Tameside Hospital NHS
Foundation Trust
Data Pack
9th July, 2013
Overview
Sources of Information
On 6th February the Prime Minister asked Professor Sir Bruce
Keogh to review the quality of the care and treatment being
provided by those hospital trusts in England that have been
persistent outliers on mortality statistics. The 14 trusts which fall
within the scope of this review were selected on the basis that they
have been outliers for the last two consecutive years on either the
Summary Hospital Mortality Index or the Hospital Standardised
Mortality Ratio.
Document review
Trust information
submission for
review
These two measures are being used as a ‘smoke alarm’ for
identifying potential quality problems which warrant further
review. No judgement about the actual quality of care being
provided to patients is being made at this stage, or should be
reached by looking at these measures in isolation.
The review will follow a three stage process:
Stage 1 – Information gathering and analysis
Stage 2 – Rapid Responsive Review
Benchmarking
analysis
Information shared
by key national
bodies including
the CQC
Stage 3 – Risk summit
This data pack forms one of the sources within the information
gathering and analysis stage.
Information and data held across the NHS and other public bodies
has been gathered and analysed and will be used to develop the Key
Lines of Enquiry (KLOEs) for the individual reviews of each Trust.
This analysis has included examining data relating to clinical
quality and outcomes as well as patient and staff views and
feedback. A full list of evidence sources can be found in the
Appendix.
Given the breadth and depth of information reviewed, this pack is
intended to highlight only the exceptions noted within the evidence
reviewed in order to inform Key Lines of Enquiry.
Slide 2
Tameside Hospital NHS Foundation Trust
Context
A brief overview of the Tameside area and Tameside Hospital NHS Foundation Trust. This section will provide a profile of the area,
outline performance of local healthcare providers and give a brief introduction to the Trust.
Mortality
An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the
Trust which are outliers.
Patient Experience
A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient
experience surveys.
Safety and Workforce
A summary of the Trust’s safety record and workforce profile.
Clinical and Operational Effectiveness
A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This
section compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures
(PROMs).
Leadership and Governance
An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership,
current top risks to quality and outcomes from external reviews.
Slide 3
Context
Slide 4
Context
Overview:
This section will provide an introduction to the Trust, providing
an overview, health profile and an understanding of why the
Trust has been chosen for this review.
Summary:
Review Areas:
Tameside has a population of 250,000. 9% of Tameside’s
population belongs to non-White ethnic minorities, including 6%
Indians.
To provide an overview of the Trust, we have reviewed the
following areas:
Relative to the national average, Tameside is a small Trust for
inpatient and outpatient activity.
•
Local area and market share;
•
Health profile;
•
Service overview; and
•
Initial mortality analysis.
Data Sources:
•
Board of Directors meeting 30th Jan, 2013;
•
Department of Health: Transparency Website, Dec 12;
•
Healthcare Evaluation Data (HED);
•
NHS Choices;
•
Office of National Statistics, 2011 Census data;
•
Index of Multiple Deprivation, 2011;
•
© Google Maps;
•
Public Health Observatories – Area health profiles; and
•
Background to the review and role of the national
advisory group.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Tameside’s health profile outlines that there are a number of
aspects for which children’s and young people’s and adults’
health is significantly lower than the national average. The
profile also shows that in Tameside life expectancy for both men
and women is significantly lower than the national average.
The Trust has one hospital site. It became a Foundation Trust in
2008 and has a total of 502 beds. Tameside has a 42% market
share of inpatient activity within a 2 mile radius of the hospital.
However, the Trust’s market share falls to 28% within a radius
of 5 miles and 12% within a radius of 10 miles.
A review of ambulance response times showed that the North
West service meets its 8 minute response target, but not its 19
minutes target.
Finally, Tameside’s SHMI has been above the expected level for
last two years and the Trust was therefore selected for this
review.
Slide 5
Trust Overview
Tameside became a Foundation Trust in 2008. Prior to this, it had
operated as Tameside and Glossop Acute Services NHS Trust since
1994. The Trust services a population of approximately 250,000 and
employs approximately 2,000 staff. The Trust consists of a single
hospital site, divided into four divisions: emergency services and critical
care, elective services, diagnostic & therapeutic, and the women and
children’s division. In addition, the Trust offers knowledge and library
services within a non-clinical services category.
Tameside Hospital NHS Foundation Trust
Trust Status
Foundation Trust (2008)
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
502
89.4%
86%
General and
Acute
463
92.2%
88%
Maternity
40
56.6%
59%
Source: Department of Health: Transparency Website
Acute Hospital
Tameside General Hospital
Inpatient/Outpatient Activity
Inpatient Activity
Finance Indicator
Elective
20,415 (39%)
Value
2012-13 Income
£159m
2012-13 Expenditure
£148m
2012-13 EBITDA
£11m
2012-13 Net surplus (deficit)
(£6m)
2013-14 Budgeted Income
£154m
2013-14 Budgeted Expenditure
£142m
2013-14 Budgeted EBITDA
£12m
2013-14 Budgeted Net surplus
(deficit)
£2m
Outpatient Activity
Non Elective
31,771 (61%)
Total
52,186
Total
238,676
(Jan12-Dec12)
Day Case Rate:
84%
Source: Healthcare Evaluation Data (HED)
Departments and Services
Source: Tameside website: Trust Board backing papers 2013
Accident & Emergency, Breast Surgery, Cardiology, Children’s and
Adolescent Services, Dermatology, Diabetic Medicine, Diagnostic
Physiological Measurement, ENT, Endocrinology and Metabolic
Medicine, Gastro Intestinal and Liver Services, General Medicine,
General Surgery, Geriatric Medicine, Gynaecology, Haematology,
Maternity Service, Nephrology, Neurosurgery, Oral and Maxillofacial
Surgery, Ophthalmology, Orthopaedics, Pain Management, Plastic
Surgery, Respiratory Medicine, Rheumatology, Urology, Vascular
Surgery.
Source: NHS Choices
Slide 6
Trust Overview continued...
General Medicine and
General Surgery are
the largest inpatient
specialities, while
Trauma &
Orthopaedics and
General Medicine are
the largest for
outpatients.
Outpatient Activity by Trust
300
1200
250
1000
200
150
Tameside
52,186
100
50
Number of Outpatient
Spells (Thousands)
Tameside is a small
sized Trust for both
inpatient and
outpatient activity,
relative to the rest of
England. Indeed, the
Trust is the second
smallest of all those
selected for this review
by both measures of
activity.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of
Tameside against
national trusts in
terms of inpatient and
outpatient activity.
800
600
Tameside
238,676
400
200
0
0
Trusts
Trusts Covered by Review
Trusts
National Inpatient Activity Curve
Top 6 Inpatient Main Specialties as a
% of Total Inpatient Activity
Trusts Covered by Review
Bottom 6 Inpatient Main Specialties
and Spells
National Outpatient Activity Curve
Top 6 Outpatient Main Specialties as
a % of Total Outpatient Activity
General Medicine
37%
Obstetrics
12
Trauma & Orthopaedics
16%
General Surgery
18%
Rheumatology
26
General Medicine
16%
Gynaecology
13%
Oral Surgery
351
General Surgery
10%
Paediatrics
13%
Clinical Haematology
811
Dermatology
8%
Trauma & Orthopaedics
8%
Anaesthetics
978
Obstetrics
7%
Ear, Nose & Throat
2%
Midwifery
1018
Gynaecology
6%
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
Slide 7
Tameside Area Overview
Tameside is a relatively small Trust region. It is among the most deprived
quartile of counties in England and has sizeable ethnic minorities, particularly
from South Asia. Teenage pregnancy and alcohol-related hospital stays for
under-18 year olds are particularly common in this region, just as violent
crime and long-term unemployment are relatively more common than in
England as a whole. The age distribution in Tameside is mostly similar to the
age distribution nationally.
Tameside Area Demographics
0-9
10-19
FACT BOX
Population
250,000
The Royal College of Surgeons recommend that the
"...catchment population size...for an acute general hospital
providing the full range of facilities, specialist staff and
expertise for both elective and emergency medical and
surgical care would be 450,000 - 500,000."
IMD
Of 149 English unitary authorities, Tameside
is the 36th most deprived.
Ethnic
diversity
In Tameside, 9% belong to non-white
minorities, in line with the average for
England. This includes 6% Indians.
Rural or
Urban
Tameside is a rural-urban region
Children’s
and young
people’s
health
Teenage pregnancy is particularly common in
this region, as is alcohol-related hospital
stays for people under 18. Smoking in
pregnancy is also proportionally more
common here than in England as a whole.
Deprived
community
Violent crime and long-term unemployment
are significantly more common in Tameside
than in England as a whole.
20-29
30-39
40-49
50-59
60-69
70-79
80+
Female/TAM
20%
15%
10%
Female/ENG
5%
0%
Male/TAM
5%
Male/ENG
10%
Source: Office of National Statistics, Census 2011; Index of Multiple Deprivation, 2010
15%
20%
Slide 8
Tameside Geographic Overview
The map on the right shows the geographical location of Tameside.
Tameside is located in Greater Manchester in the Northwest of
England. As shown by the map, Tameside is located close to the
M60.
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 Tameside
Hospital NHS Foundation Trust. From the wheel it can be seen
that Tameside has a 42% market share of inpatient activity within
a 2 mile radius of the Trust.
As the size of the radius is increased, the market share falls to 28%
within 5 miles and 12% within 10 miles.
The wheel shows that the main competitors in the local area are
Central Manchester University Hospitals NHS Foundation Trust,
Pennine Acute Hospitals NHS Trust, Stockport NHS Foundation
Trust, and Salford Royal NHS Foundation Trust.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 9
Tameside’s Health Profile
Health Profiles, depicted on this slide and the following two, 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 economic deprivation experienced in Tameside.
Tameside has on average the same level of deprivation as England as a whole,
The tables below outline Tameside’s health profile information in comparison
to the rest of England.
Deprivation by unitary authority area
Tameside
1.
Tameside’s
performance on
communities indicators 1
is below the national
average on almost all
indicators. Tameside
have higher levels of
deprivation, children in
poverty and violent
crime as well as higher
levels of unemployment
2
than the national
average.
2. All indicators
within Children’s and
young people’s health
are statistically below
the national average in
Tameside. These
indicators include
teenage pregnancy,
smoking in pregnancy
and alcoholic specific
hospital stays.
Source: Public Health Observatories – area health profiles
Slide 10
Tameside’s Health Profile
3. Health and
lifestyle indicators
3
show that Tameside
have a high number
of smokers and obese
adults while healthy
eating and physically
active adults are also
below the national
4
average.
4. Tameside’s
performance on
disease and poor
health is statistically
below the national
average on a number
of indicators
including self harm,
alcohol related
hospital stays,
diabetes, drug misuse
and acute sexually
transmitted
infections.
Source: Public Health Observatories – area health profiles
Slide 11
Tameside’s Health Profile
5. In terms of life
expectancy and causes
of death, Tameside is
statistically below the
national average on a
number of indicators,
these include life
expectancy, smoking
related deaths and
early deaths due to
heart disease and
cancer.
5
Source: Public Health Observatories – area health profiles
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 represent some key
performance indicators for
England’s Ambulance services.
Proportion of calls responded to within 8 minutes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Isle of Wight
NHS Trust
The North West service is
meeting the 8 min response
target but not the 19 minute
target.
South
West
South Central
Western
Midlands
Ambulance
Ambulance Ambulance Service NHS
Service NHS Service NHS Foundation
Foundation
Trust
Trust
Trust
South East
East of
London
North West
Great
North East
Yorkshire East Midlands
Coast
England
Ambulance Ambulance
Western
Ambulance Ambulance Ambulance
Ambulance Ambulance Service NHS Service NHS Ambulance Service NHS Service NHS Service NHS
Service NHS Service NHS
Trust
Trust
Service NHS
Trust
Trust
Trust
Foundation
Trust
Trust
Trust
Ambulance Trust
England
Proportion of calls responded to within 19 minutes
100%
98%
96%
94%
92%
90%
88%
86%
84%
Source: Department of Health: Transparency Website Dec 12
Isle of Wight
NHS Trust
West
London
South East
Yorkshire
South
Great
North East North West South Central
East of
East Midlands
Midlands
Ambulance
Coast
Ambulance
Western
Western
Ambulance Ambulance Ambulance
England
Ambulance
Ambulance Service NHS Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Ambulance Service NHS
Service NHS
Trust
Service NHS
Trust
Service NHS Service NHS
Trust
Trust
Foundation Service NHS
Trust
Trust
Foundation
Foundation
Trust
Trust
Trust
Trust
Trust
Ambulance Trusts
England
Slide 13
Why was Tameside 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 the 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 review based on
the fact that they had been outliers on SHMI for
the last two years.
Subsequent to these five hospital trusts being
announced, Professor Sir Bruce Keogh took the
decision that those hospitals trusts that had also
been outliers for the last two consecutive years on
HSMR should also fall within the scope of this
Review. The rationale for this was that it had
been HSMR that had provided the trigger for the
Healthcare Commission’s initial review into the
quality of care provided at Mid Staffordshire
Hospitals NHS Foundation Trust.
Tameside Hospital NHS Foundation Trust has
been above the expected level in the SHMI for the
last 2 years and was therefore selected for this
review.
Trust
SHMI 2011 SHMI 2012
HSMR
FY 11
HSMR
FY 12
Within
Expected?
Basildon and Thurrock University Hospitals NHS
Foundation Trust
1
1
98
102
Within expected
Blackpool Teaching Hospitals NHS Foundation Trust
1
1
112
114
Above expected
Buckinghamshire Healthcare NHS Trust
112
110
Above expected
Burton Hospitals NHS Foundation Trust
112
112
Above expected
Colchester Hospital University NHS Foundation Trust
1
1
107
102
Within expected
East Lancashire Hospitals NHS Trust
1
1
108
103
Within expected
George Eliot Hospital NHS Trust
117
120
Above expected
Medway NHS Foundation Trust
115
112
Above expected
North Cumbria University Hospitals NHS Trust
118
118
Above expected
Northern Lincolnshire And Goole Hospitals NHS
Foundation Trust
116
118
Above expected
Sherwood Forest Hospitals NHS Foundation Trust
114
113
Above expected
101
102
Within expected
The Dudley Group Of Hospitals NHS Foundation Trust
116
111
Above expected
United Lincolnshire Hospitals NHS Trust
113
111
Above expected
Tameside Hospital NHS Foundation Trust
1
1
Banding 1 – ‘higher than expected’
Source: Background to the review and role of the national advisory group Financial years 2010-11, 2011-12
Slide 14
Why was Tameside chosen for this review?
The way that levels of observed
deaths that are higher than the
expected deaths can be
understood is by using HSMR
and SHMI. Both compare the
number of observed deaths 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.
The funnel chart for 2010/11
and 2011/12, the period when
the trusts were selected for
review, shows that Tameside’s
SHMI is statistically above the
expected range, supported by
the time series which shows the
SHMI being consistently
higher than expected. The
HSMR for Tameside from Dr
Foster is within the expected
for financial years 2009/10,
2010/11, and 2011/12.
SHMI Time Series
SHMI Funnel Chart
Tameside
Selected trusts Outside Range
Selected trusts w/in Range
Source: Healthcare Evaluation Data (HED); Apr 10-Mar12
Source: Healthcare Evaluation Data (HED); Apr 10-Mar12
Time series of HSMR, Tameside FT
130
125
120
119
115
110
105
105
102
102
100
95
90
2008/09
2009/10
HSMR
2010/11
I
2011/12
95% Confidence interval
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 15
Mortality
Slide 16
Mortality
Overview:
Summary:
This section will focus upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The Trust has an overall HSMR of 107 for the period January
2012 to December 2012, meaning that the number of actual
deaths is higher than the expected level. However, this is
statistically within the expected range.
The measures identified are being used as a ‘smoke alarm’ for
highlighting potential quality issues. No judgement about the
actual quality of care being provided to patients is being made at
this stage, nor should it be reached by looking at these measures in
isolation.
Review areas
To undertake a detailed analysis of the trust’s mortality, it is
necessary to look at the following areas:
• Differences between the HSMR and SHMI;
• Elective and non-elective mortality;
• Specialty and Diagnostic groups; and
• Alerts and investigations.
Data sources
• Healthcare Evaluation Data (HED);
• Health & Social Care Information Centre – SHMI and
contextual indicators;
Further analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure,
with a similar HSMR of 107, also within the expected range.
Elective admissions are within the expected range, despite a
high HSMR, due to a low level of expected deaths.
Currently, Tameside has a SHMI of 116, which is statistically
above the expected range.
Similar to HSMR, non-elective admissions are seen to be
contributing primarily to the overall Trust SHMI, with a similar
figure of 115. Elective admission are also above the expected
range, with a SHMI of 166.
The Cardiology clinical area has had three outlier alerts since
2007, including the most recent for Acute myocardial infarction
in March 2013.
The trust’s HSMR has reduced over the past few years, whereas
their SHMI has remained higher than expected since April 2010.
One factor affecting this could be changes in coding, including
for palliative care.
• Dr Foster – HSMR; and
• Care Quality Commission – alerts, correspondence and findings.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Slide 17
Mortality Overview
Mortality
The following overview provides a summary of the Trust’s key mortality areas:
Overall HSMR
Elective mortality (SHMI and HSMR)
Overall SHMI*
Non-elective mortality (SHMI and HSMR)
Weekend or weekday mortality outliers
Palliative care coding issues
Outcome 1 (R17) Respecting and involving e who use services
Emergency specialty groups much worse than expected
30-day mortality following specific surgery / admissions
Emergency specialty groups worse than expected
Mortality among patients with diabetes
Diagnosis group alerts to CQC
Mortality in low-risk groups
Diagnosis group alerts followed up by CQC
SHMI*
Outside expected range of the HSCIC for Mar 11 – Sep 12
Outside expected range
Outside expected range based on Poisson distribution for Dec 11 – Nov 12
Within expected range
Within expected range
*The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model,
which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14
trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the
purposes of this review.
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR,
Care Quality Commission – alerts, correspondence and findings
Slide 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 groups (CCS groups); in a specified patient group. The expected deaths are calculated
from logistic 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.
2.
3.
4.
Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
The Indicator will utilise 5 factors to adjust mortality rates by
a.
The primary admitting diagnosis;
b.
The type of admission;
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities);
d.
Age; and
e.
Sex.
All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models all deviations from the expected are highlighted
using a Random Effects funnel plot.
Slide 20
Some key differences between SHMI and HSMR
Indicator
HSMR
SHMI
Are all hospital deaths included?
No, around 80% of in hospital deaths are
included, which varies significantly
dependent upon the services provided by
each hospital
If a patient is transferred between hospitals
within 2 days the death is counted multiple
times
Yes all deaths are included
Does the use of the palliative care code
reduce the relative impact of a death on the
indicator?
Yes
No
Does the indicator consider where deaths
occur?
Only considers in hospital deaths
Considers in hospital deaths but also those
up to 30 days post discharge anywhere too.
Is this applied to all health care providers?
Yes
No, does not apply to specialist hospitals
When a patient dies how many times is this
counted?
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
Slide 21
SHMI overview
Month-on-month time series
The Trust’s SHMI level for the 12 months from Dec11-Nov12 is 116,
which means, as shown below, it is statistically above the expected
range and so classified as an outlier, based on the 95% confidence
interval of the Poisson distribution.
The time series show a general trend of decreasing SHMI both yearon-year and month-on-month.
SHMI funnel chart –12 months
Tameside
Year-on-year time series
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 Tameside.
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 75.3% of
SHMI deaths occur in
hospital at Tameside, which
is more than the national
average of 73.3%.
Percentage of patient deaths in hospital
90%
85%
80%
Tameside 75.3%
75%
70%
65%
60%
Trusts selected for review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 23
Mortality - SHMI Tree
Elective
SHMI 166
-
-
-
-
Clinical haematology
Dermatology
Rheumatology
Paediatrics
Gynaecology
General medicine
SHMI 115
-
-
Oral surgery
Pain management
-
Ear, nose and throat (ENT)
-
-
Non
Elective
Treatment Specialties
-
Gynaecology
Midwife episode
Obstetrics
-
-
Well babies
Clinical haematology
-
-
General medicine (119, 198)
Neonatology
-
Pain management
-
-
Oral surgery
Paediatrics
-
Ear, nose and throat (ENT)
-
-
Trauma & orthopaedics
Rheumatology
-
General surgery
-
-
The number of observed
deaths in two specific
areas are highlighted as
being higher than
expected: in General
surgery for elective
admissions, and General
medicine for nonelective admissions.
These are potential
areas for review.
Trauma & orthopaedics
The tree shows that
Tameside has a SHMI of
116 which is above the
expected range.
-
SHMI 116
General surgery (181, 10)
Overall
Trust
Treatment Specialties
-
Mortality trees provide
a breakdown of SHMI
into elective and nonelective admissions. The
SHMI score for nonelective admissions has
a greater impact on the
overall indicator due to
a higher number of
expected deaths.
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Key
Diagnosis (100 ; 1 )
SHMI
Observed deaths that are higher
than the expected
Slide 24
SHMI sub-tree of non-elective specialties
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
The SHMI sub-tree highlights the specialties for non-elective admissions with a
statistically higher SHMI than expected and highlights the diagnostic groups with
at least four more observed deaths than expected. When identifying areas to
review, it is important to consider the number of deaths as well as the SHMI.
General medicine has the highest number of greater than expected deaths with
Pneumonia (81), Acute myocardial infarction (26) and Acute cerebrovascular
disease (16) seen as the main diagnostic groups contributing to this. Those groups
highlighted below may potentially be areas to be reviewed.
Overall118.2
(116; 188)
Elective (166; 12)
Treatment Specialties
Diagnostic Groups
General surgery (181, 10)
Non-elective (115; 176)
General medicine (119, 198)
Acute myocardial infarction
(150, 26)
Acute cerebrovascular disease
(130, 16)
Other and ill-defined cerebrovascular disease
(1239, 4)
Pneumonia
(146, 81)
Intestinal infection
(137, 5)
Other liver diseases
(264, 7)
Acute and unspecified renal failure
(111, 4)
Cancer of pancreas
(152, 4)
Key
Cancer of bronchus; lung
(123, 14)
Diagnosis (100 ; 1 )
Chronic ulcer of skin
(259, 4)
Cancer of breast
(159, 4)
Secondary malignancies
(136, 4)
Senility and organic mental disorders
(170, 14)
SHMI
Observed deaths that are higher
than the expected
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 25
HSCIC SHMI overview
The Health and Social Care Information Centre (HSCIC) publish
the SHMI quarterly. This official statistic covers a rolling 12
month reporting period using a model based on a 3-year dataset
refreshed quarterly. The earliest publication was in October
2011, for the period from April 2010 to March 2011.
The HSCIC produce two sets of upper and lower limits. One set
uses 99.8% control limits from an exact Poisson distribution
based on the number of expected deaths. The other set uses a
Random effects model applying a 10% trim for over-dispersion,
based on the standardised Pearson residual for each provider
excluding the top and bottom 10% of scores. This latter set is
broader than the Poisson and is the one against which the
HSCIC report whether the SHMI is within, below or above the
expected range.
SHMI published by HSCIC, Tam eside FT
125
120
115
110
105
100
95
90
85
80
Mar-11
Jun-11
Sep-11
Dec-11
Mar-12
Jun-12
Sep-12
Rolling 12 months ending
Lower limit
Upper limit
SHMI
The SHMI for Tameside was 118 in the year to Sept-12 (England
baseline = 100) and has been above the expected range
throughout.
Source: Health & Social Care Information Centre – SHMI
Slide 26
HSMR overview
Month-on-month time series
The Trust’s HSMR level for the 12 months from Jan12-Dec12 is 107,
which means, as shown below, although it is above 100, it is within
the expected range and so not classified as an outlier.
The time series show a general trend of decreasing HSMR year-onyear, however the month on month time series shows no real trend,
changing between extremes of 87 and 131.
HSMR funnel plot –12 months
Year-on-year time series
Tameside
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 27
HSMR Statistics
The table to the right shows
Tameside’s HSMR broken
down by admission type.
Admission type
The breakdown illustrates
the overall HSMR is 107
which is within the expected
range. The table identifies
that both elective and nonelective admissions have an
HSMR within the expected
range.
Key – colour by
alert level:
Weekend admission (January-December 2012)
HSMR
Weekend
Week
All
Elective
206
141
147
Non-elective
110
106
107
All
111
106
107
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Red – Higher than
expected (above the
95% confidence
interval)
Blue – Within
expected range
Green – Lower than
expected (below the
95th 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:
•
Pneumonia (56 observed deaths that are higher than the
expected, 227 total deaths, HSMR 133);
•
Acute myocardial infarction (27, 78, 152);
•
Acute cerebrovascular disease (8 ,64, 114); and
•
Gastrointestinal haemorrhage (7, 21, 154)
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 29
Mortality - HSMR Tree
Elective
HSMR 147
Paediatrics
Gynaecology
-
Clinical haematology
-
-
General medicine
Ear, nose and throat (ENT)
-
-
HSMR107
Treatment Specialties
-
-
-
-
Well babies
*Obstetrics (2498, 8)
Gynaecology
Midwife episode
Clinical haematology
Neonatology
-
General medicine (110, 78)
-
-
Ear, nose and throat (ENT)
Paediatrics
-
Trauma & orthopaedics
-
-
General surgery
*Obstetrics was not
highlighted as an outlier
on HED, however with
HSMR of 2498 and with 8
observed deaths compared
to an expected level of 0.3,
it is an area for potential
review.
Non
Elective
-
Within non-elective
admissions General
medicine and obstetrics
have the highest number of
observed deaths above the
expected level.
Trauma & orthopaedics
Elective admissions is
within the expected range,
despite its high HSMR
level, due to relatively few
expected deaths.
-
HSMR 107
General surgery
Overall
Trust
Treatment Specialties
-
The tree shows that the
HSMR for Tameside is 107
which is within above the
expected range. When
breaking this down by
admission type, it is clear
that it is driven by non
elective admissions, which
are at similar level.
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Key
Diagnosis (100 ; 1 )
HSMR
Observed deaths that are higher
than the expected
Slide 30
HSMR sub-tree of specialties
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
The HSMR sub-tree indicates the specialities with a statistically higher
HSMR than expected and with diagnostic groups with at least four more
observed deaths than expected. When identifying areas to review, it is
important to consider the number of deaths as well as the HSMR.
The sub-tree indicates that General medicine has the highest number of
above expected deaths. These are spread over numerous diagnostic
groups such as Pneumonia (55) and Acute myocardial infarction
(26).Within Obstetrics, Other perinatal conditions has the highest number
of above expected deaths (8).
Overall118.2
(107; 65)
Non-elective (107; 60)
Treatment Specialties
Obstetrics* (2498, 8)
Other perinatal conditions
General medicine (110, 78)
(2550, 8)
Diagnostic Groups
Key
Diagnosis (100 ; 1 )
HSMR
Observed deaths that are higher
than the expected
Acute cerebrovascular disease
(111, 6)
Acute myocardial infarction
(151, 26)
Chronic ulcer of skin
Congestive heart failure;
nonhypertensive
(239, 4)
Deficiency and other anemia
(176, 5)
Gastrointestinal hemorrhage
(198, 9)
Other liver diseases
(342, 6)
Pneumonia
(133, 55)
(117, 7)
*Obstetrics was not highlighted as an outlier on HED,
however with HSMR of 2498 and with 8 observed
deaths compared to an expected level of 0.3, it is an
area for potential review.
Slide 31
HSMR – Dr Foster
The HSMR time series for Tameside from Dr Foster shows a
fall in the HSMR since 2008/09 and shows the HSMR is within
the expected range. 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 year 2008/09.
Time series of HSMR, Tameside FT
130
125
120
119
115
110
105
105
102
102
100
The latest SHMI published by the HSCIC, for Oct 11 to Sept 12,
is higher 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.
95
90
2008/09
2009/10
HSMR
140
2010/11
I
2011/12
95% Confidence interval
Comparison of mortality measures,
Tameside FT
130
123
120
118
110
108
100
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.
94
90
80
SHMI
SHMI adjusted
SHMI in
for palliative hospital deaths
care
only
HSMR
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 32
Coding
Diagnosis coding depth
has an impact on the
expected number of
deaths. A higher average
diagnosis coding depth is
more likely to collect comorbidity which will
influence the expected
mortality calculation.
When looking at the Depth
of Coding for Tameside, it
is clear that the Trust’s
average diagnosis coding
depth is above the national
average and greater than
the average of the 14
trusts covered by this
review.
Average Diagnosis Coding Depth
Elective
6
Non-elective
6
5
5
4
4
3
3
2
2
1
1
0
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
2012/13
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
2012/13
National Average Diagnosis Coding Depth
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
Tameside
Tameside
The elective and non
elective graphs both show
that Tameside has been
above the national
average over the last few
years.
Source: Health Evaluation Data (HED)
Slide 33
Palliative care
Tameside currently make above average use of
palliative care coding on admissions (by treatment
specialty or diagnosis). The proportion of SHMI deaths
with a palliative care code is growing to above
average. HSMR takes account of palliative care but
SHMI does not.
The trust’s HSMR has reduced over the past few years,
whereas their SHMI has remained higher than expected
since April 2010. One factor affecting this could be
changes in coding, including for palliative care.
Percentage of admissions with palliative care
coding
2.0
1.5
1.0
0.5
Oct-11
Jan-12
Apr-12
Tameside
Jul-12
Oct-12
National
Jan-13
Apr-13
SHMI publication
Percentage of deaths with palliative care coding
25
20
15
10
5
Oct-11
Jan-12
Apr-12
Tameside
Jul-12
National
Oct-12
Jan-13
Apr-13
SHMI publication
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 34
Care quality commission findings
Care Quality Commission (CQC) review mortality alerts for
each Trust on an ongoing basis. These alerts, which indicate
observed deaths significantly above expected for specialties
or diagnoses, come from different sources based on either
HSMR or SHMI. Where these appear unexplained, CQC
correspond with the Trust to agree any appropriate action.
Emergency specialty groups much worse than expected
Sep 11 to Aug 12
2
Cardiology
Respiratory Medicine
Emergency specialty groups worse than expected
For Tameside, the common themes that have arisen across
the patient groups alerting since 2007 are the Emergency
care pathway, Cardiology and Elderly Care.
No common themes arise from responses to the CQC from the
Trust.
Sep 11 to Aug 12
3
Gastroenterology and Hepatology
Cerebrovascular
Trauma and Orthopaedics
Diagnosis group alerts (2007 to date)
The Cardiology clinical area has had three outlier alerts
since 2007. Although the trust’s review of the Aug-11 AMI
alert found no problems with the quality of care provided to
the patients, a number of improvement actions were outlined
and the trust have recently re-alerted for AMI.
Alerts to CQC
7
Alerts followed up by CQC
5+
Analysis of emergency admissions has indicated significantly
high mortality across a range of clinical areas, which could
reflect problems across the emergency care pathway.
Furthermore, mortality among emergency admissions is
‘much worse than expected’ for the 75 and over age group.
Any related patient groups alerting more than once since 2007
Recent diagnosis group alerts pursued by CQC
Acute myocardial infarction (Aug-11; Mar-13)
Coronary atherosclerosis and other heart disease
Acute myocardial infarction
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 three diagnosis groups and
no procedure groups with above expected SMRs. One
diagnosis group, other liver diseases, had above expected
mortality for admissions at the weekend, which may highlight
a potential area for review.
Apr 2012 to Mar 2013
Diagnosis groups
Procedure groups
SMRs above expected
3
0
CUSUM alerts
4
4
Diagnosis groups with SMRs above expected
Acute myocardial infarction
Other liver diseases
Other perinatal conditions
SMR
143
257
210
Obs – Exp
deaths
22
6
7
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, Tameside had two CUSUM alerts for other
liver diseases and one for acute myocardial infarction. It also
had one other diagnostic group alert and four for procedure
groups that did not have a high SMR.
Tameside had higher than expected deaths after surgery in the
year to March 2013 (25 deaths, compared with 15 expected).
Source: Dr Foster: HSMR, SMRs, CUSUM alerts, deaths after surgery
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.
Tameside’s Myocardial infarction rate is high and improving
substantially below the national average in the data to 2010-11
(published in Feb 2013).
Variable Life Adjusted Display (VLAD) charts are produced by
the HSCIC to visualise the cumulative number of “statistical
lives gained” over a period. A downward trend indicates a run
of more deaths than expected compared to the national
baseline and one with a sustained downward trend and
multiple dips to the lower control limit may warrant further
investigation.
30-day mortality following specific surgery / admissions
•
Myocardial infarction (high and improving 9% below national rate in
2010/11),
VLAD charts with a negative SHMI trend
(year to Jun-12)
•
•
•
Pneumonia
Acute myocardial infarction
Acute cerebrovascular disease
8
2
1
Percentage of deaths occuring in hospital
90
80
70
Tameside had such VLAD charts for three diagnosis group in
the year to June 2012.
In addition, Tameside had worse than expected mortality for
Pneumonia and Stroke on the Acute Trust Quality Dashboard
(year to Q1 2012-13). It also had higher than expected deaths
for Pneumonia (83 deaths, 47% more than expected), Acute
cerebrovascular disease (21 deaths, 40% more than expected)
and Acute myocardial infarction (20 deaths , 44% more than
expected) in the HSCIC’s SHMI to September 2012.
No. dips to the
lower control limit
60
50
40
30
20
10
Apr-12
Jul-12
Tameside
Oct-12
National
Jan-13
Apr-13
SHMI publication
Tameside has seen an increase in out of hospital deaths in
recent years relative to in-hospital deaths (SHMI contextual
indicators), with in-hospital deaths static.
Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.
Slide 37
Patient Experience
Slide 38
Patient Experience
Overview:
Summary:
The following section will provide an insight into the Trust’s
patient experience.
Of the 9 measures reviewed within Patient Experience and
Complaints there are two which are rated ‘red’: The inpatient
survey and comments collected through CQC’s patient voice
system.
Review Areas:
To undertake a detailed analysis of the Trust’s Patient Experience
it is necessary to review the following areas:
•
Patient Experience, and
•
Complaints.
Data Sources:
•
Patient Experience Survey;
•
Cancer Patient Experience Survey;
•
Peoples Voice Summary; and
•
Complaints data.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
There were several areas of concern across the inpatient survey
results, including delays in being admitted to a ward,
weaknesses in information given to patients on discharge, lack
of patient involvement in decisions and being treated with
respect and dignity.
Whilst more than half of the comments recorded on patient voice
were positive, the negative comments included some worrying
points including indications that whistle-blowing concerns from
the chair of the senior medical committee had been ignored.
There were several comments about disrespectful or
unprofessional staff.
The Trust is A-rated by the Ombudsman for satisfactory
remedies and low-risk of non-compliance.
Slide 39
Patient Experience
Patient Experience
This page shows the Patient Experience measures which are considered to be the most pertinent for this review. Further analysis,
where relevant, is detailed in the following pages.
Inpatient
PEAT : environment
Cancer survey
PEAT : food
PEAT : privacy and dignity
Friends and family test
Complaints about clinical aspects
Patient voice comments
Ombudsman’s rating
Outside expected range
Within expected range
Slide 40
Inpatient Experience Survey
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
Tameside scores above average on survey questions relating to gaining admission to wards quickly and on the planned date, but
below average on several questions, including those relating to involvement in decisions, staff communication on medication, getting
clear answers from doctors, the degree of privacy provided during treatment, and the level of respect shown by staff.
Overall
Length of time spent on waiting list
Alteration of admission date by hospital
Length of time to be allocated a bed on a
ward
Overall
Delay of patient discharge
Consistency of staff communication
Information provided on post-discharge
danger signals
Overall
Staff communication on purpose of
medication provided
Patient involvement in decision-making
Staff communication on medication
side-effects
Overall
Clarity of doctors’ responses to
important questions
Language used by doctors in front of
patients
Clarity of nurses’ responses to
important questions
Language used by nurses in front of
patients
Overall
Hospital food
Patient noise levels at night
Degree of privacy provided
Staff noise levels at night
Level of respect shown by staff
Hospital/ward cleanliness
Overall staff effort to ease pain
Above expected range
Within expected range
Below expected range
Slide 41
Patient experience and patient voice
Inpatient
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
•
Tameside: 73.7 (two standard deviations below the
average)
Overall patient experience score: Inpatients 2012
95
90
80
75
70
65
60
55
50
Cancer Survey
•
Tameside
85
England
average
Of 58 Questions, 36 were in the ‘top 20%’ with only two in
the ‘bottom 20%’
Trusts in
this review
National
results curve
Source :Patient Experience Survey, Cancer patient experience survey
Complaints Handling
Patient Voice
•
The quality risk profiles compiled by the Care Quality
Commission collate comments from individuals and
various sources. In the two years to 31st January 2013,
there were 150 comments on Tameside of which 69 were
negative (46%). Whilst this is a low percentage, there
were serious concerns around some comments, in
particular relating to ignoring formal whistle-blowing
from Chair of the Senior Medical Committee, lack of
professionalism and poor or disrespectful communication
to patients, patients bullied or shouted at.
•
Data returns to the Health and Social Care Information
Centre showed 363 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, 60% of complaints related to clinical treatment
(compared to the national average of 47%).
•
A separate report by the Ombudsman rates the Trust as
A-rated for satisfactory remedies and low-risk of noncompliance. The Trust is identified as above average for
conversion rate of complaints to trust becoming
complaints to the Ombudsman and for ‘unnecessary
delay’ in complaint handling.
Slide 42
Safety and workforce
Slide 43
Safety and Workforce
Overview:
Summary:
The following section will provide an insight into the Trust’s
workforce profile and safety record. This section outlines whether
the Trust is adequately staffed and is safely operated.
Tameside is ‘red rated’ in five of the safety indicators: MRSA, C
diff, “Harm” for all four safety thermometer indicators, Clinical
negligence scheme payments and Rule 43 coroner reports.
Review Areas:
Tameside is one of the worst ranked Trusts for MRSA and C diff
in the country.
To undertake a detailed analysis of the Trust’s Safety and
Workforce it is necessary to review the following areas:
Tameside’s Clinical Negligence payments have exceeded
contributions to the ‘risk sharing scheme’ over the last 3 years to
a large degree.
•
General Safety;
•
Staffing;
•
Staff Survey;
A review of the Coroners rule 43 reports flagged eight items,
highlighting a number of areas for potential review.
•
Litigation and Coroner; and
A review of the workforce data flagged six ‘red rated’ indicators.
•
Analysis of patient safety incident reporting.
Most notably, Tameside had a high agency spend compared to
the region median. The data also shows the three month vacancy
rate for medical staff is over 50% higher than the national
average rate and that the sickness absence rate for medical staff
is nearly twice the national average.
Data Sources:
•
Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;
•
Safety Thermometer, Apr 12 – Mar 13;
•
Litigation Authority Reports;
•
GMC Evidence to Review 2013;
•
National Staff Survey 2011, 2012;
•
2011/12 Organisational Readiness Self-Assessment (ORSA);
•
National Training Survey, 2012; and
•
NHS Hospital & Community Health Service (HCHS), monthly
workforce statistics.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Finally, detailed in the National Training Scheme (NTS) patient
safety comments 2012, the overall rate of patient safety
concerns is 13.99%, this is almost three times the national
average of 4.7%
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.
Litigation and
Coroner
Specific
Safety
Measures
General
Reporting of patient safety incidents
Number of harm incidents reported as ‘moderate, severe or death’ from April ‘11 to March ’12
13
Number of ‘never events’ (2009-2012)
1
x
Pressure ulcers
Medication error
MRSA
C diff
“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
Source: See ‘Safety and Workforce’ summary slide for list of relevant data sources.
Within expected range
Slide 45
Safety Analysis
The trust has reported patient safety incidents at a rate that is
not significantly different from similar trusts.
The Trust is lower than the national average (8.9%) for
performance on “harm” for all four NHS Safety Thermometer
measures (pressure ulcers, falls, UTI and VTE – Venous
thromboembolisms) with 10% - the 35th highest rate (out of 141
non-specialist trusts), although it must be noted that due to
potential differences in case mix and data collection practices at
different organisations, definitive conclusions about differences
in the burden of harm between organisations cannot be made.
Rate of reported patient safety incidents per 100 admissions
Tameside
Median Rate for small acutes
6.5
6.5
Source: incidents occurring between 1 April 2012 to 30 September 2012 and reported to the
National Reporting and Learning System’
20 %
Percentage of patients harmed
Safety Thermometer
April to December 2012
Tameside
0%
Trusts covered by review
All other non specialist trusts
Source: Safety Thermometer April-December 2012
Slide 46
Safety Incident Breakdown
Since 2009, one ‘never event’ has occurred at Tameside, classified as such
because they are incidents that are so serious they should never happen.
Never Events Breakdown (2009-2012)
The patient safety incidents reported are broken down into five levels of harm
below, ranging from ‘no harm’ to ‘death’. 81% of incidents which have been
reported at Tameside have been classed as ‘no harm’, with 18% ‘low’, with just
eight, three and two occurrences for those classified as ‘moderate’, ‘severe’ and
‘death’ respectively.
Wrong site surgery
1
Tameside Hospital NHS Foundation Trust
1
Source: Freedom of information request, BBC http://www.bbc.co.uk/news/health-22466496
When broken down by category, the most regular occurrences of patient
incident at Tameside are in ‘patient accident’ and ‘clinical assessment’.
Breakdown of patient
incidents by degree of harm
3000
Breakdown of patient incidents by incident type
2742
Consent, communication,
confidentiality
53
Medical device / equipment
66
2500
2000
Medication
87
Implementation of care and ongoing
monitoring / review
95
103
Infrastructure
1500
194
All others categories
242
Treatment, procedure
1000
619
265
Documentation
500
289
Access, admission, transfer, discharge
8
3
2
Moderate
Severe
Death
0
No Harm
Low
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
832
Clinical assessment
1148
Patient accident
0
500
1000
1500
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
Slide 47
Infection control
For MRSA, Tameside has the 7th highest
rate of infection of 141 trusts and is in the
bottom 5% of the national distribution.
For C diff, Tameside has the second highest
infection rates in the country.
MRSA 2010 - 2012
Combined z score of rates per bed day
over the 3 separate years
with the value 2 added so that all values are shown as
positive
6.0
Tameside
4.0
3 year
z score
2.0
+2
0.0
Trusts under review
All non specialist trusts
Tameside
MRSA volumes : Public Health England mandatory reporting of Healthcare Associated infections
Bed days:
Department of Health: Unify2 data collection - KH03
6.0
5.0
C difficile 2010 - 2012
Combined z score of rates per bed day
over the 3 separate years
with the value 2 added so that all values are shown
as positive
Tameside
4.0
3 year
3.0
z score
+ 2 2.0
1.0
0.0
Trusts under review
All non specialist trusts
Tameside
CDI volumes : Public Health England mandatory reporting of Healthcare Associated infections
Bed days:
Department of Health: Unify2 data collection - KH03
Slide
Slide
48 48
Pressure ulcers
This slide outlines the total
number of pressure ulcers and
the number of new pressure
ulcers broken down by
category for the last 12 months.
Due to the effects of seasonality
on hospital acquired pressured
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.
In recent months, Tameside’s
new pressure ulcer prevalence
rate has fallen from 1.0% to
0.5%. Throughout the last 12
months, Tameside as been
consistently below the national
rate of 1.3%.
From the data, it is apparent
that the prevalence rate of total
pressure ulcers for Tameside is
also below the national average
and below the average of the
selected 14 trusts in this review.
The data shows that the total
pressure ulcer rate has been
below the national average an
all but three months over the
previous year.
Total pressure ulcers prevalence
New pressure ulcers prevalence
1.0%
1.0%
4
0.7%
3
3
0.5%
0.5%
2
2
0.0%
0.0% 0.0%
Category 4
4.5%
4.7%
4.6% 5.0%
15
0.4%
10
0.2%
5
1.0%
0.0%
-
0.0%
0.0%
Category 3
4.9%
0.5% 0.6%
-
Category 2
6.0%
5.1%
4.4%
20
0.2%
0.2%
7.0%
5.6%
6.2%
5.5%
0.8%
1
1
25
1.0%
4
6.3%
30
1.2%
5
3.5%
3.5%
4.0%
3.0%
2.0%
Category 2
Rate
Category 3
Category 4
Rate
New pressure ulcer analysis
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
371
407
415
460
394
402
403
409
410
404
400
395
2
0
4
0
0
4
3
1
2
1
0
2
Trust new pressure ulcer rate
0.5%
0.0%
1.0%
0.0%
0.0%
1.0%
0.7%
0.2%
0.5%
0.2%
0.0%
0.5%
Selected 14 Trusts new pressure
ulcer rate
1.4%
1.5%
1.4%
1.5%
1.5%
0.9%
1.0%
1.1%
0.9%
1.1%
1.0%
1.2%
National new presseure ulcer rate
1.7%
1.7%
1.5%
1.5%
1.4%
1.3%
1.2%
1.2%
1.2%
1.3%
1.3%
1.3%
Number of records submitted
Trust new pressure ulcers
Total pressure ulcer prevalence percentage
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
371
407
415
460
394
402
403
409
410
404
400
395
19
18
23
16
25
18
25
20
23
19
14
18
Trust total pressure ulcer rate
Selected 14 Trusts total pressure
ulcer rate
5.1%
4.4%
5.5%
3.5%
6.3%
4.5%
6.2%
4.9%
5.6%
4.7%
3.5%
4.6%
6.4%
6.2%
6.5%
7.0%
6.3%
5.5%
5.4%
5.9%
5.8%
6.0%
5.7%
6.2%
National total pressure ulcer rate
6.8%
6.7%
6.6%
6.1%
6.0%
5.5%
5.4%
5.3%
5.2%
5.4%
5.6%
5.3%
Number of records submitted
Trust total pressure ulcers
Source: Safety Thermometer Apr 12 to Mar 13
Slide 49
Litigation and Coroner
Clinical negligence scheme analysis:
Tameside’s Clinical Negligence payments have exceeded
contributions to the ‘risk sharing scheme’ over the last 3
years to a large degree. Payouts exceeded contributions by a
total of £21m over this period.
Clinical negligence payments
2009/10
2010/11
2011/12
Payouts (£000s)
8,823
7,087
13,818
Contributions (£000s)
2,543
2,724
3,528
Excess of Payouts over
Contributions (£000s)
-6,280
-4,363
-10,290
Coroners rule 43 reports flagged eight items:
(i)
(ii)
(iii)
(iv)
To consider a review of arrangements for transfer of
patients between hospitals, and communication
procedures between staff
Meridian Health Care to consider a review of its
procedures for recording patient accidents; Tameside
Hospital to review its communication procedures
To consider implementing a process whereby locum
doctors can have immediate access to the
computerised x-ray request programme; a review of
senior house officer and house officer staffing levels
and installing lavatory locks that can be opened from
the outside by staff.
To consider whether there should be a protocol for
obtaining a patient's consent for a surgical procedure
when the patient lacks mental capacity.
(v)
To consider a review of staffing levels within the
emergency department and medical admissions unit;
written procedures for handling incident reports;
arrangements for nurses to summon help if required
and the need to maintain accurate comprehensive and
accessible notes.
(vi) To consider reviewing procedures to ensure concerns
about a patient are accurately verified and recorded.
(vii) To consider a review of procedures at Tameside
General Hospital including procedures for
observation, note-keeping and examination of young
children.
(viii) To consider improving arrangements for staffing
levels and record keeping.
Source :Litigation Authority Reports
Slide 50
Workforce
Staff Surveys and
Deanery
Workforce Indicators
This page shows the Workforce measures which are considered to be the most pertinent for this review. Further analysis, where
relevant, is detailed in the following pages.
WTE nurses per bed day
Sickness absence- Overall
Medical Staff to Consultant Ratio
2.10
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
2.29
Vacancies –medical
Sickness
absence
-Nursing
staff
Staff to Total Staff Ratio
Outcome
1 (R17)
Respecting
and involving eNon-clinical
who u
Vacancies - Non-medical
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days) 928
Staff leaving rates
Nurse Hours per Patient Bed Day
Consultant appraisal rates
Agency spend
Response Rate from National Staff
Survey 2012
Staff Engagement from NSS 2012
Training Doctors – “undermining”
indicator
se services
0.31
6.35
Staff joining rates
Overall Rate of Patient
Safety Concerns
x
Care of patients / service users is my organisation’s top priority
I would recommend my organisation as a place to work
If a friend or relative needed treatment: I would be happy
with the standard of care provided by this organisation
GMC monitoring under “response
to concerns process”
Outside expected range
Within expected range
Slide 51
General Medical Council (GMC) National Training Scheme Survey 2012
Emergency Medicine
The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results Given the volume of
data only specialities with red outliers are noted below (where those specialties also have green outliers, they are included).
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
General (internal) medicine
Feedback
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Green outlier
Within expected range
Red outlier
Slide 52
General Medical Council (GMC) National Training Scheme Survey 2012
Geriatric medicine
The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results Given the volume of
data only specialities with red outliers are noted below (where those specialties also have green outliers, they are included).
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Feedback
Tameside has green outliers in four specialties:
•
General psychiatry has green outliers for handover and induction;
•
Otolaryngology has green outliers for overall satisfaction, clinical supervision, workload, adequate experience, induction, access to
educational resources and local teaching;
•
Paediatrics has green outliers for handover and feedback; and
•
Trauma and orthopaedic surgery has a green outlier for handover.
Green outlier
Within expected range
Red outlier
Slide 53
Workforce Analysis
The Trust has a patient spells per whole time equivalent rate of 25, which is
an average capacity in relation to the other trusts in this review and
nationally.
Number of FTEs (Dec 11Nov 12 average)
2,081
Agency Staff (2011/12)
The consultant appraisal rate of Tameside is 82.4% which is average
compared to the other trusts under review.
Tameside’s staff leaving rate is 6.2% which is lower than the median average
of 6.8%. Additionally, the joining rate of 6.9 % is higher than the regional
average.
Tameside
Expenditure
Percentage of
Total Staff Costs
Median within
Region
£9.1m
9.4%
3.5%
(Sep 11 – Sep 12)
Staff Turnover
Tameside
North West
SHA Average
Joining Rate
6.9%
5.7%
Leaving Rate
6.2%
6.8%
WTE nurses per bed day December 2012
Tameside
National Average
1.31
1.96
Source: Health and Social Care Information Centre (HSCIC)
Spells per WTE for Acute Trusts
Consultant appraisal rate, 2011/12
50
100%
45
Spells per WTE
40
35
30
Tameside
80%
Tameside
25
60%
25
20
40%
15
20%
10
5
0%
0
Trusts covered by review
All Trusts
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
Trusts covered by review
All other trusts
Tameside
Slide 54
Workforce Analysis continued…
Sickness Absence Rates
Tameside’s total sickness absence rate is lower
than the North West Strategic Health Authority
average, and that of England on the whole. This
pattern is replicated in the more granular
nursing and other staff categories, both of which
are below their relative national averages, while
medical staff is above the national average.
Tameside has a medical staff to consultant ratio
broadly in-line with the national average.
However, its nurse staff to qualified staff ratio is
substantially in excess of the average figure for all
Trusts in England.
The Trust’s consultant productivity ratio is below
the national average.
The data shows the three month vacancy rate for
medical staff which is over 50% higher than the
national average rate.
3 month Vacancies–Medical as at 31st March
2010
Tameside
England
2.2%
1.4%
Source: NHS Hospital & Community Health Service (HCHS) Vacancy
survey 2010.
Staff in post data from 2009 NHS workforce census.
IC for Trust data, DH for England data
(2011-2012)
Tameside
North West
SHA Average
National Average
4.02%
4.52%
4.12%
All Staff
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
Tameside
National Average
Medical Staff
2.17%
1.25%
Nursing Staff
4.6%
4.8%
Other Staff
3.7%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
Tameside
National Average
Medical Staff to Consultant Ratio
2.10
2.59
Nurse Staff to Qualified Staff Ratio
2.29
2.50
Non-Clinical Staff to Total Staff Ratio
0.31
0.34
Registered Nurse Hours to Patient
Day Ratio *
6.35
8.57
Source: Electronic Staff Record (ESR) April 13
* Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Consultant Productivity
(Spells/FTE)
Tameside
National Average
928
492
Source: Electronic Staff Record (ESR), Apr 13
Slide 55
Deanery
The trust is not currently subject to enhanced monitoring. While the National Training Survey did not indicate any specific patterns
of concern, doctors in training reported more patient safety concerns than the average. These concerns, and those raised by the
Deanery, related in the main to the Emergency Department and are being actively monitored by the Deanery.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Obstetrics and Gynaecology and Trauma and Orthopaedic Surgery were the programmes with the most below outliers between 2010
and 2012. F2s in Emergency Medicine recorded the most above outliers during the same period. No indicator had programme level
outliers across multiple years.
NTS 2012 Patient Safety Comments
15 doctors in training commented, representing 13.99% of respondents. This was nearly three times 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:
•
An over dependence on locum staffing;
•
Excessive waiting times for transfer from A&E to MAU;
•
Lack of senior supervision, especially at weekends;
•
High number of vacant medical posts; and
•
High volume of patients resulting in frequent bed shortages.
Source: GMC evidence to Review 2013
Slide 56
Deanery Reports
The 2012 report identified a concern relating to a revisit to the CMT and Emergency Medicine programmes at the trust. A visit
identified seven patient safety recommendations, which are being implemented by the trust. An update is expected from the Deanery
in April 2013.
Monitored under the response to concerns process?
No, the trust is not subject to increased monitoring at the time of the report. The trust has not been visited as part of our Education Quality
Assurance programme.
Slide 57
Clinical and operational
effectiveness
Slide 58
Clinical and Operational Effectiveness
Overview:
The following section will provide an insight in to the Trust’s
clinical and operational performance based on nationally
recognised key performance indicators.
Review Areas:
To undertake a detailed analysis of the Trust’s clinical and
operational performance it is necessary to review the following
areas:
•
Clinical Effectiveness;
•
Operational Effectiveness; and
•
Patient Reported Outcome Measures (PROMs) for the review
areas.
Summary:
The analysis highlighted that 90.1% of patients are being seen
within the 18 week target time (RTT) which is higher than the
target level. The data showed that Tameside have been
performing above the target level throughout the last 12 months.
The Trust’s crude readmission rate is at 13.1% which is high
relative to the national level and highlights an area for potential
review. However, it should be noted that the standardised
readmission rate, which takes into account case mix, shows the
Trust to be performing within the expected level.
The PROMs dashboard shows that Tameside was a relatively
poor performer in general, with some decline in performance
over the last 3 years.
Data Sources:
•
Clinical Audit Data Trust, CQC Data Submission;
•
Healthcare Evaluation Data (HED), Jan – Dec 2012;
•
Department of Health;
•
Cancer Waits Database, Q3, 2012-13; and
•
PROMs Dashboard.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Slide 59
Clinical and Operational Effectiveness
Clinical
effectiveness
This page shows the Clinical and Operational Effectiveness measures which are considered to be the most pertinent for this review.
Further analysis, where relevant, is detailed in the following pages.
Neonatal – women receiving steroids
Coronary angioplasty
Heart failure
Adult Critical care
Peripheral vascular surgery
Lung cancer
Diabetes safety/ effectiveness
Carotid interventions
Bowel cancer
PROMS safety/ effectiveness
Acute MI
Hip fracture - mortality
Joints – revision ratio
Acute stroke
Severe trauma
Elective Surgery
Cancelled operations
Emergency readmissions
PbR coding Audit
Operational
Effectivenes
s
RTT Waiting Times
Cancer Waits
A&E Waits
PROMs
Dashboard
Hip Replacement EQ-5D
Knee Replacement EQ-5D
Varicose Vein EQ-5D
Hip Replacement OHS
Knee Replacement OKS
Outcome 1 (R17) Respecting and involving people who use services
Groin Hernia EQ-5D
Outside expected range
Within expected range
Slide 60
Clinical Effectiveness: National Clinical Audits
The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the clinical audit
results we have considered as part of this review.
Clinical Audit
Diabetes
Elective Surgery
Safety Measure
Clinical Audit
Proportion with medication
error
Proportion experiencing
severe hypoglycaemic
episode
Neonatal intensive and special care
(NNAP)
Proportion of women receiving antenatal steroids
Diabetes
Proportion foot risk assessment
Adult Critical Care
Standardised hospital mortality ratio
Proportion of patient reported
post-operative complications
Coronary angioplasty
Acute Myocardial Infarction
Proportion receiving primary PCI
within 90 mins
Elective abdominal aortic aneurysm
post-op mortality
Proportion having surgery within 14
days of referral
Proportion discharged on beta-blocker
Acute Stroke
Proportion compliant with 12 indicators
Heart Failure
Proportion referred for cardiology
follow up
90 day post-op mortality
Peripheral vascular surgery
Adult Critical Care (ICNARC
CMPD)
Effectiveness Measures
Proportion of night-time
discharges
Carotid interventions
Bowel cancer
Hip Fracture
Elective surgery (PROMS)
Severe Trauma
Hip, knee and ankle
Lung Cancer
Source: Clinical Audit Data Trust, CQC Data Submission.
30 day mortality
Prop’n operations within 36 hrs
Mean adjusted post-operative score
Proportion surviving to hospital
discharge
Standardised revision ratio
Proportion small cell patients receiving
chemotherapy
Slide 61
Clinical effectiveness: Clinical Audits
Hip Fracture: % surgery within 36 hours of admission
In the National Hip Fracture Database, a key measure of
effectiveness is the percentage of patients undergoing
surgery within 36 hours of admission.
% surgery within 36 hours of admission
On this measure, Tameside is an outlier, being some way
outside the lower control limits.
100%
90%
80%
70%
60%
50%
40%
Tameside
30%
20%
0
50
100
150
200
250
300
350
400
450
500
550
600
650
No of admissions
Slide 62
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
Tameside see 95.8% of
A&E patients within 4
hours which is just
above the 95% target
level. The time series
for 4 hour A&E waits
shows no real trend.
90.1% of the patients
are seen within the 18
week target time
which is just above
the 90% target level.
In addition, the time
series shows
Tameside has been
consistently
performing above the
target rate although
this has dropped in
recent months.
A&E Percentage of Patients Seen
within 4 Hours
105%
Tameside
95.8%
100%
Tameside 4 Hour A&E Waits
Attendances (Thousands)
A&E wait times and
RTT times may
indicate the
effectiveness with
which demand is
managed.
95%
90%
85%
80%
7.2
7
6.8
6.6
6.4
6.2
6
5.8
5.6
5.4
5.2
98%
97%
96%
95%
94%
93%
92%
91%
75%
70%
Trusts Covered by Review
All Trusts
A&E Target 95%
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Patients Seen
Patients Not Seen
Seen within 4 hours (%)
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Referral to Treatment (Admitted)
Tameside Referral to Treatment
Performance
105%
100%
100%
Tameside
90.1%
95%
90%
85%
95%
90%
80%
85%
75%
Trusts Covered by Review
All Trusts
RTT Target 90%
Referral to Treatment Rate
Source: Department of Health. Feb 13
RTT Target 90%
Source: Department of Health. Apr 12 – Feb 13
Slide 63
Operational Effectiveness – Emergency Re-admissions and Length of Stay
Tameside’s crude
readmission rate is one of
the higher readmission
rates of the trusts in the
review as well as nationally,
at 13.10%.
Crude Readmission Rate by Trust
25%
Crude Readmission Rate
The readmission rate may
indicate the
appropriateness of
treatment offered, whilst
average length of stay may
indicate the efficiency of
treatment.
20%
Tameside
13.10%
15%
10%
5%
0%
Trusts Covered by Review
The standardised
readmission rate most
importantly accounts for
the Trust’s case mix and
shows Tameside is within
the expected range.
Tameside
Selected trusts Outside
Selected trusts w/in Range
All Trusts
Average Length of Stay by Trust
Spell Duration (Days)
Tameside’s average length
of stay is 4.77 days, which is
shorter than the national
mean average of 5.2 days.
Standardised 30-day Readmission
Rate
10
9
8
7
6
5
4
3
2
1
0
Tameside
4.77
Trusts Covered by Review
Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12
All Trusts
Slide 64
PROMs Dashboard
The PROMs dashboard shows that Tameside was a
relatively poor performer in general, with some
decline in performance over the last 3 years. However,
none of the series breached the lower 99.8% control
limit.
Hip Replacement OHS
30
25
England Average
The scores were between 2 and 3 standard deviations
below average for both measures on hip replacement
and both measures on knees for 2011-12.
20
Tameside
15
Upper Control Limit
10
Lower Control Limit
5
2
20
11
/1
1
20
10
/1
20
09
/1
0
0
Source: PROMs Dashboard and NHS Litigation Authority
Slide 65
Leadership and
governance
Slide 66
Leadership and governance
Overview:
Summary:
This section will provide an indication of the Trust’s governance
procedures.
All Board positions are substantively filled. The most recent
appointment to the Board was the Director of Nursing in
Autumn 2012.
Review Areas:
To provide this indication of the Trust’s leadership and
governance procedures we have reviewed the following areas:
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Trust Board has three main subcommittees, including the
Quality and Clinical Governance Committee, which is chaired by
a Non Executive Director and provides assurance to the Board
on quality. The Clinical Audit, Patient Safety and Effectiveness
Committee is a subgroup of the Quality and Clinical Governance
Committee and considers mortality each month.
The Trust is compliant with all CQC standards. The Trust has
breached the A&E standard and its MRSA target in 2012/13.
The Trust has had a number of external reviews, including the
including the PwC review of quality governance in 2011, and a
follow up review in 2012. The Trust has implemented a number
of actions in response to these reviews.
Key risks identified by the Trust relate to capacity issues and
horizontal integration with the local health economy.
There have been no never events at the Trust in 2012/13.
Slide 67
Leadership and governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in
the following pages.
Leadership and
governance
Monitor governance risk rating
Monitor finance rating
CQC Outcomes
2
Governance risk rating
Red - Likely or actual significant breach of terms of authorisation
Amber-red - Material concerns surrounding terms of authorisation
Amber-green - Limited concerns surrounding terms of authorisation
Green - No material concerns
CQC Concerns
Red – Major concern
Amber – Minor or Moderate concern
Green – No concerns
Financial risk rating
rated 1-5, where 1 represents the highest risk and 5 the lowest
Slide 68
Leadership and governance
Trust Board
All of the Board members hold substantive posts. The most recent change to the Board has been the appointment of the Director of Nursing
in autumn 2012. Board responsibility for clinical governance and quality is split between the Medical Director and Director of Nursing.
Governance and clinical structures
Following a review of quality governance by PricewaterhouseCoopers in 2011, clinical and quality governance structures in the Trust have
been further developed, including the strengthening of clinical leadership throughout the Trust.
The Trust Board has three main sub-committees including the Quality and Clinical Governance Committee, which is chaired by a Non
Executive Director (Tricia Kalloo). The subcommittee receives monthly reports from the Clinical Audit, Patient Safety and Effectiveness
Committee (CAPSEC) which considers clinical audit, NICE, patient safety and mortality matters, includes representation from each of the
divisions and has CCG clinical involvement.
Quality priorities (Everyone Matters at Tameside)
•
Ensuring that every patient experience is excellent and that Tameside Hospital is ‘the local healthcare provider of choice’;
•
Ensuring staff experience is consistently excellent and that Tameside Hospital is a ‘great place to work’; and
•
Engaging with stakeholders (staff, patients and partner organisations) to rebuild, restore and enhance the reputation of Tameside
Hospital.
External reviews and regulation
A review by the CQC in September 2012 identified moderate concerns relating to Outcome 4 (care and welfare of people who use services).
However, a follow up review in March 2013 found that the actions taken by the Trust had led to compliance against this standard.
The Trust has had a number of external reviews including the Department of Health’s Intensive Support Team and the North West’s
Utilisation Review Team. More detail is provided on subsequent slides.
The Trust has made significant improvements to infection control in 2012/13, reducing the number of cases of C difficile to 35 (against a
target of 60). However, there were six cases of MRSA in the period, greater than the target of one avoidable and one unavoidable case.
Slide 69
Top risks to quality
The table includes the top risks to quality identified by the Trust on their corporate risk register, and other potential risks to
quality identified through review of Trust Board papers.
Trust identified risks
Trust response
Ensuring authorisation and
registration requirements
are maintained for key
regulatory bodies.
This risk has been partially successfully ameliorated and the Trust is fully registered and compliant with the
CQC standards. The breach with Monitor relates to the organisations clinical and financial viability going
forward. It is unlikely that the breach/licence condition will be lifted for some time, but the Trust Board is
satisfied it’s strategy addresses both clinical service and financial viability. The Trusts monitoring and
assurance processes provide for detailed consideration of all registration requirements.
Ensuring factors impacting
on mortality are
understood, addressed
and managed.
The Trust has taken a number of steps to understand, address and manage mortality, including a full review
of all deaths at the Trust. Mortality data is examined by the Medical Director monthly at a procedural and
diagnostic level, and all mortality alerts are reviewed by the CAPSEC.
Capacity issues and their
impact on patients and on
clinical specialties.
The Trust has worked hard to ensure that the CCG has fully understood the implications for patients of its
capacity and flow challenges. The CCG has, in turn, been very supportive of the historical unfunded growth
in non-elective work such that the previously non-recurrently funded activity has now been recurrently
funded in the 2013/14 contract. The CCG has also provided for an additional 2% growth in activity 2013/14.
These two major developments have allowed the Trust to recurrently fund and staff the 50 escalation beds
opened in 2012/13 for acute medicine.
Clinical Services and
Critical Mass (Horizontal
and Vertical Strategic
Partnership
Implementation).
The Trust has long recognised that national policy on clinical outcomes will result in complex general
surgery and emergency general surgery being conducted on specialist sites serving a bigger footprint. The
Trust’s horizontal integration strategy aims to address this though the cessation of such surgery at
Tameside hospital.
24/7 Consultant Cover to
Support Non-Elective
Emergency Pathways .
Achieving high quality 24/7 Consultant delivered emergency medical care in line with national policy is
considered a potential future risk. Whilst the horizontal integration will help address surgical specialities the
importance of further increasing 24/7 Consultant presence in medical specialities, is a key focus for the
organisation.
Slide 70
Leadership and governance
External reviews
In September 2012, the Care Quality Commission conducted a review of Outcomes 4 (care and welfare of people who use
services), 9 (management of medicines), 16 (assessing and monitoring the quality of service provision) and 21 (records). The
CQC found that the Trust was meeting standards 9, 16 and 21, but was not meeting outcome 4 (moderate impact). The concerns
raised related to the escalation beds located in the women’s health unit, ward 27 and ward 46. Patients were found to have been
left for long periods without being assessed or monitored, and staff did not have the relevant records for these patients.
A further visit by the CQC in March 2013 found that the Trust had taken actions to address the concerns raised in the September
2012 report, and found the Trust to be compliant against all standards. Actions taken by the Trust included moving all
escalation beds to the day surgery and endoscopy unit, introducing a new system to assess the suitability of patients for the
escalation area, and holding bed management meetings three times a day.
Further reviews included; PwC review of quality governance, Department of Health Intensive Support Team and North West
Utilisation Review Team. In January 2013 the Trust’s maternity service achieved Level 2 of the CNST Maternity Clinical Risk
Management Standards.
Cost Improvement Programme (CIP)
The Trust planned to achieve CIPs of £10.2m in the financial year 2012/13; £9.4m have been delivered (of which £9.3m have a
recurring impact.
The CIP target for 2013/14 is £9.7m. A full Quality Impact Assessment (QIA) is completed for each identified CIP by the clinical
lead for that project, and then signed off by the Medical Director and Director of Nursing. This QIA assesses any potential
negative impact upon clinical quality, safety and patient experience and also highlights any benefits arising.
Following the completion of a CIP scheme, a further QIA is undertaken to assess the actual impact on quality. This QIA is also
signed off by an Executive Sponsor, Clinical Sponsor and Project Lead.
Slide 71
Appendix
Slide 72
Trust Map
Source: Tameside Hospital NHS Foundation Trust website
Slide 73
Trust Map Floor Plan
Source: Tameside Hospital NHS Foundation Trust website
Slide 74
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 75
Workforce Indicator Calculations
Indicator
WTE nurses per bed day
Spells per WTE staff
Medical Staff to Consultant
Ratio
Nurse Staff to Qualified Staff
Ratio
Numerator /
Denominator
Calculation
Source
Numerator
Nurses FTE’s
Denominator
Total number of Bed Days
Acute
Quality
Dashboard
Numerator
Total Number of Spells
Denominator
Total number of WTE’s
Numerator
FTEs whose job role is ‘Consultant’
Denominator
FTEs in ‘Medical and Dental’ Staff Group
Numerator
FTEs in ‘Nursing & Midwifery Registered’ Staff Group
Denominator
FTEs of Additional Clinical Services – 85% of bands 2, 3 and 4
Numerator
FTEs not in ‘Nursing and Midwifery Registered’, ‘Additional Clinical
Services,’ ‘Allied Health Professionals’ or ‘Medical and Dental’ staff
groups
Denominator
Sum of FTEs for all staff groups
Numerator
Number of Inpatient Spells
Denominator
FTEs whose job role is ‘Consultant’
Numerator
Nurse FTEs multiplied by 1522 (calculated number of hours per year
which takes into account annual leave and sickness rates)
Denominator
Total Bed Days
Non-clinical Staff to Total Staff
Ratio
Consultant Productivity
(Spells/FTE)
Nurse hours per patient day
Note: ESR Data only includes substantive staff.
HED
ESR
ESR
ESR
ESR
HED
ESR
ESR
HED
Trust Executive Team
Source: Tameside Hospital NHS Foundation Trust – Information Request
Slide 77
Medical Advisory Board
Source: Tameside Hospital NHS Foundation Trust – Information Request
Slide 78
Nursing Directorate
Source: Tameside Hospital NHS Foundation Trust – Information Request
Slide 79
Trust Committee Structure
Source: Tameside Hospital NHS Foundation Trust – Information Request
Slide 80
Data Sources
No.
Data Source name
1 3 years CDI extended
2 3 years MRSA
3 Acute Trust Quality Dashboard
4 NQD alerts for 14
5 PbR review data
6 QRP time series
7 Healthcare Evaluation Data
GMC Annex - GMC summary of Education Evidence - trusts with high
8 mortality rates
9 1 Buckinghamshire Healthcare Quality Accounts
10 Burton Quality Account
11 CHUFT Annual Report 2012
12 Quality Report 2011-12
13 Annual Report 2011-12_final
14 NLG. Quality Account 2011-12
15 Annual Report 2012
16 Litigation covering email
17 Litigation summary sheet
18 Rule 43 reports by Trust
19 Rule 43 reports MOJ
20 Governance and Finance
21 MOR Board reports
22 Board papers
23 CQC data submissions
24 Evidence Chronology B&T
25 Hospital Sites within Trust
26 NHS LA Factsheet
27 NHSLA comment on five
Steering Group Agenda and Papers incl Governance Structure and
28 Timetable
29 List of products
30 Provider Site details from QRP
31 Annual Report 2011-12
32 SHMI Summary
33 Diabetes Mortality Outliers
34 Mortality among inpatient with diabetes
35 supplementary analysis of HES mortality data
36 VLAD summary
37 Mor Dr Foster HSMR
38 Outliers Elective Non elective split
39 Presentation to DH Analysts about Mid-staffs
40 CQC mortality outlier summaries
41 SHMI Materials
42 Dr Foster HSMR
43 AQuA material
44 Mortality Outlier Review
45 Original Analysis Identifying Mortality Outliers
46 Original Analysis of HSMR-2010-12
47 High-level Methodology and Timetable
48 Analytical Distribution of Work_extended table
Type
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Area
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
General
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Analysis
Analysis
General
General
General
General
General
General
General
General
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Data
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
No. Data Source name
49 Outline Timetable - Mortality Outlier Review
50 CQC review of Mortality data and alerts -Blackpool NHSFT
51 Peoples Voice QRP v4.7
52 Mortality outlier review -PE score
53 CPES Review
54 Pat experience quick wins from dh tool
55 PEAT 2008-2012 for KATE
56 PROMs Dashboard and Data for 14 trusts
57 PROMS for stage 1 review
58 NHS written complaints, mortality outlier review
59 Summary of Monitor SHA Evidence
60 Suggested KLOI CQC
61 Various debate and discussion thread
62 People Voice Summaries
63 Litigation Authority Reports
64 PROMs Dashboard
65 Rule 43 reports
66 Data from NHS Litigation Authority
67 Annual Sickness rates by org
68 Evidence from staff survey
69 Monthly HCSC Workforce Oct 2012 Quarterly tables turnover
70 Monthly HCSC Workforce Oct 2012 Annual time series turnover
71 Mortality outlier review -education and training KLOI
72 Staff in post
73 Staff survey score in Org
74 Agency and turnover
75 GMC ANNEX -GMC summary of education
76 Analysis of most recent Pat safety incident data for 14
77 Safety Thermometer for non spec
78 Acute Trust Quality Dashboard v1.1
79 Initial Findings on NHS written complaints 2011_12
80 Quality accounts First Cut Summary
81 Monitor SHA evidence
82 Care and compassion - analysis and evidence
83 United Linc never events
84 QRP Materials
85 QRP Guidance
86 QRP User Feedback
87 QRP List of 16 Outcome areas
88 Monitor Briefing on FTs
89 Acute Trust Quality Dashboard v1.1
90 Safety Thermometer
91 Agency and Turnover - output
92 Quality Account 2011-12
93 Annual Sickness Absence rates by org
94 Evidence from Staff Survey
95 Monthly HCHS Workforce October 2012 QTT
96 Monthly HCHS Workforce October 2012 ATT
Source: Freedom of information request, BBC 97 http://www.bbc.co.uk/news/health-22466496
Type
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Data
Area
Mortality
Mortality
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Data
Data
Data
Data
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Data
Safety and Workforce
Slide 81
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 ESR – This data contains substantive staff only
104 Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
Type
Area
Data
Data
Analysis
Data
Data
Data
Data
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Slide 82
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Elective
100 - General surgery
116 - Aortic and peripheral arterial embolism or thrombosis
Elective
100 - General surgery
12 - Cancer of esophagus
Elective
100 - General surgery
Elective
Observed Deaths that
are higher than the
expected
SHMI
3496.1
1
330.8
1
13 - Cancer of stomach
252
1
100 - General surgery
135 - Intestinal infection
543.48
1
Elective
100 - General surgery
14 - Cancer of colon
233.78
2
Elective
100 - General surgery
143 - Abdominal hernia
868.58
2
Elective
100 - General surgery
15 - Cancer of rectum and anus
240.67
2
Elective
100 - General surgery
152 - Pancreatic disorders (not diabetes)
2161.94
1
Elective
100 - General surgery
18 - Cancer of other GI organs; peritoneum
862.87
1
Elective
100 - General surgery
238 - Complications of surgical procedures or medical care
843.36
1
Elective
100 - General surgery
27 - Cancer of ovary
1867.35
1
Elective
100 - General surgery
43 - Malignant neoplasm without specification of site
1130.15
1
Elective
100 - General surgery
47 - Other and unspecified benign neoplasm
429.35
1
Non-elective
300 - General medicine
107 - Cardiac arrest and ventricular fibrillation
129.17
1
Non-elective
300 - General medicine
108 - Congestive heart failure; nonhypertensive
103.77
2
Non-elective
300 - General medicine
11 - Cancer of head and neck
320.71
3
Non-elective
300 - General medicine
115 - Aortic; peripheral; and visceral artery aneurysms
158.1
2
Non-elective
300 - General medicine
118 - Phlebitis; thrombophlebitis and thromboembolism
203.17
3
Non-elective
300 - General medicine
125 - Acute bronchitis
103.08
1
Non-elective
300 - General medicine
128 - Asthma
145.86
1
Non-elective
300 - General medicine
13 - Cancer of stomach
128.03
1
Non-elective
300 - General medicine
130 - Pleurisy; pneumothorax; pulmonary collapse
110.67
1
Non-elective
300 - General medicine
131 - Respiratory failure; insufficiency; arrest (adult)
163.08
2
Non-elective
300 - General medicine
134 - Other upper respiratory disease
144.32
1
Non-elective
300 - General medicine
137 - Diseases of mouth; excluding dental
937.86
2
Slide 83
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
300 - General medicine
14 - Cancer of colon
Non-elective
300 - General medicine
143 - Abdominal hernia
Non-elective
300 - General medicine
Non-elective
Observed Deaths that are
higher than the expected
SHMI
133.9
3
565
1
145 - Intestinal obstruction without hernia
164.89
1
300 - General medicine
146 - Diverticulosis and diverticulitis
219.43
1
Non-elective
300 - General medicine
149 - Biliary tract disease
131.23
1
Non-elective
300 - General medicine
15 - Cancer of rectum and anus
183.8
2
Non-elective
300 - General medicine
150 - Liver disease; alcohol-related
111.51
2
Non-elective
300 - General medicine
152 - Pancreatic disorders (not diabetes)
186.3
1
Non-elective
300 - General medicine
153 - Gastrointestinal hemorrhage
114.78
2
Non-elective
300 - General medicine
158 - Chronic renal failure
293.22
1
Non-elective
300 - General medicine
16 - Cancer of liver and intrahepatic bile duct
161.66
2
Non-elective
300 - General medicine
171 - Menstrual disorders
645.46
1
Non-elective
300 - General medicine
197 - Skin and subcutaneous tissue infections
131.64
1
Non-elective
300 - General medicine
204 - Other non-traumatic joint disorders
219.8
1
Non-elective
300 - General medicine
206 - Osteoporosis
1682.98
1
Non-elective
300 - General medicine
21 - Cancer of bone and connective tissue
361.88
1
Non-elective
300 - General medicine
211 - Other connective tissue disease
154.22
2
Non-elective
300 - General medicine
22 - Melanomas of skin
291.64
1
Non-elective
300 - General medicine
228 - Skull and face fractures
1059.68
1
Non-elective
300 - General medicine
235 - Open wounds of head; neck; and trunk
241.05
3
Non-elective
300 - General medicine
238 - Complications of surgical procedures or medical care
174.61
1
Non-elective
300 - General medicine
239 - Superficial injury; contusion
170.61
3
Non-elective
300 - General medicine
240 - Burns
247.46
1
Non-elective
300 - General medicine
241 - Poisoning by psychotropic agents
306.45
3
Non-elective
300 - General medicine
243 - Poisoning by nonmedicinal substances
574.77
1
Slide 84
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General medicine
244 - Other injuries and conditions due to external causes
299.38
1
Non-elective
300 - General medicine
249 - Shock
202.22
1
Non-elective
300 - General medicine
259 - Residual codes; unclassified
159.41
1
Non-elective
300 - General medicine
29 - Cancer of prostate
160.01
3
Non-elective
300 - General medicine
31 - Cancer of other male genital organs
374.94
1
Non-elective
300 - General medicine
32 - Cancer of bladder
271.06
2
Non-elective
300 - General medicine
35 - Cancer of brain and nervous system
186.97
3
Non-elective
300 - General medicine
38 - Non-Hodgkin`s lymphoma
259.75
2
Non-elective
300 - General medicine
39 - Leukemias
139.37
1
Non-elective
300 - General medicine
40 - Multiple myeloma
183.01
1
Non-elective
300 - General medicine
41 - Cancer; other and unspecified primary
124.96
1
Non-elective
300 - General medicine
43 - Malignant neoplasm without specification of site
110.4
1
Non-elective
300 - General medicine
44 - Neoplasms of unspecified nature or uncertain behavior
222.13
1
Non-elective
300 - General medicine
47 - Other and unspecified benign neoplasm
551.01
2
Non-elective
300 - General medicine
52 - Nutritional deficiencies
322.39
1
Non-elective
300 - General medicine
59 - Deficiency and other anemia
128.04
3
Non-elective
300 - General medicine
62 - Coagulation and hemorrhagic disorders
219.59
1
Non-elective
300 - General medicine
72 - Anxiety; somatoform; dissociative; and personality disorders
322.04
1
Non-elective
300 - General medicine
222.7
1
Non-elective
300 - General medicine
93 - Conditions associated with dizziness or vertigo
97 - Peri-; endo-; and myocarditis; cardiomyopathy (except that caused by
tuberculosis or sexually transmitted disease)
153.23
1
Slide 85
HSMR Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
300 - General medicine
Abdominal pain
Non-elective
300 - General medicine
Non-elective
Observed Deaths that
are higher than the
expected
HSMR
234
1
Acute and unspecified renal failure
107.2
2
300 - General medicine
Aortic; peripheral; and visceral artery aneurysms
128.9
1
Non-elective
300 - General medicine
Cancer of prostate
123.7
2
Non-elective
300 - General medicine
Cardiac arrest and ventricular fibrillation
148
3
Non-elective
300 - General medicine
Chronic obstructive pulmonary disease and bronchie
104.3
2
Non-elective
300 - General medicine
Chronic renal failure
233.3
2
Non-elective
300 - General medicine
Complication of device; implant or graft
206.8
1
Non-elective
300 - General medicine
Other circulatory disease
150.2
1
Non-elective
300 - General medicine
Other upper respiratory disease
170.9
1
Non-elective
300 - General medicine
Respiratory failure; insufficiency; arrest (adult)
174.7
1
Non-elective
300 - General medicine
Senility and organic mental disorders
117.7
3
Non-elective
300 - General medicine
Skin and subcutaneous tissue infections
121.1
1
Slide 86
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Elective)
Treatment Specialty
General Surgery
HSMR
SHMI
X
Slide 87
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Nonelective)
Treatment Specialty
HSMR
SHMI
General medicine
X
Obstetrics
X
X
Slide 88