The Dudley Group 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
The Dudley Group NHS Foundation Trust
Context
A brief overview of the Dudley area and The Dudley Group NHS Foundation Trust. This section provides a profile of the area, outlines
performance of local healthcare providers and gives a brief introduction to the Trust.
Mortality
An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the
Trust which are outliers.
Patient Experience
A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient
experience surveys.
Safety and Workforce
A summary of the Trust’s safety record and workforce profile.
Clinical and Operational Effectiveness
A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This
section compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures
(PROMs).
Leadership and Governance
An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership,
current top risks to quality and outcomes from external reviews.
Slide 3
Context
Slide 4
Context
Overview:
Summary:
This section provides an introduction to the Trust, providing an
overview, health profile and an understanding of why the Trust
has been chosen for this review.
Dudley has a population of 450,000 with 10% of it belonging to
non-White ethnic minorities. Obesity is significantly more
common, whilst breastfeeding is significantly less common than
in the rest of England.
Review Areas:
To provide an overview of the Trust, we have reviewed the
following areas:
•
Local area and market share;
•
Health profile;
•
Service overview; and
•
Initial mortality analysis.
Data Sources:
•
Trust’s Board of Directors meeting 30th Jan, 2013;
•
Department of Health: Transparency Website, Dec 12;
•
Healthcare Evaluation Data (HED);
•
NHS Choices;
•
Office of National Statistics, 2011 Census data;
•
Index of Multiple Deprivation, 2011;
•
© Google Maps;
•
Public Health Observatories – Area health profiles; and
•
Background to the review and role of the national
advisory group.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Relatively, The Dudley Group is a medium sized trust for both
inpatient and outpatient activity, although it is one of the larger
trusts covered by this report.
Dudley’s health profile outlines that there are a number of
aspects for which children’s & young people’s and adult’s health
is significantly lower than the national average. It also shows
that life expectancy in Dudley is below the national average.
The Trust has three hospital sites containing a total of 687 beds,
and was the first in the area to receive Foundation Trust status
in 2008. It has 68% market share of inpatient activity within a 5
mile radius of the Trust sites. However, this share falls to 15%
within a radius of 10 miles and 4% within a radius of 20 miles.
To give an informed view it was necessary to review the local
health economy. This included an indication of ambulance
response times and showed that the West Midlands ambulance
services were faster than the national average.
The Trust has been selected for this review as a result of its
HSMR for 2011 and 2012. The HSMR shows The Dudley Group
has been above the expected level over the last 2 years.
.
Slide 5
Trust Overview
The Dudley Group NHS Foundation Trust serves more than 450,000
people in Dudley and the surrounding areas. The Trust has three
hospital sites, including Russells Hall in Dudley (for inpatients), and
Corbett and Guest Outpatient Centres. The Trust was the first in the
area to receive Foundation Trust status, in 2008. The Trust’s services
focus on long-term conditions, acute care needs, rehabilitation, end-oflife care and audiology.
Russells Hall Hospital
Outpatient Centres
Corbett Outpatient Centre
Guest Outpatient Centre
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
687
69%
86%
General and
Acute
675
70%
88%
Maternity
12
22%
59%
Inpatient/Outpatient Activity
Inpatient Activity
Source: NHS Choices
Outpatient Activity
Finance Information
Elective
65,520 (53%)
Non-Elective
58,975(47%)
Total
124,495
Total
509,335
(Jan12-Dec12)
Day Case Rate:
88%
Source: Healthcare Evaluation Data (HED)
2012-13 Forecast Income
£298m
2012-13 Forecast Expenditure
£273m
2012-13 Forecast EBITDA
£25m
2012-13 Forecast Net surplus (deficit)
£4m
2013-14 Budgeted Income
N/A
2013-14 Budgeted Expenditure
N/A
2013-14 Budgeted EBITDA
N/A
2013-14 Budgeted Net surplus (deficit)
N/A
Source: Finance & Performance Report, submitted to Board of Directors; April 4, 2013
A map of Russells Hall Hospital is included in the Appendix.
Foundation Trust (2008)
Source: Department of Health: Transparency Website
The Dudley Group NHS Foundation Trust
Acute Hospital
Trust Status
Departments and Services
Accident & Emergency, Anaesthesia Services, Breast Surgery,
Children’s and Adolescent Services, Cardiology, Diabetic Medicine,
Diagnostic Imaging, Diagnostic Physiological Measurement,
Dermatology, Diagnostic Endoscopy, ENT, Endocrinology and
Metabolic Medicine, Gastro Intestinal and Liver Services, General
Medicine, General Surgery, Geriatric Medicine, Gynaecology,
Haematology, Immunology, Maternity Service, Nephrology,
Neurology, Ophthalmology, Orthopaedics, Oral and Maxillofacial
Surgery, Plastic Surgery, Pain Management, Reparatory Medicine,
Rheumatology, Trauma Services, Urology, Vascular Surgery.
Source: NHS Choices
Slide 6
Trust Overview continued…
General Medicine and
Paediatrics are the
largest inpatient
specialties while
Clinical Haematology
and Nursing Episode
are the largest for
outpatients.
Outpatient Activity by Trust
300
1200
250
1000
200
The Dudley Group
124,495
150
100
Number of Outpatient
Spells (Thousands)
The Dudley Group is a
large sized trust for
both measures of
activity, relative to the
rest of England. Of the
14 trusts selected for
this review, it is the
third largest for both
inpatient and
outpatient spells.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of The
Dudley Group against
national trusts in terms
of inpatient and
outpatient activity.
50
The Dudley Group
509,335
800
600
400
200
0
0
Trusts
Trusts Covered by Review
Trusts
National Inpatient Activity Curve
Top 10 Inpatient Main Specialties as a
% of Total Inpatient Activity
Trusts Covered by Review
Bottom 10 Inpatient Main Specialties
and Spells
National Outpatient Activity Curve
Top 10 Outpatient Main Specialties as
a % of Total Outpatient Activity
General Medicine
35%
Clinical Immunology & Allergy
21
Clinical Haematology
18%
Paediatrics
9%
Nursing Episode
29
Nursing Episode
15%
General Surgery
9%
Paediatric Surgery
49
General Medicine
12%
Obstetrics
8%
Chemical Pathology
100
Allied Health Professional Episode
11%
Trauma & Orthopaedics
6%
Neurology
104
Trauma & Orthopaedics
8%
Midwifery
4%
Dermatology
378
Ophthalmology
6%
Medical Oncology
4%
Geriatric Medicine
467
General Surgery
4%
Accident & Emergency
4%
Oral Surgery
1875
Dermatology
3%
Ophthalmology
3%
Ear, Nose & Throat
1984
Ear, Nose & Throat
3%
Clinical Haematology
3%
Anaesthetics
2081
Obstetrics
2%
Source: Healthcare Evaluation Data (HED), Jan 12 – Dec 12
Slide 7
The Dudley Area Overview
Dudley is not a particularly deprived region within England. It has a sizeable
proportion of ethnic minorities, particularly from South Asia. Aged 60 and
above constitute a relatively larger proportion of the population in Dudley
compared to their proportion of the population nationally and the population
is older than the national average. Obesity is more common in the region than
in England as a whole, and breastfeeding is relatively less common than in
England as a whole.
Dudley Area Demographics
FACT BOX
Population
450,000
The Royal College of Surgeons recommends that the
"...catchment population size...for an acute general hospital
providing the full range of facilities, specialist staff and
expertise for both elective and emergency medical and
surgical care would be 450,000 - 500,000."
IMD
Dudley is the 74th most deprived unitary
authority in England (out of 149 unitary
authorities).
Ethnic diversity
10% of the population of Dudley belong
to non-White ethnic minorities. The
largest minorities are Pakistani (3.3%),
Indian (1.8%), and White and Black
Caribbean (1.1%).
40-49
Rural or Urban
Dudley is an urban community.
50-59
Children’s and
young people’s
health
Breast feeding initiation in Dudley is
significantly less common than in
England as a whole. Childhood obesity
(year 6) is significantly more common
than in England as a whole.
Adults’ health
and lifestyle
Adults in Dudley are significantly less
physically active than the English
population as a whole. Similarly, adult
obesity is significantly more common
here than in England as a whole.
0-9
10-19
20-29
30-39
60-69
70-79
80+
20%
15%
10%
5%
Male/DUD
FemaleDUD
0%
5%
10%
Male/ENG
Female/ENG
15%
Source: Office of National Statistics, Census 2011; IMD Source: Index of Multiple Deprivation, 2010
20%
Slide 8
Dudley Geographic Overview
The map on the right shows the location of The Dudley Group Trust.
As shown on the map Dudley is an urban area located in the West
Midlands and is located in an area surrounded by a number of
major roads.
Market share analysis indicates from which GP practices the
referral s that are being provided for by the Trust originate. High
mortality may affect public confidence in a Trust, resulting in a
reduced market share as patients may be referred to alternative
providers.
Source: © Google Maps
The wheel on the left shows the market share of the
Dudley Group. It shows that the Dudley Group NHS
Foundation Trust has a 68% market share within a 5
mile radius of the Trust. However, it is clear that the
Trust’s market share falls as the radius is increased.
Within 10 miles, the market share is 15% whereas within
a 20 mile radius, the market share is only 4%.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
The wheel shows the competitors in the local area. These
were identified as Sandwell and West Birmingham
Hospitals NHS Trust, The Royal Wolverhampton
Hospitals NHS Trust, University Hospitals Birmingham
NHS Foundation Trust, and Worcestershire Acute
Hospitals NHS Trust.
Slide 9
Dudley’s Health Profile
Health Profiles, depicted on this slide and the following, are
designed to help local government and health services identify
problems in their areas and decide how to tackle these issues. They
provide a snapshot of the overall health of the local population, and
highlight potential differences against regional and national
averages.
Deprivation by unitary authority area
Dudley
The graph shows the level of deprivation in Dudley compared to the
national picture.
The tables below outline Dudley’s health profile information in
comparison with the rest of England.
1. The proportion of
children in poverty in 1
Dudley is slightly
above the national
average. Moreover,
the long term
unemployment figures
are also significantly
higher than national,
long-term
2
unemployment
figures.
2. In Dudley, all
indicators within
children’s and young
people’s health are
statistically lower
than the national
average.
Source: Public health observatories-area health profiles
Slide 10
Dudley’s Health Profile
3. Adult health in
Dudley is statistically 3
lower than the
national average
especially for healthy
eating, physically
active adults and
obese adults.
4. Self harm and
hospital stays for
alcohol related harm
are statistically
higher than national
average in Dudley.
5. In Dudley, life
expectancy in adult
males is statistically
lower than the
national average.
4
5
Source: Public health observatories-area health profiles
Slide 11
Performance of Local Healthcare Providers
To give an informed view of the
Trust’s performance it is important to
consider the service levels of nonacute local providers. For example,
slow ambulance response times will
greatly increase the risk of mortality.
The graphs on the right represent
some key performance indicators for
England’s ambulance services. The
West Midlands Ambulance Service
meets both the 8min and 19min
response targets.
Proportion of calls responded to within 8 minutes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Isle of Wight
NHS Trust
South
West
Western
Midlands
Ambulance Ambulance
Service NHS Service NHS
Foundation
Trust
Trust
South Central
Ambulance
Service NHS
Foundation
Trust
South East
East of
London
North West
Great
North East
Yorkshire
East
Coast
England
Ambulance Ambulance
Western
Ambulance Ambulance
Midlands
Ambulance Ambulance Service NHS Service NHS Ambulance Service NHS Service NHS Ambulance
Service NHS Service NHS
Trust
Trust
Service NHS
Trust
Trust
Service NHS
Foundation
Trust
Trust
Trust
Trust
Ambulance Trust
England
Source: Department of Health: Transparency Website Dec 12
Proportion of calls responded to within 19 minutes
100%
98%
96%
94%
92%
90%
88%
86%
84%
Isle of Wight
NHS Trust
West
London
South East
Yorkshire
South
Great
North East North West South Central
East of
East
Midlands
Ambulance
Coast
Ambulance
Western
Western
Ambulance Ambulance Ambulance
England
Midlands
Ambulance Service NHS Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Ambulance Ambulance
Service NHS
Trust
Service NHS
Trust
Service NHS Service NHS
Trust
Trust
Foundation Service NHS Service NHS
Trust
Foundation
Foundation
Trust
Trust
Trust
Trust
Trust
Trust
Ambulance Trusts
Source: Department of Health: Transparency Website Dec 12
England
Slide 12
Why was The Dudley Group chosen for this review?
Based on the Summary Hospital level Mortality
Indicator (SHMI) and Hospital Standardised
Mortality Ratio (HSMR), 14 trusts were selected for
this review. The table includes information on
which trusts were selected. An explanation of each
of these indicators is provided in the Mortality
section. Where it does not include the SHMI for a
trust, it is because the trust was selected due to a
high HSMR as opposed to its SHMI. The SHMI for
all 14 trusts can be found in the following pages.
Initially, five hospital trusts were announced as
falling within the scope of this investigation based
on the fact that they had been outliers on SHMI for
the last two years (SHMI data has only been
published for the last two years).
Subsequent to these five hospital trusts being
announced, Professor Sir Bruce Keogh took the
decision that those hospital trusts that had also been
outliers for the last two consecutive years on HSMR
should also fall within the scope of his review. The
rationale for this was that it had been HSMR that
had provided the trigger for the Healthcare
Commission’s initial investigation into the quality of
care provided at Mid Staffordshire Hospitals NHS
Foundation Trust.
The HSMR shows the Dudley Group has been above
the expected range for the last two years and was
therefore selected for this review.
Trust
SHMI 2011 SHMI 2012
HSMR
FY 11
HSMR
FY12
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
Tameside Hospital NHS Foundation Trust
1
1
111
Above expected
Banding 1 – ‘higher than expected’
Source: Background to the review & role of the national advisory group
Slide 13
Why was The Dudley Group chosen for this review?
The way that levels of observed
deaths that are higher than
expected deaths can be understood
is by using HSMR and SHMI. Both
compare the number of observed
deaths to the number of expected
deaths. This is different to
avoidable deaths. An HSMR and
SHMI of 100 means that there is
exactly the same number of deaths
as expected. This is very unlikely so
there is a range within which the
variance between observed and
expected deaths is statistically
insignificant. On the Poisson
distribution, appearing above and
below the dotted red and green
lines (95% confidence intervals),
respectively, means that there is a
statistically significant variance
for the trust in question.
SHMI Funnel Chart
SHMI Time Series
The Dudley Group
Selected trusts Outside Range
Selected trusts w/in Range
HSMR Funnel Chart
HSMR Time Series
The Dudley Group
Selected trusts Outside Range
Selected trusts w/in Range
The funnel charts for 2010/11 and
2011/12, the period when the trusts
were selected for review, show that
Dudley’s SHMI and HSMR is
statistically above the expected
range. This is supported by the
time series which shows both being
consistently higher than expected,
although the HSMR was in decline.
Source: Healthcare Evaluation Data (HED), Apr 10-Mar 12
Slide 14
Mortality
Slide 15
Mortality
Overview:
Summary:
This section focuses upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The Trust has an overall SHMI of 106 for the period December,
2011 to November, 2012 meaning that the number of actual
deaths is statistically higher than expected based on the 95%
confidence interval of the Poisson distribution .
The measures identified are being used as a ‘smoke alarm’ for
highlighting potential quality issues. No judgement about the actual
quality of care being provided to patients is being made at this stage,
nor should it be reached by looking at these measures in isolation.
Deeper analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure,
with a SHMI of 106 which is outside the expected range,
compared to a level of 121 for elective admissions.
Review areas
Currently, The Dudley Group has an HSMR of 98 and is within
the expected range.
To undertake a detailed analysis of the trust’s mortality, it is
necessary to look at the following areas:
• Differences between the HSMR and SHMI;
• Elective and non-elective mortality;
• Specialty and Diagnostic groups; and
• Alerts and investigations.
Data sources
• Healthcare Evaluation Data (HED);
• Health & Social Care Information Centre – SHMI and contextual
indicators;
• Dr Foster – HSMR; and
• Care Quality Commission – alerts, correspondence and findings.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Similar to SHMI, non-elective admissions are seen to be
contributing primarily to the overall Trust HSMR with 99,
against 65 for elective admissions.
The Dudley Group did not fully code its palliative care until Feb
2011. The percentage of deaths with palliative care coding (by
diagnosis rather than treatment specialty) is above the national
average.
Since 2007, The Dudley Group has had 18 diagnosis group alerts
to the CQC, of which 11 have been followed up. The most recent
of these are: Complex elderly UTI or male reproductive system
(Apr-11); Liver disease, alcohol-related (May-11; Oct-12); Large
intestinal disorders (Jun-11); Acute cerebrovascular disease
(Feb-12); Skin and subcutaneous tissue infections (Sep-12).
The following patient groups have alerted more than once since
2007: Acute cerebrovascular disease; Intestinal obstruction
without hernia; Liver disease, alcohol related; Septicaemia
(except in labour).
Slide 16
Mortality Overview
Mortality
The following overview provides a summary of the Trust’s key mortality areas:
Overall HSMR
Elective mortality (SHMI and HSMR)
Overall SHMI*
Non-elective mortality (SHMI and HSMR)
Weekend or weekday mortality outliers
Palliative care coding issues
Outcome 1 (R17) Respecting and involving e who use services
Emergency specialty groups much worse than expected
30-day mortality following specific surgery / admissions
Emergency specialty groups worse than expected
Mortality among patients with diabetes
Diagnosis group alerts to CQC
Diagnosis group alerts followed up by CQC
SHMI*
Outside expected range of the HSCIC for Mar 11 – Sep 12
Outside expected range
Outside expected range based on Poisson distribution for Dec 11 – Nov 12
Within expected range
Within expected range
*The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model,
which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14
trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the
purposes of this review.
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR,
Care Quality Commission – alerts, correspondence and findings
Slide 17
HSMR Definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a
hospital is higher or lower than you would expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it
cannot be said for certain that this reflects failings in the care provided by the hospital. However, it can be a warning sign that things are
going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of inhospital deaths (multiplied by 100) for 56 specific CCS groups in a specified patient group. The expected deaths are calculated from
logistical regression models taking into account and adjusting for a case-mix of: age band, sex, deprivation, interaction between age band
and co-morbidities, month of admission, admission method, source of admission, the presence of palliative care, number of previous
emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected
number in order to identify if variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to
calculate 95% and 99.9% confidence intervals and only when these have been crossed is performance classed as higher or lower than
expected.
Slide 18
SHMI Definition
What is the Summary Hospital-level Mortality Indicator?
The Summary Hospital-level Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department
of Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a
nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice.
How does SHMI work?
1.
2.
3.
4.
Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data
The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time
The Indicator will utilise 5 factors to adjust mortality rates by
a.
The primary admitting diagnosis;
b.
The type of admission;
c.
A calculation of co-morbid complexity (Charlson Index of co-morbidities);
d.
Age; and
e.
Sex.
All inpatient mortalities that occur within a Hospital are considered in the indicator
How should SHMI be interpreted?
Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are
highlighted using a Random Effects funnel plot.
Slide 19
Some key differences between SHMI and HSMR
Indicator
HSMR
SHMI
Are all hospital deaths included?
No, around 80% of in hospital deaths are
included, which varies significantly
dependent upon the services provided by
each hospital
If a patient is transferred between hospitals
within 2 days the death is counted multiple
times
Yes all deaths are included
Does the use of the palliative care code
reduce the relative impact of a death on the
indicator?
Yes
No
Does the indicator consider where deaths
occur?
Only considers in-hospital deaths
Considers in-hospital deaths but also those
up to 30 days post discharge anywhere too.
Is this applied to all health care providers?
Yes
No, does not apply to specialist hospitals
When a patient dies how many times is this
counted?
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
Slide 20
SHMI overview
Month-on-month time series
The Trust’s SHMI level for the 12 months from Dec 11 to Nov 12 is 106,
which means, as shown below, it is statistically above the expected
range, based on the 95% confidence interval of the Poisson
distribution.
The time series show SHMI as staying mainly at the same level
within the last couple of years, as well as during the months of the
last year, although some differences month-on-month can be seen.
SHMI funnel chart –12 months
Year-on-year time series
The Dudley Group
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 21
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for The Dudley
Group.
As SHMI includes mortalities
that occur within the hospital
and outside of it for up to 30
days following discharge, it is
imperative to understand the
percentage of deaths which
happen inside the hospital
compared to outside. This
will contribute toward
differences in HSMR and
SHMI outputs.
Percentage of patient deaths in hospital
90%
80%
The Dudley Group 74.8%
70%
60%
Trusts Covered by Review
All Trusts
The data shows that 74.8% of
SHMI deaths occur in
hospital, which is more than
the national average of
73.3%.
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 22
Lower than expected (below
the 95th confidence interval)
Elective
SHMI 106
Treatment Specialties
SHMI 121
Clinical Oncology
Chemical Pathology
Clinical Oncology
Midwife Episode
Gynaecology
Nephrology
Thoracic Medicine
Dermatology
Cardiology
Intermediate Care
Rehabilitation
Diabetic Medicine
Clinical Haematology
Endocrinology
Gastroenterology
General Medicine (180)
Paediatric Neuro-Disability
Paediatric Respiratory Medicine
Paediatric Gastroenterology
Paediatric Plastic Surgery
Paediatric ENT
Paediatric T&O
Pain Management
Not a Treatment Function
A&E
Paediatric Surgery
Plastic Surgery
Maxillo-Facial Surgery
Orthodontics
Oral Surgery
Ophthalmology
ENT
T&O
Vascular Surgery
Upper Gastrointestinal Surgery
Colorectal surgery
Breast Surgery
Urology
Slide 23
Gynaecology
Geriatric Medicine
Obstetrics
This slide provides a
breakdown of SHMI into
elective and non-elective
admissions and for
specialties. The SHMI for
non-elective admissions
has a greater impact on
the overall indicator due to
a higher number of
expected deaths. The
Dudley Group have a
SHMI 0f 106 which is
higher than anticipated
due to observed deaths
exceeding expected
deaths, specifically in nonelective admissions.
Rheumatology
Medical Oncology
Well Babies
Treatment Specialties
Neonatology
Paediatrics
Rheumatology
Medical Oncology (10)
Nephrology
Thoracic Medicine
Dermatology
Cardiology
Rehabilitation
Haemophilia
Bone and marrow
transplantation
Rehabilitation
Clinical Immunology &
Allergy
Clinical Haematology
Gastroenterology
General Surgery
Paediatric Respiratory
Medicine
Paediatric Gastroenterology
Non
Elective
Paediatric Plastic Surgery
Paediatric ENT
Paediatric T&O
Pain Management
Paediatric Surgery
Plastic Surgery
Oral Surgery
Ophthalmology
ENT
T&O
Vascular Surgery
Colorectal surgery
Breast Surgery
Urology
General Surgery
General Surgery
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Within non-elective
admissions; General
Medicine and Geriatric
Medicine have greater
numbers of deaths than
expected, while
Neonatology is also an
outlier.
Within expected range
Overall
Trust
Geriatric Medicine (26)
Well Babies
Neonatology (6)
Paediatrics
SHMI 106
Within elective
admissions, there is one
specialty with a SHMI
above the expected level.
Further review into this
shows that Medical
Oncology had 10 more
deaths than expected and
SHMI of 393.
Higher than expected (above
the 95th confidence interval)
Mortality - SHMI Tree
SHMI sub-tree of non-elective specialties
Higher than expected (above
the 95th confidence interval)
The SHMI sub-tree highlights the specialties for non-elective
admissions with a statistically higher SHMI than expected and
highlights the diagnostic groups with at least 4 more observed
deaths than expected. When identifying areas to review, it is
important to consider the number of deaths as well as the
SHMI.
Within expected range
Lower than expected (below
the 95th confidence interval)
The illustration highlights that General Medicine has the
greatest number of observed deaths that are higher than
expected, with a particularly high figure in several diagnostic
groups. Details of diagnostic groups with less than 4 deaths
more than expected are given in the appendix.
Overall118.2
(106; 132)
Diagnostic Groups
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Neonatology
(522, 6)
observed deaths greater
than expected
Geriatric Medicine
(126, 26)
SHMI
Medical Oncology (393, 10)
Diagnosis (100 ; 1 )
General Medicine
(116, 180)
Treatment Specialties
Key
Non-elective (106; 122)
Elective (121.3; 10)
Congestive heart failure;
nonhypertensive (139; 23)
Fluid and electrolyte disorders
Acute cerebrovascular disease (143; 8)
(155; 19)
Skin and subcutaneous tissue
infections(229; 17)
Cancer of bronchus; lung (150; 14)
Superficial injury; contusion(268; 12)
Slide 24
HSCIC SHMI overview
The Health and Social Care Information Centre (HSCIC) publish
the SHMI quarterly. This official statistic covers a rolling 12
month reporting period using a model based on a 3-year dataset
refreshed quarterly. The earliest publication was in October
2011, for the period from April 2010 to March 2011.
The HSCIC produce two sets of upper and lower limits. One set
uses 99.8% control limits from an exact Poisson distribution
based on the number of expected deaths. The other set uses a
Random effects model applying a 10% trim for over-dispersion,
based on the standardised Pearson residual for each provider
excluding the top and bottom 10% of scores. This latter set is
broader than the Poisson and is the one against which the
HSCIC report whether the SHMI is within, below or above the
expected range.
SHMI published by HSCIC, Dudley Group
120
115
110
113
112
109
112
107
105
104
104
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 Dudley Group was 104 in the year to Sept-12
(England baseline = 100) and has been within the expected
range throughout.
Source: Health & Social Care Information Centre – SHMI
Slide 25
HSMR overview
Month-on-month time series
As shown below, the Trust’s HSMR for the 12 months from Jan 12 to
Dec 12 is 98, which means that the Trust’s HSMR score is well within
the expected range.
The time series show significant variations both over the past 12
months and year-on-year. While the past 12 months have mostly seen
HSMR below 100, year-on-year HSMR figures have recently fallen
noticeably following a previous, equally significant spike.
HSMR funnel plot – 12 months
Year-on-year time series
The Dudley Group
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 26
HSMR Statistics - Dudley
The table to the right shows
The Dudley Group’s HSMR
broken down by admission
type.
It can be seen that The Dudley
Group has an HSMR of 98
and is within the expected
range. From the table, it can
be seen that the mortality rate
for non-elective admissions is
higher and drives the Trust’s
overall HSMR up. This is
mainly a result of the
weekend admissions.
However, it should be noted
that HSMR is within the
expected range for all
admission types.
Key – colour by
alert level:
HSMR
Weekend
Week
All
Elective
n/a
69
65
Non-elective
104
96
98
Red – Higher than
expected (above the
95% confidence
interval)
All
104
96
98
Blue – within
expected range
Green – Lower than
expected (below the
95th confidence
interval)
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 27
HSMR CCS Diagnostic Group Overview
The darker colour boxes have the highest HSMR scores while
the size of the boxes represent the number of deaths above
those expected. The larger and darker boxes within the tree
plot will highlight areas for potential review.
From this tree plot it is clear that the following areas could
potentially be reviewed:
•
Cancer of bronchus; lung (HSMR = 158; Observed
deaths above those expected = 22);
•
Skin and subcutaneous tissue infections (214; 17);
•
Congestive heart failure; nonhypertensive (119; 14);
•
Fluid and electrolyte disorders (139; 13); and
•
Liver disease; alcohol-related (169; 11).
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 28
Treatment Specialties
HSMR 65
Clinical Oncology
Gynaecology
Geriatric Medicine
Paediatrics
Clinical Oncology
Midwife Episode
Gynaecology
Geriatric Medicine
Medical Oncology
Rheumatology
Neonatology
Paediatrics
Well Babies
Nephrology
Rheumatology
Thoracic Medicine
Dermatology
Transient Ischaemic Attack
Thoracic Medicine
Stroke Medicine
Urology
General Surgery
Breast Surgery
Vascular Surgery
Colorectal surgery
T&O
ENT
Plastic Surgery
Oral Surgery
Ophthalmology
A&E
Paediatric Surgery
Pain Management
Paediatric ENT
Paediatric T&O
Paediatric Gastroenterology
Paediatric Respiratory Medicine
General Medicine
Gastroenterology
Endocrinology
Clinical Haematology
Intermediate Care
Rehabilitation
Diabetic Medicine
Cardiology
Clinical Haematology
Paediatric ENT
Pain Management
Paediatric Surgery
Plastic Surgery
Oral Surgery
Ophthalmology
ENT
Non
Elective
Paediatric Gastroenterology
Gastroenterology
Rehabilitation
Cardiology
Medical Oncology
Nephrology
Treatment Specialties
HSMR 99
T&O
Vascular Surgery
Colorectal Surgery
Breast Surgery
Urology
HSMR 98
Lower than expected (below
the 95th confidence interval)
Elective
Slide 29
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
General Surgery
Overall
Trust
When using HSMR, it can be
seen that The Dudley Group
have an HSMR of 98, driven
by fewer deaths than
expected for both nonelective and elective
admissions, with ratios of 99
and 65 respectively.
Within expected range
This slide provides a
breakdown of HSMR into
elective and non-elective
admissions and specialty
level. The HSMR 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)
Mortality - HSMR Tree
HSMR – Dr Foster
Time series of HSMR, Dudley Group
The HSMR time series for The Dudley Group from Dr Foster
shows the HSMR since 2008/09. This measures the observed
in-hospital death rate against an expected value based on all
the data for that year. An HSMR (or SHMI) of 100 means that
there is exactly the same number of deaths as expected. The
HSMR is classified as above expected if the lower 95%
confidence limit exceeds 100, which was the case in each year
from 2008/09.
125
120
116
116
115
112
110
111
105
100
95
Dudley Group FT’s 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.
90
2008/09
2009/10
2010/11
I
HSMR
2011/12
95% Confidence interval
Com parison of m ortality m easures,
Dudley Group
115
110
108
105
104
104
100
The remaining variances are largely due to:
• The scope of deaths included (SHMI covers all deaths
whereas HSMR covers clinical areas accounting for an
average of around 80% of deaths), and
• The definition of spells, which includes those provider(s) the
death attributes to.
97
95
90
SHMI
SHMI
adjusted for
palliative care
SHMI in
hospital
deaths only
HSMR
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 30
Coding
Diagnosis coding depth
has an impact on the
expected number of
deaths. A higher than
average diagnosis coding
depth is more likely to
collect co-morbidity which
will influence the expected
mortality calculation.
Average Diagnosis Coding Depth
Elective
5
5
4
3.5
4
3
2.5
3
2
2
1.5
1
When looking at the depth
of coding for The Dudley
Group, it is apparent that
its average diagnosis
coding depth has, until
recently, been below the
national average. Since
Q4 2011/12, the average
diagnosis coding depth
has risen significantly in
line with national
average.
Non-elective
6
4.5
1
0.5
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
National Average Diagnosis Coding Depth
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
The Dudley Group
The Dudley Group
2012/13
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 31
Palliative care
Accurate coding of palliative care is important for
contextualising SHMI and HSMR. HSMR takes into
account that a patient is receiving palliative care, but
SHMI does not.
The Dudley Group did not fully code its palliative care
until Feb 2011. The number of patients admitted to the
Trust in palliative care has grown to around the national
average. The percentage of deaths with palliative care
coding (by diagnosis rather than treatment specialty in
Dudley Group) is above the national average.
1.2
Percentage of admissions with palliative
care coding
1.0
0.8
0.6
0.4
0.2
-
Oct-11
Jan-12
Apr-12
Dudley Group
30
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
Dudley Group
Jul-12
National
Oct-12
Jan-13
Apr-13
SHMI publication
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 32
Care Quality Commission findings
Emergency specialty groups much worse than expected
Care Quality Commission (CQC) review mortality
alerts for each trust on an ongoing basis. These alerts,
which indicate observed deaths significantly above
expected for specialties or diagnoses, come from
different sources based on either HSMR or SHMI.
Where these appear unexplained, CQC correspond with
the trust to agree any appropriate action.
For The Dudley Group, the common theme that has
arisen across the patient groups alerting since 2007 is
Elderly Care.
Sep 11 to Aug 12
3
Cardiology
Dermatology
Cerebrovascular
Emergency specialty groups worse than expected
Sep 11 to Aug 12
1
Neurology
Diagnosis group alerts (2007 to date)
No common themes arise from responses to the CQC
from the Trust.
Alerts to CQC
18
Alerts followed up by CQC
11
Various case note reviews by the Trust have generally
not identified any deficiencies in care. There were
some concerns around coding issues, particularly
relating to alcoholic liver disease, and a suggested
focus around A&E (including ambulance arrival and
handover times) through to liver services.
Recent diagnosis group alerts pursued by CQC
Complex elderly UTI or male reproductive system (Apr-11)
Liver disease, alcohol-related (May-11; Oct-12)
Large intestinal disorders (Jun-11)
Acute cerebrovascular disease (Feb-12)
Skin and subcutaneous tissue infections (Sep-12)
Any related patient groups alerting more than once since
2007
Acute cerebrovascular disease
Intestinal obstruction without hernia
Liver disease, alcohol related
Septicaemia (except in labour)
Source: Care Quality Commission – alerts, correspondence and findings
Slide 33
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 five diagnosis groups and no
procedure groups with above expected SMRs in Dudley Group
Hospitals, which may highlight potential areas for review. One of
these diagnosis groups, Cancer of colon, had above expected
mortality for weekend admissions but not for weekday ones.
Apr 2012 to Mar 2013
Diagnosis groups
Procedure groups
SMRs above expected
5
0
CUSUM alerts
15
4
Diagnosis groups with SMRs above expected
Cancer of bronchus, lung
Cancer of colon
Fluid and electrolyte disorders
Liver disease, alcohol-related
Skin and subcutaneous tissue infections
SMR
154
181
149
176
207
Obs – Exp
deaths
19
10
17
10
18
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, The Dudley Group had three CUSUM alerts for
skin and subcutaneous tissue infections, two for cancer of
bronchus/long and one each for cancer or colon, fluid and
electrolyte disorders and liver disease, alcohol-related. It also had
seven alerts for other diagnostic groups and four for procedure
groups that did not have a high SMR.
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 34
Mortality – other alerts
The Health and Social Care Information Centre (HSCIC)
publish 30-day mortality rates following certain types
of surgery or admission to hospital. These are not
casemix adjusted, but the rates may be compared over
time.
The Dudley Group had two rates improving
substantially below the national average in the data to
2010-11 (published in Feb 2013).
It was rated “high” for mortality among diabetic
patients, in a report published by the Yorkshire and the
Humber Public Health Observatory (YHPHO) and the
National Diabetes Information Service.
30-day mortality following specific surgery / admissions
Myocardial infarction (improving 20% below national rate in 2010/11),
Non-elective surgery (improving 9% below national rate in 2010/11)
Mortality among inpatients with diabetes
Rated as “high” compared to all trusts (2 years to Mar-12).
VLAD charts with a negative SHMI trend
(year to Jun-12)
Acute cerebrovascular disease
Cancer of bronchus / lung
No. dips to the
lower control limit
2
2
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.
The Dudley Group had such VLAD charts for two
diagnosis groups in the year to June 2012.
Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.
Slide 35
Patient Experience
Slide 36
Patient Experience
Overview:
Summary:
The following section provides an insight into the Trust’s patient
experience.
Review Areas:
Of the 9 measures reviewed within Patient Experience and
Complaints, there are four which are rated ‘red’: Inpatient
Score, Cancer Survey, Patient Voice Comments, and Complaints
about Clinical Aspects.
To undertake a detailed analysis of the Trust’s Patient Experience
it is necessary to review the following areas:
Particular areas of concern from the cancer survey were
diagnostic tests, deciding best treatment and Hospital doctors.
•
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.
Of 170 individual comments from patients and public as part of
the Patient Voice, 92 were negative (54%). Key themes centred
on communication, information provision and staff attitude,
with some comment on waiting times in A&E.
Finally, the Trust is B-rated by the Ombudsman for satisfactory
remedies and low-risk of non-compliance.
Slide 37
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 38
Inpatient Experience Survey
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
Dudley Group performs below average on a range of survey questions including time for getting onto a ward, getting clear answers
from doctors, involvement in decisions, no delays at discharge, and the quality of food.
Overall
Length of time spent on waiting list
Alteration of admission date by hospital
Length of time to be allocated a bed on a
ward
Overall
Delay of patient discharge
Consistency of staff communication
Information provided on post-discharge
danger signals
Overall
Staff communication on purpose of
medication provided
Patient involvement in decision-making
Staff communication on medication
side-effects
Overall
Clarity of doctors’ responses to
important questions
Language used by doctors in front of
patients
Clarity of nurses’ responses to
important questions
Language used by nurses in front of
patients
Overall
Hospital food
Patient noise levels at night
Degree of privacy provided
Staff noise levels at night
Level of respect shown by staff
Hospital/ward cleanliness
Overall staff effort to ease pain
Above expected range
Source: Patient Experience Survey 2012/13
Within expected range
Below expected range
Slide 39
Patient experience and patient voice
Inpatient Survey
Overall patient experience score: Inpatients 2012
The national inpatient survey 2012 measures a wide range of
aspects of patient experience. A composite ‘overall measure’ is
calculated for use in the Outcomes Framework. This measure
uses a pre-defined selection of 20 survey questions to rate the
Trust on aspects including access to services, co-ordination of
care, information & choice, relationship with staff and the
quality of the clinical environment. The England Average score
for the inpatient survey was 76.5, whereas Dudley’s score was,
73.4 (LOW – more than 2 standard deviations below average)
Dudley scores below average on a range of survey questions
including time for getting onto a ward, getting clear answers
from doctors, involvement in decisions, no delays at discharge,
quality of food
95
The Dudley Group
90
85
80
75
70
65
60
55
50
England
average
Cancer Survey
Trusts in
this review
National
results curve
Source: Patient Experience Survey, Cancer patient experience survey
•
58 Questions
Complaints Handling
•
26 of these in ‘bottom 20%’, 4 in the ‘top 20%’
•
•
Particular areas of concern:
Data returns to the Health and Social Care Information
Centre showed 375 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, 63% of complaints related to clinical treatment
(compared to the national average of 47%).
•
A separate report by the Ombudsman rates the Trust as
B-rated for satisfactory remedies and low-risk of noncompliance. The report noted that the Trust was above
average for conversion rates of complaints escalated to
the Ombudsman (15.5%) and high number of physician
complaints.
1.
Deciding best treatment
2.
Feedback on ward nurses
Patient Voice
•
The quality risk profiles compiled by the Care Quality
Commission collate comments from individuals from
various sources. In the two years to 31 January 2013,
there were 170 comments on The Dudley Group, of which
92 were negative (54%). Key themes centred on
communication, information provision and staff attitude,
with some comment on waiting times in A&E.
Slide 40
Safety and workforce
Slide 41
Safety and Workforce
Overview:
Summary:
The following section provides an insight into the Trust’s
workforce profile and safety record. This section outlines whether
the Trust is adequately staffed and is safely operated.
The Dudley Group is ‘red’ rated in five of the safety
indicators:”harm” for all four Safety Thermometer indicators,
medication error, C diff, pressure ulcers, and clinical negligence
scheme payments.
Review Areas:
To undertake a detailed analysis of the Trust’s Safety and
Workforce it is necessary to review the following areas:
•
General Safety;
•
Staffing;
•
Staff Survey;
•
Litigation and Coroner; and
•
Analysis of patient safety incident reporting.
Data Sources:
•
Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;
•
Safety Thermometer, Apr 12 – Mar 13;
•
Litigation Authority Reports;
•
GMC Evidence to Review 2013;
•
National Staff Survey 2011, 2012;
•
2011/12 Organisational Readiness Self-Assessment (ORSA);
•
National Training Survey, 2012; and
•
NHS Hospital & Community Health Service (HCHS), monthly
workforce statistics.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Trust reported more patient safety and is rated ‘green’. This
may be because the Trust is recognising patient safety incidents
more fully and completely than similar trusts.
Throughout the last 12 months, The Dudley Group has been
consistently above the national rate, as well as that of the 14
trusts selected for this review, for total pressure ulcers.
The Trust is a net recipient in the Clinical Negligence scheme. Its
contributions to this ‘risk sharing scheme’ were lower than
payouts to litigants.
A review of the workforce data flagged seven ‘red rated’
indicators. Most notably, The Dudley Group’s response rate to
the staff survey rate has fallen noticeably since 2011 and is now
clearly below the national average. The Trust’s staff engagement
is at the same level as the national average. Similarly, on all
three organisational questions, The Dudley Group is close to the
national average.
The consultant appraisal rate for the Trust places it as the thirdhighest of the Trusts included in this review.
Slide 42
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
data not available
Number of ‘never events’ (2009-2012)
0
Medication error
x
Pressure ulcers
MRSA
“Harm” for all four Safety Thermometer Indicators
C diff
Clinical negligence scheme payments
Rule 43 coroner reports
Outcome 1 (R17) Respecting and involving people who use services
Outside expected range
Within expected range
Slide 43
Safety Analysis
The Trust has reported more patient safety incidents
than similar trusts. Organisations that report more
incidents may have a stronger and more effective safety
culture. Dudley has a rate of 7.5 for its patient safety
incident reporting per 100 admissions.
The rate of medication errors for Dudley is 26.89,
which is higher than the mean rate of 7.17 for all acute
trusts.
As shown in the graph on the right, between 2010 and
2012 The Dudley Group had a higher C diff % infection
rate than 11 of the other trusts in this review and much
above than the national median.
Rate of reported patient safety incidents per 100 admissions (April –
September 2012)
Dudley
Median rate for medium acutes
7.5
6.7
Source: incidents occurring between 1 April 2012 to 30 September
2012 and reported to the National Reporting and Learning System
Rate of medication errors per 1,000 bed days (October 2011 – March
2012)
Dudley
Mean rate for all acute
26.89
7.17
Source: Acute Trust Quality Dashboard Winter 2012/13
Since 2009, no ‘never events’, classified as that because
they are incidents that are so serious they should never
happen, have occurred at The Dudley Group.
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
The Dudley
Dudley
Group
3 year
z score
+2
4.0
3.0
2.0
1.0
0.0
Trusts under review
All non specialist trusts
Source: HPA/PHE published data and KH03 data return.
Dudley
Slide 44
Pressure Ulcers
This slide outlines the total
number of pressure ulcers
and the number of new
pressure ulcers broken down
by category for the last 12
months. Due to the effects of
seasonality on hospital
acquired pressure ulcer
rates, the national rate has
been included which allows a
comparison that takes this in
to account. This provides a
comparison against the
national rate as well as the
14 trusts selected for the
review.
In recent months, The
Dudley Group’s new
pressure ulcer prevalence
rate has fallen below the
national rate.
The total pressure ulcer
prevalence rate for The
Dudley Group has been
consistently above the
national rate and may
highlight an area for review.
New pressure ulcers prevalence
Total pressure ulcers prevalence
140
30
1.9% 1.8%
10.0%
8.1%
100
1.5%
1.2%
1.1%
1.1%
0.9%
5
0.5%
40
-
0.0%
0.6%
Category 3
7.1% 7.3%
6.6%
6.9%
6.5%
0.5%
Category 4
8.0%
6.0%
60
0.7%
7.4% 7.4% 7.3%
80
1.0%
0.7%
Category 2
8.5%
9.2%
2.0%
1.5%
15
10
9.7%
120
2.0%
25
20
12.0%
2.5%
4.0%
20
2.0%
-
0.0%
Rate
Category 2
Category 3
Category 4
Rate
New pressure ulcer analysis
Number of records submitted
Trust new pressure ulcers
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
1336
1309
1274
1224
1267
1217
1169
1269
1205
1284
1154
1229
27
20
9
23
23
13
10
7
14
9
6
13
Trust new pressure ulcer rate
2.0%
1.5%
0.7%
1.9%
1.8%
1.1%
0.9%
0.6%
1.2%
0.7%
0.5%
1.1%
Selected 14 trusts new pressure
ulcer rate
1.4%
1.5%
1.4%
1.5%
1.5%
0.9%
1.0%
1.1%
0.9%
1.1%
1.0%
1.2%
National new pressure ulcer rate
1.7%
1.7%
1.5%
1.5%
1.4%
1.3%
1.2%
1.2%
1.2%
1.3%
1.3%
1.3%
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
1336
1309
1274
1224
1267
1217
1169
1269
1205
1284
1154
1229
130
121
94
90
93
86
85
84
102
84
94
85
Trust total pressure ulcer rate
9.7%
9.2%
7.4%
7.4%
7.3%
7.1%
7.3%
6.6%
8.5%
6.5%
8.1%
6.9%
Selected 14 trusts total pressure
ulcer rate
6.4%
6.2%
6.5%
7.0%
6.3%
5.5%
5.4%
5.9%
5.8%
6.0%
5.7%
6.2%
National total pressure ulcer rate
6.8%
6.7%
6.6%
6.1%
6.0%
5.5%
5.4%
5.3%
5.2%
5.4%
5.6%
5.3%
Total pressure ulcer prevalence percentage
Number of records submitted
Trust total pressure ulcers
Source: Safety Thermometer Apr 12 to Mar 13
Slide 45
Litigation
Clinical negligence payments
Clinical negligence scheme analysis
2009/10
The Dudley Group’s clinical negligence payments have
exceeded contributions to the ‘risk sharing scheme ‘in each of
the last five years.
Coroners’ Rule
2010/11
2011/12
Payouts (£000s)
5,159
6,058
6,848
Contributions (£000s)
4,078
5,373
5,644
Variance between
payouts and contributions
(£000s)
-1,081
-685
-1,204
There were no recorded reports under rule 43 of the
Coroners’ rules.
Source: Litigation Authority Reports
Slide 46
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
2.54
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
2.20
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) 756
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
0.27
8.59
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 47
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 specialties with red outliers are noted below (where those specialties also have green outliers, they are included).
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Geriatric 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 48
General Medical Council (GMC) National Training Scheme Survey 2012
Rehabilitation Medicine
The GMC Survey results continue as follows.
Overall satisfaction
Induction
Clinical supervision
Undermining
Workload
Access to educational resource
Handover
Local teaching
Adequate experience
Study leave
Educational supervision
Regional teaching
Renal 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
In addition to the green outliers displayed, Acute Intestinal Medicine has one green outlier, Anaesthetics has three, Cardiology has two,
Haematology has two, Ophthalmology has one, Otolaryngology has two, Paediatrics has one, Rheumatology has one, and Trauma and
Orthopaedic Surgery has two.
Green outlier
Within expected range
Red outlier
Slide 49
Workforce Analysis
The Dudley Group has a patient spells per whole time equivalent rate of 33,
which is above average capacity in relation to the other trusts in this review
and nationally.
The data shows that the Trust’s agency staff costs, as a percentage of total
staff costs, are higher than the median within the region. The data also
illustrates that the Trust has a lower joining rate than the regional median
but also a lower leaving rate.
Number of FTEs (Dec 11-Nov 12 average)
Agency Staff (2011/12)
The Dudley Group
Percentage of
Total Staff Costs
Median within
Region
£7.2m
4.3%
3.9%
The Dudley
Group
West Midlands SHA
Median
Joining Rate
7.1%
7.4%
Leaving Rate
5.5%
6.1%
WTE nurses per bed day December 2012
National Average
1.85
1.96
(Sep 11 – Sep 12)
Staff Turnover
The Dudley Group has a consultant appraisal rate of 94.4%
The Dudley Group
3,772
Source: Health and Social Care Information Centre (HSCIC)
Source: Acute Trust Quality Dashboard, Methods Insight
Spells per WTE for Acute Trusts
Consultant
appraisal rate
2011/12
Consultant
appraisal
rate,
2011/12
50
100%
45
Spells per WTE
40
35
The Dudley
Group: 33
The Dudley Group:
94.4%
Dudley
80%
30
25
60%
20
15
40%
10
5
20%
0
Trusts covered by review
All Trusts
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
0%
Trusts covered by review
All other trusts
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Data based on the appraisal year from April 2011 to March 2012
Dudley50
Slide
Workforce Analysis continued…
The Dudley Group’s total sickness absence rate is
lower than both the West Midlands Strategic
Health Authority average and the national
average. However, at a more granular level it can
be seen that the sickness absence rates for the
Trust’s medical and other staff categories both
exceed their respective national averages.
The Trust has medical staff to consultant, and
nurse staff to qualified staff, ratios that are below
the average figures for all trusts in England. In
addition, its registered nurse hours to patient day
ratio is also below the national mean.
The Dudley Group’s consultant productivity rate
is above the national average.
The Trust’s 3 month medical staff vacancy rate is
seven times the national rate.
3 month Vacancy Rates by
Staff Category
The Dudley
Group
(March 2010)
National
Average
Medical Staff
10.8%
1.4%
Non-medial Staff
0.1%
0.4%
Source: The Health and Social Care Information Centre Non-Medical
Workforce Census (Sept 2009), Vacancies Survey March 2010
Workforce indicator calculations are listed in the Appendix.
Sickness Absence Rates
(2011-2012)
The Dudley Group
West Midlands SHA
Average
National Average
3.54%
4.31%
4.12%
All Staff
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
The Dudley Group
National Average
Medical Staff
1.44%
1.3%
Nursing Staff
4.7%
4.8%
Other Staff
5.1%
4.7%
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
The Dudley Group
National Average
Medical Staff to Consultant Ratio
2.54
2.59
Nurse Staff to Qualified Staff Ratio
2.20
2.50
Non-Clinical Staff to Total Staff
Ratio
0.27
0.34
Registered Nurse Hours to Patient
Day Ratio *
8.59
8.57
Source: Electronic Staff Record (ESR), Apr 13
*Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Consultant Productivity
(Spells/FTE)
Source: Electronic Staff Record (ESR), Apr 13
The Dudley Group
National Average
756
492
Slide 51
Workforce Analysis
In 2012, the Trust was below the
national average in three of the five
indicators. The response rate of 36%
was significantly lower than the
national average and the 2011 response
rate for the Trust.
However, these results also show that
59% of staff would recommend their
organisation as a place to work in 2012,
which is 4% more than the national
average.
61% of staff would be happy with the
standard of care provided by the
organisation for friends or family
members. It is also apparent that the
percentage of staff that would be happy
with the standard of care has fallen
since 2011.
National Staff Survey results
The Dudley
Group
2011
Average for all
trusts
2011
The Dudley
Group
2012
Average for all
trusts
2012
Response rate
43%
50%
36%
50%
Overall staff engagement
3.66
3.62
3.64
3.69
Care of patients/service
users is my organisation’s
top priority
62%
69%
61%
63%
I would recommend my
organisation a place to work
56%
52%
59%
55%
If a friend or relative needed
treatment, I would be happy
with the standard of care
provided by this organisation
67%
62%
61%
60%
Source: National Staff Survey 2011, 2012
Slide 52
Deanery
The Trust is not currently subject to enhanced monitoring. The National Training Survey did not indicate any specific concern and
doctors in training reported fewer patient safety concerns than the average. A number of concerns were raised by the Deanery in
2012.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Anaesthetics was the programme with the most below outliers in 2011 and 2012 (there were no outliers reported in 2010).
Respiratory Medicine had the most above outliers in the same period. The National Training Survey in 2012 reported less than half
the below outliers than a year earlier.
NTS 2012 Patient Safety Comments
5 doctors in training commented, representing 2.89% of respondents. This was lower than the national average of 4.7%. Their
concerns, which were raised in relation to specific training posts, and may apply to a single or multiple departments, related to:
•
Lack of junior doctors;
•
Lack of staff in general, especially at night;
•
Lack of staff cover due to disorganised on call rota; and
•
No recognised paediatric assessment unit.
Source: GMC evidence to Review 2013
Slide 53
Deanery Reports
NHS West Midlands Workforce Deanery raised concerns about the Dudley Group NHS Foundation Trust in its 2012 report.
Paediatrics was the source of many of the concerns, which related to the absence of a recognised paediatrics assessment unit and a
lack of regular consultant presence on the neonatal unit. Concerns were also raised in Trauma and Orthopaedic Surgery, two of
which were about staffing issues in the A&E. Multiple clinical incidents in the same department were also reported.
Monitored under the response to concerns process?
Undermining
No, the trust is not subject to increased monitoring at the time of the
report. The Trust has not been visited as part of the General Medical
Council’s Education Quality Assurance programme.
For doctors undertaking training at Dudley,
the Trust has a score on the National Training Survey on
undermining of 94.8 which is above the national average
of 94.
Mean Score on 'Undermining'
Mean Score on ‘Undermining’
105
100
Dudley
Dudley
94.8
95
90
85
80
Trusts covered by review
All other non specialist trusts
Dudley
Slide 54
Source: National Training Survey 2012
Clinical and operational
effectiveness
Slide 55
Clinical and Operational Effectiveness
Overview:
Summary:
The following section provides an insight in to the Trust’s clinical
and operational performance based on nationally recognised key
performance indicators.
With 96.3% of A&E patients seen within 4 hours, which is above
the 95% target level, The Dudley Group have one of the highest
percentages from the selected trusts in the review. However, the
percentage of patients seen within 4 hours has fallen slightly
over the past 12 months.
Review Areas:
To undertake a detailed analysis of the Trust’s clinical and
operational performance it is necessary to review the following
areas:
•
Clinical Effectiveness;
•
Operational Effectiveness; and
•
Patient Reported Outcome Measures (PROMs) for the review
areas.
Data Sources:
•
Clinical Audit Data Trust, CQC Data Submission;
•
Healthcare Evaluation Data (HED), Jan – Dec 2012;
•
Department of Health;
•
Cancer Waits Database, Q3, 2012-13; and
•
PROMs Dashboard.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
Dudley’s referral to treatment, which relates to ‘Admitted’
pathways, is 94.8%. This is higher than the target level. In
addition to this, their percentage achieved is one of the highest
amongst the trusts being reviewed.
The Trust’s crude readmission rate is lower than many of the
trusts in the review. The readmission rate of 10.8% is in the
second quartile of national trusts. Dudley also have a
comparatively low standardised readmission rate relative to the
14 selected trusts and a shorter length of stay than the national
mean average, with 3.8 days.
Finally, the PROMs dashboard shows that The Dudley Group
delivered steady performance in line with the average across
procedures covered by PROMs. However, Groin Hernia score
declined and was outside the lower 99.8% limit by 2011/12. All
scores for Hip Replacement were within control limits, but
below average and not showing any improvement.
Slide 56
Clinical and Operational Effectiveness
PROMs
Dashboard
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
x
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
RTT Waiting Times
x
Cancelled operations
Cancer Waits
PbR Audit
A&E Waits
Emergency readmissions
Hip Replacement EQ-5D
Hip Replacement OHS
Knee Replacement EQ-5D
Varicose Vein EQ-5D
Knee Replacement OKS
Outcome 1 (R17) Respecting and involving people who use services
Groin Hernia EQ-5D
Outside expected range
Within expected range
Slide 57
Clinical Effectiveness: National Clinical Audits
The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the
clinical audit results we have considered as part of this review.
Clinical Audit
Diabetes
Elective Surgery
Safety Measure
Clinical Audit
Proportion with medication
error
Proportion experiencing
severe hypoglycaemic
episode
Neonatal intensive and special care
(NNAP)
Proportion of women receiving antenatal steroids
Diabetes
Proportion foot risk assessment
Adult Critical Care
Standardised hospital mortality ratio
Proportion of patient reported
post-operative complications
Coronary angioplasty
Acute Myocardial Infarction
Proportion receiving primary PCI
within 90 mins
Elective abdominal aortic aneurysm
post-op mortality
Proportion having surgery within 14
days of referral
Proportion discharged on beta-blocker
Acute Stroke
Proportion compliant with 12 indicators
Heart Failure
Proportion referred for cardiology
follow up
90 day post-op mortality
Peripheral vascular surgery
Adult Critical Care (ICNARC
CMPD)
Effectiveness Measures
Proportion of night-time
discharges
Carotid interventions
Bowel cancer
Hip Fracture
Elective surgery (PROMS)
Severe Trauma
Hip, knee and ankle
Lung Cancer
Source: Clinical Audit Data Trust, CQC Data Submission.
30 day mortality
Proportion operations within 36 hrs
Mean adjusted post-operative score
Proportion surviving to hospital
discharge
Standardised revision ratio
Proportion small cell patients receiving
chemotherapy
Slide 58
PROMs Dashboard
Overall, The Dudley Group delivered steady performance
but Groin Hernia score declined and was outside the lower
99.8% limit by 2011/12.
All scores for Hip Replacement were within control limits,
but below average and not showing any improvement.
Groin Hernia
EQ-5DEQ-5D
Groin
Hernia
0.3
Engl and
Average
0.25
The Dudl ey
Group
0.2
0.15
Upper
Control
Li mi t
0.1
0.05
Lower
Control
Li mi t
2
20
11
/1
1
20
10
/1
20
09
/1
0
0
Source : PROMs Dashboard and NHS Litigation Authority
Slide 59
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
A&E wait times and RTT
times may indicate the
effectiveness with which
demand is managed.
A&E Percentage of Patients Seen
within 4 Hours
Dudley’s RTT is 94.8%,
higher than the target
level. Their percentage
achieved is one of the
highest amongst the
trusts being reviewed.
90%
8
98%
6
96%
4
2
94%
0
92%
80%
70%
Patients Seen
Trusts Covered by Review
All Trusts
A&E Target 95%
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Patients Not Seen
Seen within 4 hours (%)
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Referral to Treatment (Admitted)
100%
From the time series, it is
apparent that The
Dudley Group have been
consistently performing
above the target level,
although there is a slight
drop in Feb and Mar.
The Dudley Group
96.3%
100%
100%
10
Attendances
(Thousands)
Dudley see 96.3% of A&E
patients within 4 hours,
which is above the 95%
target level. On this
indicator, it has one of
the highest percentages
from the trusts in the
review. However, the
time series shows that
this percentage has fallen
slightly over the last 12
months.
The Dudley Group 4 Hour A&E Waits
The Dudley Group
94.8%
The Dudley Group Referral to
Treatment Performance
98%
95%
96%
90%
94%
85%
92%
80%
90%
88%
75%
86%
70%
65%
Trusts Covered by Review
Source: Department of Health. Feb 13
All Trusts
RTT Target 90%
Referral to Treatment Rate
RTT Target 90%
Source: Department of Health. Apr 12 – Jan 13
Slide 60
Operational Effectiveness – Emergency Readmissions and Length of Stay
The standardised
readmission rate most
importantly accounts for
the Trust’s case mix and
shows that The Dudley
Group are statistically
lower than expected. In
fact, Dudley are on the
99% confidence interval
and so are performing
statistically better than
expected.
The Dudley Group have
an average length of stay
of 3.8 days, which is
shorter than the national
average of 5.2 days.
Standardised 30-day Readmission Rate
25%
20%
The Dudley
Group
10.8%
15%
10%
5%
0%
Trusts Covered by Review
Dudley Group
Selected trusts Outside
Selected trusts w/in Range
All Trusts
Average Length of Stay by Trust
10
Spell Duration (Days)
The Dudley Group’s crude
readmission rate is one of
the lower readmission
rates out of the trusts in
the review at 10.8%. It is
in the second quartile of
trusts nationally.
Crude Readmission Rate by Trust
Crude Readmission Rate
Readmission rates may
indicate the
appropriateness of
treatment offered, whilst
average length of stay
may indicate the
efficiency of treatment.
8
6
The Dudley Group
3.8
4
2
0
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Trusts Covered by Review
All Trusts
Slide 61
Leadership and
governance
Slide 62
Leadership and governance
Overview:
Summary:
This section provides an indication of the Trust’s governance
procedures.
In April 2013 the Trust made amendments to the Director
portfolio to introduce a new Director of Strategy and
Transformation who will focus on a refresh of the Trust’s
Integrated Business Plan.
Review Areas:
To provide this indication of the Trust’s leadership and
governance procedures we have reviewed the following areas:
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.
The Board of Directors have seven sub-committees including the
Clinical Quality, Safety and Patient Experience Committee
(CQSPE). The CQSPE has many sub-groups covering a wide
range of quality and safety.
There is a long standing rolling programme of Chairman and
Chief Executive Mortality and Morbidity meetings which
requires each specialty to present once a year, however there is
no evidence of a monthly mortality review meeting that reports
into this Committee structure .
The current Monitor governance rating is green, and recent
CQC inspections did not raise any concerns in relation to the
standards that were tested.
Slide 63
Leadership and governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in
the following pages.
Leadership and
governance
Monitor governance risk rating
Monitor finance rating
CQC Outcomes
3
Governance risk rating
Red - Likely or actual significant breach of terms of authorisation
Amber-red - Material concerns surrounding terms of authorisation
Amber-green - Limited concerns surrounding terms of authorisation
Green - No material concerns
CQC Concerns
Red – Major concern
Amber – Minor or Moderate concern
Green – No concerns
Financial risk rating
rated 1-5, where 1 represents the highest risk and 5 the lowest
Slide 64
Leadership and governance
Trust Board
In April 2013 the Trust made some changes to the Director portfolio to enable the Executive team to find the capacity for long term strategic
planning alongside other duties. They currently have an interim Director of Operations filling in for the new Director of Strategy and
Transformation who will focus on a refresh of the Trust’s Integrated Business Plan. See Appendix A for Board of directors structure.
Governance and clinical structures
The Board of Directors have seven sub-committees (see Appendix B) including the Clinical Quality, Safety and Patient Experience Committee
(CQSPE). The CQSPE has many sub-groups covering a wide range of quality and safety including a patient safety group.
The Trust has not provided evidence of a monthly mortality review meeting that reports into this Committee structure. There is however a
long standing rolling programme of Chairman and Chief Executive Mortality and Morbidity meeting which requires each specialty to present
once a year.
The Trust has a clinically led operational structure with seven Directorates including surgery and anaesthetics, trauma and orthopaedics,
diagnostics, women and children, ambulatory medicine, emergency and specialty medicine and community services and integrated care.
External reviews
The most recent CQC inspections in February 2013 found all hospitals to be meeting the essential standards of quality and safety that were
tested.
The Trust was found in significant breach of three terms of its authorisation in December 2009: its general duty to exercise its functions
effectively, efficiently and economically, its governance duty and its healthcare targets and other standards duty. The Trust has since
demonstrated considerable progress towards addressing Monitor’s concerns and was removed from significant breach in December 2010. In
Q3 of 12/13 the Trust had a Monitor Governance rating of Green.
A diagram of board members and committee structure can be found in the Appendix.
Slide 65
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
Further risks for review
Sub-optimal management of diabetes patients; in particular there
are challenges around staff following guidelines and attending
mandatory training.
Significant concerns have been raised by both the Directorate
Management Team and the Renal Network, with regard to clinical
practice in the Renal Unit.
Urgent care demand exceeds capacity - the Trust is facing
significant challenges from emergency care pressures.
In 2012/13 there have been 101 serious incidents to date, of which
26 were patient falls leading to fracture. There has been 1 never
event in 2012/13 (retained instrument).
Unable to admit patients due to externally caused delayed
discharge / transfer .
Nurse staffing levels are sub optimal in certain areas - staffing
levels fall below acceptable safe levels and the optimal skill mix not
fully funded. Corporate risk register does not identify these areas
by name.
There is a risk currently under assessment regarding workforce
availability problems in terms of middle grade doctors in
emergency and acute medicine
Slide 66
Leadership and governance – other areas for further review
The following areas have been identified from the review of information submitted by the Trust
•
The Trust has been visited by their solicitors, to inform and to discuss their response to a potential Group Action by complainants
through Leigh Day, the company which represented the Mid Staffs families. There is a potential for nine complaints in the action, all
of which relate to quality of care provided.
•
The CQSPE’s effectiveness is currently being reviewed by the Executive team and directorates are individually discussing their
prospective governance arrangements, it is not clear how established this governance structure and processes are.
Slide 67
Appendix
Slide 68
Trust Map
Slide 69
Workforce Indicator Calculations
Indicator
WTE nurses per bed day
Spells per WTE staff
Medical Staff to Consultant
Ratio
Nurse Staff to Qualified Staff
Ratio
Numerator /
Denominator
Calculation
Source
Numerator
Nurses FTE’s
Denominator
Total number of Bed Days
Acute
Quality
Dashboard
Numerator
Total Number of Spells
Denominator
Total number of WTE’s
Numerator
FTEs whose job role is ‘Consultant’
Denominator
FTEs in ‘Medical and Dental’ Staff Group
Numerator
FTEs in ‘Nursing & Midwifery Registered’ Staff Group
Denominator
FTEs of Additional Clinical Services – 85% of bands 2, 3 and 4
Numerator
FTEs not in ‘Nursing and Midwifery Registered’, ‘Additional Clinical
Services,’ ‘Allied Health Professionals’ or ‘Medical and Dental’ staff
groups
Denominator
Sum of FTEs for all staff groups
Numerator
Number of Inpatient Spells
Denominator
FTEs whose job role is ‘Consultant’
Numerator
Nurse FTEs multiplied by 1522 (calculated number of hours per year
which takes into account annual leave and sickness rates)
Denominator
Total Bed Days
Non-clinical Staff to Total Staff
Ratio
Consultant Productivity
(Spells/FTE)
Nurse hours per patient day
HED
ESR
ESR
ESR
ESR
HED
ESR
ESR
HED
Note: ESR Data only includes substantive staff.
Slide 70
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 71
Board of Directors
Slide 72
Board and Committee structure
Slide 73
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 74
Data Sources
No.
Data Source Name
Health and Social Care Information Centre (HSCIC) monthly workforce
98 statistics
99 National Staff Survey, 2011, 2012
100 GMC evidence to review, 2013
101 2011/12 Organisational Readiness Self-Assessment (ORSA)
102 National Training Survey, 2012
103 National Patient Safety Agency (NPSA) Apr 11 – Mar 12
Type
Area
Data
Data
Analysis
Data
Data
Data
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Slide 75
SHMI Appendix
Observed Deaths that
are Higher than
Expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Elective
Medical Oncology
Intestinal infection
1124
1
Elective
Medical Oncology
Other liver diseases
852
1
Elective
Medical Oncology
Intestinal obstruction without hernia
729
1
Elective
Medical Oncology
Secondary malignancies
552
1
Elective
Medical Oncology
Cancer of colon
514
1
Elective
Medical Oncology
Cancer of bronchus; lung
444
1
N0n-elective
General Medicine
Liver disease; alcohol-related
193
10
N0n-elective
General Medicine
Leukemias
342
7
N0n-elective
General Medicine
Pulmonary heart disease
209
7
N0n-elective
General Medicine
Aspiration pneumonitis; food/vomitus
122
6
N0n-elective
General Medicine
Cancer of colon
260
5
N0n-elective
General Medicine
Epilepsy; convulsions
169
5
N0n-elective
General Medicine
Other lower respiratory disease
149
5
N0n-elective
General Medicine
Secondary malignancies
141
5
N0n-elective
General Medicine
Cancer of head and neck
406
4
N0n-elective
General Medicine
Cancer of bladder
277
4
N0n-elective
General Medicine
Cancer of other GI organs; peritoneum
257
4
N0n-elective
General Medicine
Biliary tract disease
222
4
N0n-elective
General Medicine
Cancer of pancreas
163
4
N0n-elective
General Medicine
Cancer of esophagus
157
4
N0n-elective
General Medicine
Malignant neoplasm without specification of site
153
4
N0n-elective
General Medicine
Other gastrointestinal disorders
150
4
N0n-elective
General Medicine
Deficiency and other anemia
147
4
N0n-elective
General Medicine
Other diseases of kidney and ureters
569
3
Slide 76
SHMI Appendix
Observed Deaths that
are Higher than
Expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
N0n-elective
General Medicine
Diverticulosis and diverticulitis
496
3
N0n-elective
General Medicine
Hypertension with complications and secondary hypertension
415
3
N0n-elective
General Medicine
Multiple myeloma
398
3
N0n-elective
General Medicine
Parkinson`s disease
356
3
N0n-elective
General Medicine
Diabetes mellitus with complications
231
3
N0n-elective
General Medicine
Cancer of prostate
206
3
N0n-elective
General Medicine
Cancer of liver and intrahepatic bile duct
197
3
N0n-elective
General Medicine
Other endocrine disorders
166
3
N0n-elective
General Medicine
Other psychoses
160
3
N0n-elective
General Medicine
Gout and other crystal arthropathies
434
2
N0n-elective
General Medicine
Other disorders of stomach and duodenum
415
2
N0n-elective
General Medicine
Fracture of lower limb
399
2
N0n-elective
General Medicine
Other hereditary and degenerative nervous system conditions
357
2
N0n-elective
General Medicine
Cancer of uterus
243
2
N0n-elective
General Medicine
Cancer of kidney and renal pelvis
232
2
N0n-elective
General Medicine
Abdominal pain
204
2
N0n-elective
General Medicine
Peripheral and visceral atherosclerosis
190
2
N0n-elective
General Medicine
Cancer of breast
188
2
N0n-elective
General Medicine
Bacterial infection; unspecified site
187
2
N0n-elective
General Medicine
Open wounds of head; neck; and trunk
178
2
N0n-elective
General Medicine
Spondylosis; intervertebral disc disorders; other back problems
167
2
N0n-elective
General Medicine
Intestinal infection
109
2
N0n-elective
General Medicine
Anal and rectal conditions
1912
1
N0n-elective
General Medicine
Hyperplasia of prostate
1460
1
Slide 77
SHMI Appendix
Observed Deaths that
are Higher than
Expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
N0n-elective
General Medicine
Thyroid disorders
1051
1
N0n-elective
General Medicine
Skull and face fractures
1005
1
N0n-elective
General Medicine
Other mental conditions
698
1
N0n-elective
General Medicine
Occlusion or stenosis of precerebral arteries
632
1
N0n-elective
General Medicine
Other male genital disorders
571
1
N0n-elective
General Medicine
Hepatitis
488
1
N0n-elective
General Medicine
Diseases of mouth; excluding dental
362
1
N0n-elective
General Medicine
Gastroduodenal ulcer (except hemorrhage)
327
1
N0n-elective
General Medicine
Multiple sclerosis
305
1
N0n-elective
General Medicine
Headache; including migraine
298
1
N0n-elective
General Medicine
Abdominal hernia
292
1
N0n-elective
General Medicine
Cancer; other respiratory and intrathoracic
288
1
N0n-elective
General Medicine
Other non-epithelial cancer of skin
276
1
N0n-elective
General Medicine
Cancer of other female genital organs
266
1
N0n-elective
General Medicine
Chronic renal failure
249
1
N0n-elective
General Medicine
Cancer of ovary
246
1
N0n-elective
General Medicine
Mycoses
241
1
N0n-elective
General Medicine
Melanomas of skin
239
1
N0n-elective
General Medicine
Other inflammatory condition of skin
230
1
N0n-elective
General Medicine
Non-Hodgkin`s lymphoma
211
1
N0n-elective
General Medicine
Alcohol-related mental disorders
211
1
N0n-elective
General Medicine
Cancer of rectum and anus
208
1
N0n-elective
General Medicine
Cancer of bone and connective tissue
206
1
N0n-elective
General Medicine
Regional enteritis and ulcerative colitis
195
1
Slide 78
SHMI Appendix
Observed Deaths that
are Higher than
Expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
N0n-elective
General Medicine
Complications of surgical procedures or medical care
191
1
N0n-elective
General Medicine
Intestinal obstruction without hernia
188
1
N0n-elective
General Medicine
Diabetes mellitus without complication
184
1
N0n-elective
General Medicine
Other non-traumatic joint disorders
182
1
N0n-elective
General Medicine
Allergic reactions
177
1
N0n-elective
General Medicine
Cancer; other and unspecified primary
170
1
N0n-elective
General Medicine
Peritonitis and intestinal abscess
160
1
N0n-elective
General Medicine
Aortic; peripheral; and visceral artery aneurysms
145
1
N0n-elective
General Medicine
Heart valve disorders
145
1
N0n-elective
General Medicine
Neoplasms of unspecified nature or uncertain behavior
142
1
N0n-elective
General Medicine
Open wounds of extremities
137
1
N0n-elective
General Medicine
Pancreatic disorders (not diabetes)
134
1
N0n-elective
General Medicine
Nausea and vomiting
133
1
N0n-elective
General Medicine
Cancer of stomach
120
1
N0n-elective
General Medicine
Chronic ulcer of skin
119
1
N0n-elective
General Medicine
Noninfectious gastroenteritis
118
1
N0n-elective
General Medicine
Coagulation and hemorrhagic disorders
115
1
N0n-elective
General Medicine
Complication of device; implant or graft
114
1
N0n-elective
General Medicine
Syncope
109
1
N0n-elective
General Medicine
Other fractures
108
1
N0n-elective
General Medicine
Nutritional deficiencies
108
1
N0n-elective
General Medicine
Gastrointestinal hemorrhage
106
1
N0n-elective
General Medicine
Pleurisy; pneumothorax; pulmonary collapse
103
1
N0n-elective
General Medicine
Cancer of brain and nervous system
102
1
Slide 79
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
N0n-elective
Neonatology
Short gestation; low birth weight; and foetal growth retardation
N0n-elective
Neonatology
Intrauterine hypoxia and birth asphyxia
N0n-elective
Neonatology
N0n-elective
Observed Deaths that
are Higher than
Expected
SHMI
355
3
17,393
2
Other congenital anomalies
3,416
1
Neonatology
Other perinatal conditions
15,010
1
N0n-elective
Geriatric Medicine
Conduction disorders
8696
1
N0n-elective
Geriatric Medicine
Occlusion or stenosis of precerebral arteries
4648
1
N0n-elective
Geriatric Medicine
Esophageal disorders
2511
1
N0n-elective
Geriatric Medicine
Other upper respiratory disease
1367
1
N0n-elective
Geriatric Medicine
Complication of device; implant or graft
800
1
N0n-elective
Geriatric Medicine
Spondylosis; intervertebral disc disorders; other back problems
681
1
N0n-elective
Geriatric Medicine
Peritonitis and intestinal abscess
636
1
N0n-elective
Geriatric Medicine
Nausea and vomiting
531
1
N0n-elective
Geriatric Medicine
Noninfectious gastroenteritis
509
1
N0n-elective
Geriatric Medicine
Chronic ulcer of skin
376
1
N0n-elective
Geriatric Medicine
Cancer of bladder
367
1
N0n-elective
Geriatric Medicine
Other and ill-defined cerebrovascular disease
341
1
N0n-elective
Geriatric Medicine
Other endocrine disorders
332
1
N0n-elective
Geriatric Medicine
Parkinson`s disease
293
1
N0n-elective
Geriatric Medicine
Cancer of esophagus
251
1
N0n-elective
Geriatric Medicine
Melanomas of skin
241
1
N0n-elective
Geriatric Medicine
Cancer of brain and nervous system
239
1
N0n-elective
Geriatric Medicine
Biliary tract disease
238
1
N0n-elective
Geriatric Medicine
Non-Hodgkin`s lymphoma
233
1
N0n-elective
Geriatric Medicine
Cardiac dysrhythmias
220
1
Slide 80
SHMI Appendix
Observed Deaths that
are Higher than
Expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
N0n-elective
Geriatric Medicine
Gastrointestinal hemorrhage
215
1
N0n-elective
Geriatric Medicine
Malignant neoplasm without specification of site
191
1
N0n-elective
Geriatric Medicine
Aortic; peripheral; and visceral artery aneurysms
179
1
N0n-elective
Geriatric Medicine
Senility and organic mental disorders
176
1
N0n-elective
Geriatric Medicine
Fluid and electrolyte disorders
160
1
N0n-elective
Geriatric Medicine
Pulmonary heart disease
150
1
N0n-elective
Geriatric Medicine
Cancer of bronchus; lung
149
1
N0n-elective
Geriatric Medicine
Cardiac arrest and ventricular fibrillation
141
1
N0n-elective
Geriatric Medicine
Cancer of prostate
135
1
N0n-elective
Geriatric Medicine
Acute and unspecified renal failure
113
1
N0n-elective
Geriatric Medicine
Acute bronchitis
111
1
N0n-elective
Geriatric Medicine
Congestive heart failure; nonhypertensive
111
1
N0n-elective
Geriatric Medicine
Intestinal infection
109
1
N0n-elective
Geriatric Medicine
Respiratory failure; insufficiency; arrest (adult)
103
1
N0n-elective
Geriatric Medicine
Epilepsy; convulsions
101
1
N0n-elective
Geriatric Medicine
Intestinal obstruction without hernia
292
1
N0n-elective
Geriatric Medicine
Cancer of colon
322
1
N0n-elective
Geriatric Medicine
Coma; stupor; and brain damage
372
1
N0n-elective
Geriatric Medicine
Acute myocardial infarction
299
3
Slide 81
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Elective)
Treatment Specialty
Medical Oncology
HSMR
SHMI
X
Slide 82
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Non-elective)
Treatment Specialty
HSMR
SHMI
General Medicine
X
Neonatology
X
Geriatric Medicine
X
Slide 83