Medway NHS Foundation
Trust
Data Pack
9th July, 2013
Overview
Sources of Information
On 6th February the Prime Minister asked Professor Sir Bruce
Keogh to review the quality of the care and treatment being
provided by those hospital trusts in England that have been
persistent outliers on mortality statistics. The 14 trusts which fall
within the scope of this review were selected on the basis that they
have been outliers for the last two consecutive years on either the
Summary Hospital Mortality Index or the Hospital Standardised
Mortality Ratio.
Document review
Trust information
submission for
review
These two measures are being used as a ‘smoke alarm’ for
identifying potential quality problems which warrant further
review. No judgement about the actual quality of care being
provided to patients is being made at this stage, or should be
reached by looking at these measures in isolation.
The review will follow a three stage process:
Stage 1 – Information gathering and analysis
Stage 2 – Rapid Responsive Review
Benchmarking
analysis
Information shared
by key national
bodies including
the CQC
Stage 3 – Risk summit
This data pack forms one of the sources within the information
gathering and analysis stage.
Information and data held across the NHS and other public bodies
has been gathered and analysed and will be used to develop the Key
Lines of Enquiry (KLOEs) for the individual reviews of each Trust.
This analysis has included examining data relating to clinical
quality and outcomes as well as patient and staff views and
feedback. A full list of evidence sources can be found in the
Appendix.
Given the breadth and depth of information reviewed, this pack is
intended to highlight only the exceptions noted within the evidence
reviewed in order to inform Key Lines of Enquiry.
Slide 2
Medway NHS Foundation Trust
Context
A brief overview of the Medway area and Medway NHS Foundation Trust. This section provides a profile of the area, outlines
performance of local healthcare providers and gives a brief introduction to the Trust.
Mortality
An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the
Trust which are outliers.
Patient Experience
A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient
experience surveys.
Safety and Workforce
A summary of the Trust’s safety record and workforce profile.
Clinical and Operational Effectiveness
A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This
section compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures
(PROMs).
Leadership and Governance
An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership,
current top risks to quality and outcomes from external reviews.
Slide 3
Context
Slide 4
Context
Overview:
Summary:
This section provides an introduction to the Trust, providing an
overview, health profile and an understanding of why the Trust
has been chosen for this review.
Medway has a population of 400,000 with 10% of it belonging
to non-White ethnic minorities. Obesity and smoking in
pregnancy are significantly more common than in the rest of
England.
Review Areas:
To provide an overview of the Trust, we have reviewed the
following areas:
•
Local area and market share;
•
Health profile;
•
Service overview; and
•
Initial mortality analysis.
Data Sources:
•
Trust’s Board of Directors meeting 30th Jan, 2013;
•
Department of Health: Transparency Website, Dec 12;
•
Healthcare Evaluation Data (HED);
•
NHS Choices;
•
Office of National Statistics, 2011 Census data;
•
Index of Multiple Deprivation, 2011;
•
© Google Maps;
•
Public Health Observatories – Area health profiles; and
•
Background to the review and role of the national
advisory group.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
It is, relative to the rest of England, a medium sized trust for
both inpatient and outpatient activity. The Trust has a higher
level of outpatient activity than inpatient activity.
Aspects of Medway’s health profile which relate to adult’s health
and lifestyle are below the national average. These indicators
relate to obesity, smoking and physical activity.
The Trust became a Foundation Trust in 2008, and has one
main hospital which provides a range of specialist services,
including a cardiac catheter suite, vascular centre, centre for
Urology, a stroke unit and the Macmillan Cancer Care Unit.
The Trust has 59% market share of inpatient activity within a 5
mile radius of the Trust. As the radius increases, the market
share falls to 39% within 10 miles and 13% within 20 miles.
To give an informed view it was necessary to review the local
health economy. This included an indication of ambulance
response times and showed that the South East Coast ambulance
services were performing above the national average.
The Trust has been selected for this review as a result of its
HSMR results for 2011 and 2012. In both years, the HSMR is
statistically above the expected level.
Slide 5
Trust Overview
Medway NHS Foundation Trust treats around 400,000 people a
year. Medway NHS Foundation Trust’s main hospital is the Maritime
Hospital which was opened in 1905 as the Royal Naval Hospital, reopening as an NHS hospital in 1965. The Trust offers a range of
specialist services, including a cardiac catheter suite, West Kent
Vascular centre, West Kent centre for Urology, a stroke unit and the
Macmillan Cancer Care Unit.
Medway NHS Foundation Trust
Acute Hospital
Medway Maritime Hospital
Trust Status
Foundation Trust (2008)
Number of Beds and Bed Occupancy
Beds
Available
Percentage
Occupied
National
Average
Total
541
91%
86%
General & Acute
477
95%
87%
Maternity
60
61%
59%
Source: Department of Health: Transparency Website
Source: NHS Choices
(Jan12-Dec12)
Inpatient/Outpatient Activity
Finance Information
Inpatient Activity
Elective
34,384 (43%)
£237m
Non Elective
44,910 (57%)
2012-13 Expenditure
£226m
Total
79,294
2012-13 EBITDA
£11m
Total
309,640
2012-13 Net surplus (deficit)
(£2m)
2013-14 Budgeted Income
£242m
2013-14 Budgeted Expenditure
£230m
2013-14 Budgeted EBITDA
£12m
2013-14 Budgeted Net surplus
(deficit)
(£1m)
2012-13 Income
Source: Information submitted by Medway NHS Foundation Trust
(Oct 12-Dec 12)
Outpatient Activity
Day Case Rate:
83%
Source: Healthcare Evaluation Data (HED)
Departments and Services
Accident & Emergency, Breast Surgery, Cardiology, Clinical
Haematology, Colorectal Surgery , Dermatology, Diabetic Medicine,
Diagnostic Imaging, Ear, Nose and Throat (ENT), Endocrinology,
Gastroenterology, General Medicine, General Surgery, Geriatric
Medicine, Gynaecology, Interventional Radiology, Medical Oncology,
Midwife Episode, Neonatology, Nephrology, Neurology, Nuclear
Medicine, Obstetrics, Paediatric Surgery, Paediatrics, Pain
Management, Rheumatology, Thoracic Medicine, Trauma &
Orthopaedics, Urology, Vascular Surgery, Well Babies
Source: NHS Choices
Slide 6
A map of Medway NHS Foundation Trust is included in the Appendix.
Trust Overview continued...
Paediatrics and
General Surgery are
the largest inpatient
specialties while
Dermatology and
Trauma &
Orthopaedics are the
largest outpatient
specialties.
Outpatient Activity by Trust
300
1200
250
1000
200
150
Medway
79,294
100
50
Number of Outpatient
Spells (Thousands)
Medway is a
medium sized trust
for both measures of
activity, relative to
the rest of England.
The Trust has a
higher level of
outpatient activity
than inpatient
activity.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of
Medway against
national trusts in
terms of inpatient
and outpatient
activity.
800
Medway
309,640
600
400
200
0
0
Trusts
Trusts Covered by Review
Trusts
National Inpatient Activity Curve
Top 10 Inpatient Main Specialties as a
% of Total Inpatient Activity
Trusts Covered by Review
Bottom 10 Inpatient Main Specialties
and Spells
National Outpatient Activity Curve
Top 10 Outpatient Main Specialties as
a % of Total Outpatient Activity
Paediatrics
16%
Nuclear Medicine
146
Dermatology
13%
General Surgery
13%
Neurology
179
Trauma & Orthopaedics
12%
General Medicine
13%
Radiology
194
Ear, Nose and Throat (ENT)
11%
Gynaecology
11%
Obstetrics
346
Gynaecology
11%
Trauma & Orthopaedics
8%
Adult Mental Illness
405
General Medicine
7%
Urology
7%
Paediatric Surgery
497
Paediatrics
7%
Geriatric Medicine
5%
Midwifery
1123
General Surgery
6%
Ear, Nose and Throat (ENT)
5%
Rheumatology
1132
Anaesthetics
6%
Gastroenterology
4%
Medical Oncology
1259
Urology
5%
Clinical Haemotology
4%
Cardiology
1411
Rheumatology
4%
Source: Healthcare Evaluation Data (HED) Jan ‘12 – Dec ‘12
Slide 7
Medway Area Overview
Medway is not a particularly deprived region in England. The region has a
slightly larger proportion of ethnic minorities than England as a whole with
Indians being the most numerous of ethnic minorities. Adult obesity is more
prevalent in Medway than almost anywhere else in England; other
significant health concerns relate to pregnancy. The population of Medway is
generally younger than the English population as a whole.
Medway Area Demographics
0-9
FACT BOX
Population
The Royal College of Surgeons recommend that the
"...catchment population size...for an acute general hospital
providing the full range of facilities, specialist staff and
expertise for both elective and emergency medical and
surgical care would be 450,000 - 500,000."
IMD
Medway Unitary Authority has IMD rank
of 136 out of 326 local authorities
(including unitary authorities).
Ethnic diversity
10.4% of the population belong to nonWhite ethnic minorities (as opposed to
9.1% in England as a whole). The most
numerous of ethnic minorities are
Indians (2.7%) and Black African
(1.8%).
Rural or Urban
Medway is a rural-urban region
Adult obesity
Adult obesity is more common in
Medway than almost anywhere else in
England. Similarly, healthy eating is
much less common that in most of
England.
Pregnancy
Smoking in pregnancy is significantly
more common in Medway than in most
of England. Similarly, teenage
pregnancy is more common here than in
most of England.
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80+
20%
15%
10%
5%
0%
5%
10%
Male/MED
Male/ENG
Female/MED
Female/ENG
15%
Source: Office of National Statistics, Census 2011; IMD Source: Index of Multiple Deprivation, 2010
20%
400,000
Slide 8
Medway Geographic Overview
The map on the right shows the location of Medway geographically.
Medway is a rural-urban area within Kent sitting on the shoreline of the
River Medway. As shown on the map, Medway is located near the M2 and
surrounded by a number of main roads.
Market share analysis indicates from which GP practices the referrals that
are being provided for by the Trust originate. High mortality may affect
public confidence in a Trust, resulting in a reduced market share as patients
may be referred to alternative providers.
Source: © Google Maps
The wheel on the left shows the market share of Medway. The
wheel shows the Trust has a 59% market share within a 5 mile
radius of the Trust. However, it is clear that the market share
falls as the radius is increased. Within 10 miles, the market
share is 39% whereas within a 20 mile radius, the market
share is only 13%.
The wheel shows the competitors in the local area, these were
identified as Maidstone and Tunbridge Wells NHS Trust, Care
UK, Guy’s and St Thomas’ NHS Foundation Trust, East Kent
Hospitals University NHS Foundation Trust and Dartford and
Gravesham NHS Trust.
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Slide 9
Medway’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
Medway
The graph shows the level of economic deprivation experienced in
Medway. This area has slightly lower level of deprivation than
England as a whole. The tables below show Medway’s health profile
in comparison with the rest of England.
1. Medway’s GCSE
results are significantly 1
lower than the national
average. Long term
unemployment is also
at a significantly higher
rate than the national
average.
2
2. All indicators in
children’s and young
people’s health are
significantly below the
national average, apart
from obese children
(year 6) and alcoholspecific hospital stays
9under 18)..
Source: Public Health Observatories-area health profiles
Slide 10
Medway’s Health Profile
3. The number of
healthy eating adults is
significantly below the
national average, with
the number of obese
adults is significantly
above the national
average.
4. Self harm levels
and diabetes diagnoses
are significantly higher
than national average.
3
4
5. Life expectancy is
significantly lower than
the national average .
Smoking related deaths
and early cancer deaths 5
are significantly higher
than national average.
Source: Public Health Observatories-area health profiles
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 non-acute
local providers. For example,
slow ambulance response
times may increase the risk of
mortality.
A review of the data shows
higher than average
performance for both of the
ambulance response
indicators in the South East
Coast area.
Proportion of calls responded to within 8 minutes
100%
80%
60%
40%
20%
0%
Isle of Wight
NHS Trust
South
West
South Central South East
East of
London
North West Great Western North East
Yorkshire East Midlands
Western
Midlands
Ambulance
Coast
England
Ambulance Ambulance Ambulance Ambulance Ambulance Ambulance
Ambulance Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Service NHS Service NHS Service NHS
Service NHS Service NHS Foundation Service NHS Service NHS
Trust
Trust
Trust
Trust
Trust
Trust
Foundation
Trust
Trust
Foundation
Trust
Trust
Trust
Ambulance Trust
England
Proportion of calls responded to within 19 minutes
100%
98%
96%
94%
92%
90%
88%
86%
84%
Source: Department of Health: Transparency Website Dec 2012
Isle of Wight
NHS Trust
West
Midlands
Ambulance
Service NHS
Trust
London
Ambulance
Service NHS
Trust
South East
Coast
Ambulance
Service NHS
Foundation
Trust
Yorkshire South Western Great Western North East
Ambulance
Ambulance
Ambulance
Ambulance
Service NHS Service NHS Service NHS Service NHS
Trust
Foundation
Trust
Trust
Trust
Ambulance Trusts
North West South Central
East of
East Midlands
Ambulance
Ambulance
England
Ambulance
Service NHS Service NHS Ambulance Service NHS
Trust
Foundation Service NHS
Trust
Trust
Trust
England
Slide 12
Why was Medway 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.
Medway has been above the expected level for
HSMR over the last 2 years and was therefore
selected for this review.
Trust
SHMI 2011 SHMI 2012
HSMR
FY 11
HSMR
FY 12
Within
Expected?
Basildon and Thurrock University Hospitals NHS
Foundation Trust
1
1
98
102
Within expected
Blackpool Teaching Hospitals NHS Foundation Trust
1
1
112
114
Above expected
Buckinghamshire Healthcare NHS Trust
112
110
Above expected
Burton Hospitals NHS Foundation Trust
112
112
Above expected
Colchester Hospital University NHS Foundation Trust
1
1
107
102
Within expected
East Lancashire Hospitals NHS Trust
1
1
108
103
Within expected
George Eliot Hospital NHS Trust
117
120
Above expected
Medway NHS Foundation Trust
115
112
Above expected
North Cumbria University Hospitals NHS Trust
118
118
Above expected
Northern Lincolnshire And Goole Hospitals NHS
Foundation Trust
116
118
Above expected
Sherwood Forest Hospitals NHS Foundation Trust
114
113
Above expected
101
102
Within expected
The Dudley Group Of Hospitals NHS Foundation Trust
116
111
Above expected
United Lincolnshire Hospitals NHS Trust
113
111
Above expected
Tameside Hospital NHS Foundation Trust
1
1
Banding 1 – ‘higher than expected’
Source: Background to the review and role of the national advisory group Financial years 2010-11, 2011-12
Slide 13
Why was Medway chosen for this review?
SHMI Funnel Chart
The way that levels of observed
deaths that are higher than
expected deaths can be
understood is by using HSMR and
SHMI. Both compare the number
of observed deaths to the number
of expected deaths. This is
different to avoidable deaths. An
HSMR and SHMI of 100 means
that there is exactly the same
number of deaths as expected.
This is very unlikely so there is a
range within which the variance
between observed and expected
deaths is statistically
insignificant. On the Poisson
distribution, appearing above andHSMR 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
Medway
Selected trusts Outside Range
Selected trusts w/in Range
HSMR Time Series
Medway
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 Medway’s SHMI and
HSMR is statistically above the
expected range. This is supported
by the time series which shows the
SHMI and HSMR as being
consistently higher than expected.
Source: Healthcare Evaluation Data (HED) Apr 10 – Mar 12.
Slide 14
Mortality
Slide 15
Mortality
Overview:
Summary:
This section focuses upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The Trust has an overall SHMI of 109 for the last 12 months,
meaning that the number of actual deaths is higher than the
expected level.
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.
Deeper analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure,
with a SHMI of 110, compared to 106 for elective admissions.
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;
Specialty-level analysis of SHMI results highlight some key
diagnostic groups within General Medicine which could
potentially be reviewed: urinary tract infections, cancer of
bronchus; lung, septicaemia.
The Trust has an overall HSMR of 113, which is statistically
above the expected range.
Similar to SHMI, non-elective admissions are seen to be
contributing primarily to the overall Trust HSMR with 114,
against 72 for elective admissions.
Specialty-level analysis highlights potential areas for further
review in non-elective admissions: septicaemia and pneumonia.
From a specialty-level review of HSMR, it is clear that the
following areas should be considered: septicaemia , acute
cerebrovascular disease, other perinatal conditions, acute
myocardial infarction and intestinal obstruction without hernia.
• Dr Foster – HSMR; and
• Care Quality Commission – alerts, correspondence and findings.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Slide 16
Mortality Overview
Mortality
The following overview provides a summary of the Trust’s key mortality areas:
Overall HSMR
SHMI/HSMR Elective mortality
Overall SHMI*
SHMI/HSMR Non-elective mortality
Weekend or weekday mortality outliers
Palliative care coding issues
Outcome
(R17) Respecting 30-day
and involving
e whofollowing
use services
Emergency specialty groups much worse
than1expected
mortality
specific surgery / admissions
Emergency specialty groups worse than expected
Mortality among patients with diabetes
Diagnosis group alerts to CQC
Diagnosis group alerts followed up by CQC
SHMI*
Outside expected range of the HSCIC for Mar 11 – Sep 12
Outside expected range
Outside expected range based on Poisson distribution for Dec 11 – Nov 12
Within expected range
Within expected range
*The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model,
which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14
trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the
purposes of this review.
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR,
Care Quality Commission – alerts, correspondence and findings
Slide 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 for the 12 months from Dec 11 to Nov 12 is 109,
which means, as shown below, it is statistically above the expected
range and therefore an outlier, based on the 95% confidence interval
of the Poisson distribution.
The time series show SHMI has fallen gradually since 2007/08 and
during the period December, 2011 to November, 2012, although a
recent spike is noticeable.
SHMI Funnel chart – 12 months
Year-on-year time series
Medway
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 11 – Nov 12
Slide 21
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for Medway.
As SHMI includes mortalities
that occur within the hospital
and outside of it for up to 30
days following discharge, it is
imperative to understand the
percentage of deaths which
happen inside the hospital
compared to outside. This
may contribute to differences
in HSMR and SHMI
outcomes.
The data shows that 73.9% of
SHMI deaths occur in
hospital, which is more than
the national mean average of
73.3%.
Percentage of patient deaths in hospital
90%
80%
Medway 73.9%
70%
60%
Trusts Covered by Review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 22
Mortality - SHMI Tree
Lower than expected (below the
95th confidence interval)
Treatment Specialties
Adult Mental Illness
Midwife Episode
Interventional Radiology
Diagnostic Imaging
Learning Disability
Interventional Radiology
Gynaecology
Treatment Specialties
Well babies
Neonatology
Paediatrics
Neurology
Medical oncology
Dermatology
Cardiology
Clinical Haematology
Endocrinology
Gastroenterology
General Medicine(154)
A&E
Paediatric Surgery
ENT
T&O
Vascular Surgery
Colorectal Surgery
Breast Surgery
Urology
General Surgery
Gynaecology
Obstetrics
Geriatric Medicine
Obstetrics
Geriatric Medicine
Neonatology
Paediatrics
Rheumatology
Nuclear Medicine
Medical oncology
Cardiology
Non
Elective
SHMI 110
Clinical Haematology
Endocrinology
Gastroenterology
General Medicine
Pain Management
Paediatric Surgery
ENT
T&O
Vascular Surgery
Colorectal Surgery
Breast Surgery
Urology
The tree shows that
Medway NHS Foundation
Trust has a SHMI of 109
which is higher than
expected. This is due to
higher than expected
deaths in non-elective
admissions. Mortality is
significantly higher than
expected in General
Medicine. This is a potential
area for review.
Within expected range
Elective
SHMI 106
General Surgery
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.
Higher than expected (above
the 95th confidence interval)
Overall
Trust
SHMI 109
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 23
SHMI sub-tree of non-elective specialties
Within expected range
Overall (109; 156)
Non-elective (110; 153)
Lower than expected (below the
95th confidence interval)
Treatment specialties
General Medicine has the
highest number of above
expected deaths with a
number diagnostic groups
having greater than 10:
chronic obstructive
pulmonary disease and
bronchiectasis, urinary
Diagnostic Groups
tract infections, cancer of
bronchus; lung, and
septicaemia. However, the
remaining diagnosis
Key
groups, may also
Diagnosis (100 ; 1 )
potentially want to be
SHMI
observed deaths
reviewed.
that are higher
than expected
Acute myocardial
infarction (154; 9)
Acute cerebrovascular
disease (115; 5)
Cancer of oesophagus
(168; 4)
Chronic obstructive
pulmonary disease and
bronchiectasis (129; 12)
Intestinal infection (190;
8)
General Medicine (117; 232)
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 4 more
observed deaths than
expected. When identifying
areas to review, it is
important to consider the
number of deaths as well as
the SHMI.
Higher than expected (above
the 95th confidence interval)
Cancer of bronchus; lung
(143; 12)
Skin and subcutaneous
tissue infections (216; 5)
Septicaemia (128; 14)
Superficial injury;
contusion (291; 7)
Cancer of prostate (166;
4)
Cancer of kidney and
renal pelvis (249; 5)
Gastrointestinal
haemorrhage (132; 5)
Leukemias (173; 4)
Urinary tract infections
(140; 12)
Senility and organic
mental disorders (185; 8)
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.
The HSCIC produce two sets of upper and lower limits. One set
uses 99.8% control limits from an exact Poisson distribution
based on the number of expected deaths. The other set uses a
Random effects model applying a 10% trim for over-dispersion,
based on the standardised Pearson residual for each provider
excluding the top and bottom 10% of scores. This latter set is
broader than the Poisson and is the one against which the
HSCIC report whether the SHMI is within, below or above the
expected range.
SHMI published by HSCIC, Medway FT
120
115
116
116
113
110
114
113
113
113
105
100
95
90
85
80
Mar-11
Jun-11
Sep-11
Dec-11
Mar-12
Jun-12
Sep-12
Rolling 12 months ending
Lower limit
Upper limit
SHMI
The SHMI for Medway was 113 in the year to Sept-12 (England
baseline = 100). Although Medway was selected on the basis of
its HSMR, its SHMI has been higher than expected in 4 of the 7
periods to date.
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
113, which means that it is above the expected range and therefore an
outlier.
Since 2007/08 the HSMR has fallen from 120 to 112. During the time
between January, 2011 and December, 2012 the HSMR has
fluctuated between 132 and 89 with a most recent increase.
HSMR Funnel chart - 12 months
Year-on-year time series
Medway
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Jan 2011 – Dec 2012
Slide 26
HSMR Statistics
It is useful to breakdown
HSMR by admission type and
whether or not it was a
weekend admission.
Medway’s HSMR of weekend
admissions is 121, yet it is still
within the expected range.
The HSMR of non-elective,
week-day admissions is 111
which is statistically above the
expected range. This figure
drives up the overall Trust
HSMR to a statistically,
‘above the expected range’
value of 113.
Key – colour by
alert level:
HSMR
Weekend
Week
All
Elective
n/a
73
72
Non-elective
122
111
114
Red – Higher than
expected (above the
95% confidence
interval)
All
121
110
113
Blue – Within
expected range
Source: Health Evaluation Data (HED) – Jan 2011 – Dec 2012
Green – Lower than
expected (below the
95th confidence
interval)
Slide 27
HSMR CCS Diagnostic Group Overview
This tree map which has been used to demonstrate the
diagnostic groups with the greatest number of observed
deaths that are higher than the expected deaths and the
highest HSMR for the last 12 months.
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:
•
Septicaemia (145; 26);
•
Acute cerebrovascular disease (128; 18);
•
Other perinatal conditions (163; 10);
•
Acute myocardial infarction (119; 6); and
•
Intestinal obstruction without hernia (179; 6).
Source: Health Evaluation Data (HED) – Jan 2011 – Dec 2012
Slide 28
Mortality - HSMR Tree
Higher than expected (above
the 95th confidence interval)
Lower than expected (below the
95th confidence interval)
Elective
Treatment
Specialties
HSMR 72
Rheumatology
Paediatrics
Neonatology
Gynaecology
Geriatric medicine
Interventional Radiology
Diagnostic Imaging
Medical Oncology
Neurology
Paediatrics
Neonatology
Geriatric Medicine
Obstetrics
Nuclear Medicine
Medical Oncology
Cardiology
Clinical Haematology
HSMR 114
Gastroenterology
Non
Elective
General Medicine (2)
Pain management
Paediatric Surgery
ENT
T&O
Vascular Surgery
Colorectal Surgery
HSMR
113
Breast Surgery
Overall
Trust
Urology
Within non-elective
admissions General
Medicine and Well
Babies have an HSMR
above the expected
range and have a higher
number of deaths than
expected.
Within expected range
General Surgery
The tree shows that the
HSMR for Medway is
113 which is statistically
higher than expected.
When breaking this
down by admission
type, it is clear that it is
driven by non-elective
admissions.
Treatment
Specialties
Gynaecology
Well Babies (10)
Cardiology
Clinical Haematology
Gastroenterology
General Medicine (128)
A&E
Paediatric Surgery
ENT
T&O
Vascular Surgery
Colorectal Surgery
Urology
General Surgery
Source: Health Evaluation Data (HED) – Jan 2011 – Dec 2012
Slide 29
HSMR sub-tree of specialties
Within expected range
Overall (113; 131)
118.2
Lower than expected (below the
95th confidence interval)
Non-elective (114; 134 )
Treatment
specialties
The sub-tree indicates that
General Medicine has the
highest number of above
expected deaths. These are
spread over numerous
diagnostic groups such as
septicaemia (20) and
pneumonia (12).
Well Babies (179; 10)
General Medicine (117; 128)
The HSMR sub-tree
indicates the specialties
with a statistically higher
HSMR than expected and
with diagnostic groups with
more than 4 deaths above
expected. When identifying
areas to review, it is
important to consider the
number of deaths as well as
the HSMR.
Higher than expected (above
the 95th confidence interval)
Other perinatal
conditions (179; 10)
Septicaemia (147; 20)
Diagnostic
Groups
Pneumonia (109; 12)
Acute myocardial infarction (137; 7)
Urinary tract infections (128; 7)
Chronic obstructive pulmonary disease and
bronchiecstasis (118; 6)
Acute cerebrovascular disease (114; 5)
Source: Health Evaluation Data (HED) – Jan 2011 – Dec 2012
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Key
Diagnosis (100 ; 1 )
HSMR
observed deaths that are
higher than the expected
Slide 30
HSMR – Dr Foster
Time series of HSMR, Medway
The HSMR time series for Medway FT 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 2010/11
and 2011/12..
Medway FT’s latest SHMI published by the HSCIC, for Oct 11 to
Sept 12, is similar to the Dr Foster HSMR for the same period.
Dr Foster have made the following adjustments to show the
impact of factors that can affect this comparison:
• Adjustment for palliative care: used the SHMI observed
deaths but changed expected deaths to take account of
palliative care.
• Adjustment for in-hospital deaths:
• Removed out-of-hospital deaths from the observed
figure, and
• Reduced expected deaths to only those in-hospital.
125
120
115
115
112
110
105
99
100
95
90
85
91
2008/09
2009/10
HSMR
125
I
2010/11
2011/12
95% Confidence interval
Com parison of m ortality m easures,
Medway
120
115
113
114
112
110
111
105
Any remaining variances are largely due to:
• The scope of deaths included (SHMI covers all deaths
whereas HSMR covers clinical areas accounting for an
average of around 80% of deaths), and
• The definition of spells, which includes those provider(s) the
death attributes to.
100
SHMI
95
SHMI adjusted
for palliative
care
SHMI in
hospital
deaths only
HSMR
90
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 31
Coding
Diagnosis coding depth has
an impact on the expected
number of deaths. A higher
than average diagnosis
coding depth is more likely
to collect co-morbidity
which will influence the
expected mortality
calculation.
Average Diagnosis Coding Depth
5
4
3
2
1
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
When looking at the depth
of coding for Medway, it is
apparent that for elective
admissions, the Trust has
been consistently
performing slightly below
the national average. The
average diagnosis coding
depth for non-elective
admissions has been close to
the national average, and
this has dropped lower from
Q2 of 2011/12.
Non-elective
6
Elective
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
2008/09
2009/10
2010/11
2011/12
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
Medway
2012/13
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
2012/13
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
Medway
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 32
Palliative care
Percentage of admissions with palliative care coding
Accurate coding of palliative care is important for
contextualising SHMI and HSMR. HSMR takes into
account that a patient is receiving palliative care, but
SHMI does not.
Medway’s percentage of admissions with palliative care
coding is consistently below the national average from
July 2012. The percentage of deaths with palliative care
coding has dropped from above the national average
since October 2012. However, the Trust has mirrored the
national average from October.
Percentage of deaths with palliative care coding
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 33
Care Quality Commission findings
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.
Since 2007, CQC investigations have shown Elderly Care
as a common theme across the patient groups, an
example of this is around inappropriate admissions, and
is shown below:
In the trust’s review of the septicaemia outlier alert,
almost 20% of the patients reviewed were considered to
have been already at the end of their life on admission
and should not have been admitted to hospital.
Emergency specialty groups much worse than expected
Sep 11 to Aug 12
2
Gastroenterology and Hepatology
Infectious diseases
Emergency specialty groups worse than expected
Sep 11 to Aug 12
1
Cerebrovascular
Diagnosis group alerts (2007 to date)
Alerts to CQC
6
Alerts followed up by CQC
4
Recent diagnosis group alerts pursued by CQC
No common themes arise from responses to the CQC
from the Trust.
Acute and unspecified renal failure (Jun-11)
Septicaemia except in labour (Sep-12)
Medway have developed a Mortality Working Group
Action Plan (dated January 2013) to identify,
understand and act upon the persistently high mortality
rates. The Trust identified sepsis as an important cause
of death and established a ‘Think Sepsis’ project.
Any related patient groups alerting more than once
since 2007
None
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 seven diagnosis groups and no
procedure groups with above expected SMRs in Medway FT,
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
7
0
CUSUM alerts
8
1
Diagnosis groups with SMRs above expected
Chronic obstructive pulmonary disease and
bronchiectasis
Fluid and electrolyte disorders
Intestinal obstruction without hernia
Other circulatory disease
Other perinatal conditions
Septicaemia (except in labour)
Skin and subcutaneous tissue infections
SMR
Obs – Exp
deaths
134
15
190
191
238
187
135
200
9
8
6
9
20
7
During the year, Medway had CUSUM alerts for COPD and
bronchiectasis, intestinal obstruction without hernia, other
circulatory disease, other perinatal conditions, septicaemia
(except in labour), and skin and subcutaneous tissue infections. It
also had alerts for two other diagnostic groups and one
procedure group that did not have a high SMR.
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 35
Mortality – other alerts
The Health and Social Care Information Centre (HSCIC)
publish 30-day mortality rates following certain types of
surgery or admission to hospital. These are not casemix
adjusted, but the rates may be compared over time.
Medway had one rate improving substantially below the
national average in the data to 2010-11 (published in Feb
2013).
Variable Life Adjusted Display (VLAD) charts are
produced by the 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 a further review.
30-day mortality following specific surgery / admissions
The absolute 30 day mortality rate for non-elective surgical
admissions from the information centre is within range but the
improvement rate is 15% below the national rate of improvement
in 2010/11)
VLAD charts with a negative SHMI trend
(year to Jun-12)
Septicaemia (not labour)
Cancer of bronchus / lung
No. dips to the
lower control
limit
2
2
Medway had such VLAD charts for two diagnosis groups
in the year to June 2012.
Although Medway was selected on the basis of its HSMR,
its SHMI has been higher than expected in a number of
time periods over recent years.
In .a review by the National Diabetes Information
Service, Medway was noted as an outlier with a higher
standardised mortality ratio; comparing inpatients with
diabetes in Medway to all inpatients with diabetes
included in the analysis from 1st April 2010 to 31st March
2012.
Source: Health & Social Care Information Centre (HSCIC) – SHMI and contextual indicators, Dr Foster – HSMR.
Slide 36
Patient Experience
Slide 37
Patient Experience
Overview:
Summary:
The following section provides an insight into the Trust’s patient
experience.
Of the 8 measures reviewed within Patient Experience and
Complaints there are two which are rated ‘red’: Inpatients and
patient voice comments.
Review Areas:
To undertake a detailed analysis of the Trust’s Patient Experience
it is necessary to review the following areas:
•
Patient Experience, and
•
Complaints.
Data Sources:
•
Patient Experience Survey;
•
Cancer Patient Experience Survey;
•
Peoples’ Voice Summary; and
•
Complaints data.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Medway had an inpatient score lower than the national
average.
Of 76 individual comments from patients and public as part of
the Patient Voice, 42 were negative (55%).
Data returns to the Health and Social Care Information Centre
showed 484 written complaints in 2011-12. The number of
complaints is not always a good indicator, because stronger
trusts encourage comments from patients. However, central
returns are categorised by subject matter against a list of 25
headings. For this Trust, the proportion of complaints relating to
clinical treatment was in line with the average (52% compared
to an average of 47%).
A separate report by the Ombudsman rates the trust as B-rated
for satisfactory remedies and low-risk of non-compliance. It was
ranked above average for 'failure to respond to complaints in
writing’.
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 aspect
Patient voice comments
Data not available
Ombudsman’s rating
Lower than expected
Within Normal range
Slide 39
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
Inpatient Experience Survey
Medway performs below average on a range of survey questions including time for getting onto a ward, getting consistent and clear
answers from doctors and nurses, involvement in decisions, coherent discharge processes with information about side effects and
other risks, cleanliness of wards, and the quality of food.
Overall
Length of time spent on waiting list
Alteration of admission date by hospital
Length of time to be allocated a bed on a
ward
Overall
Delay of patient discharge
Consistency of staff communication
Information provided on post-discharge
danger signals
Overall
Staff communication on purpose of
medication provided
Patient involvement in decision-making
Staff communication on medication
side-effects
Overall
Clarity of doctors’ responses to
important questions
Language used by doctors in front of
patients
Clarity of nurses’ responses to
important questions
Language used by nurses in front of
patients
Overall
Hospital food
Patient noise levels at night
Degree of privacy provided
Staff noise levels at night
Level of respect shown by staff
Hospital/ward cleanliness
Overall staff effort to ease pain
Above expected range
Source: Patient Experience Survey 2012/13
Within expected range
Below expected range
Slide 40
Patient experience and patient voice
Inpatient survey
The national inpatient survey 2012 measures a wide range of
aspects of patient experience. A composite ‘overall measure’
is calculated for use in the Outcomes Framework. This
measure uses a pre-defined selection of 20 survey questions
to rate the Trust on aspects including access to services, coordination of care, information & choice, relationship with
staff and the quality of the clinical environment. Medway
scores below average on a range of survey questions
including time for getting onto a ward, getting consistent
and clear answers from doctors and nurses, involvement in
decisions, coherent discharge processes with information
about side effects and other risks, cleanliness of wards,
quality of food.
Cancer Survey
•
58 Questions
•
24 of these in ‘top 20%’, only 2 in the ‘bottom 20%’
Patient Voice
•
The quality risk profiles compiled by the Care Quality
Commission collate comments from individuals from
various sources. In the two years to 31 January 2013,
there were 76 comments on Medway of which 42 were
negative (55%). Key themes included a poor complaints
procedure, a poor reputation locally, insensitivity of staff
and a lack of emotional support (e.g. in suicide cases and
bereavement.
Source: Patient Experience Survey, peoples Voice Summar
Overall inpatient experience score: Inpatients 2012
95
90
85
Medway
80
75
70
65
60
55
50
Trusts in this
review
England
average
National
results curve
PEAT scores
The Score for ‘Privacy and Dignity’ dipped to ‘Acceptable’ in
2010. This is a low score, but scores have improved to good in
2012.
Complaints Handling
•
Data returns to the Health and Social Care Information Centre
showed 484 written complaints in 2011-12. The number of complaints
is not always a good indicator, because stronger Trusts encourage
comments from patients. However, central returns are categorised by
subject matter against a list of 25 headings. For this Trust, the
proportion of complaints relating to clinical treatment was in line
with the average (52% compared to an average of 47%).
•
A separate report by the Ombudsman rates the trust as B-rated for
satisfactory remedies and low-risk of non-compliance. It was ranked
above average for 'failure to respond to complaints in writing’.
Slide 41
Safety and workforce
Slide 42
Safety and Workforce
Overview:
Summary:
The following section provides an insight into the Trust’s
workforce profile and safety record. This section outlines whether
the Trust is adequately staffed and is safely operated.
Medway is ‘red rated’ in two of the safety indicators: reporting of
patient safety incidents and Rule 43 Coroner’s report.
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 data and sources used are 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 207 incidents reported as either moderate, severe or
death between April 2011 and March 2012. Since 2009, four
‘never events’ have occurred at Medway, classified as that
because they are incidents that are so serious they should never
happen. Similarly, Medway has a rate of medication errors of
4.74, that is lower than the mean rate of 7.17 for all acute trusts.
Throughout the last 12 months, Medway has been fallen below
the national rate for new pressure ulcers since June 2012. The
prevalence rate of total pressure ulcers for Medway has been
fluctuating over the last 12 months but was above the national
average in the most recent month.
The Trust’s Clinical Negligence payments have been lower than
its contributions to the ‘risk sharing scheme’ over the last two
years, and flagged once in Rule 43 Coroner’s reports.
Medway is ‘red rated’ in nine of the workforce indicators. It
notably has a sickness absence rate for medical staff, medical
staff to consultant, and nurse staff to qualified ratios above their
respective national mean rates. For training of its doctors, it has
a lower score on ‘undermining’ than the national average. In
addition, Medway has an overall rate of patient safety concerns
that is significantly higher than the national 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
207
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. Medway has a rate of 4.8 for its patient safety
incident reporting per 100 admissions.
The rate of medication errors for Medway is 4.74,
which is lower than the mean rate of 7.17 for all acute
trusts.
Rate of reported patient safety incidents per 100 admissions (April –
September 2012)
Medway
Median rate for medium acutes
4.8
6.7
Source: incidents occurring between 1 April 2012 to 30 September
2012 and reported to the National Reporting and Learning System
Rate of medication errors per 1,000 bed days (October 2011 – March
2012)
Medway
Mean rate for all acute
4.74
7.17
Source: Acute Trust Quality Dashboard Winter 2012/13
Slide 45
Safety Incident Breakdown
Since 2009, four ‘never events’ have occurred at Medway, classified as that
because they are incidents that are so serious they should never happen.
Never Events Breakdown (2009-2012)
The patient safety incidents reported are broken down into five levels of harm
below, ranging from ‘no harm’ to ‘death’. 71% of incidents which have been
reported at Medway have been classed as ‘no harm’, with 23% ‘low’, 5%
‘moderate’, 1% ‘severe’ and 8 occurrences classified as ‘death’.
When broken down by category, the most regular occurrences of patient
incident at Medway are in ‘patient accident’ and ‘’treatment, procedure’.
Breakdown of patient
incidents by degree of harm
Misplaced naso-or oro-gastric tubes
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
Medical device / equipment
3000
97
Consent, communication,…
2562
2500
2000
1500
99
All others categories
152
Infrastructure
159
Documentation
199
Clinical assessment
210
Access, admission, transfer,…
Medication
849
1000
252
385
Implementation of care and…
386
Treatment, procedure
500
179
20
8
Severe
Death
0
No Harm
Low
Moderate
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
A definition of serious harm is given in the Appendix.
500
Patient accident
1179
0
200
400
600
800 1000 1200 1400
Source: National Patient Safety Agency (NPSA) . Apr 11 – Mar 12
Slide 46
Pressure Ulcers
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.
From April 12 – June 12, the
Trust had a new pressure
ulcer rate above the national
average. However, the trusts
new pressure ulcer rate has
fallen considerably meaning
the Trust has been below the
national rate.
The Trust’s total pressure
ulcer prevalence rate has
been fluctuating over the 12
months shown. However, it
should be noted, the Trust’s
rate was higher than the
national average in the most
recent month.
New pressure ulcers prevalence
Total pressure ulcers prevalence
25
7
6
5.0%
4.2%
5
4
6.0%
15
1.3%
1.0%
0.6%
2.0%
0.9%
0.7%
0.7%
0.3% 0.3%
-
5.7%
3.5%
3.9%3.6%4.1%
3.2%
10
5.0%
4.0%
2.6%
3.0%
1.0%
0.0%
5
2.0%
1.0%
-
Category 2
Category 3
Category 4
7.0%
6.0%
5.0%
4.4%
3
1
8.0%
4.0%
3.2%
2.9%
9.0%
7.2%
20
3.0%
2
10.0%
9.2%
6.0%
5.2%
0.0%
Rate
Category 2
Category 3
Category 4
Rate
New pressure ulcer analysis
Number of records submitted
Trust new pressure ulcers
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
136
97
142
201
158
178
302
318
144
332
306
401
4
5
6
2
5
1
4
3
1
1
1
3
Trust new pressure ulcer rate
2.9%
5.2%
4.2%
1.0%
3.2%
0.6%
1.3%
0.9%
0.7%
0.3%
0.3%
0.7%
Selected 14 Trusts new pressure
ulcer rate
1.4%
1.5%
1.4%
1.5%
1.5%
0.9%
1.0%
1.1%
0.9%
1.1%
1.0%
1.2%
National new pressure ulcer rate
1.7%
1.7%
1.5%
1.5%
1.4%
1.3%
1.2%
1.2%
1.2%
1.3%
1.3%
1.3%
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
136
97
142
201
158
178
302
318
144
332
306
401
6
7
13
10
5
7
11
13
5
20
8
23
Trust total pressure ulcer rate
4.4%
7.2%
9.2%
5.0%
3.2%
3.9%
3.6%
4.1%
3.5%
6.0%
2.6%
5.7%
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%
6.2%
National total pressure ulcer rate
6.8%
6.7%
6.6%
6.1%
6.0%
5.5%
5.4%
5.3%
5.2%
5.4%
5.6%
5.3%
Total pressure ulcer prevalence percentage
Number of records submitted
Trust total pressure ulcers
Source: Safety Thermometer Apr 12 to Mar 13
Slide 47
Litigation and Coroner
Clinical negligence scheme analysis
Medway is a net contributor to the Clinical Negligence scheme.
Their contributions to this ‘risk sharing scheme’ exceed payouts to
litigants.
Clinical negligence payments
2009/10
2010/11
2011/12
Payouts (£000s)
3,464
3,287
3,459
Contributions (£000s)
4,657
4,969
5,179
Variance between payouts and
contributions (£000s)
1,193
1,682
1,720
Coroner’s Rule
Coroners rule 43 reports flagged one item:
•
Investigate adequacy of communication with South London
Healthcare Trust.
Source: Litigation Authority Reports
Slide 48
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
2.88
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
2.46
Vacancies –medical
Sickness
absence
-Nursing
staff
Staff to Total Staff Ratio
Outcome
1 (R17)
Respecting
and involving eNon-clinical
who u
Vacancies - Non-medical
Consultant appraisal rates
Agency spend
Response Rate from National Staff
Survey 2012
Staff Engagement from NSS 2012
Training Doctors – “undermining”
indicator
se services
0.36
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days) 541
Staff leaving rates
Nurse Hours per Patient Bed Day
7.49
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 49
General Medical Council (GMC) National Training Scheme Survey 2012
Acute Medicine
The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results. Given the volume
of data only specialties with red outliers are noted below (where those specialties also have green outliers, they are included).
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Gastroenterology
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 50
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
General Practice
General (internal) Medicine
The GMC Survey results continue as follows.
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 51
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
Geriatric Medicine
The GMC Survey results continue as follows.
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
`
Neonatal Medicine
Feedback
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 continued…
Respiratory Medicine
The GMC Survey results continue as follows.
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Trauma and Orthopedic
Surgery
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 53
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
Urology
The GMC Survey results continue as follows.
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
In addition to the green outliers displayed, Intensive Care Medicine has two green outliers for workload and handover and Otolaryngology
has one green outlier for adequate experience.
Green outlier
Within expected range
Red outlier
Slide 54
Workforce Analysis
The Trust has a patient spell per whole time equivalent rate of 24, which is
average capacity in relation to the other trusts in this review and nationally.
Number of FTEs (Dec 11-Nov 12 average)
The consultant appraisal rate of Medway is 87% which is average among the
trusts under review.
Agency Staff (2011/12)
Medway’s staff leaving rate is 7.6% which is in line with the median average
of 7.6%. The joining rate of 6.1% is less than the national average.
The data shows that the agency staff costs, as a percentage of total staff
costs, is lower than the median within the region
National Average
1.54
1.96
Medway
Expenditure
Percentage of
Total Staff Costs
Median within
Region
£5.4m
3.6%
3.9%
(Sep 11 – Sep 12)
Staff Turnover
WTE nurses per bed day December 2012
Medway
3,300
Medway
South East Coast
SHA Median
Joining Rate
6.1%
9.2%
Leaving Rate
7.6%
7.6%
Source: Health and Social Care Information Centre (HSCIC)
Source: Acute Trust Quality Dashboard, Methods Insight
Spells per WTE for Acute Trusts
Consultantappraisal
appraisal raterate
2011/12
Consultant
2011/12
50
45
100%
Medway
Medway
87%
Spells per WTE
40
35
30
25
80%
Medway
24
60%
20
40%
15
20%
10
5
0%
0
Trusts covered by review
Trusts covered by review
All Trusts
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
All other trusts
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Data based on the appraisal year from April 2011 to March 2012
Medway
Slide 55
Workforce Analysis continued…
Medway’s total sickness absence rate is lower
than the South East Coast Strategic Health
Authority average and the national average. This
pattern is replicated in the more granular
nursing and other staff categories, both of which
have sickness absence rates below their respective
national averages, although the Trust’s medical
staff rate is above the average for all English
trusts.
The Trust has medical staff to consultant, and
non-clinical staff to total staff, ratios that are
above the average figures for all trusts in
England. However, Medway’s registered nurse
hours to patient day ratio is below the national
mean.
The Trust’s consultant productivity rate is above
the national average.
Sickness Absence Rates
All Staff
(2011-2012)
Medway
South East Coast SHA
Median
National Average
3.74%
3.87%
4.12%
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
Medway
National Average
Medical Staff
1.5%
1.3%
Nursing Staff
4.5%
4.8%
Other Staff
4.6%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
Medway
National Average
Medical Staff to Consultant Ratio
2.88
2.59
Nurse Staff to Qualified Staff Ratio
2.46
2.50
Non-Clinical Staff to Total Staff
Ratio
0.36
0.34
Registered Nurse Hours to Patient
Day Ratio *
7.49
8.57
Source: Electronic Staff Record (ESR), Apr 13
*Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Consultant Productivity
(Spells/FTE)
Workforce indicator calculations are listed in the Appendix.
Source: Electronic Staff Record (ESR), Apr 13
Medway
National Average
541
492
Slide 56
Workforce Analysis continued…
National Staff Survey results
Medway response rate to the staff
survey is significantly below average
and has fallen in 2012. The staff
engagement score is below average
when compared with trusts of a similar
type, although it improved in 2012.
Medway is 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 also below average on
recommending it as a place to work
which has fallen in 2012 compared with
2011.
Medway
2011
Average for all
trusts
2011
Medway
2012
Average for all
trusts
2012
45%
50%
43%
50%
3.57
3.62
3.61
3.69
Care of patients/service
users in my organisation’s
top priority
57%
69%
58%
63%
I would recommend my
organisation a place to work
50%
52%
48%
55%
If a friend or relative needed
treatment, I would be happy
with the standard of care
provided by this organisation
54%
62%
57%
60%
Response rate
Overall staff engagement
Source: National Staff Survey 2011, 2012
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Source: GMC evidence to Review 2013
Data based on the appraisal year from April 2011 to March 2012
Slide 57
Deanery
The trust is not currently subject to enhanced monitoring. While the National Training Survey and Deanery reports did not indicate
any specific concerns, doctors in training reported more patient safety concerns through the national trainee survey than the
average. These concerns were shared with the Deanery.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
F2s in Emergency Medicine and F1s in Medicine reported the most below outliers between 2010 and 2012. F2s in Medicine reported
the most above outliers in the same period. 2012 saw many more below outliers reported compared to previous years.
NTS 2012 Patient Safety Comments
11 doctors in training commented, representing 6.47% of respondents. This was higher than the national average of 4.7%. Their
concerns, which were raised in relation to specific training posts, and may apply to a single or multiple departments, related to:
•
Hospital running beyond capacity in order to meet targets, particularly in A&E;
•
No out of hours endoscopy service;
•
Lack of staff, especially weekends and holidays;
•
Poor trainee supervision; and
•
Poor weekend handover.
Source: GMC evidence to Review 2013
Slide 58
Deanery Reports
Kent, Surrey and Sussex Deanery reported concerns against the Medway NHS Foundation Trust in 2011 and 2012, relating to
Deanery funds not being ring-fenced for education and training.
Monitored under the response to concerns process?
Undermining
No, the trust is not subject to increased monitoring at the time of the
report. The trust was visited on 13 May 2009 by PMETB to look at
paediatrics. The visit did not identify any concerns specific at this
site.
For doctors undertaking training at Medway,
the trust has a score on the National Training Survey on
undermining of 93.1 which is below the national average
of 94.
Mean Score on 'Undermining'
Mean Score on ‘Undermining’
105
100
Medway
Medway
93.1
95
90
85
80
Trusts covered by review
All other non specialist trusts
Medway
Slide 59
Source: National Training Survey 2012
Clinical and operational
effectiveness
Slide 60
Clinical and Operational Effectiveness
Overview:
Summary:
The following section provides an insight in to the Trust’s clinical
and operational performance based on nationally recognised key
performance indicators.
The Trust records a low percentage of diabetes patients
receiving a foot risk assessment during their hospital stay.
Review Areas:
To undertake a detailed analysis of the Trust’s clinical and
operational performance it is necessary to review the following
areas:
•
Clinical Effectiveness;
•
Operational Effectiveness; and
•
Patient Reported Outcome Measures (PROMs) for the review
areas.
Data Sources:
•
Clinical Audit Data Trust, CQC Data Submission;
•
Healthcare Evaluation Data (HED), Jan – Dec 2012;
•
Department of Health;
•
Cancer Waits Database, Q3, 2012-13; and
•
PROMs Dashboard.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Similarly, results suggest that Medway is close to being an
outlier on the ‘hip fracture - mortality’ indicator.
The Trust’s crude readmission rate is 11% and the average
length of stay is 3.93, shorter than the national average.
With 95% of A&E patients seen within 4 hours, Medway are in
line with the target level.
The RTT is 93.2% which is higher than the target level. They
have been consistently performing above the 90% target level
since August 2012 but there was a dip in performance in recent
months.
The PROMS dashboard shows that Medway is in line with the
average across procedures covered by PROMS.
Slide 61
Clinical and Operational 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.
Coronary angioplasty
Heart failure
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
Adult Critical care
RTT Waiting Times
Cancelled Operations x
Emergency readmissions
PbR Audit
PROMs
Dashboard
Clinical
Effectiveness
Neonatal – women receiving steroids
Operational
Effectiveness
.
Cancer Waits
A&E Waits
Hip Replacement EQ-5D
Knee Replacement EQ-5D
Varicose Vein EQ-5D
Hip Replacement OHS
Knee Respecting
Replacement
OKS
Outcome 1 (R17)
and
involving people who use services
Groin Hernia EQ-5D
Above the expected range
Within the expected range
Slide 62
Clinical Effectiveness: National Clinical Audits
The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the clinical audit results
considered as part of this review.
Clinical Audit
Diabetes
Elective Surgery
Safety Measure
Clinical Audit
Proportion with medication
error
Proportion experiencing
severe hypoglycaemic
episode
Neonatal intensive and special care
(NNAP)
Proportion of women receiving antenatal steroids
Diabetes
Proportion foot risk assessment
Adult Critical Care
Standardised hospital mortality ratio
Proportion of patient reported
post-operative complications
Coronary angioplasty
Acute Myocardial Infarction
Proportion receiving primary PCI
within 90 mins
Elective abdominal aortic aneurysm
post-op mortality
Proportion having surgery within 14
days of referral
Proportion discharged on beta-blocker
Acute Stroke
Proportion compliant with 12 indicators
Heart Failure
Proportion referred for cardiology
follow up
90 day post-op mortality
Peripheral vascular surgery
Adult Critical Care (ICNARC
CMPD)
Effectiveness Measures
Proportion of night-time
discharges
Carotid interventions
Bowel cancer
Hip Fracture
Elective surgery (PROMS)
Severe Trauma
Hip, knee and ankle
Source: Clinical Audit Data Trust, CQC Data Submission.
Lung Cancer
30 day mortality
Proportion operations within 36 hrs
Mean adjusted post-operative score
Proportion surviving to hospital
discharge
Standardised revision ratio
Proportion small cell patients receiving
chemotherapy
Slide 63
Clinical Effectiveness: Clinical Audit - Diabetes
National Diabetes Inpatient Audit 2012:
Received a foot risk assessment during the hospital stay 2012
Each graph ranks the percentage of patients with diabetes at
each hospital that reported that they:
- received a foot risk assessment during their stay;
- experienced a severe hypoglycaemic episode (<3mmol/L);
- experienced at least one medication error.
100%
The red line in each graph shows where this specific hospital
ranks.
60%
80%
40%
20%
0%
Medication Error
Medication
Error2012
2012
Severe
Hypoglycaemic
Severe
HypoglycaemicEpisode
Episode2012
2012
70%
50%
30%
10%
-10%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Note: Caution should be borne when looking at the data for some sites in these summaries as they may be based on a small sample of inpatients with diabetes. This means that a small variation
would have a substantial impact on the indicators presented.
Source: http://www.hscic.gov.uk/catalogue/PUB10506/nati-diab-inp-audi-12-comp.xlsx
Slide 64
Clinical effectiveness: Clinical Audits
Proportion of patients reporting post-operative
complications – Groin Hernia repair
150
% with complications in groin surgery
The National PROMs programme measures outcomes, both
in terms of health gain and also in relation to post-operative
complications.
For this review, we examined data on both aspects across all
four treatment areas addressed by PROMs
Results for groin hernia show Medway as above the 95th
percentile confidence interval for post-operative
complications.
Medway
Tameside
100
George Eliot
North Cumbria
50
United Lincolnshire
0
Sherwood Forest
Northern Lincoshire
-50
-100
0
Source: PROMs dashboard
100
200
300
Number of operations
400
500
Slide 65
Clinical effectiveness: Clinical Audits
Adjusted 30 day mortality rate for Hip fracture
– by hospital
Medway is an outlier at the 95% confidence level on the key
indicator here, which is mortality within 30 days
20%
Re-admissions as a percentage of discharges
The National Hip Fracture Database audits outcomes and
effectiveness for treatment following fracture of the hip.
Medway
15%
10%
5%
0%
-5%
0
50
100
150
200
250
300
350
400
450
500
550
600
650
700
750
800
No of discharges in 2010
Slide 66
Operations – A&E wait times and Referral to Treatment (RTT) times
100%
A&E Percentage of Patients Seen
within 4 Hours
Medway
95.0%
95%
Medway see 95% of A&E 90%
patients within 4 hours
85%
which means the Trust is at
80%
the target level. However,
the graph shows that the 75%
Trust is performing below 70%
the median level for all
Trusts Covered by Review
All Trusts
A&E Target 95%
trusts. Additionally, the
percentage of patients seen Source: Healthcare Evaluation Data (HED). Jan – Dec 12
within 4 hours has been
falling since September,
2012.
Referral to Treatment (Admitted)
Medway’s referral to
treatment time is at 93.2%, 95%
which is above the 90%
target level. They have been 90%
85%
consistently performing
above the 90% target rate 80%
since August 2012 but there
was a dip in performance in 75%
January and February
70%
2013.
65%
100%
Medway
93.2%
Trusts Covered by Review
Source: Department of Health. Feb 13
Medway 4 Hour A&E Waits
Attendances
(Thousands)
A&E wait times and RTT
times may indicate the
effectiveness with which
demand is managed.
9
8
7
6
5
4
3
2
1
0
100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
Patients Seen
Patients Not Seen
Seen within 4 hours (%)
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Medway Referral to Treatment
Performance
96%
95%
94%
93%
92%
91%
90%
89%
88%
87%
All Trusts
RTT Target 90%
Referral to Treatment Rate
RTT Target 90%
Source: Department of Health. Apr 12 – Feb 13
Slide 67
Operations – Readmission rates and average length of stay
The standardised
readmission rate most
importantly accounts for
the Trust’s case mix and
shows that Medway are
within the expected range.
Medway have an average
length of stay of 3.93 days
which is shorter than the
national mean average of
5.22. On this indicator,
Medway is one of the
highest performing trusts
covered by the review.
Standardised 30-day readmission rate
25%
Crude Readmission Rate
The graph shows that
Medway’s crude
readmission rate is 11%.
Crude readmission rate by Trust
20%
Medway
11%
15%
10%
5%
0%
Trusts Covered by Review
All Trusts
Average length of stay by Trust
Medway
Selected trusts Outside
Selected trusts w/in Range
10
Spell Duration (Days)
Readmission rates may
indicate the
appropriateness of
treatment offered, whilst
average length of stay may
indicate the efficiency of
treatment.
8
Medway
3.93
6
4
2
0
Trusts Covered by Review
Source: Healthcare Evaluation Data (HED) Jan-Dec ‘12
All Trusts
Slide 68
Leadership and
governance
Slide 69
Leadership and governance
Overview:
Summary:
This section provides an indication of the Trust’s governance
procedures.
The trust has been in significant breach of two terms of its
authorisation since April 2011 for the following reasons:
Review Areas:
•
To provide this indication of the Trust’s leadership and
governance procedures we have reviewed the following areas:
Its general duty to exercise its functions effectively,
efficiently and economically, and
•
Its governance duty.
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
There have been a number of changes to the Board in the last
year. The Chair was appointed in April 2012, a new Director of
Finance started in September 2012, a new Director of Strategy &
Governance started in March 2013 and a new Director of
Organisational Development and Communications started in
May 2013. An Interim Director of Nursing has been in post since
April 2013, a new substantive Director of Nursing has been
appointed and will start in June 2013. A new Medical Director
has been appointed and will start in Autumn 2013.
Slide 70
Leadership and governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in
the following pages.
Leadership and
governance
Monitor governance risk rating
Monitor finance rating
CQC Outcomes
3
Governance risk rating
Red - Likely or actual significant breach of terms of authorisation
Amber-red - Material concerns surrounding terms of authorisation
Amber-green - Limited concerns surrounding terms of authorisation
Green - No material concerns
CQC Concerns
Red – Major concern
Amber – Minor or Moderate concern
Green – No concerns
Financial risk rating
rated 1-5, where 1 represents the highest risk and 5 the lowest
Slide 71
Leadership and governance
Trust Board
There have been a number of changes to the Board in the last year. The Chair was appointed in April 2012, a new Director of Finance
started in September 2012, a new Director of Strategy & Governance started in March 2013 and a new Director of Organisational
Development and Communications started in May 2013. An Interim Director of Nursing has been in post since April 2013, a new
substantive Director of Nursing has been appointed and will start in June 2013. A new Medical Director has been appointed and will start
in Autumn 2013.
The Trust has been planning to integrate with the Dartford and Gravesham NHS Trust since early 2011 but since the announcement of
these reviews in February 2013, there has been a temporary pause in the Monitor assessment process of the integration.
Governance and clinical structures
The governance structures within the Trust include:
•
The Quality Committee which is one of six sub-committee of the Trust Board. The Quality Committee, chaired by John Sands (a NonExecutive Director) has several supporting committees (see Appendix A) including the Patient Safety Committee which monitors
mortality data.
•
An independently chaired, multi-agency Mortality Working Party (chaired by the Director of Public Health for Medway) which was set
up in December 2012 in response to the Trust’s HSMR.
•
The operational management structure is arranged around directorates: Adult and Emergency Medicine, Women’s and Children’s.
Surgery , Anaesthesia and Critical Care, Diagnostics (Pathology and Imaging) and Facilities, Clinical Support Services and
Outpatients (see Appendix B). Each clinical directorate has patient safety, governance and audit leads that are either a consultant or
head of nursing.
External reviews
Details of these are given overleaf.
A diagram of the directorate, management and committee structures can be found in the Appendix.
Slide 72
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’s response (actions and mitigation)
Not always being able to provide beds for patients in the right
specialty and in a timely way.
The Trust is working with the Intensive Support Team from the
Department of Health with regard to emergency patient flow. There
have been recent changes to pathways including short stay wards
and increased timeliness in assessment areas.
The Trust will fail to resolve the high HSMR issues to the
satisfaction of the Board and external regulators.
Areas being reviewed include fractured neck of femur, cerebral
vascular disease and pneumonia.
There will be patient falls resulting in harm.
The Trust set up a Mortality Working Party in December 2012, a
multi-agency group supporting an increased focus on improving
patient safety and reducing HSMR. Action plan being implemented.
A permanent falls Nurse Practitioner has been recruited and the
Falls Programme continues.
The Trust will fail to address properly the issue of deteriorating
patients who are not recognised.
24/7 Critical Care Outreach Team established in October. Patient
safety workstreams continuing. ‘Big Conversation’ events held to
listen to the views of staff.
There will continue to be high numbers of omissions and delays in
administering medications.
DON and Principal Pharmacist for Medicines Management are
devising an audit tool against specific criteria for auditing.
Further risks for review:
• Three never events occurred in 2012/13 – two in Nov ’12 and one in Feb ’13. They all occurred in theatres but we have not been provided
with any further information or evidence.
• Hospital deep vein thrombosis (DVTs) and pulmonary embolism (PEs) are rated red on the performance scorecard.
Slide 73
Leadership and governance – other areas for further review
External reviews
Care Quality Commission
The September 2012 report for the Maritime Hospital indicated that all essential standards were being met. The Trust has received three
CQC mortality alerts: 1) Sepsis (Nov 2012) ; 2) Acute renal failure (July 2011) ; and 3) Pneumonia (Feb 2011). There are no further
enquiries from the CQC regarding acute renal failure and the Trust has initiated the Think Sepsis campaign.
Monitor
Medway NHS FT has been in significant breach of two terms of its authorisation since April 2011 for the following reasons: its general duty
to exercise its functions effectively, efficiently and economically and its governance duty. This was as a result of an unplanned financial risk
rating of 2 at quarter three and concerns around board level scrutiny and assurance processes concerning financial planning and
performance. The Trust conducted a self-assessment of Monitor’s Quality Governance Framework in July 2011. This was reviewed by
Southampton Hospitals NHS FT in April 2012. which identified that the Trust’s processes were good and that were opportunities to further
develop aspects of the QGF (we have not been provided with evidence of this review). Ernst & Young conducted a financial governance
review which the Finance Director gave a verbal update on at the March 2013 Board meeting.
Burnett Vincent
The consultancy conducted a due diligence review of clinical governance in January 2012 as part of the Integration Feasibility
Programme. In response to this the Trust developed a Clinical Due Diligence action plan which was last updated in January 2013.
Intensive support team for Emergency Care
The Trust is currently working with this team in regard to emergency patient flow, looking critically at emergency pathways across the
Trust.
Slide 74
Appendix
Slide 75
Trust map
Slide 76
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 77
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
Directorate structure
Slide 79
Management structure
Slide 80
Directorate structure
Slide 81
Committee structure
Slide 82
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 83
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 84
SHMI Appendix
Observed deaths above
the expected level
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Nonelective
300 - General medicine
107 - Cardiac arrest and ventricular fibrillation
118.61
2
Nonelective
300 - General medicine
108 - Congestive heart failure; nonhypertensive
102.46
1
Nonelective
300 - General medicine
11 - Cancer of head and neck
157.92
1
Nonelective
300 - General medicine
111 - Other and ill-defined cerebrovascular disease
294.46
1
Nonelective
300 - General medicine
114 - Peripheral and visceral atherosclerosis
230.44
2
Nonelective
300 - General medicine
116 - Aortic and peripheral arterial embolism or thrombosis
256.2
1
Nonelective
300 - General medicine
12 - Cancer of esophagus
124.42
2
Nonelective
300 - General medicine
121 - ther diseases of veins and lymphatics
211.42
1
Nonelective
300 - General medicine
126 - Other upper respiratory infections
253.94
1
Nonelective
300 - General medicine
133 - Other lower respiratory disease
152.83
3
Nonelective
300 - General medicine
134 - Other upper respiratory disease
155.36
1
Nonelective
300 - General medicine
143 - Abdominal hernia
427.48
2
Nonelective
300 - General medicine
148 - Peritonitis and intestinal abscess
1283.31
2
Nonelective
300 - General medicine
149 - Biliary tract disease
143.5
2
Nonelective
300 - General medicine
153 - Gastrointestinal hemorrhage
118.27
3
Nonelective
300 - General medicine
158 - Chronic renal failure
408.75
3
Nonelective
300 - General medicine
161 - Other diseases of kidney and ureters
268.35
1
Nonelective
300 - General medicine
168 - Inflammatory diseases of female pelvic organs
129314.6
1
Nonelective
300 - General medicine
140.48
1
Nonelective
300 - General medicine
18 - Cancer of other GI organs; peritoneum
201 - Infective arthritis and osteomyelitis (except that caused by tuberculosis or
sexually transmitted disease)
516.3
1
Nonelective
300 - General medicine
207 - Pathological fracture
297.59
2
Nonelective
300 - General medicine
21 - Cancer of bone and connective tissue
237.25
1
300 - General medicine
22 - Melanomas of skin
298.61
1
Nonelective
300 - General medicine
229 - Fracture of upper limb
447.19
3
Nonelective
300 - General medicine
23 - Other non-epithelial cancer of skin
235.51
1
Slide 85
SHMI Appendix
Observed deaths above
the expected level
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Nonelective
300 - General medicine
231 - Other fractures
285.46
3
Nonelective
300 - General medicine
233 - Intracranial injury
171.59
3
Nonelective
300 - General medicine
234 - Crushing injury or internal injury
304.89
1
Nonelective
300 - General medicine
235 - Open wounds of head; neck; and trunk
149.12
1
Nonelective
300 - General medicine
237 - Complication of device; implant or graft
191.85
1
Nonelective
300 - General medicine
241 - Poisoning by psychotropic agents
361.05
3
Nonelective
300 - General medicine
242 - Poisoning by other medications and drugs
223.52
1
Nonelective
300 - General medicine
244 - Other injuries and conditions due to external causes
154.31
1
Nonelective
300 - General medicine
245 - Syncope
176.23
2
Nonelective
300 - General medicine
32 - Cancer of bladder
258.81
2
Nonelective
300 - General medicine
35 - Cancer of brain and nervous system
132.78
1
Nonelective
300 - General medicine
37 - Hodgkin`s disease
438.08
1
Nonelective
300 - General medicine
38 - Non-Hodgkin`s lymphoma
122.57
1
Nonelective
300 - General medicine
39 - Leukemias
161.84
3
Nonelective
300 - General medicine
41 - Cancer; other and unspecified primary
164.33
2
Nonelective
300 - General medicine
42 - Secondary malignancies
144.58
3
Nonelective
300 - General medicine
44 - Neoplasms of unspecified nature or uncertain behavior
204.43
1
Nonelective
300 - General medicine
49 - Diabetes mellitus without complication
263.03
2
Nonelective
300 - General medicine
50 - Diabetes mellitus with complications
173.92
2
Nonelective
300 - General medicine
51 - Other endocrine disorders
137.43
1
Nonelective
300 - General medicine
59 - Deficiency and other anemia
115.08
1
Nonelective
300 - General medicine
60 - Acute posthemorrhagic anemia
1840.09
1
300 - General medicine
62 - Coagulation and hemorrhagic disorders
815.85
2
Nonelective
300 - General medicine
685.9
2
Nonelective
300 - General medicine
63 - Diseases of white blood cells
77 - Encephalitis (except that caused by tuberculosis or sexually transmitted
disease)
199.1
1
Slide 86
SHMI Appendix
Observed deaths above
the expected level
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Nonelective
300 - General medicine
79 - Parkinson`s disease
271.28
2
Nonelective
300 - General medicine
81 - Other hereditary and degenerative nervous system conditions
176.51
1
Nonelective
300 - General medicine
82 – Paralysis
598.98
1
Nonelective
300 - General medicine
83 - Epilepsy; convulsions
137.33
2
Nonelective
300 - General medicine
84 - Headache; including migraine
198.49
1
Nonelective
300 - General medicine
229.15
3
Nonelective
300 - General medicine
85 - Coma; stupor; and brain damage
97 - Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by
tuberculosis or sexually transmitted disease)
187.71
2
Nonelective
300 - General medicine
99 - Hypertension with complications and secondary hypertension
665.76
3
Slide 87
HSMR Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Nonelective
General Medicine
Acute and unspecified renal failure
Nonelective
General Medicine
Aortic; peripheral; and visceral artery aneurysms
Nonelective
General Medicine
Nonelective
Observed deaths above
the expected level
HSMR
108.6
2
153
1
Aspiration pneumonitis; food/vomitus
113.8
3
General Medicine
Biliary tract disease
144.7
2
Nonelective
General Medicine
Cancer of bronchus; lung
111.7
2
Nonelective
General Medicine
Cancer of colon
165.7
2
Nonelective
General Medicine
Cancer of prostate
168.2
3
Nonelective
General Medicine
Cancer of rectum and anus
278.5
3
Nonelective
General Medicine
Cancer of stomach
230.3
1
Nonelective
General Medicine
Cardiac arrest and ventricular fibrillation
122.4
3
Nonelective
General Medicine
Chronic renal failure
205.6
2
Nonelective
General Medicine
Deficiency and other anemia
164.7
3
Nonelective
General Medicine
Fluid and electrolyte disorders
108.6
1
Nonelective
General Medicine
Gastrointestinal hemorrhage
129.8
3
Nonelective
General Medicine
Intestinal obstruction without hernia
273.6
3
Nonelective
General Medicine
Intracranial injury
123.1
1
Nonelective
General Medicine
Malignant neoplasm without specification of site
156.9
3
Nonelective
General Medicine
Other circulatory disease
131.8
1
Nonelective
General Medicine
Other fractures
241.1
2
Nonelective
General Medicine
Other upper respiratory disease
449
3
Nonelective
General Medicine
Peripheral and visceral atherosclerosis
345.9
3
Nonelective
General Medicine
Pulmonary heart disease
116.7
1
Nonelective
General Medicine
Secondary malignancies
140.7
2
Nonelective
General Medicine
Syncope
132.5
1
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Elective)
Treatment Specialty
N/A
HSMR
SHMI
N/A
N/A
Slide 89
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Nonelective)
Treatment Specialty
HSMR
SHMI
General Medicine
X
Well Babies
X
X
Slide 90