Title of Report Executive Summary Actions requested Mortality Information Report (August 214 position) Mortality report providing the Board with an update on progress with the mortality reduction project. The report offers a series of key performance indicators (KPIs) to assist the Board with monitoring the progress of this work. These indicators incorporate those required to monitor the mortality corporate objectives. The Board is asked to note the contents of this report, progress against the plan, and suggest any new actions identified to improve the current position with regards to mortality. Corporate Objectives supported by this paper: Objective 1 Improving Patient Safety - Reduction in standardised mortality Risks: Board Risk Register: Poor quality of care provided to patients as measured by HSMR if higher than expected mortality is not noticed and addressed at Trust site and speciality level. Public and/or patient involvement: N/A Resource implications: N/A Communication: Regular mortality reduction bulletin to staff. Communications through the Trust governance structures. Dedicated section on Trust Intranet site. Regular programme of visits to teams Have all implications been considered? YES NO N/A Assurance Contract Equality and Diversity Financial / Efficiency HR Information Governance Assurance IM&T Local Delivery Plan / Trust Objectives National policy / legislation Sustainability Name Anton Sinniah Job Title Deputy Medical Director Date December 214 Email Anton sinniah@pat.nhs.uk 1
Mortality Information Report December 214 Contents Section Sub Title Page 1. Introduction 3 2. Approach 3 3. Summary 3 4. Rebased HSMR 3 5. HSMR and Crude Mortality Rates 4 5.1 North West Peers 4 5.2 HSMR by Month 5 5.3 HSMR by Site 5 5.4 Acuity by Site 7 5.5 HSMR by Day of Admission 8 5.6 SHMI 1 5.7 Crude Mortality Rate 12 6. KPIs 12 6.1 Palliative Care 12 6.4 Depth of Coding (Co-morbidities) 14 6.7 Consultant Review of Death Alerts 14 2
Mortality Information Report December 214 (August position) 1. Introduction This report reflects the rebased Mortality position for the Trust up to the end of August 214 and includes the latest data from Dr Foster updated on 28 th November 214. 2. Approach The Dr Foster data is reviewed routinely with in-depth analysis particularly for areas showing no improvement or an adverse variance. 3. Summary 3.1 HSMR. August April to August Pennine 78.5 84.4 (NW 92.8) Oldham 82.2 96. North Manchester 76.4 85.9 Bury 82. 75.1 Rochdale 2.6 21.4 3.2 The Mortality Validation Tool is now fully live across the Trust. The compliance for use of the tool is being monitored and will be tabled at the February Safety Committee. The second version of the Tool will allow Consultants to carry out a clinical review at the same time as validating the coding. This is still in development with Woodward Associates Ltd (company who developed the tool) and will be available for piloting February 215. 3.3 Mortality Reduction Partnership (CQUIN: Mortality Reduction) - An audit was undertaken of 5 consecutive death casenotes and 45 were analysed. The audit tool is based on the NHS Institute Mortality Review Tool combined with the global trigger tool. The audit included a clinical review by Deputy Medical Directors. The audit results will be shared at the Mortality Reduction Partnership meeting which was due to have its first meeting in October. 4. Rebased HSMR This took place at the end of November 214 and moved the HSMR for 213/14 to 91 (as predicted) from previously reported 82.5. Dr Foster updated Quality Investigator with remodelled statistical risks for the full financial year 213/14. 3
5. HSMR and Crude Mortality Rates 5.1 North West Peers The graphs below show how the Trust is performing against its North West peers* for the period April to August 214 plus April 213 to March 214. The Trust is below the North West average of 92.8 with an HSMR for the 5 month period to August 214 of 84.4. The Trust has improved significantly against several of its peers and has nd retained 2 best position within the North West. HSMR NW Acute Providers - April to August 214 14 12 111.5 18.6 8 16.1 16.1 99.5 98.9 96.7 95.7 95.1 94.5 92.5 91.2 87.9 87.8 87.8 87.5 87.2 86.4 86.3 84.6 84.4 82.4 6 4 2 HSMR NW Average HSMR NW Acute Providers - April 213 to March 214 14 12 119.3 11.5 17.917.5 16.15.9 14.814.414.1 13.7 12.8 11.7.8 98.8 98.7 98.6 97.1 96. 94. 93.9 91.1 85.2 8 6 4 2 HSMR NW Average *The peer performance includes any patients treated at Pennine who were also seen at other providers for related care during their spell, known as the super spell. The number of super spells during the period may vary and therefore the impact on the HSMR will differ slightly when comparing Pennine only based reports as a result. 4
5.2 HSMR by Month The 12 month rolling HSMR up to the end of August is 88.28. This is an improvement of 1.2 compared to the July refreshed and rebased position of 89.3. The chart below shows the trend over the last 29 months comparing month by month and year on year. 12 HSMR Year on Year 212/13, 213/14 and 214/15 8 6 4 2 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 212/13.3 11.2 93.2 97.4 98.9 17.7 93.9 9.2.8 17. 96.3 95.4 213/14.5 84.2 95. 81.1 92.6 97.4 89.8 92.7 78.3 92.4 93. 95.2 214/15 89.9 8.8 93.4 77.6 78.7 5.3 HSMR by Site A further breakdown by site shows a significant improvement in Oldham in month. Dr Sinniah (Deputy Medical Director and Acute Physician) has spent the last 2 months working on the Acute Medical Unit at Oldham to gain a greater understanding of the site pressures. He and Dr Prudham (Deputy Medical Director and Gastroenterologist) have met with the Oldham team to discuss ways to improve performance and outcomes. Task and finish groups have been set up by Dr Ng Man Kwong (Clinical Director and Respiratory consultant) and Dr Gili (Clinical Director and A&E consultant), which have previously been successful in addressing concerns. There have also been discussions with the Clinical Commissioning Groups about 5
reducing delayed discharges, as these are having a significant adverse impact on the site and these are beginning to demonstrate change. The graphs below show the comparison between the rebased 213/14 and the most recent 5 months to August 214. All sites are now showing an improvement on last year s position. It should be noted that following the rebasing exercise Oldham s score for 213/14 is.96. 6
5.4 Acuity by Site (Actual % HSMR against Expected % HSMR January August 214) It is clear from the graphs below that FGH has the sicker patients as on average 9.3% of all non-elective patients in the 8 month period were expected to die compared to 6.1% at both Oldham and NMGH. The actual HSMRs were lower than expected at all sites hence HSMR <. This links with the higher SHMI rates at Fairfield where patients approaching end of life are still being sent into hospital by the community teams, to be discharged by the Trust to die at home. (see 5.6 below) 7
5.5 HSMR by Day of Admission The graphs below show the comparison between the rebased 12 month period 213/14 and the most recent 5 month period to August 214. It should be noted that following the rebasing exercise Saturday s score for 213/14 is.56. HSMR by Day of Admission - April to August 214 12 8 6 4 2 91.9 89.89 8.72 8.12 85.73 84.32 74.64 Monday Tuesday Wednesday Thursday Friday Saturday Sunday HSMR by Day of Admission - April 213 to March 214 12 8 6 4 2 92.48 91.46 87.55 9.4 85.67.56 9.55 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 8
There is quite a range across the days at each site (see actual numbers of deaths in graph at bottom of page) and currently Oldham on Tuesdays and Sundays and North Manchester on Mondays having an HSMR greater than. Non-Elective HSMR by day of the week - April to August 214 14 12 8 6 4 2 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Bury 9.1 92.6 59.4 84.4 82.5 67.95 59.1 NMGH 13.11 77.57 94.3 75.84 85.33 75.94 83.1 RI 38.53 39.69 29.51 19.85 39.14 ROH 91.33 19.75 92.46 8.44 94.4 82.47 11.59 Bury NMGH RI ROH 14 12 8 6 4 2 Non-Elective HSMR by day of the week - April 213 to March 214 Monday Tuesday Wednesday Thursday Friday Saturday Sunday Bury 87.91 75.94 87.68 8.11 82.45 86.63 89.29 NMGH 91.7 93.55 9.66 88.68 9.41 14.64 82.7 RI 44.1 44.32 36.92 22.7 51.65 62.46 84.76 ROH 11.25 17.51 92.28 18.9 88.93 19.55 98.36 Bury NMGH RI ROH 9
5.6 SHMI The graph below shows the quarterly SHMI trend for the last 3 years. April 213 to March 214 has just been released and SHMI has increased to 13.6. Quarter 4 has seen the steepest increase for some time with both Oldham and Fairfield at 12. Pennine FGH Oldham NMGH 1
Pennine (yellow) has a lower confidence interval above like the other red Trusts. In the graph below actual in-hospital deaths in SHMI is 95.47 compared to 9.97 for HSMR. SHMI has over twice as many spells (127,332) as HSMR (6,11) due to the fact that HSMR only looks at 56 diagnosis groups. On the graph below you can see how SHMI compares across sites. Oldham now has the highest SHMI at 19.5. Fairfield has the highest proportion of deaths in the community (37.8%), NMGH (31.8%), Oldham (28.6%). This suggests patients approaching end of life are still being sent into hospital by the community teams, to be discharged by the Trust to die at home. (see 5.4 above). 11
5.7 Crude Mortality Rate The graph below reflects the crude mortality rate for the Trust over the last rolling 24 months. Crude Mortality Rate (%) 6.% 5.% 4.% 3.% 2.% 1.%.% Crude Mortality Rate - All Admissions Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 35 3 25 2 15 5 Deaths Crude Mortality rate (%) Deaths A breakdown for the last 24 months by age shows the marked higher mortality rate for patients 75+ who account for 65% of all deaths. Crude Mortality Rate - Aged 75+ Crude Mortality Rate (%) 6.% 5.% 4.% 3.% 2.% 1.%.% Dec-12 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 35 3 25 2 15 5 Deaths Crude Mortality rate (%) Deaths 6. Key Performance Indicators 6.1 Palliative Care Coding Title Description/Rationale Metric Target/ Outcome Palliative Care Coding Compared to peers, our Palliative Care Coding remains around the median. We need to ensure that we are capturing all spells where Specialist Palliative Care is involved. [Number of Spells with Z515 (Specialist Palliative Care)] / [Total Number of Spells] This will be a dynamic target to continuously achieve the North West average. This will be realigned as rebased data is loaded into Dr. Foster 12
6.2 Key Performance Indicators - Percentage of Spells with Palliative Care Coded 5.% 4.5% 4.% 3.5% 3.% 2.5% 2.% 1.5% 1.%.5%.% % Spells with Specialist Palliative Care - April to August 214 4.4% 4.% 2.6% 2.6% 2.5% 2.5% 2.3% 2.3% 2.2% 2.2% 2.2% 2.2% 2.1% 2.1% 2.1% 2.1% 2.% 1.9% 1.7% 1.7% 1.5%.5% % Palliative NW Avge 4.5% 4.% 3.5% 3.% 2.5% 2.% 1.5% 1.%.5%.% % Spells with Specialist Palliative Care - April 213 to March 214 4.1% 3.3% 2.6% 2.5% 2.5% 2.4% 2.3% 2.2% 2.2% 2.2% 2.2% 2.2% 2.2% 2.1% 2.1% 1.9% 1.8% 1.8% 1.5% 1.5% 1.2%.9% % Palliative NW Avge 6.3 Actions & Ongoing work The Trust remains slightly above the NW average but continues to be monitored. As with other metrics Specialist Palliative Care coding is monitored through the clinical coding dashboard and via a routine monthly audit carried out between the clinical coding department and the Consultant Specialist. 13
6.4 Depth of Coding Title Description/Rationale Metric Target/ Outcome Depth of Coding To ensure that appropriate relative risks are applied we need to ensure that all co-morbidities are captured by clinicians and then coded accordingly Average number of co-morbidities per FCE (finished consultant episode) National mean average from Trust Quality Dashboard = 4.51 6.5 Key Performance Indicators Average Number of co-morbidities per FCE 5.5 5. 4.5 4. 3.5 3. 2.5 2. Average co-morbities Non-Elec - November 212 to October 214 PAT Avge Co-morb. National Mean Q1 13/14 6.6 Actions & Ongoing work As mentioned in point 6.3 above the Clinical Coding Specialty Leads work closely with the clinicians to improve the recording in the clinical documentation for comorbidities. Clinical Coding Co-morbidity Awareness Training has been provided to the clinical coders and will be refreshed annually. 6.7 Consultant review of Death Alerts prior to coding of episodes Title Description/Rationale Metric Target/ Outcome Consultant review of Case notes Consultants will be asked to review all deaths before the casenote is sent to clinical coding. [Number of cases reviewed by Consultant] / [Total number of deaths] Arising from comments from a previous Trust Board, the target now needs to be agreed following the completion of the pilot for the Mortality Validation tool. 14
6.8 Key Performance Indicators Percentage of Deaths that have been reviewed before being coded Actions & Ongoing work The Mortality Validation tool The Clinical coding team have had a new validation tool built to support the Trust in ensuring that the deaths are coded correctly before the data is submitted to SUS for Dr Foster. This is an electronic tool which allows a two way conversation between the coding team and the consultant who was responsible for the care of the patient at time of death. The consultant is asked to sign off the coding as correct or provide additional information through the tool to improve the accuracy of the coded data. Version 1 of the Mortality Validation Tool is undergoing improvements to enhance its potential. Clinical coding speciality leads will now begin to monitor Consultant compliance in using the tool. The second version of the Tool will allow Consultants to carry out a clinical review at the same time as validating the coding. This is still in development with Woodward s and is due for release February 215. A demonstration of the tool was shown to Dr Anton Sinniah, Dr Roger Prudham and Dr Jason Raw who all gave good and positive feedback regarding the next version and the ability to record clinical information regarding the death alongside the validation of the coding to assist in the analysis into hospital deaths. Anton Sinniah Deputy Medical Director December 214 Glossary & Terms Appendix 1 Ref HSMR SHMI FCE RR Explanation/Detail Hospital Standardised Mortality Ratio Summary Hospital-Level Mortality Indicator Finished Consultant Episode Relative Risk 15