Stethoscope CCG Indicator Metadata

Stethoscope CCG Indicator Metadata Version Number 1.12 Version Date 22 June 2015 Publish Status Authors Owner Approved By Simon McInerney, Dylan Knight Simon Swift Approved Date 22 June 2015 Methods Stethoscope CCG Indicator Metadata Website version V1 11 version 1.11 version date 22 June 2015 printed 22 Jun 2015 22:07 1 of 64

Document control Revision History Date of this revision: 22 June 2015 Revision No Revision Date Summary of Changes 1.6 13/05/14 Split SHMI Indicator into Poisson limits and IC OD limits Inserted Available Drills and Available Views for subscriber view Split Reporting Schedule into Subscriber and Public Aligned indicator numbering scheme with Stethoscope Correction to indicator C5.07: OPCS = R18 Updated PROMs indicators (C3.07 and C3.08) to primary procedures only Updated indicator C1.03 from low risk HRGs to low risk CCS groups 1.7 28/05/14 Updated indicator A4.05 from 95 th percentile to percentage under 18 weeks Updated indicators C2.01 and C2.02 with HSCIC definition for ACSCs 1.8 12/01/15 Aligned mortality indicator C1.03 with CQC IMR definition Updated emergency admissions to include ADMIMETH = 2A, 2B, 2C, 2D 1.9 16/01/15 Added new indicators C1.09, C3.13 and C1.14 1.10 09/06/15 Added new indicators 0145, 0146, 0147, 0148, 0149, 0150 and renamed C6.01 0415 and moved it to Domain 7 1.11 22/06/15 Updated indicator codes to numbers 0049 indicator name updated to BADS Day Case Rate (including outpatient procedures) Added 0106, 01,07, 0108, 0109 Methods Stethoscope CCG Indicator Metadata Website version V1 11 version 1.11 version date 22 June 2015 printed 22 Jun 2015 22:07 2 of 64

1.12 28/07/2015 Corrected 0046 to reflect use of Elective codes Methods Stethoscope CCG Indicator Metadata Website version V1 11 version 1.11 version date 22 June 2015 printed 22 Jun 2015 22:07 3 of 64

Contents Acknowledgments... 7 Domain 1: Preventing people from dying prematurely... 8 Domain 2: Enhancing the quality of life for people with long term conditions... 17 Domain 3: Helping people recover from episodes of ill health or following injury... 26 Methods Stethoscope CCG Indicator Metadata Website version V1 11 version 1.11 version date 22 June 2015 printed 22 Jun 2015 22:07 4 of 64

Domain 4: Ensuring that people have a positive experience of care... 41 Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm... 46 Methods Stethoscope CCG Indicator Metadata Website version V1 11 version 1.11 version date 22 June 2015 printed 22 Jun 2015 22:07 5 of 64

Domain 6: Organisational Context... 53 Domain 7: Market Share... 60 Methods Stethoscope CCG Indicator Metadata Website version V1 11 version 1.11 version date 22 June 2015 printed 22 Jun 2015 22:07 6 of 64

Acknowledgments In creating Stethoscope, Methods Insight Analytics have accessed a wide range of data sources, the majority of which are publically available. The organisations below represent the sources of data and methodologies used. National HES data has been used for many of the indicators included in Stethoscope. Data for 2014/15 is provisional. Further information and detailed footnotes are available at www.hscic.gov.uk/hes. Stethoscope also uses published reports from the HSCIC which are available at www.hscic.gov.uk for the NHS to re-use. All data Copyright 2015, Health and Social Care Information Centre Stethoscope uses published reports from NHS England which are available at www.england.nhs.uk. Stethoscope includes data from published DH information Stethoscope uses methodology employed by HQIP Workforce data from ESR which is available through iview has been usedin Stethoscope SPC Methodology published by APHO (now a part of Public Health England) has been used to create some of the statistics. Stethoscope uses the BADS directory of daycase surgery Published infection control data available at www.hpa.org.uk has been used in stethoscope Stethoscope uses published CQC patient survey data Published national patient safety data from www.npsa.nhs.uk has been used. Prescribing data from the NHS Business Services Authority has been used within Stethoscope Methods Stethoscope CCG Indicator Metadata Website version V1 12 version 1.9 version date 16 January 2015 printed 28 Jul 2015 10:31 7 of 64

Domain 1: Preventing people from dying prematurely Domain 1: Preventing people from dying prematurely 0011: In-hospital mortality in low risk CCS groups (Standardised Mortality Ratio) In-hospital mortality in low risk diagnosis groups (Crude rate per 1,000 admissions) Count of denominator spells with method of discharge as death: DISMETH = 4 Count of Spells with a primary diagnosis associated with a low mortality diagnosis group where the mortality rate has been shown to be consistently below 0.5%. CCS group inclusions: Exclusions: 7, 10, 46, 47, 53, 57, 61, 64, 66, 67, 69, 72, 74, 75, 80, 84, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 98, 102, 112, 119, 120, 124, 126, 136, 137, 138, 140, 141, 142, 143, 144, 147, 160, 162, 163, 164, 165, 166, 167, 168, 169, 170, 171, 172, 173, 174, 175, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 190, 191, 192, 193, 194, 195, 196, 198, 200, 202, 203, 205, 206, 208, 209, 210, 211, 212, 225, 232, 234, 235, 236, 241, 242, 247, 251, 253, 254, 256, 257, 258 Exclude spells where admission age is under 19: STARTAGE < 19 Exclude spells where DISDATE = NULL Exclude spells with Primary diagnosis or Secondary diagnosis = R296 ( Tendency to fall, not elsewhere classified ) in any position Exclude spells where primary diagnosis is trauma, cancer, or immunocompromised states, see table below: 8 of 64

Domain 1: Preventing people from dying prematurely Condition group Primary Diagnosis Trauma S011, S020, S021, S022, S023, S024, S026, S027, S028, S029, S030, S052, S053, S054, S055, S057, S058, S059, S060, S062, S062, S064, S064, S065, S066, S068, S068, S070, S099, S120, S121, S127, S128, S129, S131, S133, S141, S142, S143, S150, S152, S153, S157, S158, S159, S179, S220, S222, S223, S224, S225, S231, S241, S242, S250, S251, S252, S253, S254, S255, S257, S258, S259, S268, S269, S270, S271, S272, S273, S274, S278, S278, S279, S320, S321, S323, S324, S325, S328, S331, S332, S341, S342, S343, S344, S350, S351, S352, S353, S354, S355, S357, S358, S359, S360, S361, S362, S363, S364, S365, S366, S368, S369, S370, S371, S372, S376, S378, S379, S380, S381, S420, S421, S422, S423, S424, S430, S431, S432, S433, S451, S452, S47, S520, S521, S522, S523, S524, S525, S526, S528, S529, S531, S552, S570, S579, S580, S581, S620, S621, S622, S623, S624, S628, S630, S631, S652, S655, S670, S678, S710, S720, S721, S722, S723, S724, S729, S730, S750, S751, S752, S772, S789, S810, S820, S821, S822, S824, S825, S826, S828, S830, S831, S832, S833, S850, S851, S855, S858, S859, S870, S878, S880, S881, S889, S913, S920, S921, S922, S923, S929, S930, S931, S933, S951, S958, S959, S970, S971, S978, S980, T012, T021, T024, T025, T039, T041, T042, T043, T049, T052, T053, T055, T061, T080, T081, T092, T093, T094, T100, T101, T114, T116, T120, T121, T131, T142, T143, T145, T147, T148, T200, T201, T202, T203, T210, T211, T212, T213, T220, T221, T222, T223, T230, T260, T261, T262, T264, T790, T791, T792, T793, T794, T795, T796, T797, T798 Cancer B21, C, D46, D47, D48, D00-D09, M724, Z08, Z12, Z511, Z85 Immunocompromised B24, B59, D70, D71, D720, D800, D801, D802, D803, D804, States D805, D808, D814, D819, D820, D821, D830, D831, D838, D849, D898, D899, E40, E41, E43, I120, I131, I132, K912, M359, N18, T860, T861, T862, T864, T868, T869, Z452, Z491, Z940, Z941, Z942, Z944, Z948, Z992 9 of 64

Domain 1: Preventing people from dying prematurely Deaths per 1,000 spells SUS Square Root Method RY RY GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend, Pathway 0012: In-hospital perinatal mortality, including still births (Crude rate per 1,000 births) Number of deaths within 7 days of birth / Total number of births Include all records from denominator and restrict to: DISMETH = 5 or DISMETH = 4 and ENDAGE = 7001, 7002 All HES Inpatient records satisfying the following criteria: HRG_3.5 = N01 N05 or SUS generated HRG = PB01Z, PB02Z, PB03Z Crude rate per 1,000 births 10 of 64

Domain 1: Preventing people from dying prematurely HES (Admited Patient Care) Poisson Distribution RY RY GP, Trust, Weekend/Weekend 0264: Summary Hospital-level Mortality Indicator (HED - SHMI) (IC OD Control Limits) Observed elective & emergency mortality rate / Expected elective and emergency mortality rate Published method of calculation on IC website www.hscic.gov.uk/shmi HES (Admitted Patient Care) / ONS Over dispersion control limits RY RY Specialty, Age Group, Sex, CCS Group, Weekend/Weekend, Pathway 11 of 64

Domain 1: Preventing people from dying prematurely 0265: Summary Hospital-level Mortality Indicator (HED - SHMI) (Poisson Control Limits) Observed elective & emergency mortality rate / Expected elective and emergency mortality rate Published method of calculation on IC website www.hscic.gov.uk/shmi HES (Admitted Patient Care) / ONS Poisson Distribution Subscription only N/A RY Specialty, Age Group, Sex, CCS Group, Weekend/Weekend, Pathway 0268: Hospital Standardised Mortality Ratio (HSMR) Observed elective & emergency mortality rate / Expected elective and emergency mortality rate Published method of calculation by Dr Foster, data provided by UHB http://drfosterintelligence.co.uk/wp-content/uploads/2011/10/hsmr-toolkit-version-6-october-2011.pdf HES (Admitted Patient Care) 12 of 64

Domain 1: Preventing people from dying prematurely Reporting Schedule: RY Poisson Distribution Subscription only N/A RY Specialty, Age Group, Sex, CCS Group, Weekend/Weekend, Pathway, VLAD 0013: In-hospital mortality rate for Cardiovascular / Respiratory / Liver disease in under 75 year olds (Crude rate per 1,000 admissions) Number of deaths in the <75 for Cardiovascular, Respiratory or Liver disease / Number of < 75 admissions Include all records from denominator and restrict to: DISMETH = 4 All HES Inpatient records satisfying the following criteria: STARTAGE <75 OR STARTAGE >7000 Cardiovascular Disease: ICD-10 Codes: DIAG1 = I00 - I99 Respiratory Disease: ICD-10 Codes: DIAG1 = J00 J99 Liver Disease: ICD-10 Codes: DIAG1 = K70 K77, B15 B19, C22, T864 Exclude records where DISDATE = NULL Crude rate per 1,000 admissions 13 of 64

Domain 1: Preventing people from dying prematurely HES (Admitted Patient Care) Square Root Method RY RY GP, Trust 0014: Emergency admissions for alcohol related liver disease (Directly Standardised Rate per 100,000 population) Number of emergncy admissions for alcohol related conditions / CCG population All HES Inpatient records satisfying the following criteria: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D EPISTAT = 1, 3 SEX = 1, 2 EPIORDER = 1 ADMISOURCE is not 51, 52 or 53 CLASSPAT = 1 Alcohol related admissions: DIAG1 = K70 CCG population based on patients registered with the constituent GP practices 14 of 64

Domain 1: Preventing people from dying prematurely Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES Poisson Distribution RY RY GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend, Pathway, VLAD 0015: In-hospital mortality rate (Crude rate per 1,000 admissions) Number of discharges coded as deaths / Number of admissions Include all records from denominator and restrict to: DISMETH = 4 or 5 Include all records where: Exclude records where DISMETH = NULL Exclude records where DISDATE = NULL CLASSPAT = 1 or 2 Crude rate per 1,000 admissions 15 of 64

Domain 1: Preventing people from dying prematurely HES (Admitted Patient Care) Square Root Method Subscription only N/A RY Trust, GP, Specialty, Age Group, Sex, CCS Group, Weekday/Weekend, Pathway, VLAD 16 of 64

Domain 2: Enhancing the quality of life for people with long term conditions Domain 2: Enhancing the quality of life for people with long term conditions 0024: Emergency admissions for acute Ambulatory Care Sensitive Conditions (Directly Standardised Rate per 100,000 population) Number of patients admited in an emergency for acute ambulatory care sensitive conditions / CCG population All HES Inpatient records satisfying the following criteria: EPIORDER = 1 STARTAGE BETWEEN 0 AND 120 OR STARTAGE >=7000 ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D EPISTAT = 1, 3 SEX = 1, 2 ADMISORC NOT IN (51,52,53) EPITYPE = 1 CLASSPAT = 1 SPELDUR IS NOT NULL Any acute ACS condition in the following list: DIAG1 IN ('J10', 'J11', 'J13', 'J14', 'A36', 'A37', 'B05', 'B06', 'B26','J153', 'J154', 'J157', 'J159', 'J168', 'J181', 'J188', 'B161', 'B169', 'M014') AND DIAG2 - DIAG14 <> 'D57' 17 of 64

Domain 2: Enhancing the quality of life for people with long term conditions DIAG1 IN ('I240','I248','I249') AND OPERTN1 - OPERTN14 ('A', 'B', 'C', 'D', 'E', 'F', 'G', 'H', 'I', 'J', 'K', 'L', 'M', 'N', 'O', 'P', 'Q', 'R', 'S', 'T', 'V', 'W') AND OPERTN1 - OPERTN14 NOT IN ('X0','X1','X2','X4','X5') DIAG1 IN ('E86','K52','A04','A08','A09','A020','A059','A072') DIAG1 IN ('N10','N11','N12','N136','N159','N390','N300','N308','N309') DIAG1 IN ('K20', 'K21', 'K250', 'K251', 'K252', 'K254', 'K255', 'K256', 'K260', 'K261', 'K262', 'K264', 'K265', 'K266', 'K270', 'K271', 'K272', 'K274', 'K275', 'K276', 'K280', 'K281', 'K282', 'K284', 'K285', 'K286') DIAG1 IN ('L03','L04','L88','L01','L02','L080','L088','L089','L980','I891') AND OPERTN1 - OPERTN14 NOT IN ('A', 'B', 'C', 'D', 'E', 'F', 'G', 'H', 'I', 'J', 'K', 'L', 'M', 'N', 'O', 'P', 'Q', 'R', 'T', 'V', 'W', 'X0', 'X1', 'X2', 'X4', 'X5', 'S1', 'S2', 'S3', 'S41', 'S42', 'S43', 'S44', 'S45', 'S48', 'S49') DIAG1 IN ('H66','H67','J02','J03','J06','J312','J040') DIAG1 IN ('K02','K03','K04','K05','K06','K08','K12','K13','A690','K098','K099') DIAG1 IN ('R56','O15','G253') CCG population based on patients registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES (Admitted Patient Care) Poisson Distribution GP, Trust, Specialty, Age Group, Sex, Weekend/Weekend, ACS Condition 18 of 64

Domain 2: Enhancing the quality of life for people with long term conditions 0025: Emergency admissions for chonic Ambulatory Care Sensitive Conditions (Directly Standardised Rate per 100,000 population) Number of patients admited in an emergency for chonic ambulatory care sensitive conditions / CCG population All HES Inpatient records satisfying the following criteria: EPIORDER = '1' STARTAGE BETWEEN 0 AND 120 OR STARTAGE >=7000 ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D EPISTAT = 1, 2 SEX = 1, 2 ADMISORC NOT IN (51,52,53) EPITYPE = 1 CLASSPAT = 1 SPELDUR IS NOT NULL Any chonic ACS condition in the following list: DIAG1 IN ('B180','B181') AND DIAG2 - DIAG14 <> 'D57' DIAG1 IN ('J45','J46') DIAG1 IN ('I50','J81') DIAG1 IN ('I110','I130') AND OPERTN1 - OPERTN14 NOT IN ('K0', 'K1', 'K2', 'K3', 'K4', 'K50', 'K52', 'K55', 'K56', 'K57', 'K60', 'K61', 'K66', 'K67', 'K68', 'K69', 'K71') 19 of 64

Domain 2: Enhancing the quality of life for people with long term conditions DIAG1 IN ('E10','E11','E12','E13','E14') DIAG1 IN ('J41','J42','J43','J44','J47') DIAG1 = 'J20' AND DIAG2 DIAG14 IN ('J41','J42','J43','J44','J47') DIAG1 IN ('I20','I25') AND OPERTN1 NOT IN ('A', 'B', 'C', 'D', 'E', 'F', 'G', 'H', 'I', 'J', 'K', 'L', 'M', 'N', 'O', 'P', 'Q', 'R', 'S', 'T', 'V', 'W', 'X0', 'X1', 'X2', 'X4', 'X5') DIAG1 IN ('D51','D52','D501','D508','D509') DIAG1 IN ('I10','I119') AND OPERTN1 - OPERTN14 NOT IN ('K0', 'K1', 'K2', 'K3', 'K4', 'K50', 'K52', 'K55', 'K56', 'K57', 'K60', 'K61', 'K66', 'K67', 'K68', 'K69', 'K71') DIAG1 IN ('G40','G41','F00','F01','F02','F03','I48') CCG population based on patients registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES (Admitted Patient Care) Poisson Distribution GP, Trust, Specialty, Age Group, Sex, Weekend/Weekend, ACS Condition 20 of 64

Domain 2: Enhancing the quality of life for people with long term conditions 0026: Emergency admissions for patients age 65 and over with Dementia (Directly Standardised Rate per 100,000 population) Number of admissions for patients aged over 65 years old with any coding of Dementia in any secondary position / CCG population All HES Inpatient records satisfying the following criteria: STARTAGE >= 65 AND STARTAGE < 7000 ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D EPIORDER= 1 CLASSPAT = 1, 2 Exclude records where SPELLDUR is NULL Dementia ICD-10 codes: F00, F01, F02, F03, F05, R54, G20, G30 present in DIAG2 DIAG14 CCG population based on patients aged over 65 years old registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES (Admitted Patient Care) Poisson Distribution GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 21 of 64

Domain 2: Enhancing the quality of life for people with long term conditions 0027: Emergency admissions for asthma, diabetes and epilepsy in under 19 year olds (Directly Standardised Rate per 100,000 population) Number of emergency admissions in under 19 year olds for asthma, diabetes and epilepsy / CCG population All HES Inpatient records satisfying the following criteria: STARTAGE <19 OR STARTAGE >7000 ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D EPIORDER = 1 Asthma ICD-10 codes DIAG1 = J45, J46 Diabetes ICD-10 codes DIAG1 = E10 E14 Epilepsy ICD-10 codes DIAG1 = G40, G41 Indicator Definition: CCG population based on patients aged under 19 years old registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HSCIC Indicator Portal: https://indicators.ic.nhs.uk/download/outcomes%20framework/specification/nhsof_2.3.ii_i00671_s_v8.pdf HES (Admitted Patient Care) Poisson Distribution 22 of 64

Domain 2: Enhancing the quality of life for people with long term conditions GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 0028: Diabetes admissions with complications (Directly Standardised Rate per 100,000 population) Number of admissions with diabetes complications / CCG population All HES Inpatient records satisfying the following criteria: STARTAGE >17 AND STARTAGE <7000 ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D EPISTAT = 1, 3 SEX = 1, 2 CLASSPAT = 1 EPIORDER = 1 Diabetes Complications = E10.0 - E10.8, E11.0 - E11.8, E12.0 - E12.8, E13.0 - E13.8, E14.0 - E14.8 CCG population based on patients registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES Poisson Distribution 23 of 64

Domain 2: Enhancing the quality of life for people with long term conditions GP, Trust, Specialty, Age Group, Sex, Weekend/Weekend 0029: Admissions for patients age 65 and over for or with a fall (Directly Standardised Rate per 100,000 population) Number of patients aged over 65 years old admitted with or for a fall / CCG Population All HES Inpatient records satisfying the following criteria: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D SEX = 1, 2 CLASSPAT = 1 EPIORDER = 1 Fall ICD-10: W00 W19 present in DIAG1 DIAG14 CCG population based on patients over 65 years old registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES Poisson Distribution 24 of 64

Domain 2: Enhancing the quality of life for people with long term conditions GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 25 of 64

Domain 3: Helping people recover from episodes of ill health or following injury Domain 3: Helping people recover from episodes of ill health or following injury 0041: Emergency re-admissions: Percentage within 30 days of an elective admission Number of emergency re-admissions within 30 days of discharge / Number of discharges following an elective admission Count of re-admissions where PSEUDOHESID can be matched and when DISDATE of the discharge episode and ADMIDATE of the admission episode are within 30 days. Note: may include a small number of inter-provider transfers. Readmissions other than to the same trust are attributed to the discharging organisation (the trust that created the first spell in a series) Admission episode inclusions: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D CLASSPAT = 1 EPIORDER = 1 Admission episode exclusions: TRETSPEF = 700-715, 501, 560, 610 DIAG1 = O, C, D0, D1, D2, D3, D4, F, Z08, Z51.1, Z51.2, Z51.3, Z51.5 Discharge episode inclusions: ADMIMETH = 11, 12, 13 CLASSPAT = 1 Discharge episode exclusions: DISMETH = 4, 26 of 64

Domain 3: Helping people recover from episodes of ill health or following injury DISDATE = NULL TRETSPEF = 700-715, 501, 560, 610 DIAG1 = O, C, D0, D1, D2, D3, D4, F, Z08, Z51.1, Z51.2, Z51.3, Z51.5 Percentage HES (Admitted Patient Care) Square Root Method GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 0042: Emergency re-admissions: Percentage within 2 days of an elective admission Number of emergency re-admissions within 2 days of discharge / Number of discharges following an elective admission Count of re-admissions where PSEUDOHESID can be matched and when DISDATE of the discharge episode and ADMIDATE of the admission episode are within 2 days. Note: may include a small number of inter-provider transfers. Readmissions other than to the same trust are attributed to the discharging organisation (the trust that created the first spell in a series) Admission episode inclusions: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D CLASSPAT = 1 27 of 64

Domain 3: Helping people recover from episodes of ill health or following injury EPIORDER = 1 Admission episode exclusions: TRETSPEF = 700-715, 501, 560, 610 DIAG1 = O, C, D0, D1, D2, D3, D4, F, Z08, Z51.1, Z51.2, Z51.3, Z51.5 Discharge episode inclusions: ADMIMETH = 11, 12, 13 CLASSPAT = 1 Discharge episode exclusions: DISMETH = 4, DISDATE = NULL TRETSPEF = 700-715, 501, 560, 610 DIAG1 = O, C, D0, D1, D2, D3, D4, F, Z08, Z51.1, Z51.2, Z51.3, Z51.5 Percentage HES (Admitted Patient Care) Square Root Method GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 28 of 64

Domain 3: Helping people recover from episodes of ill health or following injury 0043: Emergency re-admissions: Percentage within 30 days of a non-elective admission Number of emergency re-admissions within 30 days of discharge / Number of discharges following an elective admission Count of re-admissions where PSEUDOHESID can be matched and when DISDATE of the discharge episode and ADMIDATE of the admission episode are within 30 days. Note: may include a small number of inter-provider transfers. Readmissions other than to the same trust are attributed to the discharging organisation (the trust that created the first spell in a series) Admission episode inclusions: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D CLASSPAT = 1 EPIORDER = 1 Admission episode exclusions: TRETSPEF = 700-715, 501, 560, 610 DIAG1 = O, C, D0, D1, D2, D3, D4, F, Z08, Z51.1, Z51.2, Z51.3, Z51.5 Discharge episode inclusions: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D CLASSPAT = 1 Discharge episode exclusions: DISMETH = 4, DISDATE = NULL TRETSPEF = 700-715, 501, 560, 610 29 of 64

Domain 3: Helping people recover from episodes of ill health or following injury DIAG1 = O, C, D0, D1, D2, D3, D4, F, Z08, Z51.1, Z51.2, Z51.3, Z51.5 Percentage HES (Admitted Patient Care) Square Root Method GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 0044: Emergency re-admissions: Percentage within 2 days of a non-elective admission Number of emergency re-admissions within 2 days of discharge / Number of discharges following an elective admission Count of re-admissions where PSEUDOHESID can be matched and when DISDATE of the discharge episode and ADMIDATE of the admission episode are within 2 days. Note: may include a small number of inter-provider transfers. Readmissions other than to the same trust are attributed to the discharging organisation (the trust that created the first spell in a series) Admission episode inclusions: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D CLASSPAT = 1 EPIORDER = 1 Admission episode exclusions: 30 of 64

Domain 3: Helping people recover from episodes of ill health or following injury TRETSPEF = 700-715, 501, 560, 610 DIAG1 = O, C, D0, D1, D2, D3, D4, F, Z08, Z51.1, Z51.2, Z51.3, Z51.5 Discharge episode inclusions: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D CLASSPAT = 1 Discharge episode exclusions: DISMETH = 4, DISDATE = NULL TRETSPEF = 700-715, 501, 560, 610 DIAG1 = O, C, D0, D1, D2, D3, D4, F, Z08, Z51.1, Z51.2, Z51.3, Z51.5 Reporting Schedule: Percentage HES (Admitted Patient Care) Square Root Method GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 31 of 64

Domain 3: Helping people recover from episodes of ill health or following injury 0045: Emergency admissions (Directly Standardised Rate per 100,000 population) Number of emergency admissions / CCG population All HES Inpatient records satisfying the following criteria: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D EPIORDER = 1 SEX = 1, 2 CLASSPAT = 1, 2 CCG population based on patients registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES Poisson Distribution GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 32 of 64

Domain 3: Helping people recover from episodes of ill health or following injury 0046: Elective admissions (Directly Standardised Rate per 100,000 population) Number of emergency admissions / CCG population All HES Inpatient records satisfying the following criteria: ADMIMETH = 11, 12, 13 EPIORDER = 1 SEX = 1, 2 CLASSPAT = 1, 2 CCG population based on patients registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES Poisson Distribution GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 33 of 64

Domain 3: Helping people recover from episodes of ill health or following injury 0047: Patient Reported Outcome Measures for primary hip replacement (Adjusted average health gain) Case-mix adjusted average health gain for primary hip procedures using the Oxford Hip Score The Oxford hip score is a joint-specific outcome measure tools designed to assess symptoms and function in patients undergoing joint replacement surgery. The case-mix adjusted average health gain score is used, with 0 indicating the worst possible and 48 indicating the highest possible score. Organisations with a questionnaire count of less than 30 have been highlighted in grey italics. No adjusted results have been calculated for these providers as the underlying statistical methods break down when counts are low. HSCIC http://www.hscic.gov.uk/proms Square Root Method Year to date quarterly (switch to next year in November/December update) Year to date quarterly (switch to next year in November/December update) None 0048: Patient Reported Outcome Measures for primary knee replacement (Adjusted average health gain) Case-mix adjusted average health gain for primary knee procedures using the Oxford Knee Score will then need to do case-mix adjustment 34 of 64

Domain 3: Helping people recover from episodes of ill health or following injury The Oxford knee score is a joint-specific outcome measure tools designed to assess symptoms and function in patients undergoing joint replacement surgery. The case-mix adjusted average health gain score is used, with 0 indicating the worst possible and 48 indicating the highest possible score. Organisations with a questionnaire count of less than 30 have been highlighted in grey italics. No adjusted results have been calculated for these providers as the underlying statistical methods break down when counts are low. HSCIC http://www.hscic.gov.uk/proms Square Root Method Year to date quarterly (switch to next year in November/December update) Year to date quarterly (switch to next year in November/December update) None 0049: BADS Day Case Rate (including outpatient procedures) Number of procedures performed as a daycase / Number of procedures Number of BADS procedures given in denominator performed as a daycase: CLASSPAT = 2 (day case) ADMIMETH = 11, 12, 13 (Elective admission) OPCS codes from the BADs handbook 4 th Edition 35 of 64

Domain 3: Helping people recover from episodes of ill health or following injury HES (Admitted Patient Care) Poisson distribution GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend, BADS Procedure 0050: Fratured Neck of Femur: Percentage operated on within 48 hours Total number of #NOF patients operated on within 48 hours / Total number of #NOF patients operated on Include all records from denominator and restrict to: Difference between ADMIDATE and procedure date (OPDTE_NN) < 2 Procedure date (OPDTE_NN) determined by first procedure field OPER_NN (0 < NN <= 5) where OPCS codes in denominator are present. All HES Inpatient records satisfying the following criteria: CLASSPAT = 1, 2 EPISTAT = 3 Exclude records where DISDATE = NULL Primary Diagnosis ICD-10 codes = S72 36 of 64

Domain 3: Helping people recover from episodes of ill health or following injury Operation codes are filtered at the 5th level - OPSC Codes = W461, W471, W472, W473, W474, W475, W476, W477, W478, W479, W480, W481, W371, W381, W391, W191, W241 Percentage HES (Admitted Patient Care) Poisson distribution GP, Trust, Specialty, Age Group, Sex, CCS Group, Weekend/Weekend 0051: Outpatient first attendances following GP referral (Directly Standardised Rate per 100,000 population) Number of first out-patient attendances where the referal source is GP / CCG population All HES Outpatient records satisfying the following criteria: REFSOURCE = 3 SEX = 1, 2 ATENTYPE = 1, 4, 7, 10, 21, 24, 27, 30 DNADATE = NULL CCG population based on patients registered with the constituent GP practices 37 of 64

Domain 3: Helping people recover from episodes of ill health or following injury Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES (OP) Square Root Method GP, Trust, Specialty, Age Group, Sex, Weekend/Weekend 0052: Proportion of first out-patient appointments which result in discarge Number of first out-patient attendances referred from a GP where the outcome is discharge / Number of first out-patient attendances referred from a GP Include all records from denominator and restrict to: OUTCOME = 1 All HES Inpatient records satisfying the following criteria: SEX = 1, 2 ATENTYPE = 1, 21 REFSOURCE = 3 Percentage 38 of 64

Domain 3: Helping people recover from episodes of ill health or following injury HES (OP) Square Root Method GP, Trust, Specialty, Age Group, Sex, Weekend/Weekend 0269: A&E Attendances (Directly Standardised Rate per 100,000 population) Number of A&E Attendances / CCG population Count of all HES A&E attendances CCG population based on patients registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the constituent GP Practices HES (A&E) and ONS Poisson Distribution 39 of 64

Domain 3: Helping people recover from episodes of ill health or following injury GP, Trust, Specialty, Age Group, Sex, Weekend/Weekend 0053: A&E Conversion Rate (Percentage admitted following an A&E attendance) Number of A&E Attendances / Number of A&E attendances who are admitted as an inpatient All records from the denominator where: AEATTENDDISP = 01 All HES A&E records satisfying the following criteria: AEDEPTTYPE = 01 Percentage HES (A&E) Poisson Distribution GP, Trust, Specialty, Age Group, Sex, Weekend/Weekend 40 of 64

Domain 4: Ensuring that people have a positive experience of care Domain 4: Ensuring that people have a positive experience of care 0063: Proportion of people attending A&E who have more than 3 attendances in the last 12 months Number of A&E frequent flyers / Number of patients attending A&E Number of A&E frequent flyers defined by having more than 3 attendences in the rolling year Number of patients attending A&E Percentage HES (A&E) Square Root Method GP, Trust, Age Group, Sex 0064: Diagnostic waits: Percentage of patients waiting over 6 weeks Patients waiting 6 weeks or more for diagnostic tests from the date of request / Number of diagnostic tests Percentage 41 of 64

Domain 4: Ensuring that people have a positive experience of care NHS England http://www.england.nhs.uk/statistics/statistical-work-areas/diagnostics-waiting-times-and-activity/ Square Root Method Diagnostic Group 0065: Inpatient Referral to Treatment (RTT): Percentage of patients seen within 18 weeks Number of completed admitted pathways (with a known clock start) within 18 weeks / Total number of completed admitted pathways Total number of completed admitted pathways (with a known clock start) within 18 weeks Total number of completed admitted pathways (all) NHS England http://www.england.nhs.uk/statistics/statistical-work-areas/rtt-waiting-times/ Square Root Method 42 of 64

Domain 4: Ensuring that people have a positive experience of care None 0066: Cancer waits: Percentage with first out-patient appointment within 14 days of GP referral Number of patients seeing a specialist within 14 days after being urgently referred with suspected cancer by their GP Total number of patients seeing a specialist after being urgently referred with suspected cancer by their GP Percentage NHS England http://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/ Square Root Method None 43 of 64

Domain 4: Ensuring that people have a positive experience of care 0067: Cancer waits: Percentage waiting less than 31 days from diagnosis to first treatment Number of patients starting their first definitive treatment within 31 days of receiving their diagnosis Total number of cancer patients starting their first definitive treatment Percentage NHS England http://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/ Square Root Method None 0068: Cancer waits: Percentage waiting less than 62 days from GP referral to first treatment Number of patients starting their first definitive treatment within 62 days of receiving their diagnosis Total number of cancer patients starting their first definitive treatment Percentage NHS England 44 of 64

Domain 4: Ensuring that people have a positive experience of care http://www.england.nhs.uk/statistics/statistical-work-areas/cancer-waiting-times/ Square Root Method None 45 of 64

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm 0080: MRSA bacteraemia (Rate per 1,000,000 population) Number of MRSA infections recorded CCG population based on patients registered with the constituent GP practices Crude rate per 1,000,000 population HPA http://www.hpa.org.uk/web/hpaweb&page&hpawebautolistname/page/1191942169773 Views requried Funnel plot, run chart, bar chart Square Root Method None 46 of 64

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm 0081: Clostridium difficile infections (Rate per 100,000 population) Number of Cdiff infections recorded CCG population based on patients registered with the constituent GP practices Crude rate per 100,000 population HPA http://www.hpa.org.uk/web/hpaweb&page&hpawebautolistname/page/1179745282408 None 0082: MSSA bacteraemia (Rate per 100,000 population) Number of MSSA infections recorded CCG population based on patients registered with the constituent GP practices Crude rate per 100,000 population HPA http://www.hpa.org.uk/web/hpaweb&page&hpawebautolistname/page/1191942169773 47 of 64

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Views requried Funnel plot, run chart, bar chart Square Root Method None 0083: Proportion of babies born with a low birth weight (< 2500g) Total number of births where birth weight is less than 2500g / Total number of births All records from the denominator where: BIRWEIT < 2500 All HES Inpatient records satisfying the following criteria: BIRWEIT is not NULL Data source: Percentage HES Square Root Method 48 of 64

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm GP, Trust, Weekday/Weekend 0084: Proportion of births which are premature (< 37 weeks) Total number of births where gestation period is less than 37 weeks / Total number of births All records from the denominator where: GESTAT1 < 37 All HES Inpatient records satisfying the following criteria: GESTAT1 is not NULL Data source: Percentage HES Square Root Method GP, Trust, Weekday/Weekend 49 of 64

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm 0085: Proportion of births delivered by elective caesarian section Total number of births where deliver method was elective caesarian section / Total number of births All records from the denominator where: Elective C-Section: OPCS = R17 All HES Inpatient records satisfying the following criteria: HRG_3.5 = N06 - N11 OR SUS generated HRG = NZ01A - NZ01H, NZ02A, NZ02B, NZ03C - NZ03E Data source: Percentage HES Square Root Method GP, Trust, Weekday/Weekend 0086: Proportion of births delivered by non-elective caesarian section Total number of births where deliver method was non-elective caesarian section / Total number of births All records from the denominator where: 50 of 64

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Non-elective C-Section: OPCS = R18 All HES Inpatient records satisfying the following criteria: HRG_3.5 = N06 - N11 OR SUS generated HRG = NZ01A - NZ01H, NZ02A, NZ02B, NZ03C - NZ03E Data source: Percentage HES Square Root Method GP, Trust, Weekday/Weekend 0087: Admissions for self harm in under 16 year olds (Rate per 100,000 population) Number of admissions for unintentional and deliberate injuries in under 16 year olds / CCG population All HES Inpatient records satisfying the following criteria: EPISTAT = 1, 3 STARTAGE < 16 OR STARTAGE >= 7000 SEX = 1, 2 51 of 64

Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm EPIORDER = 1 EPITYPE = 1 ADMISOURCE is not 51, 52 or 53 CLASSPAT = 1 Unintentional and deliberate injuries: DIAG1 = X60 - X84 constituent GP Practices Data source: Reporting Schedule: CCG population based on patients under 16 years of age registered with the constituent GP practices Directly standardised rate by age and sex per 100,000 population based on CCG level count of patients registered with the HES Poisson Distribution GP, Trust, Sex, Weekday/Weekend 52 of 64

Domain 6: Organisational Context Domain 6: Organisational Context 0102: All prescribing Net Ingredient Cost (NIC) per Astro PU (Age Sex Temporary Resident Originated Prescribing Unit) Total Net Ingredient Cost (NIC) for all prescribing Astro PU (Age Sex Temporary Resident Originated Prescribing Unit) NIC is the basic price of a drug, ie the price listed in Part II Clause 8 of the Drug Tariff (www.ppa.org.uk/ppa/edt_intro.htm) ASTRO-PU stands for Age, Sex and Temporary Resident Originated Prescribing Units. This weighting is designed to weight individual practice populations for age, sex and temporary residents to allow for better comparison of prescribing patterns. These figures are based on the cost of prescribing across all therapeutic areas. (www.hscic.gov.uk/prescribing/measures) Data source: NHS Business Services Authority https://apps.nhsbsa.nhs.uk/infosystems/guestlogin.do?captchatext=hbpfx Poisson Distribution None 53 of 64

Domain 6: Organisational Context 0103: Number of antibacterial items per STAR-PU (Specific Therapeutic Group Age-sex Related Prescribing Unit) Data source: Total number of prescription items for antibacterial drugs STAR-PUs (Specific Therapeutic Group Age-sex Related Prescribing Units) There are differences in the age and sex of patients who are prescribed drugs in specific therapeutic groups, for instance dementia drugs will be represented in older age brackets. STAR-PUs (Specific Therapeutic Group Age-sex weightings Related Prescribing Units) allow you to make comparisons within a specific therapeutic group by taking into account the types of people who will be receiving that treatment. They have been developed along similar lines to the ASTRO-PU but based on costs within therapeutic groups. (www.hscic.gov.uk/prescribing/measures) NHS Business Services Authority https://apps.nhsbsa.nhs.uk/infosystems/guestlogin.do?captchatext=hbpfx Poisson Distribution None 0104: Cephalosporins and quinolones prescribed as a percentage of selected antibacterial prescriptions Total number of prescription items for cephalosporins and quinolones Total number of prescription items for selected antibacterial drugs 54 of 64

Domain 6: Organisational Context Denominator includes: o Penicillins (BNF code: 050101) o Cephalosporins (BNF code: 0501021) o Tetracyclines (BNF code: 050103) o Macrolides (BNF code: 050105) o Sulfonamides And Trimethoprim (BNF code: 050108) o Metronidazole, Tinidazole & Ornidazole (BNF code: 050111) o Quinolones (BNF code: 050112) o Urinary-Tract Infections (BNF code: 050113) Data source: NHS Business Services Authority https://apps.nhsbsa.nhs.uk/infosystems/guestlogin.do?captchatext=hbpfx Poisson Distribution None 55 of 64

Domain 6: Organisational Context 0105: Proportion of patients attending A&E with no recorded investigation or treatment Number of A&E attendences with no recorded investigation or treatment / Number of A&E attendences Number of A&E attendences where: HRG = VB11Z, V08 Data source: Total number of A&E attendences Rate per 1,000 admissions HES Poisson Distribution GP, Trust 0106: Elective admissions count Count of admissions coded with: ADMIMETH = 11, 12, 13 EPIORDER = 1 N/A 56 of 64

Domain 6: Organisational Context Count HES (APC) Poisson Subscription only N/A Age Group, CCS Group, Day of Week, GP, GP Locality, ICD10 Chapter, Sex, Site, Specialty, Trust 0107: Emergency admission count Count of admissions coded with: ADMIMETH = 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D EPIORDER = 1 N/A Count HES (APC) Poisson Subscription only N/A 57 of 64

Domain 6: Organisational Context Age Group, CCS Group, Day of Week, GP, GP Locality, ICD10 Chapter, Sex, Site, Specialty, Trust 0108: Outpatient appointment count All HES Outpatient records satisfying the following criteria: DNADATE = NULL N/A Count HES (OP) Poisson Subscription only N/A Age Group, Attended, Day of Week, GP, GP Locality, Sex, Site, Specialty, Trust 58 of 64

Domain 6: Organisational Context 0109: A&E and Urgent Care Centre attendance count Count of all A&E attendances N/A Count HES (A&E) Poisson Subscription only N/A Age Group, Day of Week, GP, GP Locality, Sex, Trust 59 of 64

Domain 7: Market Share Domain 7: Market Share 0415: Proportion of patients admitted to main provider Total number of admissions to main provider / Total number of admissions Main provider identified by the highest number of admissions for patients registered with the constituent GP practices All HES Inpatient records satisfying the following criteria: ADMIMETH = 11, 12, 13, 21, 22, 23, 24, 28, 2A, 2B, 2C, 2D Data source: Percentage HES Square Root Method GP, Specialty, Pathway 0145: Total PbR spend for inpatient activity (Pounds) Total PBR_FINAL_TARIFF for all discharged spells Sum of PBR_FINAL_TARIFF for discharged spells 60 of 64

Domain 7: Market Share N/A Count SUS PbR APC Spells N/A Subscription only N/A Age Group, CCS Group, Day of Week, GP, GP Locality, ICD10 Chapter, Pathway, Sex, Specialty, Site, Trust 0146: Age\Sex standardised PbR spend for inpatient activity (Directly Standardised spend per population) (Pounds) Total PBR_FINAL_TARIFF for all discharged spells / CCG population Sum of PBR_FINAL_TARIFF for discharged s CCG population based on patients registered with the constituent GP practices DSR SUS PbR APC Spells Poisson distribution Subscription only N/A 61 of 64

Domain 7: Market Share Age Group, CCS Group, Day of Week, GP, GP Locality, ICD10 Chapter, Pathway, Sex, Specialty, Site, Trust 0147: Total PbR spend for activity in A&E and Urgent Care Centres (Pounds) Total PBR_FINAL_TARIFF for all attendances Sum of PBR_FINAL_TARIFF for attendances N/A Count SUS PbR A&E N/A Subscription only N/A Age Group, Day of Week, GP, GP Locality, Sex, Site, Trust 0148: Age\Sex standardised PbR spend for activity in A&E and Urgent Care Centres (Directly Standardised spend per population) (Pounds) Total PBR_FINAL_TARIFF for all attendances / CCG population Sum of PBR_FINAL_TARIFF for attendances 62 of 64

Domain 7: Market Share CCG population based on patients registered with the constituent GP practices DSR SUS PbR A&E Poisson distribution Subscription only N/A Age Group, Day of Week, GP, GP Locality, Sex, Site, Trust 0149: Total PbR spend for outpatient activity (Pounds) Total PBR_FINAL_TARIFF for all outpatient attendances Sum of PBR_FINAL_TARIFF for outpatient attendances N/A Count SUS PbR OP N/A Subscription only N/A 63 of 64

Domain 7: Market Share Age Group, Day of Week, GP, GP Locality, Sex, Specialty, Site, Trust 0150: Age\Sex standardised PbR spend for outpatient activity (Directly Standardised spend per population) (Pounds) Total PBR_FINAL_TARIFF for all outpatient attendances / CCG population Sum of PBR_FINAL_TARIFF for outpatient attendances CCG population based on patients registered with the constituent GP practices DSR SUS PbR OP Poisson distribution Subscription only N/A Age Group, Day of Week, GP, GP Locality, Sex, Specialty, Site, Trust 64 of 64