George Eliot Hospital 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 George Eliot Hospital NHS Trust Context A brief overview of the Nuneaton area and the George Eliot Hospital NHS Trust. This section will provide a profile of the area, outline performance of local healthcare providers and give 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 will provide an introduction to the Trust, providing an overview, health profile and an understanding of why the Trust has been chosen for this review. Review Areas: George Eliot is situated in Nuneaton, which has a population of just above 292,344. 8% of Nuneaton’s population belongs to nonwhite ethnic minorities. Teenage pregnancy and adult obesity are significantly more common than the national average. To provide an overview of the Trust, we have reviewed the following areas: This is a relatively small Trust for both inpatient and outpatient activity, serving a population of just over 80,000. • 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. Nuneaton’s health profile shows that in this area male and female life expectancy is somewhat lower than the national average. The Trust has one hospital site, the George Eliot Hospital in Nuneaton. George Eliot became a Trust in 1994 and has a total of 318 beds. It has 72% market share of inpatient activity within a 5 mile radius of the Trust. However, the Trust’s market share falls to 14% within a radius of 10 miles and 7% within a radius of 20 miles. A review of ambulance response times showed that the West Midlands services were performing at a level slightly above the national average. Finally, George Eliot’s HSMR was above the expected level in 2011 and 2012, and was therefore selected for this review. Slide 5 Trust Overview The George Eliot Hospital was opened in 1948. The Trust serves a population of just over 292,000 in Nuneaton, as well as people in surrounding areas. The Trust has approximately 10,000 members. The Trust offers a range of inpatient and outpatient services, including surgical and medical services, services for women and children, diagnostic and support services, and community services. In August, 2013, the Trust will launch a new paediatric service, including the opening of a new Paediatric Assessment Unit. The Trust provides some community services, such as dental and sexual health to the wider population of Warwickshire. Trust Status NHS Trust (1994) Number of Beds and Bed Occupancy Beds Available Percentage Occupied National Average Total 318 88.4% 86% General and Acute 301 88.4% 88% Maternity 17 88.4% 59% Source: Department of Health: Transparency Website George Eliot Hospital NHS Trust Inpatient/Outpatient Activity 21,809 (50%) Value Non Elective 21,578 (50%) Apr –Dec 2012 Income £90m Total 43,387 Apr-Dec 2012 Expenditure £86m Apr-Dec 2012 EBITDA £4m 2012-13 Net surplus (deficit) (£1m) 2013-14 Budgeted Income £115m 2013-14 Budgeted Expenditure £109m 2013-14 Budgeted EBITDA £7m 2013-14 Budgeted Net surplus (deficit) £0 George Eliot Hospital NHS Trust Finance Indicator Source: Board of Directors meeting 30th January, 2013 Inpatient Activity (Jan12-Dec12) Elective (inc. Day Cases) Acute Hospital (Oct12-Dec12) Outpatient Activity DC Rate: 88% Total Source: Healthcare Evaluation Data (HED) 208,451 Departments and Services Accident & Emergency, Cardiology, Children’s and Adolescent Services, Dermatology, Diabetic Medicine, Diagnostic Endoscopy, Diagnostic Physiological Measurement, ENT, Endocrinology and Metabolic Medicine, Gastro Intestinal and Liver Services, General Medicine, General Surgery, Genetics, Gynaecology, Haematology, Immunology, Maternity Service, Nephrology, Neurology, Neurosurgery, Ophthalmology, Orthopaedics, Oral and Maxillofacial Surgery, Pain management, Plastic Surgery, Respiratory Medicine, Rheumatology, Urology, Vascular Surgery. Source: NHS Choices Slide 6 A map of George Eliot Hospital NHS Trust is included in the Appendix. Trust Overview continued... General Medicine and General Surgery are the largest inpatient specialities while Allied Health Professional Episodes and General Surgery are the largest for outpatients. Outpatient Activity by Trust 300 1200 250 200 George Eliot 43,387 150 100 50 Number of Outpatient Spells (Thousands) George Eliot is a small sized Trust for both inpatient and outpatient activity, relative to the rest of England. Indeed, the Trust is the smallest 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 George Eliot against national trusts in terms of inpatient and outpatient activity. 0 1000 800 George Eliot 208,451 600 400 200 0 Trusts Trusts Covered by Review Trusts National Inpatient Activity Curve Top 9 Inpatient Main Specialties as a % of Total Inpatient Activity Trusts Covered by Review Bottom 9 Inpatient Main Specialties and Spells National Outpatient Activity Curve Top 9 Outpatient Main Specialties as a % of Total Outpatient Activity General Medicine 24% Dermatology 8 Allied Health Professional Episode 21% General Surgery 16% Oral Surgery 25 General Surgery 12% Gynaecology 11% Paediatric Surgery 53 General Medicine 12% Trauma & Orthopaedics 9% Oral and Maxillo Facial Surgery 493 Trauma & Orthopaedics 9% Paediatrics 8% Midwifery 639 Ophthalmology 8% Urology 6% Anaesthetics 658 Gynaecology 5% Medical Oncology 6% Plastic Surgery 668 Dermatology 4% Clinical Haematology 5% Ophthalmology 872 Clinical Haematology 4% Accident & Emergency 5% Obstetrics 902 Midwifery 3% Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12 Slide 7 The Nuneaton and Surroundings Area Overview Nuneaton is a town of average deprivation in the English county of Warwickshire. The area has a sizeable proportion of ethnic minorities, particularly from South Asia. People aged 60 and above constitute a relatively larger proportion of the population in the area compared to their proportion of the population nationally. Obesity is more common in the region than in England as a whole, and breastfeeding is relatively less common than in England as a whole. FACT BOX Population 292,344 80+ The Royal College of Surgeons recommends 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." 70-79 IMD Nuneaton and Bedworth is the 115th most deprived unitary authority in England (out of 149 unitary authorities). Ethnic diversity 8% of the population of Nuneaton belong to non-White ethnic minorities. Rural or Urban Nuneaton is part urban and part rural. Children’s and young people’s health Breast feeding initiation in Nuneaton is slightly less common than in England as a whole. Teenage pregnancy is significantly more common than in England as a whole. Adults’ health and lifestyle Adults in Nuneaton are significantly less likely to eat healthy food than the English population as a whole. Similarly, adult obesity is significantly more common than in England as a whole. 60-69 50-59 40-49 20-39 20-29 10-19 0-9 5% -0.2 20%-0.15 15% -0.110% -0.05 ENG/Women 00% ENG/Men 5% 0.05 NUN/Women 10% 0.1 15% 0.15 NUN/Men 20%0.2 Source: Office of National Statistics, 2011 Census data Slide 8 Nuneaton Geographic Overview The map on the right shows the location of the George Eliot Hospital NHS Trust. Nuneaton is a large town in the West Midlands. The city of Coventry lies south of Nuneaton, and Birmingham is located to the west. There are a number of large motorways in close proximity including the M1, M6, M42 and the M69. 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 the George Eliot Hospital NHS Trust. It shows that the Trust has a 72% market share within a 5 mile radius of the Trust. However, it is clear that the Trust’s market share falls as the radius is increased. Within 10 miles, the market share is 14% whereas within a 20 mile radius, the market share is only 7%. Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12 The wheel shows the main competitors in the local area. These were identified as University Hospitals Coventry and Warwickshire NHS Trust, Heart of England NHS Foundation Trust, University Hospitals of Leicester NHS Trust, and Burton Hospitals NHS Foundation Trust. Slide 9 Nuneaton’s Health Profile Health Profiles, depicted on this slide and the following, are designed to help local government and health services identify problems in their areas, and decide how to tackle these issues. They provide a snapshot of the overall health of the local population, and highlight potential differences against regional and national averages. Deprivation by unitary authority area Nuneaton and Bedworth The graph shows the level of deprivation in Nuneaton and Bedworth compared nationally. The tables below outline Nuneaton’s health profile information in comparison to the rest of England. 1. GCSE results achieved in Nuneaton are significantly lower 1 than the national average. 2. In Nuneaton, four of the five indicators within children’s and young people’s health are statistically lower than the national average. 2 Slide 10 Nuneaton’s Health Profile 3. Adult health in Nuneaton is within 3 the expected range for three of the five indicators, though obesity amongst adults is significantly more common than the national average. 4 This correlates to the area’s poor eating habits, although the levels of obese children (under 6 years) is the same as the national average. 4. In Nuneaton, hospital stays for self-harm, people diagnosed with diabetes and acute sexually transmitted infections are significantly higher than the English average. 5. Life expectancy is significantly lower than the national average for both men and women in Nuneaton. 5 Slide 11 Performance of Local Healthcare Providers To give an informed view of the Trust’s performance it is important to consider the service levels of nonacute local providers. For example, slow ambulance response times could potentially increase the risk of mortality. The graphs on the right represent some key performance indicators for England’s ambulance services and show the West Midlands Ambulance Service NHS Trust have a higher proportion of calls responded to within target times than the national average. 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 Western Midlands Ambulance Ambulance Service NHS Service NHS Foundation Trust Trust South Central Ambulance Service NHS Foundation Trust South East East of London North West Great North East Yorkshire East Coast England Ambulance Ambulance Western Ambulance Ambulance Midlands Ambulance Ambulance Service NHS Service NHS Ambulance Service NHS Service NHS Ambulance Service NHS Service NHS Trust Trust Service NHS Trust Trust Service NHS Foundation Trust Trust Trust Trust Ambulance Trust Proportion of calls responded to within 19 minutes 100% 98% 96% 94% 92% 90% 88% 86% 84% Isle of Wight NHS Trust West London South East Yorkshire South Great North East North West South Central East of East Midlands Ambulance Coast Ambulance Western Western Ambulance Ambulance Ambulance England Midlands Ambulance Service NHS Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Ambulance Ambulance Service NHS Trust Service NHS Trust Service NHS Service NHS Trust Trust Foundation Service NHS Service NHS Trust Foundation Foundation Trust Trust Trust Trust Trust Trust Ambulance Trusts Source: Department of Health: Transparency Website Dec 12 Foreword from the Trust Board England England Slide 12 Why was George Eliot Hospital chosen for this review? Based on the Summary Hospital level Mortality Indicator (SHMI) and Hospital Standardised Mortality Ratio (HSMR), 14 trusts were selected for this review. The table includes information on which trusts were selected. An explanation of each of these indicators is provided in the Mortality section. Where it does not include the SHMI for a trust, it is because the trust was selected due to a high HSMR as opposed to its SHMI. The SHMI for all 14 trusts can be found in the following pages. Initially, five hospital trusts were announced as falling within the scope of this investigation based on the fact that they had been outliers on SHMI for the last two years (SHMI data has only been published for the last two years). Subsequent to these five hospital trusts being announced, Professor Sir Bruce Keogh took the decision that those hospital trusts that had also been outliers for the last two consecutive years on HSMR should also fall within the scope of his review. The rationale for this was that it had been HSMR that had provided the trigger for the Healthcare Commission’s initial investigation into the quality of care provided at Mid Staffordshire Hospitals NHS Foundation Trust. George Eliot has been above the expected level for HSMR over the last 2 years and was therefore selected for this review. Trust SHMI 2011 SHMI 2012 HSMR 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 13 Why was George Eliot Hospital chosen for this review? SHMI Funnel Chart 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 with 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 HSMR Funnel Chart below the dotted red and green lines (95% confidence intervals), respectively, means that there is a statistically significant variance for the trust in question. SHMI Time Series George Eliot Selected trusts Outside Range Selected trusts w/in Range HSMR Time Series George Eliot Selected trusts Outside Range Selected trusts w/in Range The funnel charts for 2010/11 and 2011/12, the period when the trusts were selected for review, show that George Eliot’s SHMI and HSMR is statistically above the expected range. This is supported by the time series graphs which show the SHMI being consistently higher than expected. Source: Healthcare Evaluation Data (HED), Apr 10-Mar 12 Slide 14 Mortality Slide 15 Mortality Overview: Summary: This section will focus 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 122 for the period January 2012 to December 2012, meaning that the number of actual deaths is higher than the expected level. This is statistically above the expected range. The measures identified are being used as a ‘smoke alarm’ for highlighting potential quality issues. No judgement about the actual quality of care being provided to patients is being made at this stage, nor should it be reached by looking at these measures in isolation. Review areas To undertake a detailed analysis of the trust’s mortality, it is necessary to look at the following areas: • Differences between the HSMR and SHMI; • Elective and non-elective mortality; • Specialty and Diagnostic groups; and • Alerts and investigations. Data sources • Healthcare Evaluation Data (HED); • Health & Social Care Information Centre – SHMI and contextual indicators; • Dr Foster – HSMR; and • Care Quality Commission – alerts, correspondence and findings. All use and display of sourcing is consistent across the packs for the 14 trusts included in this review. Further analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with an HSMR of 123, compared with a level of 68 for elective admissions. George Eliot has a SHMI of 108 for the period December 2011 to November 2012, which is outside the expected range (using Healthcare Evaluation data). However, the official SHMI produced by HSCIC is within the expected range (at 110 for the period October 2011 to September 2012). Similar to HSMR, non-elective admissions are seen to be contributing primarily to the overall Trust SHMI with 109, against 95 for elective admissions. Since 2007, George Eliot has had eight diagnosis group alerts to the CQC, of which five were followed up directly with the Trust. The patient groups alerting more than once since 2007 are Septicaemia and Complications of surgical procedures or medical care. A common theme arising from responses to the CQC from the Trust is the coding of co-morbidities, which is likely to have an effect on mortality rates. George Eliot commissioned an external review of mortality in 2012 which resulted in a comprehensive action plan . Slide 16 Mortality Overview Mortality The following overview provides a summary of the Trust’s key mortality areas: Overall HSMR Elective mortality (SHMI and HSMR) Overall SHMI* Non-elective mortality (SHMI and HSMR) Weekend or weekday mortality outliers Palliative care coding issues Outcome 1 (R17) Respecting and involving e who use services Emergency specialty groups much worse than expected 30-day mortality following specific surgery / admissions Emergency specialty groups worse than expected Mortality among patients with diabetes Diagnosis group alerts to CQC Mortality in low-risk groups Diagnosis group alerts followed up by CQC SHMI* Outside expected range of the HSCIC for Mar 11 – Sep 12 Outside expected range Outside expected range based on Poisson distribution for Dec 11 – Nov 12 Within expected range Within expected range *The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model, which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14 trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the purposes of this review. Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12 Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR, Care Quality Commission – alerts, correspondence and findings Slide 17 HSMR Definition What is the Hospital Standardised Mortality Ratio? The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the hospital. However, it can be a warning sign that things are going wrong. How does HSMR work? The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of inhospital deaths (multiplied by 100) for 56 specific CCS groups; in a specified patient group. The expected deaths are calculated from logistical regression models taking into account and adjusting for a case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of palliative care, number of previous emergency admissions and financial year of discharge. How should HSMR be interpreted? Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number in order to identify if variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when these have been crossed is performance classed as higher or lower than expected. Slide 18 SHMI Definition What is the Summary Hospital-level Mortality Indicator? The Summary Hospital-level Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice. How does SHMI work? 1. 2. 3. 4. Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time The Indicator will utilise 5 factors to adjust mortality rates by a. The primary admitting diagnosis; b. The type of admission; c. A calculation of co-morbid complexity (Charlson Index of co-morbidities); d. Age; and e. Sex. All inpatient mortalities that occur within a Hospital are considered in the indicator How should SHMI be interpreted? Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are highlighted using a Random Effects funnel plot. Slide 19 Some key differences between SHMI and HSMR Indicator HSMR SHMI Are all hospital deaths included? No, around 80% of in hospital deaths are included, which varies significantly dependent upon the services provided by each hospital If a patient is transferred between hospitals within 2 days the death is counted multiple times Yes all deaths are included Does the use of the palliative care code reduce the relative impact of a death on the indicator? Yes No Does the indicator consider where deaths occur? Only considers in-hospital deaths Considers in-hospital deaths but also those up to 30 days post discharge anywhere too. Is this applied to all health care providers? Yes No, does not apply to specialist hospitals When a patient dies how many times is this counted? 1 death is counted once, and if the patient is transferred the death is attached to the last acute/secondary care provider Slide 20 SHMI overview Month-on-month time series The Trust’s SHMI level for the 12 months from Dec 11 to Nov 12 is 108, which means, as shown below it is statistically above the 95th confidence interval on the Poisson distribution. The time series show SHMI as decreasing over the last couple of years,, although in the last recorded year it has fluctuated around the expected level and has dropped below the 100 mark twice. SHMI funnel chart – 12 months Year-on-year time series George Eliot Selected trusts Outside Range Selected trusts w/in Range Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012 Slide 21 SHMI Statistics This slide shows the percentage of patient deaths occurring within George Eliot Hospital. 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 will contribute toward differences in HSMR and SHMI outputs. The data shows that 79.2% of SHMI deaths occur in hospital, which is greater than the national average of 73.3%. Percentage of patient deaths in hospital 90% George Eliot 79.2% 80% 70% 60% Trusts Covered by Review All Trusts Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012 Slide 22 Mortality - SHMI Tree Overall Trust SHMI 108 Within expected range Elective Lower than expected (below the 95th confidence interval) SHMI 95 Gynaecology Paediatrics Medical Oncology Clinical Haematology SHMI 109 General Medicine Non Elective Pain Management Oral Surgery Ophthalmology T&O Urology General Surgery The tree shows that George Eliot has a SHMI of 108 which is above the expected range. Treatment Specialties Accident and Emergency 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. Treatment Specialties Midwife Episode Gynaecology Obstetrics Well Babies Paediatrics Clinical Haematology General Medicine (115,105) A&E Plastic Surgery Ophthalmology T&O Urology General Surgery The number of observed deaths are highlighted as being above the expected level in General Medicine for non-elective admissions. This is a potential area for review. Higher than expected (above the 95th confidence interval) Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012 Slide 23 SHMI sub-tree of non-elective specialties Higher than expected (above the 95th confidence interval) The SHMI sub-tree highlights the specialties for non-elective admissions with a statistically higher SHMI than expected and highlights the diagnostic groups with at least four more observed deaths than expected. When identifying areas to review, it is important to consider the number of deaths as well as the SHMI. Within expected range Lower than expected (below the 95th confidence interval) Within non-elective admissions, General Medicine has the highest number of greater than expected deaths and congestive heart failure (18) and pneumonia (16) are seen as the main diagnostic groups contributing to this. Overall118.2 (108; 78) Non-elective (109; 78) Treatment Specialties General Medicine (115, 105) Congestive heart failure; non-hypertensive (138,18) Pneumonia (except that caused by tuberculosis or sexually transmitted disease)(111,16) Acute cerebrovascular disease(133,15) Diagnostic Groups Senility and organic mental disorders(208,10) Cancer of bronchus; lung(143,9) Key Urinary tract infections(116,7) Diagnosis (100 ; 1 ) Septicemia (except in labor)(124,7) SHMI Observed deaths that are higher than the expected(if any) * Diagnosis where SHMI is high as well as the number of excess death Biliary tract disease(314,5) Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012 The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix. Slide 24 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. SHMI published by HSCIC, George Eliot 130 120 110 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. 100 90 80 Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12 Rolling 12 months ending Lower limit Upper limit SHMI The SHMI for George Eliot was 110 in the year to Sept-12 (England baseline = 100). It has been within the expected range for the latest two periods, having been above expected in all periods prior to that. Source: Health & Social Care Information Centre – SHMI Slide 25 HSMR overview Month-on-month time series The Trust’s HSMR level for the 12 months from Jan 12 to Dec 12 is 122, which means, as shown below, that it is outside the expected range and so classified as an outlier. The time series show a general trend of increasing HSMR year-onyear. However, the month on month time series shows no strong trend, rising to 134 for the month of December 2012. HSMR funnel plot – 12 months Year-on-year time series George Eliot Selected trusts Outside Range Selected trusts w/in Range Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012 Slide 26 HSMR Statistics The table to the right shows George Eliot’s HSMR broken down by admission type. A further breakdown of the overall HSMR of 122 is identified in the table. It shows that non elective admissions are the main driver of the Trust’s overall HSMR, with 123 (above the expected range) compared to an elective level of 68 (within the expected range). This could be an area for further review. HSMR Weekend Week All Elective No. discharged = 10 No. of deaths = 1 56 68 Non-elective 130 120 123 All 130 Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012 119 122 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) Black – subject to further review Slide 27 HSMR CCS Diagnostic Group Overview The darker colour boxes have the highest HSMR while the size of the boxes represent the number of observed deaths that are higher than the expected deaths. The larger and darker boxes within the tree plot will highlight potential areas for further review. From this tree plot it is clear that the following areas have the greatest number of above expected deaths: • Pneumonia (HSMR = 123; Deaths above expected level = 29); • Congestive heart failure (161; 24); • Acute cerebrovascular disease (126; 12); • Cancer of bronchus; lung (158; 11); • Acute myocardial infection (183; 10); and • Septicemia (138; 10). Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012 Slide 28 Mortality - HSMR Tree Elective HSMR 68 Gynaecology Paediatrics Medical Oncology Clinical Haematology General Medicine A&E Non Elective HSMR 123 Treatment Specialties Slide 29 Midwife Episode Gynaecology Obstetrics Well Babies Paediatrics Medical Oncology Clinical Haematology General Medicine (136) A&E Ophthalmology T&O Urology General Surgery Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012 T&O HSMR 122 Urology Overall Trust Elective admissions have an HSMR statistically within the expected range, with no treatment specialties showing as outliers. Treatment Specialties General Surgery The tree shows that the HSMR for George Eliot is 122 which is above the expected range and so classed as an outlier. When breaking this down by admission type, it is clear that it is driven by statistically higher than expected non-elective admissions, particularly in General Medicine, which will be further explored on the following page and could be an area for further review. Higher than expected (above the 95th confidence interval) Within expected range Lower than expected (below the 95th confidence interval) 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 specialities with a statistically higher HSMR than expected and with diagnostic groups with greater than four deaths more than expected. When identifying areas to review, it is important to consider the number of deaths above what is expected as well as the HSMR. Treatment Specialties Key Diagnosis (100 ; 1 ) HSMR Observed deaths that are higher than the expected(if any) * Diagnosis where SHMI is high as well as the number of excess death Non-elective (123; 134) General Medicine (128; 136) The sub-tree indicates that the deaths above the expected level within General Medicine are spread over numerous diagnostic groups such as acute cerebrovascular disease, congestive heart failure and pneumonia, among others. Overall 118.2 (122; 132) Acute cerebrovascular disease (129; 13) Senility and organic mental disorders (272; 11) Acute myocardial infarction (192; 11) Septicaemia (131; 8) Diagnostic Groups Biliary tract disease (265; 4) Cancer of bronchus; lung (161; 10) Skin and subcutaneous tissue infections (255; 6) Urinary tract infections (135; 10) Cancer of oesophagus (173; 4) Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12 The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix. Congestive heart failure; nonhypertensive (164; 25) Pneumonia (125; 31) Slide 30 HSMR – Dr Foster The HSMR time series for George Eliot from Dr Foster shows a rise in the HSMR since 2008/09. This measures the observed in-hospital death rate against an expected value based on all the data for that year. An HSMR (or SHMI) of 100 means that there is exactly the same number of deaths as expected. The HSMR is classified as above expected if the lower 95% confidence limit exceeds 100, which was the case in financial years 2009/10, 2010/11 and 2011/12. The latest SHMI published by the HSCIC, for Oct 11 to Sept 12, is lower than the Dr Foster HSMR for the same period, which may be due to a number of factors. Dr Foster have made the following adjustments to show differences explained by these factors: • Adjustment for palliative care: used the SHMI observed deaths but changed expected deaths to take account of palliative care. • Adjustment for in-hospital deaths: • Removed out-of-hospital deaths from the observed figure, and • Reduced expected deaths to only those in-hospital. The remaining variances are largely due to: • The scope of deaths included (SHMI covers all deaths whereas HSMR covers 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, George Eliot 135 130 125 120 115 110 105 100 95 90 118 100 2008/09 2009/10 125 2010/11 I HSMR 130 120 113 2011/12 95% Confidence interval Comparison of mortality measures, George Eliot 120 116 115 110 113 110 108 105 100 95 90 SHMI SHMI adjusted SHMI in for palliative hospital deaths care only HSMR Source: Dr Foster HSMRs, HSCIC SHMI Slide 31 Coding Average Diagnosis Coding Depth Diagnosis coding depth has an impact on the expected number 5 of deaths. A higher average 4.5 diagnosis coding depth is more 4 likely to collect co-morbidity 3.5 which will influence the 3 expected mortality calculation. Elective Non-elective 6 5 4 2.5 3 2 When looking at the depth of 1.5 coding for George Eliot, it is 1 clear that the Trust’s average 0.5 diagnosis coding depth is below 0 the national average and also Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 below the average of the 14 2008/09 2009/10 2010/11 2011/12 2012/13 trusts covered by this review. The elective and non-elective graphs both show that George Eliot was at a similar level to the national average in Q4 2009/10, but since then, as the national average for the diagnosis coding depth has increased, George Eliot has remained relatively constant. 2 1 0 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 2008/09 2009/10 2010/11 2011/12 National Average Diagnosis Coding Depth National Average Diagnosis Coding Depth 14 Trusts' Average Diagnosis Coding Depth 14 Trusts' Average Diagnosis Coding Depth George Eliot George Eliot 2012/13 The Trust conducted a review of coding as part of the report ‘George Eliot Hospital: System, Care and Mortality Review (Jan12), which commented on possible improvements in practice. Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012 Slide 32 Palliative care Percentage of care coding coding Percentage of admissions admissionswith with palliative palliative care Accurate coding of palliative care is important for contextualising SHMI and HSMR. HSMR takes into account that a patient is receiving palliative care, but SHMI does not. 1.4 1.2 1.0 0.8 George Eliot currently make average use of palliative care coding on admissions (by treatment specialty or diagnosis). Around 14% of SHMI deaths had a palliative care code, slightly below the national average. 0.6 0.4 0.2 Oct-11 Jan-12 Apr-12 George Eliot Jul-12 Oct-12 National Jan-13 Apr-13 SHMI publication Percentage of palliativecare carecoding coding Percentage of deaths deaths with with palliative 25 20 15 10 5 Oct-11 Source: Health & Social Care Information Centre – SHMI contextual indicators Jan-12 Apr-12 George Eliot Jul-12 National Oct-12 Jan-13 Apr-13 SHMI publication Slide 33 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, CQC correspond with the Trust to agree any appropriate action. For George Eliot, the common themes that have arisen across the patient groups alerting since 2007 are Elderly Care and Emergency admissions. A common theme arising from responses to the CQC from the Trust is the coding of co-morbidities, which is likely to have an effect on mortality rates. George Eliot commissioned an external review of mortality in 2012 which resulted in a comprehensive action plan that included actions relating to: • Elderly care • Continuity of care • Governance • Morbidity and mortality reviews • Culture • Communication • Coding • Medical records • IT systems • Palliative care • Whole health economy issues Sep 11 to Aug 12 2 Cardiology Dermatology (numbers small) Emergency specialty groups worse than expected Sep 11 to Aug 12 0 Diagnosis group alerts (2007 to date) Alerts to CQC 8 Alerts followed up by CQC 5 Recent diagnosis group alerts pursued by CQC Complications of surgical procedures or medical care (Jul-11) Fluid and electrolyte disorders (Sep-11) Deficiency and other anaemia (Jan-12) Any related patient groups alerting more than once since 2007 Septicaemia Complications of surgical procedures or medical care Source: Care Quality Commission – alerts, correspondence and findings Slide 34 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 six diagnosis groups and one procedure group with above expected SMRs, 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 6 1 CUSUM alerts 9 1 Diagnosis groups with SMRs above expected Acute myocardial infarction Cancer of bronchus, lung Congestive heart failure, nonhypertensive Other perinatal conditions Senility and organic mental disorders Septicaemia (except in labour) Procedure groups with SMRs above expected Other drainage of peritoneal cavity SMR 193 162 176 198 185 156 SMR 220 Obs – Exp deaths 12 12 28 6 7 14 Obs – Exp deaths 7 During the year, George Eliot had two CUSUM alerts for congestive heart failure, non-hypertensive, and one each for acute myocardial infarction, cancer of bronchus/lung, senility and organic mental disorders, and other drainage of peritoneal cavity. It also had four alerts for other diagnostic groups that did not have a high SMR. Source: Dr Foster HSMR, SMRs, CUSUM alerts Slide 35 Mortality – other alerts George Eliot was rated “very high” for mortality among diabetic patients, in a report published by the Yorkshire and Humber Public Health Observatory (YHPHO) and the National Diabetes Information Service. Variable Life Adjusted Display (VLAD) charts are produced by the Health & Social Care Information Centre (HSCIC) to visualise the cumulative number of “statistical lives gained” over a period. A downward trend indicates a run of more deaths than expected compared to the national baseline and one with a sustained downward trend and multiple dips to the lower control limit may warrant further investigation. George Eliot had such a VLAD chart for one diagnosis group in the year to June 2012. Mortality among inpatients with diabetes Rated as “very high” compared to all trusts (2 years to Mar-12). VLAD charts with a negative SHMI trend (year to Jun-12) Pneumonia No. dips to the lower control limit 2 Dr Foster’s 2012 HSMR found George Eliot above expected mortality for weekday admissions but not for weekend ones. This is in agreement with findings from HED for the financial year 2012. Source: YHPHO Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR. Healthcare Evaluation Data (Apr 2011 – Mar 2012) Slide 36 Patient Experience Slide 37 Patient Experience Overview: Summary: The following section will provide an insight into the Trust’s patient experience. Of the nine measures reviewed within Patient Experience and Complaints there are two which are rated ‘red’: The inpatient survey and results from the Midlands and East Friends and Family Test. Review Areas: To undertake a detailed analysis of the Trust’s Patient Experience it is necessary to review the following areas: • Patient Experience, and • Complaints. Data Sources: • Patient Experience Survey; • Cancer Patient Experience Survey; • Peoples Voice Summary; and • Complaints data. All use and display of sourcing is consistent across the packs for the 14 trusts included in this review. Particular areas of concern on the inpatient survey were issues around communication to patients, hospital discharge processes and some issues around the environment including cleanliness and noise from patients. Of 26 individual comments from patients and public as part of the Patient Voice, 16 were negative. These comments highlight no particular areas for concern. The Trust is B-rated by the Ombudsman for satisfactory remedies and low-risk of non-compliance. Slide 38 Patient Experience Patient Experience This page shows the Patient Experience measures which are considered to be the most pertinent for this review. Further analysis, where relevant, is detailed in the following pages. Inpatient PEAT : environment Cancer survey PEAT : food PEAT : privacy and dignity Friends and family test Complaints about clinical aspects Patient voice comments Ombudsman’s rating Outside expected range Within expected range Slide 39 Inpatient Experience Survey Clean, Comfortable, Friendly Place to Be Building Closer Relationships Better Information, More Choice Safe, High Quality, Coordinated Care Access and Waiting George Eliot scores below average on a range of survey questions including coherent discharge processes with information about side effects and other risks, getting clear answers from doctors, patient noise levels, cleanliness of wards, the degree of privacy provided during treatment, and the overall staff effort to control patient pain. Overall Length of time spent on waiting list Alteration of admission date by hospital Length of time to be allocated a bed on a ward Overall Delay of patient discharge Consistency of staff communication Information provided on post-discharge danger signals Overall Staff communication on purpose of medication provided Patient involvement in decision-making Staff communication on medication side-effects Overall Clarity of doctors’ responses to important questions Language used by doctors in front of patients Clarity of nurses’ responses to important questions Language used by nurses in front of patients Overall Hospital food Patient noise levels at night Degree of privacy provided Staff noise levels at night Level of respect shown by staff Hospital/ward cleanliness Overall staff effort to ease pain Above expected range Source: Patient Experience Survey 2012/13 Within expected range Below expected range Slide 40 Patient experience and patient voice Overall patient experience score: Inpatients 2012 Inpatient Survey The national inpatient survey 2012 measures a wide range of aspects of patient experience. A composite ‘overall measure’ is calculated for use in the Outcomes Framework. This measure uses a pre-defined selection of 20 survey questions to rate the Trust on aspects including access to services, coordination of care, information & choice, relationship with staff and the quality of the clinical environment. 95 George Eliot 90 85 80 75 70 65 • England Average: 76.5 • George Eliot: 72.7 (2 standard deviations below the average) 60 55 50 England average Cancer Survey • • George Eliot has consistently been at the lower end of scores for the Midlands & East Friends and Family Test. In February, the score of 61 placed them in the bottom quartile. Complaints Handling • Data returns to the Health and Social Care Information Centre showed 271 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 George Eliot, 55% of complaints related to clinical treatment, which is in line with the national average of 47%. • A separate report by the Ombudsman rates the Trust as B-rated for satisfactory remedies and low-risk of noncompliance. The Trust is identified as above average for ‘poor explanation’ complaint handling. Patient Voice • The quality risk profiles compiled by the Care Quality Commission collate comments from individuals and various sources. In the two years to 31st January 2013, there were 26 comments on George Eliot of which 16 were negative (62%). The main themes were staff attitude and being treated with respect, although positive comments reflected the opposite view. National results curve Source :Patient Experience Survey, Cancer patient experience survey Of 58 Questions, 30 were in the ‘top 20%’ with only one in the ‘bottom 20%’ Friends and Family Test Trusts in this review Slide 41 Safety and workforce Slide 42 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. George Eliot is ‘red rated’ in five of the safety indicators: reporting of patient safety incidents, “harm” for all four safety thermometer indicators, pressure ulcers, C difficile 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 may be recognising and reporting patient safety incidents less fully and completely than similar trusts. It recorded 263 incidents reported as either moderate, sever or death between April 2011 and March 2012. It is 37th highest out of 141 for percentage of patients harmed for the four Safety Thermometer indicators when compared with other nonspecialist trusts. Similarly, between 2010 and 2012 George Eliot was ranked 9th highest out of 143 trusts for C difficile infection rates. In recent months, George Eliot’s new pressure ulcer prevalence rate has sharply risen above the national rate and it is apparent that the prevalence rate of total pressure ulcers for George Eliot is above that of the selected 14 trusts. The Trust’s Clinical Negligence payments have exceeded contributions to the ‘risk sharing scheme’ over the last three years, although this is primarily because of a high level of payouts in 2011/12. George Eliot is ‘red rated’ in 12 of the workforce indicators. It notably has a sickness absence rate above the national mean and employs more agency staff than the regional median. It also has low levels of staff engagement and has a low score for the training of its doctors. However, staff joining rates are higher than the West Midlands SHA average. Slide 43 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 ’12 263 Number of ‘never events’ (2009-2012) 4 Medication error x Pressure ulcers MRSA “Harm” for all four Safety Thermometer Indicators C diff Clinical negligence scheme payments Rule 43 coroner reports Outcome 1 (R17) Respecting and involving people who use services Outside expected range Within expected range Slide 44 Safety Analysis The Trust has reported fewer patient safety incidents than similar trusts. Organisations that report fewer incidents may have a weaker and less effective safety culture. George Eliot has a rate of 4.3 for its patient safety incident reporting per 100 admissions. The Trust is higher than the national average (8.9%) for performance on “harm” for all four NHS Safety Thermometer measures (pressure ulcers, falls, UTI and VTE – Venous thromboembolisms) with 10.1% - the 37th highest rate (out of 141 non-specialist trusts), although it must be noted that due to potential differences in case mix and data collection practices at different organisations, definitive conclusions about differences in the burden of harm between organisations cannot be made. Rate of reported patient safety incidents per 100 admissions (April – September 2012) George Eliot Median rate for small acutes 4.3 6.5 Source: incidents occurring between 1 April 2012 to 30 September 2012 and reported to the National Reporting and Learning System 20 % Percentage of patients harmed for the Percentage of patients harmed four safety thermometer indicators Safety Thermometer April to December 2012 George Eliot 0% Trusts covered by review All other non specialist trusts Source: Safety Thermometer April-December 2012 Slide 45 Safety Incident Breakdown Since 2009, four ‘never events’ have occurred at George Eliot, classified as that because they are incidents that are so serious they should never happen. The patient safety incidents reported are broken down into five levels of harm below, ranging from ‘no harm’ to ‘death’. 70% of incidents which have been reported at George Eliot have been classed as ‘no harm’, with 15% ‘low’, 10% ‘moderate’, 5% ‘severe’ and just one occurrence classified as ‘death’. When broken down by category, the most regular occurrences of patient incident at George Eliot are in ‘patient accident’ and ‘implementation of care and ongoing monitoring/review’. 1400 1246 1200 Breakdown of patient incidents by degree of harm Never Events Breakdown (2009-2012) Wrong implant/prosthesis 2 Wrong site surgery 1 Retained foreign object post-operation 1 Total 4 Source: Freedom of information request, BBC http://www.bbc.co.uk/news/health-22466496 Breakdown of patient incidents by incident type 1 Medical device / equipment 1000 800 Infrastructure 14 Consent, communication, confidentiality 20 85 Documentation 98 Clinical assessment 600 104 Access, admission, transfer, discharge 400 265 182 200 Medication 136 Treatment, procedure 142 Implementation of care and ongoing monitoring / review 80 1 283 311 All others categories 0 No Harm Low Moderate Severe Death 580 Patient accident 0 Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12 200 400 600 800 Source: National Patient Safety Agency (NPSA) . Apr 11 – Mar 12 Slide 46 Safety Analysis C difficile 2010 – 2012 rates per bed day 6.0 3 year z score As shown in the graph on the right, between 2010 and 2012 George Eliot had the 9th highest rate of infection out of 143 trusts for C difficile, meaning its level of performance is among the lowest nationally. Data does show that the Trust has improved since last year. However, it should be noted that the national rate has also improved therefore the Trust’s rates have remained high relative to the mean. 5.0 4.0 George Eliot 3.0 2.0 1.0 0.0 Source: HPA/PHE published data and KH03 data return. Slide 47 Pressure ulcers New pressure ulcers prevalence This slide outlines the total number of pressure ulcers and the number of new pressure ulcers broken down by category for the last 12 months. Due to the effects of seasonality on hospital acquired pressure ulcer rates, the national rate has been included which allows a comparison that takes this in to account. This provides a comparison against the national rate as well as the 14 trusts selected for the review. 12 Total pressure ulcers prevalence 40 In recent months, George Elliot’s new pressure ulcer prevalence rate has sharply risen sharply to 3.6% compared to the national rate of 1.3%. 3.5% 3.1% 10 6 2.1% 1.8% 2.1% 35 9.3% 12.0% 9.0% 2.5% 25 1.7% 1.4% 1.1% 1.0% 0.7% 4 2 10.4% 11.6% 3.0% 30 2.6% 8 14.0% 3.6% 4.0% 2.0% 1.5% 1.0% 0.3% 20 6.3% 7.1%6.7% 15 0.5% 10 - 6.4% 5 0.0% 10.0% 8.1% 7.2% 8.0% 6.0% 6.0% 4.0% 1.3% 2.0% - Category 2 Category 3 Category 4 Rate 0.0% Category 2 Category 3 Category 4 Rate New pressure ulcer analysis Number of records submitted Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 320 329 289 294 286 268 268 283 298 300 292 308 Trust new pressure ulcers 1 6 6 From the data, it is apparent that Trust new pressure ulcer rate 0.3% 1.8% 2.1% the prevalence rate of total Selected 14 trusts’ new pressure pressure ulcers for George Eliot is ulcer rate 1.4% 1.5% 1.4% also above the national average National new pressure ulcer rate 1.7% 1.7% 1.5% and above the average of the Total pressure ulcer prevalence percentage selected 14 trusts in this review. Apr-12 May-12 Jun-12 The data shows that the total Number of records submitted pressure ulcer rate has been 320 329 289 consistently over the national Trust total pressure ulcers 4 21 27 average since June 12. Trust total pressure ulcer rate 1.3% 6.4% 9.3% 9 6 7 3 4 3 2 5 11 3.1% 2.1% 2.6% 1.1% 1.4% 1.0% 0.7% 1.7% 3.6% 1.5% 1.5% 0.9% 1.0% 1.1% 0.9% 1.1% 1.0% 1.2% 1.5% 1.4% 1.3% 1.2% 1.2% 1.2% 1.3% 1.3% 1.3% Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13 294 286 268 268 283 298 300 292 308 34 18 24 19 19 31 18 21 25 11.6% 6.3% 9.0% 7.1% 6.7% 10.4% 6.0% 7.2% 8.1% 6.2% Selected 14 trusts’ total pressure ulcer rate 6.4% 6.2% 6.5% 7.0% 6.3% 5.5% 5.4% 5.9% 5.8% 6.0% 5.7% 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% Source: Safety Thermometer Apr 12 to Mar 13 5.3% Slide 48 Litigation and Coroner Clinical negligence payments 2009/10 Clinical negligence scheme analysis George Eliot’s Clinical Negligence payments have exceeded contributions to the ‘risk sharing scheme’ over the last three years, but this is primarily because of a high level of payouts in 2011/12. 2010/11 2011/12 Payouts (£000s) 3,702 971 7,414 Contributions (£000s) 2,103 2,436 2,647 Variance between payouts and contributions (£000s) -1,599 1,465 -4,767 Source :Litigation Authority Reports Slide 49 Workforce Staff Surveys and Deanery Workforce Indicators This page shows the Workforce measures which are considered to be the most pertinent for this review. Further analysis, where relevant, is detailed in the following pages. WTE nurses per bed day Sickness absence- Overall Medical Staff to Consultant Ratio 2.73 Spells per WTE staff Sickness absence- Medical Nurse Staff to Qualified Staff Ratio 2.33 Vacancies –medical Sickness absence -Nursing staff Staff to Total Staff Ratio Outcome 1 (R17) Respecting and involving eNon-clinical who u Vacancies - Non-medical Sickness absence - Other staff Consultant Productivity (Spells/FTE) 1,057 Staff leaving rates Nurse Hours per Patient Bed Day 7.08 Consultant appraisal rates Agency spend Response Rate from National Staff Survey 2012 Staff Engagement from NSS 2012 Training Doctors – “undermining” indicator se services 0.38 Staff joining rates Overall Rate of Patient Safety Concerns x Care of patients / service users is my organisation’s top priority I would recommend my organisation as a place to work If a friend or relative needed treatment: I would be happy with the standard of care provided by this organisation GMC monitoring under “response to concerns process” Outside expected range Within expected range Slide 50 General Medical Council (GMC) National Training Scheme Survey 2012 Cardiology The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results Given the volume of data only specialities 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 Emergency Medicine Feedback Overall satisfaction Induction Clinical supervision Undermining Workload Access to educational resource Handover Local teaching Adequate experience Study leave Educational supervision Regional teaching Feedback Green outlier Within expected range Red outlier Slide 51 General Medical Council (GMC) National Training Scheme Survey 2012 Obstetrics and Gynaecology General (internal) Medicine The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results Given the volume of data only specialities 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 52 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 specialities 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 In addition to the green outliers displayed, General Surgery has three green outliers: workload, access to educational resources and regional teaching. Green outlier Within expected range Red outlier Slide 53 Workforce Analysis The Trust has a patient spells per whole time equivalent rate of 25, which is an average capacity in relation to the other trusts in this review and nationally. The consultant appraisal rate of George Eliot is 95.6% and is the second highest of the trusts under review. George Eliot’s staff leaving rate is 7.7% which is higher than the median average of 6.1%. However, the joining rate of 8.2 % is also higher than the national average. Number of FTEs (Dec 11-Nov 12 average) Agency Staff (2011/12) George Eliot Expenditure Percentage of Total Staff Costs Median within Region £5.4m 6.9% 3.9% (Sep 11 – Sep 12) Staff Turnover George Eliot West Midlands SHA Median Joining Rate 8.2% 7.4% Leaving Rate 7.7% 6.1% WTE nurses per bed day December 2012 George Eliot National Average 1.51 1.96 Source: Health and Social Care Information Centre (HSCIC) Spells per WTE for Acute Trusts 50 1,736 100% George Consultant appraisal rate 2011/12 Eliot: 95.6% 45 80% Spells per WTE 40 35 George Eliot 25 60% 30 25 40% 20 15 20% 10 5 0% 0 Trusts covered by review All Trusts Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics Trusts covered by review All other trusts Source: 2011/12 Organisational Readiness Self-Assessment (ORSA) Data based on the appraisal year from April 2011 to March 2012 George Eliot Slide 54 Workforce Analysis continued… George Eliot’s total sickness absence rate is higher than the West Midlands Strategic Health Authority average and the national average. This pattern of exceeding the national average is replicated in the more granular medical, nursing, and other staff categories. George Eliot has a medical staff to consultant ratio that is above the national average, although its nurse staff to qualified staff ratio is below the average for all English trusts. The Trust’s registered nurse hours to patient day ratio is also significantly below the national mean. The Trust’s consultant productivity rate is over double the national average. Sickness Absence Rates All Staff (2011-2012) George Eliot West Midlands SHA Average National Average 4.39% 4.31% 4.12% Source: Health and Social Care Information Centre (HSCIC) Sickness Absence Rates by Staff Category (Dec 12) George Eliot National Average Medical Staff 1.69% 1.25% Nursing Staff 6.8% 4.8% Other Staff 5.1% 4.7% Source: Acute Trust Quality Dashboard, Methods Insight Staff Ratios George Eliot National Average Medical Staff to Consultant Ratio 2.73 2.59 Nurse Staff to Qualified Staff Ratio 2.33 2.50 Non-Clinical Staff to Total Staff Ratio 0.38 0.34 Registered Nurse Hours to Patient Day Ratio * 7.08 8.57 Source: Electronic Staff Record (ESR), Apr 13 *Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13 Staff Productivity Consultant Productivity (FTE/Bed Days) Workforce indicator calculations are listed in the Appendix. Source: Electronic Staff Record (ESR), Apr 13 George Eliot National Average 1,057 492 Slide 55 Workforce Analysis continued… National Staff Survey results George Eliot's response rate to the staff survey is above average and rose further in 2012. The staff engagement score is below average when compared with trusts of a similar type, although it also improved in 2012. George Eliot 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 the other staff recommendation findings, but all of these measures improved in 2012 compared with 2011. George Eliot 2011 Average for all trusts 2011 George Eliot 2012 Average for all trusts 2012 Response rate 55% 50% 58% 50% Overall staff engagement 3.45 3.62 3.65 3.69 Care of patients/service users is my organisation’s top priority 56% 69% 61% 63% I would recommend my organisation a place to work 46% 52% 54% 55% If a friend or relative needed treatment, I would be happy with the standard of care provided by this organisation 49% 62% 55% 60% Source: National Staff Survey 2011, 2012 Slide 56 Deanery The Trust has been subject to enhanced monitoring since 2010, as a result of poor supervision provision for doctors in training in paediatrics. They were removed from one site at the trust after a follow up visit identified that initial progress made to address the issues did not support a long term improvement. The Deanery has no plans to reintroduce the doctors in training. Double the national average number of patient safety concerns were raised by doctors in training in 2012 through the national training survey, which were shared with the Deanery. National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12 Obstetrics and Gynaecology, Anaesthetics and Paediatrics were the only programmes to record below outliers between 2010 and 2012. F1s in Surgery and F2s in Medicine reported the most above outliers in the same period. Perceptions of training improved in 2012, with fewer below outliers and a greater number of above outliers reported, compared to 2011. NTS 2012 Patient Safety Comments 7 doctors in training commented, representing 10.0% of respondents. This was double 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: • Large numbers of medical patients on other wards resulting in a lack of continuity of care; • A lack of cover in rotas; and • A lack of patient review by specialists. Source: GMC evidence to Review 2013 Slide 57 Deanery Reports NHS West Midlands Workforce Deanery reported concerns about the George Eliot Hospital NHS Trust in the 2012 Deanery Report about adequate experience and overall satisfaction in Anaesthetics. Concerns about senior support and handover were also reported in General Surgery. Doctors in training in Paediatrics at the George Eliot Hospital, Nuneaton were withdrawn due to a patient safety issue attributed to multiple locums being employed at middle grade. Monitored under the response to concerns process? Undermining George Eliot Hospital NHS Trust has been monitored through the ‘response to concerns’ process since October 2010, when the Deanery highlighted clinical supervision issues for Paediatrics doctors in training. For doctors which are undertaking their training at George Eliot, the Trust has a score of 92 which is below the national average of 94. Deanery Action • A visit in May 2011 noted that there were still concerns about training and safety. • Immediate action plans improved clinical supervision but a further Deanery visit in October 2011 indicated slippage and trainees in paediatrics were removed. • The Deanery has no immediate plans to re-instate trainees in Paediatrics, and considers the issue to be closed. 105 Mean Score on 'Undermining' 100 George Eliot 95 90 GMC Action 85 GMC visited site as part of QA of University of Warwick in November 2011, and did not identify any new issues. 80 Trusts covered by review George Eliot Source: GMC evidence to Review 2013 All other non specialist trusts Source: National Training Survey 2012 Slide 58 Clinical and operational effectiveness Slide 59 Clinical and Operational Effectiveness Overview: The following section will provide an insight in to the Trust’s clinical and operational performance based on nationally recognised key performance indicators. Review Areas: To undertake a detailed analysis of the Trust’s clinical and operational performance it is necessary to review the following areas: • Clinical Effectiveness; • Operational Effectiveness; and • Patient Reported Outcome Measures (PROMs) for the review areas. Data Sources: • Clinical Audit Data Trust, CQC Data Submission; • Healthcare Evaluation Data (HED), Jan – Dec 2012; • Department of Health; • Cancer Waits Database, Q3, 2012-13; and • PROMs Dashboard. All use and display of sourcing is consistent across the packs for the 14 trusts included in this review. Summary: George Eliot is at the lower end of the distribution for the proportion of women receiving ante-natal steroids. and some way short of the 85% national standard. The Trust sees 96.2% of A&E patients within 4 hours which is above the 95% target level. The percentage of patients seen within 4 hours was relatively consistent during 2012. 95.8% of the patients start treatment within the 18 week target time which is just above the target level. The percentage achieved is the highest amongst the trusts being reviewed. George Eliot’s crude readmission rate is one of the higher readmission rates of the trusts in the review as well as nationally, at 13.1% although the average length of stay is shorter than that of the national average. Finally, George Eliot was similar or above the expected level of performance on six out of seven of the latest cancer waiting time measures (Q3 2012-13). It was however underperforming on the proportion of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer. The PROMs dashboard shows that George Eliot was a relatively poor performer in 2009/10 but has improved over the last two years. In 2011/12 only one of the six measures was an outlier the Hip Replacement OHS measure. Slide 60 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 61 Clinical Effectiveness: National Clinical Audits The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the clinical audit results 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 Prop’n operations within 36 hrs Mean adjusted post-operative score Proportion surviving to hospital discharge Standardised revision ratio Proportion small cell patients receiving chemotherapy Slide 62 Clinical effectiveness: Clinical Audits In the Neonatal intensive and special care National Audit, a key measure of effectiveness is the proportion of women receiving ante-natal steroids. National Neonatal Audit Programme – Annual Report 2011- Proportion of women receiving antenatal steroids (level 1) On this measure, George Eliot is at the lower end of the distribution, and some way short of the 85% national standard. George Eliot North Cumbria Source: Clinical Audit Data Trust, CQC Data Submission Slide 63 Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times 5 4.5 Dec-12 Nov-12 Oct-12 Sep-12 Aug-12 Jul-12 Jun-12 4 May-12 75% 5.5 Apr-12 80% 100% 98% 96% 94% 92% 90% Mar-12 85% 6 Feb-12 90% George Eliot 4 Hour A&E Waits Jan-12 George Eliot sees 96.2% of A&E patients within 4 hours which is above the 95% target level. The percentage of patients seen within 4 hours was relatively consistent during 2012. A&E Percentage of Patients Seen within 4 Hours George Eliot 96.2% Attendances (Thousands) A&E wait times and RTT times may indicate the effectiveness with 105% which demand is 100% managed. 95% 70% Number of patients seen within 4 hours Trusts Covered by Review All Trusts Patients Not Seen A&E Target 95% Seen within 4 hours (%) Source: Healthcare Evaluation Data (HED). Jan – Dec 12 95.77% of the patients start treatment within Referral to Treatment (Admitted) the 18 week target time George 105% which is above the Eliot target level. The 100% 95.77% percentage achieved is the highest amongst the 95% trusts being reviewed. 90% The time series shows that George Eliot has 85% performed above the target rate for the time 80% period April 2012 75% through February 2013. Trusts Covered by Review All Trusts RTT Target 90% Source: Department of Health. Feb 13 Source: Healthcare Evaluation Data (HED). Jan – Dec 12 George Eliot Referral to Treatment Performance 100% 98% 96% 94% 92% 90% 88% 86% Referral to Treatment Rate Source: Department of Health. Apr 12 – Feb 13 RTT Target 90% Slide 64 Operational Effectiveness – Emergency Readmissions and Length of Stay The standardised readmission rate most importantly accounts for the Trust’s case mix and shows George Eliot is statistically higher than expected; having the highest standardised readmission rate of the 14 selected trusts. George Eliot’s average length of stay is 4.7 days, which is shorter than the national mean average of 5.2 days. Standardised 30-day Readmission Rate 25% Crude Readmission Rate George Eliot’s crude readmission rate is one of the higher readmission rates of the trusts in the review as well as nationally, at 13.1%. Crude Readmission Rate by Trust 20% 15% George Eliot 13.10% 10% 5% 0% Trusts Covered by Review All Trusts George Eliot Selected trusts Outside Selected trusts w/in Range Average Length of Stay by Trust 10 Spell Duration (Days) The readmission rate may indicate the appropriateness of treatment offered, whilst average length of stay may indicate the efficiency of treatment. 8 6 George Eliot 4.7 4 2 0 Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12 Trusts Covered by Review All Trusts Slide 65 Operational Effectiveness – Cancer waits George Eliot was similar or better than expected on six out of seven of the latest cancer waiting time measures (Q3 2012-13). Proportion of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer However, it was worse that expected on the proportion of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer. In Q3 2012-13 this was 75.6% compared with an operational standard of 85%. Source: Department of Health, Cancer Waits Database, Q3 2012-13 Cancer Waiting Time Metrics Effectiveness Measure The proportion of patients first seen by a specialist within two weeks when urgently referred by their GP or dentist with suspected cancer Similar to expected The proportion of patients receiving subsequent drug treatment within one month (31 days) of a decision to treat Much better than expected The proportion of patients receiving subsequent surgery treatment within one month (31 days) of a decision to treat Much better than expected The proportion of patients receiving their first definitive treatment for cancer within two months (62 days) of GP or dentist urgent referral for suspected cancer Worse than expected The proportion of patients receiving their first definitive treatment for cancer within two months (62 days) of urgent referral from a consultant (consultant upgrade) for suspected cancer Much better than expected The proportion of patients receiving their first definitive treatment for cancer within two months (62 days) of urgent referral from the national screening service Similar to expected The proportion of patients receiving their first definitive treatment within one month (31 days) of a decision to treat (as a proxy for diagnosis) for cancer Much better than expected Source: Department of Health, Cancer Waits Database, Q3 2012-13, from Quality & Risk profile Slide 66 PROMs Dashboard 20 England Average 15 George Eliot 10 Upper Control Limit 5 Lower Control Limit 20 11 /1 20 09 /1 2 0 0 In 2011/12 only one of the six measures was an outlier the Hip Replacement OHS measure was below the 95.0% control limit, and very close to the 99.8% control limit. 25 1 The Trust had three instances when it was classified as a negative outlier below the lower 99.8% control limit. It had a further three occasions when one of the measures returned a score between two standard deviations (95%) and 3 standard deviations (99.8%) below the average score for England. Hip Replacement OHS 20 10 /1 The PROMs dashboard shows that George Eliot was a relatively poor performer in 2009/10 but has improved over the last two years. Source: PROMs Dashboard Slide 67 Leadership and governance Slide 68 Leadership and governance Overview: Summary: This section will provide an indication of the Trust’s governance procedures. All Board positions are substantively filled; the Trust Board has been relatively stable over the past two years. There has been a recent review of the Director portfolios, which resulted in the expansion of director portfolios. 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. The Trust Board has five subcommittees, including the Quality Assurance Committee, which is chaired by a Non Executive Director and provided assurance to the Board on quality. The Mortality Group is a subgroup of the Quality Assurance Committee. The Trust is compliant with all CQC standards. The Trust does not have foundation trust status. The Trust has breached the 62 day cancer target for the Q2 and Q3 2012/13, but met this target in Q1 and Q4 of the same year . The Trust has had a number of external reviews, including the including the Mott Macdonald “System, Care and Mortality review” and a Nursing Mortality Review in 2011 and 2012. The Trust has implemented a number of actions in response to these reviews. Key risks identified by the Trust relate to staffing levels, in particular in maternity and in the neonatal and paediatric services. There have been 87 serious incidents in the Trust in 2012/13 including 20 related to falls and 32 relating to pressure ulcers. There was one never event in July 2012. All use and display of sourcing is consistent across the packs for the 14 trusts included in this review. Slide 69 Leadership and governance Leadership and governance This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in the following pages. Monitor governance risk rating n/a Monitor finance rating n/a Governance risk rating Red - Likely or actual significant breach of terms of authorisation Amber-red - Material concerns surrounding terms of authorisation Amber-green - Limited concerns surrounding terms of authorisation Green - No material concerns CQC Outcomes CQC Concerns Red – Major concern Amber – Minor or Moderate concern Green – No concerns Financial risk rating rated 1-5, where 1 represents the highest risk and 5 the lowest Slide 70 Leadership and governance Trust Board All of the Board members hold substantive posts. Over the last 18 months there have been changes to all Director portfolios. The Director of Governance & Quality is the lead for Governance Quality, whilst the Director of Nursing & Quality is the lead for clinical quality. Governance and clinical structures The implementation of a revised organisational structure commenced in October 2010, with the introduction of 3 clinical divisions with clear lines of accountability for performance, finance, quality and safety, workforce, mortality and increased clinical leadership. The Trust Board has 5 sub-committees including the Quality Assurance Committee. The role and remit of the committee was extended to include a wider governance remit such as Information Governance, Patient Safety/ Experience, Safeguarding, Healthcare Risk Group, and the Care Group with a clear reporting matrix. The mortality group is a sub-group of the Quality Assurance Committee. Quality priorities • Reductions in HSMR; • High quality care for the elderly; • Ensuring personalised and responsive services are in place for all our patients and staff; • Improving patient experience; and • Making every contact count. External reviews and regulation The Trust has carried out a self assessment against CQC’s 16 Core standards and declared compliance against CQC 16 core standards in 2011/12 and 2012/13. No enforcement actions or notices have been issued by the CQC in the past two years. The Trust has had a number of external reviews including the Mott Macdonald “System, Care and Mortality review” and a Nursing Mortality Review. More detail is provided on subsequent slides. The Trust’s performance report lists the governance risk rating for February as red due to breach of the 62 day cancer waiting time target for quarter two and three 2012/13. The Trust met this target for quarter four 2012/13. Slide 71 Top risks to quality The table includes the top risks to quality identified by the Trust on their corporate risk register, and other potential risks to quality identified through review of Trust Board papers. Trust identified risks Trust response Risk of potential harm to patients as a result of an inability to provide safe neonatal and paediatric service following removal of trainee doctors by Deanery. Arden cluster public consultation ruled in favour of sustained high risk and low risk maternity care continuing to be delivered at George Eliot Hospital, with 16 hour paediatric service at George Eliot Hospital. Overnight paediatric to be delivered at UHCW. Progressing towards change of service. Appointments process continuing with the need to update deanery once all positions filled successfully recruited to 8 posts (mixture of full and part time), paediatric champion in post and working on elements of care within the new paediatric model. Risk of harm to patients as a result of staffing levels below those recommended by Safer Childbirth for midwives The business plan is to be considered in the appropriate forums and progression towards Safer Childbirth and improved staffing levels will be monitored. Approval from Board with support for 1:32 ratio - Process for appointing staff being followed, with offer going out to existing staff if wishing to increase substantive contract hours. Other potential risks identified through document review There have been 87 serious incidents reported in 12/13: 20 related to falls and 32 related to grade 3 or 4 pressure ulcers. A monthly report setting out serious incidents requiring investigations (SIRIs) is presented to the Board. This includes benchmarking against the Arden group. There is a Serious Incident Group which reviews incidents and assesses key themes and lessons learnt. There was 1 Never Event reported in July 2012. The governance processes considered above include the never event. Slide 72 Leadership and governance External reviews Mott Macdonald Review: This independent external review, commissioned by the Trust in October 2011, published reports entitled “System, Care and Mortality review” and their key findings and recommendations in January 2012 which focussed on three specific areas of concern; evaluation of Patient Safety and the Quality of Clinical Care, review of Information and Coding and an assessment of External Factors and population health. An analysis of HSMR modelling was also provided. Nursing Mortality review: The Arden Cluster commissioned a review of Nursing within the trust following the concern around the Trusts Mortality rates. This was undertaken in February 2012 and initial feedback given at the end of the review from which an interim action plan was drawn up by the Trust. The final report was received in August 2012. Actions required included improvements in sepsis management and multi-disciplinary team working. There was an overlap between these findings and those from the Mott Macdonald review. Further reviews included; West Midlands Quality review service, The Royal College of Surgeons, CNST, NHSLA and PEAT review. Cost Improvement Programme (CIP) At the end of the financial year 2012/13 the planned CIP delivery has been achieved in full, although in different areas than originally planned and with the use of some non recurrent items. The CIP target for 13/14 is £5.24m. A full Quality Impact Assessment (QIA) has been completed for each identified CIP by the work programme lead. The Trust has assessed any potential negative impact upon clinical quality, safety and patient experience and risk scored confidence in delivery. Only schemes scoring amber or green on the QIA and with a medium or high degree of confidence in delivery have been taken forward for 2013/14. Slide 73 Appendix Slide 74 Trust Map Slide 75 Source: University Hospitals Coventry and Warwickshire website 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 Corporate Director Structure Source: George Eliot Hospital NHS Trust – Information Request Slide 78 Clinical Leadership Structure Source: George Eliot Hospital NHS Trust – Information Request Slide 79 Nursing & Quality Structure Source: George Eliot Hospital NHS Trust – Information Request Slide 80 Trust Committee Structure Source: George Eliot Hospital NHS Trust – Information Request Slide 81 Data Sources No. Data Source name 1 3 years CDI extended 2 3 years MRSA 3 Acute Trust Quality Dashboard 4 NQD alerts for 14 5 PbR review data 6 QRP time series 7 Healthcare Evaluation Data GMC Annex - GMC summary of Education Evidence - trusts with high 8 mortality rates 9 1 Buckinghamshire Healthcare Quality Accounts 10 Burton Quality Account 11 CHUFT Annual Report 2012 12 Quality Report 2011-12 13 Annual Report 2011-12_final 14 NLG. Quality Account 2011-12 15 Annual Report 2012 16 Litigation covering email 17 Litigation summary sheet 18 Rule 43 reports by Trust 19 Rule 43 reports MOJ 20 Governance and Finance 21 MOR Board reports 22 Board papers 23 CQC data submissions 24 Evidence Chronology B&T 25 Hospital Sites within Trust 26 NHS LA Factsheet 27 NHSLA comment on five Steering Group Agenda and Papers incl Governance Structure and 28 Timetable 29 List of products 30 Provider Site details from QRP 31 Annual Report 2011-12 32 SHMI Summary 33 Diabetes Mortality Outliers 34 Mortality among inpatient with diabetes 35 supplementary analysis of HES mortality data 36 VLAD summary 37 Mor Dr Foster HSMR 38 Outliers Elective Non elective split 39 Presentation to DH Analysts about Mid-staffs 40 CQC mortality outlier summaries 41 SHMI Materials 42 Dr Foster HSMR 43 AQuA material 44 Mortality Outlier Review 45 Original Analysis Identifying Mortality Outliers 46 Original Analysis of HSMR-2010-12 47 High-level Methodology and Timetable 48 Analytical Distribution of Work_extended table Type Analysis Analysis Analysis Analysis Data Analysis Analysis Area Clinical and Operational Effectiveness Clinical and Operational Effectiveness Clinical and Operational Effectiveness Clinical and Operational Effectiveness Clinical and Operational Effectiveness Clinical and Operational Effectiveness General Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Data Analysis Analysis General General General General General General General General Governance and leadership Governance and leadership Governance and leadership Governance and leadership Governance and leadership Governance and leadership Governance and leadership Governance and leadership Governance and leadership Governance and leadership Governance and leadership Governance and leadership Analysis Data Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Data Analysis Analysis Analysis Analysis Analysis Analysis Data Data Governance and leadership Governance and leadership Governance and leadership Governance and leadership Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality Mortality No. Data Source name 49 Outline Timetable - Mortality Outlier Review 50 CQC review of Mortality data and alerts -Blackpool NHSFT 51 Peoples Voice QRP v4.7 52 Mortality outlier review -PE score 53 CPES Review 54 Pat experience quick wins from dh tool 55 PEAT 2008-2012 for KATE 56 PROMs Dashboard and Data for 14 trusts 57 PROMS for stage 1 review 58 NHS written complaints, mortality outlier review 59 Summary of Monitor SHA Evidence 60 Suggested KLOI CQC 61 Various debate and discussion thread 62 People Voice Summaries 63 Litigation Authority Reports 64 PROMs Dashboard 65 Rule 43 reports 66 Data from NHS Litigation Authority 67 Annual Sickness rates by org 68 Evidence from staff survey 69 Monthly HCSC Workforce Oct 2012 Quarterly tables turnover 70 Monthly HCSC Workforce Oct 2012 Annual time series turnover 71 Mortality outlier review -education and training KLOI 72 Staff in post 73 Staff survey score in Org 74 Agency and turnover 75 GMC ANNEX -GMC summary of education 76 Analysis of most recent Pat safety incident data for 14 77 Safety Thermometer for non spec 78 Acute Trust Quality Dashboard v1.1 79 Initial Findings on NHS written complaints 2011_12 80 Quality accounts First Cut Summary 81 Monitor SHA evidence 82 Care and compassion - analysis and evidence 83 United Linc never events 84 QRP Materials 85 QRP Guidance 86 QRP User Feedback 87 QRP List of 16 Outcome areas 88 Monitor Briefing on FTs 89 Acute Trust Quality Dashboard v1.1 90 Safety Thermometer 91 Agency and Turnover - output 92 Quality Account 2011-12 93 Annual Sickness Absence rates by org 94 Evidence from Staff Survey 95 Monthly HCHS Workforce October 2012 QTT 96 Monthly HCHS Workforce October 2012 ATT Source: Freedom of information request, BBC 97 http://www.bbc.co.uk/news/health-22466496 Type Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Data Analysis Analysis Data Area Mortality Mortality Patient Experience Patient Experience Patient Experience Patient Experience Patient Experience Patient Experience Patient Experience Patient Experience Patient Experience Patient Experience Patient Experience Analysis Analysis Analysis Analysis Analysis Analysis Analysis Data Analysis Analysis Analysis Analysis Analysis Data Analysis Data Data Data Data Analysis Analysis Analysis Analysis Data Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Analysis Patient Experience Patient Experience Patient Experience Patient Experience Patient Experience Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Data Safety and Workforce Slide 82 Data Sources No. Data Source Name Health and Social Care Information Centre (HSCIC) monthly workforce 98 statistics 99 National Staff Survey, 2011, 2012 100 GMC evidence to review, 2013 101 2011/12 Organisational Readiness Self-Assessment (ORSA) 102 National Training Survey, 2012 103 National Patient Safety Agency (NPSA) Apr 11 – Mar 12 Type Area Data Data Analysis Data Data Data Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Safety and Workforce Slide 83 SHMI Appendix Observed deaths above expected level Admission Method Treatment Specialty Diagnostic Group SHMI Nonelective 300 - General medicine 103 - Pulmonary heart disease 110.09 1 Nonelective 300 - General medicine 11 - Cancer of head and neck 203.06 1 Nonelective 300 - General medicine 111 - Other and ill-defined cerebrovascular disease 522.05 2 Nonelective 300 - General medicine 115 - Aortic; peripheral; and visceral artery aneurysms 249.65 1 Nonelective 300 - General medicine 118 - Phlebitis; thrombophlebitis and thromboembolism 227.54 3 Nonelective 300 - General medicine 12 - Cancer of esophagus 144.32 3 Nonelective 300 - General medicine 121 - ther diseases of veins and lymphatics 366.52 1 Nonelective 300 - General medicine 127 - Chronic obstructive pulmonary disease and bronchiectasis 111.62 4 Nonelective 300 - General medicine 132 - Lung disease due to external agents 285.98 1 Nonelective 300 - General medicine 133 - Other lower respiratory disease 111.74 1 Nonelective 300 - General medicine 134 - Other upper respiratory disease 203.83 2 Nonelective 300 - General medicine 140 - Gastritis and duodenitis 228.67 1 Nonelective 300 - General medicine 141 - Other disorders of stomach and duodenum 387.78 1 Nonelective 300 - General medicine 145 - Intestinal obstruction without hernia 159.51 1 Nonelective 300 - General medicine 148 - Peritonitis and intestinal abscess 312.6 1 Nonelective 300 - General medicine 15 - Cancer of rectum and anus 261.52 1 Nonelective 300 - General medicine 150 - Liver disease; alcohol-related 122.23 2 Nonelective 300 - General medicine 151 - Other liver diseases 226.24 4 Nonelective 300 - General medicine 153 - Gastrointestinal hemorrhage 129.82 3 Nonelective 300 - General medicine 161 - Other diseases of kidney and ureters 653.24 1 Nonelective 300 - General medicine 162 - Other diseases of bladder and urethra 8720.71 1 Nonelective 300 - General medicine 18 - Cancer of other GI organs; peritoneum 194.5 2 300 - General medicine 197 - Skin and subcutaneous tissue infections 189.39 4 Nonelective 300 - General medicine 199 - Chronic ulcer of skin 222.13 3 Nonelective 300 - General medicine 20 - Cancer; other respiratory and intrathoracic 224.92 1 Slide 84 SHMI Appendix Admission Method Treatment Specialty Diagnostic Group Nonelective 300 - General medicine 207 - Pathological fracture Nonelective 300 - General medicine Nonelective Observed deaths above expected level SHMI 1190.22 1 229 - Fracture of upper limb 208.98 1 300 - General medicine 231 - Other fractures 277.07 1 Nonelective 300 - General medicine 234 - Crushing injury or internal injury 653.3 1 Nonelective 300 - General medicine 237 - Complication of device; implant or graft 254.47 1 Nonelective 300 - General medicine 254 - Rehabilitation care; fitting of prostheses; and adjustment of devices 505.52 1 Nonelective 300 - General medicine 28 - Cancer of other female genital organs 281.25 1 Nonelective 300 - General medicine 29 - Cancer of prostate 205.83 2 Nonelective 300 - General medicine 32 - Cancer of bladder 184.39 2 Nonelective 300 - General medicine 33 - Cancer of kidney and renal pelvis 233.15 1 Nonelective 300 - General medicine 38 - Non-Hodgkin`s lymphoma 219.9 3 Nonelective 300 - General medicine 40 - Multiple myeloma 138.05 1 Nonelective 300 - General medicine 41 - Cancer; other and unspecified primary 224.28 1 Nonelective 300 - General medicine 42 - Secondary malignancies 127.82 4 Nonelective 300 - General medicine 43 - Malignant neoplasm without specification of site 130.38 1 Nonelective 300 - General medicine 44 - Neoplasms of unspecified nature or uncertain behavior 222.61 2 Nonelective 300 - General medicine 47 - Other and unspecified benign neoplasm 282.66 1 Nonelective 300 - General medicine 51 - Other endocrine disorders 173.06 2 Nonelective 300 - General medicine 58 - Other nutritional; endocrine; and metabolic disorders 140.86 1 Nonelective 300 - General medicine 78 - Other CNS infection and poliomyelitis 489.68 1 Nonelective 300 - General medicine 81 - Other hereditary and degenerative nervous system conditions 238.78 2 Nonelective 300 - General medicine 82 - Paralysis 164.26 1 Nonelective 300 - General medicine 85 - Coma; stupor; and brain damage 298.44 3 Slide 85 HSMR Appendix Observed deaths above expected level Admission Method Treatment Specialty Diagnostic Group HSMR Nonelective General Medicine Aortic; peripheral; and visceral artery aneurysms 406 2 Nonelective General Medicine Cancer of bladder 151 1 Nonelective General Medicine Cancer of breast 122 1 Nonelective General Medicine Cancer of pancreas 113 1 Nonelective General Medicine Cancer of prostate 138 1 Nonelective General Medicine Cancer of rectum and anus 121 1 Nonelective General Medicine Cardiac arrest and ventricular fibrillation 145 1 Nonelective General Medicine Chronic obstructive pulmonary disease and bronchie 108 2 Nonelective General Medicine Chronic renal failure 180 1 Nonelective General Medicine Chronic ulcer of skin 151 1 Nonelective General Medicine Deficiency and other anemia 164 2 Nonelective General Medicine Fracture of neck of femur (hip) 228 1 Nonelective General Medicine Gastrointestinal hemorrhage 122 2 Nonelective General Medicine Intestinal obstruction without hernia 140 1 Nonelective General Medicine Leukemias 187 1 Nonelective General Medicine Liver disease; alcohol-related 106 1 Nonelective General Medicine Malignant neoplasm without specification of site 161 2 Nonelective General Medicine Non-Hodgkin`s lymphoma 213 2 Nonelective General Medicine Noninfectious gastroenteritis 114 1 Nonelective General Medicine Other fractures 128 1 Nonelective General Medicine Other liver diseases 253 3 Nonelective General Medicine Other lower respiratory disease 134 1 Nonelective General Medicine Other upper respiratory disease 227 1 Nonelective General Medicine Peripheral and visceral atherosclerosis 114 1 Slide 86 HSMR Appendix Observed deaths above expected level Admission Method Treatment Specialty Diagnostic Group HSMR Nonelective General Medicine Peritonitis and intestinal abscess 127 1 Nonelective General Medicine Pleurisy; pneumothorax; pulmonary collapse 118 1 Nonelective General Medicine Respiratory failure; insufficiency; arrest (adult) 118 1 Slide 87 Higher than Expected Diagnostic Groups HSMR / SHMI Summary (Elective) Treatment Specialty N/A HSMR SHMI N/A N/A Slide 88 Higher than Expected Diagnostic Groups HSMR / SHMI Summary (Nonelective) Treatment Specialty General Medicine HSMR SHMI X X Slide 89