East Lancashire Hospitals
NHS Trust
Data Pack
9th July, 2013
Overview
Sources of Information
On 6th February the Prime Minister asked Professor Sir Bruce
Keogh to review the quality of the care and treatment being
provided by those hospital trusts in England that have been
persistent outliers on mortality statistics. The 14 trusts which fall
within the scope of this review were selected on the basis that they
have been outliers for the last two consecutive years on either the
Summary Hospital Mortality Index or the Hospital Standardised
Mortality Ratio.
Document review
Trust information
submission for
review
These two measures are being used as a ‘smoke alarm’ for
identifying potential quality problems which warrant further
review. No judgement about the actual quality of care being
provided to patients is being made at this stage, or should be
reached by looking at these measures in isolation.
The review will follow a three stage process:
Stage 1 – Information gathering and analysis
Stage 2 – Rapid Responsive Review
Benchmarking
analysis
Information shared
by key national
bodies including
the CQC
Stage 3 – Risk summit
This data pack forms one of the sources within the information
gathering and analysis stage.
Information and data held across the NHS and other public bodies
has been gathered and analysed and will be used to develop the Key
Lines of Enquiry (KLOEs) for the individual reviews of each Trust.
This analysis has included examining data relating to clinical
quality and outcomes as well as patient and staff views and
feedback. A full list of evidence sources can be found in the
Appendix.
Given the breadth and depth of information reviewed, this pack is
intended to highlight only the exceptions noted within the evidence
reviewed in order to inform Key Lines of Enquiry.
Slide 2
East Lancashire Hospitals NHS Trust
Context
A brief overview of the Lancashire area and East Lancashire Hospitals NHS Trust. This section provides a profile of the area, outline
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.
East Lancashire Hospitals NHS Trust services a population of
521,000, which makes the Trust slightly larger than the size
recommended by the Royal College of Surgeons. 31% of the
population in Blackburn with Darwen, and 13% of the
population in Burnley, belong to non-White ethnic minorities,
particularly Indians, Pakistani, and Bangladeshi. Alcoholrelated diseases and adult smoking are among the most
prominent health concerns in both Blackburn with Darwen and
Burnley.
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:
•
Board of Directors meeting 30th Jan, 2013;
•
Department of Health: Transparency Website, Dec 12;
•
Healthcare Evaluation Data (HED);
•
NHS Choices;
•
Office of National Statistics, 2011 Census data;
•
Index of Multiple Deprivation, 2011;
•
© Google Maps;
•
Public Health Observatories – Area health profiles; and
•
Background to the review and role of the national
advisory group.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Trust has two acute hospital sites: Royal Blackburn
Hospital and Burnley General Hospital, as well as three
community hospitals: Accrington Victoria, Clitheroe, and
Pendle. East Lancashire became a Trust in 2003 and has a total
of 946 beds. It has a 62% market share of inpatient activity
within a 5 mile radius of the Trust sites. However, the Trust’s
market share falls to 56% within a radius of 10 miles, and 21%
within a radius of 20 miles.
A review of ambulance response times shows that the North
West meets the national 8min response target, but fails to meet
the national 19min response target.
Finally, East Lancashire’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
East Lancashire Hospitals NHS Trust was established in 2003. The
Trust primarily services the population of East Lancashire and
Blackburn with Darwen, a total of 521,000 people. The Trust has two
acute hospitals, Royal Blackburn Hospital and Burnley General
Hospital, as well as three community hospitals. The Trust offers a large
range of inpatient and outpatient services, as well as a number of
community services. The Trust has a slightly higher bed occupancy rate
than the national average, and treats nearly 750,000 cases yearly.
Trust Status
Not currently a Foundation Trust
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
946
86.9%
86%
General and
Acute
876
89.0%
88%
Maternity
70
61.6%
59%
Source: Department of Health: Transparency Website
East Lancashire Hospitals NHS Trust
Acute Hospital
Inpatient/Outpatient Activity
Burnley General Hospital, Royal Blackburn
Hospital
Community Hospitals
Inpatient Activity
Accrington Victoria Community Hospital, Clitheroe
Community Hospital, Pendle Community Hospital
Source: NHS Choices
Outpatient Activity
Elective
68,163 (49%)
Non Elective
71,751 (51%)
Total
139,914
Total
571,246
(Jan12-Dec12)
Day Case Rate:
85%
Source: Healthcare Evaluation Data (HED)
Finance Information
2012–2013 Income
£405m
Departments and Services
2012–2013 Expenditure
£373m
2012–2013 EBITDA
£32m
2012–2013 Net surplus (deficit)
£8m
2013-14 Budgeted Income
N/A
2013-14 Budgeted Expenditure
N/A
2013-14 Budgeted EBITDA
N/A
Accident & Emergency, Breast Surgery, Cardiology, Children’s &
Adolescent Services, Dermatology, Diabetic Medicine, Diagnostic
Endoscopy, Diagnostic Physiological Measurement, ENT,
Endocrinology and Metabolic Medicine, General Medicine, General
Surgery, Geriatric Medicine, Gynaecology, Haematology, Maternity
Service, Minor Injuries, Oral and Maxillofacial Surgery, Occupational
Therapy Services, Ophthalmology, Orthopaedics, Pharmacy
Services, Physiotherapy, Rehabilitation, Respiratory Medicine,
Rheumatology, Urology, Vascular Surgery.
2013-14 Budgeted Net surplus (deficit)
Source: East Lancashire Hospitals NHS Trust, board meeting papers,
N/A
24th
April, 2013
Source: NHS Choices
(Maps of Royal Blackburn Hospital and Burnley General Hospital are included in the Appendix)
Slide 6
Trust Overview continued...
General Medicine and
Paediatrics are the
largest inpatient
specialities while
Midwifery and
Ophthalmology are the
largest for outpatients.
Outpatient Activity by Trust
300
250
200
1200
Number of Outpatient Spells
(Thousands)
East Lancashire is a
large Trust for both
inpatient and
outpatient activity,
relative to the rest of
England. Indeed, the
Trust is the second
largest of all those
selected for this review
by both measures of
activity.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of East
Lancashire against
national trusts in
terms of inpatient and
outpatient activity.
East Lancashire
139,914
150
100
50
0
1000
800
East Lancashire
571,246
600
400
200
0
Trusts
Trusts Covered by Review
Trusts
National Inpatient Activity Curve
Top 10 Inpatient Main Specialties as a
% of Total Inpatient Activity
Trusts Covered by Review
Bottom 10 Inpatient Main Specialties
and Spells
National Outpatient Activity Curve
Top 10 Outpatient Main Specialties as
a % of Total Outpatient Activity
General Medicine
23%
Genito-Urinary Medicine
6
Midwifery
18%
Paediatrics
14%
Gastroenterology
7
Ophthalmology
12%
General Surgery
12%
Radiology
26
Trauma & Orthopaedics
11%
Gynaecology
7%
Rehabilitation
120
Gynaecology
8%
Urology
6%
Nephrology
467
Dermatology
7%
Trauma & Orthopaedics
6%
Dermatology
568
General Surgery
7%
Respiratory Medicine
4%
Geriatric Medicine
773
General Medicine
5%
Oral and Maxillofacial Surgery
3%
Oral Surgery
974
Cardiology
5%
Clinical Haemotology
3%
Anaesthetics
1541
Paediatrics
5%
Ophthalmology
3%
Clinical Oncology
2261
Ear, Nose & Throat
5%
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
Slide 7
Blackburn with Darwen and Burnley Area Overview
Lancashire, in which both Blackburn with Darwen and Burnley are situated, is
not a particularly deprived region of England. However, there are a number of
deprived areas within the region. The population of Blackburn with Darwen
and Burnley is younger than the population of England as a whole. Alcoholrelated deaths and adults smoking are among the most significant health
concerns in these two urban areas. The ethnic composition of the population in
Blackburn with Darwen is highly diverse, with Indians and Pakistani
constituting the largest non-White ethnic minorities. A significant proportion
of the population of Burnley also belong to non-White minorities, particularly
Pakistani and Bangladeshi.
Blackburn with Darwen and Burnley Demographics
0-9
FACT BOX
Population
The Royal College of Surgeons recommend that the
"...catchment population size...for an acute general hospital
providing the full range of facilities, specialist staff and
expertise for both elective and emergency medical and
surgical care would be 450,000 - 500,000."
IMD
Of 149 English unitary authorities, Lancashire
is the 79th most deprived.
Ethnic
diversity
In Blackburn with Darwen, 30.9% belong to
non-White ethnic minorities, including 13.4%
Indian and 12.1% Pakistani.
In Burnley, 12.7% belong to non-White ethnic
minorities, including 6.8% Pakistani and 2.8%
Bangladeshi.
Rural or
Urban
Blackburn with Darwen and Burnley are both
urban regions.
Alcoholrelated
disease
In both Blackburn with Darwen and Burnley
hospital stays for alcohol-related diseases
are more common than almost anywhere
else in England.
Adults
smoking
In both Blackburn with Darwen and Burnley
smoking among adults is significantly more
common than in England as a whole.
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80+
Female/BLA and BUR
20%
15%
10%
Female/ENG
5%
Male/BLA and BUR
0%
5%
10%
521,400
Male/ENG
15%
Source: Office of National Statistics, Census 2011; IMD Source: Index of Multiple Deprivation, 2010
20%
Slide 8
East Lancashire and Surroundings Geographic Overview
The map on the right shows the location of East Lancashire
Hospitals NHS Trust. Lancashire is a rural-urban area located in
the North West of England. As shown by the map, the Trust is
located in proximity to a number of larger urban areas, such as
Blackburn, Burnley and Preston.
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 East Lancashire
Hospitals NHS Trust. From the wheel it can be seen that East
Lancashire has a 62% 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 56%
within 10 miles and 21% within 20 miles.
The wheel shows that the main competitors in the local area are
Lancashire Teaching Hospitals NHS Foundation Trust, Ramsay
Health Care UK, and Pennine Acute Hospitals NHS Trust.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 9
East Lancashire’s Health Profile
Health Profiles, depicted on this slide and the following two, are designed to
help local government and health services identify problems in their areas
and decide how to tackle these issues. They provide a snapshot of the overall
health of the local population, and highlight potential differences against
regional and national averages.
Deprivation by unitary authority area
Blackburn with
Darwen
Burnley
The graph shows the level of economic deprivation experienced in Burnley
and Blackburn with Darwen.
The tables below outline Burnley and Blackburn with Darwen’s health profile
information in comparison with the rest of England.
1.
Burnley and
Blackburn with
1
Darwen both have
significantly more
deprivation, more child
poverty and higher
rates of violent crime
than the national
average. GCSE’s
achieved are also below
the national level in
both areas.
2
2. When looking at
children’s and young
people’s health, Burnley
is below the expected
range in almost all
indicators. Blackburn
with Darwen has a
significantly higher
rate of smoking in
pregnancy than the
national average.
Source: Public Health Observatories – area health profiles
Slide 10
East Lancashire’s Health Profile
3. In both areas,
smoking and healthy
eating are both
performing below the
expected range.
4. There are a
number of indicators
which show both
areas performing
significantly below
the expected range.
These include alcohol
related hospital
stays, hospital stays
for self harm, drug
misuse and diabetes.
Both areas are
amongst the worst in
the country for
alcohol related
hospital stays.
Source: Public Health Observatories – area health profiles
Slide 11
East Lancashire’s Health Profile
5. Life expectancy in
Blackburn with
Darwen and Burnley
is lower than the
national average.
There are a higher
number of smoking
related deaths and a
greater number of
deaths due heart
disease and cancer.
Source: Public Health Observatories – area health profiles
Slide 12
Performance of Local Healthcare Providers
To give an informed view of the
Trust’s performance it is
important to consider the
service levels of non-acute local
providers. For example, slow
ambulance response time may
increase the risk of mortality.
The graphs on the right
represent some key
performance indicators for
England’s Ambulance services.
The North West service meets
the 8min response target.
However, it fails to meet the
19min response target.
Proportion of calls responded to within 8 minutes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Isle of Wight
NHS Trust
South
West
South Central
Western
Midlands
Ambulance
Ambulance Ambulance Service NHS
Service NHS Service NHS Foundation
Foundation
Trust
Trust
Trust
South East
East of
London
North West
Great
North East
Yorkshire East Midlands
Coast
England
Ambulance Ambulance
Western
Ambulance Ambulance Ambulance
Ambulance Ambulance Service NHS Service NHS Ambulance Service NHS Service NHS Service NHS
Service NHS Service NHS
Trust
Trust
Service NHS
Trust
Trust
Trust
Foundation
Trust
Trust
Trust
Ambulance Trust
England
Proportion of calls responded to within 19 minutes
100%
98%
96%
94%
92%
90%
88%
86%
84%
Source: Department of Health: Transparency Website Dec 12
Isle of Wight
NHS Trust
West
London
South East
Yorkshire
South
Great
North East North West South Central
East of
East Midlands
Midlands
Ambulance
Coast
Ambulance
Western
Western
Ambulance Ambulance Ambulance
England
Ambulance
Ambulance Service NHS Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Ambulance Service NHS
Service NHS
Trust
Service NHS
Trust
Service NHS Service NHS
Trust
Trust
Foundation Service NHS
Trust
Trust
Foundation
Foundation
Trust
Trust
Trust
Trust
Trust
Ambulance Trusts
England
Slide 13
Why was East Lancashire 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, 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.
East Lancashire has been above the expected
range for the SHMI for the last two years and
was therefore selected for this review.
Trust
SHMI 2011 SHMI 2012 HSMR 2011 HSMR 2012
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 & role of the national advisory group
Slide 14
Why was East Lancashire chosen for this review?
The way that levels of observed
deaths that are higher than the
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 East Lancashire’s
SHMI and HSMR are above
the higher confidence interval
meaning there are higher than
expected deaths. The SHMI
time series shows that East
Lancashire was above the
expected level throughout the
time period.
SHMI Time Series
SHMI Funnel Chart
East Lancashire
Selected trusts Outside Range
Selected trusts w/in Range
HSMR Time Series
HSMR Funnel Chart
East Lancashire
Selected trusts Outside Range
Selected trusts w/in Range
Source: Healthcare Evaluation Data (HED); Apr 10-Mar12
Slide 15
Mortality
Slide 16
Mortality
Overview:
Summary:
This section focuses upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The Trust has an overall HSMR of 105 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
Further analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure,
with an HSMR of 106, compared with a level of 61 for elective
admissions.
Currently, East Lancashire has a SHMI of 114 for the period of
December 2011 to November 2012, which is statistically outside
the expected range.
Non-elective admissions are seen to be contributing primarily to
the overall Trust SHMI, with a SHMI of 114 for non-elective
admissions.
East Lancashire has had two high mortality alerts for diagnostic
groups since 2007.
East Lancashire developed five care bundles to improve the
delivery of care in diagnostic groups with a high mortality rate,
as part of their involvement with the Advancing Quality (AQuA)
Mortality Collaborative. They plan to develop more care
pathways and care bundles and to continue to develop the Early
Warning Score system to alert the trust of patients at risk of
deteriorating.
• Care Quality Commission – alerts, correspondence and findings.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Slide 17
Mortality Overview
Mortality
The following overview provides a summary of the Trust’s key mortality areas:
Overall HSMR
Elective mortality (SHMI and HSMR)
Overall SHMI*
Non-elective mortality (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 18
HSMR Definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a
hospital is higher or lower than you would expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it
cannot be said for certain that this reflects failings in the care provided by the hospital. However, it can be a warning sign that things are
going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of inhospital deaths (multiplied by 100) for 56 specific (CCS) groups; in a specified patient group. The expected deaths are calculated from
logistical regression models taking into account and adjusting for a case-mix of: age band, sex, deprivation, interaction between age band
and co-morbidities, month of admission, admission method, source of admission, the presence of palliative care, number of previous
emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected
number, in order to identify if variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to
calculate 95% and 99.9% confidence intervals and only when these have been crossed is performance classed as higher or lower than
expected.
Slide 19
SHMI Definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of
Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a
nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice.
How does SHMI work?
1.
2.
3.
4.
Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
The Indicator will utilise 5 factors to adjust mortality rates by
a.
The primary admitting diagnosis;
b.
The type of admission;
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities);
d.
Age; and
e.
Sex.
All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are
highlighted using a Random Effects funnel plot.
Slide 20
Some key differences between SHMI and HSMR
Indicator
HSMR
SHMI
Are all hospital deaths included?
No, around 80% of in hospital deaths are
included, which varies significantly
dependent upon the services provided by
each hospital
If a patient is transferred between hospitals
within 2 days the death is counted multiple
times
Yes all deaths are included
Does the use of the palliative care code
reduce the relative impact of a death on the
indicator?
Yes
No
Does the indicator consider where deaths
occur?
Only considers in-hospital deaths
Considers in-hospital deaths but also those
up to 30 days post discharge anywhere too.
Is this applied to all health care providers?
Yes
No, does not apply to specialist hospitals
When a patient dies how many times is this
counted?
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
Slide 21
SHMI overview
The Trust’s SHMI level for the past 12 months (Dec11-Nov12) is 114,
which means, as shown below, it is statistically above the expected
range , based on the 95% confidence interval of the Poisson
distribution.
Month-on-month time series
The time series show that SHMI has stayed roughly the same yearon-year. Month-on-month, the SHMI has been consistently above
100; however, there is a general decreasing trend and since June
2012 the SHMI has been within the expected range.
SHMI funnel chart –12 months
East Lancashire
Year-on-year time series
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 22
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for East
Lancashire.
As SHMI includes mortalities
that occur within the hospital
and outside of it for up to 30
days following discharge, it is
imperative to understand the
percentage of deaths which
happen inside the hospital
compared to outside. This
may contribute to differences
in HSMR and SHMI
outcomes.
Percentage of patient deaths in hospital
90%
85%
80%
East Lancashire
71.0%
75%
70%
65%
60%
Trusts selected for review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The data shows that 71.0% of
SHMI deaths at East
Lancashire occur in hospital,
which is less than the
national average of 73.3%.
Slide 23
Clinical Oncology
-
Midwife Episode
Obstetrics
-
Geriatric Medicine (135; 35)
Gynaecology
Well Babies
-
Neonatology
Midwife Episode
Well Babies
-
-
Neonatology
Paediatrics
Gynaecology
Paediatrics
Rheumatology
-
Rheumatology
-
Geriatric Medicine
Medical Oncology
Diagnosis (100 ; 1 )
Treatment Specialties
SHMI 121
-
Medical Oncology
Nephrology
-
Nephrology
Thoracic Medicine
-
Thoracic Medicine (150; 23)
Dermatology
-
Cardiology
Dermatology
Rehabilitation
-
Cardiology
Diabetic Medicine (822; 3)
-
Rehabilitation
Clinical Haematology
-
Diabetic Medicine
Gastroenterologoy
-
Clinical Haematology
General Medicine
-
Gastroenterology
Critical Care Medicine
-
-
General Medicine (111; 183)
Pain Management
-
-
Paediatric Neuro-disability
Maxillo-facial Surgery
-
Critical Care Medicine (269; 62)
-
-
Accident & Emergency (A&E)
-
Non
Elective
SHMI 114
The tree shows that
East Lancashire NHS
Trust has a SHMI of
114 which is higher
than the expected
range.
-
Ophthalmology
Ear, Nose And Throat
(ENT)
Trauma & Orthopaedics
Maxillo-facial Surgery
-
Vascular Surgery
Ophthalmology
-
Ear, Nose And Throat (ENT)
Breast Surgery
-
Trauma & Orthopaedics
-
-
Vascular Surgery
Urology
-
Breast Surgery
-
-
Urology
Key
Slide 24
The diagnostic groups with one to three more observed deaths than expected are listed in the Appendix.
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Treatment Specialties
General Surgery
SHMI 114
-
-
General Surgery
Observed deaths that are higher
than the expected
SHMI
-
The number of
observed deaths in
four specific nonelective areas are
highlighted as being
higher than expected.
These are potential
areas for review.
Elective
Mortality trees
provide a breakdown
of SHMI into elective
and non-elective
admissions. The SHMI
score for non-elective
admissions has a
greater impact on the
overall indicator due
to a higher number of
expected deaths.
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
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
The SHMI sub-tree highlights the specialties for elective and non-elective
admissions with a statistically higher SHMI than expected and highlights the
diagnostic groups with at least 4 more observed deaths than expected. When
identifying areas to review, it is important to consider the number of deaths as
well as the SHMI.
General Medicine has the highest number of greater than expected deaths with
pneumonia, pleurisy; pneumothorax; pulmonary collapse, and other
gastrointestinal disorders seen as the main diagnostic groups contributing to this.
Overall118.2
(114; 332)
Non-elective (114; 317)
Treatment Specialties
Critical Care Medicine (269; 62)
Diagnostic Groups
Acute cerebrovascular disease
(670; 11)
Acute myocardial infarction
Cardiac arrest and ventricular
fibrillation
(575; 7)
Pneumonia
(161; 7)
(259; 12)
Key
Diagnosis (100 ; 1 )
SHMI
Observed deaths that are higher
than the expected
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
General Medicine (111; 183)
Acute and unspecified renal failure
Acute cerebrovascular disease
Biliary tract disease
Cancer of esophagus
Cancer of kidney and renal pelvis
Cancer of pancreas
Cardiac arrest and ventricular fibrillation
Complication of device; implant or graft
Intestinal infection
Open wounds of head; neck; and trunk
Other connective tissue disease
Other fractures
Other gastrointestinal disorders
Other nutritional; endocrine; and
metabolic disorders
Pleurisy; pneumothorax; pulmonary
collapse
Pneumonia
Septicemia (except in labor)
Spondylosis; intervertebral disc
disorders; other back problems
Superficial injury; contusion
Syncope
Urinary tract infections
Thoracic Medicine (150; 23) Geriatric Medicine (135; 35)
(122; 11)
(109; 9)
(221; 12)
(135; 4)
(221; 4)
(186; 6)
(144; 6)
(247; 4)
(127; 7)
(208; 4)
(153; 7)
(152; 5)
(166; 80)
Chronic
obstructive
pulmonary
disease and
bronchiectasis
Pneumonia
Acute cerebrovascular
disease
Pneumonia
(114; 6)
(145; 6)
(177; 7)
(184; 8)
(147; 4)
(127; 50)
(113; 41)
(110; 4)
(194; 7)
(206; 14)
(163; 8)
(113; 7)
Slide 25
HSCIC SHMI overview
The Health and Social Care Information Centre (HSCIC) publish
the SHMI quarterly. This official statistic covers a rolling 12
month reporting period using a model based on a 3-year dataset
refreshed quarterly. The earliest publication was in October
2011, for the period from April 2010 to March 2011.
The HSCIC produce two sets of upper and lower limits. One set
uses 99.8% control limits from an exact Poisson distribution
based on the number of expected deaths. The other set uses a
Random effects model applying a 10% trim for over-dispersion,
based on the standardised Pearson residual for each provider
excluding the top and bottom 10% of scores. This latter set is
broader than the Poisson and is the one against which the
HSCIC report whether the SHMI is within, below or above the
expected range.
SHMI published by HSCIC, East Lancashire
120
115
114
114
113
110
113
112
113
114
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 East Lancashire was 114 in the year to Sept-12
(England baseline = 100) and has been above the expected
range for 5 of the 7 periods to date.
Source: Health & Social Care Information Centre – SHMI
Slide 26
HSMR overview
As shown below, the Trust’s HSMR for the past 12 months (Jan 12Dec 12) is 105, which means that it is statistically within the expected
range.
Month-on-month time series
The time series demonstrates that there has been a general
downward trend in the Trust’s HSMR since 2007/08, with an overall
decrease from 110 to 106. The month-on-month series for the past 12
months has shown considerable variation.
HSMR funnel plot – past 12 months
Year-on-year time series
East Lancashire
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 27
HSMR Statistics
The table to the right shows
East Lancashire’s HSMR
broken down by admission
type.
HSMR
The breakdown illustrates
the overall HSMR is 105,
which is lower than the
expected range. The table
identifies that non-elective
admissions have an HSMR
higher than the expected
range due to non-elective,
weekend admissions being
statistically above the
expected level.
Non-elective
All
0
Week
64
All
61
115
103
106
114
102
105
Key – colour by
alert level:
Red – Higher than
expected (above the
95% confidence
interval)
Blue – Within
expected range
Green – Lower than
expected (below the
95th confidence
interval)
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Admission type
Elective admissions are
seen to be below the
expected range. The HSMR
for elective admissions at
the weekend is zero.
Elective
Weekend
Slide 28
HSMR CCS Diagnostic Group Overview
The darker colour boxes have the highest HSMR while the size
of the boxes represents the number of observed deaths that are
higher than the expected. The larger and darker boxes within
the tree plot will highlight potential areas for further review.
These are as follows:
•
Pneumonia (HSMR = 120; Deaths above expected level =
60);
•
Acute cerebrovascular disease (125; 36);
•
Congestive heart failure; nonhypertensive (117; 12)
•
Biliary tract disease (142; 8)
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 29
Mortality - HSMR Tree
Elective
HSMR 61
-
-
-
-
-
-
Dermatology
Thoracic medicine
Nephrology
Medical oncology
Rheumatology
Paediatrics
Well babies
Gynaecology
-
Cardiology
-
-
Rehabilitation
Clinical oncology
-
Diabetic medicine
-
-
Clinical haematology
Obstetrics (2517; 20)
-
Gastroenterology
-
-
General medicine
Gynaecology
-
Maxillo-facial surgery
-
-
Opthamology
Geriatric medicine (129; 22)
-
Ear nose and throat (ENT)
-
-
Trauma & orthopaedics
Geriatric medicine
-
Breast surgery
Vascular surgery
-
Urology
-
-
HSMR 106
Treatment Specialties
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
General surgery
Urology
Breast surgery
Vascular surgery
Trauma & orthopaedics
Ear, nose and throat (ENT)
Ophthalmology
Maxillo-facial surgery
Accident & emergency (A&E)
Critical care medicine (245; 47)
General medicine
Gastroenterology
Clinical haematology
Diabetic medicine
Rehabilitation
Cardiology
Dermatology
Thoracic medicine (177; 23)
Rheumatology
Paediatrics
Neonatology
Well babies
Key
Diagnosis (100 ; 1 )
HSMR
General surgery
Non
Elective
-
The HSMR for non-elective
admissions is above the
expected range. Critical
Care Medicine, Thoracic
Medicine, Geriatric
Medicine and Obstetrics all
have a higher number of
observed deaths than the
expected level and are
above the expected range.
-
The HSMR for elective
admissions is below the
expected range.
Treatment Specialties
-
The tree shows that the
HSMR for East Lancashire
is 105 which is within the
expected range. When
breaking this down by
admission type, it is clear
Overall
that it is despite
Trust
statistically higher than
HSMR 105
expected non-elective
admissions.
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Observed deaths that are higher
than the expected
Source: Healthcare Evaluation Data (HED). Jan 12 – Dec 12
Slide 30
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 Critical Care Medicine has the highest number of
above expected deaths. These are spread over four diagnostic groups,
including pneumonia (12) and acute cerebrovascular disease (12). acute
cerebrovascular disease has the highest number of above expected deaths
within Geriatric Medicine (8), as well. The highest number of above expected
deaths for a single diagnostic group is for Other perinatal conditions (20)
within Obstetrics.
Overall118.2
(105; 79)
Non-elective (106; 91)
Treatment Specialties
Critical Care Medicine (245; 47)
Thoracic Medicine (177; 23)
Geriatric Medicine (129; 22)
Obstetrics (2517; 20)
Diagnostic Groups
Acute cerebrovascular
disease
Acute myocardial
infarction
Cardiac arrest and
ventricular fibrillation
Pneumonia (except that
caused by tuberculosis or
sexually transmitted
disease)
(759; 12)
(324; 6)
(147; 5)
(285; 12)
Chronic obstructive
pulmonary disease and
bronchiectasis
Pneumonia (except that
caused by tuberculosis or
sexually transmitted
disease)
(123; 8)
Other perinatal
conditions
(2531; 20)
(134; 5)
(185; 7)
Key
Diagnosis (100 ; 1 )
HSMR
Source: Healthcare Evaluation Data (HED). Jan 12 – Dec 12
(234; 9)
Acute cerebrovascular
disease
Pneumonia (except that
caused by tuberculosis
or sexually transmitted
disease)
Observed deaths that are higher
than the expected
The diagnostic groups with one to three more observed deaths than expected are listed in the Appendix
Slide 31
HSMR – Dr Foster
The HSMR time series for East Lancashire Trust 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 financial year from
2008/09, apart from 2011/12.
East Lancashire’s latest SHMI published by the HSCIC, for Oct 11
to Sept 12, is higher than the Dr Foster HSMR for the same period.
Dr Foster have made the following adjustments to show the impact
of factors that can affect this comparison:
• Adjustment for palliative care: used the SHMI observed deaths
but changed expected deaths to take account of palliative care.
• Adjustment for in-hospital deaths:
• Removed out-of-hospital deaths from the observed
figure, and
• Reduced expected deaths to only those in-hospital.
Any remaining variances are largely due to:
• The scope of deaths included (SHMI covers all deaths whereas
HSMR covers clinical areas accounting for an average of
around 80% of deaths), and
• The definition of spells, which includes those provider(s) the
death attributes to.
Time series of HSMR, East Lancashire
115
110
108
107
105
105
103
100
95
2008/09
2009/10
HSMR
I
2010/11
2011/12
95% Confidence interval
Com parison of m ortality m easures,
East Lancashire
125
120
115
118
114
110
109
105
100
95
90
85
99
SHMI
SHMI adjusted
for palliative
care
SHMI in
hospital
deaths only
HSMR
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 32
Coding
Diagnosis coding depth has
an impact on the expected
number of deaths. A higher
than average diagnosis
coding depth is more likely to
collect co-morbidity which
will influence the expected
mortality calculation.
When looking at the Depth of
Coding for East Lancashire,
it is apparent that the Trust’s
average diagnosis coding
depth has been above the
national average in the past.
However, both elective and
non-elective graphs show a
slight dip in Q2 and Q3
2012/13.
Average Diagnosis Coding Depth
Elective
6
Non-elective
6
5
5
4
4
3
3
2
2
1
1
0
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
2012/13
National Average Diagnosis Coding Depth
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
East Lancashire
East Lancashire
When looking at non-elective
admissions, the Trust has
fallen slightly below the
national level which may
highlight an area for review.
The average diagnosis
coding depth for elective
admissions is still above the
national level.
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 33
Palliative care
Accurate coding of palliative care is important for
contextualising SHMI and HSMR. HSMR takes into
account that a patient is receiving palliative care, but
SHMI does not.
1.2
Percentage of admissions with palliative
care coding
1.0
0.8
0.6
East Lancashire’s percentage of admissions with
palliative care coding is consistently below the national
average. The percentage of deaths with palliative care
coding is also below the national average. It should be
noted that the level is not significantly low in either
case.
0.4
0.2
-
Oct-11
Jan-12
Apr-12
East Lancashire
20
18
16
14
12
10
8
6
4
2
-
Jul-12
Oct-12
National
Jan-13
Apr-13
SHMI publication
Percentage of deaths with palliative care
coding
Oct-11
Jan-12
Apr-12
East Lancashire
Jul-12
National
Oct-12
Jan-13
Apr-13
SHMI publication
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 34
Care Quality Commission findings
Emergency specialty groups much worse than expected
The Care Quality Commission (CQC) review mortality alerts for
each trust on an ongoing basis. These alerts, which indicate
observed deaths significantly above expected for specialties or
diagnoses, come from different sources based on either HSMR
or SHMI. Where these appear unexplained, the CQC correspond
with the trust to agree any appropriate action.
For East Lancashire, the common theme that has arisen across
the patient groups alerting since 2007 is Emergency care.
No common themes arise from responses to the CQC from the
Trust. None of the alerts identified by the CQC are currently
ongoing or 'open’.
East Lancashire are involved with the Advancing Quality
(AQuA) Mortality Collaborative and developed five care
bundles to improve the delivery of care in diagnostic groups
with a high mortality rate.
Sep 11 to Aug 12
1
Miscellaneous ie not mapping to a specific clinical
area, eg groups based on signs and symptoms or
covering a range of clinical areas.
Emergency specialty groups worse than expected
Sep 11 to Aug 12
0
Diagnosis group alerts (2007 to date)
Alerts to CQC
2
Alerts followed up by CQC
2
Recent diagnosis group alerts pursued by CQC
Peripheral and visceral atherosclerosis (Sep 11)
Any related patient groups alerting more than once since 2007
The high ‘miscellaneous’ mortality may make it harder to
monitor outcomes for specific clinical groups.
None
The trust have outlined to CQC a plan to develop more care
pathways and care bundles to improve standardisation and
reliability of care delivery and to continue to develop the Early
Warning Score system to alert the trust of patients at risk of
deteriorating.
Source: Care Quality Commission – alerts, correspondence and findings
Slide 35
SMRs for Diagnostic and Procedure groups – Dr Foster
The standardised mortality ratio (SMR) is used to calculate the
mortality rate for diagnosis and procedure groups. This is
available for the 56 diagnosis groups that are included in the
HSMR and the 96 procedure groups that are part of the Real
Time Monitoring system.
SMRs are not yet remodelled for the year but are projected,
rebased estimates. SMRs are classified as above expected if their
lower 95% confidence limit exceeds 100 (excluding those with
fewer than four more observed deaths than expected).
From Apr 12 to Mar 13, there were five diagnosis groups and two
procedure groups with above expected SMRs in East Lancashire,
which may highlight potential areas for review.
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.
Apr 2012 to Mar 2013
Diagnosis groups
Procedure groups
SMRs above expected
5
2
CUSUM alerts
3
4
Diagnosis groups with SMRs above expected
Acute and unspecified renal failure
Congestive heart failure, nonhypertensive
Fracture of neck of femur (hip)
Liver disease, alcohol-related
Pneumonia
Procedure groups with SMRs above expected
Head of femur replacement
Other drainage of peritoneal cavity
SMR
133
132
135
146
116
SMR
180
151
Obs – Exp
deaths
20
24
14
12
48
Obs – Exp
deaths
10
11
During the year, East Lancashire had two CUSUM alerts for
pneumonia, one for liver disease, alcohol-related, and one for
head of femur replacement. It also had three alerts for other
procedure groups that did not have a high SMR.
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 36
Mortality – other alerts
Variable Life Adjusted Display (VLAD) charts are produced by
the Health and Social Care Information Centre to visualise the
cumulative number of “statistical lives gained” over a period.
A downward trend indicates a run of more deaths than
expected compared to the national baseline and one with a
sustained downward trend and multiple dips to the lower
control limit may warrant further investigation.
VLAD charts with a negative SHMI trend
(year to Jun-12)
•
•
•
No. dips to the
lower control limit
Pneumonia
Acute cerebrovascular disease
Fractured neck of femur
East Lancashire had such VLAD charts for three diagnosis
groups in the year to June 2012: Pneumonia, Acute
cerebrovascular disease and Fractured neck of femur.
In addition, East Lancashire had worse than expected
mortality for Pneumonia on the Acute Trust Quality
Dashboard (year to Q1 2012-13). It also had high excess
deaths for Pneumonia (63 deaths, 18% more than expected)
and Acute cerebrovascular disease (28 deaths, 19% more than
expected) in the HSCIC’s SHMI to September 2012.
50
45
40
35
30
25
20
15
10
5
5
2
1
Percentage of spells by deprivation quintile,
SHMI April 2013
1 Most
deprived
2
East Lancashire
East Lancashire has a relatively high proportion of patients
from the lowest deprivation quintile, which may affect
expected deaths. Deprivation is taken into account in the
HSMR, whereas the SHMI methodologists concluded that it
did not add sufficient value to the model (over and above comorbidities, etc), although they show it as context.
45
40
35
30
25
20
15
10
5
3
National
4
5 Least
deprived
SHMI publication
Percentage of deaths by deprivation quintile,
SHMI April 2013
1 Most
deprived
Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.
2
East Lancashire
3
National
4
5 Least
deprived
SHMI publication
Slide 37
Patient Experience
Slide 38
Patient Experience
Overview:
Summary:
The following section will provide an insight into the Trust’s
patient experience.
Of the 9 measures reviewed within Patient Experience and
Complaints the Trust was rated ‘red’ on four separate measures.
Review Areas:
On the cancer survey, the Trust was rated in the bottom 20% on
a range of questions relating to hospital doctors and treatment
as a day case or outpatient.
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 use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Around 70% of all complaints relate to clinical aspects of care,
and this is unusually high. Almost two thirds of comments
recorded on CQC’s patient voice monitoring were negative, with
comments focussing on communication and attitude of staff.
There were suggestions that staffing levels were too low and
that staff were too busy to answer the call bell.
Results from the patient environment action teams (PEAT)
sometimes show results as ‘acceptable’ for environment. This is a
low score in the context of this monitoring system, and Royal
Blackburn has been marked at this level twice in recent years.
Slide 39
Patient Experience
Patient Experience
This page shows the Patient Experience measures which are considered to be the most pertinent for this review. Further analysis,
where relevant, is detailed in the following pages.
Inpatient
PEAT : environment
Cancer survey
PEAT : food
PEAT : privacy and dignity
Friends and family test
Complaints about clinical aspects
Patient voice comments
Ombudsman’s rating
Outside expected range
Within expected range
Not applicable
Slide 40
Inpatient Experience Survey
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
East Lancashire ranks within the expected range for the vast majority of survey questions, though its performance is above average
on staff noise levels at night, and below average on the clarity of doctors’ responses to patient questions.
Overall
Length of time spent on waiting list
Alteration of admission date by hospital
Length of time to be allocated a bed on a
ward
Overall
Delay of patient discharge
Consistency of staff communication
Information provided on post-discharge
danger signals
Overall
Staff communication on purpose of
medication provided
Patient involvement in decision-making
Staff communication on medication
side-effects
Overall
Clarity of doctors’ responses to
important questions
Language used by doctors in front of
patients
Clarity of nurses’ responses to
important questions
Language used by nurses in front of
patients
Overall
Hospital food
Patient noise levels at night
Degree of privacy provided
Staff noise levels at night
Level of respect shown by staff
Hospital/ward cleanliness
Overall staff effort to ease pain
Above expected range
Within expected range
Below expected range
Slide 41
Patient experience and patient voice
Inpatient Survey
The national inpatient survey 2012 measures a wide range of
aspects of patient experience. A composite ‘overall measure’
is calculated for use in the Outcomes Framework. This
measure uses a pre-defined selection of 20 survey questions
to rate the Trust on aspects including access to services, coordination of care, information & choice, relationship with
staff and the quality of the clinical environment .
Overall patient experience score: Inpatients 2012
95
90
85
East Lancashire
80
75
70
65
•
England Average: 76.5
•
East Lancashire: 76.3 (average)
60
55
50
Cancer Survey
Of 58 Questions, 3 were in the ‘top 20%’ whilst 13 were in
the ‘bottom 20%’. Negative areas included hospital
doctors and treatment as a day case or outpatient.
Patient Voice
England
average
•
•
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 156 comments on East Lancashire of which
101 were negative (65%). The most common area of
complaint was around communication and attitude of
staff, with suggestions that staffing levels were too low
and that staff were too busy to answer the call bell.
PEAT results
•
Scores from patient environment action teams report a
number of ratings of ‘acceptable’ for environment,
particularly at Royal Blackburn. This is a low score in the
context of this data system.
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 457 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, 70% of complaints related to clinical treatment
(compared to the national average of 47%).
•
A separate report by the Ombudsman rates the Trust as
B-rated for its satisfactory remedies and low-risk of noncompliance. High incidence of poor explanation or poor
personal remedy complaints and a high number of
physician complaints are behind this.
Slide 42
Safety and workforce
Slide 43
Safety and Workforce
Overview:
Summary:
The following section will provide an insight into the Trust’s
workforce profile and safety record. This section outlines whether
the Trust is adequately staffed and is safely operated.
East Lancashire is ‘red rated’ in two of the safety indicators:
MRSA infection rates and clinical negligence scheme payments.
Review Areas:
To undertake a detailed analysis of the Trust’s Safety and
Workforce it is necessary to review the following areas:
•
General Safety;
•
Staffing;
•
Staff Survey;
•
Litigation and Coroner; and
•
Analysis of patient safety incident reporting.
Data Sources:
•
Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;
•
Safety Thermometer, Apr 12 – Mar 13;
•
Litigation Authority Reports;
•
GMC Evidence to Review 2013;
•
National Staff Survey 2011, 2012;
•
2011/12 Organisational Readiness Self-Assessment (ORSA);
•
National Training Survey, 2012; and
•
NHS Hospital & Community Health Service (HCHS), monthly
workforce statistics.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Trust recorded 102 incidents reported as either moderate,
severe or death between April 2011 and March 2012. It also
recorded one ‘never event’. Between 2010 and 2012 East
Lancashire’s performance was in the lower quartile of the
national distribution for its high rates of MRSA infection per bed
day.
Throughout the last 12 months, East Lancashire has been
consistently below the national rate and below the average of the
selected 14 trusts in this review for new pressure ulcers. It is
apparent that the prevalence rate of total pressure ulcers for
East Lancashire has also been below the national average on all
but 3 months.
East Lancashire’s Clinical Negligence payments have exceeded
contributions to the ‘risk sharing scheme’ over the last 3 years to
a large degree. Payouts exceeded contributions by a total of £11m
over this period.
East Lancashire is ‘red rated’ in 11 of the workforce indicators. It
notably has a sickness absence rate above the national mean and
has higher than average rates of medical vacancies. The Trust is
being monitored under the GMC’s ‘response to concerns process’.
Slide 44
Safety
This page shows the Safety measures which are considered to be the most pertinent for this review. Further analysis, where relevant,
is detailed in the following pages.
Litigation and
Coroner
Specific
Safety
Measures
General
Reporting of patient safety incidents
Number of harm incidents reported as ‘moderate, severe or death’ from April ‘11 to March ’12
102
Number of ‘never events’ (2009-2012)
1
Medication error
Pressure ulcers
MRSA
“Harm” for all four Safety Thermometer Indicators
C diff
Clinical negligence scheme payments
Rule 43 coroner reports
Outcome 1 (R17) Respecting and involving people who use services
Outside expected range
Within expected range
Slide 45
Safety Incident Breakdown
Since 2009, one ‘never event’ has occurred at East Lancashire, classified as
such because they are incidents that are so serious they should never happen.
The patient safety incidents reported are broken down into five levels of harm
below, ranging from ‘no harm’ to ‘death’. 85% of incidents which have been
reported at East Lancashire have been classed as ‘no harm’, with 14% ‘low’,
with 1% ‘moderate’, and 3 occurrences of incidents classified as ‘death’.
Never Events Breakdown (2009-2012)
Retained foreign object post-operation
1
Total
1
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 East Lancashire are in ‘patient accident’ and ‘treatment
procedure’.
Breakdown of patient
incidents by degree of harm
9000
Breakdown of patient incidents by incident type
8530
8000
Clinical assessment
Medical device / equipment
Infrastructure
All others categories
Consent, communication, confidentiality
Documentation
Medication
Access, admission, transfer, discharge
Implementation of care and ongoing…
Treatment, procedure
Patient accident
7000
6000
5000
4000
3000
2000
1403
1000
99
0
3
Moderate
Severe
Death
0
500
1000 1500 2000 2500 3000
0
No Harm
Low
Source: Healthcare Evaluation Data (HED). Apr 11 – Mar 12
Source: Healthcare Evaluation Data (HED). Apr 11 – Mar 12
A definition of serious harm is given in the Appendix.
Slide 46
Safety Analysis
The Trust’s performance is in the lower quartile of the
national distribution for its high rates of MRSA infection
per bed day over the three year period. MRSA rates have
fallen at the Trust and the this is in line with local or
national targets. However, the rating in this category is
based on an 'absolute' measure of MRSA rates averaged
over 3 years. This measure has been used consistently
for all trusts involved in the review.
The Trust has a rate of medication errors of 6.12 which is
below the mean rate for all acute trusts of 7.17
MRSA 2010 - 2012
Combined z score of rates per bed day
over the 3 separate years
with the value 2 added so that all values are shown as
positive
6.0
5.0
4.0
East
Lancashire
3 year
z score 3.0
+2
2.0
1.0
0.0
Trusts under review
All non specialist trusts
East Lancs
Sources:
MRSA Trust apportioned cases: Public Health England mandatory reporting of Healthcare
Associated infections.
Bed days:
Department of Health: Unify2 data collection - KH03
Rate of medication errors per 1,000 bed days (October 2011 – March 2012)
East Lancashire
Mean rate for all acute
6.12
7.17
Slide 47
Throughout the last 12 months,
East Lancashire has been
consistently below the national
rate and below the average of
the selected 14 trusts in this
review.
From the data, it is apparent
that the prevalence rate of total
pressure ulcers for East
Lancashire has also been below
the national average on all but
3 months. In addition, the Trust
has been below the average of
the selected 14 trusts in this
review for the majority of the
previous year.
4.0%
3.0%
40
2.0%
20
0.0%
-
1.0%
0.0%
Category 2
Category 3
Category 4
Category 2
Rate
Category 3
Mar-13
0.2%
Jan-13
-
5.0%
Feb-13
5
6.0%
4.9%
Dec-12
0.4%
6.1% 7.0%
5.1%
5.8%
60
Nov-12
0.6%
80
Oct-12
10
5.4%
5.0%5.3%
4.7%
Sep-12
0.8%
6.0%
5.6%
100
8.0%
Aug-12
15
7.4%
120 7.2%
Jul-12
20
1.3%
1.3%
1.3%
1.4%
1.1%
1.1%
1.2%
1.0%
1.0%0.9%0.9%1.0%
0.9%
1.0%
0.8%
Jun-12
25
Total pressure ulcers prevalence
Apr-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
into account. This provides a
comparison against the
national rate as well as the 14
trusts selected for the review.
New pressure ulcers prevalence
May-12
Pressure ulcers
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
1584
1489
1431
1410
1407
1419
1408
1382
1366
1395
1539
1597
20
17
15
13
18
12
18
15
13
13
14
16
Trust new pressure ulcer rate
Selected 14 Trusts new pressure
ulcer rate
1.3%
1.1%
1.0%
0.9%
1.3%
0.8%
1.3%
1.1%
1.0%
0.9%
0.9%
1.0%
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
1584
1489
1431
1410
1407
1419
1408
1382
1366
1395
1539
1597
114
84
86
105
71
75
76
65
70
81
76
98
Trust total pressure ulcer rate
Selected 14 Trusts total pressure
ulcer rate
7.2%
5.6%
6.0%
7.4%
5.0%
5.3%
5.4%
4.7%
5.1%
5.8%
4.9%
6.1%
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 48
Litigation and Coroner
Clinical negligence payments
Clinical negligence scheme analysis
East Lancashire’s Clinical Negligence payments have
exceeded contributions to the ‘risk sharing scheme’ over the
last 3 years to a large degree. Payouts exceeded
contributions by a total of £11m over this period.
Coroner’s rule
2009/10
2010/11
2011/12
Payouts (£000s)
7,091
10,016
13,666
Contributions (£000s)
6,007
6,607
6,935
Variance between
payouts and contributions
(£000s)
-1,084
-3,409
-6,731
Coroner’s rule 43 reports flagged just one item:
“To consider the appropriateness of major surgery being
undertaken at Burnley General Hospital when there is no
haematology department or intensive care unit…”
However, supplementary information was provided by the
Trust to the Coroner, and the report was subsequently
withdrawn. There are therefore no areas for review for this
Trust.
Source :Litigation Authority Reports
Slide 49
Workforce
Response Rate to
National Staff Survey
2012
Workforce Indicators
This page shows the Workforce measures which are considered to be the most pertinent for this review. Further analysis, where
relevant, is detailed in the following pages.
WTE nurses per bed day
Sickness absence- Overall
Medical Staff to Consultant Ratio
2.06
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
2.31
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
se services
0.34
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days) 177
Staff leaving rates
Nurse Hours per Patient Bed Day
9.72
Staff joining rates
Response Rate from National Staff
Survey 2012
x / service users is my organisation's top priority
Care of patients
Staff Engagement from NSS 2012
I would recommend my organisation as a place to work
Training Doctors – “undermining”
indicator
If a friend or relative needed treatment: I would be happy with
the standard of care provided by this organisation
GMC monitoring under “response
to concerns process”
Outside expected range
Within expected range
Slide 50
General Medical Council (GMC) National Training Scheme Survey 2012
General (internal) medicine
Endocrinology and diabetes
mellitus
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
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 51
General Medical Council (GMC) National Training Scheme Survey 2012
Respiratory Medicine
The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results Given the volume
of data only specialties with red outliers are noted below (where those specialties also have green outliers, they are included).
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
The following specialties have green outliers as detailed below:
•
Clinical radiology – clinical supervision, feedback and induction;
•
General psychiatry – local teaching;
•
Neonatal medicine – overall satisfaction, clinical supervision, workload, adequate experience, feedback, and induction;
•
Otolaryngology – clinical supervision, workload, adequate experience, feedback, induction and access to educational resources;
•
Rheumatology – clinical supervision and induction; and
•
Trauma and orthopaedic surgery – handover and regional teaching.
Green outlier
Within expected range
Red outlier
Slide 52
Workforce Analysis
Number of FTEs (Dec 11Nov 12 average)
The data shows that the agency staff costs, as a percentage of total staff
costs, is lower than the median within the region. The data also illustrates
that the trust has more staff joining compared with leaving.
6.291
Agency Staff (2011/12)
East Lancashire has a patient spells per whole time equivalent rate of 22,
which is below average capacity in relation to the other trusts in this review
and nationally.
The consultant appraisal rate of East Lancashire is 87.8% which is above the
median rate.
East Lancashire
Expenditure
Percentage of
Total Staff Costs
Median within
Region
£6.9m
2.7%
3.5%
(Sep 11 – Sep 12)
Staff Turnover
WTE nurses per bed day December 2012
East
Lancashire
North West SHA
Median
East Lancashire
National Average
Joining Rate
5.9%
6.8%
2.21
1.96
Leaving Rate
5.3%
5.7%
Source: Health and Social Care Information Centre (HSCIC)
Spells per WTE for Acute Trusts
Consultant appraisal rate 2011/12
50
100%
45
East Lancashire
Spells per WTE
40
35
East Lancashire
22
30
25
80%
Ed
60%
20
40%
15
10
20%
5
0
0%
Trusts covered by review
All Trusts
Trusts covered by review
East Lancs
All other trusts
Slide 53
Workforce Analysis continued…
Sickness Absence Rates
East Lancashire’s total sickness absence rate is
lower than the North West Strategic Health
Authority average, although it is above the
average figure for all trusts in England. This
pattern of exceeding the national average is
replicated in the more granular medical, nursing,
and other staff categories.
East Lancashire has medical staff to consultant,
and nurse staff to qualified staff, ratios that are
below the national average, although the Trust’s
non-clinical staff to total staff ratio is in-line with
the average figure for all trusts in England. East
Lancashire’s registered nurse hours to patient
day ratio is substantially in excess of the national
average.
The Trust’s consultant productivity ratio is below
the national average.
The Trust’s 3 month vacancy rate for medical
staff is more than three times the national rate.
3 month Vacancy Rates by
Staff Category
(March 2010)
(2011-2012)
East Lancashire
North West SHA
Average
National Average
4.20%
4.52%
4.12%
All Staff
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
East Lancashire
National Average
Medical Staff
1.4%
1.3%
Nursing Staff
5.3%
4.8%
Other Staff
4.8%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
East Lancashire
National Average
Medical Staff to Consultant Ratio
2.06
2.59
Nurse Staff to Qualified Staff Ratio
2.31
2.50
Non-Clinical Staff to Total Staff
Ratio
0.34
0.34
Registered Nurse Hours to Patient
Day Ratio *
9.72
8.57
Source: Electronic Staff Record (ESR), Apr 13
*Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
East
Lancashire
National
Average
Medical Staff
5.2%
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
Staff Productivity
Consultant Productivity
(Spells/FTE)
Source: Electronic Staff Record (ESR), Apr 13
East Lancashire
National Average
177
492
Slide 54
Workforce Analysis continued…
National Staff Survey results
East Lancashire’s response rate to the
staff survey is significantly below
average and has fallen in 2012. The
staff engagement score is well above
the average when compared with trusts
of a similar type and improved in 2012.
East Lancashire 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
although this has risen in 2012
compared with 2011.
East
Lancashire
2011
Average for all
trusts
2011
East
Lancashire
2012
Average for all
trusts
2012
Response rate
61%
50%
46%
50%
Overall staff engagement
3.59
3.62
3.72
3.69
Care of patients/service
users in my organisation’s
top priority
52%
I would recommend my
organisation a place to work
49%
If a friend or relative needed
treatment, I would be happy
with the standard of care
provided by this organisation
52%
69%
52%
62%
63%
54%
57%
63%
55%
60%
Source: National Staff Survey 2011, 2012
Source: GMC evidence to Review 2013
Workforce Indicator Calculations are listed in the Appendix.
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Data based on the appraisal year from April 2011 to March 2012
Slide 55
Deanery
The Trust has been subject to enhanced monitoring since 2012, as a result of poor supervision. GP doctors in training were removed
from one site at the Trust and a number of visits have taken place to investigate the issues. A number of patient safety concerns,
which were shared with the Deanery, were raised by trainees .
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Trainees in the Geriatric Medicine programme reported the most below outliers between 2010 and 2012. Anaesthetics and Clinical
Radiology were the programmes with the most above outliers, during the same period. Trainees’ perceptions of training improved in
2012, with fewer below outliers and a greater number of above outliers reported, compared to other years.
NTS 2012 Patient Safety Comments
15 doctors in training commented, representing 4.9% of respondents. This is in line with 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:
•
A&E is under skilled and understaffed making it difficult to manage emergencies;
•
Lack of medical cover on wards, particularly senior cover;
•
Prescribing errors; and
•
Insufficient nursing-cover, e.g. to provide analgesia, non-invasive ventilation.
Source: GMC evidence to Review 2013
Slide 56
Deanery Reports
The 2011 Deanery Report indentified concerns in Medicine and GP around handover and supervision particularly on the Burnley
site. Here, trainees were being asked to review patients on the Pendle site without a face to face assessment. The 2012 report stated
that there had been improvement in this area.
Monitored under the response to concerns process?
GMC Action
Yes, since 2012. Issues emerged during a Deanery visit in October
2011 which identified a number of concerns in GP training in
medical posts at the Trust regarding supervision, workload, and
lack of education. Lack of progress meant it was referred to the
Response to Concerns Process in July 2012.
Action plans have been produced by the Trust, the GMC are
currently reviewing these (as of March 2013).
Deanery Action
Undermining
For doctors which are undertaking their training at East
Lancashire, the Trust has a score of 93 which is below the national
average of 94.
In Spring 2012 the doctors in training contacted the Deanery to note
improvements were not forthcoming, and the Deanery undertook a
responsive visit in June 2012 which confirmed that the issues
remained.
The Deanery contacted the GMC in July 2012 to inform us of the
verified concerns.
The Deanery removed GP doctors in training from the Pendle
Community Hospital site from August 2012 where issues were most
serious, but similar issues exist at the Blackburn and Burnley
Hospital sites.
The GMC Responses to Concerns Assessment Team took part in a
Deanery visit on 15 November 2012. The team noted that GP doctors
in training were not always receiving appropriate education at the
Blackburn and Burnley sites. No immediate patient safety concerns
were identified during this visit.
Mean Score on 'Undermining'
105
100
East Lancashire
95
90
85
80
trust covered by review
East Lancs
All other non specialist trusts
Slide 57
Source: National Training Survey 2012
Clinical and operational
effectiveness
Slide 58
Clinical and Operational Effectiveness
Overview:
Summary:
The following section will provide an insight in to the Trust’s
clinical and operational performance based on nationally
recognised key performance indicators.
East Lancashire sees 95.9% of A&E patients within 4 hours
which is just above the 95% target level. However, the
percentage of patients seen within 4 hours has been falling over
recent months. 92.8% of the patients start treatment within the
18 week target time which is above the target level. The Trust
has been consistently performing above the target level since
June 2012.
Review Areas:
To undertake a detailed analysis of the Trust’s clinical and
operational performance it is necessary to review the following
areas:
•
Clinical Effectiveness;
•
Operational Effectiveness; and
•
Patient Reported Outcome Measures (PROMs) for the review
areas.
Data Sources:
•
Clinical Audit Data Trust, CQC Data Submission;
•
Healthcare Evaluation Data (HED), Jan – Dec 2012;
•
Department of Health;
•
Cancer Waits Database, Q3, 2012-13; and
•
PROMs Dashboard.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
East Lancashire’s crude readmission rate is one of the higher
readmission rates of the trusts in the review as well as
nationally, at 13.2%, although the average length of stay is
shorter than that of the national average.
Compliance with 12 key indicators for acute stroke is considered
a good measure of clinical effectiveness. East Lancashire was
outside the 95% control limit of stroke patients whose treatment
was compliant with the 12 key indicators.
Finally, the PROMs dashboard shows that East Lancashire was
an average performer overall. None of the indicators fell outside
the control limits for the 3 years shown in the dashboard.
Slide 59
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 60
Clinical Effectiveness: National Clinical Audits
The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the
clinical audit results we have considered as part of this review.
Clinical Audit
Diabetes
Elective Surgery
Safety Measure
Clinical Audit
Proportion with medication
error
Proportion experiencing
severe hypoglycaemic
episode
Neonatal intensive and special care
(NNAP)
Proportion of women receiving antenatal steroids
Diabetes
Proportion foot risk assessment
Adult Critical Care
Standardised hospital mortality ratio
Proportion of patient reported
post-operative complications
Coronary angioplasty
Acute Myocardial Infarction
Proportion receiving primary PCI
within 90 mins
Elective abdominal aortic aneurysm
post-op mortality
Proportion having surgery within 14
days of referral
Proportion discharged on beta-blocker
Acute Stroke
Proportion compliant with 12 indicators
Heart Failure
Proportion referred for cardiology
follow up
90 day post-op mortality
Peripheral vascular surgery
Adult Critical Care (ICNARC
CMPD)
Effectiveness Measures
Proportion of night-time
discharges
Carotid interventions
Bowel cancer
Hip Fracture
Elective surgery (PROMS)
Severe Trauma
Hip, knee and ankle
Lung Cancer
Source: Clinical Audit Data Trust, CQC Data Submission.
30 day mortality
Proportion operations within 36 hrs
Mean adjusted post-operative score
Proportion surviving to hospital
discharge
Standardised revision ratio
Proportion small cell patients receiving
chemotherapy
Slide 61
Clinical effectiveness: Clinical Audits
Proportion of stroke patients whose treatment was
compliant with the 12 key indicators
In the National Clinical Audit for Acute Stroke, a key
measure of effectiveness is the degree of compliance
with 12 key indicators.
On this measure, one of the Trust’s sites, the Royal
Blackburn Hospital is outside the 95% control limit
and is therefore an outlier.
% stroke patients compliant with 12 key indicators
100%
90%
80%
70%
60%
50%
Royal
Blackburn
Hospital
40%
30%
20%
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Total stroke patients
Slide 62
PROMs Dashboard
PROMs Dashboard Analysis
The PROMs dashboard shows that East Lancashire
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
0.6
England
Average
0.5
East
Lanacashire
0.4
0.3
Upper
Control
Limit
0.2
Lower
Control
Limit
0.1
0
2009/10
2010/11
2011/12
Source: PROMs Dashboard and NHS Litigation Authority
Slide 63
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
East Lancashire sees
95.9% of A&E patients
within 4 hours which
is slightly above the
95% target level.
However, the
percentage of patients
seen within 4 hours is
falling over recent
months.
92.8% of the patients
are seen within the 18
week target time
which is above the
target level. In
addition, the time
series shows that East
Lancashire has been
consistently
performing above the
target rate since June
2012.
A&E Percentage of Patients Seen
within 4 Hours
105%
100%
East Lancashire
95.9%
95%
90%
85%
East Lancashire 4 Hour A&E Waits
Attendances (Thousands)
A&E wait times and
RTT times may
indicate the
effectiveness with
which demand is
managed.
18
16
14
12
10
8
6
4
2
0
98%
97%
96%
95%
94%
93%
92%
91%
90%
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)
East Lancashire Referral to Treatment
Performance
105%
100%
95%
95%
East Lancashire
92.8%
90%
90%
85%
85%
80%
80%
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 64
Operational Effectiveness – Emergency Re-admissions and Length of Stay
East Lancashire’s crude
readmission rate is among
the higher readmission
rates of the trusts in the
review as well as nationally,
at 13.2%.
Crude Readmission Rate by Trust
20%
15%
East Lancashire
13.2%
10%
5%
0%
Trusts Covered by Review
The standardised
readmission rate, most
importantly, accounts for
the trust’s case mix and
shows East Lancashire is
outside the expected range.
All Trusts
East Lancashire
Selected trusts Outside
Selected trusts w/in Range
Average Length of Stay by Trust
10
9
Spell Duration (Days)
East Lancashire’s average
length of stay is 3.95 days,
which is shorter than the
national mean average of
5.2 days.
Standardised 30-day Readmission
Rate
25%
Crude Readmission Rate
Readmission rate may
indicate the
appropriateness of
treatment offered, whilst
average length of stay may
indicate the efficiency of
treatment.
8
7
East Lancashire
3.95
6
5
4
3
2
1
0
Trusts Covered by Review
Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12
All Trusts
Slide 65
Leadership and
governance
Slide 66
Leadership and governance
Overview:
Summary:
This section will provide an indication of the Trust’s governance
procedures.
The Trust Board is stable, with all Executive posts being
substantive and the majority of Board members having been
with the Trust for at least three years.
Review Areas:
To provide this indication of the Trust’s leadership and
governance procedures we have reviewed the following areas:
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
There are two groups with direct responsibility for quality;
these are the Governance Committee, and the Quality & Safety
Board (which reports to the Governance Committee). The
Governance Committee is chaired by a non executive (Paul
Fletcher). The Trust has also established a Mortality Steering
Group.
A review of quality governance was performed by KPMG in July
2012. This review compared the governance arrangements in
the Trust against Monitor’s Quality Governance Framework.
KMPG scored the Trust 1.5 (trusts must achieve a score below
3.5 to be authorised as a foundation trust).
Key risks for the Trust relate to staffing levels, working across
the health economy, demand management, the discharge
process and mortality.
Slide 67
Leadership and governance
Leadership and
governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in
the following pages.
Monitor governance risk rating
n/a
Monitor finance rating
n/a
Governance risk rating
Red - Likely or actual significant breach of terms of authorisation
Amber-red - Material concerns surrounding terms of authorisation
Amber-green - Limited concerns surrounding terms of authorisation
Green - No material concerns
CQC Outcomes
CQC Concerns
Red – Major concern
Amber – Minor or Moderate concern
Green – No concerns
Financial risk rating
rated 1-5, where 1 represents the highest risk and 5 the lowest
Slide 68
Leadership and governance
Trust Board
The Trust Board is stable, with all Executive posts being substantive and the majority of Board members having been with the Trust for at
least three years. There are five executive posts, being the Chief Executive, Director of Clinical Care & Governance, Medical Director,
Director of Operations and Director of Finance.
Governance and clinical structures
The Trust is clinically led; each of the five divisions (Community, Diagnostic & Clinical Support, Family Care, Medicine and Surgery &
Anaesthetics) is led by a Divisional Director, with support from a Clinical Director in each of the specialties. There are also a number of
Associate Medical Director posts, with responsibility for Medical Education, Research & Development, Information Management &
Technology, and Service Integration.
There are a number Board sub-committees, including the Audit Committee, Remuneration Committee and Charitable Funds Committee.
The Governance Committee reports directly to the Executive Management Board, but also provides assurance to the Audit Committee. The
Governance Committee is chaired by a non executive director (Paul Fletcher). The Governance Committee also receives reports from the
Quality & Safety Board.
The Trust has established a Mortality Steering Group, a multi-disciplinary group which provides strategic oversight and clinical leadership
for the mortality agenda, including reviewing diagnoses or procedures with elevated mortality and reviewing the coding process.
The Trust committee structure and board members are shown in the Appendix.
Slide 69
Leadership and governance
Clinical objectives (as set out in the Trust’s Clinical Strategy 2012-2015)
1.
To improve patient experience by putting quality at the heart of everything we do;
2.
To develop services of the highest quality through innovation, pathway reform and the implementation of best practice;
3.
To invest in and develop our workforce, and improve staff engagement and satisfaction levels;
4.
To continually promote equality and diversity at every level within the organisation;
5.
To maintain all regulatory requirements with the CQC and therefore be licensed to provide services without conditions;
6.
To further develop clinical services with key internal and external stakeholders to reduce health inequalities, improve public health and
reduce costs across the health economy; and
7.
To improve the Trust’s liquidity position and deliver the required efficiencies.
External reviews and regulation
The Trust has had a number of recent reviews, including a review of quality governance by KPMG, CQC inspections of Royal Blackburn
Hospital, Burnley General Hospital and Pendle Hospital, a review by Investors in People and an NHSLA level three assessment. We
consider the results of these reviews on the following pages.
Slide 70
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks
Trust response
Failure to deliver Essential Standards of Quality and Safety
including failure to reduce and manage healthcare acquired
infections.
The highest risks to these are identified in risks related to
• Medical staffing levels
• Nurse and Midwifery staffing levels
• Demand and volume management including use and
availability of escalation areas
• Provision of right care in right place including timely
movement of patient to speciality wards
• Discharge processes
• Understanding and improving mortality
Established reporting arrangements are providing reports for
constituent targets key deliverables - Performance monitoring
through to Board reporting, and contractual obligations and contract
Monitoring
Issue specific Local Implementation Teams are addressing
operational requirements and have constituent action plans in place
to address requirements
Network reports and activity performance reports monitor these and
ensure remedial action as needed
Commissioner & SHA monitoring and reporting Trust Information
Performance Summary - Breach report and analysis and SITREPs
ensure early alerts and action is taken as needed
The benefits of Transforming Community services transaction
are not realised and failure to maintain a patient centred and
commercially focussed organisation.
The highest risks to these are identified in risks related to
• Demand and volume management
• Provision of right care in right place including timely
movement of patient to speciality wards
• Discharge processes
Strategic and operational infrastructure is in place, TCS transaction
completed with transformation programme in place.
Enabling plans in place to support the vision and journey towards
FT status. FT Steering group with Executive reporting to Trust Board
and constituent action plan reporting through to SHA and DH.
MPN Service Models are integrated into the operational infrastructure
and direction and have outcome and performance
indicators aligned and monitoring mechanisms in place with corporate
goals for corporate teams which have been set and communicated.
Constituent work streams across the organisation are in place via
sub committees and Divisional boards’ organisational work streams
are in place to address the requirements.
Slide 71
Leadership and governance – other areas for further review
External reviews
In July 2012, the Trust received a report from KMPG on its quality governance arrangements. This review assessed the Trust against
Monitor’s Quality Governance Framework. The Trust received a score of 1.5 (all aspirant trusts must achieve a score below 4.0 to be
authorised as a foundation trust). Whilst this report did not identify any areas where significant improvement was required, KMPG
identified three areas as ‘amber-green’, that is, some elements of good practice, has no major omissions and robust action plans to address
perceived short falls with proven track record of delivery. These areas were:
•
2A: Does the Board have the necessary leadership, skills and knowledge to ensure the delivery of the quality agenda?
•
2B: Does the Board promote a quality focused culture throughout the trust?
•
3C: Does the Board actively engage patients, staff and other key stakeholders on quality?
Recent CQC inspections of Royal Blackburn Hospital, Burnley General Hospital and Pendle Hospital have not identified any areas of
concern, and the Trust is currently fully compliant against all CQC standards.
An Investors in People report from September 2011 indicated that there had been significant improvements in over the past two years, a
passion for delivery of quality and an improvement in the strength of the Trust Board. It concluded that the Trust met the Investors in
People standard, but identified some areas for continuous improvement at the Trust.
The Trust passed its NHSLA Level Three assessment in November 2012.
Cost Improvement Programme
The Trust planned to deliver a cost improvement programme of £16.2m in 2012-13 against which it delivered £16.0m recurrently. The
largest project included workforce redesign and procurement savings.
In 2013/14, the Trust plans to achieve cost improvements of £12.6m.
A detailed Quality Impact Assessment is undertaken in respect of each QIPP and CIP scheme incorporating the potential impact on patient
safety, clinical effectiveness, patient experience and staff engagement to produce a RAG rating for each scheme.
The Board regularly reviews the cost improvement programmes and their delivery across the organisation and their impact on quality.
Non-Executive Directors have provided appropriate challenge and support for delivery of strategic and high impact schemes which
continue to be monitored at Board level.
Slide 72
Appendix
Slide 73
Royal Blackburn Hospital Map
Source: http://mappery.com
Slide 74
Burnley General Hospital Map
Source: http://bda-burnley.com
Slide 75
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 76
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
Trust Committee Structure
Slide 78
Board Members
Slide 79
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 http://mappery.com
35 UK National Screening Committee
Appendix
Appendix
Slide 80
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Elective
307 - Diabetic medicine
19 - Cancer of bronchus; lung
1225.57
2
Elective
307 - Diabetic medicine
59 - Deficiency and other anemia
1062.85
1
Non-elective
192 - Critical care
1 - Tuberculosis
303.13
1
Non-elective
192 - Critical care
103 - Pulmonary heart disease
1017.59
2
Non-elective
192 - Critical care
108 - Congestive heart failure; nonhypertensive
367.09
1
Non-elective
192 - Critical care
127 - Chronic obstructive pulmonary disease and bronchiectasis
202.02
1
Non-elective
192 - Critical care
129 - Aspiration pneumonitis; food/vomitus
271.52
1
Non-elective
192 - Critical care
145 - Intestinal obstruction without hernia
228.78
1
Non-elective
192 - Critical care
146 - Diverticulosis and diverticulitis
668.51
1
Non-elective
192 - Critical care
148 - Peritonitis and intestinal abscess
406.07
1
Non-elective
192 - Critical care
152 - Pancreatic disorders (not diabetes)
739.35
2
Non-elective
192 - Critical care
153 - Gastrointestinal hemorrhage
2392.95
3
Non-elective
192 - Critical care
155 - Other gastrointestinal disorders
2086.73
2
Non-elective
192 - Critical care
157 - Acute and unspecified renal failure
141.33
1
Non-elective
192 - Critical care
16 - Cancer of liver and intrahepatic bile duct
305.93
1
Non-elective
192 - Critical care
2 - Septicemia (except in labor)
204.78
1
Non-elective
192 - Critical care
233 - Intracranial injury
297.93
2
Non-elective
192 - Critical care
238 - Complications of surgical procedures or medical care
3004.50
3
Non-elective
192 - Critical care
243 - Poisoning by nonmedicinal substances
30396.10
1
Non-elective
192 - Critical care
259 - Residual codes; unclassified
3125.05
1
Non-elective
192 - Critical care
50 - Diabetes mellitus with complications
823.78
2
Non-elective
192 - Critical care
76 - Meningitis (except that caused by tuberculosis or sexually transmitted disease)
652.46
1
Non-elective
192 - Critical care
83 - Epilepsy; convulsions
738.05
1
Non-elective
192 - Critical care
85 - Coma; stupor; and brain damage
210.60
1
Non-elective
300 - General Medicine
1 - Tuberculosis
218.12
2
Slide 81
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General Medicine
102 - Nonspecific chest pain
129.84
2
Non-elective
300 - General Medicine
105 - Conduction disorders
365.17
2
Non-elective
300 - General Medicine
11 - Cancer of head and neck
289.63
1
Non-elective
300 - General Medicine
111 - Other and ill-defined cerebrovascular disease
409.83
2
Non-elective
300 - General Medicine
114 - Peripheral and visceral atherosclerosis
151.81
2
Non-elective
300 - General Medicine
115 - Aortic; peripheral; and visceral artery aneurysms
166.19
2
Non-elective
300 - General Medicine
119 - Varicose veins of lower extremity
216.61
1
Non-elective
300 - General Medicine
121 - ther diseases of veins and lymphatics
310.08
1
Non-elective
300 - General Medicine
125 - Acute bronchitis
101.81
1
Non-elective
300 - General Medicine
128 - Asthma
122.86
1
Non-elective
300 - General Medicine
129 - Aspiration pneumonitis; food/vomitus
104.68
2
Non-elective
300 - General Medicine
13 - Cancer of stomach
117.66
1
Non-elective
300 - General Medicine
133 - Other lower respiratory disease
121.15
3
Non-elective
300 - General Medicine
137 - Diseases of mouth; excluding dental
380.50
1
Non-elective
300 - General Medicine
14 - Cancer of colon
139.56
3
Non-elective
300 - General Medicine
145 - Intestinal obstruction without hernia
166.30
2
Non-elective
300 - General Medicine
147 - Anal and rectal conditions
329.28
1
Non-elective
300 - General Medicine
148 - Peritonitis and intestinal abscess
289.77
3
Non-elective
300 - General Medicine
15 - Cancer of rectum and anus
140.83
1
Non-elective
300 - General Medicine
16 - Cancer of liver and intrahepatic bile duct
142.49
3
Non-elective
300 - General Medicine
161 - Other diseases of kidney and ureters
582.03
1
Non-elective
300 - General Medicine
166 - Other male genital disorders
1369.90
1
Non-elective
300 - General Medicine
18 - Cancer of other GI organs; peritoneum
328.56
1
Non-elective
300 - General Medicine
19 - Cancer of bronchus; lung
106.17
3
Non-elective
300 - General Medicine
197 - Skin and subcutaneous tissue infections
117.35
2
Slide 82
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General Medicine
199 - Chronic ulcer of skin
183.42
2
Non-elective
300 - General Medicine
20 - Cancer; other respiratory and intrathoracic
172.89
1
Non-elective
300 - General Medicine
204 - Other non-traumatic joint disorders
159.95
2
Non-elective
300 - General Medicine
226 - Fracture of neck of femur (hip)
122.66
1
Non-elective
300 - General Medicine
230 - Fracture of lower limb
138.06
1
Non-elective
300 - General Medicine
232 - Sprains and strains
411.54
1
Non-elective
300 - General Medicine
236 - Open wounds of extremities
190.60
1
Non-elective
300 - General Medicine
238 - Complications of surgical procedures or medical care
133.75
1
Non-elective
300 - General Medicine
24 - Cancer of breast
171.96
2
Non-elective
300 - General Medicine
248 - Gangrene
293.09
1
Non-elective
300 - General Medicine
251 - Abdominal pain
168.38
2
Non-elective
300 - General Medicine
259 - Residual codes; unclassified
109.58
1
Non-elective
300 - General Medicine
27 - Cancer of ovary
120.31
1
Non-elective
300 - General Medicine
28 - Cancer of other female genital organs
259.77
1
Non-elective
300 - General Medicine
32 - Cancer of bladder
275.04
1
Non-elective
300 - General Medicine
35 - Cancer of brain and nervous system
143.44
2
Non-elective
300 - General Medicine
38 - Non-Hodgkin`s lymphoma
190.10
1
Non-elective
300 - General Medicine
39 - Leukemias
129.34
2
Non-elective
300 - General Medicine
4 - Mycoses
277.41
2
Non-elective
300 - General Medicine
40 - Multiple myeloma
333.69
3
Non-elective
300 - General Medicine
43 - Malignant neoplasm without specification of site
130.74
1
Non-elective
300 - General Medicine
44 - Neoplasms of unspecified nature or uncertain behavior
234.00
2
Non-elective
300 - General Medicine
47 - Other and unspecified benign neoplasm
255.35
1
Non-elective
300 - General Medicine
50 - Diabetes mellitus with complications
181.77
2
Non-elective
300 - General Medicine
51 - Other endocrine disorders
136.04
3
Slide 83
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
300 - General Medicine
60 - Acute posthemorrhagic anemia
Non-elective
300 - General Medicine
Non-elective
Observed Deaths that
are higher than the
expected
SHMI
2697.39
1
62 - Coagulation and hemorrhagic disorders
208.89
2
300 - General Medicine
63 - Diseases of white blood cells
174.80
2
Non-elective
300 - General Medicine
84 - Headache; including migraine
221.10
1
Non-elective
300 - General Medicine
5938.22
1
Non-elective
300 - General Medicine
92 - Otitis media and related conditions
97 - Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by
tuberculosis or sexually transmitted disease)
134.11
1
Non-elective
300 - General Medicine
99 - Hypertension with complications and secondary hypertension
280.90
1
Non-elective
340 - Thoracic medicine
1 - Tuberculosis
372.64
1
Non-elective
340 - Thoracic medicine
100 - Acute myocardial infarction
467.53
1
Non-elective
340 - Thoracic medicine
103 - Pulmonary heart disease
306.73
1
Non-elective
340 - Thoracic medicine
108 - Congestive heart failure; nonhypertensive
166.96
1
Non-elective
340 - Thoracic medicine
109 - Acute cerebrovascular disease
241.03
3
Non-elective
340 - Thoracic medicine
11 - Cancer of head and neck
356.64
1
Non-elective
340 - Thoracic medicine
125 - Acute bronchitis
766.39
1
Non-elective
340 - Thoracic medicine
131 - Respiratory failure; insufficiency; arrest (adult)
158.05
1
Non-elective
340 - Thoracic medicine
157 - Acute and unspecified renal failure
663.20
1
Non-elective
340 - Thoracic medicine
2 - Septicemia (except in labor)
202.22
1
Non-elective
340 - Thoracic medicine
230 - Fracture of lower limb
1376.54
1
Non-elective
340 - Thoracic medicine
231 - Other fractures
431.04
1
Non-elective
340 - Thoracic medicine
27 - Cancer of ovary
255.68
1
Non-elective
340 - Thoracic medicine
3 - Bacterial infection; unspecified site
552.28
1
Non-elective
340 - Thoracic medicine
35 - Cancer of brain and nervous system
642.74
1
Non-elective
340 - Thoracic medicine
42 - Secondary malignancies
167.80
1
Non-elective
340 - Thoracic medicine
50 - Diabetes mellitus with complications
13391.18
1
Non-elective
340 - Thoracic medicine
83 - Epilepsy; convulsions
2108.04
2
Slide 84
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
340 - Thoracic medicine
85 - Coma; stupor; and brain damage
Non-elective
430 - Geriatric medicine
Non-elective
Observed Deaths that
are higher than the
expected
SHMI
1063.91
1
106 - Cardiac dysrhythmias
271.96
1
430 - Geriatric medicine
108 - Congestive heart failure; nonhypertensive
184.45
2
Non-elective
430 - Geriatric medicine
114 - Peripheral and visceral atherosclerosis
524.46
1
Non-elective
430 - Geriatric medicine
125 - Acute bronchitis
143.81
1
Non-elective
430 - Geriatric medicine
127 - Chronic obstructive pulmonary disease and bronchiectasis
1001.09
2
Non-elective
430 - Geriatric medicine
129 - Aspiration pneumonitis; food/vomitus
171.33
2
Non-elective
430 - Geriatric medicine
133 - Other lower respiratory disease
236.49
1
Non-elective
430 - Geriatric medicine
134 - Other upper respiratory disease
1989.07
1
Non-elective
430 - Geriatric medicine
149 - Biliary tract disease
172.51
1
Non-elective
430 - Geriatric medicine
150 - Liver disease; alcohol-related
209.90
1
Non-elective
430 - Geriatric medicine
151 - Other liver diseases
588.17
1
Non-elective
430 - Geriatric medicine
153 - Gastrointestinal hemorrhage
324.20
1
Non-elective
430 - Geriatric medicine
155 - Other gastrointestinal disorders
413.60
1
Non-elective
430 - Geriatric medicine
157 - Acute and unspecified renal failure
251.22
3
Non-elective
430 - Geriatric medicine
158 - Chronic renal failure
428.69
1
Non-elective
430 - Geriatric medicine
16 - Cancer of liver and intrahepatic bile duct
210.73
1
Non-elective
430 - Geriatric medicine
197 - Skin and subcutaneous tissue infections
237.02
1
Non-elective
430 - Geriatric medicine
2 - Septicemia (except in labor)
129.69
1
Non-elective
430 - Geriatric medicine
204 - Other non-traumatic joint disorders
1320.65
1
Non-elective
430 - Geriatric medicine
233 - Intracranial injury
214.95
1
Non-elective
430 - Geriatric medicine
259 - Residual codes; unclassified
490.14
1
Non-elective
430 - Geriatric medicine
3 - Bacterial infection; unspecified site
264.59
1
Non-elective
430 - Geriatric medicine
39 - Leukemias
507.05
1
Non-elective
430 - Geriatric medicine
42 - Secondary malignancies
129.04
1
Slide 85
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
430 - Geriatric medicine
43 - Malignant neoplasm without specification of site
192.49
1
Non-elective
430 - Geriatric medicine
219.69
3
Non-elective
430 - Geriatric medicine
68 - Senility and organic mental disorders
77 - Encephalitis (except that caused by tuberculosis or sexually transmitted
disease)
789.58
1
Non-elective
430 - Geriatric medicine
269.56
1
Non-elective
430 - Geriatric medicine
82 - Paralysis
97 - Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by
tuberculosis or sexually transmitted disease)
821.18
1
Slide 86
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
HSMR
Non-elective
192 - Critical care medicine
Aspiration pneumonitis; food/vomitus
460.2
1
Non-elective
192 - Critical care medicine
Chronic obstructive pulmonary disease and bronchie
324.7
2
Non-elective
192 - Critical care medicine
Congestive heart failure; nonhypertensive
530
1
Non-elective
192 - Critical care medicine
Gastrointestinal hemorrhage
893.2
2
Non-elective
192 - Critical care medicine
Intestinal obstruction without hernia
417.4
1
Non-elective
192 - Critical care medicine
Intracranial injury
304.2
2
Non-elective
192 - Critical care medicine
Other gastrointestinal disorders
3298.9
2
Non-elective
192 - Critical care medicine
Other liver diseases
3130.3
1
Non-elective
192 - Critical care medicine
Peritonitis and intestinal abscess
380.2
1
Non-elective
192 - Critical care medicine
Pulmonary heart disease
3751.1
1
Non-elective
192 - Critical care medicine
Septicemia (except in labor)
145.6
1
Non-elective
340 - Thoracic medicine
Acute and unspecified renal failure
888
1
Non-elective
340 - Thoracic medicine
Acute cerebrovascular disease
314.4
3
Non-elective
340 - Thoracic medicine
Aspiration pneumonitis; food/vomitus
208.6
1
Non-elective
340 - Thoracic medicine
Cancer of esophagus
419.9
1
Non-elective
340 - Thoracic medicine
Congestive heart failure; nonhypertensive
348.7
1
Non-elective
340 - Thoracic medicine
Other fractures
484.3
1
Non-elective
340 - Thoracic medicine
Pulmonary heart disease
255
1
Non-elective
340 - Thoracic medicine
Secondary malignancies
254.5
1
Non-elective
340 - Thoracic medicine
Septicemia (except in labor)
186.9
1
Non-elective
430 - Geriatric medicine
Acute and unspecified renal failure
208
1
Non-elective
430 - Geriatric medicine
Acute bronchitis
266
1
Non-elective
430 - Geriatric medicine
Aspiration pneumonitis; food/vomitus
163
1
Non-elective
430 - Geriatric medicine
Cancer of esophagus
228
1
Non-elective
430 - Geriatric medicine
Cardiac dysrhythmias
392
1
Slide 87
HSMR Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
430 - Geriatric medicine
Chronic obstructive pulmonary disease and bronchie
Non-elective
430 - Geriatric medicine
Non-elective
Observed Deaths that
are higher than the
expected
HSMR
1351
2
Chronic renal failure
305
1
430 - Geriatric medicine
Congestive heart failure; nonhypertensive
174
1
Non-elective
430 - Geriatric medicine
Intestinal obstruction without hernia
391
1
Non-elective
430 - Geriatric medicine
Intracranial injury
193
1
Non-elective
430 - Geriatric medicine
Leukemias
973
1
Non-elective
430 - Geriatric medicine
Liver disease; alcohol-related
257
1
Non-elective
430 - Geriatric medicine
Other liver diseases
1017
1
Non-elective
430 - Geriatric medicine
Pleurisy; pneumothorax; pulmonary collapse
278
1
Non-elective
430 - Geriatric medicine
Respiratory failure; insufficiency; arrest (adult)
209
1
Non-elective
430 - Geriatric medicine
Senility and organic mental disorders
131
1
Non-elective
430 - Geriatric medicine
Septicemia (except in labor)
120
1
Slide 88
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Nonelective)
Treatment Specialty
Critical care medicine
HSMR
SHMI
X
General medicine
X
X
Thoracic medicine
X
X
Geriatric medicine
X
X
Obstetrics
X
Slide 89