2.0%
1.8%
1.4%
1.6%
1.4%
1.2%
1.0%
0.7%
0.8%
0.5%
0.3% 0.6%
0.4%
0.2%0.2%0.2%
0.2%
0.0%
Category 3
Category 4
45
8.0%
6.9%
6.1%
40
5.7%
35
5.3%
25
7.0%
6.0%
5.2%5.1%
4.8%
4.4%
30
20
5.6%
6.6%
5.0%
3.7%
4.0%
2.8%
3.0%
15
10
2.0%
5
1.0%
-
0.0%
Rate
Category 2
Category 3
Category 4
Rate
New pressure ulcer analysis
Number of records submitted
Trust new pressure ulcers
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
604
602
618
592
584
569
610
572
608
614
642
620
2
3
6
9
11
3
4
8
1
1
1
2
Trust new pressure ulcer rate
Selected 14 trusts new pressure
ulcer rate
0.3%
0.5%
1.0%
1.5%
1.9%
0.5%
0.7%
1.4%
0.2%
0.2%
0.2%
0.3%
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
604
602
618
592
584
569
610
572
608
614
642
620
17
22
35
41
31
25
29
32
37
32
33
41
Trust total pressure ulcer rate
Selected 14 trusts total pressure
ulcer rate
2.8%
3.7%
5.7%
6.9%
5.3%
4.4%
4.8%
5.6%
6.1%
5.2%
5.1%
6.6%
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 scheme analysis
Colchester’s Clinical Negligence payments have exceeded
contributions to the ‘risk sharing scheme’ for the last two
years. Over the last 3 years payouts exceeded contributions
by a total of £4.7m over this period.
Coroner’s rule
Coroner’s rule 43 reports flagged one item:
•
Clinical negligence
payments
2009/10
2010/11
2011/12
Payouts (£000s)
2,648
7,154
6,754
Contributions (£000s)
3,405
3,878
4,597
Variance between
payouts and contributions
(£000s)
757
-3,276
-2,157
To consider keeping a record of the location of
scanners that can accommodate obese 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
2.55
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
2.07
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
0.38
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days) 574.62
Staff leaving rates
Nurse Hours per Patient Bed Day
7.43
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
Anaesthetics
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
Cardiology
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…
Clinical oncology
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
Emergency 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 54
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
Gastroenterology
Endocrinology and diabetes
mellitus
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
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…
Paediatrics
Intensive care medicine
The GMC Survey results continue as follows.
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
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 56
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
Respiratory Medicine
The GMC Survey results continue as follows.
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 57
Workforce Analysis
The Trust has a patient spell per whole time equivalent rate of 27, which is a
slightly above average capacity in relation to the other trusts in this review
and nationally.
Number of FTEs (Dec 11-Nov 12 average)
3,549
Agency Staff (2011/12)
The consultant appraisal rate of Colchester is 55.6% which is the lowest of the
trusts under review.
Colchester’s staff leaving rate is 5.9% which is lower than the median
average of 7.6%. The joining rate of 19.8% is more than double the national
average.
Colchester
Expenditure
Percentage of
Total Staff Costs
Median within
Region
£8.2m
5.6%
4.6%
The data shows that the agency staff costs, as a percentage of total staff
costs, is higher than the median within the region
WTE nurses per bed day December 2012
Colchester
National Average
1.61
1.96
Spells per WTE for Acute Trusts
Colchester
East of England
SHA Median
Joining Rate
19.8%
8.1%
Leaving Rate
5.9%
7.6%
Source: Health and Social Care Information Centre (HSCIC)
Source: Acute Trust Quality Dashboard, Methods Insight
50
(Sep 11 – Sep 12)
Staff Turnover
Consultant appraisal rate, 2011/12
100%
45
Spells per WTE
40
35
30
Ed
80%
Colchester:
27
Colchester
55.6%
60%
25
40%
20
15
20%
10
5
0%
0
Trusts covered by review
All Trusts
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
Trusts covered by review
Colchester
All other trusts
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Data based on the appraisal year from April 2011 to March 2012
Slide 58
Workforce Analysis continued…
Colchester’s total sickness absence rate is lower
than the East of England Strategic Health
Authority average and the national average. This
pattern is replicated in the more granular
nursing and other staff categories, both of which
are lower than their respective national
averages, although the figure for medical staff is
higher than the average for all trusts in England.
Colchester has a medical staff to consultant ratio
below the national average, as is its nurse staff to
qualified staff ratio. The Trust’s registered nurse
hours to patient day ratio is also lower than the
average for all trusts in England. However, its
non-clinical staff to total staff ratio is above the
national average.
The Trust’s consultant productivity ratio is above
the national average.
Colchester’s three month vacancy rate for its
medical staff is above the national average.
3 month Vacancy Rates by
Staff Category
Colchester
(March 2010)
National
Average
Medical Staff
1.6%
1.4%
Non-medial Staff
0.0%
0.4%
Source: The Health and Social Care Information Centre Non-Medical
Workforce Census (Sept 2009), Vacancies Survey March 2010
Workforce indicator calculations are listed in the Appendix.
Sickness Absence Rates
(2011-2012)
Colchester
East of England
SHA Average
National Average
3.59%
4.03%
4.12%
All Staff
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
Colchester
National Average
Medical Staff
1.7%
1.3%
Nursing Staff
3.9%
4.8%
Other Staff
4.4%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
Colchester
National Average
Medical Staff to Consultant Ratio
2.55
2.59
Nurse Staff to Qualified Staff Ratio
2.07
2.50
Non-Clinical Staff to Total Staff
Ratio
0.38
0.34
Registered Nurse Hours to Patient
Day Ratio *
7.43
8.57
Source: Electronic Staff Record (ESR), Apr 13
*Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Consultant Productivity
(Spells/FTE)
Source: Electronic Staff Record (ESR), Apr 13
Colchester
National Average
575
492
Slide 59
Workforce Analysis continued…
National Staff Survey results
Colchester response rate to the staff
survey is significantly below average
and has fallen in 2012. The staff
engagement score is below average
when compared with trusts of a similar
type, although it improved in 2012.
Colchester is significantly below the
national average for the percentage of
staff who would be happy with the
standard of care if a friend or relative
needed treatment. It is below average
on recommending it as a place to work
which has fallen in 2012 compared with
2011.
Colchester
2011
Average for all
trusts
2011
Colchester
2012
Average for all
trusts
2012
57%
50%
39%
50%
3.60
3.62
3.62
3.69
Care of patients/service
users in my organisation’s
top priority
57%
69%
64%
63%
I would recommend my
organisation a place to work
54%
52%
53%
55%
If a friend or relative needed
treatment, I would be happy
with the standard of care
provided by this organisation
56%
62%
58%
60%
Response rate
Overall staff engagement
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 60
Deanery
The Trust was subject to enhanced monitoring in January 2010, when concerns were raised by the CQC. The GMC asked the Deanery
to visit the Trust, and they provided assurance that there were no major education concerns.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Obstetrics and Gynaecology and General Surgery were the programmes with the most activity below outliers between 2010 and
2012. Anaesthetics was the programme with the most above outliers reported during the same period. Trainees at the Trust reported
a similar number of outliers in each year, and no indicator was an outlier in two or more years.
NTS 2012 Patient Safety Comments
10 doctors in training commented, representing 5.99% of respondents. This was higher than the national average of 4.7%. Their
concerns, which were raised in relation to specific training posts, and may apply to a single or multiple departments, related to:
•
Low staffing levels, especially at night and weekends;
•
Lack of formal handover;
•
Informal patient handover between consultants;
•
Long waiting times;
•
Patients move between wards frequently; and
•
Unsafe rota design.
Source: GMC evidence to Review 2013
Slide 61
Deanery Reports
The Deanery Report in 2012 identified a number of concerns, including a breach of information governance (use of passwords), the
board level governance of education and training, compliance with mandatory training requirements (E&D and safeguarding),
provision of safe clinical services at Essex County Hospital and the lack of adequate infrastructure to ensure timely access to patient
results and reports.
Monitored under the response to concerns process?
Undermining
Yes, the Trust was monitored, but this case is now closed. A concern
at Colchester Hospital University NHS Foundation Trust was raised
by Postgraduate Medical Education and Training Board (PMETB)
in January 2010, following a CQC report.
For doctors in training, Colchester has a score of 92.6 on
“undermining,” below the national average of 94, which is the
rationale for the Trust’s red rating on this measure. The Trust’s
score is among the lowest of all 14 trusts covered by the review.
The Deanery undertook a programme of visits to the Trust at
PMETB’s request; reports back to PMETB stated that there were no
major educational concerns, and that quality control of training at
the Trust was being dealt with appropriately.
Mean Score on 'Undermining'
105
100
Colchester
92.6
95
90
85
80
Trusts covered by review
All other non specialist trusts
Slide 62
Source: National Training Survey 2012
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:
Colchester is at the lower end of the distribution for the
proportion of women receiving ante-natal steroids, and some
way short of the 85% national standard.
The Trust sees 96.6% of A&E patients within 4 hours which is
above the 95% target level. The percentage of patients seen
within 4 hours was relatively consistent during 2012. 93.8% 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.
Colchester’s crude readmission rate is among the lower
readmission rates of the trusts in the review as well as
nationally, at 10.9%. Similarly, their standardised readmission
rate shows a level of performance that is statistically below what
is expected. The Trust’s average length of stay is shorter than
that of the national average.
The PROMs dashboard shows that Colchester was an average
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
A&E Waits
PROMs
Dashboard
Hip Replacement EQ-5D
Knee Replacement EQ-5D
Varicose Vein EQ-5D
Hip Replacement OHS
Knee Replacement OKS
Outcome 1 (R17) Respecting and involving people who use services
Groin Hernia EQ-5D
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
In the National Clinical Audit for Neonatal intensive and
special care (NNAP), a key measure of effectiveness is the
percentage of women receiving ante-natal steroids.
Proportion of women receiving ante-natal steroids (level 2)
On this measure, Colchester is at the lower end of the
distribution, and some way short of the national average.
Colchester
Hospital
Slide 67
PROMs Dashboard
The PROMs dashboard shows that Colchester was an
average performer overall. None of the indicators fell
outside the control limits for the 3 years shown in the
dashboard.
Hip Replacement EQ-5D
0.5
0.4
England Average
0.3
Colchester
0.2
Upper Control Limit
Lower Control Limit
0.1
2
20
11
/1
1
20
10
/1
20
09
/1
0
0
Source: PROMs Dashboard and NHS Litigation Authority
Slide 68
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
Colchester sees
96.6% of A&E
patients within 4
hours which is above
the 95% target level.
The time series
graph shows that
this has been a
consistent trend
January 2012 to
December 2012.
A&E Percentage of Patients Seen
within 4 Hours
105%
100%
Colchester 4 Hour A&E Waits
Attendances (Thousands)
A&E wait times and
RTT times may
indicate the
effectiveness with
which demand is
managed.
Colchester
96.6%
95%
90%
85%
98.0%
7
97.5%
6
97.0%
5
96.5%
4
96.0%
3
95.5%
2
95.0%
1
94.5%
0
94.0%
80%
75%
Number of patients seen within 4 hours
70%
Patients Not Seen
Trusts Covered by Review
All Trusts
A&E Target 95%
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Seen within 4 hours (%)
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Referral to Treatment (Admitted)
Colchester Referral to Treatment
Performance
105%
93.8% of patients are
seen within the 18
week target time
which is above the
target level. In
addition, the time
series shows that
Colchester has been
consistently
performing above
the target rate.
8
100%
95%
Colchester
93.8%
98%
96%
94%
90%
92%
85%
90%
80%
88%
86%
75%
Trusts Covered by Review
Source: Department of Health. Feb 13
All Trusts
RTT Target 90%
Referral to Treatment Rate
RTT Target 90%
Source: Department of Health. Apr 12 – Feb 13
Slide 69
Operational Effectiveness – Emergency Re-admissions and Length of Stay
The standardised
readmission rate, most
importantly, accounts for
the trust’s case mix and
shows Colchester is
statistically lower than
expected having one of the
lowest standardised
readmission rates of the 14
selected trusts.
Colchester’s average length
of stay is 4.0 days, which is
shorter than the national
mean average of 5.2 days.
25%
Crude Readmission Rate
Colchester’s crude
readmission rate is among
the lower readmission rates
of the trusts in the review as
well as nationally, at 10.9%.
Standardised 30-day Readmission
Rate
Crude Readmission Rate by Trust
20%
Colchester
10.9%
15%
10%
5%
0%
Trusts Covered by Review
Colchester
Selected trusts Outside
Selected trusts w/in Range
All Trusts
Average Length of Stay by Trust
10
9
Spell Duration (Days)
Readmission rates may
indicate the
appropriateness of
treatment offered, whilst
average length of stay may
indicate the efficiency of
treatment.
8
7
Colchester
3.96
6
5
4
3
2
1
0
Trusts Covered by Review
Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12
All Trusts
Slide 70
Operational Effectiveness – Payment by Results coding audit
The Payment by Results (PbR) Data Assurance Framework has a national
clinical coding audit programme managed by the Audit Commission, which
provides assurance around the quality of data underpinning PbR payments.
Inpatient coding was audited for all Trusts from 2007/08. In 2010/11 it was
only audited for the 30 Trusts with previously consistently high error rates
(using a sample of episodes and targeted using local knowledge). Outpatient
coding was added in 2009/10 and the most poorly performing 20% of Trusts
were followed up in 2010/11.
Colchester was identified among the 30 Trusts with a consistently high
inpatient coding error rate up to 2009/10. In 2010/11 it remained in the
worst performing category. It had 12% of HRGs derived incorrectly and
19.4% of clinical codes (procedures and diagnoses) recorded incorrectly,
based on 300 cases reviewed by accredited clinical coding auditors.
QRP data shows the proportion of secondary procedures recorded
incorrectly remains worse than expected in 2011/12, at 15.7%. However the
error rates for primary procedures and for primary and secondary
diagnoses were within an expected range.
Colchester was also identified as being in the worst performing 20% of
Trusts for outpatient coding in 2009/10. It showed improvement in
attendance errors in 2010/11, but the recording of outpatient procedures
showed a 24% error.
There were no issues at the Trust with the coding of reference costs.
Source: PbR Data Assurance Framework, Audit Commission
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 comprised of primarily substantive
appointments (except the Director of Nursing and the Director
of Workforce), and has been relatively stable for the past two
years. The Chair and Chief Executive took up their posts at the
Trust in late summer 2010 following the removal of the previous
Chair (Monitor intervention) and the retirement of the previous
Chief Executive.
Review Areas:
To provide this indication of the Trust’s leadership and
governance procedures we have reviewed the following areas:
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
The Board sub-committee with responsibility for quality
governance is the Quality and Patient Safety Committee. This
sub-committee is chaired by a non-executive director.
A recent review by the CQC has identified minor concerns in
relation to outcome 1 (Respecting and involving people who use
services) and moderate concerns in relation to outcome 16
(Assessing and monitoring the quality of service provision ).
Key risks for the Trust relate to mortality (in particular
perinatal mortality), end of life provision across the community,
serious incidents in obstetrics, surgical site infections, learning
from experience, staffing levels and the emergency assessment
unit.
The latest serious incident report (for the period 1 Nov 2012 to 8
Feb 2013) has identified 44 serious incidents including two never
events (retained swab and suboptimal care).
Slide 73
Leadership and governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in
the following pages.
Leadership and
governance
Monitor governance risk rating
Monitor finance rating
CQC Outcomes
4
Governance risk rating
Red - Likely or actual significant breach of terms of authorisation
Amber-red - Material concerns surrounding terms of authorisation
Amber-green - Limited concerns surrounding terms of authorisation
Green - No material concerns
CQC Concerns
Red – Major concern
Amber – Minor or Moderate concern
Green – No concerns
Financial risk rating
rated 1-5, where 1 represents the highest risk and 5 the lowest
Slide 74
Leadership and governance
Trust Board
The Trust Board is comprised of primarily substantive appointments, and has been relatively stable for the past two years. The Chair and
Chief Executive took up their posts at the Trust in late summer 2010 following the removal of the previous Chair (Monitor intervention) and
the retirement of the previous Chief Executive.
The Director of Nursing is an ‘acting’ role, appointed in April 2013, and the Director of Workforce is an interim role.
Governance and clinical structures
The Trust Board receives assurance from four sub-committees; the Quality & Patient Safety Committee, Finance & Resourcing Committee,
Performance Assurance Committee and Audit & Risk Assurance Committee. These sub-committees are chaired by non-executive directors.
Board priorities for 2012/13
1.
Inspiring our employees
2.
Delivering high quality services
3.
Strengthening our centre of excellence
4.
Shaping the future, ready to respond
5.
Building a sustainable future
External reviews and regulation
Monitor amended the financial risk rating for the Trust from 3 to 4 in November 2012 due to an improvement in the Trust's financial
position. The governance risk rating for this foundation trust was amended from green to amber-red in December 2012 due the Trust
breaching the C difficile target in Q3 2012/13.
A recent review by the Care Quality Commission found that the Trust was not meeting two outcomes:
•
Respecting and involving people who use services (minor concerns);
•
Assessing and monitoring the quality of service provision (moderate concerns); and
The Trust has also had a number of external reviews, which we consider further on the following pages.
A diagram of board members and committee structure can be found in the Appendix.
Slide 75
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified
risks
Trust response
Relative risk and
observed mortality
SHMI significantly above the expected level with the current reported HSMR in line with the expected level. Mortality
performance including progress against the improvement work is routinely reported by the Medical Director and Chief Executive
to the Board and the Board actively debates mortality issues.
Copies of detailed reviews are also submitted to the Board as and when they arise.
Examples of such reports include the report commissioned from Dr Foster Group to investigate the unaccounted for variance
between the Trust’s reported SHMI and HSMR and the detailed patient review of mortalities such as that undertaken for deaths
in August 2012.
Since December 2010 the Trust has operated a weekly mortality review process where10% of deaths are randomly selected
and the responsible consultant and matron are invited to present the case to a group of clinical peers, executives and clinical
safety managers. More recently GP representation has joined this weekly review to enable improvements in the patient pathway
that straddle multiple organisations.
The Trust operates a monthly alerts review process using the Dr Foster Intelligence tool to identify diagnosis or procedure
groups where the relative risk is higher than expected or where there is an emerging risk. This process has been co-ordinated
by the Associate Director of Service Improvement who supports the Medical Director in improving clinical and documentation
processes that impact on mortality since October 2012. This process is supported through the Trust Quality Hub.
End of life provision
across the economy
Clinical reviews and audits have identified that a high proportion of deaths occur in patients admitted at the end of their life.
A review of end of life provision was undertaken by Marie Curie Cancer Centre in 2011 as part of the “Delivering Choice
Agenda”. This identified that end of life care in North East Essex is provided by a variety of organisations and professional
groups. Consequently a very complex system has arisen, with limited joined-up working and out-of-hours /weekend provision
and fewer hospice beds compared with the national.
Implementation of key recommendations from this review has been slow and has been impacted by transition from PCTs to
CCGs. However, work is now in train to implement end of life transformational change in 2013/14, including a single point of
access (through transition funding) increasing the number of patients on the GSF Register (through Locally Enhanced Services)
and improving discharge communication (through CQUINs).
Slide 76
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified
risks
Trust response
Perinatal mortality
The Trust has a higher observed mortality compared to the historical national. In the absence of contemporary national
benchmark data Professor Elizabeth Draper, Professor of Perinatal & Paediatric Epidemiology, University of Leicester was
asked to review the Trust’s mortality. She identified that we are ‘obviously very rigorous in our reporting of any signs of life for all
possible cases of live birth and that there is large variation in the registration of live births around the time of viability across
England which has a major impact upon neonatal mortality and infant death rates. The national variability makes it difficult for
the department to assess whether the higher observed rate seen is as a result of clinical quality of care or national variability. All
mortalities undergo a full clinical review as part of the Divisions’ governance process.
Obstetric serious
incidents
Following six Serious Incidents over a 16-month period including a maternal death in 2011, the Trust invited the Royal College
of Obstetricians and Gynaecologists to undertake a review. Overall the college identified that the service was safe, complied
with the majority of standards, that satisfactory governance processes were in place and that there was evidence of good
practice. Several recommendations to improve patient flow and communication were also identified. A task group to implement
the recommendations has been set up and progress is being made. This is being kept under regular review and is monitored
through the Quality & Patient Safety Committee.
Surgical site
infections
The Trust invited the Health Protection Agency to support improvements in surgical site infection rates in large bowel surgery.
Working with the clinical teams to develop an improvement plan, the Trust has set up a surveillance group to provide assurance
on progress against the plan to deliver the improvements.
Learning from
experience
The processes for reporting incidents, themes from complaints and closing down Learning from Experience Action Plans
(LEAPs) has been identified as an area for improvement within the Trust. This has been demonstrated through the recent Care
Quality Commission (CQC) inspection where a moderate concern to compliance was raised and through a contract query from
the CCG.
A review has identified areas for improvement related to the reporting of serious incidents in line with national guidance and the
documentation of the actions taken to conclude LEAPs.
Although evidence suggests actions have been taken at Divisional level this is not comprehensively documented. Independent
internal audit of current processes has been undertaken and a detailed plan has been submitted to the CQC and CCG to both
close LEAPs and ensure reporting structures and processes are robust going forward.
Slide 77
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified
risks
Trust response
Staffing levels and
recruitment
The number of nursing staff has increased by 105 and the number of consultants has increased by 16 in the last three years.
Recruitment of sufficient numbers of nurses has proven difficult locally and a recruitment strategy has been agreed including
seeking opportunities outside of the local population area.
A review of midwifery numbers identifies a gap to meet the Birthrate plus standards. The economy currently does not have an
agreed position on how this gap will be funded. The Trust is funding these additional posts whilst the Director to Director
discussions with the CCG continue.
Emergency
Assessment Unit
(EAU)
Although some improvement in hospital standardised mortality rates (HSMR) had been made this was not reducing at the rate the
Board would have liked. As 98% of deaths are in the emergency pathway the Trust invited the Emergency Care Intensive Support
Team (ECIST) in February 2011 to support improvements in emergency care and patient safety. Good progress has been made
delivering phase 1 improvements in early and timely senior medical review (expanded consultant presence on site until midnight),
timely assessment and treatment in the emergency department, reduction in outliers, structured ward board rounds and
development of core quality standards across the patient pathway. ECIST have included the work undertaken at the Trust as an
example of good practice in work they have undertaken in other organisations as part of their improving emergency pathway work
programmes.
While good progress has been made in the first phase of work, further work is required to improve the patient flow, capacity and
capability within the EAU to improve the quality and consistency of the care provided. Work has started to restructure the senior
nursing and management leadership within the department. Facilitated patient flow workshops have been arranged to develop the
next phase of the change programme.
Slide 78
Leadership and governance
External reviews
A recent CQC inspection of Colchester General Hospital in January 2013 considered the Trust’s compliance with six outcomes (respecting
and involving people who use services, care and welfare of people who use services, meeting nutritional needs, management of medicines,
supporting workers and assessing and monitoring the quality of service provision.
The Trust was found to be compliant with all but two of these standards:
•
Respecting and involving people who use services (minor concerns).
•
Assessing and monitoring the quality of service provision (moderate concerns).
In particular, this review identified 21 incidents from 1 April to 31 December 2012 that the CQC felt should have been classified as a serious
incident but weren’t. The Trust has reviewed these incidents; a paper presented to the March Board concluded that four of these incidents
should be reclassified.
The Trust has engaged with a number of external bodies to review its services including Cambridge University Hospitals NHS Foundation
Trust, Emergency Care Intensive Support Team, Dr Foster, Professor Elizabeth Draper (Professor of Perinatal and Paediatric
Epidemiology, University of Leicester), the Health Protection Agency, Royal College of Obstetricians and Gynaecologists and Foresight
Partnership LLP.
A number of these reviews have focused on historic issues with the maternity services provided by the Trust. As noted in the risks section
above, the Trust has had a higher than expected perinatal mortality, and experienced six serious untoward incidents in maternity over a 16
month period around 2011. Concerns were also raised in relation to serious incidents in maternity historically being reported on an
incorrect system.
Cost Improvement Programme
In 2012/13 the Trust achieved cost improvement programmes of £4.5m (£1.8m pay, £2.7m non-pay). The largest projects related to bed
reductions and estates and facilities.
In 2013/14, the Trust plans to achieve cost improvements of £9.7m (of which £3.1m relates to income generation, and £6.6m relates to cost
savings).
Each CIP is developed by the divisions with sign off from clinical leadership within the divisions. The planned CIPs are then approved by
the Medical Director and Director of Nursing, prior to Executive Team and Trust Board sign off.
Slide 79
Appendix
Slide 80
Trust Map – Colchester General Hospital
Source: Colchester Hospital University NHS Foundation Trust website
Slide 81
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 82
Workforce Indicator Calculations
Indicator
WTE nurses per bed day
Spells per WTE staff
Medical Staff to Consultant
Ratio
Nurse Staff to Qualified Staff
Ratio
Numerator /
Denominator
Calculation
Source
Numerator
Nurses FTE’s
Denominator
Total number of Bed Days
Acute
Quality
Dashboard
Numerator
Total Number of Spells
Denominator
Total number of WTE’s
Numerator
FTEs whose job role is ‘Consultant’
Denominator
FTEs in ‘Medical and Dental’ Staff Group
Numerator
FTEs in ‘Nursing & Midwifery Registered’ Staff Group
Denominator
FTEs of Additional Clinical Services – 85% of bands 2, 3 and 4
Numerator
FTEs not in ‘Nursing and Midwifery Registered’, ‘Additional Clinical
Services,’ ‘Allied Health Professionals’ or ‘Medical and Dental’ staff
groups
Denominator
Sum of FTEs for all staff groups
Numerator
Number of Inpatient Spells
Denominator
FTEs whose job role is ‘Consultant’
Numerator
Nurse FTEs multiplied by 1522 (calculated number of hours per year
which takes into account annual leave and sickness rates)
Denominator
Total Bed Days
Non-clinical Staff to Total Staff
Ratio
Consultant Productivity
(Spells/FTE)
Nurse hours per patient day
Note: ESR Data only includes substantive staff.
HED
ESR
ESR
ESR
ESR
HED
ESR
ESR
HED
Board members
Slide 84
Committee structures
Slide 85
Data Sources
No.
Data Source name
1 Board of Directors Meeting 30th January, 2013
2 Department of Health: Transparency Website, Dec 12
3 Healthcare Evaluation Data (HED)
4 NHS Choices
5 Office of National Statistics, 2011 Census data
6 Index of Multiple Deprivation, 2011
7 © Google Maps
8 Public Health Observatories – Area health profiles
Area
Context
Context
Context, Mortality, Clinical and
Operational Effectiveness
Context
Context
Context
Context
Context
9 Background to the review and role of the national advisory group
Context
Health & Social Care Information Centre – SHMI and contextual
10 indicators
11 Dr Foster – HSMR
Mortality
Mortality
12 Care Quality Commission – alerts, correspondence and findings
13 Patient Experience Survey
14 Cancer Patient Experience Survey
15 Peoples Voice Summary
16 Complaints data
Mortality
Patient Experience
Patient Experience
Patient Experience
Patient Experience
17 Acute Trust Quality Dashboard, Oct 2011 – Mar 2012
18 Safety Thermometer, Apr – Dec 2012
19 Litigation Authority Reports
20 GMC Evidence to Review 2013
21 National Staff Survey 2011, 2012
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
22 2011/12 Organisational Readiness Self-Assessment (ORSA)
23 National Training Survey, 2012
Safety and Workforce
Safety and Workforce
NHS Hospital & Community Health Service (HCHS), monthly workforce
24 statistics
25 Clinical Audit Data Trust, CQC Data Submission
26 Department of Health
27 Cancer Waits Database, Q3, 2012-13
28 PROMs Dashboard
Safety and Workforce
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
29 Board and quality subcommittee agendas, minutes and papers
30 Quality strategy
31 Reports from external agencies on quality
Leadership and Governance
Leadership and Governance
Leadership and Governance
32 Board Assurance Framework and Trust Risk Register
Leadership and Governance
33 Organisational structures and CVs of Board members
Leadership and Governance
34 Colchester Hospital University NHS Foundation Trust website
35 UK National Screening Committee
Appendix
Appendix
Slide 86
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Elective
800 - Clinical oncology (previously known as Radiotherapy)
264.6
1
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Cancer of head and neck
Pneumonia (except that caused by tuberculosis or
sexually transmitted disease)
641.8
1
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Acute bronchitis
553.6
1
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Other upper respiratory disease
16093
1
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Cancer of colon
1755
1
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Melanomas of skin
7037
1
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Non-Hodgkin`s lymphoma
397.8
1
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Malignant neoplasm without specification of site
2851
2
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Other nutritional; endocrine; and metabolic disorders
1614
1
Elective
800 - Clinical oncology (previously known as Radiotherapy)
Deficiency and other anemia
207.8
1
Non-elective
300 - General medicine
Conduction disorders
128.3
1
Non-elective
300 - General medicine
Cardiac dysrhythmias
106.1
1
Non-elective
300 - General medicine
Cardiac arrest and ventricular fibrillation
113.1
1
Non-elective
300 - General medicine
Other circulatory disease
181.8
3
Non-elective
300 - General medicine
Phlebitis; thrombophlebitis and thromboembolism
191.6
2
Non-elective
300 - General medicine
Cancer of esophagus
131.7
1
Non-elective
300 - General medicine
ther diseases of veins and lymphatics
301.3
1
Non-elective
300 - General medicine
Asthma
236.7
3
Non-elective
300 - General medicine
Cancer of stomach
132
1
Non-elective
300 - General medicine
Lung disease due to external agents
312.2
1
Non-elective
300 - General medicine
Disorders of teeth and jaw
990.2
1
Non-elective
300 - General medicine
Cancer of colon
126.9
1
Non-elective
300 - General medicine
Other disorders of stomach and duodenum
592
2
Non-elective
300 - General medicine
Abdominal hernia
207
2
Non-elective
300 - General medicine
Regional enteritis and ulcerative colitis
411.4
3
Slide 87
SHMI Appendix
Diagnostic Group
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
SHMI
Non-elective
300 - General medicine
Diverticulosis and diverticulitis
255.8
2
Non-elective
300 - General medicine
Peritonitis and intestinal abscess
694.4
1
Non-elective
300 - General medicine
Biliary tract disease
133.5
1
Non-elective
300 - General medicine
Cancer of liver and intrahepatic bile duct
191.7
3
Non-elective
300 - General medicine
Calculus of urinary tract
536.6
1
Non-elective
300 - General medicine
Other diseases of kidney and ureters
589.7
2
Non-elective
300 - General medicine
Inflammatory conditions of male genital organs
1736
2
Non-elective
300 - General medicine
Cancer of pancreas
121.5
1
Non-elective
300 - General medicine
222.5
1
Non-elective
300 - General medicine
Cancer of other GI organs; peritoneum
Infective arthritis and osteomyelitis (except that caused by tuberculosis or sexually
transmitted disease)
182.1
1
Non-elective
300 - General medicine
Osteoarthritis
352.7
2
Non-elective
300 - General medicine
Other non
113
1
Non-elective
300 - General medicine
Cancer of bone and connective tissue
223.8
1
Non-elective
300 - General medicine
Systemic lupus erythematosus and connective tissue disorders
3243
1
Non-elective
300 - General medicine
Other connective tissue disease
108.7
1
Non-elective
300 - General medicine
Cardiac and circulatory congenital anomalies
2966
2
Non-elective
300 - General medicine
Skull and face fractures
207.3
1
Non-elective
300 - General medicine
Other fractures
156.1
3
Non-elective
300 - General medicine
Intracranial injury
124.3
2
Non-elective
300 - General medicine
Complication of device; implant or graft
181
2
Non-elective
300 - General medicine
Complications of surgical procedures or medical care
193.9
1
Non-elective
300 - General medicine
Superficial injury; contusion
116.9
2
Non-elective
300 - General medicine
Cancer of breast
162.5
2
Non-elective
300 - General medicine
Poisoning by psychotropic agents
361.1
3
Non-elective
300 - General medicine
Abdominal pain
141.1
1
Slide 88
SHMI Appendix
Diagnostic Group
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
SHMI
Non-elective
300 - General medicine
Allergic reactions
192.3
1
Non-elective
300 - General medicine
Cancer of ovary
151.3
1
Non-elective
300 - General medicine
Cancer of kidney and renal pelvis
293.4
2
Non-elective
300 - General medicine
Cancer of thyroid
292.8
1
Non-elective
300 - General medicine
Mycoses
342.6
1
Non-elective
300 - General medicine
Multiple myeloma
248.1
2
Non-elective
300 - General medicine
Cancer; other and unspecified primary
233.1
1
Non-elective
300 - General medicine
Nutritional deficiencies
223.1
1
Non-elective
300 - General medicine
Gout and other crystal arthropathies
213.9
1
Non-elective
300 - General medicine
Fluid and electrolyte disorders
111.4
2
Non-elective
300 - General medicine
Deficiency and other anemia
145
3
Non-elective
300 - General medicine
Other psychoses
145
2
Non-elective
300 - General medicine
Other CNS infection and poliomyelitis
566.2
2
Non-elective
300 - General medicine
Parkinson`s disease
244.3
3
Non-elective
300 - General medicine
Epilepsy; convulsions
136.2
2
Non-elective
300 - General medicine
Coma; stupor; and brain damage
210.8
3
Non-elective
422 - Neonatology
Nervous system congenital anomalies
8243
1
Non-elective
422 - Neonatology
Intrauterine hypoxia and birth asphyxia
5792
3
Non-elective
422 - Neonatology
Respiratory distress syndrome
1059
1
Non-elective
422 - Neonatology
Other perinatal conditions
408.5
2
Non-elective
422 - Neonatology
Residual codes; unclassified
20235
1
Non-elective
430 - Geriatric medicine
Pulmonary heart disease
242.6
2
Non-elective
430 - Geriatric medicine
Cardiac dysrhythmias
139.2
1
Non-elective
430 - Geriatric medicine
Congestive heart failure; nonhypertensive
122.1
2
Non-elective
430 - Geriatric medicine
Cancer of head and neck
266.3
1
Slide 89
SHMI Appendix
Diagnostic Group
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
SHMI
Non-elective
430 - Geriatric medicine
Phlebitis; thrombophlebitis and thromboembolism
606.9
1
Non-elective
430 - Geriatric medicine
Pneumonia (except that caused by tuberculosis or sexually transmitted disease)
106.9
2
Non-elective
430 - Geriatric medicine
Acute bronchitis
168.2
3
Non-elective
430 - Geriatric medicine
Chronic obstructive pulmonary disease and bronchiectasis
162.6
3
Non-elective
430 - Geriatric medicine
Asthma
359.9
1
Non-elective
430 - Geriatric medicine
Aspiration pneumonitis; food/vomitus
126.2
1
Non-elective
430 - Geriatric medicine
Other lower respiratory disease
267.6
1
Non-elective
430 - Geriatric medicine
Diseases of mouth; excluding dental
3683
1
Non-elective
430 - Geriatric medicine
Cancer of colon
338
1
Non-elective
430 - Geriatric medicine
Abdominal hernia
220
1
Non-elective
430 - Geriatric medicine
Biliary tract disease
194.2
2
Non-elective
430 - Geriatric medicine
Pancreatic disorders (not diabetes)
2299
1
Non-elective
430 - Geriatric medicine
Noninfectious gastroenteritis
284.8
1
Non-elective
430 - Geriatric medicine
Other diseases of kidney and ureters
727.3
1
Non-elective
430 - Geriatric medicine
Genitourinary symptoms and ill
1411
1
Non-elective
430 - Geriatric medicine
Cancer of pancreas
148.5
1
Non-elective
430 - Geriatric medicine
Skin and subcutaneous tissue infections
218.2
2
Non-elective
430 - Geriatric medicine
Other inflammatory condition of skin
317.1
1
Non-elective
430 - Geriatric medicine
Chronic ulcer of skin
185.4
1
Non-elective
430 - Geriatric medicine
Septicemia (except in labor)
129.2
1
Non-elective
430 - Geriatric medicine
Osteoarthritis
624.2
1
Non-elective
430 - Geriatric medicine
Spondylosis; intervertebral disc disorders; other back problems
368.6
1
Non-elective
430 - Geriatric medicine
Other connective tissue disease
183.9
1
Non-elective
430 - Geriatric medicine
Other fractures
467.2
2
Non-elective
430 - Geriatric medicine
Open wounds of head; neck; and trunk
490.9
2
Slide 90
SHMI Appendix
Diagnostic Group
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
SHMI
Non-elective
430 - Geriatric medicine
Superficial injury; contusion
302.4
2
Non-elective
430 - Geriatric medicine
Nausea and vomiting
281.7
1
Non-elective
430 - Geriatric medicine
Residual codes; unclassified
435.4
3
Non-elective
430 - Geriatric medicine
Cancer of bladder
272.5
1
Non-elective
430 - Geriatric medicine
Senility and organic mental disorders
161.9
3
Non-elective
430 - Geriatric medicine
Parkinson`s disease
407.5
1
Non-elective
430 - Geriatric medicine
Other hereditary and degenerative nervous system conditions
221.1
1
Non-elective
430 - Geriatric medicine
Epilepsy; convulsions
261.5
2
Non-elective
501 - Obstetrics
Short gestation; low birth weight; and fetal growth retardation
4401
1
Slide 91
HSMR Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
300 - General medicine
Abdominal pain
Non-elective
300 - General medicine
Cancer of bladder
Non-elective
300 - General medicine
Non-elective
Observed Deaths that
are higher than the
expected
HSMR
266.9
3
156
2
Cancer of ovary
157.9
1
300 - General medicine
Cancer of pancreas
112.7
1
Non-elective
300 - General medicine
Cancer of rectum and anus
176.8
2
Non-elective
300 - General medicine
Cancer of stomach
166.2
1
Non-elective
300 - General medicine
Cardiac arrest and ventricular fibrillation
105.4
1
Non-elective
300 - General medicine
Cardiac dysrhythmias
134.2
3
Non-elective
300 - General medicine
Chronic ulcer of skin
147.2
2
Non-elective
300 - General medicine
Complication of device; implant or graft
129.2
1
Non-elective
300 - General medicine
Coronary atherosclerosis and other heart disease
143.6
3
Non-elective
300 - General medicine
Fluid and electrolyte disorders
127
3
Non-elective
300 - General medicine
Intestinal obstruction without hernia
188.5
2
Non-elective
300 - General medicine
Malignant neoplasm without specification of site
133.1
2
Non-elective
300 - General medicine
Non-Hodgkin`s lymphoma
219.8
3
Non-elective
300 - General medicine
Other circulatory disease
205.7
3
Non-elective
300 - General medicine
Other fractures
135.2
2
Non-elective
300 - General medicine
Other gastrointestinal disorders
114.2
1
Non-elective
300 - General medicine
Other liver diseases
127.3
3
Non-elective
300 - General medicine
Other upper respiratory disease
178.7
3
Non-elective
300 - General medicine
Peripheral and visceral atherosclerosis
174.8
2
Non-elective
300 - General medicine
Peritonitis and intestinal abscess
243
1
Non-elective
300 - General medicine
Secondary malignancies
126
2
Non-elective
300 - General medicine
Senility and organic mental disorders
118.6
2
Slide 92
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Elective)
Treatment Specialty
Clinical oncology
HSMR
SHMI
X
Slide 93
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Nonelective)
Treatment Specialty
General medicine
HSMR
SHMI
X
X
Geriatric medicine
X
Neonatology
X
Obstetrics
X
X
Slide 94