th

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.
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
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

Sherwood Forest Hospitals NHS Foundation Trust
Context
A brief overview of the Nottinghamshire area and Sherwood Forest 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

Slide 4

Context
Overview:
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.
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 30 th Jan, 2013;
• Department of Health: Transparency Website, Dec 12;
• Healthcare Evaluation Data (HED);
• NHS Choices;
• Office of National Statistics, 2011 Census data;
• Index of Multiple Deprivation, 2011;
• © Google Maps;
• Public Health Observatories – Area health profiles; and
• Background to the review and role of the national advisory group.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Summary:
Sherwood Forest is located in Nottinghamshire, with its main sites placed in Ashfield and in Newark and Sherwood, and services a population of 400,000 people. In Nottinghamshire,
4.5% of the population belong to non-White ethnic minorities;
Indians constitute the largest single minority with 0.9%.
Smoking in pregnancy is the single largest health-related concern in Ashfield, Mansfield, Newark and Sherwood, where the proportion of the population gaining at least a C in five or more GSCEs is also significantly lower than in the country as a whole.
The Trust services slightly fewer people than the number recommended by the Royal College of Surgeons.
Sherwood Forest has two main hospitals sites, the acute King’s
Mill Hospital in Ashfield, and the community hospital in
Newark. Sherwood Forest became a Foundation Trust in 2007 and has a total of 744 beds with a bed occupancy rate above the national average. The market share of the Trust for inpatient activity is 69% within a 5 mile radius, falling to 37% within a 10 mile radius, and 9% within a 20 mile radius.
A review of ambulance response times showed that East
Midlands Ambulance Service fails to meet both the 8mins and the 19mins national response target.
Finally, Sherwood Forest’s HSMR was above the expected level in 2011 and 2012, and the Trust was therefore selected for this review.
Slide 5

Trust Overview
Sherwood Forest Hospitals NHS Foundation Trust has two hospital sites, King’s Mill Hospital is an acute hospital, and Newark. The Trust gained foundation status in 2007 and had a net deficit in its 2012-13 budget of £15m. The occupancy rate for the Trust’s 744 beds is above the national average. The Trust offers a large range of services and in 2012 treated a total of almost 85,000 inpatients, as well as almost 340,000 outpatients.
Trust Status
General and
Acute
Foundation Trust (2007)
Number of Beds and Bed Occupancy
Total
Maternity
Beds
Available
744
695
48
Percentage
Occupied
94.6%
95.1%
88.2%
Source: Department of Health: Transparency Website
(Oct12-Dec12)
National
Average
86%
88%
59%
Inpatient/Outpatient Activity (Jan12-Dec12)
Sherwood Forest Hospitals NHS Foundation Trust
Acute Hospital King’s Mill Hospital
Inpatient Activity Elective
Non-Elective
40,456 (48%)
44,247 (52%)
Day Case Rate:
80%
Community Hospital Newark Hospital
Total
84,703
Outpatient Activity Total
338,651
Source: NHS Choices
Source: Healthcare Evaluation Data (HED)
Finance Information Departments and Services
2012 –2013 Income
2012 –2013 Expenditure
2012 –2013 EBITDA
2012 –2013 Net surplus (deficit)
2013-14 Budgeted Income
2013-14 Budgeted Expenditure
2013-14 Budgeted EBITDA
£255m
£243m
£13m
(£15m)
N/A
N/A
N/A
2013-14 Budgeted Net surplus (deficit) N/A
Source: Sherwood Forest Hospitals NHS Foundation Trust Financial Performance Report, submitted for board meeting of 25 April 2013.
A map of King’s Mill Hospital is included in the Appendix.
Accident & Emergency, Allergy Services, Breast Surgery, Cardiology,
Children’s & Adolescent Services, Dentistry and Orthodontics, Dental
Medicine Specialties, Dermatology, Diabetic Medicine, Diagnostic
Endoscopy, Diagnostic Physiological Measurement, ENT,
Endocrinology and Metabolic Medicine, Gastrointestinal and Liver
Services, General Medicine, General Surgery, Gynaecology,
Haematology, Maternity Service, Minor Injuries Unit, Neurology,
Occupational Therapy Services, Older People’s Services,
Ophthalmology, Oral and Maxillofacial Surgery, Orthopaedics,
Orthotics and Prosthetics, Pain Management, Physiotherapy, Plastic
Surgery, Podiatry, Respiratory Medicine, Rheumatology, Sleep
Medicine, Urology, Vascular Surgery
Source: NHS Choices
Slide 6

Trust Overview continued...
The graphs show the relative size of
Sherwood Forest against national trusts in terms of inpatient and outpatient activity.
Sherwood Forest 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 tenth and eighth largest by the number of inpatient and outpatient spells, respectively.
300
250
200
150
100
50
0
Inpatient Activity by Trust
Trusts Covered by Review
Sherwood Forest
84,703
Trusts
National Inpatient Activity Curve
Top 10 Inpatient Main Specialties as a
% of Total Inpatient Activity
General Medicine
General Medicine and
Gynaecology are the largest inpatient specialties while
Trauma &
Orthopaedics and
Ophthalmology are the largest for outpatients.
Gynaecology
General Surgery
Paediatrics
Trauma and Orthopaedics
Urology
Gastroenterology
Dermatology
16%
16%
13%
9%
9%
5%
5%
3%
Paediatric Surgery
Midwifery
Neurology
Rheumatology
Rehabilitation
Plastic Surgery
Accident & Emergency
Anaesthetics
1200
1000
800
600
400
200
0
Outpatient Activity by Trust
Trusts Covered by Review
Bottom 10 Inpatient Main Specialties and Spells
16
113
168
201
288
433
534
993
Sherwood Forest
Trusts
338,651
National Outpatient Activity Curve
Top 10 Outpatient Main Specialties as a % of Total Outpatient Activity
Trauma and Orthopaedics
Ophthalmology
General Medicine
Allied Health Professional Episode
Gynaecology
Ear, Nose & Throat (ENT)
General Surgery
Dermatology
17%
10%
9%
9%
7%
6%
6%
5%
3%
Oral surgery
1086
Cardiology
5%
Obstetrics
Geriatric Medicine
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
3%
Cardiology
1264
Paediatrics
4%
Slide 7

Nottinghamshire Area Overview
Nottinghamshire, in which the Trust’s main sites are situated in Ashfield and in
Newark and Sherwood, is not a particularly deprived region of England. The age distribution in Nottinghamshire is somewhat similar to that of England as a whole. However, the population in this region is older than the population of the country as a whole. Smoking in pregnancy is a particular health problem for Ashfield, Mansfield, Newark and Sherwood, where the proportion of the population gaining at least a C in 5+ GSCEs is also significantly lower than in the country as a whole. 4.5% of Nottinghamshire’s population belong to non-
White ethnic minorities, including 0.9% Indians.
FACT BOX
Population 400,000
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."
Nottinghamshire Area Demographics
0-9
10-19
20-29
IMD Of 149 English unitary authorities,
Nottinghamshire is the 93 rd most deprived.
Ethnic diversity In Nottinghamshire, 4.5% belong to non-
White ethnic minorities, including 0.9%
Indians.
Rural or Urban Nottinghamshire is a rural-urban region.
30-39
40-49
Smoking in pregnancy
50-59
60-69
70-79
80+
GCSEs achieved
In Ashfield, Mansfield, Newark and
Sherwood, smoking in pregnancy is significantly more common than in the country as a whole.
In Ashfield, Mansfield, Newark and
Sherwood, the proportion of the population gaining at least a C in 5+
GCSEs is significantly lower than in the country as a whole.
Female/NOT Female/ENG Male/NOT Male/ENG
20% 15% 10% 5% 0% 5% 10% 15% 20%
Source: BBC News (www.bbc.co.uk/news/uk-england-nottinghamshire-19679070) as accessed on 23.5.2013; Index of
Multiple Deprivation 2010; 2011 ONS Census; Department of Health Instant Atlas tables 2010.
Slide 8

Nottinghamshire Geographic Overview
The map on the right shows the location of the two main hospital sites of Sherwood Forest Hospitals NHS Foundation Trust in
Nottinghamshire, a rural-urban area located in the East Midlands.
As shown on the map, the Trust’s sites are located near several urban areas, including Derby, Nottingham and Sheffield, as well as near to the M1.
Market share analysis indicates from which GP practices the referrals that are being provided for by the Trust originate. High mortality may affect public confidence in a Trust, resulting in a reduced market share as patients may be referred to alternative providers.
Source: © Google Maps
The wheel on the left shows the market share of Sherwood Forest
Hospitals NHS Foundation Trust. From the wheel it can be seen that Sherwood Forest has a 69% 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 37% within 10 miles and 9% within 20 miles.
The wheel shows that the main competitors in the local area are
Nottingham University Hospitals NHS Trust, United Lincolnshire
Hospitals NHS Trust, Derby Hospitals NHS Foundation Trust,
Circle, and Chesterfield Royal Hospital NHS Foundation Trust.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 9

Ashfield and Mansfield’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 Ashfield and Mansfield compared nationally.
The tables below outline Ashfield and Mansfield’s health profile information in comparison with the rest of England.
1.
Mansfield and
Ashfield are both performing significantly below the national level in almost all community indicators. Statutory homelessness in
Ashfield is the only indicator performing significantly higher than the national average.
1
2
2.
Both smoking in pregnancy and teenage pregnancy are more common in Ashfield and Mansfield than the national average.
Deprivation by unitary authority area
Mansfield
Ashfield
Slide 10

Ashfield and Mansfield’s Health Profile
3.
Within adult health and lifestyle, both
Ashfield and Mansfield
3 have a lower number of healthy eating adults.
Ashfield has a higher number of obese children that the national average while
Mansfield has a higher number of smoking adults.
4.
Ashfield and
Mansfield are both significantly lower than the national average on
4
Drug Misuse and have a higher number of hip fracture in 65s and over and people with diabetes. Mansfield had a higher number of alcohol related hospital stays and acute STIs.
Slide 11

Ashfield and Mansfield’s Health Profile
5.
Life expectancy in
Ashfield and Mansfield is lower than the national average. Both areas have a higher number of smoking related deaths, while early deaths due to heart disease or cancer and the number of road injuries and deaths are higher than the national average in
Mansfield
5
Slide 12

Performance of Local Healthcare Providers
To give an informed view of the
Trust’s performance it is important to consider the service levels of non-acute local providers. For example, slow ambulance response time may increase the risk of mortality.
The graphs on the right represent some key performance indicators for
England’s Ambulance services.
The 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
Western
Ambulance
Service NHS
Foundation
Trust
West
Midlands
Ambulance
Service NHS
Trust
South Central
Ambulance
Service NHS
Foundation
Trust
South East
Coast
Ambulance
Service NHS
Foundation
Trust
East of
England
Ambulance
Service NHS
Trust
London
Ambulance
Service NHS
Trust
North West
Ambulance
Service NHS
Trust
Great
Western
Ambulance
Service NHS
Trust
North East
Ambulance
Service NHS
Trust
Yorkshire
Ambulance
Service NHS
Trust
East Midlands
Ambulance
Service NHS
Trust
Ambulance Trust England
Proportion of calls responded to within 19 minutes
100%
98%
96%
94%
92%
90%
88%
86%
84%
Isle of Wight
NHS Trust
West
Midlands
Ambulance
Service NHS
Trust
London
Ambulance
Service NHS
Trust
South East
Coast
Ambulance
Service NHS
Foundation
Trust
Yorkshire
Ambulance
Service NHS
Trust
South
Western
Ambulance
Service NHS
Foundation
Trust
Great
Western
Ambulance
Service NHS
Trust
North East
Ambulance
Service NHS
Trust
North West
Ambulance
Service NHS
Trust
South Central
Ambulance
Service NHS
Foundation
Trust
East of
England
Ambulance
Service NHS
Trust
East Midlands
Ambulance
Service NHS
Trust
Source: Department of Health: Transparency Website Dec 12
Ambulance Trusts England
Slide 13

Why was Sherwood Forest 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.
Sherwood Forest has been above the expected level for HSMR over the last 2 years and was therefore selected for this review.
Trust
Basildon and Thurrock University Hospitals NHS
Foundation Trust
Blackpool Teaching Hospitals NHS Foundation Trust
Buckinghamshire Healthcare NHS Trust
Burton Hospitals NHS Foundation Trust
Colchester Hospital University NHS Foundation Trust
East Lancashire Hospitals NHS Trust
George Eliot Hospital NHS Trust
Medway NHS Foundation Trust
North Cumbria University Hospitals NHS Trust
Northern Lincolnshire And Goole Hospitals NHS
Foundation Trust
Sherwood Forest Hospitals NHS Foundation Trust
Tameside Hospital NHS Foundation Trust
The Dudley Group Of Hospitals NHS Foundation Trust
United Lincolnshire Hospitals NHS Trust
Banding 1 – ‘higher than expected’
SHMI 2011 SHMI 2012
1
1
1
1
1
1
1
1
1
1
HSMR
FY 11
98
112
112
112
107
108
117
115
118
116
114
101
116
113
HSMR
FY 12
102
114
110
112
102
103
120
112
118
118
113
102
111
111
Source: Background to the review and role of the national advisory group Financial years 2010-11, 2011-12
Within
Expected?
Within expected
Above expected
Above expected
Above expected
Within expected
Within expected
Above expected
Above expected
Above expected
Above expected
Above expected
Within expected
Above expected
Above expected
Slide 14

Why was Sherwood Forest 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 Funnel Chart
HSMR Funnel Chart
The funnel charts for 2010/11 and 2011/12, the period when the trusts were selected for review, show that Sherwood
Forest’s SHMI is statistically within the expected range. While the time series has been above the expected level from Sept
2011, it has dropped below numerous times during the time period shown. Sherwood
Forest’s HSMR is just above the expected range, and the time series supports this .
Sherwood Forest
Selected trusts Outside Range
Selected trusts w/in Range
Sherwood Forest
Selected trusts Outside Range
Selected trusts w/in Range
Source: Healthcare Evaluation Data (HED); Apr 10-Mar 12
SHMI Time Series
HSMR Time Series
Slide 15

Slide 16

Mortality
Overview:
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 measures identified are being used as a ‘smoke alarm’ for highlighting potential quality issues. No judgement about the actual quality of care being provided to patients is being made at this stage, nor should it be reached by looking at these measures in isolation.
Review areas
To undertake a detailed analysis of the trust’s mortality, it is necessary to look at the following areas:
• Differences between the HSMR and SHMI;
• Elective and non-elective mortality;
• Specialty and Diagnostic groups; and
• Alerts and investigations.
Data sources
• Healthcare Evaluation Data (HED);
• Health & Social Care Information Centre – SHMI and contextual indicators;
• Dr Foster – HSMR; and
• Care Quality Commission – alerts, correspondence and findings.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Summary:
The Trust has an overall HSMR of 116 for the period January
2012 to December 2012, meaning that the number of actual deaths is higher than the expected level. This is statistically above the expected range.
Further analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with a similar HSMR of 117, also above the expected range.
Elective admissions are within the expected range at 54.
Sherwood Forest has a SHMI of 108 for the period December
2011 to November 2012, which is statistically above the expected range (using Healthcare Evaluation data) . However, the official SHMI produced by HSCIC is within the expected range
(for the period October 2011 to September 2012).
Similar to HSMR, non-elective admissions are seen to be contributing primarily to the overall Trust SHMI, with a similar figure of 109. Elective admissions are within the expected range, with a SHMI of 82.
Sherwood Forest had five high mortality alerts for diagnostic groups since 2007.
A common theme has arisen around sepsis, with two high mortality alerts for septicaemia (except in labour). The Trust put in place a sepsis action plan to address the issues found.
Sherwood Forest developed a Mortality Work Streams action plan in response to their elevated HSMR.
Slide 17

Mortality Overview
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 much worse than expected (CQC) 30-day mortality following specific surgery / admissions
Emergency specialty worse than expected (CQC) Mortality among patients with diabetes
Diagnosis group alerts to CQC Mortality in low-risk groups
Diagnosis group alerts followed up by CQC
SHMI*
Outside expected range of the HSCIC for Mar 11 – Sep 12 Outside expected range
Outside expected range based on Poisson distribution for Dec 11 – Nov 12
Within expected range
Within expected range
*The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model, which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14 trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the purposes of this review.
Source: Healthcare Evaluation Data (HED)
Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR,
Care Quality Commission – alerts, correspondence and findings
Slide 18

HSMR Definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a hospital is higher or lower than you would expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it cannot be said for certain that this reflects failings in the care provided by the hospital. However, it can be a warning sign that things are going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of inhospital deaths (multiplied by 100) for 56 specific CCS groups; in a specified patient group. The expected deaths are calculated from logistical regression models taking into account and adjusting for a case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of palliative care, number of previous emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number in order to identify if variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when these have been crossed is performance classed as higher or lower than expected.
Slide 19

SHMI Definition
What is the Summary Hospital-level Mortality Indicator?
The Summary Hospital-level Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice.
How does SHMI work?
1. Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
2. The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
3. 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.
4. All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are highlighted using a Random Effects funnel plot.
Slide 20

Some key differences between SHMI and HSMR
Indicator
Are all hospital deaths included?
When a patient dies how many times is this counted?
HSMR
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
Does the use of the palliative care code reduce the relative impact of a death on the indicator?
Does the indicator consider where deaths occur?
Yes
Only considers in-hospital deaths
Is this applied to all health care providers? Yes
SHMI
Yes all deaths are included
1 death is counted once, and if the patient is transferred the death is attached to the last acute/secondary care provider
No
Considers in-hospital deaths but also those up to 30 days post discharge anywhere too.
No, does not apply to specialist hospitals
Slide 21

SHMI overview
The Trust’s SHMI for the 12 months from Dec 11 to Nov 12 is 108, 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 no real trend month-on-month; however, the
SHMI does fluctuate between 92 and 122. There is a roughly stable trend year-on-year, although there was a slight increase in the past
Month-on-month time series
Year-on-year time series
Sherwood Forest
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 22

SHMI Statistics
This slide demonstrates the number of mortalities in and out of hospital for Sherwood
Forest.
As SHMI includes mortalities that occur within the hospital and outside of it for up to 30 days following discharge, it is imperative to understand the percentage of deaths which happen inside the hospital compared to outside. This may contribute to differences in HSMR and SHMI outcomes.
The data shows that 77.8% of
SHMI deaths occur in hospital at Sherwood Forest, which is more than the national average of 73.3%, and is the second highest of the trusts selected for review.
90%
85%
80%
75%
70%
65%
60%
Percentage of patient deaths in hospital
Sherwood Forest 77.8%
Trusts selected for review
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
All Trusts
Slide 23

Mortality - SHMI Tree
Mortality trees provide a breakdown of SHMI into elective and non-elective admissions. The SHMI score for non-elective admissions has a greater impact on the overall indicator due to a higher number of expected deaths.
The tree shows that
Sherwood Forest has a SHMI of 108 which is above the expected range.
The number of observed deaths are highlighted as being above the expected level in General
Medicine for nonelective admissions.
This is a potential area for review.
Key
Diagnosis (100 ; 1 )
SHMI 108
SHMI Observed deaths that are higher than the expected
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Elective
SHMI 82
Non
Elective
SHMI 109
Treatment Specialties
Higher than expected (above the 95th confidence interval)
Within expected range
Lower than expected (below the 95 th confidence interval)
Treatment Specialties
Slide 24

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.
When identifying areas to review, it is important to consider the number of deaths as well as the SHMI.
Within non-elective admissions, General Medicine has the highest number of greater than expected deaths and septicaemia (21) and acute cerebrovascular disease (19) are seen as the main diagnostic groups contributing to this.
Overall (108; 155)
118.2
Higher than expected (above the 95th confidence interval)
Within expected range
Lower than expected (below the 95 th confidence interval)
Non-elective (109; 161)
Treatment Specialties General Medicine (110; 148)
Diagnostic Groups
Acute and unspecified renal failure
Acute cerebrovascular disease
Acute myocardial infarction
Aspiration pneumonitis; food/vomitus
Biliary tract disease
Cancer of bronchus; lung
Complication of device; implant or graft
Deficiency and other anemia
Fluid and electrolyte disorders
Key
Diagnosis (100 ; 1 )
SHMI Observed deaths that are higher than the expected
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.
(127; 11)
(122; 19)
(136; 10)
(113; 5)
(225; 6)
(115; 7)
(375; 4)
(168; 8)
(132; 6)
Gastrointestinal haemorrhage
Intracranial injury
Other non-traumatic joint disorders
Other upper respiratory disease
Pneumonia (except that caused by tuberculosis or sexually transmitted disease)
Pulmonary heart disease
Secondary malignancies
Septicemia (except in labor)
Urinary tract infections
Slide 25
(128; 6)
(157; 4)
(262; 5)
(211; 5)
(102; 6)
(136; 4)
(134; 9)
(129; 21)
(108; 6)

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.
The SHMI for Sherwood Forest was 108 in the year to Sept-12
(England baseline = 100) and has been within the expected range throughout.
120
115
110
105
100
95
90
85
80
SHMI published by HSCIC, Sherwood Forest FT
Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12
Rolling 12 months ending
Lower limit Upper limit SHMI
Source: Health & Social Care Information Centre – SHMI
Slide 26

HSMR overview
The Trust’s HSMR for the 12 months from Jan 12 to Dec 12 is 116, which means, as shown below, it is above the expected range and so classified as an outlier.
The time series show a general increase for HSMR year-on-year and month-on-month time series shows no real trend. Further to this, the month-on-month time series fluctuates between extremes of 88 and
136.
HSMR funnel plot –12 months
Month-on-month time series
Year-on-year time series
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Sherwood Forest
Selected trusts Outside Range
Selected trusts w/in Range
Slide 27

HSMR Statistics
The table to the right shows
Sherwood Forest’s HSMR broken down by admission type.
The breakdown illustrates the overall HSMR is 116 which is above the expected range. The table identifies that elective admissions have an HSMR within the expected range, whereas non-elective admissions have an HSMR above the expected range.
Mortality from both week and weekend admissions are highlighted as being above the expected level, due to the high non-elective admissions.
HSMR
Elective
Weekend
0
Week
60
Non-elective 124 115
All 123
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
114
All
54
117
116
Key – colour by alert level:
Red – Higher than expected (above the
95% confidence interval)
Blue – Within expected range
Green – Lower than expected (below the
95 th confidence interval)
Slide 28

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:
• Septicaemia (except in labour) (HSMR of 144, and 30 observed deaths that are higher than the expected);
• Pneumonia (except that caused by tuberculosis or sexually transmitted disease) (108, 25);
• Acute cerebrovascular disease (129, 24);
• Urinary tract infections (136, 18); and
• Acute and unspecified renal failure (145, 16).
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 29

Mortality - HSMR Tree
The tree shows that the
HSMR for Sherwood
Forest is 116 which is above the expected range.
When breaking this down by admission type, it is clear that it is driven by non-elective admissions, which is at a similar level and is also above the expected range.
Within non-elective admissions General
Medicine and Obstetrics have the highest number of observed deaths above the expected level.
HSMR 116
Elective
HSMR 54
Non
Elective
HSMR 117
Key
Diagnosis (100 ; 1 )
HSMR Observed deaths that are higher than the expected
Source : Healthcare Evaluation Data (HED). Jan 12 – Dec 12
Higher than expected (above the 95th confidence interval)
Within expected range
Lower than expected (below the 95 th confidence interval)
Treatment Specialties
Treatment Specialties
Slide 30

HSMR sub-tree of specialties
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 acute cerebrovascular disease (23), septicaemia (25), pneumonia (16) and urinary tract infections (16). Within Obstetrics, there are no diagnostic groups with at least four more observed deaths than expected.
Treatment Specialties
Obstetrics (2352; 3)
Diagnostic Groups
Key
Diagnosis (100 ; 1 )
HSMR Observed deaths that are higher than the expected
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Higher than expected (above the 95th confidence interval)
Within expected range
Lower than expected (below the 95 th confidence interval)
Non-elective (117; 192)
General Medicine (118; 163)
Acute and unspecified renal failure
Acute bronchitis
Acute cerebrovascular disease
Acute myocardial infarction
Aspiration pneumonitis; food/vomitus
Cancer of bronchus; lung
Fluid and electrolyte disorders
(147; 15)
(124; 4)
(131; 23)
(141; 10)
(133; 9)
(119; 5)
(176; 7)
Gastrointestinal hemorrhage
Intracranial injury
Other gastrointestinal disorders
Other upper respiratory disease
Pneumonia (except that caused by tuberculosis or sexually transmitted disease)
Pulmonary heart disease
Secondary malignancies
Septicemia (except in labor)
Urinary tract infections
(123; 4)
(178; 4)
(185; 4)
(284; 4)
(106; 16)
(165; 5)
(131; 5)
(143; 25)
(138; 16)
Slide 31

HSMR – Dr Foster
The HSMR time series for Sherwood Forest Foundation Trust from Dr Foster shows a rise in the HSMR since 2008/09. This measures the observed in-hospital death rate against an expected value based on all the data for that year. An HSMR
(or SHMI) of 100 means that there is exactly the same number of deaths as expected. The HSMR is classified as above expected if the lower 95% confidence limit exceeds 100, which was the case in financial years 2010/11 and 2011/12.
The latest SHMI published by the HSCIC, for Oct 11 to Sept 12, is lower than the Dr Foster HSMR for the same period, which may be due to a number of factors.
Dr Foster have made the following adjustments to show differences explained by these factors:
• Adjustment for palliative care: used the SHMI observed deaths but changed expected deaths to take account of palliative care.
• Adjustment for in-hospital deaths:
• Removed out-of-hospital deaths from the observed figure, and
• Reduced expected deaths to only those in-hospital.
The remaining variances are largely due to:
• The scope of deaths included (SHMI covers all deaths whereas HSMR covers areas accounting for an average of around 80% of deaths), and
• The definition of spells, which includes those provider(s) the death attributes to.
Source: Dr Foster HSMRs, HSCIC SHMI
Time series of HSMR, Sherwood Forest
FT
125
120
115
110
105
100
95
90
103
105
113
113
2008/09 2009/10
HSMR
2010/11 2011/12
I
95% Confidence interval
125
120
115
110
105
100
95
90
Comparison of mortality measures,
108
Sherwood FT
108
111
SHMI SHMI adjusted for palliative care
SHMI in hospital deaths only
HSMR
115
Slide 32

Coding
Diagnosis coding depth has an impact on the expected number of deaths. A higher than average diagnosis coding depth is more likely to collect co-morbidity which will influence the expected mortality calculation.
Sherwood’s average diagnosis coding depth for elective patients has been fluctuating around the same level over the time period shown. However, the national average and average of the 14 trusts in this review has been rising meaning Sherwood has fallen below the national average.
Similarly, for non-elective patients, Sherwood’s average diagnosis coding depth has fallen below the national average. This is due to a dip in the most recent quarter.
Average Diagnosis Coding Depth
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Elective
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
6
5
4
3
2
1
Non-elective
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
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
Sherwood Forest
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
Sherwood Forest
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 33

Palliative care
Accurate coding of palliative care is important for contextualising SHMI and HSMR. HSMR takes into account that a patient is receiving palliative care, but
SHMI does not.
Sherwood Forest have made growing use of palliative care coding (by diagnosis rather than treatment specialty), which is slightly below the national rate.
Source: Health & Social Care Information Centre – SHMI contextual indicators
Percentage of admissions with palliative care coding
0.6
0.4
-
0.2
1.2
1.0
0.8
Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13
Sherwood Forest National SHMI publication
-
10
8
6
4
2
20
18
16
14
12
Percentage of deaths with palliative care coding
Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13
Sherwood Forest National SHMI publication
Slide 34

Care Quality Commission findings
The Care Quality Commission (CQC) review mortality alerts for each Trust on an ongoing basis. These alerts, which indicate observed deaths significantly above expected for specialties or diagnoses, come from different sources based on either HSMR or SHMI. Where these appear unexplained, CQC correspond with the Trust to agree any appropriate action.
For Sherwood Forest, the common themes that have arisen across the patient groups alerting since 2007 are
Sepsis and emergency care, with two alerts for septicaemia (not in labour).
There are no common themes arising from responses to the CQC from the Trust. The Trust put in place a sepsis action plan to address the issues found.
Sherwood Forest developed a Mortality Work Streams action plan in response to their elevated HSMR. A draft was shared with CQC (Oct 2012), with some general and some diagnosis-specific actions.
Emergency specialty groups much worse than expected
Sep 11 to Aug 12 0
Emergency specialty groups worse than expected
Sep 11 to Aug 12 3
Haematology
Cerebrovascular
Musculoskeletal
Diagnosis group alerts (2007 to date)
Alerts to CQC
Alerts followed up by CQC
5
3
Recent diagnosis group alerts pursued by CQC
Septicaemia (except in labour) (Sept 12)
Any related patient groups alerting more than once since 2007
Septicaemia (except in labour)
Source: Care Quality Commission – alerts, correspondence and findings
Slide 35

SMRs for Diagnostic and Procedure groups – Dr Foster
The standardised mortality ratio (SMR) is used to calculate the mortality rate for diagnosis and procedure groups. This is available for the 56 diagnosis groups that are included in the
HSMR and the 96 procedure groups that are part of the Real
Time Monitoring system.
SMRs are not yet remodelled for the year but are projected, rebased estimates. SMRs are classified as above expected if their lower 95% confidence limit exceeds 100 (excluding those with fewer than four more observed deaths than expected).
From Apr 12 to Mar 13, there were six diagnosis groups and one procedure groups with above expected SMRs in Sherwood Forest, which may highlight potential areas for review. There were two diagnosis groups with above expected mortality for weekend admissions but not for weekday ones (leukaemias and congestive heart failure, non-hypertensive), but these did not have high
SMRs overall.
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. During the year, Sherwood
Forest had two CUSUM alerts for septicaemia (except in labour) and one each for fluid and electrolyte disorders and therapeutic endoscopic procedures on upper GI tract. It also had alerts for another diagnostic group and another procedure group that did not have a high SMR.
Apr 2012 to Mar 2013
SMRs above expected
CUSUM alerts
Diagnosis groups Procedure groups
6 1
4 2
Diagnosis groups with SMRs above expected SMR
Acute cerebrovascular disease
Aspiration pneumonitis, food/vomitus
Fluid and electrolyte disorders
Peritonitis and intestinal abscess
Pneumonia
Septicaemia (except in labour)
131
144
219
295
115
154
Procedure groups with SMRs above expected SMR
Therapeutic endoscopic procedures on upper GI tract
205
Obs – Exp deaths
25
12
10
4
44
32
Obs – Exp deaths
11
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 36

Mortality – other alerts
The Health and Social Care Information Centre publish 30day mortality rates following certain types of surgery or admission to hospital. These are not casemix adjusted, but the rates may be compared over time. Sherwood Forest FT had one rate improving substantially below the national average in the data to 2010-11 (published in Feb 2013).
Although its overall SHMI was as expected in the period July
2011 to June 2012, Sherwood Forest had 17 more deaths than expected in the diagnosis category that includes ICD10 code
R69.X Unknown and unspecified causes of morbidity. It had a high level of coding in this category in July 2011 (both for admissions and deaths), which may have affected expected deaths. However, the use of this non-specific diagnosis code has reduced markedly for the Trust since then.
The Trust had no other significant alerts.
30-day mortality following specific surgery / admissions
Fractured hip (in top decile and improving 7% below national rate in 2010/11)
Source: Health & Social Care Information Centre .
Slide 37

Slide 38

Patient Experience
Overview:
The following section provides an insight into the Trust’s patient experience.
Review Areas:
To undertake a detailed analysis of the Trust’s Patient Experience it is necessary to review the following areas:
• Patient Experience, and
• Complaints.
Data Sources:
• Patient Experience Survey;
• Cancer Patient Experience Survey;
• Peoples’ Voice Summary; and
• Complaints data.
Summary:
Sherwood was not rated ‘red’ on any of the 9 measures reviewed within Patient Experience and Complaints.
There were some minor concerns on the inpatient survey relating to delays on discharge, some negative points around access to research options on the cancer survey, some indication of covering up medical errors in the patient voice data and higher than average for factual errors in complaint responses.
Overall though, this Trust scores well on patient experience measures.
Slide 39
All data and sources used are consistent across the packs for the 14 trusts included in this review.

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
Cancer survey
PEAT : privacy and dignity
Complaints about clinical aspects
Ombudsman’s rating
PEAT : environment
PEAT : food
Friends and family test
Patient voice comments
Outside expected range
Within expected range
Slide 40

Inpatient Experience Survey
Sherwood Forest performs above average on survey questions relating to the length of time spent on waiting lists, information provided on post-discharge danger signals and medication side-effects, patient noise levels at night, hospital cleanliness, and the quality of hospital food, but below average on those relating to coherent patient discharge processes.
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
Consistency of staff communication
Overall
Patient involvement in decision-making
Overall
Delay of patient discharge
Information provided on post-discharge danger signals
Staff communication on purpose of medication provided
Staff communication on medication side-effects
Clarity of doctors’ responses to important questions
Language used by doctors in front of patients
Overall
Patient noise levels at night
Staff noise levels at night
Hospital/ward cleanliness
Clarity of nurses’ responses to important questions
Language used by nurses in front of patients
Hospital food
Degree of privacy provided
Level of respect shown by staff
Overall staff effort to ease pain
Above expected range
Source: Patient Experience Survey 2012/13
Within expected range Below expected range Slide 41

Patient experience and patient voice
Inpatient Survey
The national inpatient survey 2012 measures a wide range of aspects of patient experience. A composite ‘overall measure’ is calculated for use in the Outcomes Framework. This measure uses a pre-defined selection of 20 survey questions to rate the Trust on aspects including access to services, coordination of care, information & choice, relationship with staff and the quality of the clinical environment.
• England Average: 76.5
• Sherwood Forest: 77.3 (average)
Cancer Survey
• Of 58 Questions, 21 were in the ‘top 20%’ whilst 6 were in the ‘bottom 20%’. Negative areas included two of the three questions on cancer research options.
Patient Voice
• The quality risk profiles compiled by the Care Quality
Commission collate comments from individuals and various sources. In the two years to 31 st January 2013, there were 141 comments on Sherwood of which 57 were negative (40%). Whilst this is a low percentage, negative comments related to lack of professionalism, covering up medical errors, lack of compassion, wet beds left unattended etc.
Friends and Family Test
• Sherwood has consistently been the highest scorer on the
Midlands and East Friends and Family test. The Trust scored 97 in February 2013.
Overall patient experience score: Inpatients 2012
80
75
70
65
60
55
50
95
90
85
Sherwood Forest
England average
Trusts in this review
National results curve
Source : Patient Experience Survey, Cancer patient experience survey
Complaints Handling
•
•
Data returns to the Health and Social Care Information
Centre showed 584 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, 51% of complaints related to clinical treatment, in line with national average of 47%.
A separate report by the Ombudsman rates the Trust as
A-rated for satisfactory remedies and low-risk of noncompliance, although the report noted that it is likely to be downgraded at the next review. It is higher than average on factual errors in responses and there was one case of service failure potentially indicating wider organisational failure.
Slide 42

Slide 43

Safety and Workforce
Overview:
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.
Review Areas:
To undertake a detailed analysis of the Trust’s Safety and
Workforce it is necessary to review the following areas:
• General Safety;
• Staffing;
• Staff Survey;
• Litigation and Coroner; and
• Analysis of patient safety incident reporting.
Data Sources:
• Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;
• Safety Thermometer, Apr – Mar 2013;
• Litigation Authority Reports;
• GMC Evidence to Review 2013;
• National Staff Survey 2011, 2012;
• 2011/12 Organisational Readiness Self-Assessment (ORSA);
• National Training Survey, 2012; and
• NHS Hospital & Community Health Service (HCHS), monthly workforce statistics.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Summary:
Sherwood is rated ‘red’ on two of the safety measures: medication errors and pressure ulcers.
It has a rate of medication error that is more then three standard deviations from the mean although it should be noted that there is no desired direction on this indicator. Throughout the last 12 months, Sherwood’s new pressure ulcer rate has been consistently below the national average. However, the total pressure ulcer prevalence rate has been above the national average in more recent months and may highlight an area of review.
259 incidents were reported as ‘moderate, severe or death’ from
April 11 to March 12, while two ‘never events’ have been recorded at the Trust since 2009.
Sherwood is a net contributor to the Clinical Negligence Scheme for Trusts and only had two flags on the Rule 43 Coroners’ reports.
The Trust flagged red 11 times for the workforce measures. Most notably the Trust has high sickness absence rates and medical staff vacancy rates. It also spends a greater percentage of its total expenditure on agency staff compared with the regional average.
Slide 44

Safety
This page shows the safety measures which are considered to be the most pertinent for this review. Further analysis, where relevant, is detailed in the following pages.
Reporting of patient safety incidents
Number of harm incidents reported as ‘moderate, severe or death’ from April ‘11 to March ’12 259
Number of ‘never events’ (2009-2012) 2
Medication error
MRSA
C diff
Pressure ulcers
“Harm” for all four Safety Thermometer Indicators
Clinical negligence scheme payments
Rule 43 coroner reports
Outcome 1 (R17) Respecting and involving people who use services
Outside expected range
Within expected range
Slide 45

Safety 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. Sherwood has a rate of 7.4 for its patient safety incident reporting per 100 admissions.
Sherwood Forest has rate of medication error that is more then three standard deviations from the mean although it should be noted that there is no desired direction on this indicator.
Rate of reported patient safety incidents per 100 admissions (April –
September 2012)
Sherwood Forest
7.4
Median rate for medium acutes
6.7
Source: incidents occurring between 1 April 2012 to 30 September
2012 and reported to the National Reporting and Learning System
Rate of medication errors per 1,000 bed days (October 2011 – March
2012)
Sherwood Forest Mean rate for all acute
11.06
Source: Acute Trust Quality Dashboard Winter 2012/13
7.17
Slide 46

Safety Incident Breakdown
Since 2009, two ‘never events’ have occurred at Sherwood Forest, classified as that because they are incidents that are so serious they should never happen.
The patient safety incidents reported are broken down into five levels of harm below, ranging from ‘no harm’ to ‘death’. 79% of incidents which have been reported at Sherwood Forest have been classed as ‘no harm’, with 16% ‘low’,
4% ‘moderate’, 0.1% ‘severe’ and three occurrences classified as ‘death’.
When broken down by category, the most regular occurrences of patient incident at Sherwood Forest are in ‘patient accident’ and ‘medication’.
Breakdown of patient incidents by degree of harm
5000
Retained foreign object post-operation
Total
Never Events Breakdown (2009-2012)
Source: Freedom of information request, BBC - http://www.bbc.co.uk/news/health-22466496
104
2
2
Breakdown of patient incidents by incident type
Medical device / equipment
4502
All others categories 142
4500
Consent, communication, …
4000
167
Infrastructure
3500
254
Access, admission, transfer, …
3000
277
Implementation of care and …
2500
295
2000
Clinical assessment 429
1500
Documentation 442
1000
937
Treatment, procedure 656
500
253
3 3
Medication
Patient accident
876
2056
0
No Harm Low Moderate
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
A definition of serious harm is given in the Appendix.
Severe Death
1000 1500 2000 2500
Slide 47

Pressure ulcers
New pressure ulcers prevalence Total pressure ulcers prevalence
This slide outlines the total number of pressure ulcers and the number of new pressure ulcers broken down by category for the last 12 months.
Due to the effects of seasonality on hospital acquired pressure ulcer rates, the national rate has been included which allows a comparison that takes this in to account. This provides a comparison against the national rate as well as the 14 trusts selected for the review.
10
9
8
7
6
5
4
3
2
1
-
1.0%
1.3%
0.8% 0.8%
0.7%
0.5%
Category 2
0.2%
Category 3
0.8%
0.3%
1.3%
1.4%
Category 4
1.6%
1.4%
1.2%
1.0%
0.6%
0.8%
0.6%
0.4%
0.2%
0.0%
Rate
Throughout the last 12 months,
Sherwood’s new pressure ulcer rate has been consistently below the national average.
However, the total pressure ulcer prevalence rate has been above the national average in more recent months and may highlight an area of review.
New pressure ulcer analysis
Number of records submitted
Trust new pressure ulcers
Trust new pressure ulcer rate
Selected 14 trusts new pressure ulcer rate
National new presseure ulcer rate
Apr-12 May-12 Jun-12
617 596 613
6
1.0%
1.4%
1.7%
8
1.3%
1.5%
1.7%
Total pressure ulcer prevalence percentage
5
0.8%
1.4%
1.5%
50
40
5.8% 6.0%
Category 2
Jul-12 Aug-12 Sep-12
591 604 613
5
0.8%
1.5%
1.5%
60
30
20
10
-
4
0.7%
1.5%
1.4%
3
0.5%
0.9%
1.3%
7.8%
7.1%
5.8%
6.0%
4.0%
Category 3
Oct-12 Nov-12 Dec-12
620 666 667
1
0.2%
1.0%
1.2%
5
0.8%
1.1%
1.2%
5.9%
2
0.3%
0.9%
1.2%
Category 4
3.0%
2.0%
1.0%
0.0%
Jan-13 Feb-13 Mar-13
629 666 654
8
1.3%
1.1%
1.3%
9
1.4%
1.0%
1.3%
Rate
4
0.6%
1.2%
1.3%
9.0%
8.0%
7.0%
6.0%
5.0%
4.0%
Number of records submitted
Trust total pressure ulcers
Trust total pressure ulcer rate
Selected 14 trusts total pressure ulcer rate
Apr-12 May-12 Jun-12
617
36
5.8%
596
36
6.0%
613
48
7.8%
6.4% 6.2%
National total pressure ulcer rate 6.8%
Source: Safety Thermometer Apr 12 to Mar 13
6.7%
6.5%
6.6%
Jul-12 Aug-12 Sep-12
591
34
5.8%
604
43
7.1%
613
37
6.0%
7.0%
6.1%
6.3%
6.0%
5.5%
5.5%
Oct-12 Nov-12 Dec-12
620
25
4.0%
666
39
5.9%
667
37
5.5%
5.4%
5.4%
5.9%
5.3%
5.8%
5.2%
Jan-13 Feb-13 Mar-13
629
38
6.0%
666
41
6.2%
654
40
6.1%
6.0%
5.4%
5.7% 6.2%
5.6% 5.3%
Slide 48

Litigation and Coroner
Clinical negligence scheme analysis
Sherwood is a net contributor to the Clinical Negligence
Scheme for Trusts. Contributions to the scheme have exceeded payouts to litigants in each of the last 3 years, and in total by £3.8m.
Coroners’ Rule
Coroners’ rule 43 reports flagged two items:
• To consider a review of the hospital protocol on
• procedures to be followed when police are called to the hospital to deal with an incident and to ensure that staff and police are aware of this protocol and are trained in its application; and
To consider introducing a policy which ensures any material changes of opinion between a radiologist's verbal and written report is communicated to the relevant clinician at the time the written report is made.
Clinical negligence payments
Payouts (£000s)
Contributions (£000s)
2009/10
3,004
3,257
Variance between payouts and contributions
(£000s)
253
2010/11
1,865
3,655
1,790
2011/12
2,519
4,227
1,708
Source :Litigation Authority Reports
Slide 49

Workforce
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
Spells per WTE staff
Sickness absence- Medical Nurse Staff to Qualified Staff Ratio
Vacancies –medical
Vacancies - Non-medical
Consultant appraisal rates
Agency spend
Staff joining rates se services
Sickness absence - Other staff
Staff leaving rates
Non-clinical Staff to Total Staff Ratio
Consultant Productivity (FTE/Bed Days)
Nurse Hours per Patient Bed Day
Response Rate from National Staff
Survey 2012
Staff Engagement from NSS 2012
Training Doctors – “undermining”
indicator
GMC monitoring under “response to concerns process”
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
Outside expected range
Within expected range
2.64
1.81
0.36
348
6.61
Slide 50

General Medical Council (GMC) National Training Scheme Survey 2012
The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results. Given the volume of data only specialties with red outliers are noted below (where those specialties also have green outliers, they are included).
Overall satisfaction Induction
Clinical supervision Undermining
Workload Access to educational resource
Handover Local teaching
Adequate experience Study leave
Educational supervision Regional teaching
Feedback
Overall satisfaction
Clinical supervision
Induction
Undermining
Workload Access to educational resource
Handover Local teaching
Adequate experience Study leave
Educational supervision Regional teaching
Feedback
In addition to the green outlier displayed, Obstetrics and Gynaecology had an additional green outlier for regional teaching.
Green outlier Within expected range Red outlier Slide 51

Workforce Analysis
The Trust has a patient spells per whole time equivalent rate of 23, which is slightly 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. In addition, the data illustrates that the Trust not only has a lower joining rate than the regional median, but also a lower leaving rate.
Sherwood Forest has a consultant appraisal rate of 98.7% which is the highest of the trusts under review.
WTE nurses per bed day December 2012
Sherwood Forest National Average
1.52
Source: Acute Trust Quality Dashboard, Methods Insight
Spells per WTE for Acute Trusts
1.96
50
45
40
35
30
25
20
15
10
5
0
Sherwood
Forest
23
Trusts covered by review All Trusts
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
Staff Turnover
Sherwood
Forest
5.6%
(Sep 11 – Sep 12)
East Midlands
SHA Median
5.9% Joining Rate
Leaving Rate 5.4%
Source: Health and Social Care Information Centre (HSCIC)
6.7%
100%
Sherwood
Forest:
98.7%
Consultant appraisal rate 2011/12
80%
60%
40%
20%
0%
Number of FTEs (Dec 11-Nov 12 average) 6,648
Sherwood Forest
Expenditure
£6.9m
Agency Staff (2011/12)
Percentage of
Total Staff Costs
4.4%
Median within
Region
4.2%
Trusts covered by review All other trusts
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Data based on the appraisal year from April 2011 to March 2012
Slide 52
Slide 52

Workforce Analysis continued…
Sherwood Forest’s total sickness absence rate is higher than the East Midlands Strategic Health
Authority average and the national average. This pattern of exceeding the national average is replicated in the more granular medical, nursing, and other staff categories.
Sherwood Forest has a medical staff to consultant ratio that is above the national average, although its nurse staff to qualified staff ratio is below the average for all English trusts. The Trust’s registered nurse hours to patient day ratio is also below the national mean.
The Trust’s consultant productivity rate is below the national average.
The three month vacancy rates for medical staff is
2.3%, which is above the national average rate of
1.4%.
3 month Vacancy Rates by
Staff Category
(March 2010)
Sherwood
Forest
National
Average
Medical Staff 2.3% 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.
Sickness Absence Rates
All Staff
Sherwood Forest East Midlands SHA
Average
4.60%
Source: Health and Social Care Information Centre (HSCIC)
4.33%
Sickness Absence Rates by Staff Category
Medical Staff
Sherwood Forest
1.8%
Nursing Staff 5.2%
Other Staff
Source: Acute Trust Quality Dashboard, Methods Insight
6.5%
Staff Ratios
Medical Staff to Consultant Ratio
Nurse Staff to Qualified Staff Ratio
Sherwood Forest
2.64
1.81
Non-Clinical Staff to Total Staff
Ratio
Registered Nurse Hours to Patient
Day Ratio *
0.36
6.61
Source: Electronic Staff Record (ESR) April 13
* Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Sherwood Forest
348 Consultant Productivity
(Spells/FTE)
Source: Electronic Staff Record (ESR) April 13
(2011-2012)
National Average
4.12%
(Dec 12)
National Average
1.3%
4.8%
4.7%
National Average
2.59
2.50
0.34
8.57
National Average
492
Slide 53

Workforce Analysis continued…
Sherwood Forest’s response rate to the staff survey is at the national average rate. The staff engagement score is below average when compared with trusts of a similar type in 2012.
Sherwood Forest is significantly below the national average for the percentage of staff who would recommend the organisation as a place to work, and lower than national average for care of patients as a top priority. For the question on standard of care, the
Trust’s score has fallen substantially but is still above national average.
National Staff Survey results
Response rate
Overall staff engagement
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
Source: National Staff Survey 2011, 2012
Sherwood
Forest
2011
49%
3.71
59%
50%
74%
Average for all trusts
2011
50%
3.62
69%
52%
62%
Sherwood
Forest
2012
50%
3.65
Average for all trusts
2012
50%
3.69
61% 63%
50%
62%
55%
60%
Slide 54

Deanery
The Trust is not currently subject to enhanced monitoring. While the National Training Survey and Deanery reports did not indicate any specific concerns, doctors in training reported more patient safety concerns than the average. These concerns were shared with the Deanery.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Anaesthetics and Emergency Medicine were the programmes with the most below outliers between 2010 and 2012. Trauma and
Orthopaedic Surgery was the programme with the most above outliers during the same period. Only one above outlier was recorded in 2012, much less that the previous years.
NTS 2012 Patient Safety Comments
12 doctors in training commented, representing 7.69% 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 staff (noted that this had been addressed in acute medicine by appointment of acute medical consultants;
• Lack of beds in critical care unit;
• Lack of robust handover and continuity of care;
• Lack of weekend cover; and
• Locum cover of variable ability.
Source: GMC evidence to Review 2013
Slide 55

Deanery Reports
East Midlands Healthcare Workforce Deanery reported one concern in 2012 for the Sherwood Forest Hospitals NHS Foundation
Trust: over half of the doctors in training in General Surgery felt that they were regularly forced to cope with problems beyond their experience or competence, with some reporting that they were required to take consent for procedures they did not fully understand.
Monitored under the response to concerns process?
The trust is not subject to increased monitoring at the time of the report. The GMC visited the Kings Mill Hospital in January 2013 as part of their series of Emergency Medicine checks. The resulting report is still in draft, but no serious concerns were raised as part of the visit.
Undermining
For doctors undertaking training at Sherwood, the Trust has a score on the National Training Survey on undermining of 94.6 which is above the national average of 94.
Source: GMC evidence to Review 2013
Mean Score on 'Undermining'
105
100
95
90
85
80
Sherwood
Forest
Trusts covered by review
Source: National Training Survey 2012
All other non specialist trusts
Slide 56

Slide 57

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 data and sources used are consistent across the packs for the 14 trusts included in this review.
Summary:
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. On this measure,
Sherwood is at the lower end of the distribution, and some way short of the national average.
Sherwood Forest sees 94.7% of A&E patients within 4 hours which is slightly below the 95% target level. Performance has been decreasing since July 2012.
93.8% of patients are seen within the 18 week target time which is above the target level. The Trust’s performance has varied on this measure between April 2012 and February 2013, but has recently risen just above the target rate.
Sherwood Forest’s crude readmission rate is average for readmission rates of the trusts in the review as well as nationally, at 11.3%. The standardised readmission rate shows the Trust to be within the expected range. It has an average length of stay of 4.7 days, which is shorter than the national mean average of 5.2 days.
The PROMs dashboard shows that Sherwood Forest was within the 99.8% control limits in all three years for all measures.
Slide 58

Clinical and Operational Effectiveness
This page shows the Clinical and Operational Effectiveness measures which are considered to be the most pertinent for this review.
Further analysis, where relevant, is detailed in the following pages.
Neonatal – women receiving steroids
Adult Critical care
Diabetes safety/ effectiveness
PROMS safety/ effectiveness
Joints – revision ratio
RTT Waiting Times
Emergency readmissions
Cancer Waits
A&E Waits
Hip Replacement EQ-5D
Knee Replacement EQ-5D
Varicose Vein EQ-5D
Coronary angioplasty
Peripheral vascular surgery
Carotid interventions
Acute MI
Acute stroke
Cancelled Operations
PbR Coding Audit
Heart failure
Lung cancer
Bowel cancer
Hip fracture - mortality
Severe trauma
Elective Surgery
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 59

Clinical Effectiveness: National Clinical Audits
The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the clinical audit results considered as part of this review.
Clinical Audit
Diabetes
Elective Surgery
Safety Measure
Proportion with medication error
Proportion experiencing severe hypoglycaemic episode
Proportion of patient reported post-operative complications
Adult Critical Care (ICNARC
CMPD)
Proportion of night-time discharges
Clinical Audit
Neonatal intensive and special care
(NNAP)
Diabetes
Adult Critical Care
Coronary angioplasty
Peripheral vascular surgery
Carotid interventions
Acute Myocardial Infarction
Acute Stroke
Heart Failure
Bowel cancer
Hip Fracture
Elective surgery (PROMS)
Severe Trauma
Hip, knee and ankle
Lung Cancer
Effectiveness Measures
Proportion of women receiving antenatal steroids
Proportion foot risk assessment
Standardised hospital mortality ratio
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
Proportion compliant with 12 indicators
Proportion referred for cardiology follow up
90 day post-op mortality
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
Source: Clinical Audit Data Trust, CQC Data Submission.

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.
On this measure, Sherwood is at the lower end of the distribution, and some way short of the national average.
Proportion of women receiving ante-natal steroids (level 2)
Sherwood
Slide 61

Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
A&E wait times and
RTT times may indicate the effectiveness with which demand is managed.
Sherwood Forest sees
94.7% of A&E patients within 4 hours which is slightly below the
95% target level. The time series graph shows a decreasing trend from July 2012.
93.8% of patients are seen within the 18 week target time which is above the target level. The time series shows that
Sherwood Forest has been performing near the target rate and has risen just above the target rate from
December 2012.
100%
95%
90%
85%
80%
A&E Percentage of Patients Seen within 4 Hours
Sherwood
Forest
94.7%
12
10
8
6
4
2
0
Sherwood Forest 4 Hour A&E Waits
75%
70%
100%
90%
85%
80%
Trusts Covered by Review All Trusts A&E Target 95%
Source : Healthcare Evaluation Data (HED). Jan – Dec 12
95%
Referral to Treatment (Admitted)
Sherwood
Forest
93.8%
100%
96%
92%
88%
84%
80%
76%
72%
Number of patients seen within 4 hours
Patients Not Seen
Seen within 4 hours (%)
Source : Healthcare Evaluation Data (HED). Jan – Dec 12
Sherwood Forest Referral to Treatment
Performance
75%
Trusts Covered by Review All Trusts RTT Target 90% Referral to Treatment Rate RTT Target 90%
Source: Department of Health. Feb 13 Source: Department of Health. Apr 12 – Feb 13
Slide 62
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%

Operational Effectiveness – Emergency Readmissions and Length of Stay
Readmission rates may indicate the appropriateness of treatment offered, whilst average length of stay may indicate the efficiency of treatment.
Sherwood Forest’s crude readmission rate is among the average for readmission rates of the trusts in the review as well as nationally, at 11.3%.
The standardised readmission rate, most importantly, accounts for the trust’s case mix and shows Sherwood Forest is statistically within the expected range.
Sherwood Forest’s average length of stay is 4.71 days, which is shorter than the national mean average of
5.2 days.
10
9
8
7
6
5
4
3
2
1
0
10%
5%
0%
25%
20%
15%
Crude Readmission Rate by Trust
Trusts Covered by Review All Trusts
Average Length of Stay by Trust
Sherwood
Forest
4.71
Sherwood
Forest
11.3%
Trusts Covered by Review Sherwood
Standardised 30-day Readmission
Rate
All Trusts
Sherwood Forest
Selected trusts Outside
Selected trusts w/in Range
Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12 Slide 63

PROMs Dashboard
The PROMs dashboard shows that Sherwood Forest was within the 99.8% control limits in all three years for all measures.
20
15
10
5
0
20
09
/1
0
Hip Replacement EQ-5D
20
10
/1
1
20
11
/1
2
England Average
Sherwood Forest
Upper Control Limit
Lower Control Limit
Source: PROMs Dashboard and NHS Litigation Authority
Slide 64

Slide 65

Leadership and governance
Overview:
This section provides an indication of the Trust’s governance procedures.
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 data and sources used are consistent across the packs for the 14 trusts included in this review.
Summary:
Following Monitor’s intervention in October 2012, there were a number of changes to the Trust Board, including the appointment of an interim CEO and Chairman, and a number of new Non-Executive Directors. The Trust has now recruited permanently to these posts, the new permanent CEO, Paul
O’Connor, and the permanent Chairman, Sean Lyons will commence on 10 June 2013.
The Board sub-committee with responsibility for quality governance is the Quality & Clinical Governance Committee.
This sub-committee is chaired by a non-executive director with a clinical background.
A recent review by the CQC has identified moderate concerns in relation to outcome 16 (assessing and monitoring the quality of service provision).
Key risks for the Trust relate to loss of trust and confidence leading to a reputational risk, quality governance, board stability and leadership, financial performance (including cost improvement programmes), use of agency and temporary staff, and staff sickness.
Slide 66

Leadership and governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in the following pages.
Monitor governance risk rating
Monitor finance rating 1
CQC Outcomes
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
Financial risk rating rated 1-5, where 1 represents the highest risk and 5 the lowest
CQC Concerns
Red – Major concern
Amber – Minor or Moderate concern
Green – No concerns
Slide 67

Leadership and governance
Trust Board
Following Monitor’s intervention in October 2012, there were a number of changes to the Trust Board, including the appointment of an interim CEO and
Chairman, and a number of new Non-Executive Directors. The Trust has now recruited permanently to these posts, the new permanent CEO, Paul
O’Connor, and the permanent Chairman, Sean Lyons will commence on 10 June 2013 .
Governance and clinical structures
The Trust Board receives assurance from five sub-committees; the Audit Committee, Clinical Governance & Quality Committee, Risk & Assurance
Committee, Finance & Performance Committee, and the Remuneration & Nomination Committee.
The Clinical Governance & Quality Committee is the sub-committee responsible for provided assurance in relation to quality. This sub-committee has a clinically experienced Non-Executive Director chair (who reports directly to the Board) and another Non-Executive member.
Strategy
The Trust currently does not have a separate quality strategy, but quality goals and priorities have been integrated within the annual plan and will have a separate section within the new Trust strategy that is being developed. Each year the Trust identifies a small number of quality goals covering safety, clinical outcomes and patient experience. These reflect local and national priorities and are decided through a series of engagement processes including survey monkey, meetings with Governors and communication with local CCGs.
External reviews and regulation
Monitor amended the Financial risk rating for the Trust from 3 to 1 in August 2012 due to a deterioration in the Trust's financial position. On 5 October
2012, Monitor issued the Trust with a notice of exercise of intervention powers under Section 52 of the National Health Services Act (2006). Monitor found that the Trust was in breach of its terms of authorisation, in particular:
Condition 2, which requires the Trust to exercise its functions effectively, efficiently and economically; and
Condition 5, which requires the Trust to ensure the existence of appropriate arrangements to provide representative and comprehensive governance.
A recent review by the Care Quality Commission found that the Trust was not meeting one outcome; the services should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16). This was found to have a moderate impact.
The Trust has also had a number of external reviews, which are summarised in the following pages.
Slide 68
A diagram of board members and committee structure can be found in the Appendix.

Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks Trust response
Loss of trust and confidence leading to a reputational risk
On 5 October 2012, Monitor placed the Trust in significant Breach of its
Terms of Authorisation (Licence) for failure on Governance and Finance.
The Trust had received lots of analysis from Management Consultants but had failed to deliver decisions and actions. Governance, i.e. Corporate and
Quality, were identified as not fit for purpose by a recent PwC Board and
Quality Governance Review (Document 5). The Board were not sighted on the right information or risks related to quality of care and treatment. This resulted in a number of serious incidents (e.g. under-reporting of oestrogen status) which were not only detrimental to the care and welfare of patients, but impacted upon the reputation of the trust. This led to a failure in trust and confidence of not only our patients or service users, but also Regulators and Governors.
Board stability and leadership
In recent years membership of the Board has been unstable. There have been five Chief Executives, including interim appointments since
November 2009. Many positions were held on an interim basis. This led to a lack of strategic planning (including a Board Quality Strategy), little engagement with stakeholders, and disempowered clinical staff.
• Quality and patient safety is now the first item on each Board agenda.
• Trust reports openly and accurately to Monitor and CQC to rebuild confidence and trust.
• The Trust has developed an integrated action plan with agreed objectives. This action plan is reviewed through the Monitor Review meeting.
• Four experienced interim NED advisors were co-opted in November
2012, ahead of the substantive appointments from May 2013.
• A new Council of Governors has been re-elected, due to commence in
June 2013. Lead Governor to be identified, with an induction/development plan for all governors.
• An improved relationship with CCGs. CCG Chief Operating Officer chairs a combined CCG/Trust Mortality Group to address wider issues contributing to high HSMR.
The current interim Chairman and Chief Executive have implemented a number of actions to provide stabilisation, whilst also improving the effectiveness of the way the Board operates. This has included recruiting:
• A substantive chairman
• A substantive, experienced CEO
• 4 experienced co-opted NEDs, prior to substantive appointments
• 5 substantive NED advisors, including one from a clinical background
• A functioning PMO
Supported by improved communications and engagement with commissioners, Governors and clinicians.
Slide 69

Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks Trust response
Quality governance
Management Consultant finding (October 2012) – Whilst the Trust has established governance structure, a number of significant deficiencies in the operation of governance at Board, Divisional and Service level was identified. Ownership of, and engagement in, governance by Trust staff was identified as insufficient. Important governance processes and activities had not operated in a systematic manner. As a result, there was inadequate anticipation and management of risk throughout the Trust.
The operation of the Board, and its Sub-Committees, was too operationally focused with a lack of focus on strategic direction or decision making.
Board level scrutiny of Divisional and Service level performance was ineffective. Clinical engagement and leadership, particularly at Divisional level, was identified as weak, leading to a disproportionate focus on financial and operational performance and a lack of scrutiny over quality and safety related aspects of performance.
The Trust did not operate with an adequate focus on managing risks to quality and performance. Appropriate risk management processes and policies existed, but were not being used in a consistent or an effective way. Discussion about risks and the management of risks did not happen as frequently as expected. The Board were therefore not assured fully in respect of risks or the management of risk.
Actions (Approved by the Board December 2012):
• The organisation has been turned around with clinicians leading, supported by management and devolved decision making, within a clearer framework of accountability and control. Experienced governance and risk management expertise has been utilised to develop and strengthen governance and risk management processes.
• The organisation has reformed the Clinical Governance Committee as a Board Sub-Committee chaired by a NED. The terms of reference for the Committee have been reviewed. This Committee primarily focuses on assurance and clinical risk.
• The Risk Management Committee has been disbanded and reformed, with responsibility for reviewing the BAF and high rated risks escalated from Divisions transferred to an Executive Group which feeds actions into the Board and down to Divisions.
• Roles and responsibilities in relation to governance have been clarified and management of risks is now clearly being established.
• The Trust has successfully appointed an Associate Medical Director for
Patient Safety and a new Patient Safety Manager to drive the harms and mortality improvement plan.
• A governance support unit is being established with a Head of
Governance.
Slide 70

Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks Trust response
Financial Performance
Over the past few years the Trust track record on delivery had been considered strong, however,2011/12 was the first year of full PFI charges.
At the end of 2011/12 the Trust, excluding the impact of impairments, reported a deficit of £6.2m (£4.2m surplus including impairments).This was the first reported loss since authorisation as a Foundation Trust. For
2012/13 the Trust Financial plan indicated a £12.6m deficit in line with the continued PFI pressures and resulting deterioration in the underlying financial position of the Trust. The plan made clear the Trust would be an
FRR1 during the 2012/13 year. At the time of Monitor’s intervention in
October 2012 a deficit of £22m was forecast.
For the year ending 2012/13 the Trust has recorded a (subject to audit)
£15.1m deficit. Whilst this is adverse to plan, it is a substantive improvement on October 2012 forecast and reflects the in-year work undertaken with commissioners to contribute to ensuring ongoing viability of the Trust. Commissioners have actively engaged with the Trust during the year to support service redesign and cost improvement programmes and this is reflected in the outturn position.
As planned, the Trust at Q4 of 2012/13 had a financial risk rating with
Monitor of 1, due to the operating deficit and associated impact on cash, and the forward plan anticipates a deficit position and similar rating through 2013/14. The Board recognises that whilst this will continue to place the Trust in breach of its terms of authorisation, it acknowledges that the Trust requires a viable medium/long term solution, with full engagement from our commissioners and partners.
• The Board of Directors has taken steps throughout the year to continue to monitor and prepare prudent, risk assessed financial plans, for the year ahead. This includes reconciliation to the CCG future funding assumptions. Work continues with CCGs to understand and manage future changes to commissioning intentions. The steps taken to mitigate can be given if required.
• Development of a detailed 2013/14 cost improvement plans has continued in year with the continuing support of external advisers and the appointment of PMO additional resource.
• The Trust has ensured that Monitor have been kept closely informed of our future financial and compliance risks. The Trust meets with Monitor to share our plans, outturn, future risk and to discuss the steps and actions to mitigate forward risks.
Slide 71

Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks Trust response
Financial Performance continued…
The Board have been fully sighted of its need to “put its house in order” i.e. do everything it can to improve performance, efficiency and attract profitable business, to close the financial gap. The Board has continued to invest in services and initiatives that drive quality. This includes the purchase of e.g. ‘Vitalpac’ (an electronic monitoring system), additional clinical staff, governance roles and investment in new wards.
Cost Improvement Programme
The Trust has not had a good track record in delivering significant cost improvements and so has utilised specialist external support to refine its
CIP approach for 2012/13 and put in place better capability and assurance processes to be used into the future. The in-house team has been strengthened as a result of this work and much clearer and transparent assurance information is provided to the Board of Directors. The CIP
Programme Board is chaired by the CEO and CIP delivery forms part of the refreshed performance management arrangements being put in place across the Trust. This will help ensure delivery and reporting and allow the early identification and development of future years programmes.
Detailed above under ‘Financial Performance’,
Slide 72

Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks Trust response
Use of agency and temporary staffing
The 2012/13 activity contract was based upon PCT growth assumptions.
The Commissioners planned for a 1.2% growth in Non-Elective activity in
2012/13. The Trust has seen a significant higher growth rate. Despite this, non-elective activity growth could not have been anticipated to the extent experienced. Due to the earlier growth assumptions the Trust utilised temporary additional wards, leading to a reliance on agency staff throughout the year.
The increased pressure on beds meant additional unplanned ward capacity has been made available throughout the year at premium cost.
The estimate for the unplanned capacity for 2012/13 has cost the Trust in excess of £2 million. The Trust isnow spending £0.55m more each month on pay than they were a year ago. This increase in run rate is largely driven by the use of premium rate variable pay for medicine and nursing.
Medical agency and locum spend to cover vacancies has increased by
£0.10m per month since March 2012 and is now averaging £0.52m per month. Nursing agency spend has increased by £0.04m per month since
March 2012 and is now running at £0.40m per month. This increased reliance on agency has both quality and safety implications for the Trust.
• The Trust has negotiated a realistic activity contract, based upon
2012/13 outturn. This will enable the Trust to recruit to substantive posts and reduce its heavy reliance on agency support.
• Focused budget management within Divisions and Service Lines.
• The Trust has funded the additional Winter Wards, which enables substantive recruitment to key posts. Trust budgets have been funded at outturn (March 2013/14) to support investment in staff for high acuity/dependency areas.
• Dementia staffing increased to reduce reliance on agency for 1:1 care.
• Nurse bank strengthened to reduce reliance on agency staff.
• Preferred agency provider identified to support quality of staff commissioned.
Slide 73

Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks Trust response
Sickness and absence
Trust absence rates for 2012/13 was 4.73%, for short term 2.45% and long term 4.29%.Over the year, short term absence accounts for 52% of absence, whilst long term accounts for 48% of total absence. Since the previous year, increases in absence have occurred in Ancillary,
Administrative &Clerical, Scientific & Professional & Technical & Other staff groups; however decreases were observed in Medical & Dental,
Allied Health Professionals. Areas that remained stable against 11/12 include Registered and Unregistered Nursing.
Currently, the Trust absence is considered to be high against other Trusts in the local region and is having a direct impact on cost; the direct cost of paying staff whilst absent on sick leave was £4.70m for financial year
12/13 and would have contributed to a proportion of the variable pay spend of £22.17m (total spend 12-13).
Considerable effort is being taken to ensure that absence is driven down and reduced to an acceptable level, minimising the potential impact it can have on patient care and quality and decreasing the financial impact. The
Trust has formed an action group to directly address the issues which may be contributing to the high absence rates and implement the necessary improvements required.
Slide 74

Leadership and governance
External reviews
A recent CQC inspection of Kings Mill Hospital in October 2012 considered the Trust’s compliance with two outcomes (care and welfare of people who use services (outcome 4) and assessing and monitoring the quality of service provision (outcome 16)). This review focused on the breast care unit, in response concerns that the treatment of women with breast cancer had been based on incorrect test results .
The Trust was found to be compliant with outcome 4, but moderate concerns were raised in relation to outcome 16.
The report concluded that “The provider had systems in place to identify, assess and manage risks to the health, safety and welfare of people using the service and others. However, these systems were not sufficiently robust to ensure that governance arrangements were managed effectively and in a timely fashion.”
In response to Monitor’s intervention, the Trust commissioned a number of external reviews, including reviews of quality governance, board governance, mortality governance and a diagnostic review of the Trust’s financial position.
A review of quality governance in November 2012 concluded that the Trust had scored 13.0 against Monitor’s Quality Governance
Framework (aspirant foundation trusts much achieve a score of 3.5 or lower to be authorised as foundation trusts). The Trust has taken a number of actions since this report to strengthen quality governance arrangements; many of these actions are ongoing.
In addition in November 2012, the Trust commissioned an external review of mortality.
Cost Improvement Programme
The finance paper presented to the Board in April 2013 states that cost improvement programmes of £7.7m (3.2% of operating expenditure) were achieved against a plan of £14.0m. The report also noted that for 2013/14, “The value of savings identified to date is still short of the in-year Cost Improvement Programme savings target.”
Each CIP is developed by the divisions with sign off from clinical leadership (Clinical Director, Matron and General Manager) within the divisions. The planned CIPs are then approved by the Medical Director and Director of Nursing, prior to Executive Team and Trust Board sign off.
Slide 75

Slide 76

Trust Map – King’s Mill Hospital
Source : Sherwood Forest Hospitals NHS Foundation Trust website
Slide 77

Trust Map – Newark Hospital
Source : Sherwood Forest Hospitals NHS Foundation Trust website
Slide 78

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 79

Workforce Indicator Calculations
Indicator
WTE nurses per bed day
Numerator /
Denominator
Calculation
Numerator Nurses FTE’s
Denominator Total number of Bed Days
Spells per WTE staff
Numerator Total Number of Spells
Denominator Total number of WTE’s
Numerator FTEs whose job role is ‘Consultant’
Medical Staff to Consultant
Ratio
Nurse Staff to Qualified Staff
Ratio
Non-clinical Staff to Total Staff
Ratio
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
Consultant Productivity
(Spells/FTE)
Nurse hours per patient day
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
Note: ESR Data only includes substantive staff.
Source
Acute
Quality
Dashboard
HED
ESR
ESR
ESR
ESR
HED
ESR
ESR
HED
Slide 80

Board members
Source : Sherwood Forest Hospitals NHS Foundation Trust website
Board Members update (29 th April, 2013):
Five new Non-Executive Directors members appointed:
Ray Dawson
Sean Lyons
Peter Marks
Claire Ward
Gerry McSorley
Board Members update (10 th June, 2013):
-Paul O’Connor replaces Eric Morton as CEO
Slide 81

Committee structure for assuring quality and safety
CEO Reports Items
From HMB To BOD
Mortality reports directly to CCG
Quality &
Clinical Governance
Committee
Finance &
Performance
Committee
Clinical Management
Team
Audit committee
Remuneration &
Nomination
Committee
Risk Committee
Finance & Performance
Committee receive minutes
Committees & Groups
• Clinical Audit Committee
•
Resuscitation Committee
• Blood Transfusion
Committee
• Medical Devices Group
• Harms Group (being established)
• Medicines & Therapeutics
Committee
• Mortality Steering Group
• Infection Control
Committee
Committees are currently being renewed as part of
Governance Action Plan
Planned Care &
Surgery Clinical
Governance
Committee
Service Level
Governance
Committee
Diagnostic &
Rehabilitation Clinical
Governance
Committee
Service Level
Governance
Committee
Emergency Care &
Medicine Clinical
Governance
Committee
Service Level
Governance
Committee
Hospital
Management
Board (HMB)
Business &
Performance
Committee’s
Report into
HMB
Source : Trust submitted documentation
Executive Team
Meeting
(items referred from here to relevant committee)
Slide 82

Data Sources
No.
Data Source name
1 3 years CDI extended
2 3 years MRSA
3 Acute Trust Quality Dashboard
4 NQD alerts for 14
5 PbR review data
6 QRP time series
7 Healthcare Evaluation Data
GMC Annex - GMC summary of Education Evidence - trusts with high
8 mortality rates
9 1 Buckinghamshire Healthcare Quality Accounts
10 Burton Quality Account
11 CHUFT Annual Report 2012
12 Quality Report 2011-12
13 Annual Report 2011-12_final
14 NLG. Quality Account 2011-12
15 Annual Report 2012
16 Litigation covering email
17 Litigation summary sheet
18 Rule 43 reports by Trust
19 Rule 43 reports MOJ
20 Governance and Finance
21 MOR Board reports
22 Board papers
23 CQC data submissions
24 Evidence Chronology B&T
25 Hospital Sites within Trust
26 NHS LA Factsheet
27 NHSLA comment on five
Steering Group Agenda and Papers incl Governance Structure and
28 Timetable
29 List of products
30 Provider Site details from QRP
31 Annual Report 2011-12
32 SHMI Summary
33 Diabetes Mortality Outliers
34 Mortality among inpatient with diabetes
35 supplementary analysis of HES mortality data
36 VLAD summary
37 Mor Dr Foster HSMR
38 Outliers Elective Non elective split
39 Presentation to DH Analysts about Mid-staffs
40 CQC mortality outlier summaries
41 SHMI Materials
42 Dr Foster HSMR
43 AQuA material
44 Mortality Outlier Review
45 Original Analysis Identifying Mortality Outliers
46 Original Analysis of HSMR-2010-12
47 High-level Methodology and Timetable
48 Analytical Distribution of Work_extended table
Type Area
Analysis Clinical and Operational Effectiveness
Analysis Clinical and Operational Effectiveness
Analysis Clinical and Operational Effectiveness
Analysis Clinical and Operational Effectiveness
Data Clinical and Operational Effectiveness
Analysis Clinical and Operational Effectiveness
Analysis General
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
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
Data Governance and leadership
Analysis Governance and leadership
Analysis Governance and leadership
Analysis Governance and leadership
Data Governance and leadership
Analysis Governance and leadership
Analysis Governance and leadership
Analysis Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Data Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Analysis Mortality
Data Mortality
Data 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 Area
Analysis Mortality
Analysis Mortality
Analysis Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Data Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Data Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Analysis Patient Experience
Analysis Safety and Workforce
Analysis Safety and Workforce
Data Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Data Safety and Workforce
Analysis Safety and Workforce
Data Safety and Workforce
Data
Data
Data
Safety and Workforce
Safety and Workforce
Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Data Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Analysis Safety and Workforce
Data Safety and Workforce
Slide 83

Data Sources
No. Data Source Name
Health and Social Care Information Centre (HSCIC) monthly workforce
98 statistics
99 National Staff Survey, 2011, 2012
100 GMC evidence to review, 2013
101 2011/12 Organisational Readiness Self-Assessment (ORSA)
102 National Training Survey, 2012
103 National Patient Safety Agency (NPSA) Apr 11 – Mar 12
Type Area
Data
Data
Safety and Workforce
Safety and Workforce
Analysis Safety and Workforce
Data
Data
Data
Safety and Workforce
Safety and Workforce
Safety and Workforce
Slide 84

SHMI Appendix
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Admission Method
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Treatment Specialty
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
Diagnostic Group
11 - Cancer of head and neck
12 - Cancer of esophagus
14 - Cancer of colon
15 - Cancer of rectum and anus
16 - Cancer of liver and intrahepatic bile duct
18 - Cancer of other GI organs; peritoneum
21 - Cancer of bone and connective tissue
24 - Cancer of breast
25 - Cancer of uterus
27 - Cancer of ovary
29 - Cancer of prostate
38 - Non-Hodgkin`s lymphoma
39 - Leukemias
41 - Cancer; other and unspecified primary
43 - Malignant neoplasm without specification of site
48 - Thyroid disorders
50 - Diabetes mellitus with complications
51 - Other endocrine disorders
52 - Nutritional deficiencies
54 - Gout and other crystal arthropathies
58 - Other nutritional; endocrine; and metabolic disorders
63 - Diseases of white blood cells
81 - Other hereditary and degenerative nervous system conditions
83 - Epilepsy; convulsions
101 - Coronary atherosclerosis and other heart disease
SHMI
134
539
423
120
237
148
244
120
135
149
111
120
125
178
121
145
193
287
152
376
259
Observed Deaths that are higher than the expected
2
147
118
161
152
2
2
3
1
1
3
1
2
2
1
2
1
2
1
2
2
1
1
1
2
1
2
1
1
Slide 85

SHMI Appendix
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Admission Method
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Treatment Specialty
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
Diagnostic Group
107 - Cardiac arrest and ventricular fibrillation
110 - Occlusion or stenosis of precerebral arteries
114 - Peripheral and visceral atherosclerosis
115 - Aortic; peripheral; and visceral artery aneurysms
117 - Other circulatory disease
121 - ther diseases of veins and lymphatics
123 - Influenza
125 - Acute bronchitis
136 - Disorders of teeth and jaw
137 - Diseases of mouth; excluding dental
138 - Esophageal disorders
139 - Gastroduodenal ulcer (except hemorrhage)
143 - Abdominal hernia
145 - Intestinal obstruction without hernia
146 - Diverticulosis and diverticulitis
148 - Peritonitis and intestinal abscess
151 - Other liver diseases
155 - Other gastrointestinal disorders
158 - Chronic renal failure
163 - Genitourinary symptoms and ill-defined conditions
166 - Other male genital disorders
197 - Skin and subcutaneous tissue infections
202 - Rheumatoid arthritis and related disease
206 - Osteoporosis
226 - Fracture of neck of femur (hip)
SHMI
500
145
133
418
384
160
292
356
134
570
2075
109
820
1907
139
128
292
322
111
1316
858
114
Observed Deaths that are higher than the expected
1
1413
138
126
1
1
1
3
1
2
1
1
1
3
2
3
3
1
1
1
1
2
2
1
2
1
1
1
Slide 86

SHMI Appendix
Admission Method
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Treatment Specialty
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
Diagnostic Group
229 - Fracture of upper limb
230 - Fracture of lower limb
231 - Other fractures
234 - Crushing injury or internal injury
239 - Superficial injury; contusion
244 - Other injuries and conditions due to external causes
249 - Shock
250 - Nausea and vomiting
259 - Residual codes; unclassified
SHMI
125
205
258
137
109
169
411
Observed Deaths that are higher than the expected
1
2
136
333
1
2
1
1
1
2
1
Slide 87

HSMR Appendix
Admission Method
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Non-elective
Treatment Specialty
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
300 - General medicine
501 - Obstetrics
Diagnostic Group
Biliary tract disease
Cancer of breast
Cancer of esophagus
Cardiac arrest and ventricular fibrillation
Chronic renal failure
Complication of device; implant or graft
Coronary atherosclerosis and other heart disease
Deficiency and other anemia
Intestinal obstruction without hernia
Malignant neoplasm without specification of site
Non-Hodgkin`s lymphoma
Other liver diseases
Other lower respiratory disease
Peripheral and visceral atherosclerosis
Peritonitis and intestinal abscess
Respiratory failure; insufficiency; arrest (adult)
Skin and subcutaneous tissue infections
Other perinatal conditions
HSMR
172
166
155
154
239
107
134
2460
206
293
137
160
170
168
147
152
Observed Deaths that are higher than the expected
3
1
119
116
1
2
3
3
1
3
1
1
3
1
1
3
2
1
3
3
Slide 88

Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Non-elective)
Treatment Specialty
General medicine
Obstetrics
HSMR
X
X
SHMI
X
Slide 89