April Clinical Governance Corporate Report Narrative

Transcription

1 April 14 - Clinical Governance Corporate Report Narrative ITEM 7B Narrative has been provided where there is something of note in relation to a specific metric; this could be positive improvement, decline or lack of improvement or for information/further review. Key: positive improvement for information/further review decline/no improvement Quality Ambition: Safe Unadjusted Inpatient Mortality: Following a run of seven consecutive data points below the median up to Nov 13, we saw an increase in inpatient mortality in December which has reduced again in January 14. This reflects seasonal trends albeit from a lower base than in 12. Adverse Event : Following a run of four consecutive points below the median, the adverse event rate in Dec 13 has spiked. A higher rate of adverse events in this review period at Hairmyres was contributed to by one patient having three adverse events during their inpatient stay. Emergency Medical Readmissions within 7 and 28 days: The 7 day readmission rate in December 13 was the highest noted in the two year reporting period. Further review indicated a higher increase at Hairmyres. A case review has been undertaken to explore possible reasons for this and to enhance learning. The outcome of this will report by June 14. The 7 day medical readmission rate in January has reduced to within a normal range and the 28 day readmission rate has also reduced, although is still elevated in comparison to the same period the previous year. Emergency Surgical Readmissions within 7 and 28 days: With the exception of October 13, these rates have been consistently above both the Lanarkshire median rate and the national average. The January rate has reduced slightly on the previous months in both cases. Modified Early Warning Score Compliance: All three sites have seen increased compliance with this process measure in March, exceeding %. Performance is being reviewed through the DPS Group. Cardiac Arrest (link to MEWS process measure): Following a spike in the February cardiac arrest rate, further review suggested there was no one hospital contributing to the higher rate, just a slight increase overall. This rate has reduced again in March 14 to the lowest in the two year reporting period. Quality Ambition: Effective Medicines Reconciliation Compliance: The approach to improvement work relating to medicines reconciliation is being reviewed and will be re-focused as part of the new Head of Safety s prioritised safety plan due by the end of April /04/14 Page 1 of

2 A&E Waiting Time Breeches 4 and 12 hours: Following an increased rate of breeches in January and February in both 4 and 12 hour waits, the rates have both reduced in March 14. Compliance with the 4 hour metric has not been within target since July 12. Quality Ambition: Person Centred There are no person centred metrics included in the corporate report at this time but the new dashboard report will include a range of metrics from the inpatient experience survey and the newly collected ward level complaints and compliments data and through time will incorporate the new metrics from the Person Centred Health and Care Programme. 22/04/14 Page 2 of

3 Quality Ambition: Safe There will be no avoidable injury or harm to people from healthcare they receive, and an appropriate, clean and safe environment will be provided for the delivery of healthcare services at all times. Progress on this ambition is measured through standardised hospital mortality ratios, SPSP unadjusted patient mortality rates, key performance indicators for incidents and critical incident reviews and HAI indicators. Safe: Percent Unadjusted Inpatient Mortality (NHSL Acute Hospitals) Percent Unadjusted Inpatient Mortality (NHSL Acute Hospitals) Total number of in-hospital deaths Total number of deaths (TD) + live discharges (LD) Following a run of 7 consecutive data points below the median up to Nov 13, we seen an increase in inpatient mortality in December which has reduced again in January 14. This reflects seasonal trends albeit less pronounced than in 12. SMR-UIP Unadjusted Inpatient Mortality % % Median Description: A Complementary measure to HSMR is unadjusted mortality. This provides and indicator of trend. The trend should be decreasing and under the red line. 22/04/14 Page 3 of

4 Safe: Hospital Standardised Mortality Ratio (HSMR) - Hairmyres Number of Observed Deaths versus Predicted Deaths (30 days) -Hairmyres Hospital Standardised Mortality Ratio - Hairmyres Number of Observed deaths and Number of Predicted deaths Number of Observed deaths Not Applicable Number of Predicted deaths The number of observed deaths has reduced for three consecutive quarters and Jul- Sep 13 quarter saw the lowest number of observed deaths since HSMR was first reported in 06. HSMR has reduced in three consecutive quarters and is the lowest it has been (0.76) during the 5+ years reporting period Number Predicted Deaths Observed Deaths HSMR Median Description: Predicted probability of death is calculated based on primary diagnosis; specialty; age; sex; where admitted from; number and severity of prior morbidities; number of emergency admissions in previous 12 months; whether admitted as an inpatient or day case and type of admission (elective / non-elective). a non-random change. (Please see page 17) Description: HSMR is calculated as: Observed Deaths Within 30 Days / Predicted Deaths Within 30 Days and is calculated for all acute inpatient and day case patients admitted to all specialties. 22/04/14 Page 4 of

5 Safe: Hospital Standardised Mortality Ratio (HSMR) - Monklands Number of Observed Deaths versus Predicted Deaths (30 days) -Monklands Hospital Standardised Mortality Ratio - Monklands Number of Observed deaths and Number of Predicted deaths Number of Observed deaths Not Applicable Number of Predicted deaths The number of observed deaths has reduced in the last two quarters and Jul-Sep 13 saw the lowest number of observed deaths since HSMR was first reported in 06. HSMR has reduced in the last two quarters and in Jul-Sep 13 at 0.91, equaled the lowest recorded HSMR for Monklands Hospital during the 5+ year reporting period Number Predicted Deaths Observed Deaths HSMR Median Description: Predicted probability of death is calculated based on primary diagnosis; specialty; age; sex; where admitted from; number and severity of prior morbidities; number of emergency admissions in previous 12 months; whether admitted as an inpatient or day case and type of admission (elective / non-elective). a non-random change. (Please see page 17) Description: HSMR is calculated as: Observed Deaths Within 30 Days / Predicted Deaths Within 30 Days and is calculated for all acute inpatient and day case patients admitted to all specialties. 22/04/14 Page 5 of

6 Safe: Hospital Standardised Mortality Ratio (HSMR) - Wishaw Number of Observed Deaths versus Predicted Deaths (30 days) -Wishaw Hospital Standardised Mortality Ratio - Wishaw Number of Observed deaths and Number of Predicted deaths Number of Observed deaths Not Applicable Number of Predicted deaths The number of observed deaths has increased slightly on the previous quarter, as have predicted deaths. Overall HSMR was still lower than the previous quarter. HSMR has reduced in the last two consecutive quarters and shows less variability overall in comparison to previous years Number Predicted Deaths Observed Deaths HSMR Median Description: Predicted probability of death is calculated based on primary diagnosis; specialty; age; sex; where admitted from; number and severity of prior morbidities; number of emergency admissions in previous 12 months; whether admitted as an inpatient or day case and type of admission (elective / non-elective). a non-random change. (Please see page 17) Description: HSMR is calculated as: Observed Deaths Within 30 Days / Predicted Deaths Within 30 Days and is calculated for all acute inpatient and day case patients admitted to all specialties. 22/04/14 Page 6 of

7 Safe: Percent of Low, Medium, High & Very High incidents recorded, verified, investigated and closed in Datix within (low), (med) & 45 (High+Very High) working days of the incident occurring as a percentage of total low rated incidents Percent of Low, Medium, High & very High rated incidents recorded, verified, investigated and closed in Datix within (low), (med) & 45 (high+very High) working days of the incident occurring as a percentage of total low rated incidents Total No. incidents recorded, verified, graded as low & closed in days, Medium closed in days, High & Very High closed in 45 days. Adverse Event (NHSL Acute Hospitals) The number of adverse events (AE) in a monthly random sample of closed case notes (deaths and live discharges) using the GTT. Total number incidents recorded, verified & closed in DATIX graded as low, medium & high. The total number of patient days (PD) in the month for the randomly drawn patients in the sample. From October 12 all three metrics (low, medium and high processing times) have improved however there is still some variability, particularly in the high rated incidents. Following a run of four consecutive points below the median, the adverse event rate in December has spiked. It appears that Hairmyres had a higher rate of adverse events in this review period, contributed to by one patient having three events. Process Measure RSK-LOWI Low d Incidents SPSP-AER Adverse Event RSK-MEDI Medium d Incidents RSK-HIGHI High d Incidents % Compliance Low d Incidents Medium d Incidents High d Incidents Median Description: The risk management steering group set performance indicators (KPIs) The KPIs inform the board on the effectiveness of incident management. The board should look for performance to be improving. Description: Case note reviews are undertaken each month to identify adverse events using the Global Trigger Tool. Adverse events should be reducing. This rate is per 00 patient days. 22/04/14 Page 7 of

8 Safe: Compliance with PVC Bundles Percent compliance with Peripheral Vascular Bundle (NHSL Acute Hospitals) The total number of opportunities in the sample who have all elements of the PVC bundle in place The total number of opportunities in the sample Consistently high compliance is reported against this process. SPSP-PVCM Process Measure PVC Maintenance Compliance 0 90 % Compliance % Compliance Median Goal Goal: 95% Compliance Description: The use and compliance with PVC bundles is a means to prevent infections. The board should look for compliance at or above the compliance line. 22/04/14 Page 8 of

9 Safe: Compliance with CVC Maintenance Percent compliance with the Central Venous Catheter Maintenance Bundle (NHSL Acute Hospitals) The total number of patients receiving all 5 components of the CVC maintenance bundle The total number of patients with a CVC Compliance has increased in the last four months reported, however this followed a sustained period of lower compliance which requires further review to enhance learning and ensure this is sustained in future. SPSP-CVCM Process Measure CVC Maintenance Compliance 0 90 % Compliance % Compliance Median Goal Goal: 95% Compliance Description: The use and compliance with CVC bundles is a means to prevent infections. The board should look for compliance at or above the compliance line. 22/04/14 Page 9 of

10 Safe: Compliance with Hospital Length of Stay Average Hospital Length of Stay: Surgical Average Hospital Length of Stay: Medical Total bed days used for patients discharged from a Surgical specialty Total bed days used for patients discharged from a Medical specialty Number of hospital discharges, for patients discharged from a Surgical specialty ALOS has reduced in the last 3 months up to January 14 - minimal variability. Number of hospital discharges, for patients discharged from a Medical specialty Minimal variability. Balancing Measure Balancing Measure HLOS Hospital Length of Stay HLOS Hospital Length of Stay Average 5.00 Average % Compliance Median Average Median Description: Reducing Length of Stay releases capacity in the system, including beds and staff time. This increase in capacity will help to minimise waiting times, maximise productivity and improve the patient experience. However, if patients are discharged too early this could lead to readmissions Description: Reducing Length of Stay releases capacity in the system, including beds and staff time. This increase in capacity will help to minimise waiting times, maximise productivity and improve the patient experience. However, if patients are discharged too early this could lead to readmissions 22/04/14 Page of

11 Safe: Compliance with Emergency Medical Readmissions of Emergency Medical Readmissions within 7 days (per 00 discharges) Number of emergency readmissions to any medical specialty within 7 days of discharge for patients initially admitted to a medical specialty Number of hospital discharges, for patients admitted to a medical specialty The readmission rate in Dec was the highest noted in the two year reporting period. Further review indicated a higher increase at Hairmyres. Suggested case review to enhance learning. The rate in January has come back down to within a normal range. of Emergency Medical Readmissions within 28 days (per 00 discharges) Number of emergency readmissions to any medical specialty within 28 days of discharge for patients initially admitted to a medical specialty Number of hospital discharges, for patients admitted to a medical specialty 28 day readmission rate in December showed a spike which has reduced slightly in January. We did see a similar, albeit slightly lower spike in December 12 and January 13. ReAdm-Med7Day Emergency Medical Readmissions within 7 days ReAdm-Med28Day Emergency Medical Readmissions within 28 days Median National Average Median National Average a non-random change. (Please see page 17) National Average: of readmissions should be benchmarked, with the goal of having a rate less than the national average rate of readmissions. The national average goal line is based on the last reported data on the national Hospital Scorecard (June 13). See notes in Appendix A. Description: Readmissions within 7 days give a more accurate picture of readmissions which are clinically related to the index episode and it has been shown that readmissions within 7 days are likely to contain a higher proportion of 'avoidable' readmissions than the broader category of readmissions within 28 days (Levy et al, 00).**Clinical Outcome Indicators, Clinical Resource and Audit Group (CRAG), 02 a non-random change. (Please see page 17) National Average: of readmissions should be benchmarked, with the goal of having a rate less than the national average rate of readmissions. The national average goal line is based on the last reported data on the national Hospital Scorecard (June 13). See notes in Appendix A. Description: Around 15% to up to % of 28-day readmissions could be regarded as avoidable*. The most promising interventions to prevent readmission appear to be those that concentrate on coordination and communication around the time of discharge. *Preventing emergency readmissions to hospital, a scoping review, E. Nolte, M. Roland, S. Guthrie, Laura Brereton, 12 (prepared for the UK Department of Health) 22/04/14 Page 11 of

12 Safe: Compliance with Emergency Surgical Readmissions of Emergency Surgical Readmissions within 7 days (per 00 discharges) Number of emergency readmissions to any surgical specialty within 7 days of discharge for patients initially admitted to a surgical specialty Number of hospital discharges, for patients admitted to a surgical specialty With the exception of October 13, this rate has been consistently above both the median and national average. The January rate has reduced slightly. of Emergency Surgical Readmissions within 28 days (per 00 discharges) Number of emergency readmissions to any surgical specialty within 28 days of discharge for patients initially admitted to a surgical specialty Number of hospital discharges, for patients admitted to a surgical specialty This rate had increased for two consecutive months but has reduced in January 14 back to within a normal range. ReAdm-Surg7Day Emergency Surgical Readmissions within 7 days ReAdm-Surg28Day Emergency Surgical Readmissions within 28 days Median National Average Median National Average a non-random change. (Please see page 17) National Average: of readmissions should be benchmarked, with the goal of having a rate less than the national average rate of readmissions. The national average goal line is based on the last reported data on the national Hospital Scorecard (June 13). See notes in Appendix A. Description: Readmissions within 7 days give a more accurate picture of readmissions which are clinically related to the index episode and it has been shown that readmissions within 7 days are likely to contain a higher proportion of 'avoidable' readmissions than the broader category of readmissions within 28 days (Levy et al, 00).**Clinical Outcome Indicators, Clinical Resource and Audit Group (CRAG), 02 a non-random change. (Please see page 17) National Average: of readmissions should be benchmarked, with the goal of having a rate less than the national average rate of readmissions. The national average goal line is based on the last reported data on the national Hospital Scorecard (June 13). See notes in Appendix A. Description: Around 15% to up to % of 28-day readmissions could be regarded as avoidable*. The most promising interventions to prevent readmission appear to be those that concentrate on coordination and communication around the time of discharge. *Preventing emergency readmissions to hospital, a scoping review, E. Nolte, M. Roland, S. Guthrie, Laura Brereton, 12 (prepared for the UK Department of Health) 22/04/14 Page 12 of

13 Safe: Compliance with MEWS Bundle Percent compliance with the Modified Early Warning Score Bundle (NHSL Acute Hospitals) Cardiac Arrest (True cardiac +/- respiratory arrests) per 00 total deaths and live discharges (NHSL Acute Hospitals) The total number of patients receiving all 6 components of the MEWS bundle Total number of true cardiac +/- respiratory arrests The total number of patients audited for MEWS compliance Total number of deaths & live discharges for the same period All three sites have seen increased compliance with this process measure in March and have exceeded % compliance. Performance is being reviewed through the DPS Group. Following a spike in the February rate, further review suggested there was no one hospital contributing to the higher rate, just a slight increase overall. This rate has reduced again in March 14 to the lowest in the two year reporting period. Process Measure CHD-CA Cardiac Arrest Median Goal: 95% Compliance Description: The Modified Early Warning score is used to quickly determine the degree of illness of a patient. Prompt treatment can then take place. The board should look for compliance at or above the compliance line. Description: The rate of cardiac arrests should be reduced by the prompt treatment and by patients, where appropriate, being identified as not for resuscitation. This rate is per 00 deaths and live discharges. 22/04/14 Page 13 of

14 Quality Ambition: Effective The most appropriate treatments, interventions, support and services will be provided at the right time to everyone who will benefit, and wasteful or harmful variation will be eradicated. Progress on this ambition is measured through clinical quality indicators, stroke care, medicine reconciliation and cost effective prescribing in primary care. Effective: Compliance with Falls Prevention CQI - Monklands Hospital Percent compliance with Falls Prevention CQI (Monklands Hospital) Falls (Monklands Hospital) No. of observations fully compliant Number of patient falls that resulted in injury. Total no. of Falls Prevention CQI Observations Total number of occupied bed days (OBDS) for the same period Improvement work in this area is being reviewed as part of the new Head of Safety s prioritised safety plan. This will take into consideration the effectiveness of the bundle and pace of/plan for spread. of falls had increased for three consecutive months but has reduced in January 14. This appears to be normal variation. Process Measure LBC-FALLS_MK Falls Prevention Compliance RSK-FALLS_MK Falls % Compliance % Compliance Median Goal Median Goal: 95% Compliance Description: In line with SPSP-Acute Phase 2, NHSL is rolling out an evidence based FallSafe Bundle commencing at Hairmyres Description: Falls with injury are reported as an adverse incident through DATIX. The board should look for the number of falls to be reduced through effective falls assessment and interventions. 22/04/14 Page 14 of

15 Effective: Compliance with Falls Prevention CQI - Wishaw General Hospital Percent compliance with Falls Prevention CQI (Wishaw General Hospital) Falls (Wishaw General Hospital) No. of observations fully compliant Number of patient falls that resulted in injury. Total no. of Falls Prevention CQI Observations Total number of occupied bed days (OBDS) for the same period Improvement work in this area is being reviewed as part of the new Head of Safety s prioritised safety plan. This will take into consideration the effectiveness of the bundle and pace of/plan for spread. of falls had increased for two consecutive months but has reduced in January 14. There appears to be slightly less variation in the rate in recent months but still appears to be normal variation. Process Measure LBC-FALLS_WG Falls Prevention Compliance RSK-FALLS_WG Falls % Compliance % Compliance Median Goal Median Goal: 95% Compliance Description: In line with SPSP-Acute Phase 2, NHSL is rolling out an evidence based FallSafe Bundle commencing at Hairmyres Description: Falls with injury are reported as an adverse incident through DATIX. The board should look for the number of falls to be reduced through effective falls assessment and interventions. 22/04/14 Page 15 of

16 Effective: Compliance with FallSafe Bundle - Hairmyres Hospital Percent compliance with FallSafe Bundle (Hairmyres Hospital) Falls (Hairmyres Hospital) No. of observations fully compliant Number of patient falls that resulted in injury. Total no. of FallSafe Bundle Observations Total number of occupied bed days (OBDS) for the same period Improvement work in this area is being reviewed as part of the new Head of Safety s prioritised safety plan. This will take into consideration the effectiveness of the bundle and pace of/plan for spread. Normal variance suggests there is not a strong link between process and outcome. Process Measure SPSP-FS_HM FallSafe Bundle Compliance RSK-FALLS_HM Falls % Compliance % Compliance Median Goal Median Goal: 95% Compliance Description: In line with SPSP-Acute Phase 2, NHSL is rolling out an evidence based FallSafe Bundle commencing at Hairmyres Description: Falls with injury are reported as an adverse incident through DATIX. The board should look for the number of falls to be reduced through effective falls assessment and interventions. 22/04/14 Page 16 of

17 Effective: Admission to Stroke Unit & Stroke Treatment Indicators Admission to Stroke Unit Stroke Treatment Indicators No. of patients admitted to stroke unit on day of admission or day after. Total no. of inpatients with diagnosis of stroke. A decline in performance was noted in December 13. This was as a consequence of ward closures due to Norovirus in Monklands and Wishaw General. Compliance has returned to within a normal range in January 14. CT: No. of patients who had CT/MRI within 24 hours of admission. Swallow Screen: No. of patients who had swallow screen on day of admission. Aspirin: No. of patients who had aspirin on day of admission or day after. Total no. of inpatients with diagnosis of stroke. Compliance with all three treatment indicators has improved this month and remains within a normal range. Process Measure STR-ADM Admission to Stroke Unit STR-TRE Stroke Treatment Indicators % Compliance % Compliance On Day or Day After On Day or Day After Swallow Screen on Day CT Scan on Day of Target of Admission Admission Aspirin on day of admission or day Screen Target Aspirin Target Goal: Admitted to a stroke unit on day of admission or day after - 90% Description: As the criteria for some of the standards has been reviewed and implemented as of January 13 Revised as - Admission to Stroke Unit (now only 1 standard) - HEAT Target 90% on the day of admission, or the day following presentation at hospital Goal: CT: 90%, Swallow Screen: 90%, Aspirin: 0% Description: As the criteria for some of the standards has been reviewed and implemented as of January 13 Revised as - CT Imaging - changed from % to 90% of patients have CT/ MRI imaging within 24 hours of admission Swallow screening - changed from 0% to 90% Aspirin - Target remains, changes to wording only 22/04/14 Page 17 of

18 Effective: Compliance with Medicines Reconciliation Percent of patients with medication reconciliation performed (NHSL Acute Hospitals) The total number of patients with accurate medication reconciliation performed The total number of patients in the sample The approach to improvement in medicines reconciliation is being reviewed and will be re-focused as part of the Head of Safety s prioritised plan. This is an aggregated representation and includes only the three pilot sites (medical receiving units) SPSP-MR Process Measure Medicine Reconciliation Compliance 0 90 % Compliance OUTCOME MEASURE TO BE DETERMINED 0 % Compliance Median Goal Goal: 95% Compliance Description: One of the outcomes of SPSP is to provide safe and effective medicines management. This is supported by effective reconciliation at the interface between primary and hospital care. The board should look for compliance at or above the compliance line. 22/04/14 Page 18 of

19 Effective: Compliance with A&E Treatment Target % of A&E attendances waiting more than 4 hours % of A&E attendances waiting more than 12 hours The number of patients waiting for more than 4 hours at an A&E clinic. The number of patients waiting for more than 12 hours at an A&E clinic. The number of patients attending an A&E department. The number of patients attending an A&E department. Following an increased rate of breeches in January and February, the rate has returned to within a normal range in March 14. Compliance with this metric has not been within target since July 12. Similar to the 4 hour rate, the increased rate we seen in January and February has reduced significantly in March 14. A&E-Breach A&E Waiting Times Breaches - 4Hrs A&E-Breach A&E Waiting Times Breaches - 12Hrs % of A&E waiting times breaches % of A&E waiting times breaches % Breaches Median Goal % Breaches Median Goal Goal: 5% or less of A&E attendances waiting more than 4 hours Description: The Scottish Government standard for Accident and Emergency departments is that 95 % of all attendances are seen within 4 hours. The board should look for % of A&E waiting times breaches to be at or below the compliance line. Goal: Eliminate 12 hour waits by March 13 Description: The 12/13 NHSL Strengthening Quality goal for implementation of the emergency access programme includes elimination of 12 hour waits in A&E by March 13. The Board should look for % of A&E waiting times breaching 12 hours to be reducing to zero. 22/04/14 Page 19 of

20 Appendix A - Notes on the data Average Hospital Length of Stay. The data reported only shows Inpatient Hospital Discharges. Total Hospital Length of Stay (HLOS) is linked to the discharge specialty and discharge date even if part of the hospital stay took place under different specialties and/or across different specified dates. This ultimately means some outlier long stays could have a big impact on Average HLOS for a specific specialty. The data reported only shows admissions where hospital Spell start date = admission date, therefore some hospital transfers will be excluded. Measures have not been standardised by age, sex and deprivation Average HLOS has not been adjusted for case mix so may reflect variations in complexity of patients treated Denominators are based on discharge dates to allow shorter reporting lag times. This means that the data on the local report will not be directly comparable with the national Early Warning Scorecard which uses admission dates for reporting. Data are subject to change following SMR validation processes. Readmissions data Measures have not been standardised by age, sex and deprivation s are only calculated using linked data held in the Lanarkshire TrakCare PMS and therefore does not include readmissions to other Health Boards Denominators are based on discharge dates to allow shorter reporting lag times. This means that the data on the local report will not be directly comparable with the national Early Warning Scorecard which uses admission dates for reporting. Data are subject to change following SMR validation processes. DATIX Old KPIs were: Low Graded incidents - investigated and closed within working days of the incident date Medium Graded incidents - investigated and closed within 22 working days of the incident date High Graded incidents - investigated and closed within 27 working days of the incident date New KPIs are: Low Graded incidents - investigated and closed within working days of the incident date Medium Graded incidents - investigated and closed within working days of the incident date High Graded incidents - investigated and closed within 45 working days of the incident date (Continued on next page) 22/04/14 Page of

21 Appendix A - Notes on the data continued Stroke Indicators As the criteria for some of the standards has been reviewed and implemented as of January 13, the report now only shows 4 standards: Admission to Stroke Unit (now only 1 standard) - HEAT Target 90% on the day of admission, or the day following presentation at hospital CT Imaging - changed from % to 90% of patients have CT/ MRI imaging within 24 hours of admission Swallow screening - changed from 0% to 90% Aspirin - Target remains, changes to wording only Interpreting run charts using run chart rules RULE 1: A SHIFT - 6 or more consecutive points either all above or all below the median line RULE 2: A TREND - 5 or more consecutive points all going in the one direction (up or down) RULE 3: TOO MANY OR TOO FEW RUNS - A non random pattern would be indicated by the data crossing the median too many or too few times (Reference table for this one) RULE 4: AN ASTRONOMICAL VALUE - A value that is obviously, blatantly different and really stands out as being highly unusual (Continued on next page) 22/04/14 Page 21 of

22 Appendix A - Notes on the data continued Deaths and Live Discharges The denominator for Unadjusted Patient Mortality includes Deaths and Live Discharges in all areas except for Obstetrics. Both the numerator and the denominator for Cardiac Arrest exclude Cardiac Arrests and Deaths and Live Discharges in these areas respectively:- -Hairmyres CCU -Hairmyres Day Surgery Unit -Hairmyres Dental Day Unit -Hairmyres ITU -Hairmyres Maternity Day Assessment -Monklands Endoscopy Unit -Monklands Hospital Day Surgery Unit -Monklands Ward 16 Haematology Day Unit -Monklands Ward 26 ITU -Wishaw General CCU -Wishaw General ICU -Wishaw General Medical Day Unit -Wishaw General Neonatal ICU -Wishaw General Surgical Day Unit -Wishaw General Ward 19 -Wishaw General Ward -Wishaw General Ward 21 -Wishaw General Ward 22 -Wishaw General Ward 23 -Wishaw General Ward 24 22/04/14 Page 22 of