Northern Lincolnshire and
Goole Hospitals 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
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
Context
A brief overview of the North Lincolnshire and Goole area and Northern Lincolnshire and Goole Hospitals 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.
Northern Lincolnshire and Goole is situated in Yorkshire and the
Humber and services a population of 358,000. In the three
localities covered by the Trust (North East Lincolnshire, North
Lincolnshire, and Goole) non-White ethnic minorities constitute
between 1.9% and 4.0% of the population. Diabetes as well as
road injuries and death are particular sources of concern for the
health of the local population.
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 use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Trust services slightly fewer people than the number
recommended by the Royal College of Surgeons.
North Lincolnshire’s health profile shows that male life
expectancy in the region is significantly lower than the national
average.
The Trust has three hospital sites, the Diana, Princess of Wales
Hospital in Grimsby, Goole and District Hospital, and
Scunthorpe General Hospital. Northern Lincolnshire and Goole
became a Foundation Trust in 2007 and has a total of 853 beds.
The market share of inpatient activity for the three hospitals
varies significantly; Diana, Princess of Wales Hospital and
Scunthorpe General Hospital have much larger market shares
within a 5-, 10-, and 20-mile radius than has Goole and District
Hospital.
A review of ambulance response times showed that the East
Midlands Ambulance Service fails to meet both the 8mins and
the 19mins national response target.
Finally, Northern Lincolnshire and Goole’s HSMR was above the
expected level in 2011 and 2012, and was therefore selected for
this review.
.
Slide 5
Trust Overview
Northern Lincolnshire and Goole became a Foundation Trust in 2007.
The Trust services a population in North Lincolnshire, North East
Lincolnshire, and Goole, of 358,000 people and has three acute
hospitals: Diana, Princess of Wales Hospital; Goole and District
Hospital; and Scunthorpe General Hospital. The Trust has a lower bed
occupancy rate than the national average and offers a large range of
services, having 56,158 inpatients and 49,109 outpatients in 2012.
Trust Status
Foundation Trust (2007)
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
853
69.5%
86%
General and
Acute
774
75.3%
88%
Maternity
79
12.7%
59%
Source: Department of Health: Transparency Website
Inpatient/Outpatient Activity
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
Acute Hospitals
Inpatient Activity
Diana, Princess of Wales Hospital; Goole and
District Hospital; Scunthorpe General Hospital
Source: NHS Choices
Outpatient Activity
Elective
56,158 (53%)
Non Elective
49,109 (47%)
Total
105,267
Total
387,399
(Jan12-Dec12)
Day Case Rate:
83%
Source: Healthcare Evaluation Data (HED)
Finance Information
2012–13 Income
£318m
Departments and Services
2012–13 Expenditure
£304m
2012–13 EBITDA
£14m
2012–13 Net surplus (deficit)
£2m
2013-14 Budgeted Income
£312m
2013-14 Budgeted Expenditure
£300m
2013-14 Budgeted EBITDA
£12m
2013-14 Budgeted Net surplus (deficit)
0.3m
Accident & emergency, Breast Surgery, Cardiology, Children’s &
Adolescent Services, Dental Medicine Specialties, Dentistry and
Orthodontics, Dermatology, Diabetic Medicine, Dermatology,
Diagnostic Imaging, Diagnostic Physiological Measurement, ENT,
Endocrinology and Metabolic Medicine, Gastro Intestinal and Liver
Services, General Medicine, General Surgery, Geriatric Medicine,
Gynaecology, Haematology, Immunology, Maternity Service,
Neurology, Oncology, Ophthalmology, Oral and Maxillofacial Surgery,
Pain Management, Physiotherapy, Respiratory Medicine,
Rheumatology, Urology, Vascular Surgery
Source: Appendix 2 of documents provided by Northern Lincolnshire and Goole Hospitals NHS
Foundation Trust, 03/06/2013.
Source: NHS Choices
Slide 6
Trust Overview continued...
General Medicine and
General Surgery are
the largest inpatient
specialties while
Nursing Episodes and
Trauma &
Orthopaedics are the
largest for outpatients.
Outpatient Activity by Trust
300
1200
250
1000
200
150
Northern Lincolnshire and Goole
105,267
100
Number of Outpatient
Spells (Thousands)
Northern Lincolnshire
and Goole is a medium
sized trust for both
measures of activity,
relative to the rest of
England. Of the 14
trusts selected for this
review, it is the fifth
and sixth largest by the
number of inpatient
and outpatient spells,
respectively.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of
Northern Lincolnshire
and Goole against
national trusts in
terms of inpatient and
outpatient activity.
50
800
600
Northern Lincolnshire and Goole
387,399
400
200
0
0
Trusts
Trusts Covered by Review
Trusts
National Inpatient Activity Curve
Top 10 Inpatient Main Specialties as a
% of Total Inpatient Activity
Trusts Covered by Review
Bottom 10 Inpatient Main Specialties
and Spells
National Outpatient Activity Curve
Top 10 Outpatient Main Specialties as
a % of Total Outpatient Activity
General Medicine
21%
Dermatology
17
Nursing Episode
16%
General Surgery
15%
Neurology
63
Trauma & Orthopaedics
12%
Gynaecology
10%
Clinical Immunology and Allergy
327
Ophthalmology
12%
Paediatrics
9%
Accident & Emergency
386
General Medicine
9%
Urology
7%
Midwifery
518
General Surgery
8%
Trauma & Orthopaedics
6%
Respiratory Medicine
576
Gynaecology
6%
Ophthalmology
5%
Rheumatology
1192
Ear, Nose & Throat
5%
Medical Oncology
5%
Cardiology
1292
Paediatrics
4%
Clinical Haemotology
4%
Anaesthetics
1460
Urology
4%
Geriatric Medicine
3%
Ear, Nose & Throat
1899
Dermatology
3%
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
Slide 7
Northern Lincolnshire and Goole Area Overview
Levels of deprivation vary significantly in Northern Lincolnshire and Goole.
The local population is significantly older than the English population as a
whole. Diabetes, as well as road injuries and deaths, are particular health
concerns in this region. The ethnic composition of the population is less varied
than the national average; Chinese, Bangladeshi and Indians constitute the
largest minorities.
FACT BOX
Population
358,000
The Royal College of Surgeons recommend that the
"...catchment population size...for an acute general hospital
providing the full range of facilities, specialist staff and
expertise for both elective and emergency medical and
surgical care would be 450,000 - 500,000."
IMD
Of 149 English unitary authorities, North East
Lincolnshire is the 39th most deprived, North
Lincolnshire is the 83rd most deprived, and
East Riding of Yorkshire is the 122nd most
deprived.
Ethnic
diversity
In North East Lincolnshire, 2.6% belong to
non-White minorities, as do 4.0% in North
Lincolnshire, and 1.9% in East Riding of
Yorkshire. Chinese, Bangladeshi and Indians,
respectively, are the largest minorities in
these regions..
60-69
Rural or
Urban
All three areas are rural-urban regions.
70-79
Diabetes
In all three regions serviced by this Trust,
people diagnosed with diabetes are
significantly more common than in England
as a whole.
Road
injuries and
deaths
In all three regions serviced by this Trust,
road injuries and deaths are significantly
more common than in England as a whole.
Northern Lincolnshire and Goole Area Demographics
0-9
10-19
20-29
30-39
40-49
50-59
80+
Female/NLG
20%
15%
10%
Female/ENG
5%
Male/NLG
0%
5%
Male/ENG
10%
15%
Source: Office of National Statistics, Census 2011; IMD Source: Index of Multiple Deprivation, 2010
20%
Slide 8
Northern Lincolnshire and Goole and Surroundings Geographic Overview
The map on the right shows the location of the three Trust sites for
Northern Lincolnshire and Goole Hospitals NHS Foundation Trust
in a rural-urban area in Lincolnshire.
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 three wheels on this and the following slide show the market
share of the three hospitals belonging to Northern Lincolnshire and
Goole Hospitals NHS Foundation Trust. From the first wheel it can
be seem that Diana, Princess of Wales Hospital has an 80% market
share of inpatient activity within a 5 mile radius of the Trust. As the
size of the radius is increased, the market share falls to 75% within
10 miles and 27% within 20 miles.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 9
Northern Lincolnshire and Goole and Surroundings Geographic Overview
From the second wheel it can be seen that Scunthorpe
General Hospital has a 74% market share of inpatient
activity within a 5 mile radius of the Trust. As the size of the
radius is increased, the market share falls to 75% within 10
miles and 27% within 20 miles.
The corresponding figures for Goole, represented on the
final wheel, are much lower at just 4%, 3% and 1%. This is
due to the smaller range of services provided at this site.
The three wheels also show that the main competitors for
these hospitals are Hull and East Yorkshire Hospitals NHS
Trust, United Lincolnshire Hospitals NHS Trust, Sheffield
Teaching Hospitals NHS Foundation Trust, Doncaster &
Bassetlaw Hospitals NHS Foundation Trust, York Teaching
Hospital NHS Foundation Trust, Leeds Teaching Hospitals
NHS Trust, and Mid Yorkshire Hospitals NHS Trust.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 10
East Riding, North Lincolnshire and North East Lincolnshire’s Health Profile
Health Profiles, depicted on this slide and the following, are designed to
help local government and health services identify problems in their
areas, and decide how to tackle these issues. They provide a snapshot of
the overall health of the local population, and highlight potential
differences against regional and national averages.
The graph shows the level of deprivation in East Riding, North
Lincolnshire and North East Lincolnshire compared nationally.
Deprivation by unitary authority area
NE Lincolnshire
N Lincolnshire
East Riding
The tables below outline East Riding, North Lincolnshire and North East
Lincolnshire’s health profile information in comparison with the rest of
England.
1. In North
Lincolnshire and East
Riding, almost all
indicators are
performing at the
national level.
However, East Riding
has a higher number of
people and in statutory
homelessness and both
areas have a lower
number of GCSE’s
achieved than the
national average. In
North East
Lincolnshire, all
indicators are
performing below the
national average.
1
Source: Public Health Observatories – area health profiles
Slide 11
East Riding, North Lincolnshire and North East Lincolnshire’s Health Profile
2. Within all three
2
3
areas, smoking in
pregnancy and breast
feeding initiation are
all performing lower
than the national
average. In North
Lincolnshire and North
East Lincolnshire,
teenage pregnancy is
higher than the
national average.
4
3. Adult health and
3
lifestyle indicators
show that smoking is
more common in North
Lincolnshire and North
East Lincolnshire.
These two areas also
have a lower number of
healthy eating adults
than the national
average. In all three
areas, Obesity is also
more common.
Source: Public Health Observatories – area health profiles
Slide 12
East Riding, North Lincolnshire and North East Lincolnshire’s Health Profile
4. Within the disease
and poor health
4
indicators, both North
Lincolnshire and North
East Lincolnshire had
higher levels of alcohol
related hospital stays
and drug misuses than
the national average.
All three areas had
higher levels of diabetes
than the national
average.
Source: Public Health Observatories – area health profiles
Slide 13
East Riding, North Lincolnshire and North East Lincolnshire’s Health Profile
5. All three areas
have a higher number
of road injuries and
deaths than the
national average.
North East Lincolnshire
has a lower life
expectancy for both
males and females,
while North
Lincolnshire has a
lower life expectancy
for males. Smoking
related deaths are more
coomon in North
Lincolnshire and North
East Lincolnshire and
there are a higher
number of early deaths
due to cancer in North
Lincolnshire.
5
Source: Public Health Observatories – area health profiles
Slide 14
Performance of Local Healthcare Providers
To give an informed view of the
Trust’s performance it is
important to consider the
service levels of non-acute local
providers. For example, slow
ambulance response time may
increase the risk of mortality.
The graphs on the right
represent some key
performance indicators for
England’s Ambulance services.
The East Midlands Ambulance
Service fails to meet both the
8min and 19min response
targets, and is, indeed, the
worst performing ambulance
trust in England on both
measures.
Proportion of calls responded to within 8 minutes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Isle of Wight
NHS Trust
South
West
South Central
Western
Midlands
Ambulance
Ambulance Ambulance Service NHS
Service NHS Service NHS Foundation
Foundation
Trust
Trust
Trust
South East
East of
London
North West
Great
North East
Yorkshire East Midlands
Coast
England
Ambulance Ambulance
Western
Ambulance Ambulance Ambulance
Ambulance Ambulance Service NHS Service NHS Ambulance Service NHS Service NHS Service NHS
Service NHS Service NHS
Trust
Trust
Service NHS
Trust
Trust
Trust
Foundation
Trust
Trust
Trust
Ambulance Trust
England
Proportion of calls responded to within 19 minutes
100%
98%
96%
94%
92%
90%
88%
86%
84%
Source: Department of Health: Transparency Website Dec 12
Isle of Wight
NHS Trust
West
London
South East
Yorkshire
South
Great
North East North West South Central
East of
East Midlands
Midlands
Ambulance
Coast
Ambulance
Western
Western
Ambulance Ambulance Ambulance
England
Ambulance
Ambulance Service NHS Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Ambulance Service NHS
Service NHS
Trust
Service NHS
Trust
Service NHS Service NHS
Trust
Trust
Foundation Service NHS
Trust
Trust
Foundation
Foundation
Trust
Trust
Trust
Trust
Trust
Ambulance Trusts
England
Slide 15
Why was Northern Lincolnshire and Goole 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.
The HSMR shows Northern Lincolnshire and
Goole has been above the expected range for the
last two 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: Source: Background to the review and role of the national advisory group, Financial years 2010-11, 2011-12
Slide 16
Why was Northern Lincolnshire and Goole chosen for this review?
The way that levels of observed
deaths that are higher than
expected deaths can be
understood is by using HSMR
and SHMI. Both compare the
number of observed deaths to
the number of expected deaths.
This is different to avoidable
deaths. An HSMR and SHMI of
100 means that there is exactly
the same number of deaths as
expected. This is very unlikely
so there is a range within
which the variance between
observed and expected deaths
is statistically insignificant. On
the Poisson distribution,
appearing above and below the
dotted red and green lines
(95% confidence intervals),
respectively, means that there
is a statistically significant
variance for the trust in
question.
SHMI Time Series
SHMI Funnel Chart
Northern Lincolnshire and Goole
Selected trusts Outside Range
Selected trusts w/in Range
HSMR Time Series
HSMR Funnel Chart
Northern Lincolnshire and Goole
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 Northern
Lincolnshire and Goole’s
HSMR and SHMI are
statistically above the expected
range.
The time series shows both the
HSMR and SHMI have been
consistently above the expected
level, however the HSMR
recently dipped below 100.
Source: Healthcare Evaluation Data (HED); Apr 10-Mar12
Slide 17
Mortality
Slide 18
Mortality
Overview:
Summary:
This section focuses upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The Trust has an overall HSMR of 114 for the period January
2012 to December 2012, meaning that the number of actual
deaths is higher than the expected level, and this is above the
statistically expected range.
The measures identified are being used as a ‘smoke alarm’ for
highlighting potential quality issues. No judgement about the actual
quality of care being provided to patients is being made at this stage,
nor should it be reached by looking at these measures in isolation.
Review areas
Further analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure,
with a similar HSMR of 115, also above the expected range.
Elective admissions are within the expected range, with an
HSMR of 86.
To undertake a detailed analysis of the trust’s mortality, it is
necessary to look at the following areas:
Currently, Northern Lincolnshire and Goole has a SHMI of 114,
which is statistically above the expected range.
• Differences between the HSMR and SHMI;
Similar to HSMR, non-elective admissions are seen to be
contributing primarily to the overall Trust SHMI, with a similar
figure of 114. Elective admission are within the expected range,
with a SHMI of 112.
• Elective and non-elective mortality;
• Specialty and Diagnostic groups; and
• Alerts and investigations.
Data sources
• Healthcare Evaluation Data (HED);
• Health & Social Care Information Centre – SHMI and contextual
indicators;
• Dr Foster – HSMR; and
• Care Quality Commission – alerts, correspondence and findings.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Northern Lincolnshire & Goole had seven high mortality alerts
for diagnostic groups since 2007. All of these fall in three
diagnostic groups: Cerebrovascular, Respiratory Medicine and
Cardiology.
In-depth reviews of stroke services have been undertaken at
each of the Trust’s three hospital sites and a comprehensive
action plan, and regular updates, have been shared with CQC.
These have been ongoing for some years.
The Trust has significantly worse than expected outcomes for
patients aged over 18 who were admitted as an emergency.
Slide 19
Mortality Overview
Mortality
The following overview provides a summary of the Trust’s key mortality areas:
Overall HSMR
Elective mortality (SHMI and HSMR)
Overall SHMI*
Non-elective mortality (SHMI and HSMR)
Weekend or weekday mortality outliers
Palliative care coding issues
Outcome 1 (R17) Respecting and involving e who use services
Emergency specialty groups much worse than expected
30-day mortality following specific surgery / admissions
Emergency specialty groups worse than expected
Mortality among patients with diabetes
Diagnosis group alerts to CQC
Diagnosis group alerts followed up by CQC
SHMI*
Outside expected range of the HSCIC for Mar 11 – Sep 12
Outside expected range
Outside expected range based on Poisson distribution for Dec 11 – Nov 12
Within expected range
Within expected range
*The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model,
which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14
trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the
purposes of this review.
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR,
Care Quality Commission – alerts, correspondence and findings
Slide 20
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 21
SHMI Definition
What is the Summary Hospital-level Mortality Indicator?
The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of
Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a
nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice.
How does SHMI work?
1.
2.
3.
4.
Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
The Indicator will utilise 5 factors to adjust mortality rates by
a.
The primary admitting diagnosis;
b.
The type of admission;
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities);
d.
Age; and
e.
Sex.
All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are
highlighted using a Random Effects funnel plot.
Slide 22
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 23
SHMI overview
Month-on-month time series
The Trust’s SHMI level for the 12 months from Dec 11 to Nov 12 is 114,
which means, as shown below, it is statistically above the expected
range and so classified as an outlier, based on the 95% confidence
interval of the Poisson distribution.
The time series show a general trend of decreasing SHMI both yearon-year and month-on-month.
SHMI funnel chart –12 months
Year-on-year time series
Northern Lincolnshire and Goole
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 24
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for Northern
Lincolnshire and Goole.
As SHMI includes mortalities
that occur within the hospital
and outside of it for up to 30
days following discharge, it is
imperative to understand the
percentage of deaths which
happen inside the hospital
compared to outside. This
may contribute to differences
in HSMR and SHMI
outcomes.
Percentage of patient deaths in hospital
90%
85%
80%
Northern
Lincolnshire and
Goole 72.5%
75%
70%
65%
60%
Trusts selected for review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The data shows that 72.5% of
SHMI deaths occur in
hospital at Northern
Lincolnshire and Goole,
which is less than the
national average of 73.3%.
Slide 25
-
-
-
-
-
-
-
-
-
-
-
Cardiology
Dermatology
Thoracic Medicine
Medical Oncology
Neurology
Rheumatology
Paediatrics
Neonatology
Geriatric Medicine
Obstetrics
Gynaecology
-
-
-
-
-
-
-
-
Neurology
Rheumatology
Paediatrics
Neonatology
Well Babies
Geriatric Medicine (118, 36)
Obstetrics
Gynaecology
Medical Oncology
Clinical Immunology
-
Thoracic Medicine
Diabetic Medicine
-
Clinical Haematology
Dermatology
Endocrinology
-
Cardiology
Gastroenterology
-
Diabetic Medicine
General Medicine (294, 9)
-
Clinical Haematology
Critical Care Medicine
-
Endocrinology
Pain Management
-
Accident & Emergency (A&E)
Gastroenterology
Plastic surgery
-
General Medicine (119, 228)
Oral Surgery
-
Critical Care Medicine
Ophthalmology
-
-
Accident & Emergency (A&E)
Ear, Nose and Throat (ENT)
-
Oral Surgery
Trauma & Orthopaedics
-
Vascular Surgery
Ophthalmology
-
Ear, Nose and Throat (ENT)
Upper Gastrointestinal Surgery
-
Trauma & Orthopaedics
-
-
Vascular Surgery
Colorectal Surgery
-
Upper Gastrointestinal Surgery
-
-
Colorectal Surgery
Breast Surgery
-
Breast Surgery
-
-
Urology
Urology
-
General Surgery
General Surgery
The tree shows that
Northern Lincolnshire
and Goole has a SHMI
of 114 which is above the
expected range.
-
SHMI 114
-
-
Observed deaths that are higher
than the expected
SHMI
NonElective
Key
Diagnosis (100 ; 1 )
Treatment Specialties
SHMI 114
The number of observed
deaths in three specific
areas are highlighted as
being higher than
expected: in General
Medicine for elective
admissions, and General
Medicine and Geriatric
Medicine for nonelective admissions.
These are potential
areas for review.
Elective
Treatment Specialties
SHMI 112
Mortality trees provide
a breakdown of SHMI
into elective and nonelective admissions. The
SHMI score for nonelective admissions has
a greater impact on the
overall indicator due to
a higher number of
expected deaths.
Overall
Trust
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Mortality - SHMI Tree
Slide 26
SHMI sub-tree of specialties
The SHMI sub-tree highlights the specialties for non-elective admissions with a statistically higher SHMI than expected and highlights the diagnostic
groups with at least four more observed deaths than expected; those with fewer than four are shown in the appendix. When identifying areas to review,
it is important to consider the number of deaths as well as the SHMI.
General Medicine has the highest number of greater than expected deaths with chronic obstructive pulmonary disease and bronchiectasis (37),
pneumonia (23), septicemia, and fluid and electrolyte disorders (both 17) seen as the main diagnostic groups contributing to this. Within Geriatric
Medicine, acute cerebrovascular disease has the greatest number of observed deaths above the expected level with 8. Those groups highlighted below
may potentially be areas to be reviewed.
Overall118.2
(114; 281)
Treatment Specialties
Elective (112, 10)
General Medicine (294, 9)
Diagnostic Groups
Geriatric Medicine (124, 28)
General Medicine (120, 161)
Acute cerebrovascular disease
(123, 8)
Acute bronchitis
(171, 7)
Gastrointestinal hemorrhage
(195, 4)
Septicemia
(136, 4)
Paralysis
(308, 5)
Key
Diagnosis (100 ; 1 )
SHMI
Non-elective (114; 270)
Observed deaths that are higher
than the expected
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
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.
Acute and unspecified renal failure
Acute bronchitis
Acute cerebrovascular disease
Aspiration pneumonitis; food/vomitus
Chronic obstructive pulmonary disease and bronchiectasis
Congestive heart failure; nonhypertensive
Fluid and electrolyte disorders
Fracture of neck of femur (hip)
Gastrointestinal hemorrhage
Hypertension with complications and secondary hypertension
Other nervous system disorders
Other upper respiratory disease
Phlebitis; thrombophlebitis and thromboembolism
Pneumonia
Respiratory failure; insufficiency; arrest (adult)
Septicemia
Spondylosis; intervertebral disc disorders; other back problems
Syncope
(117, 6)
(134, 16)
(136, 2)
(114, 5)
(148, 37)
(110, 5)
(170, 17)
(403, 4)
(146, 15)
(366, 4)
(202, 4)
(280, 10)
(225, 5)
(110, 23)
(127, 6)
(122, 17)
(274, 4)
(191, 6)
Slide 27
HSCIC SHMI overview
The Health and Social Care Information Centre (HSCIC) publish
the SHMI quarterly. This official statistic covers a rolling 12
month reporting period using a model based on a 3-year dataset
refreshed quarterly. The earliest publication was in October
2011, for the period from April 2010 to March 2011.
The HSCIC produce two sets of upper and lower limits. One set
uses 99.8% control limits from an exact Poisson distribution
based on the number of expected deaths. The other set uses a
Random effects model applying a 10% trim for over-dispersion,
based on the standardised Pearson residual for each provider
excluding the top and bottom 10% of scores. This latter set is
broader than the Poisson and is the one against which the
HSCIC report whether the SHMI is within, below or above the
expected range.
125
120
115
110
105
100
95
90
85
80
SHMI published by HSCIC, Northern
Lincolnshire & Goole FT
115
Mar-11
113
Jun-11
116
Sep-11
Dec-11
118
117
116
Mar-12
Jun-12
115
Sep-12
Rolling 12 months ending
Lower limit
Upper limit
SHMI
The SHMI for Northern Lincolnshire & Goole was 115 in the year
to Sept-12 (England baseline = 100) and has been above the
expected range for 6 of the 7 periods to date.
Source: Health & Social Care Information Centre – SHMI
Slide 28
HSMR overview
Month-on-month time series
The Trust’s HSMR level for the 12 months from Jan 12 to Dec 12 is
114, which means, as shown below, it is above the expected range and
so classified as an outlier.
The time series shows no general trend for HSMR month-on-month,
however the year-on-year time series shows an upward trend
between 2007/8 and 2011/12, before a decrease in 2012/13.
HSMR funnel plot –12 months
Year-on-year time series
Northern Lincolnshire and Goole
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 29
HSMR Statistics
The table to the right shows
Northern Lincolnshire and
Goole’s HSMR broken down
by admission type.
The breakdown illustrates
the overall HSMR is 114
which is above the expected
range. The table identifies
that non-elective
admissions have an HSMR
above the expected range,
but elective admissions are
within range.
Key – colour by
alert level:
HSMR
Weekend
Week
All
Elective
227
83
86
Non-elective
116
115
115
Red – Higher than
expected (above the
95% confidence
interval)
All
116
113
114
Blue – Within
expected range
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Green – Lower than
expected (below the
95th confidence
interval)
Slide 30
HSMR CCS Diagnostic Group Overview
The darker colour boxes have the highest HSMR while the size
of the boxes represent the number of observed deaths that are
higher than the expected deaths. The larger and darker boxes
within the tree plot will highlight potential areas for further
review.
From this tree plot it is clear that the following areas have the
greatest number of above expected deaths:
•
Pneumonia (HSMR 117 , 38 observed deaths that are
higher than the expected);
•
Acute cerebrovascular disease (140, 35);
•
Chronic obstructive pulmonary disease and bronchiectasis
(138, 27);
•
Septicemia (except in labour) (131, 26); and
•
Acute bronchitis (154, 21).
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 31
Elective
-
-
Paediatrics
Geriatric Medicine
Gynaecology
-
Obstetrics
Gynaecology
Well Babies
-
Neonatology
Geriatric Medicine (124, 28)
Neurology
Paediatrics
-
Medical Oncology
-
Rheumatology
Thoracic Medicine
Slide 32
Observed deaths that are higher
than the expected
HSMR
-
-
Gastroenterology
Rheumatology
General Medicine (120, 161)
-
Critical Care Medicine
Cardiology
-
-
Accident & Emergency (A&E)
Neurology
Clinical Immunology
Oral Surgery
-
-
Ophthalmology
Medical Oncology
Diabetic Medicine
-
Ear, Nose and Throat (ENT)
-
-
Ophthalmology
-
Trauma & Orthopaedics
Thoracic Medicine
Clinical Haematology
Ear, Nose and Throat (ENT)
-
Vascular Surgery
-
-
Trauma & Orthopaedics
-
Upper Gastrointestinal Surgery
Cardiology
Endocrinology
Vascular Surgery
-
Colorectal Surgery
-
Gastroenterology
Upper Gastrointestinal Surgery
-
Breast Surgery
Diabetic Medicine
General Medicine
Colorectal Surgery
-
Urology
-
Plastic Surgery
Breast Surgery
-
Diagnosis (100 ; 1 )
General Surgery
Clinical Haematology
-
Urology
Oral Surgery
General Surgery
NonElective
Within non-elective
admissions General
Medicine and Geriatric
Medicine have the highest
number of observed deaths
above the expected level.
Key
-
-
Treatment Specialties
HSMR 115
-
-
HSMR 114
Treatment Specialties
HSMR 86
The tree shows that the
HSMR for Northern
Lincolnshire and Goole is
114 which is above the
expected range. When
breaking this down by
admission type, it is clear
that it is driven by nonelective admissions, which
are at similar level with
115. Elective admissions is
within the expected range.
Overall
Trust
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Mortality - HSMR Tree
HSMR sub-tree of specialties
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
The HSMR sub-tree indicates the specialties with a statistically higher HSMR than
expected and with diagnostic groups with at least four more observed deaths than
expected. When identifying areas to review, it is important to consider the number of
deaths as well as the HSMR.
The sub-tree indicates that General Medicine has the highest number of above expected
deaths. These are spread over numerous diagnostic groups such as pneumonia (26),
acute cerebrovasvcular disease (26) and chronic obstructive pulmonary disease and
bronchiectasis (23).Within Geriatric Medicine, acute bronchitis and acute
cerebrovasvcular disease have the highest number of above expected deaths with 8.
Overall118.2
(114; 175)
Non-elective (115; 182)
Treatment Specialties
Geriatric Medicine (124, 28)
General Medicine (120, 161)
Acute bronchitis
(238, 8)
Acute bronchitis
(145, 13)
Acute cerebrovascular disease
(129, 8)
Acute cerebrovascular disease
(148, 26)
Chronic obstructive pulmonary disease and bronchie
(176, 5)
Aspiration pneumonitis; food/vomitus
(120, 6)
Cardiac dysrhythmias
(147, 4)
Chronic obstructive pulmonary disease and bronchie
(138, 23)
Congestive heart failure; nonhypertensive
(116, 7)
Fluid and electrolyte disorders
(132, 5)
Gastrointestinal hemorrhage
(167, 15)
Key
Other upper respiratory disease
(322, 7)
Diagnosis (100 ; 1 )
Pleurisy; pneumothorax; pulmonary collapse
(165, 6)
Pneumonia (except that caused by tuberculosis or s
(114, 26)
Respiratory failure; insufficiency; arrest (adult)
(138, 7)
Septicemia (except in labor)
(131, 20)
Skin and subcutaneous tissue infections
(186, 5)
Diagnostic Groups
HSMR
Observed deaths that are higher
than the expected
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Slide 33
HSMR – Dr Foster
The HSMR time series for Northern Lincolnshire and Goole 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 each year
except 2008/09.
Northern Lincolnshire and Goole’s latest SHMI published by the
HSCIC, for Oct 11 to Sept 12, is higher than the Dr Foster HSMR for
the same period.
Dr Foster have made the following adjustments to show the impact
of factors that can affect this comparison:
• Adjustment for palliative care: used the SHMI observed deaths
but changed expected deaths to take account of palliative care.
• Adjustment for in-hospital deaths:
• Removed out-of-hospital deaths from the observed
figure, and
• Reduced expected deaths to only those in-hospital.
Any remaining variances are largely due to:
• The scope of deaths included (SHMI covers all deaths whereas
HSMR covers clinical areas accounting for an average of
around 80% of deaths), and
• The definition of spells, which includes those provider(s) the
death attributes to.
130
Time series of HSMR, Northern
Lincolnshire & Goole FT
125
120
116
118
115
110
108
105
105
100
95
2008/09
2009/10
HSMR
125
2010/11
2011/12
I I95% Confidence interval
Com parison of m ortality m easures,
Northern Lincolnshire & Goole
120
115
115
113
114
110
109
105
100
SHMI
95
SHMI adjusted
for palliative
care
SHMI in
hospital
deaths only
HSMR
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 34
Coding
Diagnosis coding depth
has an impact on the
expected number of
deaths. A higher than
average diagnosis coding
depth is more likely to
collect co-morbidity which
will influence the expected
mortality calculation.
When looking at the depth
of coding for Northern
Lincolnshire and Goole, it
is apparent that the Trust
has an average diagnosis
coding depth below the
national average and the
average of the 14 trusts
covered in this review.
Average Diagnosis Coding Depth
Elective
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Non-elective
6
5
4
3
2
1
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
2012/13
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
National Average Diagnosis Coding Depth
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
Northern Lincolnshire and Goole
Northern Lincolnshire and Goole
2012/13
The elective and nonelective graphs both show
a significant dip in
average diagnosis coding
depth in Q3 2008/2009.
More recently, the
average diagnosis coding
depth has been closer to
the national average but
has still been below the
national level.
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 35
Palliative care
Accurate coding of palliative care is important for
contextualising SHMI and HSMR. HSMR takes into
account that a patient is receiving palliative care, but
SHMI does not.
1.4
Northern Lincolnshire and Goole currently make
average and growing use of palliative care coding on
admissions (by treatment specialty or diagnosis). The
proportion of SHMI deaths with a palliative care code
is also growing but below average.
0.6
Percentage of admissions with palliative
care coding
1.2
1.0
0.8
0.4
0.2
-
Oct-11
Jan-12
Apr-12
Jul-12
Northern Lincolnshire & Goole
20
18
16
14
12
10
8
6
4
2
-
Oct-12
Jan-13
Apr-13
National SHMI publication
Percentage of deaths with palliative care
coding
Oct-11
Jan-12
Apr-12
Jul-12
Northern Lincolnshire & Goole
Oct-12
National
Jan-13
Apr-13
SHMI publication
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 36
Care Quality Commission findings
Emergency specialty groups much worse than expected
Care Quality Commission (CQC) review mortality alerts for
each trust on an ongoing basis. These alerts, which indicate
observed deaths significantly above expected for specialties or
diagnoses, come from different sources based on either HSMR
or SHMI. Where these appear unexplained, CQC correspond
with the trust to agree any appropriate action.
For Northern Lincolnshire and Goole, the common theme that
has arisen across the patient groups alerting since 2007 is
Elderly Care.
No common themes arise from responses to the CQC from the
Trust.
All the Trust’s mortality alerts fall in three diagnostic groups:
Cerebrovascular, Respiratory Medicine and Cardiology. The
Trust has significantly worse than expected outcomes for
patients aged over 18 who were admitted as an emergency.
In-depth reviews of stroke services have been undertaken at
each of the Trust’s three hospital sites and a comprehensive
action plan, and regular updates, have been shared with CQC.
The Northern Lincolnshire Health Community mortality action
plan (September 2012) was developed in response to the high
SHMI indicator. The Trust is developing care bundles. They
also plan to ensure that deteriorating patients are being
actively identified and appropriate action taken via a National
Early Warning Score (NEWS) system .
Sep 11 to Aug 12
4
Trauma and Orthopaedics
Cardiology
Cerebrovascular
Respiratory medicine
Emergency specialty groups worse than expected
Sep 11 to Aug 12
2
Genito-urinary medicine
Miscellaneous
Diagnosis group alerts (2007 to date)
Alerts to CQC
7
Alerts followed up by CQC
5
Recent diagnosis group alerts pursued by CQC
Acute cerebrovascular disease (Jul 12 also Nov 11)
Acute bronchitis (Dec 12)
Any related patient groups alerting more than once since 2007
Acute cerebrovascular disease
Acute bronchitis
Pneumonia
Source: Care Quality Commission – alerts, correspondence and findings
Slide 37
SMRs for Diagnostic and Procedure groups – Dr Foster
The standardised mortality ratio (SMR) is used to calculate the
mortality rate for diagnosis and procedure groups. This is
available for the 56 diagnosis groups that are included in the
HSMR and the 96 procedure groups that are part of the Real
Time Monitoring system.
SMRs are not yet remodelled for the year but are projected,
rebased estimates. SMRs are classified as above expected if
their lower 95% confidence limit exceeds 100 (excluding those
with fewer than four more observed deaths than expected).
From Apr 12 to Mar 13, there were four diagnosis groups and no
procedure group with above expected SMRs in Northern
Lincolnshire and Goole FT, which may highlight potential areas
for review. Two of these diagnosis groups had above expected
mortality for weekend admissions but not for weekday ones:
Acute cerebrovascular disease and Other upper respiratory
disease.
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
4
0
CUSUM alerts
3
2
Diagnosis groups with SMRs above expected
Acute bronchitis
Acute cerebrovascular disease
Other upper respiratory disease
Septicaemia (except in labour)
SMR
Obs – Exp
deaths
143
126
323
140
20
24
8
34
Northern Lincolnshire and Goole had higher than expected
deaths after surgery in the year to March 2013 (52 deaths,
compared with 37 expected).
During the year, Northern Lincolnshire and Goole had two
CUSUM alerts for acute bronchitis and one for other upper
respiratory disease. It also had two alerts for procedure groups
that did not have a high SMR.
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 38
Mortality – other alerts
Northern Lincolnshire & Goole was rated “very high” for
mortality among diabetic patients, in a report published by the
Yorkshire and Humber Public Health Observatory (YHPHO) and
the National Diabetes Information Service.
Mortality among inpatients with diabetes
The Health and Social Care Information Centre 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.
Stroke (high and improving 19% below national rate in 2010/11).
Fractured hip (average but improving 11% below national rate in
2010/11).
Non-elective surgery (not high but improving 6% below national rate in
2010/11).
Northern Lincolnshire & Goole’s 30-day Stroke mortality is high
and improving substantially below the national average in the
data to 2010-11 (published in Feb 2013). It is also below the
national rate of improvement for Fractured hip and non-elective
surgery, although the mortality rate is not high for these groups.
VLAD charts with a negative SHMI trend
(year to Jun-12)
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 further investigation.
Northern Lincolnshire & Goole had such VLAD charts for two
diagnosis group in the year to June 2012: acute cerebrovascular
disease and acute bronchitis.
Rated as “very high” compared to all trusts (2 years to Mar-12).
30-day mortality following specific surgery / admissions
Acute cerebrovascular disease
Acute bronchitis
No. dips to the
lower control limit
3
3
In addition, Northern Lincolnshire & Goole had worse than
expected mortality for Stroke on the Acute Trust Quality
Dashboard (year to Q1 2012-13). It also had high excess deaths
for Acute bronchitis (39 deaths, 64% more than expected), Acute
cerebrovascular disease (35 deaths, 37% more than expected),
Pneumonia (31 deaths, 12% more than expected) and COPD and
bronchiectasis (24 deaths , 29% more than expected) in the
HSCIC’s SHMI to September 2012.
Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.
Slide 39
Patient Experience
Slide 40
Patient Experience
Overview:
Summary:
The following section provides an insight into the Trust’s patient
experience.
Of the 9 measures reviewed within Patient Experience and
Complaints there are two which are rated ‘red’.
Review Areas:
Of the written complaints recorded by the Health and Social
Care Information Centre, 74% related to clinical aspects of care.
This is unusually high.
To undertake a detailed analysis of the Trust’s Patient Experience
it is necessary to review the following areas:
•
Patient Experience, and
•
Complaints.
Data Sources:
•
Patient Experience Survey;
•
Cancer Patient Experience Survey;
•
Peoples’ Voice Summary; and
•
Complaints data.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Three quarters of the individual comments captured by CQC’s
patient voice monitoring were negative (50 out of 67).
Comments highlighted a wide range of issues including
victimisation of patients, pressure not to complain, poor
complaints process, cold food, lack of communication,
disrespectful comments, and lack of respect (particularly for
dementia patients).
Whilst the inpatient survey was rated green overall, the Trust
was below average on responses related to doctors talking in
front of patients as if they were not there, and being treated with
respect and dignity in general.
Slide 41
Patient Experience
Patient Experience
This page shows the Patient Experience measures which are considered to be the most pertinent for this review. Further analysis,
where relevant, is detailed in the following pages.
Inpatient
PEAT : environment
Cancer survey
PEAT : food
PEAT : privacy and dignity
Friends and family test
Complaints about clinical aspects
Patient voice comments
Ombudsman’s rating
N/A
Outside expected range
Within expected range
Slide 42
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
Inpatient Experience Survey
Northern Lincolnshire and Goole performs above average on survey questions relating to staff communication on medication side-effects,
but below average on those relating to the appropriateness of language used by doctors in front of patients and the level of respect shown
by staff towards patients.
Overall
Length of time spent on waiting list
Alteration of admission date by hospital
Length of time to be allocated a bed on a
ward
Overall
Delay of patient discharge
Consistency of staff communication
Information provided on post-discharge
danger signals
Overall
Staff communication on purpose of
medication provided
Patient involvement in decision-making
Staff communication on medication
side-effects
Overall
Clarity of doctors’ responses to
important questions
Language used by doctors in front of
patients
Clarity of nurses’ responses to
important questions
Language used by nurses in front of
patients
Overall
Hospital food
Patient noise levels at night
Degree of privacy provided
Staff noise levels at night
Level of respect shown by staff
Hospital/ward cleanliness
Overall staff effort to ease pain
Above expected range
Source: Patient Experience Survey 2012/13
Within expected range
Below expected range
Slide 43
Patient experience and patient voice
Inpatient Survey
Overall patient experience score: Inpatients 2012
The national inpatient survey 2012 measures a wide range of
aspects of patient experience. A composite ‘overall measure’
is calculated for use in the Outcomes Framework. This
measure uses a pre-defined selection of 20 survey questions
to rate the Trust on aspects including access to services, coordination of care, information & choice, relationship with
staff and the quality of the clinical environment.
•
England Average: 76.5
•
Northern Lincolnshire & Goole: 77.5 (average)
95
90
85
Northern Lincolnshire
and Goole
80
75
70
65
60
55
50
England
average
Cancer Survey
•
Of 58 questions, 1 was in the ‘top 20%’ and five in the
‘bottom 20%’.
The quality risk profiles compiled by the Care Quality
Commission collate comments from individuals and
various sources. In the two years to 31st January 2013,
there were 67 comments on Northern Lincolnshire and
Goole of which 50 were negative (75%). Comments
highlighted a wide range of issues including victimisation
of patients, pressure not to complain, poor complaints
process, cold food, lack of communication, disrespectful
comments, and lack of respect (particularly for dementia
patients).
National
results curve
Source: Patient Experience Survey, Cancer patient experience survey
Complaints Handling
•
Data returns to the Health and Social Care Information
Centre showed 305 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, 74% of complaints related to clinical treatment
(compared to the national average of 47%).
•
A separate report by the Ombudsman, which the Trust
requested, rates the Trust as B-rated for satisfactory
remedies and low-risk of non-compliance. The Trust is
identified as above average for conversion rate of
complaints to trust becoming complaints to the
Ombudsman. The Trust is also above average for poor
explanation, and for factual errors in response. In
Slide 44
addition, it receives a high number of physician
complaints.
Patient Voice
•
Trusts in
this review
Safety and workforce
Slide 45
Safety and Workforce
Overview:
Summary:
The following section provides an insight into the Trust’s
workforce profile and safety record. This section outlines whether
the Trust is adequately staffed and is safely operated.
Northern Lincolnshire and Goole is ‘red rated’ in three of the
safety indicators: MRSA infection rates, pressure ulcer rates and
clinical negligence scheme payments.
Review Areas:
The Trust reported more patient safety incidents and is rated
‘green’. This may be because the Trust is recognising patient
safety incidents more fully and completely than similar trusts. It
recorded 446 incidents reported as either moderate, severe or
death between April 2011 and March 2012 and three ‘never
events’ between 2009 and 2012. Throughout the last 12 months,
Northern Lincolnshire and Goole has been consistently above the
national rate, as well as that of the 14 trusts selected for this
review for new pressure ulcers, breaching the latter rate every
month from June 2012 onwards.
To undertake a detailed analysis of the Trust’s Safety and
Workforce it is necessary to review the following areas:
•
General Safety;
•
Staffing;
•
Staff Survey;
•
Litigation and Coroner; and
•
Analysis of patient safety incident reporting.
Data Sources:
•
Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;
•
Safety Thermometer, Apr 12 – Mar 13;
•
Litigation Authority Reports;
•
GMC Evidence to Review 2013;
•
National Staff Survey 2011, 2012;
•
2011/12 Organisational Readiness Self-Assessment (ORSA);
•
National Training Survey, 2012; and
•
NHS Hospital & Community Health Service (HCHS), monthly
workforce statistics.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Northern Lincolnshire and Goole’s Clinical Negligence payments
exceeded contributions to the ‘risk sharing scheme’ by around
£3.4m in 2009-10, although the situation has improved over the
following two years. They flagged on just one item in the Rule 43
Coroner report.
The Trust is ‘red rated’ in 14 of the workforce indicators. It
notably has sickness absence rates above the national mean and
also spends a greater percentage of its total expenditure on
agency staff than the median. It also has low levels of staff
engagement and has a low score for the training of its doctors.
Slide 46
Safety
This page shows the safety measures which are considered to be the most pertinent for this review. Further analysis, where relevant,
is detailed in the following pages.
Litigation and
Coroner
Specific
safety
Measures
General
Reporting of patient safety incidents
Number of harm incidents reported as ‘moderate, severe or death’ from April ‘11 to March ’12
446
Number of ‘never events’ (2009-2012)
3
Medication error
x
Pressure ulcers
MRSA
“Harm” for all four Safety Thermometer Indicators
C diff
Clinical negligence scheme payments
Rule 43 coroner reports
Outcome 1 (R17) Respecting and involving people who use services
Outside expected range
Within expected range
Slide 47
Safety Analysis
The Trust has reported more patient safety incidents
than similar trusts. Organisations that report more
incidents may have a stronger and more effective safety
culture. Northern Lincolnshire and Goole has a rate of
8.8 for its patient safety incident reporting per 100
admissions.
Northern Lincolnshire and Goole has a higher than
average rate of MRSA infection for the three year
period. Its MRSA infection rate is the 33rd highest out of
143 trusts. Its infection rate relative to other trusts has
improved in 2012, but it remains in the lower third
nationally for its performance levels.
Rate of reported patient safety incidents per 100 admissions (April –
September 2012)
Northern Lincolnshire and Goole
Median rate for large acutes
8.8
6.2
Source: incidents occurring between 1 April 2012 to 30 September
2012 and reported to the National Reporting and Learning System
MRSA 2010 - 2012
Combined z score of rates per bed day
over the 3 separate years
with the value 2 added so that all values are shown as
positive
6.0
5.0
4.0
3 year
z score3.0
+2
Northern Lincolnshire
NLAG
and Goole
2.0
1.0
0.0
Trusts under review
All non specialist trusts
Northern
NLAG
Lincolnshire
and Goole
Slide 48
Safety Incident Breakdown
Since 2009, three ‘never events’ have occurred at Northern Lincolnshire, classified
as such because they are incidents that are so serious they should never happen.
The patient safety incidents reported are broken down into five levels of harm
below, ranging from ‘no harm’ to ‘death’. 70% of incidents which have been
reported at Northern Lincolnshire have been classed as ‘no harm’, with 24% ‘low’,
with 5% ‘moderate’, and 13 and 5 occurrences of incidents classified as ‘severe’ and
‘death’ respectively.
Never Events Breakdown (2009-2012)
Retained foreign object post-operation
3
Total
3
Source: Freedom of information request, BBC http://www.bbc.co.uk/news/health-22466496
When broken down by category, the most regular occurrences of patient incident
at Northern Lincolnshire are in ‘patient accident’ and ‘treatment procedure’.
Breakdown of patient
incidents by degree of harm
Breakdown of patient
incidents by incident type
7000
6000
Medical device / equipment
5790
Consent, communication, confidentiality
Infrastructure
5000
Clinical assessment
Medication
4000
Documentation
Access, admission, transfer, discharge
3000
Implementation of care and ongoing…
2014
2000
Treatment, procedure
All others categories
1000
428
13
5
Severe
Death
0
Patient accident
0
No Harm
Low
Moderate
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
500
1000
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
1500
2000
Slide 49
2500
Pressure ulcers
New pressure ulcers prevalence
Total pressure ulcers prevalence
35
This slide outlines the total
number of pressure ulcers and
the number of new pressure
ulcers broken down by
category for the last 12 months.
Due to the effects of seasonality
on hospital acquired pressure
ulcer rates, the national rate
has been included which allows
a comparison that takes this in
to account. This provides a
comparison against the
national rate as well as the 14
trusts selected for the review.
Throughout the last 12 months,
Northern Lincolnshire and
Goole has been consistently
above the national rate, as well
as that of the 14 trusts selected
for this review, for new
pressure ulcers, breaching the
latter rate every month from
June 2012 onwards.
From the data, it is apparent
that the prevalence rate of total
pressure ulcers for Northern
Lincolnshire and Goole has
seen no definitive trend from
June 2012 onwards.
The data is inclusive of
community services.
2.9%
30
25
20
2.5%
2.0%
1.6%
15
1.8%
1.4%1.4%
1.1%
1.0%1.1%
10
5
3.5%
9.0%
7.7%
80
2.5%
70
2.0%
60
1.5%
50
5.0%
40
4.0%
0.5%
-
10.0%
8.7%
90
3.0%
1.0%
0.0%0.0%
100
0.0%
6.0%
5.7%
4.8%
30
7.0%
5.8%
4.6%
4.8%
6.0%
3.0%
1.6%
20
10
8.0%
7.0%
2.0%
1.0%
0.0%0.0%
-
Category 2
Category 3
Category 4
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
0
0
185
963
985
1038
1010
1086
931
1026
902
1000
0
0
3
19
25
10
11
20
10
14
13
29
Trust new pressure ulcer rate
Selected 14 trusts new pressure
ulcer rate
0%
0%
1.6%
2.0%
2.5%
1.0%
1.1%
1.8%
1.1%
1.4%
1.4%
2.9%
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%
Total pressure ulcer prevalence percentage
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
Number of records submitted
0
0
185
963
985
1038
1010
1086
931
1026
902
1000
Trust total pressure ulcers
0
0
3
74
59
50
58
76
43
60
43
87
Trust total pressure ulcer rate
Selected 14 trusts total pressure
ulcer rate
0.0%
0.0%
1.6%
7.7%
6.0%
4.8%
5.7%
7.0%
4.6%
5.8%
4.8%
8.7%
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%
Source: Safety Thermometer Apr 12 to Mar 13
Slide 50
Litigation and Coroner
Clinical negligence payments
Clinical negligence scheme analysis
2009/10
Northern Lincolnshire and Goole’s Clinical Negligence
payments exceeded contributions to the ‘risk sharing scheme’
by around £3.4m in 2009-10, although the situation has
improved over the following two years.
Coroners’ Rule
2010/11
2011/12
Payouts (£000s)
8,303
6,560
4,056
Contributions (£000s)
4,868
5,408
6,009
Variance between
payouts and contributions
(£000s)
-3,435
-1,152
1,953
The review examined all eight rule 43 bulletins published
since the Coroner's rules were amended in July 2008. These
flagged just one item:
•
“To consider staff training and observation levels for
patients undergoing surgical anastomosis to ensure
staff fully appreciate consequences of anastomic
leakage.”
This item was flagged in the second report published by the
Ministry of Justice, which covered the period April 09 to
September 09, and related to Lincoln County Hospital.
Although this location does not constitute one of the Trust’s
primary sites, the hospital does provide some services for
Northern Lincolnshire and Goole. A response was received
from the Trust, and there are no outstanding rule 43
reports.
Source: Litigation Authority Reports
Slide 51
Workforce
Staff Surveys and
Deanery
Workforce Indicators
This page shows the workforce measures which are considered to be the most pertinent for this review. Further analysis, where
relevant, is detailed in the following pages.
WTE nurses per bed day
Sickness absence- Overall
Medical Staff to Consultant Ratio
2.64
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
1.88
Vacancies –medical
Sickness
absence
-Nursing
staff
Staff to Total Staff Ratio
Outcome
1 (R17)
Respecting
and involving eNon-clinical
who u
Vacancies - Non-medical
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days) 434.37
Staff leaving rates
Nurse Hours per Patient Bed Day
Consultant appraisal rates
Agency spend
Response Rate from National Staff
Survey 2012
Staff Engagement from NSS 2012
Training Doctors – “undermining”
indicator
se services
0.37
8.83
Staff joining rates
Overall Rate of Patient
Safety Concerns
x
Care of patients / service users is my organisation’s top priority
I would recommend my organisation as a place to work
If a friend or relative needed treatment: I would be happy
with the standard of care provided by this organisation
GMC monitoring under “response
to concerns process”
Outside expected range
Within expected range
Slide 52
General Medical Council (GMC) National Training Scheme Survey 2012
Acute Internal 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
Anaesthetics
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…
Emergency 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
Endocrinology and diabetes
mellitus
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 54
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
General Practice
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
Ophthalmology
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 55
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
Otolaryngology
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
Paediatrics
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 56
General Medical Council (GMC) National Training Scheme Survey 2012 continued…
Urology
Trauma and Orthopaedic Surgery
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
In addition to the green outliers displayed, Obstetrics and Gynaecology has one green outlier for workload and Respiratory Medicine
has four green outliers for overall satisfaction, adequate experience, feedback, and access to educational experience.
Green outlier
Within expected range
Red outlier
Slide 57
Workforce Analysis
Northern Lincolnshire and Goole has a patient spell per whole time
equivalent rate of 22, which is below average capacity in relation to the other
trusts in this review and nationally.
The data shows that the Trust’s agency staff costs, as a percentage of total
staff costs, are higher than the median within the region. The data also
illustrates that the Trust has a higher leaving rate than the regional median
but also a higher joining rate than the regional median.
Number of FTEs (Dec 11-Nov 12 average)
Agency Staff (2011/12)
N Lincolnshire and
Goole Expenditure
Percentage of
Total Staff Costs
Median within
Region
£7.3m
3.5%
2.7%
N Lincolnshire
and Goole
Yorkshire and the
Humber SHA Median
Joining Rate
7.2%
6.5%
Leaving Rate
7.0%
6.0%
WTE nurses per bed day December 2012
National Average
1.86
1.96
Source: Health and Social Care Information Centre (HSCIC)
Consultant appraisal rate, 2011/12
Spells per WTE for Acute Trusts
100%
50
45
Northern Lincolnshire
and Goole: 71.5%
80%
40
Spells per WTE
(Sep 11 – Sep 12)
Staff Turnover
Northern Lincolnshire and Goole has a consultant appraisal rate of 71.5%.
N Lincolnshire and Goole
4,892
35
Northern Lincolnshire
and Goole: 22
30
60%
25
40%
20
15
20%
10
5
0%
0
Trusts covered by review
All Trusts
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
Trusts covered by review
All other trusts
Northern Lincolnshire and Goole
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Data based on the appraisal year from April 2011 to March 2012
Slide 58
Workforce Analysis continued…
Northern Lincolnshire and Goole’s total sickness
absence rate is lower than the Yorkshire and the
Humber Strategic Health Authority average,
although it is above the average figure for all
trusts in England. This pattern of exceeding the
national average is replicated in the more
granular medical, nursing, and other staff
categories.
The Trust has a medical staff to consultant ratio
above the national average, although its nurse
staff to qualified ratio is significantly below the
average for all English trusts. In addition,
Northern Lincolnshire and Goole’s registered
nurse hours to patient day ratio is also below the
national mean.
Northern Lincolnshire and Goole’s consultant
productivity rate is below the national average.
The Trust’s 3 month consultant vacancy rate is 3
times the national rate.
3 month Vacancy Rates by
Staff Category
Northern
Lincolnshire
and Goole
(March 2010)
National
Average
Sickness Absence Rates
All Staff
(2011-2012)
N Lincolnshire
and Goole
Yorkshire and the
Humber SHA Average
National Average
4.16%
4.45%
4.12%
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
N Lincolnshire and Goole
National Average
Medical Staff
1.6%
1.3%
Nursing Staff
5.4%
4.8%
Other Staff
5.0%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
N Lincolnshire and Goole
National Average
Medical Staff to Consultant Ratio
2.64
2.59
Nurse Staff to Qualified Staff Ratio
1.88
2.50
Non-Clinical Staff to Total Staff
Ratio
0.37
0.34
Registered Nurse Hours to Patient
Day Ratio *
8.83
8.57
Source: Electronic Staff Record (ESR), Apr 13
*Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Medical Staff
4.5%
1.4%
Non-medial Staff
0.0%
0.4%
Source: The Health and Social Care Information Centre Non-Medical
Workforce Census (Sept 2009), Vacancies Survey March 2010
Workforce indicator calculations are listed in the Appendix.
Consultant Productivity
(Spells/FTE)
Source: Electronic Staff Record (ESR), Apr 13
N Lincolnshire and Goole
National Average
434
492
Slide 59
Workforce Analysis continued…
National Staff Survey results
Northern Lincolnshire and Goole’s
response rate to the staff survey is
significantly below the national
average and has fallen in 2012. The
staff engagement score is below
national average when compared with
trusts of a similar type. Northern
Lincolnshire and Goole is significantly
below the national average for all three
organisational questions.
Northern
Lincolnshire
and Goole
2011
Average for all
trusts
2011
Northern
Lincolnshire
and Goole
2012
Average for all
trusts
2012
Response rate
34%
50%
30%
50%
Overall staff engagement
3.56
3.62
3.61
3.69
Care of patients/service
users is my organisation’s
top priority
54%
69%
52%
63%
I would recommend my
organisation a place to work
45%
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%
55%
60%
Source: National Staff Survey 2011, 2012
Slide 60
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 slightly more patient safety concerns through the survey than the average. These
concerns were shared with the Deanery.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Obstetrics and Gynaecology and Anaesthetics were the programmes with the most below outliers between 2010 and 2012.
Paediatrics was the programme that recorded the most above outliers during the same period. Doctors in training in Anaesthetics
rated handover positively in 2010 and 2011, but rated Induction and Workload poorly.
NTS 2012 Patient Safety Comments
12 doctors in training commented, representing 5.71% 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:
•
Lack of senior supervision, especially out of hours;
•
Poor handover; and
•
Overuse of locum support, of variable ability.
Source: GMC evidence to Review 2013
Slide 61
Deanery Reports
The Yorkshire and the Humber Postgraduate Deanery raised concerns about the Northern Lincolnshire and Goole Hospitals NHS
Foundation Trust in 2012, most of which came out of the National Training Survey. Areas of concern included Anaesthetics and
Paediatrics, senior support in Urology and ENT and policies on handover.
Monitored under the response to concerns process?
Undermining
No, Northern Lincolnshire and Goole is not subject to enhanced
monitoring at the time of the report. The Trust has not been visited
as part of the General Medical Council’s Education Quality
Assurance programme.
For doctors which are undertaking their training at Northern
Lincolnshire and Goole, the Trust has a score of 93 which is below
the national average of 94.
Mean Score on 'Undermining'
105
Northern
Lincolnshire
and Goole
100
95
90
85
80
Trusts covered by review
Source: GMC evidence to Review 2013
Source: National Training Survey 2012
All other non specialist trusts
Northern
NLAG and
Lincolnshire
Goole
Slide 62
Clinical and operational
effectiveness
Slide 63
Clinical and Operational Effectiveness
Overview:
The following section provides an insight in to the Trust’s clinical
and operational performance based on nationally recognised key
performance indicators.
Review Areas:
To undertake a detailed analysis of the Trust’s clinical and
operational performance it is necessary to review the following
areas:
•
Clinical Effectiveness;
•
Operational Effectiveness; and
•
Patient Reported Outcome Measures (PROMs) for the review
areas.
Data Sources:
•
Clinical Audit Data Trust, CQC Data Submission;
•
Healthcare Evaluation Data (HED), Jan – Dec 2012;
•
Department of Health;
•
Cancer Waits Database, Q3, 2012-13; and
•
PROMs Dashboard.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Summary:
Northern Lincolnshire and Goole is at the lower end of the
distribution for the proportion of women receiving ante-natal
steroids, and some way short of the 85% national standard.
Similarly, on reviewing the National Diabetes Inpatient Audit,
the percentage of patients receiving a foot risk assessment
during their stay was low and the percentage of patients
experiencing a severe hypoglycaemic episode was high. They are
also outliers on the hip fracture measure of the percentage of
patients undergoing surgery within 36 hours of admission and
the acute myocardial infarction measure of the percentage of
patients that are prescribed beta blockers on discharge from
hospital following acute myocardial infarction (MI).
The Trust sees 96.1% of A&E patients within 4 hours which is
above the 95% target level. The percentage of patients seen
within 4 hours was relatively consistent during 2012. 95.7% of
patients start treatment within the 18 week target time which is
just above the target level. The percentage achieved is the second
highest amongst the trusts being reviewed.
Northern Lincolnshire and Goole’s crude readmission rate is one
of the lower readmission rates of the trusts in the review as well
as nationally, at 9.9% although the average length of stay is
shorter than that of the national average. Statistically they are
performing above the average level for standardised
readmission rates.
The PROMs dashboard shows that Northern Lincolnshire and
Goole has fluctuating performance across the six measures, but
none of the indicators were outside the 99.8% control limit in
2011-12.
Slide 64
Clinical and Operational Effectiveness
Clinical
effectiveness
This page shows the Clinical and Operational Effectiveness measures which are considered to be the most pertinent for this review.
Further analysis, where relevant, is detailed in the following pages.
Neonatal – women receiving steroids
Coronary angioplasty
Heart failure
Adult Critical care
Peripheral vascular surgery
Lung cancer
Diabetes safety/ effectiveness
Carotid interventions
Bowel cancer
PROMS safety/ effectiveness
Acute MI
Hip fracture - mortality
Joints – revision ratio
Acute stroke
Severe trauma
Elective Surgery
Cancelled OPs
Emergency readmissions
PbR Audit
Operational
Effectivenes
s
RTT Waiting Times
Cancer Waits
A&E Waits
PROMs
Dashboard
Hip Replacement EQ-5D
Knee Replacement EQ-5D
Varicose Vein EQ-5D
Hip Replacement OHS
Knee Replacement OKS
Outcome 1 (R17) Respecting and involving people who use services
Groin Hernia EQ-5D
Outside expected range
Within expected range
Slide 65
Clinical Effectiveness: National Clinical Audits
The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the
clinical audit results we have considered as part of this review.
Clinical Audit
Diabetes
Elective Surgery
Safety Measure
Clinical Audit
Proportion with medication
error
Proportion experiencing
severe hypoglycaemic
episode
Neonatal intensive and special care
(NNAP)
Proportion of women receiving antenatal steroids
Diabetes
Proportion foot risk assessment
Adult Critical Care
Standardised hospital mortality ratio
Proportion of patient reported
post-operative complications
Coronary angioplasty
Acute Myocardial Infarction
Proportion receiving primary PCI
within 90 mins
Elective abdominal aortic aneurysm
post-op mortality
Proportion having surgery within 14
days of referral
Proportion discharged on beta-blocker
Acute Stroke
Proportion compliant with 12 indicators
Heart Failure
Proportion referred for cardiology
follow up
90 day post-op mortality
Peripheral vascular surgery
Adult Critical Care (ICNARC
CMPD)
Effectiveness Measures
Proportion of night-time
discharges
Carotid interventions
Bowel cancer
Hip Fracture
Elective surgery (PROMS)
Severe Trauma
Hip, knee and ankle
Lung Cancer
Source: Clinical Audit Data Trust, CQC Data Submission.
30 day mortality
Proportion operations within 36 hrs
Mean adjusted post-operative score
Proportion surviving to hospital
discharge
Standardised revision ratio
Proportion small cell patients receiving
chemotherapy
Slide 66
Clinical Effectiveness: Clinical Audits
In the National Clinical Audit for Neonatal intensive and
special care (NNAP), a key measure of effectiveness is the
percentage of women receiving ante-natal steroids.
Proportion of women receiving ante-natal steroids
(level 2)
On this measure, Northern Lincolnshire and Goole is at the
lower end of the distribution, and some way short of the
national average.
Northern
Lincolnshire
and Goole
Source: Clinical Audit Data Trust, CQC Data Submission
Slide 67
Clinical Effectiveness: Clinical Audits
National Diabetes Inpatient Audit 2012 for Diana
Princess of Wales Hospital
Each graph looks at patients with diabetes at each hospital in
the country, and ranks the percentage of patients who reported
that they:
• received a foot risk assessment during their stay;
• experienced a severe hypoglycaemic episode (<3mmol/L);
and
• experienced at least one medication error.
The red line in each graph shows where this specific
hospital ranks. The number experiencing at least one
medication error was low and hence not displayed.
Received a foot risk assessment during the
hospital stay 2012
Received a foot risk assessment during the hospital stay 2012
100%
80%
60%
Diana Princess of Wales Hospital
40%
20%
0%
Severe Hypoglycaemic Episode 2012
Severe hypoglycaemic episode 2012
70%
60%
50%
40%
30%
Diana Princess of Wales Hospital
20%
10%
0%
Source: http://www.hscic.gov.uk/catalogue/PUB10506/nati-diab-inp-audi-12-comp.xlsx
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.
Slide 68
Clinical Effectiveness: Clinical Audits
In the National Hip Fracture Database, a key measure of
effectiveness is the percentage of patients undergoing
surgery within 36 hours of admission.
Hip Fracture: % surgery within 36 hours of admission
On this measure, the Northern Lincolnshire and Goole
Trust has two separate sites that are outliers (below the
lower control limits).
% surgery within 36 hours of admission
100%
90%
80%
70%
60%
50%
40%
30%
20%
0
50
100
150
200
250
300
350
400
450
500
550
600
650
No of admissions
Scunthorpe
General
Hospital
Diana Princess of
Wales Hospital
Slide 69
Clinical Effectiveness: Clinical Audits
In the NICOR MINAP audit, a key measure of effectiveness is
the percentage of patients that are prescribed beta blockers on
discharge from hospital following acute myocardial infarction
(MI).
On this measure, Scunthorpe General Hospital is below the
lower control limit.
Percentage of patients prescribed beta blockers on
discharge
100%
95%
90%
85%
80%
75%
Scunthorpe General
Hospital
70%
65%
60%
0
200
400
600
800
1000
1200
1400
1600
Slide 70
PROMs Dashboard
The PROMs dashboard shows that Northern
Lincolnshire and Goole has fluctuating performance
across the six measures, but none of the indicators were
outside the 99.8% control limit in 2011-12.
In 2011/12 the OHS was between two and three
standard deviations below the average.
Hip Replacement OHS
25
England Average
20
N Lincoln and Goole
15
Upper Control Limit
10
Lower Control Limit
5
2
20
11
/1
1
20
10
/1
20
09
/1
0
0
Source: PROMs Dashboard and NHS Litigation Authority
Slide 71
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
Northern Lincolnshire
and Goole sees 96.1%
of A&E patients
within 4 hours which
is above the 95%
target level. However,
the percentage of
patients seen within 4
hours has fallen at the
end of 2012.
95.7% of the patients
are seen within the 18
week target time
which is above the
target level. Their
percentage achieved
is one of the highest
amongst the trusts
being reviewed. In
addition, the time
series shows that
Northern Lincolnshire
and Goole has been
consistently rising
and above the target
rate.
A&E Percentage of Patients Seen
within 4 Hours
105%
Northern Lincolnshire
and Goole 96.1%
100%
95%
90%
85%
80%
Northern Lincolnshire 4 Hour A&E
Waits
Attendances (Thousands)
A&E wait times and
RTT times may
indicate the
effectiveness with
which demand is
managed.
14
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
12
10
8
6
4
2
0
75%
70%
Number of patients seen within 4 hours
Trusts Covered by Review
All Trusts
Patients Not Seen
A&E Target 95%
Seen within 4 hours (%)
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Referral to Treatment (Admitted)
Northern Lincolnshire Referral to
Treatment Performance
105%
100%
Northern Lincolnshire
and Goole 95.7%
100%
95%
95%
90%
90%
85%
85%
80%
75%
Trusts Covered by Review
Source: Department of Health. Feb 13
All Trusts
RTT Target 90%
Referral to Treatment Rate
RTT Target 90%
Source: Department of Health. Apr 12 – Feb 13
Slide 72
Operational Effectiveness – Emergency Readmissions and Length of Stay
The standardised
readmission rate, most
importantly, accounts for
the Trust’s case mix and
shows Northern
Lincolnshire and Goole are
statistically lower than
expected having one of the
lowest standardised
readmission rates of the 14
selected trusts.
Northern Lincolnshire and
Goole’s average length of
stay is 4.2 days, which is
shorter than the national
mean average of 5.2 days.
Standardised 30-day Readmission
Rate
25%
Crude Readmission Rate
Northern Lincolnshire and
Goole’s crude readmission
rate is among the lower
readmission rates of the
trusts in the review as well
as nationally, at 9.9%.
Crude Readmission Rate by Trust
20%
15%
Northern Lincolnshire
and Goole 9.9%
10%
5%
0%
Trusts Covered by Review
All Trusts
Northern Lincolnshire and Goole
Selected trusts Outside
Selected trusts w/in Range
Average Length of Stay by Trust
10
9
Spell Duration (Days)
Readmission rates may
indicate the
appropriateness of
treatment offered, whilst
average length of stay may
indicate the efficiency of
treatment.
8
7
6
Northern Lincolnshire
and Goole 4.2
5
4
3
2
1
0
Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12
Trusts Covered by Review
All Trusts
Slide 73
Leadership and
governance
Slide 74
Leadership and governance
Overview:
Summary:
This section provides an indication of the Trust’s governance
procedures.
Following a consultation and restructuring in July 2011, the
Trust Board and management structures within the Trust have
been relatively stable.
Review Areas:
To provide this indication of the Trust’s leadership and
governance procedures we have reviewed the following areas:
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Board sub-committees with responsibility for quality and
governance are the Trust Governance and Assurance Committee
(TGAC) and the Quality & Patient Experience Committee
(QPEC). These sub-committees are chaired by a non-executive
director.
The Trust has a green governance rating from Monitor and is
compliant with all CQC outcomes. An unannounced inspection
was conducted by the CQC in February 2013 and the Trust
awaits the outcome of this review.
Key risks for the Trust relate to mortality, activity levels,
financial pressures, recruitment, training, health care acquired
infections and pressure ulcers.
The latest serious incident report (for the period 1 Nov 2012 to 8
Feb 2013) has identified 44 serious incidents including two never
events (retained swab and suboptimal care).
Slide 75
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 76
Leadership and governance
Trust Board
A consultation “Fit for the Future” saw a revised management structure being introduced at the Trust from July 2011. This included
changes to the directorate structures and to management.
All roles within the Board are substantive.
The Chief Nurse is the Board lead for quality and patient experience, whilst the Medical Director is the Board lead for mortality.
Governance and clinical structures
The Trust has quality as a key corporate priority and patient safety and quality are standing items on the Trust Board agenda. The Trust
Board routinely considers specific risk / quality issues and receives minutes from Board Sub-Committees including the Trust Governance
and Assurance Committee (TGAC) and the Quality & Patient Experience Committee (QPEC), which in turn receive information on specific
risk / quality risk issues from the sub-groups which report to them including the local level / Group governance committees. These subcommittees are chaired by non-executive directors.
To strengthen the governance arrangements in the Trust, a new Directorate of Clinical and Quality Assurance was established in
September 2012. This directorate is led by the Director of Clinical and Quality Assurance.
A diagram of board members and committee structure can be found in the Appendix.
Slide 77
Leadership and governance
Trust Strategic Priorities
1.
The Trust will clearly define the quality of care patients can expect to receive.
2.
The Trust will develop robust systems to measure the quality of care delivered.
3.
The Trust will publish data on the quality of care it delivers to its patients.
4.
The Trust will develop incentive systems for those services who demonstrate high quality care.
5.
The Trust will create a culture where raising standards is the norm.
6.
The Trust will ensure systems are in place to safeguard quality.
7.
The Trust will stay ahead and be innovative.
External Reviews and Regulation
Monitor amended the governance risk rating for the Trust from amber-red to green in August 2012 due to a return to compliance with
healthcare targets in Q1 2012/13.
All inspections by the Care Quality Commission have indicated that the Trust is compliant with all outcomes. The CQC website notes that
Goole & District Hospital has not yet been inspected, but that one or more of the Trust’s sites is currently subject to an inspection, the results
of which will be published shortly.
The Trust has also had a number of external reviews, which are summarised in the following pages.
A diagram of board members and committee structure can be found in the Appendix.
Slide 78
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified
risks
Mortality
Trust response
The Trust recognises that mortality is its foremost risk. Mortality performance compared to peers is identified as the primary risk
indicator for service care. Though the Trust’s crude mortality rate and RAMI continue to improve over time, the comparative
position with peer organisations and nationally for SHMI remains outside normal parameters. The Trust has taken a number of
steps, including:
• Appointing an executive lead for mortality (Medical Director):
• Developing and regularly reviewing a mortality strategy and action plan;
• Developing a community wide action plan, monitored by the community wide SHMI / Mortality Group;
• Using information to identify priority areas for action; these workstreams are now clinically led;
• Hosting multi-disciplinary workshops on mortality;
• Developing action plans for stroke and acute bronchitis; diagnoses identified as outliers;
• Implementation of NEWS and SBAR;
• A back to basics campaign; and
• Work to review and improve coding processes and practice.
Accelerated demand is pressuring service capacity – activity rates continue to reflect ongoing increases in underlying
demographic demand, which exceed projections drawn up by commissioners. This forces excessive occupancy rates. This has
been raised regularly by the Trust with Commissioners, who in turn commissioned work from BCG Consulting that highlighted an
association between high bed occupancy rates and increased mortality.
Activity
Delayed Transfers of Care, particularly at the DPOW site, arising from inadequate community and social care are quality issues
in themselves, but also have a wider impact on effective utilisation of resources for all patients, building delays back through the
acute system. The Trust has been proactive in bringing forward plans for increased intermediate care capacity, but wider issues
across other parts of the health economy have created obstacles to rapid progress.
Steps are also being taken to implement the recommendations from the Emergency Care Intensive Support Team (ECIST) visit
(see below) including early senior review and management plan.
Fortnightly/ weekly emergency care meetings to look at the whole patient journey including community services and social care
are being held.
Slide 79
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified
risks
Financial
Trust response
Ongoing pressures on Trust finances arising from cumulative impact of efficiency savings targets, compounded by other contract
income restrictions such as the marginal rate funding of non-elective activity, non-payment for additional activity above contract
baselines, and the potential for income penalties for an increased range of service targets. The Trust has to date protected, as far
as possible, frontline staffing levels, but this cannot continue indefinitely, without community-wide service re-design which is
being led by Sustainable Services.
Staff recruitment has proved problematic in some medical staffing areas, particularly areas of A&E and Acute Medicine. This
reflects national problems and remains a key action area that the Trust is pursuing. This has resulted in increased use of internal
staff cover and locum and agency usage. The Trust is currently engaging with the Deanery with regards to fill rates of training
posts. The most recent cohort had 300 vacancies with the Deanery failing to fill 60. This has placed additional strain on the Trust
to fill medical vacancies. Nursing recruitment is less problematic, but still puts considerable pressure on bank nursing resources,
and necessitates some agency use.
Recruitment / training
The Trust recognises that appropriately skilled and trained staff is key to assuring the quality of care and treatment but
acknowledges that mandatory training compliance is not currently where we need it to be. A review of the Trust’s Mandatory
Training Policy and Training Needs Analysis (TNA) was completed during 2012/13. A revised TNA has been agreed, supported
by an electronic Mandatory Training Information System. The aim of the revised Training Needs Analysis and System is to
demystify mandatory training and enable individual members of staff to quickly and easily identify the mandatory training
requirements of their role, whilst also over time offering a more robust monitoring and reporting system. A key focus for 2013/14
will be on ensuring an increase in compliance with mandatory training requirements. Compliance will be monitored by the
Executive Team and regular reports provided to the Trust Board.
Slide 80
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified
risks
Trust response
Health care acquired
infections
At the end of 2012/13, the Trust had incurred 37 C.difficile infections against a trajectory of 34 and against a backdrop of
considerable activity pressures during the latter part of 2012/13. Of those incidents:
•
All were subjected to RCA/DIPC review and 26 of 37 were deemed to be not preventable;
•
2 cases that occurred were repeat specimens that had also been previously reported and 6 cases were associated/identified
as part of norovirus outbreak investigations.
The Trust limit for C.difficile for 2013/14 is 30. A Trust wide C.difficile action plan is in place which is monitored by the Infection
Control Committee and the Trust Board. Other work to support this includes the introduction of site specific C.difficile action
groups and the development of local action plans.
Pressure ulcers
Avoidable harm due to Pressure Ulcers: the Trust recognises that there is still work to do in this area. The Monthly Pressure
Ulcer Group has been refocused and is chaired by the Chief Nurse and has NED representation. The Chief Nurse holds weekly
meetings with key internal staff to remove obstacles to progress. There is monthly NED challenge of pressure ulcers and
processes are robust.
Slide 81
Leadership and governance – other areas for further review
External Reviews
CQC inspections of Diana Princess of Wales Hospital (June 2012) and Scunthorpe General Hospital (October 2012) have not identified any
concerns. Goole & District Hospital has not yet been inspected by the CQC. The CQC website notes that they are currently conducting checks
on one or more of the Trust’s locations, the results of which will be published following the completion of this review.
The Trust has had a number of external reviews, including:
•
A review by Transforming Health Limited in April 2012 which aimed to identify the drivers behind the Trust’s raised mortality.
This report noted that “up until the exceptionally high SHMI published in October 2011, NLG were NOT giving mortality a high
enough priority, perhaps because they did not feel they were a significant national outlier. Reaction was initially slow at senior
level and largely focused on the technical issues but has now started to accelerate and the work of the Mortality Task Group in
particular seems much more focused and has achieved some clinical leadership buy in.” The Trust Board has concluded that the
conclusions of this report were not justified, but that with the benefit of hindsight, more might have been done sooner to move the
mortality position.
•
ECIST visited the Trust in March 2013 to support the Trust in meeting its 4 hour A&E target. This visit was carried out at the
request of the Trust, which is currently awaiting the final report from this review.
•
The Trust commissioned external reviews of its Board assurance and self-certification process in both 2011 and 2012 and will do
so again during 2013. The reviews were undertaken by KPMG. Whilst no significant control issues were identified, some actions
were identified for further strengthening the Trust’s arrangements and these have been implemented. The 2013 review is about to
commence.
Slide 82
Leadership and governance – other areas for further review
Cost Improvement Programme
A paper presented to the Finance Committee in March 2013 indicated that the Trust has an in year financial challenge of £20.3m. Of this,
the Trust considers that £15.3m of this challenge can be met in 2013/14 by cost improvement programmes. At the date this paper was
drafted, the Trust had identified £13.6m for which there were detailed plans or special measures processes in place.
Each identified CIP is reviewed by the Chief Nurse for impact on quality. Each CIP is assessed for clear supporting evidence and
involvement from staff. Any transformational schemes are assessed for evidence of a clear business case and associated quality impact
assessment. A framework has been devised to assess each CIP, which considers:
•
Quality features in the CIP;
•
Risks to quality clearly identified;
•
Sufficient leadership to ensure delivery of quality;
•
Clear escalation processes to define quality issues; and
•
Quality information used in the CIP.
Slide 83
Appendix
Slide 84
Trust Map
Source: Northern Lincolnshire and Goole Hospitals NHS Foundation Trust webpage
Slide 85
Trust Map
Source: Northern Lincolnshire and Goole Hospitals NHS Foundation Trust webpage
Slide 86
Trust Map
Source: Northern Lincolnshire and Goole Hospitals NHS Foundation Trust webpage
Slide 87
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 88
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
HED
ESR
ESR
ESR
ESR
HED
ESR
ESR
HED
Note: ESR Data only includes substantive staff.
Slide 89
Board members
Slide 90
Committee Structure
Slide 91
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 92
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 93
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Elective
300 - General medicine
109 - Acute cerebrovascular disease
Elective
300 - General medicine
13 - Cancer of stomach
Elective
300 - General medicine
150 - Liver disease; alcohol-related
Elective
300 - General medicine
16 - Cancer of liver and intrahepatic bile duct
Elective
300 - General medicine
2 - Septicemia (except in labor)
Elective
300 - General medicine
252 - Malaise and fatigue
Elective
300 - General medicine
259 - Residual codes; unclassified
Elective
300 - General medicine
42 - Secondary malignancies
Elective
300 - General medicine
58 - Other nutritional; endocrine; and metabolic disorders
Elective
300 - General medicine
Non-elective
Observed Deaths that are
higher than the expected
SHMI
837.08
3
1399.29
1
272.03
1
1274.77
1
360.86
1
2593.23
1
37825.85
1
615.42
2
1071
1
59 - Deficiency and other anemia
370.13
1
300 - General medicine
100 - Acute myocardial infarction
107.53
2
Non-elective
300 - General medicine
102 - Nonspecific chest pain
135.3
1
Non-elective
300 - General medicine
106 - Cardiac dysrhythmias
117.72
2
Non-elective
300 - General medicine
11 - Cancer of head and neck
155.3
1
Non-elective
300 - General medicine
114 - Peripheral and visceral atherosclerosis
122.32
1
Non-elective
300 - General medicine
12 - Cancer of esophagus
132.97
1
Non-elective
300 - General medicine
123 - Influenza
3692.49
2
Non-elective
300 - General medicine
132 - Lung disease due to external agents
165.52
1
Non-elective
300 - General medicine
135 - Intestinal infection
159.28
3
Non-elective
300 - General medicine
138 - Esophageal disorders
142.29
1
Non-elective
300 - General medicine
14 - Cancer of colon
166.09
1
Non-elective
300 - General medicine
141 - Other disorders of stomach and duodenum
232.42
1
Non-elective
300 - General medicine
146 - Diverticulosis and diverticulitis
142.51
1
Non-elective
300 - General medicine
148 - Peritonitis and intestinal abscess
420.94
1
Non-elective
300 - General medicine
15 - Cancer of rectum and anus
192.81
1
Slide 94
SHMI Appendix
Observed Deaths that are
higher than the expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General medicine
150 - Liver disease; alcohol-related
123.33
3
Non-elective
300 - General medicine
152 - Pancreatic disorders (not diabetes)
169.05
1
Non-elective
300 - General medicine
158 - Chronic renal failure
169.27
1
Non-elective
300 - General medicine
159 - Urinary tract infections
105.9
3
Non-elective
300 - General medicine
16 - Cancer of liver and intrahepatic bile duct
152.74
2
Non-elective
300 - General medicine
161 - Other diseases of kidney and ureters
864.1
1
Non-elective
300 - General medicine
163 - Genitourinary symptoms and ill-defined conditions
336.67
1
Non-elective
300 - General medicine
17 - Cancer of pancreas
134.22
2
Non-elective
300 - General medicine
199 - Chronic ulcer of skin
264.4
2
Non-elective
300 - General medicine
204 - Other non-traumatic joint disorders
175.98
1
Non-elective
300 - General medicine
211 - Other connective tissue disease
153.42
2
Non-elective
300 - General medicine
230 - Fracture of lower limb
1329.61
2
Non-elective
300 - General medicine
234 - Crushing injury or internal injury
1045.15
2
Non-elective
300 - General medicine
235 - Open wounds of head; neck; and trunk
167.1
1
Non-elective
300 - General medicine
239 - Superficial injury; contusion
184.18
3
Non-elective
300 - General medicine
242 - Poisoning by other medications and drugs
168.45
2
Non-elective
300 - General medicine
243 - Poisoning by nonmedicinal substances
483.22
1
Non-elective
300 - General medicine
248 - Gangrene
247.5
1
Non-elective
300 - General medicine
251 - Abdominal pain
159.71
1
Non-elective
300 - General medicine
252 - Malaise and fatigue
283.2
3
Non-elective
300 - General medicine
259 - Residual codes; unclassified
235.49
2
Non-elective
300 - General medicine
26 - Cancer of cervix
233.54
1
Non-elective
300 - General medicine
32 - Cancer of bladder
184.25
1
Non-elective
300 - General medicine
35 - Cancer of brain and nervous system
202.66
2
Non-elective
300 - General medicine
38 - Non-Hodgkin`s lymphoma
435.63
3
Slide 95
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
300 - General medicine
44 - Neoplasms of unspecified nature or uncertain behavior
Non-elective
300 - General medicine
48 - Thyroid disorders
Non-elective
300 - General medicine
Non-elective
Observed Deaths that are
higher than the expected
SHMI
331.65
1
204.4
1
50 - Diabetes mellitus with complications
127.78
1
300 - General medicine
51 - Other endocrine disorders
134.27
2
Non-elective
300 - General medicine
68 - Senility and organic mental disorders
127.16
2
Non-elective
300 - General medicine
69 - Affective disorders
1013.98
1
Non-elective
300 - General medicine
71 - Other psychoses
115.32
1
Non-elective
300 - General medicine
72 - Anxiety; somatoform; dissociative; and personality disorders
211.11
1
Non-elective
300 - General medicine
243.47
1
Non-elective
300 - General medicine
76 - Meningitis (except that caused by tuberculosis or sexually transmitted disease)
77 - Encephalitis (except that caused by tuberculosis or sexually transmitted
disease)
490.34
1
Non-elective
300 - General medicine
78 - Other CNS infection and poliomyelitis
544.05
1
Non-elective
300 - General medicine
8 - Other infections; including parasitic
465.44
1
Non-elective
300 - General medicine
89 - Blindness and vision defects
683.05
1
Non-elective
430 - Geriatric medicine
100 - Acute myocardial infarction
122.05
1
Non-elective
430 - Geriatric medicine
101 - Coronary atherosclerosis and other heart disease
231.99
1
Non-elective
430 - Geriatric medicine
103 - Pulmonary heart disease
188.57
1
Non-elective
430 - Geriatric medicine
127 - Chronic obstructive pulmonary disease and bronchiectasis
123.84
3
Non-elective
430 - Geriatric medicine
133 - Other lower respiratory disease
166.45
1
Non-elective
430 - Geriatric medicine
137 - Diseases of mouth; excluding dental
8063.58
1
Non-elective
430 - Geriatric medicine
145 - Intestinal obstruction without hernia
1918.36
1
Non-elective
430 - Geriatric medicine
150 - Liver disease; alcohol-related
293.98
1
Non-elective
430 - Geriatric medicine
151 - Other liver diseases
167.51
1
Non-elective
430 - Geriatric medicine
154 - Noninfectious gastroenteritis
183.16
1
Non-elective
430 - Geriatric medicine
199 - Chronic ulcer of skin
243.63
2
Non-elective
430 - Geriatric medicine
204 - Other non-traumatic joint disorders
563.06
2
Slide 96
SHMI Appendix
Observed Deaths that are
higher than the expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
430 - Geriatric medicine
205 - Spondylosis; intervertebral disc disorders; other back problems
208.68
1
Non-elective
430 - Geriatric medicine
211 - Other connective tissue disease
203.19
1
Non-elective
430 - Geriatric medicine
237 - Complication of device; implant or graft
223.56
1
Non-elective
430 - Geriatric medicine
238 - Complications of surgical procedures or medical care
199.17
1
Non-elective
430 - Geriatric medicine
245 - Syncope
282.42
1
Non-elective
430 - Geriatric medicine
248 - Gangrene
506.84
2
Non-elective
430 - Geriatric medicine
250 - Nausea and vomiting
265.05
1
Non-elective
430 - Geriatric medicine
252 - Malaise and fatigue
485.83
2
Non-elective
430 - Geriatric medicine
33 - Cancer of kidney and renal pelvis
294.73
1
Non-elective
430 - Geriatric medicine
38 - Non-Hodgkin`s lymphoma
410.23
2
Non-elective
430 - Geriatric medicine
49 - Diabetes mellitus without complication
309.97
1
Non-elective
430 - Geriatric medicine
52 - Nutritional deficiencies
421.88
1
Non-elective
430 - Geriatric medicine
54 - Gout and other crystal arthropathies
1343.56
1
Non-elective
430 - Geriatric medicine
68 - Senility and organic mental disorders
134.95
1
Non-elective
430 - Geriatric medicine
71 - Other psychoses
503.69
3
Non-elective
430 - Geriatric medicine
78 - Other CNS infection and poliomyelitis
716.5
1
Non-elective
430 - Geriatric medicine
423.18
1
Non-elective
430 - Geriatric medicine
96 - Heart valve disorders
97 - Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by
tuberculosis or sexually transmitted disease)
1004.64
1
Slide 97
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
300 - General medicine
Acute myocardial infarction
HSMR
107.7
2
Non-elective
300 - General medicine
Cancer of bladder
334.4
1
Non-elective
300 - General medicine
Cancer of colon
155.3
1
Non-elective
300 - General medicine
Cancer of pancreas
127
1
Non-elective
300 - General medicine
Chronic ulcer of skin
165.2
1
Non-elective
300 - General medicine
Complication of device; implant or graft
154.9
1
Non-elective
300 - General medicine
Fracture of neck of femur (hip)
212.8
2
Non-elective
300 - General medicine
Intracranial injury
113.4
1
Non-elective
300 - General medicine
Liver disease; alcohol-related
123.6
3
Non-elective
300 - General medicine
Non-Hodgkin`s lymphoma
503.8
2
Non-elective
300 - General medicine
Noninfectious gastroenteritis
120.4
2
Non-elective
300 - General medicine
Peripheral and visceral atherosclerosis
137.9
1
Non-elective
300 - General medicine
Secondary malignancies
112.8
2
Non-elective
300 - General medicine
Syncope
134.8
2
Non-elective
300 - General medicine
Urinary tract infections
103.5
1
Non-elective
430 - Geriatric medicine
Cardiac dysrhythmias
164.5
1
Non-elective
430 - Geriatric medicine
Chronic ulcer of skin
214.9
1
Non-elective
430 - Geriatric medicine
Coronary atherosclerosis and other heart disease
322.9
1
Non-elective
430 - Geriatric medicine
Gastrointestinal hemorrhage
205.5
3
Non-elective
430 - Geriatric medicine
Intestinal obstruction without hernia
3250
1
Non-elective
430 - Geriatric medicine
Noninfectious gastroenteritis
444
2
Non-elective
430 - Geriatric medicine
Other gastrointestinal disorders
235.3
2
Non-elective
430 - Geriatric medicine
Other liver diseases
437.4
2
Non-elective
430 - Geriatric medicine
Pneumonia (except that caused by tuberculosis or s
103.8
1
Non-elective
430 - Geriatric medicine
Pulmonary heart disease
197.8
1
Non-elective
430 - Geriatric medicine
Septicemia (except in labor)
130.2
3
Non-elective
430 - Geriatric medicine
Syncope
289.8
1
Slide 98
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Elective)
Treatment Specialty
General Medicine
HSMR
SHMI
X
Slide 99
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Non-elective)
Treatment Specialty
HSMR
SHMI
General Medicine
X
X
Geriatric Medicine
X
X
Slide 100