Sherwood Forest Hospitals
NHS Foundation Trust
Data Pack
9th July, 2013
Overview
Sources of Information
On 6th February the Prime Minister asked Professor Sir Bruce
Keogh to review the quality of the care and treatment being
provided by those hospital trusts in England that have been
persistent outliers on mortality statistics. The 14 trusts which fall
within the scope of this review were selected on the basis that they
have been outliers for the last two consecutive years on either the
Summary Hospital Mortality Index or the Hospital Standardised
Mortality Ratio.
Document review
Trust information
submission for
review
These two measures are being used as a ‘smoke alarm’ for
identifying potential quality problems which warrant further
review. No judgement about the actual quality of care being
provided to patients is being made at this stage, or should be
reached by looking at these measures in isolation.
The review will follow a three stage process:
Stage 1 – Information gathering and analysis
Stage 2 – Rapid Responsive Review
Benchmarking
analysis
Information shared
by key national
bodies including
the CQC
Stage 3 – Risk summit
This data pack forms one of the sources within the information
gathering and analysis stage.
Information and data held across the NHS and other public bodies
has been gathered and analysed and will be used to develop the Key
Lines of Enquiry (KLOEs) for the individual reviews of each Trust.
This analysis has included examining data relating to clinical
quality and outcomes as well as patient and staff views and
feedback. A full list of evidence sources can be found in the
Appendix.
Given the breadth and depth of information reviewed, this pack is
intended to highlight only the exceptions noted within the evidence
reviewed in order to inform Key Lines of Enquiry.
Slide 2
Sherwood Forest Hospitals NHS Foundation Trust
Context
A brief overview of the Nottinghamshire area and Sherwood Forest Hospitals NHS Foundation Trust. This section provides a profile of
the area, outlines performance of local healthcare providers and gives a brief introduction to the Trust.
Mortality
An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the
Trust which are outliers.
Patient Experience
A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient
experience surveys.
Safety and Workforce
A summary of the Trust’s safety record and workforce profile.
Clinical and Operational Effectiveness
A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This
section compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures
(PROMs).
Leadership and Governance
An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership,
current top risks to quality and outcomes from external reviews.
Slide 3
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.
Sherwood Forest is located in Nottinghamshire, with its main
sites placed in Ashfield and in Newark and Sherwood, and
services a population of 400,000 people. In Nottinghamshire,
4.5% of the population belong to non-White ethnic minorities;
Indians constitute the largest single minority with 0.9%.
Smoking in pregnancy is the single largest health-related
concern in Ashfield, Mansfield, Newark and Sherwood, where
the proportion of the population gaining at least a C in five or
more GSCEs is also significantly lower than in the country as a
whole.
Review Areas:
To provide an overview of the Trust, we have reviewed the
following areas:
•
Local area and market share;
•
Health profile;
•
Service overview; and
•
Initial mortality analysis.
Data Sources:
•
Trust’s Board of Directors meeting 30th Jan, 2013;
•
Department of Health: Transparency Website, Dec 12;
•
Healthcare Evaluation Data (HED);
•
NHS Choices;
•
Office of National Statistics, 2011 Census data;
•
Index of Multiple Deprivation, 2011;
•
© Google Maps;
•
Public Health Observatories – Area health profiles; and
•
Background to the review and role of the national
advisory group.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
The Trust services slightly fewer people than the number
recommended by the Royal College of Surgeons.
Sherwood Forest has two main hospitals sites, the acute King’s
Mill Hospital in Ashfield, and the community hospital in
Newark. Sherwood Forest became a Foundation Trust in 2007
and has a total of 744 beds with a bed occupancy rate above the
national average. The market share of the Trust for inpatient
activity is 69% within a 5 mile radius, falling to 37% within a 10
mile radius, and 9% within a 20 mile radius.
A review of ambulance response times showed that East
Midlands Ambulance Service fails to meet both the 8mins and
the 19mins national response target.
Finally, Sherwood Forest’s HSMR was above the expected level
in 2011 and 2012, and the Trust was therefore selected for this
review.
Slide 5
Trust Overview
Sherwood Forest Hospitals NHS Foundation Trust has two hospital
sites, King’s Mill Hospital is an acute hospital, and Newark. The Trust
gained foundation status in 2007 and had a net deficit in its 2012-13
budget of £15m. The occupancy rate for the Trust’s 744 beds is above the
national average. The Trust offers a large range of services and in 2012
treated a total of almost 85,000 inpatients, as well as almost 340,000
outpatients.
Trust Status
Foundation Trust (2007)
Number of Beds and Bed Occupancy
(Oct12-Dec12)
Beds
Available
Percentage
Occupied
National
Average
Total
744
94.6%
86%
General and
Acute
695
95.1%
88%
Maternity
48
88.2%
59%
Source: Department of Health: Transparency Website
(Jan12-Dec12)
Inpatient/Outpatient Activity
Sherwood Forest Hospitals NHS Foundation Trust
Acute Hospital
King’s Mill Hospital
Community Hospital
Newark Hospital
Inpatient Activity
Elective
40,456 (48%)
Outpatient Activity
Source: NHS Choices
Non-Elective
44,247 (52%)
Total
84,703
Total
338,651
Day Case Rate:
80%
Source: Healthcare Evaluation Data (HED)
Departments and Services
Finance Information
2012–2013 Income
£255m
2012–2013 Expenditure
£243m
2012–2013 EBITDA
£13m
2012–2013 Net surplus (deficit)
(£15m)
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: Sherwood Forest Hospitals NHS Foundation Trust Financial Performance Report,
submitted for board meeting of 25 April 2013.
A map of King’s Mill Hospital is included in the Appendix.
Accident & Emergency, Allergy Services, Breast Surgery, Cardiology,
Children’s & Adolescent Services, Dentistry and Orthodontics, Dental
Medicine Specialties, Dermatology, Diabetic Medicine, Diagnostic
Endoscopy, Diagnostic Physiological Measurement, ENT,
Endocrinology and Metabolic Medicine, Gastrointestinal and Liver
Services, General Medicine, General Surgery, Gynaecology,
Haematology, Maternity Service, Minor Injuries Unit, Neurology,
Occupational Therapy Services, Older People’s Services,
Ophthalmology, Oral and Maxillofacial Surgery, Orthopaedics,
Orthotics and Prosthetics, Pain Management, Physiotherapy, Plastic
Surgery, Podiatry, Respiratory Medicine, Rheumatology, Sleep
Medicine, Urology, Vascular Surgery
Source: NHS Choices
Slide 6
Trust Overview continued...
General Medicine and
Gynaecology are the
largest inpatient
specialties while
Trauma &
Orthopaedics and
Ophthalmology are the
largest for outpatients.
Outpatient Activity by Trust
300
1200
250
1000
200
Sherwood Forest
84,703
150
100
50
Number of Outpatient
Spells (Thousands)
Sherwood Forest is a
medium sized trust for
both measures of
activity, relative to the
rest of England. Of the
14 trusts selected for
this review, it is the
tenth and eighth
largest by the number
of inpatient and
outpatient spells,
respectively.
Inpatient Activity by Trust
Number of Inpatient
Spells (Thousands)
The graphs show the
relative size of
Sherwood Forest
against national trusts
in terms of inpatient
and outpatient
activity.
800
Sherwood Forest
338,651
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
16%
Paediatric Surgery
16
Trauma and Orthopaedics
17%
Gynaecology
16%
Midwifery
113
Ophthalmology
10%
General Surgery
13%
Neurology
168
General Medicine
9%
Paediatrics
9%
Rheumatology
201
Allied Health Professional Episode
9%
Trauma and Orthopaedics
9%
Rehabilitation
288
Gynaecology
7%
Urology
5%
Plastic Surgery
433
Ear, Nose & Throat (ENT)
6%
Gastroenterology
5%
Accident & Emergency
534
General Surgery
6%
Dermatology
3%
Anaesthetics
993
Dermatology
5%
Obstetrics
3%
Oral surgery
1086
Cardiology
5%
Geriatric Medicine
3%
Cardiology
1264
Paediatrics
4%
Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12
Slide 7
Nottinghamshire Area Overview
Nottinghamshire, in which the Trust’s main sites are situated in Ashfield and in
Newark and Sherwood, is not a particularly deprived region of England. The
age distribution in Nottinghamshire is somewhat similar to that of England as
a whole. However, the population in this region is older than the population of
the country as a whole. Smoking in pregnancy is a particular health problem
for Ashfield, Mansfield, Newark and Sherwood, where the proportion of the
population gaining at least a C in 5+ GSCEs is also significantly lower than in
the country as a whole. 4.5% of Nottinghamshire’s population belong to nonWhite ethnic minorities, including 0.9% Indians.
Nottinghamshire Area Demographics
FACT BOX
Population
The Royal College of Surgeons recommend that the
"...catchment population size...for an acute general hospital
providing the full range of facilities, specialist staff and
expertise for both elective and emergency medical and
surgical care would be 450,000 - 500,000."
IMD
Of 149 English unitary authorities,
Nottinghamshire is the 93rd most
deprived.
Ethnic diversity
In Nottinghamshire, 4.5% belong to nonWhite ethnic minorities, including 0.9%
Indians.
Rural or Urban
Nottinghamshire is a rural-urban region.
Smoking in
pregnancy
In Ashfield, Mansfield, Newark and
Sherwood, smoking in pregnancy is
significantly more common than in the
country as a whole.
GCSEs
achieved
In Ashfield, Mansfield, Newark and
Sherwood, the proportion of the
population gaining at least a C in 5+
GCSEs is significantly lower than in the
country as a whole.
0-9
10-19
20-29
30-39
40-49
50-59
60-69
70-79
80+
Female/NOT
20%
15%
10%
Female/ENG
5%
Male/NOT
0%
5%
400,000
Male/ENG
10%
15%
20%
Source: BBC News (www.bbc.co.uk/news/uk-england-nottinghamshire-19679070) as accessed on 23.5.2013; Index of
Multiple Deprivation 2010; 2011 ONS Census; Department of Health Instant Atlas tables 2010.
Slide 8
Nottinghamshire Geographic Overview
The map on the right shows the location of the two main hospital
sites of Sherwood Forest Hospitals NHS Foundation Trust in
Nottinghamshire, a rural-urban area located in the East Midlands.
As shown on the map, the Trust’s sites are located near several
urban areas, including Derby, Nottingham and Sheffield, as well as
near to the M1.
Market share analysis indicates from which GP practices the
referrals that are being provided for by the Trust originate. High
mortality may affect public confidence in a Trust, resulting in a
reduced market share as patients may be referred to alternative
providers.
Source: © Google Maps
The wheel on the left shows the market share of Sherwood Forest
Hospitals NHS Foundation Trust. From the wheel it can be seen
that Sherwood Forest has a 69% market share of inpatient activity
within a 5 mile radius of the Trust.
As the size of the radius is increased, the market share falls to 37%
within 10 miles and 9% within 20 miles.
The wheel shows that the main competitors in the local area are
Nottingham University Hospitals NHS Trust, United Lincolnshire
Hospitals NHS Trust, Derby Hospitals NHS Foundation Trust,
Circle, and Chesterfield Royal Hospital NHS Foundation Trust.
Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12
Slide 9
Ashfield and Mansfield’s Health Profile
Health Profiles, depicted on this slide and the following, are designed
to help local government and health services identify problems in their
areas, and decide how to tackle these issues. They provide a snapshot
of the overall health of the local population, and highlight potential
differences against regional and national averages.
The graph shows the level of deprivation in Ashfield and Mansfield
compared nationally.
Deprivation by unitary authority area
Mansfield
Ashfield
The tables below outline Ashfield and Mansfield’s health profile
information in comparison with the rest of England.
1
1. Mansfield and
Ashfield are both
performing
significantly below the
national level in almost
all community
indicators. Statutory
homelessness in
Ashfield is the only
indicator performing 2
significantly higher
than the national
average.
2. Both smoking in
pregnancy and teenage
pregnancy are more
common in Ashfield
and Mansfield than the
national average.
Slide 10
Ashfield and Mansfield’s Health Profile
3. Within adult health
and lifestyle, both
3
Ashfield and Mansfield
have a lower number of
healthy eating adults.
Ashfield has a higher
number of obese
children that the
national average while
Mansfield has a higher
number of smoking
adults.
4. Ashfield and
Mansfield are both
significantly lower than
the national average on
Drug Misuse and have
a higher number of hip
fracture in 65s and over
and people with
diabetes. Mansfield
had a higher number of
alcohol related hospital
stays and acute STIs.
4
Slide 11
Ashfield and Mansfield’s Health Profile
5. Life expectancy in
Ashfield and Mansfield 5
is lower than the
national average. Both
areas have a higher
number of smoking
related deaths, while
early deaths due to
heart disease or cancer
and the number of road
injuries and deaths are
higher than the
national average in
Mansfield
Slide 12
Performance of Local Healthcare Providers
To give an informed view of the
Trust’s performance it is
important to consider the
service levels of non-acute local
providers. For example, slow
ambulance response time may
increase the risk of mortality.
The graphs on the right
represent some key
performance indicators for
England’s Ambulance services.
The East Midlands Ambulance
Service fails to meet both the
8min and 19min response
targets, and is, indeed, the
worst performing ambulance
trust in England on both
measures.
Proportion of calls responded to within 8 minutes
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Isle of Wight
NHS Trust
South
West
South Central
Western
Midlands
Ambulance
Ambulance Ambulance Service NHS
Service NHS Service NHS Foundation
Foundation
Trust
Trust
Trust
South East
East of
London
North West
Great
North East
Yorkshire East Midlands
Coast
England
Ambulance Ambulance
Western
Ambulance Ambulance Ambulance
Ambulance Ambulance Service NHS Service NHS Ambulance Service NHS Service NHS Service NHS
Service NHS Service NHS
Trust
Trust
Service NHS
Trust
Trust
Trust
Foundation
Trust
Trust
Trust
Ambulance Trust
England
Proportion of calls responded to within 19 minutes
100%
98%
96%
94%
92%
90%
88%
86%
84%
Source: Department of Health: Transparency Website Dec 12
Isle of Wight
NHS Trust
West
London
South East
Yorkshire
South
Great
North East North West South Central
East of
East Midlands
Midlands
Ambulance
Coast
Ambulance
Western
Western
Ambulance Ambulance Ambulance
England
Ambulance
Ambulance Service NHS Ambulance Service NHS Ambulance Ambulance Service NHS Service NHS Service NHS Ambulance Service NHS
Service NHS
Trust
Service NHS
Trust
Service NHS Service NHS
Trust
Trust
Foundation Service NHS
Trust
Trust
Foundation
Foundation
Trust
Trust
Trust
Trust
Trust
Ambulance Trusts
England
Slide 13
Why was Sherwood Forest chosen for this review?
Based on the Summary Hospital level Mortality
Indicator (SHMI) and Hospital Standardised
Mortality Ratio (HSMR), 14 trusts were selected
for this review. The table includes information on
which trusts were selected. An explanation of
each of these indicators is provided in the
Mortality section. Where it does not include the
SHMI for a trust, it is because the trust was
selected due to a high HSMR as opposed to its
SHMI. The SHMI for all 14 trusts can be found in
the following pages.
Initially, five hospital trusts were announced as
falling within the scope of this investigation based
on the fact that they had been outliers on SHMI
for the last two years (SHMI data has only been
published for the last two years).
Subsequent to these five hospital trusts being
announced, Professor Sir Bruce Keogh took the
decision that those hospital trusts that had also
been outliers for the last two consecutive years on
HSMR should also fall within the scope of his
review. The rationale for this was that it had been
HSMR that had provided the trigger for the
Healthcare Commission’s initial investigation
into the quality of care provided at Mid
Staffordshire Hospitals NHS Foundation Trust.
Sherwood Forest has been above the expected
level for HSMR over the last 2 years and was
therefore selected for this review.
Trust
SHMI 2011 SHMI 2012
HSMR
FY 11
HSMR
FY 12
Within
Expected?
Basildon and Thurrock University Hospitals NHS
Foundation Trust
1
1
98
102
Within expected
Blackpool Teaching Hospitals NHS Foundation Trust
1
1
112
114
Above expected
Buckinghamshire Healthcare NHS Trust
112
110
Above expected
Burton Hospitals NHS Foundation Trust
112
112
Above expected
Colchester Hospital University NHS Foundation Trust
1
1
107
102
Within expected
East Lancashire Hospitals NHS Trust
1
1
108
103
Within expected
George Eliot Hospital NHS Trust
117
120
Above expected
Medway NHS Foundation Trust
115
112
Above expected
North Cumbria University Hospitals NHS Trust
118
118
Above expected
Northern Lincolnshire And Goole Hospitals NHS
Foundation Trust
116
118
Above expected
Sherwood Forest Hospitals NHS Foundation Trust
114
113
Above expected
101
102
Within expected
The Dudley Group Of Hospitals NHS Foundation Trust
116
111
Above expected
United Lincolnshire Hospitals NHS Trust
113
111
Above expected
Tameside Hospital NHS Foundation Trust
1
1
Banding 1 – ‘higher than expected’
Source: Background to the review and role of the national advisory group Financial years 2010-11, 2011-12
Slide 14
Why was Sherwood Forest chosen for this review?
The way that levels of observed
deaths that are higher than
expected deaths can be
understood is by using HSMR
and SHMI. Both compare the
number of observed deaths to
the number of expected deaths.
This is different to avoidable
deaths. An HSMR and SHMI of
100 means that there is exactly
the same number of deaths as
expected. This is very unlikely so
there is a range within which the
variance between observed and
expected deaths is statistically
insignificant. On the Poisson
distribution, appearing above
and below the dotted red and
green lines (95% confidence
intervals), respectively, means
that there is a statistically
significant variance for the trust
in question.
The funnel charts for 2010/11
and 2011/12, the period when
the trusts were selected for
review, show that Sherwood
Forest’s SHMI is statistically
within the expected range. While
the time series has been above
the expected level from Sept
2011, it has dropped below
numerous times during the time
period shown. Sherwood
Forest’s HSMR is just above the
expected range, and the time
series supports this .
SHMI Time Series
SHMI Funnel Chart
Sherwood Forest
Selected trusts Outside Range
Selected trusts w/in Range
HSMR Time Series
HSMR Funnel Chart
Sherwood Forest
Selected trusts Outside Range
Selected trusts w/in Range
Source: Healthcare Evaluation Data (HED); Apr 10-Mar 12
Slide 15
Mortality
Slide 16
Mortality
Overview:
Summary:
This section focuses upon recent mortality data to provide an
indication of the current position. All 14 trusts in the review have
been analysed using consistent methodology.
The Trust has an overall HSMR of 116 for the period January
2012 to December 2012, meaning that the number of actual
deaths is higher than the expected level. This is statistically
above the expected range.
The measures identified are being used as a ‘smoke alarm’ for
highlighting potential quality issues. No judgement about the actual
quality of care being provided to patients is being made at this stage,
nor should it be reached by looking at these measures in isolation.
Review areas
To undertake a detailed analysis of the trust’s mortality, it is
necessary to look at the following areas:
• Differences between the HSMR and SHMI;
• Elective and non-elective mortality;
• Specialty and Diagnostic groups; and
• Alerts and investigations.
Data sources
• Healthcare Evaluation Data (HED);
• Health & Social Care Information Centre – SHMI and contextual
indicators;
• Dr Foster – HSMR; and
• Care Quality Commission – alerts, correspondence and findings.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Further analysis of this demonstrates that non-elective
admissions are the primary contributing factor to this figure,
with a similar HSMR of 117, also above the expected range.
Elective admissions are within the expected range at 54.
Sherwood Forest has a SHMI of 108 for the period December
2011 to November 2012, which is statistically above the expected
range (using Healthcare Evaluation data) . However, the
official SHMI produced by HSCIC is within the expected range
(for the period October 2011 to September 2012).
Similar to HSMR, non-elective admissions are seen to be
contributing primarily to the overall Trust SHMI, with a similar
figure of 109. Elective admissions are within the expected range,
with a SHMI of 82.
Sherwood Forest had five high mortality alerts for diagnostic
groups since 2007.
A common theme has arisen around sepsis, with two high
mortality alerts for septicaemia (except in labour). The Trust put
in place a sepsis action plan to address the issues found.
Sherwood Forest developed a Mortality Work Streams action
plan in response to their elevated HSMR.
Slide 17
Mortality Overview
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 much worse than expected (CQC)
30-day mortality following specific surgery / admissions
Emergency specialty worse than expected (CQC)
Mortality among patients with diabetes
Diagnosis group alerts to CQC
Mortality in low-risk groups
Diagnosis group alerts followed up by CQC
SHMI*
Outside expected range of the HSCIC for Mar 11 – Sep 12
Outside expected range
Outside expected range based on Poisson distribution for Dec 11 – Nov 12
Within expected range
Within expected range
*The detailed following analysis on SHMI is based upon a narrower set of confidence intervals compared to the Random effects model,
which the HSCIC use to report whether the SHMI is within, below or above the expected range and was the range used to select the 14
trusts for this review. The narrower range is used here to increase the sensitivity to the data and serves to give an earlier warning for the
purposes of this review.
Source: Healthcare Evaluation Data (HED)
Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR,
Care Quality Commission – alerts, correspondence and findings
Slide 18
HSMR Definition
What is the Hospital Standardised Mortality Ratio?
The Hospital Standardised Mortality Ratio (HSMR) is an indicator of healthcare quality that measures whether the mortality rate at a
hospital is higher or lower than you would expect. Like all statistical indicators, HSMR is not perfect. If a hospital has a high HSMR, it
cannot be said for certain that this reflects failings in the care provided by the hospital. However, it can be a warning sign that things are
going wrong.
How does HSMR work?
The HSMR is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of inhospital deaths (multiplied by 100) for 56 specific CCS groups; in a specified patient group. The expected deaths are calculated from
logistical regression models taking into account and adjusting for a case-mix of: age band, sex, deprivation, interaction between age band
and co-morbidities, month of admission, admission method, source of admission, the presence of palliative care, number of previous
emergency admissions and financial year of discharge.
How should HSMR be interpreted?
Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected
number in order to identify if variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to
calculate 95% and 99.9% confidence intervals and only when these have been crossed is performance classed as higher or lower than
expected.
Slide 19
SHMI Definition
What is the Summary Hospital-level Mortality Indicator?
The Summary Hospital-level Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department
of Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a
nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice.
How does SHMI work?
1.
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 20
Some key differences between SHMI and HSMR
Indicator
HSMR
SHMI
Are all hospital deaths included?
No, around 80% of in hospital deaths are
included, which varies significantly
dependent upon the services provided by
each hospital
If a patient is transferred between hospitals
within 2 days the death is counted multiple
times
Yes all deaths are included
Does the use of the palliative care code
reduce the relative impact of a death on the
indicator?
Yes
No
Does the indicator consider where deaths
occur?
Only considers in-hospital deaths
Considers in-hospital deaths but also those
up to 30 days post discharge anywhere too.
Is this applied to all health care providers?
Yes
No, does not apply to specialist hospitals
When a patient dies how many times is this
counted?
1 death is counted once, and if the patient is
transferred the death is attached to the last
acute/secondary care provider
Slide 21
SHMI overview
Month-on-month time series
The Trust’s SHMI for the 12 months from Dec 11 to Nov 12 is 108,
which means, as shown below, it is statistically above the expected
range and so classified as an outlier, based on the 95% confidence
interval of the Poisson distribution.
The time series show no real trend month-on-month; however, the
SHMI does fluctuate between 92 and 122. There is a roughly stable
trend year-on-year, although there was a slight increase in the past
year.
SHMI funnel chart –12 months
Year-on-year time series
Sherwood Forest
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
Slide 22
SHMI Statistics
This slide demonstrates the
number of mortalities in and
out of hospital for Sherwood
Forest.
As SHMI includes mortalities
that occur within the hospital
and outside of it for up to 30
days following discharge, it is
imperative to understand the
percentage of deaths which
happen inside the hospital
compared to outside. This
may contribute to differences
in HSMR and SHMI
outcomes.
Percentage of patient deaths in hospital
90%
85%
80%
Sherwood Forest 77.8%
75%
70%
65%
60%
Trusts selected for review
All Trusts
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The data shows that 77.8% of
SHMI deaths occur in
hospital at Sherwood Forest,
which is more than the
national average of 73.3%,
and is the second highest of
the trusts selected for review.
Slide 23
Mortality - SHMI Tree
Elective
-
-
-
-
-
-
-
-
-
-
-
-
Paediatric Surgery
Pain Management
General Medicine
Gastroenterology
Endocrinology
Clinical Haematology
Rehabilitation
Cardiology
Dermatology
Thoracic Medicine
Rheumatology
Paediatrics
Geriatric Medicine
Podiatry
-
Oral surgery
-
-
Ophthalmology
Gynaecology
-
Ear, Nose and Throat (ENT)
-
-
Trauma & Orthopaedics
Obstetrics
-
Breast Surgery
SHMI 109
-
-
Non
Elective
Treatment Specialties
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
General Surgery
Urology
Breast Surgery
Trauma & Orthopaedics
Ear, Nose and Throat (ENT)
Ophthalmology
Oral Surgery
Plastic Surgery
Paediatric Surgery
Accident & Emergency (A&E)
Anaesthetics
General Medicine (110; 148)
Gastroenterology
Endocrinology
Clinical Haematology
Diabetic Medicine
Rehabilitation
Cardiology
Thoracic Medicine
Neurology
Rheumatology
Paediatrics
Geriatric Medicine
Obstetrics
Gynaecology
Midwife Episode
Key
Diagnosis (100 ; 1 )
SHMI
Urology
General Surgery
SHMI 108
-
Overall
Trust
The tree shows that
Sherwood Forest has
a SHMI of 108 which
is above the expected
range.
The number of
observed deaths are
highlighted as being
above the expected
level in General
Medicine for nonelective admissions.
This is a potential
area for review.
Treatment Specialties
SHMI 82
-
Mortality trees
provide a breakdown
of SHMI into elective
and non-elective
admissions. The SHMI
score for non-elective
admissions has a
greater impact on the
overall indicator due
to a higher number of
expected deaths.
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Observed deaths that are higher
than the expected
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
Slide 24
SHMI sub-tree of specialties
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
The SHMI sub-tree highlights the specialties for non-elective admissions with a statistically higher SHMI
than expected and highlights the diagnostic groups with at least four more observed deaths than expected.
When identifying areas to review, it is important to consider the number of deaths as well as the SHMI.
Within non-elective admissions, General Medicine has the highest number of greater than expected deaths
and septicaemia (21) and acute cerebrovascular disease (19) are seen as the main diagnostic groups
contributing to this.
Overall (108; 155)
118.2
Non-elective (109; 161)
\
Treatment Specialties
Diagnostic Groups
General Medicine (110; 148)
Acute and unspecified renal failure
(127; 11)
Gastrointestinal haemorrhage
(128; 6)
Acute cerebrovascular disease
(122; 19)
Intracranial injury
(157; 4)
Acute myocardial infarction
(136; 10)
Other non-traumatic joint disorders
(262; 5)
Aspiration pneumonitis; food/vomitus
(113; 5)
(211; 5)
Biliary tract disease
(225; 6)
Cancer of bronchus; lung
(115; 7)
Other upper respiratory disease
Pneumonia (except that caused by tuberculosis or
sexually transmitted disease)
(102; 6)
Complication of device; implant or graft
(375; 4)
Pulmonary heart disease
(136; 4)
Deficiency and other anemia
(168; 8)
Secondary malignancies
(134; 9)
Fluid and electrolyte disorders
(132; 6)
Septicemia (except in labor)
(129; 21)
Urinary tract infections
(108; 6)
Key
Diagnosis (100 ; 1 )
SHMI
Observed deaths that are higher
than the expected
Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
Slide 25
HSCIC SHMI overview
The Health and Social Care Information Centre (HSCIC) publish
the SHMI quarterly. This official statistic covers a rolling 12
month reporting period using a model based on a 3-year dataset
refreshed quarterly. The earliest publication was in October
2011, for the period from April 2010 to March 2011.
SHMI published by HSCIC, Sherwood Forest FT
120
115
110
105
100
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.
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 Sherwood Forest was 108 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 26
HSMR overview
Month-on-month time series
The Trust’s HSMR for the 12 months from Jan 12 to Dec 12 is 116,
which means, as shown below, it is above the expected range and so
classified as an outlier.
The time series show a general increase for HSMR year-on-year and
month-on-month time series shows no real trend. Further to this, the
month-on-month time series fluctuates between extremes of 88 and
136.
HSMR funnel plot –12 months
Year-on-year time series
Sherwood Forest
Selected trusts Outside Range
Selected trusts w/in Range
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 27
HSMR Statistics
The table to the right shows
Sherwood Forest’s HSMR
broken down by admission
type.
The breakdown illustrates
the overall HSMR is 116
which is above the expected
range. The table identifies
that elective admissions
have an HSMR within the
expected range, whereas
non-elective admissions
have an HSMR above the
expected range.
Key – colour by
alert level:
HSMR
Weekend
Week
All
Elective
0
60
54
Non-elective
124
115
117
Red – Higher than
expected (above the
95% confidence
interval)
All
123
114
116
Blue – Within
expected range
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Green – Lower than
expected (below the
95th confidence
interval)
Mortality from both week
and weekend admissions
are highlighted as being
above the expected level,
due to the high non-elective
admissions.
Slide 28
HSMR CCS Diagnostic Group Overview
The darker colour boxes have the highest HSMR while the size
of the boxes represent the number of observed deaths that are
higher than the expected deaths. The larger and darker boxes
within the tree plot will highlight potential areas for further
review.
From this tree plot it is clear that the following areas have the
greatest number of above expected deaths:
•
Septicaemia (except in labour) (HSMR of 144, and 30
observed deaths that are higher than the expected);
•
Pneumonia (except that caused by tuberculosis or sexually
transmitted disease) (108, 25);
•
Acute cerebrovascular disease (129, 24);
•
Urinary tract infections (136, 18); and
•
Acute and unspecified renal failure (145, 16).
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 29
Mortality - HSMR Tree
Elective
HSMR 54
-
-
-
-
-
-
-
-
Rehabilitation
Cardiology
Thoracic Medicine
Rheumatology
Paediatrics
Geriatric Medicine
Gynaecology
Podiatry
General Medicine
Clinical Haematology
-
Paediatric Surgery
-
-
Ear, Nose and Throat (ENT)
Gastroenterology
-
Trauma & Orthopaedics
HSMR 117
-
-
Breast Surgery
Non
Elective
Treatment Specialties
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
-
Trauma & Orthopaedics
Ear, Nose and Throat (ENT)
Ophthalmology
Accident & Emergency (A&E)
General Medicine (118; 163)
Gastroenterology
Endocrinology
Clinical Haematology
Diabetic Medicine
Rehabilitation
Cardiology
Thoracic Medicine
Neurology
Rheumatology
Paediatrics
Geriatric Medicine
Obstetrics (2352; 3)
Midwife Episode
-
Breast Surgery
Source: Healthcare Evaluation Data (HED). Jan 12 – Dec 12
-
-
Urology
Observed deaths that are higher
than the expected
Gynaecology
-
General Surgery
Diagnosis (100 ; 1 )
-
-
Key
HSMR
-
Within non-elective
admissions General
Medicine and Obstetrics
have the highest number of
observed deaths above the
expected level.
Urology
General Surgery
HSMR 116
Treatment Specialties
-
Overall
Trust
-
The tree shows that the
HSMR for Sherwood
Forest is 116 which is
above the expected range.
When breaking this down
by admission type, it is
clear that it is driven by
non-elective admissions,
which is at a similar level
and is also above the
expected range.
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
Slide 30
HSMR sub-tree of specialties
Higher than expected (above
the 95th confidence interval)
Within expected range
Lower than expected (below
the 95th confidence interval)
The HSMR sub-tree indicates the specialties with a statistically higher HSMR
than expected and with diagnostic groups with at least four more observed deaths
than expected. When identifying areas to review, it is important to consider the
number of deaths as well as the HSMR.
The sub-tree indicates that General Medicine has the highest number of above
expected deaths. These are spread over numerous diagnostic groups such as acute
cerebrovascular disease (23), septicaemia (25), pneumonia (16) and urinary tract
infections (16). Within Obstetrics, there are no diagnostic groups with at least
four more observed deaths than expected.
Overall118.2
(116; 186)
Non-elective (117; 192)
Treatment Specialties
Obstetrics (2352; 3)
Diagnostic Groups
General Medicine (118; 163)
Acute and unspecified renal failure
(147; 15)
Acute bronchitis
(124; 4)
Acute cerebrovascular disease
(131; 23)
Acute myocardial infarction
(141; 10)
Aspiration pneumonitis; food/vomitus
(133; 9)
Cancer of bronchus; lung
(119; 5)
Fluid and electrolyte disorders
(176;
Gastrointestinal hemorrhage
(123; 4)
7)
Key
Intracranial injury
(178; 4)
Diagnosis (100 ; 1 )
Other gastrointestinal disorders
(185; 4)
Other upper respiratory disease
Pneumonia (except that caused by
tuberculosis or sexually transmitted
disease)
(284; 4)
Pulmonary heart disease
(165; 5)
Secondary malignancies
(131; 5)
HSMR
Observed deaths that are higher
than the expected
Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12
The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.
(106; 16)
Septicemia (except in labor)
(143; 25)
Urinary tract infections
(138; 16)
Slide 31
HSMR – Dr Foster
The HSMR time series for Sherwood Forest Foundation Trust
from Dr Foster shows a rise in the HSMR since 2008/09. This
measures the observed in-hospital death rate against an
expected value based on all the data for that year. An HSMR
(or SHMI) of 100 means that there is exactly the same number
of deaths as expected. The HSMR is classified as above
expected if the lower 95% confidence limit exceeds 100, which
was the case in financial years 2010/11 and 2011/12.
The latest SHMI published by the HSCIC, for Oct 11 to Sept 12,
is lower than the Dr Foster HSMR for the same period, which
may be due to a number of factors.
Dr Foster have made the following adjustments to show
differences explained by these factors:
• Adjustment for palliative care: used the SHMI observed
deaths but changed expected deaths to take account of
palliative care.
• Adjustment for in-hospital deaths:
• Removed out-of-hospital deaths from the observed
figure, and
• Reduced expected deaths to only those in-hospital.
Time series of HSMR, Sherwood Forest
FT
125
120
113
115
113
110
105
105
103
100
95
90
2008/09
2009/10
I
HSMR
125
2011/12
95% Confidence interval
Comparison of mortality measures,
Sherwood FT
120
115
115
111
110
The remaining variances are largely due to:
• The scope of deaths included (SHMI covers all deaths
whereas HSMR covers areas accounting for an average of
around 80% of deaths), and
• The definition of spells, which includes those provider(s) the
death attributes to.
2010/11
108
108
105
100
SHMI
95
SHMI adjusted
SHMI in
for palliative hospital deaths
care
only
HSMR
90
Source: Dr Foster HSMRs, HSCIC SHMI
Slide 32
Coding
Diagnosis coding depth has
an impact on the expected
number of deaths. A higher
than average diagnosis
coding depth is more likely
to collect co-morbidity
which will influence the
expected mortality
calculation.
Sherwood’s average
diagnosis coding depth for
elective patients has been
fluctuating around the same
level over the time period
shown. However, the
national average and
average of the 14 trusts in
this review has been rising
meaning Sherwood has
fallen below the national
average.
Average Diagnosis Coding Depth
Elective
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Non-elective
6
5
4
3
2
1
0
Q1 Q2 Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
2012/13
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
2008/09
2009/10
2010/11
2011/12
2012/13
National Average Diagnosis Coding Depth
National Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
14 Trusts' Average Diagnosis Coding Depth
Sherwood Forest
Sherwood Forest
Similarly, for non-elective
patients, Sherwood’s
average diagnosis coding
depth has fallen below the
national average. This is
due to a dip in the most
recent quarter.
Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012
Slide 33
Palliative care
Accurate coding of palliative care is important for
contextualising SHMI and HSMR. HSMR takes into
account that a patient is receiving palliative care, but
SHMI does not.
Sherwood Forest have made growing use of palliative
care coding (by diagnosis rather than treatment
specialty), which is slightly below the national rate.
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
Sherwood Forest
20
18
16
14
12
10
8
6
4
2
-
Jul-12
Oct-12
National
Jan-13
Apr-13
SHMI publication
Percentage of deaths with palliative care
coding
Oct-11
Jan-12
Apr-12
Sherwood Forest
Jul-12
National
Oct-12
Jan-13
Apr-13
SHMI publication
Source: Health & Social Care Information Centre – SHMI contextual indicators
Slide 34
Care Quality Commission findings
Emergency specialty groups much worse than expected
The Care Quality Commission (CQC) review mortality
alerts for each Trust on an ongoing basis. These alerts,
which indicate observed deaths significantly above
expected for specialties or diagnoses, come from different
sources based on either HSMR or SHMI. Where these
appear unexplained, CQC correspond with the Trust to
agree any appropriate action.
For Sherwood Forest, the common themes that have
arisen across the patient groups alerting since 2007 are
Sepsis and emergency care, with two alerts for
septicaemia (not in labour).
There are no common themes arising from responses to
the CQC from the Trust. The Trust put in place a sepsis
action plan to address the issues found.
Sherwood Forest developed a Mortality Work Streams
action plan in response to their elevated HSMR. A draft
was shared with CQC (Oct 2012), with some general and
some diagnosis-specific actions.
Sep 11 to Aug 12
0
Emergency specialty groups worse than expected
Sep 11 to Aug 12
3
Haematology
Cerebrovascular
Musculoskeletal
Diagnosis group alerts (2007 to date)
Alerts to CQC
5
Alerts followed up by CQC
3
Recent diagnosis group alerts pursued by CQC
Septicaemia (except in labour) (Sept 12)
Any related patient groups alerting more than once since 2007
Septicaemia (except in labour)
Source: Care Quality Commission – alerts, correspondence and findings
Slide 35
SMRs for Diagnostic and Procedure groups – Dr Foster
The standardised mortality ratio (SMR) is used to calculate the
mortality rate for diagnosis and procedure groups. This is
available for the 56 diagnosis groups that are included in the
HSMR and the 96 procedure groups that are part of the Real
Time Monitoring system.
SMRs are not yet remodelled for the year but are projected,
rebased estimates. SMRs are classified as above expected if their
lower 95% confidence limit exceeds 100 (excluding those with
fewer than four more observed deaths than expected).
From Apr 12 to Mar 13, there were six diagnosis groups and one
procedure groups with above expected SMRs in Sherwood Forest,
which may highlight potential areas for review. There were two
diagnosis groups with above expected mortality for weekend
admissions but not for weekday ones (leukaemias and congestive
heart failure, non-hypertensive), but these did not have high
SMRs overall.
CUSUM alerts show how many early warning flags arose within
the diagnosis and procedure groups during the year. These are
based on cumulative sum statistical process control charts with
99% thresholds that trigger alerts once breached. The same
groups may alert multiple times. During the year, Sherwood
Forest had two CUSUM alerts for septicaemia (except in labour)
and one each for fluid and electrolyte disorders and therapeutic
endoscopic procedures on upper GI tract. It also had alerts for
another diagnostic group and another procedure group that did
not have a high SMR.
Apr 2012 to Mar 2013
Diagnosis groups
Procedure groups
SMRs above expected
6
1
CUSUM alerts
4
2
Diagnosis groups with SMRs above expected
Acute cerebrovascular disease
Aspiration pneumonitis, food/vomitus
Fluid and electrolyte disorders
Peritonitis and intestinal abscess
Pneumonia
Septicaemia (except in labour)
Procedure groups with SMRs above expected
Therapeutic endoscopic procedures on upper GI
tract
SMR
131
144
219
295
115
154
SMR
205
Obs – Exp
deaths
25
12
10
4
44
32
Obs – Exp
deaths
11
Source: Dr Foster HSMR, SMRs, CUSUM alerts
Slide 36
Mortality – other alerts
The Health and Social Care Information Centre publish 30day mortality rates following certain types of surgery or
admission to hospital. These are not casemix adjusted, but the
rates may be compared over time. Sherwood Forest FT had
one rate improving substantially below the national average
in the data to 2010-11 (published in Feb 2013).
30-day mortality following specific surgery / admissions
Fractured hip (in top decile and improving 7% below national rate in 2010/11)
Although its overall SHMI was as expected in the period July
2011 to June 2012, Sherwood Forest had 17 more deaths than
expected in the diagnosis category that includes ICD10 code
R69.X Unknown and unspecified causes of morbidity. It had
a high level of coding in this category in July 2011 (both for
admissions and deaths), which may have affected expected
deaths. However, the use of this non-specific diagnosis code
has reduced markedly for the Trust since then.
The Trust had no other significant alerts.
Source: Health & Social Care Information Centre.
Slide 37
Patient Experience
Slide 38
Patient Experience
Overview:
Summary:
The following section provides an insight into the Trust’s patient
experience.
Sherwood was not rated ‘red’ on any of the 9 measures reviewed
within Patient Experience and Complaints.
Review Areas:
There were some minor concerns on the inpatient survey
relating to delays on discharge, some negative points around
access to research options on the cancer survey, some indication
of covering up medical errors in the patient voice data and
higher than average for factual errors in complaint responses.
Overall though, this Trust scores well on patient experience
measures.
To undertake a detailed analysis of the Trust’s Patient Experience
it is necessary to review the following areas:
•
Patient Experience, and
•
Complaints.
Data Sources:
•
Patient Experience Survey;
•
Cancer Patient Experience Survey;
•
Peoples’ Voice Summary; and
•
Complaints data.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Slide 39
Patient Experience
Patient Experience
This page shows the Patient Experience measures which are considered to be the most pertinent for this review. Further analysis,
where relevant, is detailed in the following pages.
Inpatient
PEAT : environment
Cancer survey
PEAT : food
PEAT : privacy and dignity
Friends and family test
Complaints about clinical aspects
Patient voice comments
Ombudsman’s rating
Outside expected range
Within expected range
Slide 40
Clean,
Comfortable,
Friendly Place to
Be
Building Closer
Relationships
Better
Information,
More Choice
Safe, High
Quality,
Coordinated
Care
Access and
Waiting
Inpatient Experience Survey
Sherwood Forest performs above average on survey questions relating to the length of time spent on waiting lists, information
provided on post-discharge danger signals and medication side-effects, patient noise levels at night, hospital cleanliness, and the
quality of hospital food, but below average on those relating to coherent patient discharge processes.
Overall
Length of time spent on waiting list
Alteration of admission date by hospital
Length of time to be allocated a bed on a
ward
Overall
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 41
Patient experience and patient voice
Inpatient Survey
Overall patient experience score: Inpatients 2012
The national inpatient survey 2012 measures a wide range of
aspects of patient experience. A composite ‘overall measure’
is calculated for use in the Outcomes Framework. This
measure uses a pre-defined selection of 20 survey questions
to rate the Trust on aspects including access to services, coordination of care, information & choice, relationship with
staff and the quality of the clinical environment.
•
England Average: 76.5
•
Sherwood Forest: 77.3 (average)
95
90
80
75
70
65
60
55
50
Cancer Survey
•
Of 58 Questions, 21 were in the ‘top 20%’ whilst 6 were in
the ‘bottom 20%’. Negative areas included two of the
three questions on cancer research options.
Patient Voice
•
The quality risk profiles compiled by the Care Quality
Commission collate comments from individuals and
various sources. In the two years to 31st January 2013,
there were 141 comments on Sherwood of which 57 were
negative (40%). Whilst this is a low percentage, negative
comments related to lack of professionalism, covering up
medical errors, lack of compassion, wet beds left
unattended etc.
Friends and Family Test
•
Sherwood has consistently been the highest scorer on the
Midlands and East Friends and Family test. The Trust
scored 97 in February 2013.
Sherwood Forest
85
England
average
Trusts in
this review
National
results curve
Source :Patient Experience Survey, Cancer patient experience survey
Complaints Handling
•
Data returns to the Health and Social Care Information
Centre showed 584 written complaints in 2011-12. The
number of complaints is not always a good indicator,
because stronger trusts encourage comments from
patients. However, central returns are categorised by
subject matter against a list of 25 headings. For this
Trust, 51% of complaints related to clinical treatment, in
line with national average of 47%.
•
A separate report by the Ombudsman rates the Trust as
A-rated for satisfactory remedies and low-risk of noncompliance, although the report noted that it is likely to
be downgraded at the next review. It is higher than
average on factual errors in responses and there was one
case of service failure potentially indicating wider
organisational failure.
Slide 42
Safety and workforce
Slide 43
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.
Sherwood is rated ‘red’ on two of the safety measures:
medication errors and pressure ulcers.
Review Areas:
To undertake a detailed analysis of the Trust’s Safety and
Workforce it is necessary to review the following areas:
•
General Safety;
•
Staffing;
•
Staff Survey;
•
Litigation and Coroner; and
•
Analysis of patient safety incident reporting.
Data Sources:
•
Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;
•
Safety Thermometer, Apr – Mar 2013;
•
Litigation Authority Reports;
•
GMC Evidence to Review 2013;
•
National Staff Survey 2011, 2012;
•
2011/12 Organisational Readiness Self-Assessment (ORSA);
•
National Training Survey, 2012; and
•
NHS Hospital & Community Health Service (HCHS), monthly
workforce statistics.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
It has a rate of medication error that is more then three standard
deviations from the mean although it should be noted that there
is no desired direction on this indicator. Throughout the last 12
months, Sherwood’s new pressure ulcer rate has been
consistently below the national average. However, the total
pressure ulcer prevalence rate has been above the national
average in more recent months and may highlight an area of
review.
259 incidents were reported as ‘moderate, severe or death’ from
April 11 to March 12, while two ‘never events’ have been recorded
at the Trust since 2009.
Sherwood is a net contributor to the Clinical Negligence Scheme
for Trusts and only had two flags on the Rule 43 Coroners’
reports.
The Trust flagged red 11 times for the workforce measures. Most
notably the Trust has high sickness absence rates and medical
staff vacancy rates. It also spends a greater percentage of its
total expenditure on agency staff compared with the regional
average.
Slide 44
Safety
This page shows the safety measures which are considered to be the most pertinent for this review. Further analysis, where relevant,
is detailed in the following pages.
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
259
Number of ‘never events’ (2009-2012)
2
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 45
Safety Analysis
The Trust has reported more patient safety incidents
than similar trusts. Organisations that report more
incidents may have a stronger and more effective safety
culture. Sherwood has a rate of 7.4 for its patient safety
incident reporting per 100 admissions.
Sherwood Forest has rate of medication error that is
more then three standard deviations from the mean
although it should be noted that there is no desired
direction on this indicator.
Rate of reported patient safety incidents per 100 admissions (April –
September 2012)
Sherwood Forest
Median rate for medium acutes
7.4
6.7
Source: incidents occurring between 1 April 2012 to 30 September
2012 and reported to the National Reporting and Learning System
Rate of medication errors per 1,000 bed days (October 2011 – March
2012)
Sherwood Forest
Mean rate for all acute
11.06
7.17
Source: Acute Trust Quality Dashboard Winter 2012/13
Slide 46
Safety Incident Breakdown
Since 2009, two ‘never events’ have occurred at Sherwood Forest, classified as
that because they are incidents that are so serious they should never happen.
The patient safety incidents reported are broken down into five levels of harm
below, ranging from ‘no harm’ to ‘death’. 79% of incidents which have been
reported at Sherwood Forest have been classed as ‘no harm’, with 16% ‘low’,
4% ‘moderate’, 0.1% ‘severe’ and three occurrences classified as ‘death’.
Never Events Breakdown (2009-2012)
Retained foreign object post-operation
2
Total
2
Source: Freedom of information request, BBC http://www.bbc.co.uk/news/health-22466496
When broken down by category, the most regular occurrences of patient
incident at Sherwood Forest are in ‘patient accident’ and ‘medication’.
Breakdown of patient
incidents by degree of harm
5000
Breakdown of patient incidents by incident type
Medical device / equipment
4502
104
All others categories
4500
142
Consent, communication,…
4000
Infrastructure
3500
3000
2500
2000
1500
937
1000
Low
Access, admission, transfer,…
277
Implementation of care and…
295
Clinical assessment
429
Documentation
442
Moderate
Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12
A definition of serious harm is given in the Appendix.
656
Medication
3
3
Severe
Death
0
No Harm
254
Treatment, procedure
253
500
167
876
Patient accident
2056
0
500
1000
Source: National Patient Safety Agency (NPSA) . Apr 11 – Mar 12
1500
2000
2500
Slide 47
Pressure ulcers
New pressure ulcers prevalence
Total pressure ulcers prevalence
60
This slide outlines the total
number of pressure ulcers and
the number of new pressure
ulcers broken down by
category for the last 12 months.
Due to the effects of seasonality
on hospital acquired pressure
ulcer rates, the national rate
has been included which allows
a comparison that takes this in
to account. This provides a
comparison against the
national rate as well as the 14
trusts selected for the review.
Throughout the last 12 months,
Sherwood’s new pressure ulcer
rate has been consistently
below the national average.
However, the total pressure
ulcer prevalence rate has been
above the national average in
more recent months and may
highlight an area of review.
10
9
8
7
6
5
4
3
2
1
-
1.3%
1.3%
1.4%
1.4%
0.8%0.8%
1.0%
0.8%
0.7%
0.6% 0.8%
0.5%
8.0%
7.1%
50
5.8%6.0%
1.2%
1.0%
9.0%
7.8%
1.6%
5.8%
6.0%
5.9%
40
5.5% 6.2%6.1% 7.0%
6.0%
6.0%
5.0%
4.0%
30
4.0%
0.6%
0.3%
0.4%
0.2%
0.2%
0.0%
20
3.0%
2.0%
10
1.0%
-
Category 2
Category 3
Category 4
Rate
0.0%
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
617
596
613
591
604
613
620
666
667
629
666
654
6
8
5
5
4
3
1
5
2
8
9
4
Trust new pressure ulcer rate
Selected 14 trusts new pressure
ulcer rate
1.0%
1.3%
0.8%
0.8%
0.7%
0.5%
0.2%
0.8%
0.3%
1.3%
1.4%
0.6%
1.4%
1.5%
1.4%
1.5%
1.5%
0.9%
1.0%
1.1%
0.9%
1.1%
1.0%
1.2%
National new presseure ulcer rate
1.7%
1.7%
1.5%
1.5%
1.4%
1.3%
1.2%
1.2%
1.2%
1.3%
1.3%
1.3%
Total pressure ulcer prevalence percentage
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
617
596
613
591
604
613
620
666
667
629
666
654
36
36
48
34
43
37
25
39
37
38
41
40
Trust total pressure ulcer rate
Selected 14 trusts total pressure
ulcer rate
5.8%
6.0%
7.8%
5.8%
7.1%
6.0%
4.0%
5.9%
5.5%
6.0%
6.2%
6.1%
6.4%
6.2%
6.5%
7.0%
6.3%
5.5%
5.4%
5.9%
5.8%
6.0%
5.7%
6.2%
National total pressure ulcer rate
6.8%
6.7%
6.6%
6.1%
6.0%
5.5%
5.4%
5.3%
5.2%
5.4%
5.6%
5.3%
Number of records submitted
Trust total pressure ulcers
Source: Safety Thermometer Apr 12 to Mar 13
Slide 48
Litigation and Coroner
Clinical negligence payments
Clinical negligence scheme analysis
2009/10
Sherwood is a net contributor to the Clinical Negligence
Scheme for Trusts. Contributions to the scheme have
exceeded payouts to litigants in each of the last 3 years, and
in total by £3.8m.
Coroners’ Rule
Coroners’ rule 43 reports flagged two items:
•
•
2010/11
2011/12
Payouts (£000s)
3,004
1,865
2,519
Contributions (£000s)
3,257
3,655
4,227
Variance between
payouts and contributions
(£000s)
253
1,790
1,708
To consider a review of the hospital protocol on
procedures to be followed when police are called to the
hospital to deal with an incident and to ensure that
staff and police are aware of this protocol and are
trained in its application; and
To consider introducing a policy which ensures any
material changes of opinion between a radiologist's
verbal and written report is communicated to the
relevant clinician at the time the written report is
made.
Source :Litigation Authority Reports
Slide 49
Workforce
Staff Surveys and
Deanery
Workforce Indicators
This page shows the workforce measures which are considered to be the most pertinent for this review. Further analysis, where
relevant, is detailed in the following pages.
WTE nurses per bed day
Sickness absence- Overall
Medical Staff to Consultant Ratio
2.64
Spells per WTE staff
Sickness absence- Medical
Nurse Staff to Qualified Staff Ratio
1.81
Vacancies –medical
Sickness
absence
-Nursing
staff
Staff to Total Staff Ratio
Outcome
1 (R17)
Respecting
and involving eNon-clinical
who u
Vacancies - Non-medical
Consultant appraisal rates
Agency spend
Response Rate from National Staff
Survey 2012
Staff Engagement from NSS 2012
Training Doctors – “undermining”
indicator
se services
0.36
Sickness absence - Other staff
Consultant Productivity (FTE/Bed Days)
348
Staff leaving rates
Nurse Hours per Patient Bed Day
6.61
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 50
General Medical Council (GMC) National Training Scheme Survey 2012
Gastroenterology
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
General Practice
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 outlier displayed, Obstetrics and Gynaecology had an additional green outlier for regional teaching.
Green outlier
Within expected range
Red outlier
Slide 51
Workforce Analysis
The Trust has a patient spells per whole time equivalent rate of 23, which is
slightly below average capacity in relation to the other trusts in this review
and nationally.
Number of FTEs (Dec 11-Nov 12 average)
6,648
Agency Staff (2011/12)
The data shows that the Trust’s agency staff costs, as a percentage of total
staff costs, are higher than the median within the region. In addition, the
data illustrates that the Trust not only has a lower joining rate than the
regional median, but also a lower leaving rate.
Sherwood Forest has a consultant appraisal rate of 98.7% which is the
highest of the trusts under review.
National Average
1.52
1.96
Spells per WTE for Acute Trusts
100%
45
Median within
Region
£6.9m
4.4%
4.2%
(Sep 11 – Sep 12)
Sherwood
Forest
East Midlands
SHA Median
Joining Rate
5.6%
5.9%
Leaving Rate
5.4%
6.7%
Source: Health and Social Care Information Centre (HSCIC)
Source: Acute Trust Quality Dashboard, Methods Insight
50
Percentage of
Total Staff Costs
Staff Turnover
WTE nurses per bed day December 2012
Sherwood Forest
Sherwood Forest
Expenditure
Sherwood
Consultant appraisal rate 2011/12
Forest:
98.7%
80%
Spells per WTE
40
35
30
25
Sherwood
Forest
23
60%
40%
20
15
20%
10
5
0%
0
Trusts covered by review
All Trusts
Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics
Trusts covered by review
All other trusts
Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)
Data based on the appraisal year from April 2011 to March 2012
Slide 52
Slide 52
Workforce Analysis continued…
Sherwood Forest’s total sickness absence rate is
higher than the East Midlands Strategic Health
Authority average and the national average. This
pattern of exceeding the national average is
replicated in the more granular medical, nursing,
and other staff categories.
Sherwood Forest has a medical staff to consultant
ratio that is above the national average, although
its nurse staff to qualified staff ratio is below the
average for all English trusts. The Trust’s
registered nurse hours to patient day ratio is also
below the national mean.
The Trust’s consultant productivity rate is below
the national average.
The three month vacancy rates for medical staff is
2.3%, which is above the national average rate of
1.4%.
3 month Vacancy Rates by
Staff Category
Sherwood
Forest
(March 2010)
National
Average
Medical Staff
2.3%
1.4%
Non-medial Staff
0.0%
0.4%
Source: The Health and Social Care Information Centre Non-Medical
Workforce Census (Sept 2009), Vacancies Survey March 2010
Workforce indicator calculations are listed in the Appendix.
Sickness Absence Rates
(2011-2012)
Sherwood Forest
East Midlands SHA
Average
National Average
4.60%
4.33%
4.12%
All Staff
Source: Health and Social Care Information Centre (HSCIC)
Sickness Absence Rates by Staff Category
(Dec 12)
Sherwood Forest
National Average
Medical Staff
1.8%
1.3%
Nursing Staff
5.2%
4.8%
Other Staff
6.5%
4.7%
Sherwood Forest
National Average
Medical Staff to Consultant Ratio
2.64
2.59
Nurse Staff to Qualified Staff Ratio
1.81
2.50
Non-Clinical Staff to Total Staff
Ratio
0.36
0.34
Registered Nurse Hours to Patient
Day Ratio *
6.61
8.57
Source: Acute Trust Quality Dashboard, Methods Insight
Staff Ratios
Source: Electronic Staff Record (ESR) April 13
* Patient Bed Days Data: Healthcare Evaluation Data Apr 12 – Mar 13
Staff Productivity
Consultant Productivity
(Spells/FTE)
Source: Electronic Staff Record (ESR) April 13
Sherwood Forest
National Average
348
492
Slide 53
Workforce Analysis continued…
National Staff Survey results
Sherwood Forest’s response rate to the
staff survey is at the national average
rate. The staff engagement score is
below average when compared with
trusts of a similar type in 2012.
Sherwood Forest is significantly below
the national average for the percentage
of staff who would recommend the
organisation as a place to work, and
lower than national average for care of
patients as a top priority. For the
question on standard of care, the
Trust’s score has fallen substantially
but is still above national average.
Sherwood
Forest
2011
Average for all
trusts
2011
Sherwood
Forest
2012
Average for all
trusts
2012
Response rate
49%
50%
50%
50%
Overall staff engagement
3.71
3.62
3.65
3.69
Care of patients/service
users is my organisation’s
top priority
59%
69%
61%
63%
I would recommend my
organisation as a place to
work
50%
52%
50%
55%
If a friend or relative needed
treatment, I would be happy
with the standard of care
provided by this organisation
74%
62%
62%
60%
Source: National Staff Survey 2011, 2012
Slide 54
Deanery
The Trust is not currently subject to enhanced monitoring. While the National Training Survey and Deanery reports did not indicate
any specific concerns, doctors in training reported more patient safety concerns than the average. These concerns were shared with
the Deanery.
National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12
Anaesthetics and Emergency Medicine were the programmes with the most below outliers between 2010 and 2012. Trauma and
Orthopaedic Surgery was the programme with the most above outliers during the same period. Only one above outlier was recorded
in 2012, much less that the previous years.
NTS 2012 Patient Safety Comments
12 doctors in training commented, representing 7.69% of respondents. This was higher than the national average of 4.7%. Their
concerns, which were raised in relation to specific training posts, and may apply to a single or multiple departments, related to:
•
Lack of staff (noted that this had been addressed in acute medicine by appointment of acute medical consultants;
•
Lack of beds in critical care unit;
•
Lack of robust handover and continuity of care;
•
Lack of weekend cover; and
•
Locum cover of variable ability.
Source: GMC evidence to Review 2013
Slide 55
Deanery Reports
East Midlands Healthcare Workforce Deanery reported one concern in 2012 for the Sherwood Forest Hospitals NHS Foundation
Trust: over half of the doctors in training in General Surgery felt that they were regularly forced to cope with problems beyond their
experience or competence, with some reporting that they were required to take consent for procedures they did not fully understand.
Monitored under the response to concerns process?
Undermining
The trust is not subject to increased monitoring at the time of the
report. The GMC visited the Kings Mill Hospital in January 2013 as
part of their series of Emergency Medicine checks. The resulting
report is still in draft, but no serious concerns were raised as part of
the visit.
For doctors undertaking training at Sherwood, the Trust has a
score on the National Training Survey on undermining of 94.6
which is above the national average of 94.
Mean Score on 'Undermining'
105
100
95
90
Sherwood
Forest
awaiting
85
80
Source: GMC evidence to Review 2013
Trusts covered by review
All other non specialist trusts
Slide 56
Source: National Training Survey 2012
Clinical and operational
effectiveness
Slide 57
Clinical and Operational Effectiveness
Overview:
The following section provides an insight in to the Trust’s clinical
and operational performance based on nationally recognised key
performance indicators.
Review Areas:
To undertake a detailed analysis of the Trust’s clinical and
operational performance it is necessary to review the following
areas:
•
Clinical Effectiveness;
•
Operational Effectiveness; and
•
Patient Reported Outcome Measures (PROMs) for the review
areas.
Data Sources:
•
Clinical Audit Data Trust, CQC Data Submission;
•
Healthcare Evaluation Data (HED), Jan – Dec 2012;
•
Department of Health;
•
Cancer Waits Database, Q3, 2012-13; and
•
PROMs Dashboard.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
Summary:
In the National Clinical Audit for Neonatal intensive and special
care (NNAP), a key measure of effectiveness is the percentage of
women receiving ante-natal steroids. On this measure,
Sherwood is at the lower end of the distribution, and some way
short of the national average.
Sherwood Forest sees 94.7% of A&E patients within 4 hours
which is slightly below the 95% target level. Performance has
been decreasing since July 2012.
93.8% of patients are seen within the 18 week target time which
is above the target level. The Trust’s performance has varied on
this measure between April 2012 and February 2013, but has
recently risen just above the target rate.
Sherwood Forest’s crude readmission rate is average for
readmission rates of the trusts in the review as well as
nationally, at 11.3%. The standardised readmission rate shows
the Trust to be within the expected range. It has an average
length of stay of 4.7 days, which is shorter than the national
mean average of 5.2 days.
The PROMs dashboard shows that Sherwood Forest was within
the 99.8% control limits in all three years for all measures.
Slide 58
Clinical and Operational Effectiveness
Clinical
effectiveness
This page shows the Clinical and Operational Effectiveness measures which are considered to be the most pertinent for this review.
Further analysis, where relevant, is detailed in the following pages.
Neonatal – women receiving steroids
Coronary angioplasty
Heart failure
Adult Critical care
Peripheral vascular surgery
Lung cancer
Diabetes safety/ effectiveness
Carotid interventions
Bowel cancer
PROMS safety/ effectiveness
Acute MI
Hip fracture - mortality
Joints – revision ratio
Acute stroke
Severe trauma
Elective Surgery
Cancelled Operations
Emergency readmissions
PbR Coding Audit
Operational
Effectivenes
s
RTT Waiting Times
Cancer Waits
A&E Waits
PROMs
Dashboard
Hip Replacement EQ-5D
Knee Replacement EQ-5D
Varicose Vein EQ-5D
Hip Replacement OHS
Knee Replacement OKS
Outcome 1 (R17) Respecting and involving people who use services
Groin Hernia EQ-5D
Outside expected range
Within expected range
Slide 59
Clinical Effectiveness: National Clinical Audits
The National Clinical Audits provide a valuable source of evidence on clinical effectiveness. These two tables show the
clinical audit results considered as part of this review.
Clinical Audit
Diabetes
Elective Surgery
Safety Measure
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 60
Clinical Effectiveness: Clinical Audits
Proportion of women receiving ante-natal steroids (level 2)
In the National Clinical Audit for Neonatal intensive and
special care (NNAP), a key measure of effectiveness is the
percentage of women receiving ante-natal steroids.
On this measure, Sherwood is at the lower end of the
distribution, and some way short of the national average.
Sherwood
Slide 61
Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times
Sherwood Forest sees
94.7% of A&E patients
within 4 hours which
is slightly below the
95% target level. The
time series graph
shows a decreasing
trend from July 2012.
93.8% of patients are
seen within the 18
week target time
which is above the
target level. The time
series shows that
Sherwood Forest has
been performing near
the target rate and
has risen just above
the target rate from
December 2012.
100%
95%
90%
85%
Sherwood Forest 4 Hour A&E Waits
Attendances (Thousands)
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
Sherwood
Forest
94.7%
12
98%
97%
96%
95%
94%
93%
92%
91%
90%
89%
88%
10
8
6
4
2
0
80%
75%
Number of patients seen within 4 hours
70%
Patients Not Seen
Trusts Covered by Review
All Trusts
A&E Target 95%
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
100%
95%
Referral to Treatment (Admitted)
Sherwood
Forest
93.8%
Seen within 4 hours (%)
Source: Healthcare Evaluation Data (HED). Jan – Dec 12
Sherwood Forest Referral to Treatment
Performance
100%
96%
92%
88%
90%
84%
80%
85%
76%
72%
80%
75%
Trusts Covered by Review
Source: Department of Health. Feb 13
All Trusts
RTT Target 90%
Referral to Treatment Rate
RTT Target 90%
Source: Department of Health. Apr 12 – Feb 13
Slide 62
Operational Effectiveness – Emergency Readmissions and Length of Stay
The standardised
readmission rate, most
importantly, accounts for
the trust’s case mix and
shows Sherwood Forest is
statistically within the
expected range.
Sherwood Forest’s average
length of stay is 4.71 days,
which is shorter than the
national mean average of
5.2 days.
25%
Crude Readmission Rate
Sherwood Forest’s crude
readmission rate is among
the average for readmission
rates of the trusts in the
review as well as nationally,
at 11.3%.
Standardised 30-day Readmission
Rate
Crude Readmission Rate by Trust
20%
15%
Sherwood
Forest
11.3%
10%
5%
Sherwood Forest
Selected trusts Outside
Selected trusts w/in Range
0%
Trusts Covered by Review
All Trusts
Average Length of Stay by Trust
10
9
Spell Duration (Days)
Readmission rates may
indicate the
appropriateness of
treatment offered, whilst
average length of stay may
indicate the efficiency of
treatment.
8
7
6
Sherwood
Forest
4.71
5
4
3
2
1
0
Trusts Covered by Review
Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12
Sherwood
All Trusts
Slide 63
PROMs Dashboard
The PROMs dashboard shows that Sherwood Forest
was within the 99.8% control limits in all three years
for all measures.
Hip Replacement EQ-5D
20
England Average
15
Sherwood Forest
10
Upper Control Limit
5
Lower Control Limit
2
20
11
/1
1
20
10
/1
20
09
/1
0
0
Source: PROMs Dashboard and NHS Litigation Authority
Slide 64
Leadership and
governance
Slide 65
Leadership and governance
Overview:
Summary:
This section provides an indication of the Trust’s governance
procedures.
Following Monitor’s intervention in October 2012, there were a
number of changes to the Trust Board, including the
appointment of an interim CEO and Chairman, and a number of
new Non-Executive Directors. The Trust has now recruited
permanently to these posts, the new permanent CEO, Paul
O’Connor, and the permanent Chairman, Sean Lyons will
commence on 10 June 2013.
Review Areas:
To provide this indication of the Trust’s leadership and
governance procedures we have reviewed the following areas:
•
Trust Board;
•
Governance and clinical structure; and
•
External reviews of quality.
Data Sources:
•
Board and quality subcommittee agendas, minutes and
papers;
•
Quality strategy;
•
Reports from external agencies on quality;
•
Board Assurance Framework and Trust Risk Register; and
•
Organisational structures and CVs of Board members.
All data and sources used are consistent across the packs for the 14 trusts included in this review.
The Board sub-committee with responsibility for quality
governance is the Quality & Clinical Governance Committee.
This sub-committee is chaired by a non-executive director with a
clinical background.
A recent review by the CQC has identified moderate concerns in
relation to outcome 16 (assessing and monitoring the quality of
service provision).
Key risks for the Trust relate to loss of trust and confidence
leading to a reputational risk, quality governance, board
stability and leadership, financial performance (including cost
improvement programmes), use of agency and temporary staff,
and staff sickness.
Slide 66
Leadership and governance
This page shows the latest rating against regulatory standards, the items rated ‘red’ or ‘amber’ below are discussed in more detail in
the following pages.
Leadership and
governance
Monitor governance risk rating
Monitor finance rating
CQC Outcomes
1
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 67
Leadership and governance
Trust Board
Following Monitor’s intervention in October 2012, there were a number of changes to the Trust Board, including the appointment of an interim CEO and
Chairman, and a number of new Non-Executive Directors. The Trust has now recruited permanently to these posts, the new permanent CEO, Paul
O’Connor, and the permanent Chairman, Sean Lyons will commence on 10 June 2013.
Governance and clinical structures
The Trust Board receives assurance from five sub-committees; the Audit Committee, Clinical Governance & Quality Committee, Risk & Assurance
Committee, Finance & Performance Committee, and the Remuneration & Nomination Committee.
The Clinical Governance & Quality Committee is the sub-committee responsible for provided assurance in relation to quality. This sub-committee has a
clinically experienced Non-Executive Director chair (who reports directly to the Board) and another Non-Executive member.
Strategy
The Trust currently does not have a separate quality strategy, but quality goals and priorities have been integrated within the annual plan and will have
a separate section within the new Trust strategy that is being developed. Each year the Trust identifies a small number of quality goals covering safety,
clinical outcomes and patient experience. These reflect local and national priorities and are decided through a series of engagement processes including
survey monkey, meetings with Governors and communication with local CCGs.
External reviews and regulation
Monitor amended the Financial risk rating for the Trust from 3 to 1 in August 2012 due to a deterioration in the Trust's financial position. On 5 October
2012, Monitor issued the Trust with a notice of exercise of intervention powers under Section 52 of the National Health Services Act (2006). Monitor
found that the Trust was in breach of its terms of authorisation, in particular:
Condition 2, which requires the Trust to exercise its functions effectively, efficiently and economically; and
Condition 5, which requires the Trust to ensure the existence of appropriate arrangements to provide representative and comprehensive governance.
A recent review by the Care Quality Commission found that the Trust was not meeting one outcome; the services should have quality checking systems to
manage risks and assure the health, welfare and safety of people who receive care (outcome 16). This was found to have a moderate impact.
The Trust has also had a number of external reviews, which are summarised in the following pages.
A diagram of board members and committee structure can be found in the Appendix.
Slide 68
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks
Trust response
Loss of trust and confidence leading to a reputational risk
On 5 October 2012, Monitor placed the Trust in significant Breach of its
Terms of Authorisation (Licence) for failure on Governance and Finance.
The Trust had received lots of analysis from Management Consultants but
had failed to deliver decisions and actions. Governance, i.e. Corporate and
Quality, were identified as not fit for purpose by a recent PwC Board and
Quality Governance Review (Document 5). The Board were not sighted on
the right information or risks related to quality of care and treatment. This
resulted in a number of serious incidents (e.g. under-reporting of
oestrogen status) which were not only detrimental to the care and welfare
of patients, but impacted upon the reputation of the trust. This led to a
failure in trust and confidence of not only our patients or service users, but
also Regulators and Governors.
•
•
Board stability and leadership
In recent years membership of the Board has been unstable. There have
been five Chief Executives, including interim appointments since
November 2009. Many positions were held on an interim basis. This led to
a lack of strategic planning (including a Board Quality Strategy), little
engagement with stakeholders, and disempowered clinical staff.
The current interim Chairman and Chief Executive have implemented a
number of actions to provide stabilisation, whilst also improving the
effectiveness of the way the Board operates. This has included recruiting:
• A substantive chairman
• A substantive, experienced CEO
• 4 experienced co-opted NEDs, prior to substantive appointments
• 5 substantive NED advisors, including one from a clinical background
• A functioning PMO
Supported by improved communications and engagement with
commissioners, Governors and clinicians.
•
•
•
•
Quality and patient safety is now the first item on each Board agenda.
Trust reports openly and accurately to Monitor and CQC to rebuild
confidence and trust.
The Trust has developed an integrated action plan with agreed
objectives. This action plan is reviewed through the Monitor Review
meeting.
Four experienced interim NED advisors were co-opted in November
2012, ahead of the substantive appointments from May 2013.
A new Council of Governors has been re-elected, due to commence in
June 2013. Lead Governor to be identified, with an
induction/development plan for all governors.
An improved relationship with CCGs. CCG Chief Operating Officer
chairs a combined CCG/Trust Mortality Group to address wider issues
contributing to high HSMR.
Slide 69
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks
Trust response
Quality governance
Management Consultant finding (October 2012) – Whilst the Trust has
established governance structure, a number of significant deficiencies in
the operation of governance at Board, Divisional and Service level was
identified. Ownership of, and engagement in, governance by Trust staff
was identified as insufficient. Important governance processes and
activities had not operated in a systematic manner. As a result, there was
inadequate anticipation and management of risk throughout the Trust.
Actions (Approved by the Board December 2012):
• The organisation has been turned around with clinicians leading,
supported by management and devolved decision making, within a
clearer framework of accountability and control. Experienced
governance and risk management expertise has been utilised to
develop and strengthen governance and risk management processes.
• The organisation has reformed the Clinical Governance Committee as
a Board Sub-Committee chaired by a NED. The terms of reference for
the Committee have been reviewed. This Committee primarily focuses
on assurance and clinical risk.
• The Risk Management Committee has been disbanded and reformed,
with responsibility for reviewing the BAF and high rated risks escalated
from Divisions transferred to an Executive Group which feeds actions
into the Board and down to Divisions.
• Roles and responsibilities in relation to governance have been clarified
and management of risks is now clearly being established.
• The Trust has successfully appointed an Associate Medical Director for
Patient Safety and a new Patient Safety Manager to drive the harms
and mortality improvement plan.
• A governance support unit is being established with a Head of
Governance.
The operation of the Board, and its Sub-Committees, was too operationally
focused with a lack of focus on strategic direction or decision making.
Board level scrutiny of Divisional and Service level performance was
ineffective. Clinical engagement and leadership, particularly at Divisional
level, was identified as weak, leading to a disproportionate focus on
financial and operational performance and a lack of scrutiny over quality
and safety related aspects of performance.
The Trust did not operate with an adequate focus on managing risks to
quality and performance. Appropriate risk management processes and
policies existed, but were not being used in a consistent or an effective
way. Discussion about risks and the management of risks did not happen
as frequently as expected. The Board were therefore not assured fully in
respect of risks or the management of risk.
Slide 70
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks
Trust response
Financial Performance
Over the past few years the Trust track record on delivery had been
considered strong, however,2011/12 was the first year of full PFI charges.
At the end of 2011/12 the Trust, excluding the impact of impairments,
reported a deficit of £6.2m (£4.2m surplus including impairments).This was
the first reported loss since authorisation as a Foundation Trust. For
2012/13 the Trust Financial plan indicated a £12.6m deficit in line with the
continued PFI pressures and resulting deterioration in the underlying
financial position of the Trust. The plan made clear the Trust would be an
FRR1 during the 2012/13 year. At the time of Monitor’s intervention in
October 2012 a deficit of £22m was forecast.
•
For the year ending 2012/13 the Trust has recorded a (subject to audit)
£15.1m deficit. Whilst this is adverse to plan, it is a substantive
improvement on October 2012 forecast and reflects the in-year work
undertaken with commissioners to contribute to ensuring ongoing viability
of the Trust. Commissioners have actively engaged with the Trust during
the year to support service redesign and cost improvement
programmes and this is reflected in the outturn position.
•
•
The Board of Directors has taken steps throughout the year to continue
to monitor and prepare prudent, risk assessed financial plans, for the
year ahead. This includes reconciliation to the CCG future funding
assumptions. Work continues with CCGs to understand and manage
future changes to commissioning intentions. The steps taken to mitigate
can be given if required.
Development of a detailed 2013/14 cost improvement plans has
continued in year with the continuing support of external advisers and
the appointment of PMO additional resource.
The Trust has ensured that Monitor have been kept closely informed of
our future financial and compliance risks. The Trust meets with Monitor
to share our plans, outturn, future risk and to discuss the steps and
actions to mitigate forward risks.
As planned, the Trust at Q4 of 2012/13 had a financial risk rating with
Monitor of 1, due to the operating deficit and associated impact on cash,
and the forward plan anticipates a deficit position and similar rating
through 2013/14. The Board recognises that whilst this will continue to
place the Trust in breach of its terms of authorisation, it acknowledges that
the Trust requires a viable medium/long term solution, with full
engagement from our commissioners and partners.
Slide 71
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks
Trust response
Financial Performance continued…
The Board have been fully sighted of its need to “put its house in order” i.e.
do everything it can to improve performance, efficiency and attract
profitable business, to close the financial gap. The Board has continued to
invest in services and initiatives that drive quality. This includes the
purchase of e.g. ‘Vitalpac’ (an electronic monitoring system), additional
clinical staff, governance roles and investment in new wards.
Cost Improvement Programme
The Trust has not had a good track record in delivering significant cost
improvements and so has utilised specialist external support to refine its
CIP approach for 2012/13 and put in place better capability and assurance
processes to be used into the future. The in-house team has been
strengthened as a result of this work and much clearer and transparent
assurance information is provided to the Board of Directors. The CIP
Programme Board is chaired by the CEO and CIP delivery forms part of
the refreshed performance management arrangements being put in place
across the Trust. This will help ensure delivery and reporting and allow the
early identification and development of future years programmes.
Detailed above under ‘Financial Performance’,
Slide 72
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks
Trust response
Use of agency and temporary staffing
The 2012/13 activity contract was based upon PCT growth assumptions.
The Commissioners planned for a 1.2% growth in Non-Elective activity in
2012/13. The Trust has seen a significant higher growth rate. Despite this,
non-elective activity growth could not have been anticipated to the extent
experienced. Due to the earlier growth assumptions the Trust utilised
temporary additional wards, leading to a reliance on agency staff
throughout the year.
•
The increased pressure on beds meant additional unplanned ward
capacity has been made available throughout the year at premium cost.
The estimate for the unplanned capacity for 2012/13 has cost the Trust in
excess of £2 million. The Trust isnow spending £0.55m more each month
on pay than they were a year ago. This increase in run rate is largely
driven by the use of premium rate variable pay for medicine and nursing.
Medical agency and locum spend to cover vacancies has increased by
£0.10m per month since March 2012 and is now averaging £0.52m per
month. Nursing agency spend has increased by £0.04m per month since
March 2012 and is now running at £0.40m per month. This increased
reliance on agency has both quality and safety implications for the Trust.
•
•
•
•
•
The Trust has negotiated a realistic activity contract, based upon
2012/13 outturn. This will enable the Trust to recruit to substantive
posts and reduce its heavy reliance on agency support.
Focused budget management within Divisions and Service Lines.
The Trust has funded the additional Winter Wards, which enables
substantive recruitment to key posts. Trust budgets have been funded
at outturn (March 2013/14) to support investment in staff for high
acuity/dependency areas.
Dementia staffing increased to reduce reliance on agency for 1:1 care.
Nurse bank strengthened to reduce reliance on agency staff.
Preferred agency provider identified to support quality of staff
commissioned.
Slide 73
Top risks to quality
The table includes the top risks and significant challenges to quality identified by the Trust.
Trust identified risks
Trust response
Sickness and absence
Trust absence rates for 2012/13 was 4.73%, for short term 2.45% and long
term 4.29%.Over the year, short term absence accounts for 52% of
absence, whilst long term accounts for 48% of total absence. Since the
previous year, increases in absence have occurred in Ancillary,
Administrative &Clerical, Scientific & Professional & Technical & Other
staff groups; however decreases were observed in Medical & Dental,
Allied Health Professionals. Areas that remained stable against 11/12
include Registered and Unregistered Nursing.
Considerable effort is being taken to ensure that absence is driven down
and reduced to an acceptable level, minimising the potential impact it can
have on patient care and quality and decreasing the financial impact. The
Trust has formed an action group to directly address the issues which may
be contributing to the high absence rates and implement the necessary
improvements required.
Currently, the Trust absence is considered to be high against other Trusts
in the local region and is having a direct impact on cost; the direct cost of
paying staff whilst absent on sick leave was £4.70m for financial year
12/13 and would have contributed to a proportion of the variable pay
spend of £22.17m (total spend 12-13).
Slide 74
Leadership and governance
External reviews
A recent CQC inspection of Kings Mill Hospital in October 2012 considered the Trust’s compliance with two outcomes (care and welfare of
people who use services (outcome 4) and assessing and monitoring the quality of service provision (outcome 16)). This review focused on
the breast care unit, in response concerns that the treatment of women with breast cancer had been based on incorrect test results .
The Trust was found to be compliant with outcome 4, but moderate concerns were raised in relation to outcome 16.
The report concluded that “The provider had systems in place to identify, assess and manage risks to the health, safety and welfare of
people using the service and others. However, these systems were not sufficiently robust to ensure that governance arrangements were
managed effectively and in a timely fashion.”
In response to Monitor’s intervention, the Trust commissioned a number of external reviews, including reviews of quality governance,
board governance, mortality governance and a diagnostic review of the Trust’s financial position.
A review of quality governance in November 2012 concluded that the Trust had scored 13.0 against Monitor’s Quality Governance
Framework (aspirant foundation trusts much achieve a score of 3.5 or lower to be authorised as foundation trusts). The Trust has taken a
number of actions since this report to strengthen quality governance arrangements; many of these actions are ongoing.
In addition in November 2012, the Trust commissioned an external review of mortality.
Cost Improvement Programme
The finance paper presented to the Board in April 2013 states that cost improvement programmes of £7.7m (3.2% of operating
expenditure) were achieved against a plan of £14.0m. The report also noted that for 2013/14, “The value of savings identified to date is still
short of the in-year Cost Improvement Programme savings target.”
Each CIP is developed by the divisions with sign off from clinical leadership (Clinical Director, Matron and General Manager) within the
divisions. The planned CIPs are then approved by the Medical Director and Director of Nursing, prior to Executive Team and Trust Board
sign off.
Slide 75
Appendix
Slide 76
Trust Map – King’s Mill Hospital
Source: Sherwood Forest Hospitals NHS Foundation Trust website
Slide 77
Trust Map – Newark Hospital
Source: Sherwood Forest Hospitals NHS Foundation Trust website
Slide 78
Serious harm definition
A serious incident requiring investigation is defined as an incident that occurred in relation to NHS-funded services and care resulting in
one of the following:
•
Unexpected or avoidable death of one or more patients, staff, visitors or members of the public;
•
Serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention,
major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological
harm (this includes incidents graded under the NPSA definition of severe harm);
•
A scenario that prevents or threatens to prevent a provider organisation's ability to continue to deliver healthcare services, for
example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT
failure;
•
Allegations of abuse;
•
Adverse media coverage or public concern about the organisation or the wider NHS; and
•
One of the core set of "Never Events" as updated on an annual basis.
Source: UK National Screening Committee
Slide 79
Workforce Indicator Calculations
Indicator
WTE nurses per bed day
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 80
Board members
Board Members update (29th April, 2013):
-
Five new Non-Executive Directors members appointed:
-
Ray Dawson
-
Sean Lyons
-
Peter Marks
-
Claire Ward
-
Gerry McSorley
Board Members update (10th June, 2013):
-Paul O’Connor replaces Eric Morton as CEO
Source: Sherwood Forest Hospitals NHS Foundation Trust website
Slide 81
Committee structure for assuring quality and safety
Board of Directors
CEO Reports Items
From HMB To BOD
Mortality reports
directly to CCG
Committees & Groups
•
•
•
•
•
•
•
•
Clinical Audit Committee
Resuscitation Committee
Blood Transfusion
Committee
Medical Devices Group
Harms Group (being
established)
Medicines & Therapeutics
Committee
Mortality Steering Group
Infection Control
Committee
Committees are currently
being renewed as part of
Governance Action Plan
Source: Trust submitted documentation
Quality &
Clinical Governance
Committee
Finance &
Performance
Committee
Audit
committee
Clinical Management
Team
Remuneration &
Nomination
Committee
Risk Committee
Finance & Performance
Committee receive
minutes
Planned Care &
Surgery Clinical
Governance
Committee
Diagnostic &
Rehabilitation Clinical
Governance
Committee
Emergency Care &
Medicine Clinical
Governance
Committee
Service Level
Governance
Committee
Service Level
Governance
Committee
Service Level
Governance
Committee
Hospital
Management
Board (HMB)
Business &
Performance
Committee’s
Report into
HMB
Executive Team
Meeting
(items referred from
here to relevant
committee)
Slide 82
Data Sources
No.
Data Source name
1 3 years CDI extended
2 3 years MRSA
3 Acute Trust Quality Dashboard
4 NQD alerts for 14
5 PbR review data
6 QRP time series
7 Healthcare Evaluation Data
GMC Annex - GMC summary of Education Evidence - trusts with high
8 mortality rates
9 1 Buckinghamshire Healthcare Quality Accounts
10 Burton Quality Account
11 CHUFT Annual Report 2012
12 Quality Report 2011-12
13 Annual Report 2011-12_final
14 NLG. Quality Account 2011-12
15 Annual Report 2012
16 Litigation covering email
17 Litigation summary sheet
18 Rule 43 reports by Trust
19 Rule 43 reports MOJ
20 Governance and Finance
21 MOR Board reports
22 Board papers
23 CQC data submissions
24 Evidence Chronology B&T
25 Hospital Sites within Trust
26 NHS LA Factsheet
27 NHSLA comment on five
Steering Group Agenda and Papers incl Governance Structure and
28 Timetable
29 List of products
30 Provider Site details from QRP
31 Annual Report 2011-12
32 SHMI Summary
33 Diabetes Mortality Outliers
34 Mortality among inpatient with diabetes
35 supplementary analysis of HES mortality data
36 VLAD summary
37 Mor Dr Foster HSMR
38 Outliers Elective Non elective split
39 Presentation to DH Analysts about Mid-staffs
40 CQC mortality outlier summaries
41 SHMI Materials
42 Dr Foster HSMR
43 AQuA material
44 Mortality Outlier Review
45 Original Analysis Identifying Mortality Outliers
46 Original Analysis of HSMR-2010-12
47 High-level Methodology and Timetable
48 Analytical Distribution of Work_extended table
Type
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Area
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
Clinical and Operational Effectiveness
General
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Data
Analysis
Analysis
General
General
General
General
General
General
General
General
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Data
Governance and leadership
Governance and leadership
Governance and leadership
Governance and leadership
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
Mortality
No. Data Source name
49 Outline Timetable - Mortality Outlier Review
50 CQC review of Mortality data and alerts -Blackpool NHSFT
51 Peoples Voice QRP v4.7
52 Mortality outlier review -PE score
53 CPES Review
54 Pat experience quick wins from dh tool
55 PEAT 2008-2012 for KATE
56 PROMs Dashboard and Data for 14 trusts
57 PROMS for stage 1 review
58 NHS written complaints, mortality outlier review
59 Summary of Monitor SHA Evidence
60 Suggested KLOI CQC
61 Various debate and discussion thread
62 People Voice Summaries
63 Litigation Authority Reports
64 PROMs Dashboard
65 Rule 43 reports
66 Data from NHS Litigation Authority
67 Annual Sickness rates by org
68 Evidence from staff survey
69 Monthly HCSC Workforce Oct 2012 Quarterly tables turnover
70 Monthly HCSC Workforce Oct 2012 Annual time series turnover
71 Mortality outlier review -education and training KLOI
72 Staff in post
73 Staff survey score in Org
74 Agency and turnover
75 GMC ANNEX -GMC summary of education
76 Analysis of most recent Pat safety incident data for 14
77 Safety Thermometer for non spec
78 Acute Trust Quality Dashboard v1.1
79 Initial Findings on NHS written complaints 2011_12
80 Quality accounts First Cut Summary
81 Monitor SHA evidence
82 Care and compassion - analysis and evidence
83 United Linc never events
84 QRP Materials
85 QRP Guidance
86 QRP User Feedback
87 QRP List of 16 Outcome areas
88 Monitor Briefing on FTs
89 Acute Trust Quality Dashboard v1.1
90 Safety Thermometer
91 Agency and Turnover - output
92 Quality Account 2011-12
93 Annual Sickness Absence rates by org
94 Evidence from Staff Survey
95 Monthly HCHS Workforce October 2012 QTT
96 Monthly HCHS Workforce October 2012 ATT
Source: Freedom of information request, BBC 97 http://www.bbc.co.uk/news/health-22466496
Type
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Data
Area
Mortality
Mortality
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Data
Data
Data
Data
Analysis
Analysis
Analysis
Analysis
Data
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Analysis
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Patient Experience
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Data
Safety and Workforce
Slide 83
Data Sources
No.
Data Source Name
Health and Social Care Information Centre (HSCIC) monthly workforce
98 statistics
99 National Staff Survey, 2011, 2012
100 GMC evidence to review, 2013
101 2011/12 Organisational Readiness Self-Assessment (ORSA)
102 National Training Survey, 2012
103 National Patient Safety Agency (NPSA) Apr 11 – Mar 12
Type
Area
Data
Data
Analysis
Data
Data
Data
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Safety and Workforce
Slide 84
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General medicine
11 - Cancer of head and neck
259
2
Non-elective
300 - General medicine
12 - Cancer of esophagus
147
3
Non-elective
300 - General medicine
14 - Cancer of colon
118
1
Non-elective
300 - General medicine
15 - Cancer of rectum and anus
161
2
Non-elective
300 - General medicine
16 - Cancer of liver and intrahepatic bile duct
152
2
Non-elective
300 - General medicine
18 - Cancer of other GI organs; peritoneum
193
2
Non-elective
300 - General medicine
21 - Cancer of bone and connective tissue
287
1
Non-elective
300 - General medicine
24 - Cancer of breast
152
2
Non-elective
300 - General medicine
25 - Cancer of uterus
376
1
Non-elective
300 - General medicine
27 - Cancer of ovary
125
1
Non-elective
300 - General medicine
29 - Cancer of prostate
178
2
Non-elective
300 - General medicine
38 - Non-Hodgkin`s lymphoma
121
1
Non-elective
300 - General medicine
39 - Leukemias
145
3
Non-elective
300 - General medicine
41 - Cancer; other and unspecified primary
237
1
Non-elective
300 - General medicine
43 - Malignant neoplasm without specification of site
148
2
Non-elective
300 - General medicine
48 - Thyroid disorders
244
1
Non-elective
300 - General medicine
50 - Diabetes mellitus with complications
120
1
Non-elective
300 - General medicine
51 - Other endocrine disorders
134
2
Non-elective
300 - General medicine
52 - Nutritional deficiencies
539
2
Non-elective
300 - General medicine
54 - Gout and other crystal arthropathies
423
2
Non-elective
300 - General medicine
58 - Other nutritional; endocrine; and metabolic disorders
120
1
Non-elective
300 - General medicine
63 - Diseases of white blood cells
135
1
Non-elective
300 - General medicine
81 - Other hereditary and degenerative nervous system conditions
149
1
Non-elective
300 - General medicine
83 - Epilepsy; convulsions
111
1
Non-elective
300 - General medicine
101 - Coronary atherosclerosis and other heart disease
120
2
Slide 85
SHMI Appendix
Admission Method
Treatment Specialty
Diagnostic Group
Non-elective
300 - General medicine
107 - Cardiac arrest and ventricular fibrillation
Non-elective
300 - General medicine
110 - Occlusion or stenosis of precerebral arteries
Non-elective
300 - General medicine
Non-elective
300 - General medicine
Non-elective
Observed Deaths that
are higher than the
expected
SHMI
114
1
1413
1
114 - Peripheral and visceral atherosclerosis
138
1
115 - Aortic; peripheral; and visceral artery aneurysms
126
1
300 - General medicine
117 - Other circulatory disease
128
1
Non-elective
300 - General medicine
121 - ther diseases of veins and lymphatics
292
1
Non-elective
300 - General medicine
123 - Influenza
322
1
Non-elective
300 - General medicine
125 - Acute bronchitis
111
3
Non-elective
300 - General medicine
136 - Disorders of teeth and jaw
1316
1
Non-elective
300 - General medicine
137 - Diseases of mouth; excluding dental
858
2
Non-elective
300 - General medicine
138 - Esophageal disorders
160
1
Non-elective
300 - General medicine
139 - Gastroduodenal ulcer (except hemorrhage)
292
2
Non-elective
300 - General medicine
143 - Abdominal hernia
356
1
Non-elective
300 - General medicine
145 - Intestinal obstruction without hernia
134
1
Non-elective
300 - General medicine
146 - Diverticulosis and diverticulitis
570
2
Non-elective
300 - General medicine
148 - Peritonitis and intestinal abscess
500
3
Non-elective
300 - General medicine
151 - Other liver diseases
145
3
Non-elective
300 - General medicine
155 - Other gastrointestinal disorders
133
3
Non-elective
300 - General medicine
158 - Chronic renal failure
418
2
Non-elective
300 - General medicine
163 - Genitourinary symptoms and ill-defined conditions
384
1
Non-elective
300 - General medicine
166 - Other male genital disorders
2075
1
Non-elective
300 - General medicine
197 - Skin and subcutaneous tissue infections
109
1
Non-elective
300 - General medicine
202 - Rheumatoid arthritis and related disease
820
1
Non-elective
300 - General medicine
206 - Osteoporosis
1907
2
Non-elective
300 - General medicine
226 - Fracture of neck of femur (hip)
139
1
Slide 86
SHMI Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
SHMI
Non-elective
300 - General medicine
229 - Fracture of upper limb
169
1
Non-elective
300 - General medicine
230 - Fracture of lower limb
411
2
Non-elective
300 - General medicine
231 - Other fractures
136
1
Non-elective
300 - General medicine
234 - Crushing injury or internal injury
333
2
Non-elective
300 - General medicine
239 - Superficial injury; contusion
125
1
Non-elective
300 - General medicine
244 - Other injuries and conditions due to external causes
205
2
Non-elective
300 - General medicine
249 - Shock
258
1
Non-elective
300 - General medicine
250 - Nausea and vomiting
137
1
Non-elective
300 - General medicine
259 - Residual codes; unclassified
109
1
Slide 87
HSMR Appendix
Observed Deaths that
are higher than the
expected
Admission Method
Treatment Specialty
Diagnostic Group
HSMR
Non-elective
300 - General medicine
Biliary tract disease
147
3
Non-elective
300 - General medicine
Cancer of breast
152
1
Non-elective
300 - General medicine
Cancer of esophagus
119
1
Non-elective
300 - General medicine
Cardiac arrest and ventricular fibrillation
116
2
Non-elective
300 - General medicine
Chronic renal failure
206
1
Non-elective
300 - General medicine
Complication of device; implant or graft
293
3
Non-elective
300 - General medicine
Coronary atherosclerosis and other heart disease
137
3
Non-elective
300 - General medicine
Deficiency and other anemia
160
3
Non-elective
300 - General medicine
Intestinal obstruction without hernia
170
1
Non-elective
300 - General medicine
Malignant neoplasm without specification of site
168
1
Non-elective
300 - General medicine
Non-Hodgkin`s lymphoma
172
1
Non-elective
300 - General medicine
Other liver diseases
166
3
Non-elective
300 - General medicine
Other lower respiratory disease
155
3
Non-elective
300 - General medicine
Peripheral and visceral atherosclerosis
154
1
Non-elective
300 - General medicine
Peritonitis and intestinal abscess
239
2
Non-elective
300 - General medicine
Respiratory failure; insufficiency; arrest (adult)
107
1
Non-elective
300 - General medicine
Skin and subcutaneous tissue infections
134
3
Non-elective
501 - Obstetrics
Other perinatal conditions
2460
3
Slide 88
Higher than Expected Diagnostic Groups
HSMR / SHMI Summary (Non-elective)
Treatment Specialty
HSMR
SHMI
General medicine
X
Obstetrics
X
X
Slide 89