northern lincolnshire and goole hospitals nhs foundation ......9th july, 2013 overview on 6th...

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust Data Pack 9th July, 2013

Overview

On 6th February the Prime Minister asked Professor Sir Bruce Keogh to review the quality of the care and treatment being provided by those hospital trusts in England that have been persistent outliers on mortality statistics. The 14 trusts which fall within the scope of this review were selected on the basis that they have been outliers for the last two consecutive years on either the Summary Hospital Mortality Index or the Hospital Standardised Mortality Ratio.

These two measures are being used as a ‘smoke alarm’ for identifying potential quality problems which warrant further review. No judgement about the actual quality of care being provided to patients is being made at this stage, or should be reached by looking at these measures in isolation.

The review will follow a three stage process:

Stage 1 – Information gathering and analysis

Stage 2 – Rapid Responsive Review

Stage 3 – Risk summit

This data pack forms one of the sources within the information gathering and analysis stage.

Information and data held across the NHS and other public bodies has been gathered and analysed and will be used to develop the Key Lines of Enquiry (KLOEs) for the individual reviews of each Trust. This analysis has included examining data relating to clinical quality and outcomes as well as patient and staff views and feedback. A full list of evidence sources can be found in the Appendix.

Given the breadth and depth of information reviewed, this pack is intended to highlight only the exceptions noted within the evidence reviewed in order to inform Key Lines of Enquiry.

Slide 2

Document review Trust information submission for

review

Benchmarking analysis

Information shared by key national

bodies including the CQC

Sources of Information

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

Context

A brief overview of the North Lincolnshire and Goole area and Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. This section provides a profile of the area, outlines performance of local healthcare providers and gives a brief introduction to the Trust.

Mortality

An indication of the Trust’s mortality data based on the HSMR and SHMI indicators. This section identifies the key areas within the Trust which are outliers.

Patient Experience

A summary of the Trust’s patient experience feedback from a range of sources. This section takes data from the annual patient experience surveys.

Safety and Workforce

A summary of the Trust’s safety record and workforce profile.

Clinical and Operational Effectiveness

A summary of the Trust’s clinical and operational performance based on nationally recognised key performance indicators. This section compares the Trust’s performance to other national trusts and targets and includes patient reported outcome measures (PROMs).

Leadership and Governance

An indication of the Trust's leadership and their governance procedures. This section identifies any recent changes in leadership, current top risks to quality and outcomes from external reviews.

Slide 3

Context

Slide 4

Context

Overview:

This section provides an introduction to the Trust, providing an overview, health profile and an understanding of why the Trust has been chosen for this review.

Review Areas:

To provide an overview of the Trust, we have reviewed the following areas:

• Local area and market share;

• Health profile;

• Service overview; and

• Initial mortality analysis.

Data Sources:

• Trust’s Board of Directors meeting 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.

Summary:

Northern Lincolnshire and Goole is situated in Yorkshire and the Humber and services a population of 358,000. In the three localities covered by the Trust (North East Lincolnshire, North Lincolnshire, and Goole) non-White ethnic minorities constitute between 1.9% and 4.0% of the population. Diabetes as well as road injuries and death are particular sources of concern for the health of the local population.

The Trust services slightly fewer people than the number recommended by the Royal College of Surgeons.

North Lincolnshire’s health profile shows that male life expectancy in the region is significantly lower than the national average.

The Trust has three hospital sites, the Diana, Princess of Wales Hospital in Grimsby, Goole and District Hospital, and Scunthorpe General Hospital. Northern Lincolnshire and Goole became a Foundation Trust in 2007 and has a total of 853 beds. The market share of inpatient activity for the three hospitals varies significantly; Diana, Princess of Wales Hospital and Scunthorpe General Hospital have much larger market shares within a 5-, 10-, and 20-mile radius than has Goole and District Hospital.

A review of ambulance response times showed that the East Midlands Ambulance Service fails to meet both the 8mins and the 19mins national response target.

Finally, Northern Lincolnshire and Goole’s HSMR was above the expected level in 2011 and 2012, and was therefore selected for this review.

. Slide 5

All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.

Number of Beds and Bed Occupancy (Oct12-Dec12)

Beds

Available

Percentage

Occupied

National

Average

Total 853 69.5% 86%

General and

Acute

774 75.3% 88%

Maternity 79 12.7% 59%

Trust Status Foundation Trust (2007)

Inpatient/Outpatient Activity (Jan12-Dec12)

Inpatient Activity Elective 56,158 (53%)

Day Case Rate:

83%

Non Elective 49,109 (47%)

Total 105,267

Outpatient Activity Total 387,399

Northern Lincolnshire and Goole became a Foundation Trust in 2007. The Trust services a population in North Lincolnshire, North East Lincolnshire, and Goole, of 358,000 people and has three acute hospitals: Diana, Princess of Wales Hospital; Goole and District Hospital; and Scunthorpe General Hospital. The Trust has a lower bed occupancy rate than the national average and offers a large range of services, having 56,158 inpatients and 49,109 outpatients in 2012.

Trust Overview

Departments and Services

Accident & emergency, Breast Surgery, Cardiology, Children’s &

Adolescent Services, Dental Medicine Specialties, Dentistry and

Orthodontics, Dermatology, Diabetic Medicine, Dermatology,

Diagnostic Imaging, Diagnostic Physiological Measurement, ENT,

Endocrinology and Metabolic Medicine, Gastro Intestinal and Liver

Services, General Medicine, General Surgery, Geriatric Medicine,

Gynaecology, Haematology, Immunology, Maternity Service,

Neurology, Oncology, Ophthalmology, Oral and Maxillofacial Surgery,

Pain Management, Physiotherapy, Respiratory Medicine,

Rheumatology, Urology, Vascular Surgery

Northern Lincolnshire and Goole Hospitals NHS Foundation Trust

Acute Hospitals Diana, Princess of Wales Hospital; Goole and

District Hospital; Scunthorpe General Hospital

Slide 6

Source: Department of Health: Transparency Website

Source: Healthcare Evaluation Data (HED)

Source: NHS Choices

Finance Information

2012–13 Income £318m

2012–13 Expenditure £304m

2012–13 EBITDA £14m

2012–13 Net surplus (deficit) £2m

2013-14 Budgeted Income £312m

2013-14 Budgeted Expenditure £300m

2013-14 Budgeted EBITDA £12m

2013-14 Budgeted Net surplus (deficit) 0.3m

Source: NHS Choices

Source: Appendix 2 of documents provided by Northern Lincolnshire and Goole Hospitals NHS Foundation Trust, 03/06/2013.

0

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Inpatient Activity by Trust

Trusts Covered by Review National Inpatient Activity Curve

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Trusts Covered by Review National Outpatient Activity Curve

Northern Lincolnshire and Goole 105,267

Trust Overview continued...

Northern Lincolnshire and Goole 387,399

Top 10 Inpatient Main Specialties as a

% of Total Inpatient Activity

General Medicine 21%

General Surgery 15%

Gynaecology 10%

Paediatrics 9%

Urology 7%

Trauma & Orthopaedics 6%

Ophthalmology 5%

Medical Oncology 5%

Clinical Haemotology 4%

Geriatric Medicine 3%

Bottom 10 Inpatient Main Specialties

and Spells

Dermatology 17

Neurology 63

Clinical Immunology and Allergy 327

Accident & Emergency 386

Midwifery 518

Respiratory Medicine 576

Rheumatology 1192

Cardiology 1292

Anaesthetics 1460

Ear, Nose & Throat 1899

Top 10 Outpatient Main Specialties as

a % of Total Outpatient Activity

Nursing Episode 16%

Trauma & Orthopaedics 12%

Ophthalmology 12%

General Medicine 9%

General Surgery 8%

Gynaecology 6%

Ear, Nose & Throat 5%

Paediatrics 4%

Urology 4%

Dermatology 3%

The graphs show the relative size of Northern Lincolnshire and Goole against national trusts in terms of inpatient and outpatient activity.

Northern Lincolnshire and Goole is a medium sized trust for both measures of activity, relative to the rest of England. Of the 14 trusts selected for this review, it is the fifth and sixth largest by the number of inpatient and outpatient spells, respectively.

General Medicine and General Surgery are the largest inpatient specialties while Nursing Episodes and Trauma & Orthopaedics are the largest for outpatients.

Slide 7 Source: Healthcare Evaluation Data (HED); Jan 12-Dec 12

Levels of deprivation vary significantly in Northern Lincolnshire and Goole. The local population is significantly older than the English population as a whole. Diabetes, as well as road injuries and deaths, are particular health concerns in this region. The ethnic composition of the population is less varied than the national average; Chinese, Bangladeshi and Indians constitute the largest minorities.

Northern Lincolnshire and Goole Area Overview

20% 15% 10% 5% 0% 5% 10% 15% 20%

FACT BOX

Population 358,000

The Royal College of Surgeons recommend that the

"...catchment population size...for an acute general hospital

providing the full range of facilities, specialist staff and

expertise for both elective and emergency medical and

surgical care would be 450,000 - 500,000."

IMD Of 149 English unitary authorities, North East

Lincolnshire is the 39th most deprived, North

Lincolnshire is the 83rd most deprived, and

East Riding of Yorkshire is the 122nd most

deprived.

Ethnic

diversity

In North East Lincolnshire, 2.6% belong to

non-White minorities, as do 4.0% in North

Lincolnshire, and 1.9% in East Riding of

Yorkshire. Chinese, Bangladeshi and Indians,

respectively, are the largest minorities in

these regions..

Rural or

Urban

All three areas are rural-urban regions.

Diabetes In all three regions serviced by this Trust,

people diagnosed with diabetes are

significantly more common than in England

as a whole.

Road

injuries and

deaths

In all three regions serviced by this Trust,

road injuries and deaths are significantly

more common than in England as a whole.

Slide 8 Source: Office of National Statistics, Census 2011; IMD Source: Index of Multiple Deprivation, 2010

0-9

10-19

20-29

30-39

40-49

50-59

60-69

70-79

80+

Northern Lincolnshire and Goole Area Demographics

Female/NLG Female/ENG Male/NLG Male/ENG

Northern Lincolnshire and Goole and Surroundings Geographic Overview

The map on the right shows the location of the three Trust sites for Northern Lincolnshire and Goole Hospitals NHS Foundation Trust in a rural-urban area in Lincolnshire.

Market share analysis indicates from which GP practices the referrals that are being provided for by the Trust originate. High mortality may affect public confidence in a Trust, resulting in a reduced market share as patients may be referred to alternative providers.

Slide 9 Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12

Source: © Google Maps

The three wheels on this and the following slide show the market share of the three hospitals belonging to Northern Lincolnshire and Goole Hospitals NHS Foundation Trust. From the first wheel it can be seem that Diana, Princess of Wales Hospital has an 80% market share of inpatient activity within a 5 mile radius of the Trust. As the size of the radius is increased, the market share falls to 75% within 10 miles and 27% within 20 miles.

Northern Lincolnshire and Goole and Surroundings Geographic Overview

From the second wheel it can be seen that Scunthorpe General Hospital has a 74% market share of inpatient activity within a 5 mile radius of the Trust. As the size of the radius is increased, the market share falls to 75% within 10 miles and 27% within 20 miles.

The corresponding figures for Goole, represented on the final wheel, are much lower at just 4%, 3% and 1%. This is due to the smaller range of services provided at this site.

The three wheels also show that the main competitors for these hospitals are Hull and East Yorkshire Hospitals NHS Trust, United Lincolnshire Hospitals NHS Trust, Sheffield Teaching Hospitals NHS Foundation Trust, Doncaster & Bassetlaw Hospitals NHS Foundation Trust, York Teaching Hospital NHS Foundation Trust, Leeds Teaching Hospitals NHS Trust, and Mid Yorkshire Hospitals NHS Trust.

Slide 10 Source: Healthcare Evaluation Data (HED), Dec 11 – Nov 12

East Riding, North Lincolnshire and North East Lincolnshire’s Health Profile

Health Profiles, depicted on this slide and the following, are designed to help local government and health services identify problems in their areas, and decide how to tackle these issues. They provide a snapshot of the overall health of the local population, and highlight potential differences against regional and national averages.

The graph shows the level of deprivation in East Riding, North Lincolnshire and North East Lincolnshire compared nationally.

The tables below outline East Riding, North Lincolnshire and North East Lincolnshire’s health profile information in comparison with the rest of England.

1. In North Lincolnshire and East Riding, almost all indicators are performing at the national level. However, East Riding has a higher number of people and in statutory homelessness and both areas have a lower number of GCSE’s achieved than the national average. In North East Lincolnshire, all indicators are performing below the national average.

N Lincolnshire

Slide 11

Deprivation by unitary authority area

Source: Public Health Observatories – area health profiles

NE Lincolnshire

1

East Riding


2. Within all three areas, smoking in pregnancy and breast feeding initiation are all performing lower than the national average. In North Lincolnshire and North East Lincolnshire, teenage pregnancy is higher than the national average.

3. Adult health and lifestyle indicators show that smoking is more common in North Lincolnshire and North East Lincolnshire. These two areas also have a lower number of healthy eating adults than the national average. In all three areas, Obesity is also more common.

3

4

Slide 12 Source: Public Health Observatories – area health profiles

2

3


4. Within the disease and poor health indicators, both North Lincolnshire and North East Lincolnshire had higher levels of alcohol related hospital stays and drug misuses than the national average. All three areas had higher levels of diabetes than the national average.


4


5. All three areas have a higher number of road injuries and deaths than the national average. North East Lincolnshire has a lower life expectancy for both males and females, while North Lincolnshire has a lower life expectancy for males. Smoking related deaths are more coomon in North Lincolnshire and North East Lincolnshire and there are a higher number of early deaths due to cancer in North Lincolnshire.


5

Performance of Local Healthcare Providers

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

100%

Isle of Wight NHS Trust

South Western

Ambulance Service NHS Foundation

Trust

West Midlands

Ambulance Service NHS

Trust

South Central Ambulance Service NHS Foundation

Trust

South East Coast


Trust

East of England


Trust

London Ambulance Service NHS

Trust

North West Ambulance Service NHS

Trust

Great Western


Trust

North East Ambulance Service NHS

Trust

Yorkshire Ambulance Service NHS

Trust

East Midlands Ambulance Service NHS

Trust

Proportion of calls responded to within 8 minutes

Ambulance Trust England

84%

86%

88%

90%

92%

94%

96%

98%

100%

Isle of Wight NHS Trust

West Midlands


Trust

London Ambulance Service NHS

Trust

South East Coast


Trust

Yorkshire Ambulance Service NHS

Trust

South Western


Trust

Great Western


Trust

North East Ambulance Service NHS

Trust

North West Ambulance Service NHS

Trust

South Central Ambulance Service NHS Foundation

Trust

East of England


Trust

East Midlands Ambulance Service NHS

Trust

Proportion of calls responded to within 19 minutes

Ambulance Trusts England Slide 15

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.

Source: Department of Health: Transparency Website Dec 12

Why was Northern Lincolnshire and Goole chosen for this review?

Banding 1 – ‘higher than expected’

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

Tameside Hospital NHS Foundation Trust 1 1 101 102 Within expected

The Dudley Group Of Hospitals NHS Foundation Trust 116 111 Above expected

United Lincolnshire Hospitals NHS Trust 113 111 Above expected

Based on the Summary Hospital level Mortality Indicator (SHMI) and Hospital Standardised Mortality Ratio (HSMR), 14 trusts were selected for this review. The table includes information on which trusts were selected. An explanation of each of these indicators is provided in the Mortality section. Where it does not include the SHMI for a trust, it is because the trust was selected due to a high HSMR as opposed to its SHMI. The SHMI for all 14 trusts can be found in the following pages. Initially, five hospital trusts were announced as falling within the scope of this investigation based on the fact that they had been outliers on SHMI for the last two years (SHMI data has only been published for the last two years). Subsequent to these five hospital trusts being announced, Professor Sir Bruce Keogh took the decision that those hospital trusts that had also been outliers for the last two consecutive years on HSMR should also fall within the scope of his review. The rationale for this was that it had been HSMR that had provided the trigger for the Healthcare Commission’s initial investigation into the quality of care provided at Mid Staffordshire Hospitals NHS Foundation Trust. The HSMR shows Northern Lincolnshire and Goole has been above the expected range for the last two years and was therefore selected for this review.

Slide 16

Source: Source: Background to the review and role of the national advisory group, Financial years 2010-11, 2011-12

Why was Northern Lincolnshire and Goole chosen for this review?

HSMR Time Series HSMR Funnel Chart

SHMI Funnel Chart SHMI Time Series

Northern Lincolnshire and Goole

Selected trusts Outside Range Selected trusts w/in Range

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 Northern Lincolnshire and Goole’s HSMR and SHMI are statistically above the expected range.

The time series shows both the HSMR and SHMI have been consistently above the expected level, however the HSMR recently dipped below 100.

Slide 17 Source: Healthcare Evaluation Data (HED); Apr 10-Mar12



Mortality

Slide 18

Mortality

Overview:

This section focuses upon recent mortality data to provide an indication of the current position. All 14 trusts in the review have been analysed using consistent methodology.

The measures identified are being used as a ‘smoke alarm’ for highlighting potential quality issues. No judgement about the actual quality of care being provided to patients is being made at this stage, nor should it be reached by looking at these measures in isolation.

Review areas

To undertake a detailed analysis of the trust’s mortality, it is necessary to look at the following areas:

• Differences between the HSMR and SHMI;

• Elective and non-elective mortality;

• Specialty and Diagnostic groups; and

• Alerts and investigations.

Data sources

• Healthcare Evaluation Data (HED);

• Health & Social Care Information Centre – SHMI and contextual indicators;

• Dr Foster – HSMR; and

• Care Quality Commission – alerts, correspondence and findings.

Summary:

The Trust has an overall HSMR of 114 for the period January 2012 to December 2012, meaning that the number of actual deaths is higher than the expected level, and this is above the statistically expected range.

Further analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with a similar HSMR of 115, also above the expected range. Elective admissions are within the expected range, with an HSMR of 86.

Currently, Northern Lincolnshire and Goole has a SHMI of 114, which is statistically above the expected range.

Similar to HSMR, non-elective admissions are seen to be contributing primarily to the overall Trust SHMI, with a similar figure of 114. Elective admission are within the expected range, with a SHMI of 112.

Northern Lincolnshire & Goole had seven high mortality alerts for diagnostic groups since 2007. All of these fall in three diagnostic groups: Cerebrovascular, Respiratory Medicine and Cardiology.

In-depth reviews of stroke services have been undertaken at each of the Trust’s three hospital sites and a comprehensive action plan, and regular updates, have been shared with CQC. These have been ongoing for some years. The Trust has significantly worse than expected outcomes for patients aged over 18 who were admitted as an emergency.

Slide 19 All use and display of sourcing is consistent across the packs for the 14 trusts included in this review.

Mortality Overview

Slide 20

Mo

rta

lity

Outcome 1 (R17) Respecting and involving e who use services

Overall HSMR

Overall SHMI*

Weekend or weekday mortality outliers

Elective mortality (SHMI and HSMR)

Non-elective mortality (SHMI and HSMR)

Palliative care coding issues

Emergency specialty groups much worse than expected 30-day mortality following specific surgery / admissions

Emergency specialty groups worse than expected Mortality among patients with diabetes

Diagnosis group alerts to CQC

Diagnosis group alerts followed up by CQC

The following overview provides a summary of the Trust’s key mortality areas:

Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12 Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR, Care Quality Commission – alerts, correspondence and findings

Outside 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.

Outside expected range of the HSCIC for Mar 11 – Sep 12


Outside expected range based on Poisson distribution for Dec 11 – Nov 12

SHMI*

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 in-hospital deaths (multiplied by 100) for 56 specific CCS groups in a specified patient group. The expected deaths are calculated from logistical regression models taking into account and adjusting for a case-mix of: age band, sex, deprivation, interaction between age band and co-morbidities, month of admission, admission method, source of admission, the presence of palliative care, number of previous emergency admissions and financial year of discharge. How should HSMR be interpreted? Care is needed in interpreting these results. Although a score of 100 indicates that the observed number of deaths matched the expected number in order to identify if variation from this is significant confidence intervals are calculated. A Poisson distribution model is used to calculate 95% and 99.9% confidence intervals and only when these have been crossed is performance classed as higher or lower than expected.

Slide 21

SHMI Definition

What is the Summary Hospital-level Mortality Indicator? The Summary level Hospital Mortality Indicator (SHMI) is a high level hospital mortality indicator that is published by the Department of Health on a quarterly basis. The SHMI follows a similar principle to the general standardised mortality ratio; a measure based upon a nationally expected value. SHMI can be used as a potential smoke alarm for potential deviations away from regular practice. How does SHMI work? 1. Deaths up to 30 days post acute trust discharge are considered in the mortality indicator, utilising ONS data 2. The SHMI is the ratio of the Observed number of deaths in a Trust vs. Expected number of deaths over a period of time 3. The Indicator will utilise 5 factors to adjust mortality rates by

a. The primary admitting diagnosis; b. The type of admission; c. A calculation of co-morbid complexity (Charlson Index of co-morbidities); d. Age; and e. Sex.

4. All inpatient mortalities that occur within a Hospital are considered in the indicator How should SHMI be interpreted? Due to the complexities of hospital care and the high variation in the statistical models used all deviations from the expected range are highlighted using a Random Effects funnel plot.

Slide 22

Some key differences between SHMI and HSMR

Slide 23

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

Yes all deaths are included

When a patient dies how many times is this

counted?

If a patient is transferred between hospitals

within 2 days the death is counted multiple

times

1 death is counted once, and if the patient is

transferred the death is attached to the last

acute/secondary care provider

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

SHMI overview

Slide 24

Month-on-month time series

Year-on-year time series

The Trust’s SHMI level for the 12 months from Dec 11 to Nov 12 is 114, which means, as shown below, it is statistically above the expected range and so classified as an outlier, based on the 95% confidence interval of the Poisson distribution. The time series show a general trend of decreasing SHMI both year-on-year and month-on-month.

SHMI funnel chart –12 months

Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012



SHMI Statistics This slide demonstrates the

number of mortalities in and out of hospital for Northern Lincolnshire and Goole.

As SHMI includes mortalities that occur within the hospital and outside of it for up to 30 days following discharge, it is imperative to understand the percentage of deaths which happen inside the hospital compared to outside. This may contribute to differences in HSMR and SHMI outcomes.

The data shows that 72.5% of SHMI deaths occur in hospital at Northern Lincolnshire and Goole, which is less than the national average of 73.3%.

60%

65%

70%

75%

80%

85%

90%

Percentage of patient deaths in hospital

Trusts selected for review All Trusts

Northern Lincolnshire and

Goole 72.5%

Slide 25

Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012

- - - - - - - - - - - - - - - - - - - - - - - - - - - - -

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Mortality - SHMI Tree

Mortality trees provide a breakdown of SHMI into elective and non-elective admissions. The SHMI score for non-elective admissions has a greater impact on the overall indicator due to a higher number of expected deaths. The tree shows that Northern Lincolnshire and Goole has a SHMI of 114 which is above the expected range. The number of observed deaths in three specific areas are highlighted as being higher than expected: in General Medicine for elective admissions, and General Medicine and Geriatric Medicine for non-elective admissions. These are potential areas for review.

Slide 26

Higher than expected (above the 95th confidence interval)


Lower than expected (below the 95th confidence interval)

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

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gy

En

do

crino

log

y

Clin

ical H

aem

ato

log

y

Dia

betic M

edicin

e

Clin

ical Im

mu

no

log

y

Ca

rdio

log

y

Derm

ato

log

y

Th

ora

cic Med

icine

Med

ical O

nco

log

y

Neu

rolo

gy

Rh

eum

ato

log

y

Pa

edia

trics

Neo

na

tolo

gy

Geria

tric Med

icine

Ob

stetrics

Gy

na

ecolo

gy

Non-Elective

Treatment Specialties

Overall Trust

Elective

SHMI 114

SHMI 112


SHMI 114

Diagnosis (100 ; 1 )

SHMI Observed deaths that are higher than the expected

Key

SHMI sub-tree of specialties

The SHMI sub-tree highlights the specialties for non-elective admissions with a statistically higher SHMI than expected and highlights the diagnostic groups with at least four more observed deaths than expected; those with fewer than four are shown in the appendix. When identifying areas to review, it is important to consider the number of deaths as well as the SHMI. General Medicine has the highest number of greater than expected deaths with chronic obstructive pulmonary disease and bronchiectasis (37), pneumonia (23), septicemia, and fluid and electrolyte disorders (both 17) seen as the main diagnostic groups contributing to this. Within Geriatric Medicine, acute cerebrovascular disease has the greatest number of observed deaths above the expected level with 8. Those groups highlighted below may potentially be areas to be reviewed.

Slide 27

Diagnostic Groups






SHMI Observed deaths that are higher than the expected

Key

118.2

General Medicine (120, 161)

Non-elective (114; 270)

Overall (114; 281)

Geriatric Medicine (124, 28)

Acute and unspecified renal failure (117, 6)

Acute bronchitis (134, 16)

Acute cerebrovascular disease (136, 2)

Aspiration pneumonitis; food/vomitus (114, 5)

Chronic obstructive pulmonary disease and bronchiectasis (148, 37)

Congestive heart failure; nonhypertensive (110, 5)

Fluid and electrolyte disorders (170, 17)

Fracture of neck of femur (hip) (403, 4)

Gastrointestinal hemorrhage (146, 15)

Hypertension with complications and secondary hypertension (366, 4)

Other nervous system disorders (202, 4)

Other upper respiratory disease (280, 10)

Phlebitis; thrombophlebitis and thromboembolism (225, 5)

Pneumonia (110, 23)

Respiratory failure; insufficiency; arrest (adult) (127, 6)

Septicemia (122, 17)

Spondylosis; intervertebral disc disorders; other back problems (274, 4)

Syncope (191, 6)




Septicemia (136, 4)

Paralysis (308, 5)


Elective (112, 10)

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.

HSCIC SHMI overview

Slide 28

The Health and Social Care Information Centre (HSCIC) publish the SHMI quarterly. This official statistic covers a rolling 12 month reporting period using a model based on a 3-year dataset refreshed quarterly. The earliest publication was in October 2011, for the period from April 2010 to March 2011. The HSCIC produce two sets of upper and lower limits. One set uses 99.8% control limits from an exact Poisson distribution based on the number of expected deaths. The other set uses a Random effects model applying a 10% trim for over-dispersion, based on the standardised Pearson residual for each provider excluding the top and bottom 10% of scores. This latter set is broader than the Poisson and is the one against which the HSCIC report whether the SHMI is within, below or above the expected range. The SHMI for Northern Lincolnshire & Goole was 115 in the year to Sept-12 (England baseline = 100) and has been above the expected range for 6 of the 7 periods to date.

Source: Health & Social Care Information Centre – SHMI

SHMI published by HSCIC, Northern

Lincolnshire & Goole FT

115 113116 116 117

118115

80

85

90

95

100

105

110

115

120

125

Mar-11 Jun-11 Sep-11 Dec-11 Mar-12 Jun-12 Sep-12

Rolling 12 months ending

Lower limit Upper limit SHMI

HSMR overview

Slide 29

Month-on-month time series

Year-on-year time series

The Trust’s HSMR level for the 12 months from Jan 12 to Dec 12 is 114, which means, as shown below, it is above the expected range and so classified as an outlier. The time series shows no general trend for HSMR month-on-month, however the year-on-year time series shows an upward trend between 2007/8 and 2011/12, before a decrease in 2012/13.

HSMR funnel plot –12 months

Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012



HSMR Statistics

The table to the right shows Northern Lincolnshire and Goole’s HSMR broken down by admission type. The breakdown illustrates the overall HSMR is 114 which is above the expected range. The table identifies that non-elective admissions have an HSMR above the expected range, but elective admissions are within range.

Slide 30

HSMR Weekend Week All

Elective 227 83 86

Non-elective 116 115 115

All 116 113 114

Key – colour by alert level:

Red – Higher than expected (above the 95% confidence interval)

Blue – Within expected range

Green – Lower than expected (below the 95th confidence interval)


HSMR CCS Diagnostic Group Overview

The darker colour boxes have the highest HSMR while the size of the boxes represent the number of observed deaths that are higher than the expected deaths. The larger and darker boxes within the tree plot will highlight potential areas for further review.

From this tree plot it is clear that the following areas have the greatest number of above expected deaths:

• Pneumonia (HSMR 117 , 38 observed deaths that are higher than the expected);

• Acute cerebrovascular disease (140, 35);

• Chronic obstructive pulmonary disease and bronchiectasis (138, 27);

• Septicemia (except in labour) (131, 26); and

• Acute bronchitis (154, 21).

Slide 31


- - - - - - - - - - - - - - - - - - - - - - - - -

Gen

eral S

urg

ery

Uro

log

y

Brea

st Su

rgery

Co

lorecta

l Su

rgery

Up

per G

astro

intestin

al S

urg

ery

Va

scula

r Su

rgery

Tra

um

a &

Orth

op

aed

ics

Ea

r, No

se an

d T

hro

at (E

NT

)

Op

hth

alm

olo

gy

Ora

l Su

rgery

Pla

stic Su

rgery

Gen

eral M

edicin

e

Ga

stroen

terolo

gy

En

do

crino

log

y

Clin

ical H

aem

ato

log

y

Dia

betic M

edicin

e

Clin

ical Im

mu

no

log

y

Ca

rdio

log

y

Th

ora

cic Med

icine

Med

ical O

nco

log

y

Neu

rolo

gy

Rh

eum

ato

log

y

Pa

edia

trics

Geria

tric Med

icine

Gy

na

ecolo

gy

Non-Elective

Mortality - HSMR Tree

The tree shows that the HSMR for Northern Lincolnshire and Goole is 114 which is above the expected range. When breaking this down by admission type, it is clear that it is driven by non-elective admissions, which are at similar level with 115. Elective admissions is within the expected range. Within non-elective admissions General Medicine and Geriatric Medicine have the highest number of observed deaths above the expected level.

Slide 32





HSMR Observed deaths that are higher than the expected

Key

- - - - - - - - - - - - - - - - - - - - - - - - - - -

Gen

eral S

urg

ery

Uro

log

y

Brea

st Su

rgery

Co

lorecta

l Su

rgery

Up

per G

astro

intestin

al S

urg

ery

Va

scula

r Su

rgery

Tra

um

a &

Orth

op

aed

ics

Ea

r, No

se an

d T

hro

at (E

NT

)

Op

hth

alm

olo

gy

Ora

l Su

rgery

Accid

ent &

Em

ergen

cy (A

&E

)

Critica

l Ca

re Med

icine

Gen

eral M

edicin

e (120

, 161)

Ga

stroen

terolo

gy

Clin

ical H

aem

ato

log

y

Dia

betic M

edicin

e

Ca

rdio

log

y

Th

ora

cic Med

icine

Med

ical O

nco

log

y

Neu

rolo

gy

Rh

eum

ato

log

y

Pa

edia

trics

Neo

na

tolo

gy

Well B

ab

ies

Geria

tric Med

icine (12

4, 2

8)

Ob

stetrics

Gy

na

ecolo

gy


Overall Trust

Elective

HSMR 115

HSMR 86


HSMR 114

HSMR sub-tree of specialties

The HSMR sub-tree indicates the specialties with a statistically higher HSMR than expected and with diagnostic groups with at least four more observed deaths than expected. When identifying areas to review, it is important to consider the number of deaths as well as the HSMR. The sub-tree indicates that General Medicine has the highest number of above expected deaths. These are spread over numerous diagnostic groups such as pneumonia (26), acute cerebrovasvcular disease (26) and chronic obstructive pulmonary disease and bronchiectasis (23).Within Geriatric Medicine, acute bronchitis and acute cerebrovasvcular disease have the highest number of above expected deaths with 8.

Slide 33


Diagnostic Groups




118.2


Non-elective (115; 182)

Overall (114; 175)

Geriatric Medicine (124, 28)


HSMR Observed deaths that are higher than the expected

Key



Aspiration pneumonitis; food/vomitus (120, 6)

Cardiac dysrhythmias (147, 4)

Chronic obstructive pulmonary disease and bronchie (138, 23)

Congestive heart failure; nonhypertensive (116, 7)

Fluid and electrolyte disorders (132, 5)


Other upper respiratory disease (322, 7)

Pleurisy; pneumothorax; pulmonary collapse (165, 6)

Pneumonia (except that caused by tuberculosis or s (114, 26)

Respiratory failure; insufficiency; arrest (adult) (138, 7)

Septicemia (except in labor) (131, 20)

Skin and subcutaneous tissue infections (186, 5)



Chronic obstructive pulmonary disease and bronchie (176, 5)

Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012 The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.

HSMR – Dr Foster

The HSMR time series for Northern Lincolnshire and Goole FT from Dr Foster shows a rise in the HSMR since 2008/09. This measures the observed in-hospital death rate against an expected value based on all the data for that year. An HSMR (or SHMI) of 100 means that there is exactly the same number of deaths as expected. The HSMR is classified as above expected if the lower 95% confidence limit exceeds 100, which was the case in each year except 2008/09. Northern Lincolnshire and Goole’s latest SHMI published by the HSCIC, for Oct 11 to Sept 12, is higher than the Dr Foster HSMR for the same period. Dr Foster have made the following adjustments to show the impact of factors that can affect this comparison: • Adjustment for palliative care: used the SHMI observed deaths

but changed expected deaths to take account of palliative care. • Adjustment for in-hospital deaths:

• Removed out-of-hospital deaths from the observed figure, and

• Reduced expected deaths to only those in-hospital. Any remaining variances are largely due to: • The scope of deaths included (SHMI covers all deaths whereas

HSMR covers clinical areas accounting for an average of around 80% of deaths), and

• The definition of spells, which includes those provider(s) the death attributes to.

Source: Dr Foster HSMRs, HSCIC SHMI

Slide 34

Com parison of m ortality m easures,

Northern Lincolnshire & Goole

115

113 114

109

95

100

105

110

115

120

125

SHMI SHMI adjusted

for palliative

care

SHMI in

hospital

deaths only

HSMR

Time series of HSMR, Northern

Lincolnshire & Goole FT

118

105

108

116

95

100

105

110

115

120

125

130

2008/09 2009/10 2010/11 2011/12

HSMR 95% Confidence intervalII

Coding

Average Diagnosis Coding Depth

Slide 35

Diagnosis coding depth has an impact on the expected number of deaths. A higher than average diagnosis coding depth is more likely to collect co-morbidity which will influence the expected mortality calculation. When looking at the depth of coding for Northern Lincolnshire and Goole, it is apparent that the Trust has an average diagnosis coding depth below the national average and the average of the 14 trusts covered in this review. The elective and non- elective graphs both show a significant dip in average diagnosis coding depth in Q3 2008/2009. More recently, the average diagnosis coding depth has been closer to the national average but has still been below the national level. Source: Health Evaluation Data (HED) – Jan 2012 – Dec 2012

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

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

Elective

National Average Diagnosis Coding Depth

14 Trusts' Average Diagnosis Coding Depth


0

1

2

3

4

5

6

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

Non-elective

National Average Diagnosis Coding Depth

14 Trusts' Average Diagnosis Coding Depth


Percentage of admissions with palliative

care coding

-

0.2

0.4

0.6

0.8

1.0

1.2

1.4

Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13

SHMI publicationNorthern Lincolnshire & Goole National

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. Northern Lincolnshire and Goole currently make average and growing use of palliative care coding on admissions (by treatment specialty or diagnosis). The proportion of SHMI deaths with a palliative care code is also growing but below average.

Source: Health & Social Care Information Centre – SHMI contextual indicators

Percentage of deaths with palliative care

coding

-

2

4

6

8

10

12

14

16

18

20

Oct-11 Jan-12 Apr-12 Jul-12 Oct-12 Jan-13 Apr-13

SHMI publicationNorthern Lincolnshire & Goole National

Slide 36

Care Quality Commission findings

Care Quality Commission (CQC) review mortality alerts for each trust on an ongoing basis. These alerts, which indicate observed deaths significantly above expected for specialties or diagnoses, come from different sources based on either HSMR or SHMI. Where these appear unexplained, CQC correspond with the trust to agree any appropriate action. For Northern Lincolnshire and Goole, the common theme that has arisen across the patient groups alerting since 2007 is Elderly Care. No common themes arise from responses to the CQC from the Trust. All the Trust’s mortality alerts fall in three diagnostic groups: Cerebrovascular, Respiratory Medicine and Cardiology. The Trust has significantly worse than expected outcomes for patients aged over 18 who were admitted as an emergency. In-depth reviews of stroke services have been undertaken at each of the Trust’s three hospital sites and a comprehensive action plan, and regular updates, have been shared with CQC. The Northern Lincolnshire Health Community mortality action plan (September 2012) was developed in response to the high SHMI indicator. The Trust is developing care bundles. They also plan to ensure that deteriorating patients are being actively identified and appropriate action taken via a National Early Warning Score (NEWS) system .

Emergency specialty groups much worse than expected

Sep 11 to Aug 12 4

Trauma and Orthopaedics

Cardiology

Cerebrovascular

Respiratory medicine

Emergency specialty groups worse than expected

Sep 11 to Aug 12 2

Genito-urinary medicine

Miscellaneous

Diagnosis group alerts (2007 to date)

Alerts to CQC 7

Alerts followed up by CQC 5

Recent diagnosis group alerts pursued by CQC

Acute cerebrovascular disease (Jul 12 also Nov 11)

Acute bronchitis (Dec 12)

Any related patient groups alerting more than once since 2007

Acute cerebrovascular disease

Acute bronchitis

Pneumonia

Source: Care Quality Commission – alerts, correspondence and findings

Slide 37

SMRs for Diagnostic and Procedure groups – Dr Foster

The standardised mortality ratio (SMR) is used to calculate the mortality rate for diagnosis and procedure groups. This is available for the 56 diagnosis groups that are included in the HSMR and the 96 procedure groups that are part of the Real Time Monitoring system. SMRs are not yet remodelled for the year but are projected, rebased estimates. SMRs are classified as above expected if their lower 95% confidence limit exceeds 100 (excluding those with fewer than four more observed deaths than expected). From Apr 12 to Mar 13, there were four diagnosis groups and no procedure group with above expected SMRs in Northern Lincolnshire and Goole FT, which may highlight potential areas for review. Two of these diagnosis groups had above expected mortality for weekend admissions but not for weekday ones: Acute cerebrovascular disease and Other upper respiratory disease. CUSUM alerts show how many early warning flags arose within the diagnosis and procedure groups during the year. These are based on cumulative sum statistical process control charts with 99% thresholds that trigger alerts once breached. The same groups may alert multiple times. During the year, Northern Lincolnshire and Goole had two CUSUM alerts for acute bronchitis and one for other upper respiratory disease. It also had two alerts for procedure groups that did not have a high SMR.

Source: Dr Foster HSMR, SMRs, CUSUM alerts

Slide 38

Apr 2012 to Mar 2013 Diagnosis groups Procedure groups

SMRs above expected 4 0

CUSUM alerts 3 2

Diagnosis groups with SMRs above expected SMR Obs – Exp

deaths

Acute bronchitis


Other upper respiratory disease

Septicaemia (except in labour)

143

126

323

140

20

24

8

34

Northern Lincolnshire and Goole had higher than expected deaths after surgery in the year to March 2013 (52 deaths, compared with 37 expected).

Mortality – other alerts

Mortality among inpatients with diabetes

Rated as “very high” compared to all trusts (2 years to Mar-12).

30-day mortality following specific surgery / admissions

Stroke (high and improving 19% below national rate in 2010/11).

Fractured hip (average but improving 11% below national rate in

2010/11).

Non-elective surgery (not high but improving 6% below national rate in

2010/11).

VLAD charts with a negative SHMI trend

(year to Jun-12)

No. dips to the

lower control limit


Acute bronchitis

3

3

Northern Lincolnshire & Goole was rated “very high” for mortality among diabetic patients, in a report published by the Yorkshire and Humber Public Health Observatory (YHPHO) and the National Diabetes Information Service. The Health and Social Care Information Centre publish 30-day mortality rates following certain types of surgery or admission to hospital. These are not casemix adjusted, but the rates may be compared over time. Northern Lincolnshire & Goole’s 30-day Stroke mortality is high and improving substantially below the national average in the data to 2010-11 (published in Feb 2013). It is also below the national rate of improvement for Fractured hip and non-elective surgery, although the mortality rate is not high for these groups. Variable Life Adjusted Display (VLAD) charts are produced by the HSCIC to visualise the cumulative number of “statistical lives gained” over a period. A downward trend indicates a run of more deaths than expected compared to the national baseline and one with a sustained downward trend and multiple dips to the lower control limit may warrant further investigation. Northern Lincolnshire & Goole had such VLAD charts for two diagnosis group in the year to June 2012: acute cerebrovascular disease and acute bronchitis.

Source: Health & Social Care Information Centre – SHMI and contextual indicators, Dr Foster – HSMR.

In addition, Northern Lincolnshire & Goole had worse than expected mortality for Stroke on the Acute Trust Quality Dashboard (year to Q1 2012-13). It also had high excess deaths for Acute bronchitis (39 deaths, 64% more than expected), Acute cerebrovascular disease (35 deaths, 37% more than expected), Pneumonia (31 deaths, 12% more than expected) and COPD and bronchiectasis (24 deaths , 29% more than expected) in the HSCIC’s SHMI to September 2012.

Slide 39

Patient Experience Slide 40

Patient Experience

Overview:

The following section provides an insight into the Trust’s patient experience.

Review Areas:

To undertake a detailed analysis of the Trust’s Patient Experience it is necessary to review the following areas:

• Patient Experience, and

• Complaints.

Data Sources:

• Patient Experience Survey;

• Cancer Patient Experience Survey;

• Peoples’ Voice Summary; and

• Complaints data.

Summary:

Of the 9 measures reviewed within Patient Experience and Complaints there are two which are rated ‘red’.

Of the written complaints recorded by the Health and Social Care Information Centre, 74% related to clinical aspects of care. This is unusually high.

Three quarters of the individual comments captured by CQC’s patient voice monitoring were negative (50 out of 67). Comments highlighted a wide range of issues including victimisation of patients, pressure not to complain, poor complaints process, cold food, lack of communication, disrespectful comments, and lack of respect (particularly for dementia patients).

Whilst the inpatient survey was rated green overall, the Trust was below average on responses related to doctors talking in front of patients as if they were not there, and being treated with respect and dignity in general.


Patient Experience

Inpatient PEAT : environment

Cancer survey PEAT : food

PEAT : privacy and dignity Friends and family test

Patient voice comments

Complaints about clinical aspects

Ombudsman’s rating

Pa

tie

nt

Ex

pe

rie

nc

e

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.

Slide 42



N/A

Inpatient Experience Survey

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

Ac

ce

ss

an

d

Wa

itin

g Overall

Alteration of admission date by hospital

Length of time spent on waiting list

Length of time to be allocated a bed on a ward

Sa

fe,

Hig

h

Qu

ali

ty,

Co

or

din

ate

d

Ca

re

Overall

Consistency of staff communication

Delay of patient discharge

Information provided on post-discharge danger signals

Overall

Patient involvement in decision-making

Overall

Patient noise levels at night

Staff noise levels at night

Hospital/ward cleanliness

Slide 43

Be

tte

r

Info

rm

ati

on

, M

or

e C

ho

ice

Staff communication on purpose of medication provided

Staff communication on medication side-effects

Hospital food

Degree of privacy provided

Level of respect shown by staff

Overall staff effort to ease pain

Below expected range Within expected range Above expected range

Cle

an

, C

om

for

tab

le,

Fr

ien

dly

Pla

ce

to

B

e

Bu

ild

ing

Clo

se

r

Re

lati

on

sh

ips

Northern Lincolnshire and Goole performs above average on survey questions relating to staff communication on medication side-effects, but below average on those relating to the appropriateness of language used by doctors in front of patients and the level of respect shown by staff towards patients.

Source: Patient Experience Survey 2012/13

50

55

60

65

70

75

80

85

90

95

Patient experience and patient voice

Inpatient Survey

The national inpatient survey 2012 measures a wide range of aspects of patient experience. A composite ‘overall measure’ is calculated for use in the Outcomes Framework. This measure uses a pre-defined selection of 20 survey questions to rate the Trust on aspects including access to services, co-ordination of care, information & choice, relationship with staff and the quality of the clinical environment.

• England Average: 76.5

• Northern Lincolnshire & Goole: 77.5 (average)

Cancer Survey

• Of 58 questions, 1 was in the ‘top 20%’ and five in the ‘bottom 20%’.

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 67 comments on Northern Lincolnshire and Goole of which 50 were negative (75%). Comments highlighted a wide range of issues including victimisation of patients, pressure not to complain, poor complaints process, cold food, lack of communication, disrespectful comments, and lack of respect (particularly for dementia patients).

Slide 44

Overall patient experience score: Inpatients 2012


Source: Patient Experience Survey, Cancer patient experience survey

Trusts in

this review

National

results curve

England

average

Complaints Handling

• Data returns to the Health and Social Care Information Centre showed 305 written complaints in 2011-12. The number of complaints is not always a good indicator because stronger trusts encourage comments from patients. However, central returns are categorised by subject matter against a list of 25 headings. For this Trust, 74% of complaints related to clinical treatment (compared to the national average of 47%).

• A separate report by the Ombudsman, which the Trust requested, rates the Trust as B-rated for satisfactory remedies and low-risk of non-compliance. The Trust is identified as above average for conversion rate of complaints to trust becoming complaints to the Ombudsman. The Trust is also above average for poor explanation, and for factual errors in response. In addition, it receives a high number of physician complaints.

Safety and workforce Slide 45

Safety and Workforce

Overview:

The following section provides an insight into the Trust’s workforce profile and safety record. This section outlines whether the Trust is adequately staffed and is safely operated.

Review Areas:

To undertake a detailed analysis of the Trust’s Safety and Workforce it is necessary to review the following areas:

• General Safety;

• Staffing;

• Staff Survey;

• Litigation and Coroner; and

• Analysis of patient safety incident reporting.

Data Sources:

• Acute Trust Quality Dashboard, Oct 2011 – Mar 2012;

• Safety Thermometer, Apr 12 – Mar 13;

• Litigation Authority Reports;

• GMC Evidence to Review 2013;

• National Staff Survey 2011, 2012;

• 2011/12 Organisational Readiness Self-Assessment (ORSA);

• National Training Survey, 2012; and

• NHS Hospital & Community Health Service (HCHS), monthly workforce statistics.

Summary:

Northern Lincolnshire and Goole is ‘red rated’ in three of the safety indicators: MRSA infection rates, pressure ulcer rates and clinical negligence scheme payments.

The Trust reported more patient safety incidents and is rated ‘green’. This may be because the Trust is recognising patient safety incidents more fully and completely than similar trusts. It recorded 446 incidents reported as either moderate, severe or death between April 2011 and March 2012 and three ‘never events’ between 2009 and 2012. Throughout the last 12 months, Northern Lincolnshire and Goole has been consistently above the national rate, as well as that of the 14 trusts selected for this review for new pressure ulcers, breaching the latter rate every month from June 2012 onwards. Northern Lincolnshire and Goole’s Clinical Negligence payments exceeded contributions to the ‘risk sharing scheme’ by around £3.4m in 2009-10, although the situation has improved over the following two years. They flagged on just one item in the Rule 43 Coroner report.

The Trust is ‘red rated’ in 14 of the workforce indicators. It notably has sickness absence rates above the national mean and also spends a greater percentage of its total expenditure on agency staff than the median. It also has low levels of staff engagement and has a low score for the training of its doctors.


x Medication error Pressure ulcers

Safety



Sp

ec

ific

s

afe

ty

Me

as

ur

es

MRSA

C diff

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.

Slide 47

Outcome 1 (R17) Respecting and involving people who use services

Clinical negligence scheme payments

Rule 43 coroner reports

Lit

iga

tio

n a

nd

C

or

on

er

“Harm” for all four Safety Thermometer Indicators

Ge

ne

ra

l

Reporting of patient safety incidents

Number of harm incidents reported as ‘moderate, severe or death’ from April ‘11 to March ’12 446

Number of ‘never events’ (2009-2012) 3

Safety Analysis

Rate of reported patient safety incidents per 100 admissions (April –

September 2012)

Northern Lincolnshire and Goole Median rate for large acutes

8.8 6.2

The Trust has reported more patient safety incidents than similar trusts. Organisations that report more incidents may have a stronger and more effective safety culture. Northern Lincolnshire and Goole has a rate of 8.8 for its patient safety incident reporting per 100 admissions. Northern Lincolnshire and Goole has a higher than average rate of MRSA infection for the three year period. Its MRSA infection rate is the 33rd highest out of 143 trusts. Its infection rate relative to other trusts has improved in 2012, but it remains in the lower third nationally for its performance levels.

Source: incidents occurring between 1 April 2012 to 30 September 2012 and reported to the National Reporting and Learning System

NLAG

0.0

1.0

2.0

3.0

4.0

5.0

6.0

3 year z score

+ 2

MRSA 2010 - 2012 Combined z score of rates per bed day

over the 3 separate years with the value 2 added so that all values are shown as

positive

Trusts under review All non specialist trusts NLAG Northern

Lincolnshire

and Goole


Safety Incident Breakdown

Since 2009, three ‘never events’ have occurred at Northern Lincolnshire, classified as such because they are incidents that are so serious they should never happen. The patient safety incidents reported are broken down into five levels of harm below, ranging from ‘no harm’ to ‘death’. 70% of incidents which have been reported at Northern Lincolnshire have been classed as ‘no harm’, with 24% ‘low’, with 5% ‘moderate’, and 13 and 5 occurrences of incidents classified as ‘severe’ and ‘death’ respectively. When broken down by category, the most regular occurrences of patient incident at Northern Lincolnshire are in ‘patient accident’ and ‘treatment procedure’.

Source: Freedom of information request, BBC - http://www.bbc.co.uk/news/health-22466496

Never Events Breakdown (2009-2012)

Retained foreign object post-operation 3

Total 3

Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12 Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12

Breakdown of patient incidents by degree of harm

Breakdown of patient incidents by incident type

5790

2014

428 13 5

0

1000

2000

3000

4000

5000

6000

7000

No Harm Low Moderate Severe Death 0 500 1000 1500 2000 2500

Patient accident

All others categories

Treatment, procedure

Implementation of care and ongoing …

Access, admission, transfer, discharge

Documentation

Medication

Clinical assessment

Infrastructure

Consent, communication, confidentiality

Medical device / equipment

Pressure ulcers

This slide outlines the total number of pressure ulcers and the number of new pressure ulcers broken down by category for the last 12 months. Due to the effects of seasonality on hospital acquired pressure ulcer rates, the national rate has been included which allows a comparison that takes this in to account. This provides a comparison against the national rate as well as the 14 trusts selected for the review.

Throughout the last 12 months, Northern Lincolnshire and Goole has been consistently above the national rate, as well as that of the 14 trusts selected for this review, for new pressure ulcers, breaching the latter rate every month from June 2012 onwards.

From the data, it is apparent that the prevalence rate of total pressure ulcers for Northern Lincolnshire and Goole has seen no definitive trend from June 2012 onwards.

The data is inclusive of community services. Source: Safety Thermometer Apr 12 to Mar 13 Slide 50

New pressure ulcer analysis

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Number of records submitted 0 0 185 963 985 1038 1010 1086 931 1026 902 1000

Trust new pressure ulcers 0 0 3 19 25 10 11 20 10 14 13 29

Trust new pressure ulcer rate 0% 0% 1.6% 2.0% 2.5% 1.0% 1.1% 1.8% 1.1% 1.4% 1.4% 2.9%

Selected 14 trusts new pressure

ulcer rate 1.4% 1.5% 1.4% 1.5% 1.5% 0.9% 1.0% 1.1% 0.9% 1.1% 1.0% 1.2%

National new pressure ulcer rate 1.7% 1.7% 1.5% 1.5% 1.4% 1.3% 1.2% 1.2% 1.2% 1.3% 1.3% 1.3%

Total pressure ulcer prevalence percentage

Apr-12 May-12 Jun-12 Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Number of records submitted 0 0 185 963 985 1038 1010 1086 931 1026 902 1000

Trust total pressure ulcers 0 0 3 74 59 50 58 76 43 60 43 87

Trust total pressure ulcer rate 0.0% 0.0% 1.6% 7.7% 6.0% 4.8% 5.7% 7.0% 4.6% 5.8% 4.8% 8.7%

Selected 14 trusts total pressure

ulcer rate 6.4% 6.2% 6.5% 7.0% 6.3% 5.5% 5.4% 5.9% 5.8% 6.0% 5.7% 6.2%

National total pressure ulcer rate 6.8% 6.7% 6.6% 6.1% 6.0% 5.5% 5.4% 5.3% 5.2% 5.4% 5.6% 5.3%

0.0% 0.0%

1.6%

2.0%

2.5%

1.0% 1.1%

1.8%

1.1% 1.4% 1.4%

2.9%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

-

5

10

15

20

25

30

35

New pressure ulcers prevalence

Category 2 Category 3 Category 4 Rate

0.0% 0.0%

1.6%

7.7%

6.0%

4.8%

5.7%

7.0%

4.6% 5.8%

4.8%

8.7%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

-

10

20

30

40

50

60

70

80

90

100

Total pressure ulcers prevalence

Category 2 Category 3 Category 4 Rate

Litigation and Coroner

Clinical negligence payments

Clinical negligence scheme analysis Northern Lincolnshire and Goole’s Clinical Negligence payments exceeded contributions to the ‘risk sharing scheme’ by around £3.4m in 2009-10, although the situation has improved over the following two years.

Slide 51

2009/10 2010/11 2011/12

Payouts (£000s) 8,303 6,560 4,056

Contributions (£000s) 4,868 5,408 6,009

Variance between

payouts and contributions

(£000s)

-3,435 -1,152 1,953

Source: Litigation Authority Reports

Coroners’ Rule The review examined all eight rule 43 bulletins published since the Coroner's rules were amended in July 2008. These flagged just one item: • “To consider staff training and observation levels for

patients undergoing surgical anastomosis to ensure staff fully appreciate consequences of anastomic leakage.”

This item was flagged in the second report published by the Ministry of Justice, which covered the period April 09 to September 09, and related to Lincoln County Hospital. Although this location does not constitute one of the Trust’s primary sites, the hospital does provide some services for Northern Lincolnshire and Goole. A response was received from the Trust, and there are no outstanding rule 43 reports.

Workforce W

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kfo

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nd

ica

tor

s

Outcome 1 (R17) Respecting and involving e who u se services

WTE nurses per bed day

Spells per WTE staff

Vacancies –medical

Vacancies - Non-medical

Consultant appraisal rates

Agency spend



Sta

ff S

ur

ve

ys

an

d

De

an

er

y

x

Sickness absence- Overall

Sickness absence- Medical

Sickness absence -Nursing staff Sickness absence - Other staff Staff leaving rates Staff joining rates

Response Rate from National Staff Survey 2012 Staff Engagement from NSS 2012 Training Doctors – “undermining” indicator GMC monitoring under “response to concerns process”

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.

Overall Rate of Patient Safety Concerns 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

Medical Staff to Consultant Ratio

Nurse Staff to Qualified Staff Ratio

Non-clinical Staff to Total Staff Ratio Consultant Productivity (FTE/Bed Days) Nurse Hours per Patient Bed Day

2.64 1.88 0.37 434.37 8.83

Slide 52

Ac

ute

In

ter

na

l M

ed

icin

e

Overall satisfaction

Clinical supervision

Workload

Handover

Adequate experience

Educational supervision

Feedback

Induction

Undermining

Access to educational resource

Local teaching

Study leave

Regional teaching

General Medical Council (GMC) National Training Scheme Survey 2012

The below summarises the output from the General Medical Council National Training Scheme 2012 Survey Results Given the volume of data only specialties with red outliers are noted below (where those specialties also have green outliers, they are included).

Slide 53 Red outlier Within expected range Green outlier

An

ae

sth

eti

cs



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

Em

er

ge

nc

y M

ed

icin

e



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

General Medical Council (GMC) National Training Scheme Survey 2012 continued…

The GMC Survey results continue as follows.


En

do

cr

ino

log

y a

nd

dia

be

tes

m

ell

itu

s



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

Ge

ne

ra

l P

ra

cti

ce



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching




Op

hth

alm

olo

gy



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

Oto

lar

yn

go

log

y



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching




Pa

ed

iatr

ics



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching



In addition to the green outliers displayed, Obstetrics and Gynaecology has one green outlier for workload and Respiratory Medicine has four green outliers for overall satisfaction, adequate experience, feedback, and access to educational experience.

Tr

au

ma

an

d O

rth

op

ae

dic

Su

rg

er

y Overall satisfaction


Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching


Ur

olo

gy



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

0%

20%

40%

60%

80%

100%

Consultant appraisal rate, 2011/12

Trusts covered by review All other trusts


0

5

10

15

20

25

30

35

40

45

50

Spells

per

WT

E

Spells per WTE for Acute Trusts

Trusts covered by review All Trusts

Agency Staff (2011/12)

N Lincolnshire and

Goole Expenditure

Percentage of

Total Staff Costs

Median within

Region

£7.3m 3.5% 2.7%

Number of FTEs (Dec 11-Nov 12 average) 4,892

Workforce Analysis

Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics

Northern Lincolnshire and Goole has a patient spell per whole time equivalent rate of 22, which is below average capacity in relation to the other trusts in this review and nationally. The data shows that the Trust’s agency staff costs, as a percentage of total staff costs, are higher than the median within the region. The data also illustrates that the Trust

northern lincolnshire and goole hospitals nhs foundation ......9th july, 2013 overview on 6th...

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