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Colchester Hospital University NHS Foundation Trust Data Pack 5th June, 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

Colchester Hospital University NHS Foundation Trust

Context

A brief overview of the Colchester and Tendring areas and Colchester Hospital University 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:

Colchester Hospital University NHS Foundation Trust in Essex services a population of 508,000 across both Colchester and Tendring, which makes the Trust slightly larger than the size recommended by the Royal College of Surgeons. 8% of Colchester’s population belong to non-White ethnic minorities, particularly Chinese and other Asians, while only 2.5% of Tendring’s population belong to the same category. Smoking in pregnancy and a high rate of statutory homelessness are among the most prominent health and social problems in Colchester. In Tendring, adult physical education is significantly below the national average as is the proportion of the population achieving 5 Cs or better in their GCSEs.

The Trust has two main hospital sites, Colchester General Hospital and Essex County Hospital. In addition, the Trust provides services at three community hospitals. Colchester became a Foundation Trust in 2008 and has a total of 644 beds. It has a 76% market share of inpatient activity within a 5 mile radius of the Trust sites. However, the Trust’s market share falls to 72% within a radius of 10 miles, and 45% within a radius of 20 miles.

A review of ambulance response times shows that the East of England Trusts meet the national 8min response target, but not the 19min response target.

Finally, Colchester’s SHMI level has been above the expected level for the last 2 years and the Trust was therefore selected for this review.

Slide 5

All data and sources used are 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 644 81.1% 86%

General and

Acute

597 83.5% 88%

Maternity 47 49.8% 59%

Trust Status Foundation Trust (2008)

Inpatient/Outpatient Activity (Jan12-Dec12)

Inpatient Activity Elective

50,699 (53%)

Day Case Rate:

84%

Non Elective 44,113 (47%)

Total 94,812

Outpatient Activity Total 495,731

Colchester became a Foundation Trust in 2008. The Trust provides core services for the population of North East Essex with a population of approximately 370,000 people. The Trust also provides specialist services for oncology/radiotherapy for the population of Mid Essex and hosts inpatient vascular services for the population of Suffolk. The Trust owns two hospital sites (Colchester General Hospital and Essex County Hospital) and provides outreach services in three community hospitals (Clacton, Harwich, and Halstead). These community hospital sites are owned and run by the local community providers. The Trust has a lower bed occupancy than the national average. It offers a substantial range of services, and in 2012, the Trust saw 495,731 Outpatient attendances and 94,812 Inpatient attendances.

Trust Overview

Departments and Services

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

Adolescent Services, Dermatology, Diabetic Medicine, Diagnostic

Pathology, Diagnostic Physiological Measurement, Dietetics, ENT,

Endocrinology and Metabolic Medicine, Gastro Intestinal and Liver

Services, General Medicine, General Surgery, Geriatric Medicine,

Gynaecology, Haematology, Maternity Service, Neurology,

Nephrology, Ophthalmology, Oral and Maxillofacial Surgery,

Orthopaedics, Pain Management, Physiotherapy, Plastic Surgery,

Respiratory Medicine, Rheumatology, Urology, Vascular Surgery

Colchester Hospitals NHS Foundation Trust

Acute Hospital Colchester General Hospital

Outpatient Hospital Essex County Hospital

Outreach services to

Community Hospitals

Clacton Hospital, Harwich Hospital,

Halstead Hospital

Slide 6

Source: Department of Health: Transparency Website

Source: Healthcare Evaluation Data (HED)

Source: NHS Choices

Finance Information

2012–2013 Income £258m

2012–2013 Expenditure £236m

2012–2013 EBITDA £22m

2012–2013 Net surplus (deficit) £9m

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: NHS Choices

Source: Colchester Hospital University NHS Foundation Trust, Board of Directors’ Meeting, 9 May 2013, Quarter 4 Performance Report 2012/13 A map of Colchester General Hospital is included in the Appendix.

0

200

400

600

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Trusts

Outpatient Activity by Trust

Trusts Covered by Review National Outpatient Activity Curve

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Num

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Inpatient Activity by Trust

Trusts Covered by Review National Inpatient Activity Curve

Trust Overview continued...

Colchester 94,812

Colchester 495,731

Top 10 Inpatient Main Specialties as a

% of Total Inpatient Activity

General Surgery 13%

Clinical Oncology 9%

Paediatrics 8%

General Medicine 8%

Gastroenterology 7%

Gynaecology 7%

Urology 7%

Trauma & Orthopaedics 7%

Geriatric Medicine 5%

Clinical Haemotology 5%

Bottom 10 Inpatient Main Specialties

and Spells

Nursing Episode 24

Rheumatology 217

Neurology 259

Radiology 352

Plastic Surgery 502

Dental Medicine 644

Anaesthetics 912

Dermatology 1157

Nephrology 1200

Allied Health Professional Episode 1263

Top 10 Outpatient Main Specialties as

a % of Total Outpatient Activity

Allied Health Professional Episode 26%

Nursing Episode 10%

Midwifery 9%

Trauma & Orthopaedics 8%

Ophthalmology 7%

Gynaecology 5%

General Surgery 4%

Ear, Nose & Throat (ENT) 3%

Clinical Oncology 3%

Paediatrics 3%

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

Colchester is a medium sized Trust for inpatient activity, relative to both the 14 Trusts selected for this review and the rest of England. However, the Trust is in the upper quartile of all those nationally for outpatient activity.

General Surgery and Clinical Oncology are the largest inpatient specialties while Allied Health Professional Episodes and Nursing Episodes are the largest for outpatients.

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

Essex, in which Colchester is situated, is not a particularly deprived region of England. The age distribution in Colchester is largely similar to that of England as a whole; however, Colchester has significantly more women and men in their 20s. Smoking in pregnancy is a particular health concern in this region, where statutory homelessness is also much more common than in England as a whole. 8% of Colchester’s population belong to non-White minorities, particularly including Chinese and other Asians.

Colchester Area Overview

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

FACT BOX

Population 370,000

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,

Essex is the 119th most deprived.

Ethnic

diversity

In Colchester, 8.0% belong to non-

White minorities, including 1.4%

Other Asian and 1.0% Chinese.

Rural or

Urban

Colchester is a rural-urban region.

Smoking in

pregnancy

In Colchester, smoking in pregnancy

is significantly more common than in

the country as a whole.

Statutory

homelessness

Statutory homelessness is

significantly more common in

Colchester than in the country as a

whole.

Slide 8

Source: Colchester Hospital University NHS Foundation Trust website; 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+

Colchester Area Demographics

Female/COL Female/ENG Male/COL Male/ENG

The district of Tendring in Essex is a slightly deprived local authority of England. The population of Tendring is old compared to the population of England as a whole and has a significantly larger proportion of people aged 60 and above. Lack of adult physical activity is a particular health concern in Tendring, where education levels are also relatively low compared to England as a whole. 2.5% of Tendring’s population belongs to non-White ethnic minorities, with the largest minority of 0.4% being White and Black Caribbean.

Tendring Area Overview

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

FACT BOX

Population 138,000

IMD Of 326 English local authorities,

Tendring is the 86th most deprived.

Ethnic

diversity

In Tendring, 2.5% belong to non-

White minorities, including 0.4%

White and Black Caribbean.

Rural or

Urban

Tendring is a rural-urban district.

Adult physical

activity

In Tendring, adult physical activity is

significantly below the national

average.

Education In Tendring, the proportion of the

population achieving 5 Cs or better in

their GCSEs is significantly below the

national average.

Slide 9

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+

Tendring Area Demographics

Female/TEN Female/ENG Male/TEN Male/ENG

Colchester and Surrounding Areas Geographic Overview

The wheel on the left shows the market share of Colchester Hospital University NHS Foundation Trust. From the wheel it can be seen that Colchester has a 76% 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 72% within 10 miles and 45% within 20 miles.

The wheel shows that the main competitors in the local area are Ramsay Healthcare UK Operations Ltd and Mid Essex Hospital Services NHS Trust.

The map on the right shows the location of Colchester geographically within Essex, a rural-urban area located in the East of England. As shown on the map, Colchester is located near several larger roads, and in-between the urban areas of Chelmsford and Ipswich.

Slide 10

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

Source: © Google Maps

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.

Colchester’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 Colchester and Tendring compared nationally.

The tables below outline Colchester and Tendring’s health profile information in comparison to the rest of England.

1. Colchester are performing better than the national average on all community indicators apart from Statutory homelessness. Tendring have higher rates of children in poverty and unemployment than the national average.

2. Children’s and young people’s health indicators highlight that smoking in pregnancy is higher than the average in Colchester and Tendring. Tendring also has a higher number of obese children.

1

2

Colchester

Slide 11

Deprivation by unitary authority area

Tendring


3. Adult health in Colchester shows all indicators to be close to the national average. Increasing and higher risk drinking is below the national average but is still within the expected range. In Tendring, there are fewer physically active adults than the national average.

4. Disease and poor health indicators highlight acute sexually transmitted infections as being above the national average. Tendring has a high number of people diagnosed with diabetes and is above the national average.

5. The number of excess winter deaths and road injuries and deaths are higher than the national average in Colchester but within the expected range.

3

4

Slide 12


3. The number of excess winter deaths and road injuries and deaths are higher than the national average in Colchester but within the expected range. Tendring also has a higher number of road injuries and deaths than the national average but is not significantly higher than the national average.

5

Slide 13

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 14

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 times may increase the risk of mortality. The graphs on the right represent some key performance indicators for England’s Ambulance services. The East of England Ambulance Trust meets the 8min response target. However, the ambulance trust fails to meet the 19min response target.

Source: Department of Health: Transparency Website Dec 12

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. Colchester has been above the expected level for SHMI over the last 2 years and was therefore selected for this review.

Why was Colchester 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

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

Slide 15

Why was Colchester chosen for this review?

HSMR Time Series HSMR Funnel Chart

SHMI Funnel Chart SHMI Time Series

Colchester

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 Colchester’s SHMI is statistically above the expected range, supported by the time series which shows the SHMI being consistently higher than the expected. Colchester’s HSMR is within the expected range, and the time series shows the HSMR has recently risen back above the expected level.

Colchester


Slide 16 Source: Healthcare Evaluation Data (HED); Apr 10-Mar12

Mortality

Slide 17

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 106 for the period January 2012 to December 2012, meaning that the number of actual deaths is higher than the expected level. However, this is statistically within the expected range.

Further analysis of this demonstrates that non-elective admissions are the primary contributing factor to this figure, with a similar HSMR of 107, also within the expected range. Elective admissions are within the expected range also, at 93

Currently, Colchester has a SHMI of 118, 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 118. Elective admissions are within the expected range, with a SHMI of 123.

Colchester has had three high mortality alerts for diagnostic groups since 2007.

A common theme has arisen around Elderly Care, with much higher than expected mortality for patients aged 75+. The Trust has an initiative to reduce the number of avoidable admissions for patients at end of life, possibly reflected in its high but declining use of palliative care codes. Other areas previously identified for improvement action include earlier recognition and escalation of the deteriorating patient, the quality of documentation such as the ceiling of care and clinical coding.

Slide 18 All data and sources used are consistent across the packs for the 14 trusts included in this review.

Mortality Overview

Slide 19

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

Outside expected range

Within expected range

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

*Based on Poisson distribution . This is a narrower set of confidence intervals compared to the Random effects model, which the HSCIC report whether the SHMI is within, below or above the expected range, and serves to give an earlier warning for the purposes of this review.

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 20

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 21

Some key differences between SHMI and HSMR

Slide 22

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 23

Month-on-month time series

Year-on-year time series

The Trust’s SHMI level for the past 12 months (Dec11-Nov12) is 118, 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 very slight general trend of increasing SHMI month-on-month, and a stable trend year-on-year.

SHMI funnel chart –12 months

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

Colchester


SHMI Statistics This slide demonstrates the

number of mortalities in and out of hospital for Colchester.

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 70.2% of SHMI deaths occur in hospital at Colchester, 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

Colchester 70.2%

Slide 24


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tal m

edicin

e

Ob

stetrics

Gy

na

ecolo

gy

Po

dia

try

Clin

ical o

nco

log

y (2

65

, 7)

Interv

entio

na

l Ra

dio

log

y

Treatment Specialties

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 Colchester has a SHMI of 118 which is above the expected range. The number of observed deaths are highlighted as being above the expected level in Clinical Oncology for elective admissions, and in General medicine, Neonatology, Geriatric Medicine and Obstetrics for non-elective admissions. These are potential areas for review.

Slide 25

Higher than expected (above the 95th confidence interval)


Lower than expected (below the 95th confidence interval)

Source: Healthcare Evaluation Data (HED). Dec 11 – Nov 12

Overall Trust

Elective

SHMI 118

SHMI 123


SHMI 118

Diagnosis (100 ; 1 )

SHMI Observed deaths that are higher than the expected

Key

Elective (123; 9)

SHMI sub-tree of specialties

The SHMI sub-tree highlights the specialties for non-elective admissions with a statistically higher SHMI than expected and highlights the diagnostic groups with at least four more observed deaths than expected. When identifying areas to review, it is important to consider the number of deaths as well as the SHMI. General medicine has the highest number of greater than expected deaths, shown on the next slide. Within Geriatric medicine, Acute cerebrovascular disease (8) and Urinary tract infections (9) are seen as the main diagnostic groups contributing to this. Obstetrics and Neonatology both have one diagnostics group with four or more observed deaths above the expected level.

Slide 26

Diagnostic Groups

Source: Health Evaluation Data (HED) – Dec 2011 – Nov 2012 The diagnostic groups with 1 to 3 more observed deaths than the expected are listed in the Appendix.





118.2

\

General Medicine (124, 252)

(Full table shown on the next slide)

Non-elective (118; 328)

Overall (118; 337)

Clinical Oncology (265, 7)



Key

\ \ \

Neonatology (402, 14) Geriatric Medicine (123, 50) Obstetrics (1846, 6)

Short gestation; low birth weight; and fetal growth retardation ( 285 6 )

Other perinatal conditions ( 14980 5 )

Acute cerebrovascular disease ( 116 8 )

Acute and unspecified renal failure ( 144 4 )

Urinary tract infections ( 190 9 )

SHMI sub-tree of specialties continued

Slide 27

Diagnostic Groups






\





Key

Acute bronchitis ( 134, 9)

Acute cerebrovascular disease ( 128, 16)

Aspiration pneumonitis; food/vomitus ( 125, 5)

Cancer of bladder ( 205, 4)

Cancer of bronchus; lung ( 127, 8)

Chronic obstructive pulmonary disease and bronchiectasis ( 124, 10)

Chronic ulcer of skin ( 208, 5)

Congestive heart failure; nonhypertensive ( 114, 9)

Coronary atherosclerosis and other heart disease ( 149, 4)

Diabetes mellitus with complications ( 274, 4)

Gastrointestinal hemorrhage ( 141,9)

Intestinal infection ( 124, 4)

Leukemias ( 164, 4)

Malignant neoplasm without specification of site ( 169, 4)

Non-Hodgkin`s lymphoma ( 227, 4)

Open wounds of head; neck; and trunk ( 194, 4)

Other gastrointestinal disorders ( 159, 7)

Other injuries and conditions due to external causes ( 290, 6)

Other lower respiratory disease ( 139, 5)

Other upper respiratory disease ( 260, 6)

Peripheral and visceral atherosclerosis ( 190, 4)

Pneumonia ( 115,28)

Residual codes; unclassified ( 205, 6)

Secondary malignancies ( 142, 6)

Senility and organic mental disorders ( 142, 7)

Septicemia (except in labor) ( 114, 4)

Skin and subcutaneous tissue infections ( 163, 7)

Spondylosis; intervertebral disc disorders; other back problems ( 200, 4)

Urinary tract infections ( 131, 15)

Within General medicine, the diagnostic groups with the highest numbers of observed deaths above the expected level are pneumonia (28), acute cerebrovascular disease (16) and urinary tract infections (15).

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 Colchester was 117 in the year to Sept-12 (England baseline = 100) and has been above the expected range in all but the earliest period.

Source: Health & Social Care Information Centre – SHMI

SHMI published by HSCIC, Colchester FT

113115 117 118 118 116 117

80

85

90

95

100

105

110

115

120

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 for the past 12 months (Jan 12-Dec 12) is 106, which means, as shown below, although it is above 100, it is within the expected range and so not classified as an outlier. The time series show no real trend 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 93 and 126. HSMR funnel plot –12 months

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

Colchester


HSMR Statistics

The table to the right shows Colchester’s HSMR broken down by admission type. The breakdown illustrates the overall HSMR is 106 which is within the expected range. The table identifies that both elective and non-elective admissions have an HSMR within the expected range. Mortality from weekend admissions are highlighted as being above the expected level, due to the high non-elective admissions.

Slide 30

HSMR Weekend Week All

Elective 160 91 93

Non-elective 121 102 107

All 121 102 106

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 of 111, and 25 observed deaths that are higher than the expected);

• Chronic obstructive pulmonary disease and bronchiectasis (132, 14);

• Urinary tract infections (117, 9);

• Skin and subcutaneous tissue infections (159, 8);

• Intestinal obstruction without hernia (154, 8); and

• Acute bronchitis (130, 8).

Slide 31


Mortality - HSMR Tree

The tree shows that the HSMR for Colchester is 106 which is within 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, however both admission types are within the expected range. Within non-elective admissions General Medicine and Obstetrics have the highest number of observed deaths above the expected level. *Obstetrics was not highlighted as an outlier on HED, however with HSMR of 2090 and with 13 observed deaths above the expected level, it is an area for potential review.

Slide 32 Source: Healthcare Evaluation Data (HED). Jan 12 – Dec 12


HSMR Observed deaths that are higher than the expected

Key

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

Gen

eral S

urg

ery

Uro

log

y

Brea

st Su

rgery

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

No

t a T

reatm

ent F

un

ction

Critica

l Ca

re Med

icine

Gen

eral M

edicin

e (116, 117

)

Ga

stroen

terolo

gy

En

do

crino

log

y

Clin

ical H

aem

ato

log

y

Dia

betic M

edicin

e

Ca

rdio

log

y

Derm

ato

log

y

Th

ora

cic Med

icine

Nep

hro

log

y

Neu

rolo

gy

Clin

ical N

euro

ph

ysio

log

y

Pa

edia

trics

Neo

na

tolo

gy

Geria

tric Med

icine

Ob

stetrics (20

90

, 13)

Gy

na

ecolo

gy

Clin

ical O

nco

log

y

Interv

entio

na

l Ra

dio

log

y

Non Elective

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

Gen

eral S

urg

ery

Uro

log

y

Brea

st Su

rgery

Va

scula

r Su

rgery

Tra

um

a &

Orth

op

aed

ics

Ea

r, No

se an

d T

hro

at (E

NT

)

Ga

stroen

terolo

gy

Clin

ical H

aem

ato

log

y

Ca

rdio

log

y

Th

ora

cic Med

icine

Nep

hro

log

y

Pa

edia

trics

Geria

tric Med

icine

Gy

na

ecolo

gy

Clin

ical O

nco

log

y

Interv

entio

na

l Ra

dio

log

y





Overall Trust

Elective

HSMR 107

HSMR 93


HSMR 106

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 (27) and chronic obstructive pulmonary disease and bronchiectasis (10).Within Obstetrics, other perinatal conditions has the highest number of above expected deaths (13).

Slide 33


Diagnostic Groups

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.




118.2



Overall (106, 78)

Obstetrics* (2090, 13)


HSMR Observed deaths that are higher than the expected

Key

*Obstetrics was not highlighted as an outlier on HED, however with HSMR of 2090 and with 13 observed deaths compared to an expected level of 0.3, it is an area for potential review.

Other perinatal conditions (2099, 13) Acute bronchitis (144, 9)

Acute cerebrovascular disease (107, 4)

Aspiration pneumonitis; food/vomitus (125, 5)

Cancer of bronchus; lung (128, 6)

Chronic obstructive pulmonary disease and bronchie (127, 10)

Congestive heart failure; nonhypertensive (110, 5)

Deficiency and other anemia (216, 5)

Gastrointestinal hemorrhage (132, 5)

Other lower respiratory disease (183, 7)

Pneumonia (except that caused by tuberculosis or s (115, 27)

Septicemia (except in labor) (113, 4)

Skin and subcutaneous tissue infections (166, 6)

Urinary tract infections (113, 5)

HSMR – Dr Foster

The HSMR time series for Colchester from Dr Foster shows variation 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 from 2008/09. Colchester FT’s latest SHMI published by the HSCIC, for Oct 11 to Sept 12, is higher than the Dr Foster HSMR for the same period, which may be due to a number of factors. Dr Foster have made the following adjustments to show differences explained by these factors: • Adjustment for palliative care: used the SHMI observed deaths

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

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

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

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

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

Source: Dr Foster HSMRs, HSCIC SHMI

Slide 34

Com parison of m ortality m easures,

Colchester FT

101

115

112

117

85

90

95

100

105

110

115

120

125

SHMI SHMI adjusted

for palliative

care

SHMI in

hospital

deaths only

HSMR

Time series of HSMR, Colchester FT

102

107

98

112

90

95

100

105

110

115

120

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

HSMR 95% Confidence intervalII

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

Colchester

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 Colchester, it is apparent that for elective admissions, the Trust has been consistently performing below the national average. However, it should be noted that the Q2/Q3 average diagnosis coding depth is close to the national average. The average diagnosis coding depth for non-elective admissions has also been close to the national average and the most recent quarter shows the trust is above the national average and the average of the 14 trusts in this review.


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

Colchester

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. Colchester’s percentage of admissions with palliative care coding is consistently above the national average. However, there has been a recent reduction. This may relate to an initiative at the Trust, due for completion by April 2013, to reduce the number of avoidable admissions for patients at end of life.

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

Percentage of admissions with palliative care

coding

-

0.5

1.0

1.5

2.0

2.5

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

SHMI publicationColchester National

Percentage of deaths with palliative care

coding

-

5

10

15

20

25

30

35

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

SHMI publicationColchester National

Slide 36

Care Quality Commission findings

Emergency specialty groups much worse than expected

Sep 11 to Aug 12 3

Respiratory medicine

Neurology (but small numbers)

Dermatology

Emergency specialty groups worse than expected

Sep 11 to Aug 12 2

Other injuries due to external causes

Nephrology

Diagnosis group alerts (2007 to date)

Alerts to CQC 3

Alerts followed up by CQC 3

Recent diagnosis group alerts pursued by CQC

Complex elderly with a respiratory system primary diagnosis (Nov 10)

Intestinal obstruction without hernia (Nov 11)

Diabetes mellitus with complications (Sep 12)

Any related patient groups alerting more than once since 2007

None

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 Colchester, the common theme that has arisen across the patient groups alerting since 2007 is Elderly Care, with much higher than expected mortality for patients aged 75+. There are common themes arising from responses to the CQC from the Trust around deteriorating patients at end of life stage, clinical coding of co-morbidities and clinical pathways and ceiling of care. Colchester appear to have been active in monitoring and investigating mortality concerns. In addition to reducing avoidable end of life admissions, areas previously identified for improvement action include earlier recognition and escalation of the deteriorating patient, the quality of documentation such as the ceiling of care and clinical coding.

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 three diagnosis groups and no procedure groups with above expected SMRs in Colchester, which may highlight potential areas for review. Two diagnosis groups had evidence of above expected mortality for weekend admissions but not for weekday ones. One of these, deficiency and other anaemia, had a high SMR overall, although the other, senility and organic mental disorders, did not. 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, Colchester had CUSUM alerts for three diagnosis groups. However, none of these alerts were within groups that had a high SMR.

Source: Dr Foster HSMR, SMRs, CUSUM alerts

Slide 38

Apr 2012 to Mar 2013 Diagnosis groups Procedure groups

SMRs above expected 3 0

CUSUM alerts 3 0

Diagnosis groups with SMRs above expected SMR Obs – Exp

deaths

Deficiency and other anaemia

Other upper respiratory disease

Pneumonia

230

210

117

10

6

40

Mortality – other alerts

VLAD charts with a negative SHMI trend

(year to Jun-12)

No. dips to the

lower control limit

Acute cerebrovascular disease 4

Variable Life Adjusted Display (VLAD) charts are produced by the Health & Social Care Information Centre (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. On a review of the data it was apparent that although there was not only one area with a negative trend, there was only one area with a significant negative trend and several dips to the lower control limit in the year to June 2012: acute cerebrovascular disease. Colchester had high observed deaths above the expected for ccute cerebrovascular disease (37 deaths, 33% more than expected) and pneumonia (32 deaths, 14% more than expected) in the HSCIC’s SHMI to September 2012.

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

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, Colchester is rated ‘red’ on just one: The Ombudsman’s rating of their complaints processes, where the Trust is C-rated (the lowest category).

There is an above average rate of escalation for complaints becoming complaints to the Ombudsman, high average compensation payments and one case of service failure indicating wider organisation failure.

The Trust scores reasonably well on patient surveys, with some concerns about consistency of information provided by staff, the quality of hospital food, information provided on post-discharge danger signals, and waiting times.

Slide 41

All data and sources used are consistent across the packs for the 14 trusts included in this review.

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



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

Inpatient Experience Survey

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

Colchester scores above average on survey questions relating to coherent discharge processes and the appropriateness of language used by doctors in front of patients, but below average on those relating to the length of time spent on waiting lists, the consistency of staff communication, the degree of information provided on post-discharge danger signals, and the quality of hospital food.

Source: Patient Experience Survey 2012/13

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

• Colchester: 75.3 (average)

Cancer Survey

• Of 58 questions, 10 were in the ‘top 20%’ and 6 were in the ‘bottom 20%’ (including two questions about treatment as a day case or outpatient)

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 126 comments on Colchester of which 42 were negative (33%). Negative comments highlighted communication from staff, lack of clear information, responsiveness of staff, as well as some concerns about waiting times and discharge processes.

Slide 44

Overall patient experience score: Inpatients 2012

50

55

60

65

70

75

80

85

90

95 Colchester 75.3

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 551 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, 48% of complaints related to clinical treatment (in line with the national average of 47%).

• A separate report by the Ombudsman rates the Trust as C-rated for satisfactory remedies and low-risk of non-compliance. This is the worst rating. There is an above average rate of escalation of complaints to the Ombudsman, high average compensation payments and one case of service failure indicating wider organisation failure.

Friends and Family Test (FFT)

• In the Midlands & East FFT, Colchester has consistently scored in the top quartile.

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 – Dec 2012;

• 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:

Colchester is ‘red rated’ in three of the safety indicators: reporting of patient safety incidents, medication errors and clinical negligence scheme payments.

The Trust may be recognising and reporting patient safety incidents less fully and completely than similar trusts. It recorded 158 incidents reported as either moderate, severe or death between April 2011 and March 2012. Since 2009, two ‘never events’ have occurred at Colchester, classified as that because they are incidents that are so serious they should never happen. Similarly, Colchester has a rate of medication errors of 8.14, that is higher than the mean rate of 7.17 for all acute trusts.

Throughout the last 12 months, Colchester has been consistently below the national rate for new pressure ulcers, though it has breached this figure on two occasions. The prevalence rate of total pressure ulcers for Colchester is also below the national average and below the average of the selected 14 trusts in this review.

The Trust’s Clinical Negligence payments have exceeded contributions to the ‘risk sharing scheme’ over the last two years, and flagged once in Rule 43 Coroner’s reports.

Colchester is ‘red rated’ in ten of the workforce indicators. It notably has a sickness absence rate for medical staff above the national mean rate and spends more on agency staff than the median within the region. For training of its doctors, it has a lower score on ‘undermining’ than the national average. In addition, Colchester has a joining rate double the national average whilst the leaving rate is below the national average.


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.

x Medication error Pressure ulcers

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 ’12 158

Number of ‘never events’ (2009-2012) 2

Safety Analysis

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

September 2012)

Colchester Median rate for medium acutes

5.3 6.7

The Trust has reported fewer patient safety incidents than similar trusts. Organisations that report fewer incidents may have a weaker and less effective safety culture. Colchester has a rate of 5.3 for its patient safety incident reporting per 100 admissions. The rate of medication errors for Colchester is 8.14, which is higher than the mean rate of 7.17 for all acute trusts.

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)

Colchester Mean rate for all acute

8.14 7.17

Source: Acute Trust Quality Dashboard Winter 2012/13

1371

641

363

339

332

257

225

211

195

182

66

0 200 400 600 800 1000 1200 1400 1600

Patient accident

Medication

All others categories

Infrastructure

Treatment, procedure

Implementation of care and ongoing …

Clinical assessment

Documentation

Consent, communication, confidentiality

Medical device / equipment

Access, admission, transfer, discharge

Slide 49

Safety Incident Breakdown

Since 2009, two ‘never events’ have occurred at Colchester, 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’. 78% of incidents which have been reported at Colchester have been classed as ‘no harm’, with 19% ‘low’, 3% ‘moderate’, 0.4% ‘severe’ and no occurrences classified as ‘death’. However, the Trust is aware of a maternal death for this period. When broken down by category, the most regular occurrences of patient incident at Colchester are in ‘patient accident’ and ‘medication’.

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

Never Events Breakdown (2009-2012)

Retained foreign object post-operation 2

Total 2

Source: National Patient Safety Agency (NPSA) Apr 11 – Mar 12 A definition of serious harm is given in the Appendix.

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

3250

774

143 15 0

0

500

1000

1500

2000

2500

3000

3500

No Harm Low Moderate Severe Death

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, Colchester has been consistently below the national rate for new pressure ulcers, though it has breached this figure on two occasions.

From the data, it is apparent that the prevalence rate of total pressure ulcers for Colchester is also below the national average and below the average of the selected 14 trusts in this review. The data shows that the total pressure ulcer rate has been below the national average in all but four months over the previous year.

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 604 602 618 592 584 569 610 572 608 614 642 620

Trust new pressure ulcers 2 3 6 9 11 3 4 8 1 1 1 2

Trust new pressure ulcer rate 0.3% 0.5% 1.0% 1.5% 1.9% 0.5% 0.7% 1.4% 0.2% 0.2% 0.2% 0.3%

Selected 14 trusts new pressure

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

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

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 604 602 618 592 584 569 610 572 608 614 642 620

Trust total pressure ulcers 17 22 35 41 31 25 29 32 37 32 33 41

Trust total pressure ulcer rate 2.8% 3.7% 5.7% 6.9% 5.3% 4.4% 4.8% 5.6% 6.1% 5.2% 5.1% 6.6%

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%

0.3% 0.5%

1.0%

1.5%

1.9%

0.5% 0.7%

1.4%

0.2% 0.2% 0.2% 0.3%

0.0%

0.2%

0.4%

0.6%

0.8%

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%

-

2

4

6

8

10

12

New pressure ulcers prevalence

Category 2 Category 3 Category 4 Rate

2.8%

3.7%

5.7%

6.9%

5.3%

4.4% 4.8%

5.6%

6.1%

5.2% 5.1%

6.6%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

-

5

10

15

20

25

30

35

40

45

Total pressure ulcers prevalence

Category 2 Category 3 Category 4 Rate

Litigation and Coroner

Clinical negligence scheme analysis Colchester’s Clinical Negligence payments have exceeded contributions to the ‘risk sharing scheme’ for the last two years. Over the last 3 years payouts exceeded contributions by a total of £4.7m over this period.

Slide 51

Clinical negligence

payments 2009/10 2010/11 2011/12

Payouts (£000s) 2,648 7,154 6,754

Contributions (£000s) 3,405 3,878 4,597

Variance between

payouts and contributions

(£000s)

757 -3,276 -2,157

Source :Litigation Authority Reports

Coroner’s rule Coroner’s rule 43 reports flagged one item: • To consider keeping a record of the location of

scanners that can accommodate obese patients.

Workforce W

or

kfo

rc

e I

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.

Slide 52

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

2.55 2.07 0.38 574.62 30.37

An

ae

sth

eti

cs

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

Ca

rd

iolo

gy



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

Cli

nic

al

on

co

log

y



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.


Em

er

ge

nc

y M

ed

icin

e



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching

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


Ga

str

oe

nte

ro

log

y



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching



Inte

ns

ive

ca

re

me

dic

ine



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



Re

sp

ira

tor

y M

ed

icin

e



Workload

Handover

Adequate experience


Feedback

Induction

Undermining


Local teaching

Study leave

Regional teaching




Agency Staff (2011/12)

Colchester

Expenditure

Percentage of

Total Staff Costs

Median within

Region

£8.2m 5.6% 4.6%

Number of FTEs (Dec 11-Nov 12 average) 3,549

Workforce Analysis

Slide 58 Source: NHS Hospital & Community Health Service (HCHS) monthly workforce statistics

The Trust has a patient spell per whole time equivalent rate of 27, which is a slightly above average capacity in relation to the other trusts in this review and nationally. The consultant appraisal rate of Colchester is 55.6% which is the lowest of the trusts under review. Colchester’s staff leaving rate is 5.9% which is lower than the median average of 7.6%. The joining rate of 19.8% is more than double the national average.

The data shows that the agency staff costs, as a percentage of total staff costs, is higher than the median within the region

Staff Turnover (Sep 11 – Sep 12)

Colchester East of England

SHA Median

Joining Rate 19.8% 8.1%

Leaving Rate 5.9% 7.6%

Source: Health and Social Care Information Centre (HSCIC)

WTE nurses per bed day December 2012

Colchester National Average

1.61 1.96

Colchester: 27

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

Ed

Source: Acute Trust Quality Dashboard, Methods Insight

Colchester 55.6%

0%

20%

40%

60%

80%

100%

Consultant appraisal rate, 2011/12

Trusts covered by review All other trusts Colchester

Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)

Data based on the appraisal year from April 2011 to March 2012

Workforce Analysis continued…

Slide 59

Sickness Absence Rates (2011-2012)

Colchester East of England

SHA Average

National Average

All Staff 3.59% 4.03% 4.12%

Sickness Absence Rates by Staff Category (Dec 12)


Medical Staff 1.7% 1.3%

Nursing Staff 3.9% 4.8%

Other Staff 4.4% 4.7%

Source: Health and Social Care Information Centre (HSCIC)

Source: Acute Trust Quality Dashboard, Methods Insight

Colchester’s total sickness absence rate is lower than the East of England Strategic Health Authority average and the national average. This pattern is replicated in the more granular nursing and other staff categories, both of which are lower than their respective national averages, although the figure for medical staff is higher than the average for all trusts in England.

Colchester has a medical staff to consultant ratio below the national average, as is its nurse staff to qualified staff ratio. The Trust’s registered nurse hours to patient day ratio is also lower than the average for all trusts in England. However, its non-clinical staff to total staff ratio is above the national average.

The Trust’s consultant productivity ratio is above the national average.

Colchester’s three month vacancy rate for its medical staff is above the national average.

Staff Ratios (Jan 12-Mar 12)


Medical Staff to Consultant Ratio 2.55 2.59

Nurse Staff to Qualified Staff Ratio 2.07 2.50

Non-Clinical Staff to Total Staff

Ratio

0.38 0.34

Registered Nurse Hours to Patient

Day Ratio *

30.37 85.69

Source: Healthcare Evaluation Data *Patient Bed Days Data: Nov 12 – Jan 13, Nurse FTE Data: Jan 13 - Mar 13 Average

Staff Productivity (Jan 12-Mar 12)


Consultant Productivity

(Spells/FTE)

575 492

Source: Healthcare Evaluation Data Workforce indicator calculations are listed in the Appendix.

3 month Vacancy Rates by

Staff Category

(March 2010)

Colchester National

Average

Medical Staff 1.6% 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 Analysis continued…

Slide 60

Colchester response rate to the staff survey is significantly below average and has fallen in 2012. The staff engagement score is below average when compared with trusts of a similar type, although it improved in 2012. Colchester is significantly below the national average for the percentage of staff who would be happy with the standard of care if a friend or relative needed treatment. It is below average on recommending it as a place to work which has fallen in 2012 compared with 2011.

National Staff Survey results

Colchester

2011

Average for all

trusts

2011

Colchester

2012

Average for all

trusts

2012

Response rate 57% 50% 39% 50%

Overall staff engagement

3.60

3.62

3.62

3.69

Care of patients/service

users in my organisation’s

top priority

57% 69% 64% 63%

I would recommend my

organisation a place to work 54% 52% 53% 55%

If a friend or relative needed

treatment, I would be happy

with the standard of care

provided by this organisation

56% 62% 58% 60%

Source: GMC evidence to Review 2013

Source: 2011/12 Organisational Readiness Self-Assessment (ORSA)

Data based on the appraisal year from April 2011 to March 2012

Source: National Staff Survey 2011, 2012

Deanery

The Trust was subject to enhanced monitoring in January 2010, when concerns were raised by the CQC. The GMC asked the Deanery to visit the Trust, and they provided assurance that there were no major education concerns.

National Training Scheme (NTS) Outliers – Programme Groups by Trust/Board between 2010-12

Obstetrics and Gynaecology and General Surgery were the programmes with the most activity below outliers between 2010 and 2012. Anaesthetics was the programme with the most above outliers reported during the same period. Trainees at the Trust reported a similar number of outliers in each year, and no indicator was an outlier in two or more years.

NTS 2012 Patient Safety Comments

10 doctors in training commented, representing 5.99% 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:

• Low staffing levels, especially at night and weekends;

• Lack of formal handover;

• Informal patient handover between consultants;

• Long waiting times;

• Patients move between wards frequently; and

• Unsafe rota design.

Source: GMC evidence to Review 2013

Slide 61

Deanery Reports

Monitored under the response to concerns process?

Yes, the Trust was monitored, but this case is now closed. A concern at Colchester Hospital University NHS Foundation Trust was raised by Postgraduate Medical Education and Training Board (PMETB) in January 2010, following a CQC report.

The Deanery undertook a programme of visits to the Trust at PMETB’s request; reports back to PMETB stated that there were no major educational concerns, and that quality control of training at the Trust was being dealt with appropriately.

Undermining

For doctors in training, Colchester has a score of 92.6 on “undermining,” below the national average of 94, which is the rationale for the Trust’s red rating on this measure. The Trust’s score is among the lowest of all 14 trusts covered by the review.

The Deanery Report in 2012 identified a number of concerns, including a breach of information governance (use of passwords), the board level governance of education and training, compliance with mandatory training requirements (E&D and safeguarding), provision of safe clinical services at Essex County Hospital and the lack of adequate infrastructure to ensure timely access to patient results and reports.

Source: National Training Survey 2012

Colchester 92.6

80

85

90

95

100

105

Mean Score on 'Undermining'

Trusts covered by review All other non specialist trusts

Slide 62

Clinical and operational effectiveness

Slide 63


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.

Summary:

Colchester is at the lower end of the distribution for the proportion of women receiving ante-natal steroids, and some way short of the 85% national standard. The Trust sees 96.6% of A&E patients within 4 hours which is above the 95% target level. The percentage of patients seen within 4 hours was relatively consistent during 2012. 93.8% of patients start treatment within the 18 week target time which is above the target level. This has been a consistent trend from April 2012 to March 2013. Colchester’s crude readmission rate is among the lower readmission rates of the trusts in the review as well as nationally, at 10.9%. Similarly, their standardised readmission rate shows a level of performance that is statistically below what is expected. The Trust’s average length of stay is shorter than that of the national average. The PROMs dashboard shows that Colchester was an average performer overall. None of the indicators fell outside of the control limits for the 3 years shown in the dashboard.


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




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

Cli

nic

al

eff

ec

tiv

en

es

s

O

pe

ra

tio

na

l E

ffe

cti

ve

ne

ss

RTT Waiting Times Cancelled Operations

Emergency readmissions PbR Coding Audit

Cancer Waits

A&E Waits

PR

OM

s

Da

sh

bo

ar

d

Hip Replacement EQ-5D

Knee Replacement EQ-5D

Varicose Vein EQ-5D

Hip Replacement OHS

Knee Replacement OKS

Groin Hernia EQ-5D

Slide 65

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.

Slide 66

Clinical Audit Safety Measure

Diabetes Proportion with medication

error

Proportion experiencing

severe hypoglycaemic

episode

Elective Surgery Proportion of patient reported

post-operative complications

Adult Critical Care (ICNARC

CMPD)

Proportion of night-time

discharges

Clinical Audit Effectiveness Measures

Neonatal intensive and special care

(NNAP)

Proportion of women receiving ante-

natal steroids

Diabetes Proportion foot risk assessment

Adult Critical Care Standardised hospital mortality ratio

Coronary angioplasty Proportion receiving primary PCI

within 90 mins

Peripheral vascular surgery Elective abdominal aortic aneurysm

post-op mortality

Carotid interventions Proportion having surgery within 14

days of referral

Acute Myocardial Infarction Proportion discharged on beta-blocker

Acute Stroke Proportion compliant with 12 indicators

Heart Failure Proportion referred for cardiology

follow up

Bowel cancer 90 day post-op mortality

Hip Fracture 30 day mortality

Proportion operations within 36 hrs

Elective surgery (PROMS) Mean adjusted post-operative score

Severe Trauma Proportion surviving to hospital

discharge

Hip, knee and ankle Standardised revision ratio

Lung Cancer Proportion small cell patients receiving

chemotherapy

Slide 66 Source: Clinical Audit Data Trust, CQC Data Submission.

Clinical effectiveness: Clinical Audits

In the National Clinical Audit for Neonatal intensive and special care (NNAP), a key measure of effectiveness is the percentage of women receiving ante-natal steroids.

On this measure, Colchester is at the lower end of the distribution, and some way short of the national average.

Slide 67

Proportion of women receiving ante-natal steroids (level 2)

Colchester Hospital

PROMs Dashboard

The PROMs dashboard shows that Colchester was an average performer overall. None of the indicators fell outside the control limits for the 3 years shown in the dashboard.

Slide 68

Source: PROMs Dashboard and NHS Litigation Authority

Hip Replacement EQ-5D

0

0.1

0.2

0.3

0.4

0.5

2009/

10

2010/

11

2011/

12

England Average

Colchester

Upper Control Limit

Lower Control Limit

75%

80%

85%

90%

95%

100%

105%

Referral to Treatment (Admitted)

Trusts Covered by Review All Trusts RTT Target 90%

A&E wait times and RTT times may indicate the effectiveness with which demand is managed.

Colchester sees 96.6% of A&E patients within 4 hours which is above the 95% target level. The time series graph shows that this has been a consistent trend January 2012 to December 2012.

93.8% of patients are seen within the 18 week target time which is above the target level. In addition, the time series shows that Colchester has been consistently performing above the target rate.

Operational Effectiveness – A&E wait times and Referral to Treatment (RTT) times

Source: Healthcare Evaluation Data (HED). Jan – Dec 12

Source: Department of Health. Feb 13 Source: Department of Health. Apr 12 – Feb 13

Slide 69

Source: Healthcare Evaluation Data (HED). Jan – Dec 12

70%

75%

80%

85%

90%

95%

100%

105%

A&E Percentage of Patients Seen within 4 Hours

Trusts Covered by Review All Trusts A&E Target 95%

Colchester 96.6%

94.0%

94.5%

95.0%

95.5%

96.0%

96.5%

97.0%

97.5%

98.0%

0

1

2

3

4

5

6

7

8

Att

endances (T

housands)

Colchester 4 Hour A&E Waits

Number of patients seen within 4 hours

Patients Not Seen

Seen within 4 hours (%)

Colchester 93.8%

86%

88%

90%

92%

94%

96%

98%

Colchester Referral to Treatment Performance

Referral to Treatment Rate RTT Target 90%

Readmission rates may indicate the appropriateness of treatment offered, whilst average length of stay may indicate the efficiency of treatment.

Colchester’s crude readmission rate is among the lower readmission rates of the trusts in the review as well as nationally, at 10.9%.

The standardised readmission rate, most importantly, accounts for the trust’s case mix and shows Colchester is statistically lower than expected having one of the lowest standardised readmission rates of the 14 selected trusts.

Colchester’s average length of stay is 4.0 days, which is shorter than the national mean average of 5.2 days.

Operational Effectiveness – Emergency Re-admissions and Length of Stay

Colchester

Selected trusts Outside Selected trusts w/in Range

Standardised 30-day Readmission Rate

Slide 70 Source: Healthcare Evaluation Data (HED); Jan 12 – Dec 12

Colchester 10.9%

0%

5%

10%

15%

20%

25%

Cru

de R

eadm

issio

n R

ate

Crude Readmission Rate by Trust

Trusts Covered by Review All Trusts

Colchester 3.96

0

1

2

3

4

5

6

7

8

9

10

Spell

Dura

tio

n (

Days)

Average Length of Stay by Trust

Trusts Covered by Review All Trusts

The Payment by Results (PbR) Data Assurance Framework has a national clinical coding audit programme managed by the Audit Commission, which provides assurance around the quality of data underpinning PbR payments. Inpatient coding was audited for all Trusts from 2007/08. In 2010/11 it was only audited for the 30 Trusts with previously consistently high error rates (using a sample of episodes and targeted using local knowledge). Outpatient coding was added in 2009/10 and the most poorly performing 20% of Trusts were followed up in 2010/11.

Colchester was identified among the 30 Trusts with a consistently high inpatient coding error rate up to 2009/10. In 2010/11 it remained in the worst performing category. It had 12% of HRGs derived incorrectly and 19.4% of clinical codes (procedures and diagnoses) recorded incorrectly, based on 300 cases reviewed by accredited clinical coding auditors.

QRP data shows the proportion of secondary procedures recorded incorrectly remains worse than expected in 2011/12, at 15.7%. However the error rates for primary procedures and for primary and secondary diagnoses were within an expected range.

Colchester was also identified as being in the worst performing 20% of Trusts for outpatient coding in 2009/10. It showed improvement in attendance errors in 2010/11, but the recording of outpatient procedures showed a 24% error.

There were no issues at the Trust with the coding of reference costs.

Operational Effectiveness – Payment by Results coding audit

Slide 71 Source: PbR Data Assurance Framework, Audit Commission

Leadership and governance

Slide 72


Overview:

This section provides an indication of the Trust’s governance procedures.

Review Areas:

To provide this indication of the Trust’s leadership and governance procedures we have reviewed the following areas:

• Trust Board;

• Governance and clinical structure; and

• External reviews of quality.

Data Sources:

• Board and quality subcommittee agendas, minutes and papers;

• Quality strategy;

• Reports from external agencies on quality;

• Board Assurance Framework and Trust Risk Register; and

• Organisational structures and CVs of Board members.

Summary:

The Trust Board is comprised of primarily substantive appointments (except the Director of Nursing and the Director of Workforce), and has been relatively stable for the past two years. The Chair and Chief Executive took up their posts at the Trust in late summer 2010 following the removal of the previous Chair (Monitor intervention) and the retirement of the previous Chief Executive. The Board sub-committee with responsibility for quality governance is the Quality and Patient Safety Committee. This sub-committee is chaired by a non-executive director.

A recent review by the CQC has identified minor concerns in relation to outcome 1 (Respecting and involving people who use services) and moderate concerns in relation to outcome 16 (Assessing and monitoring the quality of service provision ).

Key risks for the Trust relate to mortality (in particular perinatal mortality), end of life provision across the community, serious incidents in obstetrics, surgical site infections, learning from experience, staffing levels and the emergency assessment unit.

The latest serious incident report (for the period 1 Nov 2012 to 8 Feb 2013) has identified 44 serious incidents including two never events (retained swab and suboptimal care).



Monitor governance risk rating CQC Outcomes

Monitor finance rating 4

Le

ad

er

sh

ip a

nd

g

ov

er

na

nc

e

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.

Slide 74

Governance risk rating CQC Concerns Red - Likely or actual significant breach of terms of authorisation Red – Major concern Amber-red - Material concerns surrounding terms of authorisation Amber – Minor or Moderate concern Amber-green - Limited concerns surrounding terms of authorisation Green – No concerns Green - No material concerns Financial risk rating rated 1-5, where 1 represents the highest risk and 5 the lowest

Leadership and governance Trust Board

The Trust Board is comprised of primarily substantive appointments, and has been relatively stable for the past two years. The Chair and Chief Executive took up their posts at the Trust in late summer 2010 following the removal of the previous Chair (Monitor intervention) and the retirement of the previous Chief Executive.

The Director of Nursing is an ‘acting’ role, appointed in April 2013, and the Director of Workforce is an interim role.

Governance and clinical structures

The Trust Board receives assurance from four sub-committees; the Quality & Patient Safety Committee, Finance & Resourcing Committee, Performance Assurance Committee and Audit & Risk Assurance Committee. These sub-committees are chaired by non-executive directors.

Board priorities for 2012/13

1. Inspiring our employees

2. Delivering high quality services

3. Strengthening our centre of excellence

4. Shaping the future, ready to respond

5. Building a sustainable future

External reviews and regulation

Monitor amended the financial risk rating for the Trust from 3 to 4 in November 2012 due to an improvement in the Trust's financial position. The governance risk rating for this foundation trust was amended from green to amber-red in December 2012 due the Trust breaching the C difficile target in Q3 2012/13.

A recent review by the Care Quality Commission found that the Trust was not meeting two outcomes:

• Respecting and involving people who use services (minor concerns);

• Assessing and monitoring the quality of service provision (moderate concerns); and

The Trust has also had a number of external reviews, which we consider further on the following pages. Slide 75

A diagram of board members and committee structure can be found in the Appendix.

Top risks to quality

Trust identified

risks

Trust response

Relative risk and

observed mortality

SHMI significantly above the expected level with the current reported HSMR in line with the expected level. Mortality

performance including progress against the improvement work is routinely reported by the Medical Director and Chief Executive

to the Board and the Board actively debates mortality issues.

Copies of detailed reviews are also submitted to the Board as and when they arise.

Examples of such reports include the report commissioned from Dr Foster Group to investigate the unaccounted for variance

between the Trust’s reported SHMI and HSMR and the detailed patient review of mortalities such as that undertaken for deaths

in August 2012.

Since December 2010 the Trust has operated a weekly mortality review process where10% of deaths are randomly selected

and the responsible consultant and matron are invited to present the case to a group of clinical peers, executives and clinical

safety managers. More recently GP representation has joined this weekly review to enable improvements in the patient pathway

that straddle multiple organisations.

The Trust operates a monthly alerts review process using the Dr Foster Intelligence tool to identify diagnosis or procedure

groups where the relative risk is higher than expected or where there is an emerging risk. This process has been co-ordinated

by the Associate Director of Service Improvement who supports the Medical Director in improving clinical and documentation

processes that impact on mortality since October 2012. This process is supported through the Trust Quality Hub.

End of life provision

across the economy

Clinical reviews and audits have identified that a high proportion of deaths occur in patients admitted at the end of their life.

A review of end of life provision was undertaken by Marie Curie Cancer Centre in 2011 as part of the “Delivering Choice

Agenda”. This identified that end of life care in North East Essex is provided by a variety of organisations and professional

groups. Consequently a very complex system has arisen, with limited joined-up working and out-of-hours /weekend provision

and fewer hospice beds compared with the national.

Implementation of key recommendations from this review has been slow and has been impacted by transition from PCTs to

CCGs. However, work is now in train to implement end of life transformational change in 2013/14, including a single point of

access (through transition funding) increasing the number of patients on the GSF Register (through Locally Enhanced Services)

and improving discharge communication (through CQUINs).

The table includes the top risks and significant challenges to quality identified by the Trust.

Slide 76


Trust identified

risks

Trust response

Perinatal mortality

The Trust has a higher observed mortality compared to the historical national. In the absence of contemporary national

benchmark data Professor Elizabeth Draper, Professor of Perinatal & Paediatric Epidemiology, University of Leicester was

asked to review the Trust’s mortality. She identified that we are ‘obviously very rigorous in our reporting of any signs of life for all

possible cases of live birth and that there is large variation in the registration of live births around the time of viability across

England which has a major impact upon neonatal mortality and infant death rates. The national variability makes it difficult for

the department to assess whether the higher observed rate seen is as a result of clinical quality of care or national variability. All

mortalities undergo a full clinical review as part of the Divisions’ governance process.

Obstetric serious

incidents

Following six Serious Incidents over a 16-month period including a maternal death in 2011, the Trust invited the Royal College

of Obstetricians and Gynaecologists to undertake a review. Overall the college identified that the service was safe, complied

with the majority of standards, that satisfactory governance processes were in place and that there was evidence of good

practice. Several recommendations to improve patient flow and communication were also identified. A task group to implement

the recommendations has been set up and progress is being made. This is being kept under regular review and is monitored

through the Quality & Patient Safety Committee.

Surgical site

infections

The Trust invited the Health Protection Agency to support improvements in surgical site infection rates in large bowel surgery.

Working with the clinical teams to develop an improvement plan, the Trust has set up a surveillance group to provide assurance

on progress against the plan to deliver the improvements.

Learning from

experience

The processes for reporting incidents, themes from complaints and closing down Learning from Experience Action Plans

(LEAPs) has been identified as an area for improvement within the Trust. This has been demonstrated through the recent Care

Quality Commission (CQC) inspection where a moderate concern to compliance was raised and through a contract query from

the CCG.

A review has identified areas for improvement related to the reporting of serious incidents in line with national guidance and the

documentation of the actions taken to conclude LEAPs.

Although evidence suggests actions have been taken at Divisional level this is not comprehensively documented. Independent

internal audit of current processes has been undertaken and a detailed plan has been submitted to the CQC and CCG to both

close LEAPs and ensure reporting structures and processes are robust going forward.


Slide 77


Trust identified

risks

Trust response

Staffing levels and

recruitment

The number of nursing staff has increased by 105 and the number of consultants has increased by 16 in the last three years.

Recruitment of sufficient numbers of nurses has proven difficult locally and a recruitment strategy has been agreed including

seeking opportunities outside of the local population area.

A review of midwifery numbers identifies a gap to meet the Birthrate plus standards. The economy currently does not have an

agreed position on how this gap will be funded. The Trust is funding these additional posts whilst the Director to Director

discussions with the CCG continue.

Emergency

Assessment Unit

(EAU)

Although some improvement in hospital standardised mortality rates (HSMR) had been made this was not reducing at the rate the

Board would have liked. As 98% of deaths are in the emergency pathway the Trust invited the Emergency Care Intensive Support

Team (ECIST) in February 2011 to support improvements in emergency care and patient safety. Good progress has been made

delivering phase 1 improvements in early and timely senior medical review (expanded consultant presence on site until midnight),

timely assessment and treatment in the emergency department, reduction in outliers, structured ward board rounds and

development of core quality standards across the patient pathway. ECIST have included the work undertaken at the Trust as an

example of good practice in work they have undertaken in other organisations as part of their improving emergency pathway work

programmes.

While good progress has been made in the first phase of work, further work is required to improve the patient flow, capacity and

capability within the EAU to improve the quality and consistency of the care provided. Work has started to restructure the senior

nursing and management leadership within the department. Facilitated patient flow workshops have been arranged to develop the

next phase of the change programme.


Slide 78


External reviews

A recent CQC inspection of Colchester General Hospital in January 2013 considered the Trust’s compliance with six outcomes (respecting and involving people who use services, care and welfare of people who use services, meeting nutritional needs, management of medicines, supporting workers and assessing and monitoring the quality of service provision.

The Trust was found to be compliant with all but two of these standards:

• Respecting and involving people who use services (minor concerns).

• Assessing and monitoring the quality of service provision (moderate concerns).

In particular, this review identified 21 incidents from 1 April to 31 December 2012 that the CQC felt should have been classified as a serious incident but weren’t. The Trust has reviewed these incidents; a paper presented to the March Board concluded that four of these incidents should be reclassified.

The Trust has engaged with a number of external bodies to review its services including Cambridge University Hospitals NHS Foundation Trust, Emergency Care Intensive Support Team, Dr Foster, Professor Elizabeth Draper (Professor of Perinatal and Paediatric Epidemiology, University of Leicester), the Health Protection Agency, Royal College of Obstetricians and Gynaecologists and Foresight Partnership LLP.

A number of these reviews have focused on historic issues with the maternity services provided by the Trust. As noted in the risks section above, the Trust has had a higher than expected perinatal mortality, and experienced six serious untoward incidents in maternity over a 16 month period around 2011. Concerns were also raised in relation to serious incidents in maternity historically being reported on an incorrect system.

Cost Improvement Programme

In 2012/13 the Trust achieved cost improvement programmes of £4.5m (£1.8m pay, £2.7m non-pay). The largest projects related to bed reductions and estates and facilities.

In 2013/14, the Trust plans to achieve cost improvements of £9.7m (of which £3.1m relates to income generation, and £6.6m relates to cost savings).

Each CIP is developed by the divisions with sign off from clinical leadership 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 79

Appendix

Slide 80

Trust Map – Colchester General Hospital

Slide 81

Source: Colchester Hospital University NHS Foundation Trust website

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.

Slide 82

Source: UK National Screening Committee

Workforce Indicator Calculations

Indicator Numerator /

Denominator

Calculation Source

WTE nurses per bed day

Numerator Nurses FTE’s Acute

Quality

Dashboard Denominator Total number of Bed Days

Spells per WTE staff Numerator Total Number of Spells HED

ESR Denominator Total number of WTE’s

Medical Staff to Consultant

Ratio

Numerator FTEs whose job role is ‘Consultant’ ESR

Denominator FTEs in ‘Medical and Dental’ Staff Group

Nurse Staff to Qualified Staff

Ratio

Numerator FTEs in ‘Nursing & Midwifery Registered’ Staff Group ESR

Denominator FTEs of Additional Clinical Services – 85% of bands 2, 3 and 4

Non-clinical Staff to Total Staff

Ratio

Numerator FTEs not in ‘Nursing and Midwifery Registered’, ‘Additional Clinical

Services,’ ‘Allied Health Professionals’ or ‘Medical and Dental’ staff

groups

ESR

Denominator Sum of FTEs for all staff groups

Consultant Productivity

(Spells/FTE)

Numerator Number of Inpatient Spells HED

ESR Denominator FTEs whose job role is ‘Consultant’

Nurse hours per patient day

Numerator Nurse FTEs multiplied by 1522 (calculated number of hours per year

which takes into account annual leave and sickness rates)

ESR

HED Denominator Total Bed Days

Note: ESR Data only includes substantive staff.

Board members

Slide 84

Committee structures

Slide 85

Data Sources

Slide 86

No. Data Source name Area

1 Board of Directors Meeting 30th January, 2013 Context

2 Department of Health: Transparency Website, Dec 12 Context

3 Healthcare Evaluation Data (HED)

Context, Mortality, Clinical and

Operational Effectiveness

4 NHS Choices Context

5 Office of National Statistics, 2011 Census data Context

6 Index of Multiple Deprivation, 2011 Context

7 © Google Maps Context

8 Public Health Observatories – Area health profiles Context

9 Background to the review and role of the national advisory group Context

10 Health & Social Care Information Centre – SHMI and contextual

indicators Mortality

11 Dr Foster – HSMR Mortality

12 Care Quality Commission – alerts, correspondence and findings Mortality

13 Patient Experience Survey Patient Experience

14 Cancer Patient Experience Survey Patient Experience

15 Peoples Voice Summary Patient Experience

16 Complaints data Patient Experience

17 Acute Trust Quality Dashboard, Oct 2011 – Mar 2012 Safety and Workforce

18 Safety Thermometer, Apr – Dec 2012 Safety and Workforce

19 Litigation Authority Reports Safety and Workforce

20 GMC Evidence to Review 2013 Safety and Workforce

21 National Staff Survey 2011, 2012 Safety and Workforce

22 2011/12 Organisational Readiness Self-Assessment (ORSA) Safety and Workforce

23 National Training Survey, 2012 Safety and Workforce

24 NHS Hospital & Community Health Service (HCHS), monthly workforce

statistics Safety and Workforce

25 Clinical Audit Data Trust, CQC Data Submission Clinical and Operational Effectiveness

26 Department of Health Clinical and Operational Effectiveness

27 Cancer Waits Database, Q3, 2012-13 Clinical and Operational Effectiveness

28 PROMs Dashboard Clinical and Operational Effectiveness

29 Board and quality subcommittee agendas, minutes and papers Leadership and Governance

30 Quality strategy Leadership and Governance

31 Reports from external agencies on quality Leadership and Governance

32 Board Assurance Framework and Trust Risk Register Leadership and Governance

33 Organisational structures and CVs of Board members Leadership and Governance

34 Colchester Hospital University NHS Foundation Trust website Appendix

35 UK National Screening Committee Appendix

SHMI Appendix

Admission Method Treatment Specialty Diagnostic Group SHMI

Observed Deaths that

are higher than the

expected

Elective 800 - Clinical oncology (previously known as Radiotherapy) Cancer of head and neck 264.6 1

Elective 800 - Clinical oncology (previously known as Radiotherapy)

Pneumonia (except that caused by tuberculosis or

sexually transmitted disease) 641.8 1

Elective 800 - Clinical oncology (previously known as Radiotherapy) Acute bronchitis 553.6 1

Elective 800 - Clinical oncology (previously known as Radiotherapy) Other upper respiratory disease 16093 1

Elective 800 - Clinical oncology (previously known as Radiotherapy) Cancer of colon 1755 1

Elective 800 - Clinical oncology (previously known as Radiotherapy) Melanomas of skin 7037 1

Elective 800 - Clinical oncology (previously known as Radiotherapy) Non-Hodgkin`s lymphoma 397.8 1

Elective 800 - Clinical oncology (previously known as Radiotherapy) Malignant neoplasm without specification of site 2851 2

Elective 800 - Clinical oncology (previously known as Radiotherapy) Other nutritional; endocrine; and metabolic disorders 1614 1

Elective 800 - Clinical oncology (previously known as Radiotherapy) Deficiency and other anemia 207.8 1

Non-elective 300 - General medicine Conduction disorders 128.3 1

Non-elective 300 - General medicine Cardiac dysrhythmias 106.1 1

Non-elective 300 - General medicine Cardiac arrest and ventricular fibrillation 113.1 1

Non-elective 300 - General medicine Other circulatory disease 181.8 3

Non-elective 300 - General medicine Phlebitis; thrombophlebitis and thromboembolism 191.6 2

Non-elective 300 - General medicine Cancer of esophagus 131.7 1

Non-elective 300 - General medicine ther diseases of veins and lymphatics 301.3 1

Non-elective 300 - General medicine Asthma 236.7 3

Non-elective 300 - General medicine Cancer of stomach 132 1

Non-elective 300 - General medicine Lung disease due to external agents 312.2 1

Non-elective 300 - General medicine Disorders of teeth and jaw 990.2 1

Non-elective 300 - General medicine Cancer of colon 126.9 1

Non-elective 300 - General medicine Other disorders of stomach and duodenum 592 2

Non-elective 300 - General medicine Abdominal hernia 207 2

Non-elective 300 - General medicine Regional enteritis and ulcerative colitis 411.4 3 Slide 87

SHMI Appendix



are higher than the

expected

Non-elective 300 - General medicine Diverticulosis and diverticulitis 255.8 2

Non-elective 300 - General medicine Peritonitis and intestinal abscess 694.4 1

Non-elective 300 - General medicine Biliary tract disease 133.5 1

Non-elective 300 - General medicine Cancer of liver and intrahepatic bile duct 191.7 3

Non-elective 300 - General medicine Calculus of urinary tract 536.6 1

Non-elective 300 - General medicine Other diseases of kidney and ureters 589.7 2

Non-elective 300 - General medicine Inflammatory conditions of male genital organs 1736 2

Non-elective 300 - General medicine Cancer of pancreas 121.5 1

Non-elective 300 - General medicine Cancer of other GI organs; peritoneum 222.5 1

Non-elective 300 - General medicine

Infective arthritis and osteomyelitis (except that caused by tuberculosis or sexually

transmitted disease) 182.1 1

Non-elective 300 - General medicine Osteoarthritis 352.7 2

Non-elective 300 - General medicine Other non 113 1

Non-elective 300 - General medicine Cancer of bone and connective tissue 223.8 1

Non-elective 300 - General medicine Systemic lupus erythematosus and connective tissue disorders 3243 1

Non-elective 300 - General medicine Other connective tissue disease 108.7 1

Non-elective 300 - General medicine Cardiac and circulatory congenital anomalies 2966 2

Non-elective 300 - General medicine Skull and face fractures 207.3 1

Non-elective 300 - General medicine Other fractures 156.1 3

Non-elective 300 - General medicine Intracranial injury 124.3 2

Non-elective 300 - General medicine Complication of device; implant or graft 181 2

Non-elective 300 - General medicine Complications of surgical procedures or medical care 193.9 1

Non-elective 300 - General medicine Superficial injury; contusion 116.9 2

Non-elective 300 - General medicine Cancer of breast 162.5 2

Non-elective 300 - General medicine Poisoning by psychotropic agents 361.1 3

Non-elective 300 - General medicine Abdominal pain 141.1 1 Slide 88

SHMI Appendix



are higher than the

expected

Non-elective 300 - General medicine Allergic reactions 192.3 1

Non-elective 300 - General medicine Cancer of ovary 151.3 1

Non-elective 300 - General medicine Cancer of kidney and renal pelvis 293.4 2

Non-elective 300 - General medicine Cancer of thyroid 292.8 1

Non-elective 300 - General medicine Mycoses 342.6 1

Non-elective 300 - General medicine Multiple myeloma 248.1 2

Non-elective 300 - General medicine Cancer; other and unspecified primary 233.1 1

Non-elective 300 - General medicine Nutritional deficiencies 223.1 1

Non-elective 300 - General medicine Gout and other crystal arthropathies 213.9 1

Non-elective 300 - General medicine Fluid and electrolyte disorders 111.4 2

Non-elective 300 - General medicine Deficiency and other anemia 145 3

Non-elective 300 - General medicine Other psychoses 145 2

Non-elective 300 - General medicine Other CNS infection and poliomyelitis 566.2 2

Non-elective 300 - General medicine Parkinson`s disease 244.3 3

Non-elective 300 - General medicine Epilepsy; convulsions 136.2 2

Non-elective 300 - General medicine Coma; stupor; and brain damage 210.8 3

Non-elective 422 - Neonatology Nervous system congenital anomalies 8243 1

Non-elective 422 - Neonatology Intrauterine hypoxia and birth asphyxia 5792 3

Non-elective 422 - Neonatology Respiratory distress syndrome 1059 1

Non-elective 422 - Neonatology Other perinatal conditions 408.5 2

Non-elective 422 - Neonatology Residual codes; unclassified 20235 1

Non-elective 430 - Geriatric medicine Pulmonary heart disease 242.6 2

Non-elective 430 - Geriatric medicine Cardiac dysrhythmias 139.2 1

Non-elective 430 - Geriatric medicine Congestive heart failure; nonhypertensive 122.1 2

Non-elective 430 - Geriatric medicine Cancer of head and neck 266.3 1

Slide 89

SHMI Appendix



are higher than the

expected

Non-elective 430 - Geriatric medicine Phlebitis; thrombophlebitis and thromboembolism 606.9 1

Non-elective 430 - Geriatric medicine Pneumonia (except that caused by tuberculosis or sexually transmitted disease) 106.9 2

Non-elective 430 - Geriatric medicine Acute bronchitis 168.2 3

Non-elective 430 - Geriatric medicine Chronic obstructive pulmonary disease and bronchiectasis 162.6 3

Non-elective 430 - Geriatric medicine Asthma 359.9 1

Non-elective 430 - Geriatric medicine Aspiration pneumonitis; food/vomitus 126.2 1

Non-elective 430 - Geriatric medicine Other lower respiratory disease 267.6 1

Non-elective 430 - Geriatric medicine Diseases of mouth; excluding dental 3683 1

Non-elective 430 - Geriatric medicine Cancer of colon 338 1

Non-elective 430 - Geriatric medicine Abdominal hernia 220 1

Non-elective 430 - Geriatric medicine Biliary tract disease 194.2 2

Non-elective 430 - Geriatric medicine Pancreatic disorders (not diabetes) 2299 1

Non-elective 430 - Geriatric medicine Noninfectious gastroenteritis 284.8 1

Non-elective 430 - Geriatric medicine Other diseases of kidney and ureters 727.3 1

Non-elective 430 - Geriatric medicine Genitourinary symptoms and ill 1411 1

Non-elective 430 - Geriatric medicine Cancer of pancreas 148.5 1

Non-elective 430 - Geriatric medicine Skin and subcutaneous tissue infections 218.2 2

Non-elective 430 - Geriatric medicine Other inflammatory condition of skin 317.1 1

Non-elective 430 - Geriatric medicine Chronic ulcer of skin 185.4 1

Non-elective 430 - Geriatric medicine Septicemia (except in labor) 129.2 1

Non-elective 430 - Geriatric medicine Osteoarthritis 624.2 1

Non-elective 430 - Geriatric medicine Spondylosis; intervertebral disc disorders; other back problems 368.6 1

Non-elective 430 - Geriatric medicine Other connective tissue disease 183.9 1

Non-elective 430 - Geriatric medicine Other fractures 467.2 2

Non-elective 430 - Geriatric medicine Open wounds of head; neck; and trunk 490.9 2

Slide 90

SHMI Appendix



are higher than the

expected

Non-elective 430 - Geriatric medicine Superficial injury; contusion 302.4 2

Non-elective 430 - Geriatric medicine Nausea and vomiting 281.7 1

Non-elective 430 - Geriatric medicine Residual codes; unclassified 435.4 3

Non-elective 430 - Geriatric medicine Cancer of bladder 272.5 1

Non-elective 430 - Geriatric medicine Senility and organic mental disorders 161.9 3

Non-elective 430 - Geriatric medicine Parkinson`s disease 407.5 1

Non-elective 430 - Geriatric medicine Other hereditary and degenerative nervous system conditions 221.1 1

Non-elective 430 - Geriatric medicine Epilepsy; convulsions 261.5 2

Non-elective 501 - Obstetrics Short gestation; low birth weight; and fetal growth retardation 4401 1

Slide 91

HSMR Appendix

Admission Method Treatment Specialty Diagnostic Group HSMR


are higher than the

expected

Non-elective 300 - General medicine Abdominal pain 266.9 3

Non-elective 300 - General medicine Cancer of bladder 156 2

Non-elective 300 - General medicine Cancer of ovary 157.9 1

Non-elective 300 - General medicine Cancer of pancreas 112.7 1

Non-elective 300 - General medicine Cancer of rectum and anus 176.8 2

Non-elective 300 - General medicine Cancer of stomach 166.2 1

Non-elective 300 - General medicine Cardiac arrest and ventricular fibrillation 105.4 1

Non-elective 300 - General medicine Cardiac dysrhythmias 134.2 3

Non-elective 300 - General medicine Chronic ulcer of skin 147.2 2

Non-elective 300 - General medicine Complication of device; implant or graft 129.2 1

Non-elective 300 - General medicine Coronary atherosclerosis and other heart disease 143.6 3

Non-elective 300 - General medicine Fluid and electrolyte disorders 127 3

Non-elective 300 - General medicine Intestinal obstruction without hernia 188.5 2

Non-elective 300 - General medicine Malignant neoplasm without specification of site 133.1 2

Non-elective 300 - General medicine Non-Hodgkin`s lymphoma 219.8 3

Non-elective 300 - General medicine Other circulatory disease 205.7 3

Non-elective 300 - General medicine Other fractures 135.2 2

Non-elective 300 - General medicine Other gastrointestinal disorders 114.2 1

Non-elective 300 - General medicine Other liver diseases 127.3 3

Non-elective 300 - General medicine Other upper respiratory disease 178.7 3

Non-elective 300 - General medicine Peripheral and visceral atherosclerosis 174.8 2

Non-elective 300 - General medicine Peritonitis and intestinal abscess 243 1

Non-elective 300 - General medicine Secondary malignancies 126 2

Non-elective 300 - General medicine Senility and organic mental disorders 118.6 2

Slide 92

Higher than Expected Diagnostic Groups HSMR / SHMI Summary (Elective)

Treatment Specialty HSMR SHMI

Clinical oncology X

Slide 93

Higher than Expected Diagnostic Groups HSMR / SHMI Summary (Nonelective)

Slide 94

Treatment Specialty HSMR SHMI

General medicine X X

Geriatric medicine X

Neonatology X

Obstetrics X X

colchester hospital university nhs foundation trust data ...€¦ · a brief overview of the...

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