George Eliot Hospital NHS Trust Data Pack

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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
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