Hospital Guide 2010

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NAME

FIRST

MIDDLE

LAST

HOSPITAL GUIDE 2010

WHATMAKESAGOODHOSPITAL?

TEST RESULTS

Contents: TEST RESULTS

NAME:

PATIENT: NHS HospitalsBIRTH DATE: 2010DOCTOR: FOSTER


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Contents

4 Editors letter

5 How good is my hospital?

6 Introductory message

7 Trusts of the year

10 Measuring mortality - akeysteptoensuringquality

18 Stroke - excellenceacrossacarepathway

22 Orthopaedics - excellenceamongcareteams

24 Urology - excellenceinoperations

26 Patient safety - thefoundationforquality

32 Efciency - howqualitysavesmoney

34 Patient experience - notjustamedicalmatter

36 References

37 Acknowledgements

38 About Dr Foster

38 Our methodology


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Hospital Guide 2010 4

Itis10yearssincetherstDrFosterHospitalGuidewaspublished.Insomewaysmuchhas

changedin10years,butinotherwaysnotenoughhaschanged.Adecadeagowehaddata

onallhospitaladmissions,fromwhichwecomparedmortalityratiosandothermeasures.

Thatdataisstillourmainsourceofinformation.Wehavenoprimaryandcommunitycaredata,noprivatesectordataandnodatathatshowswhathappenstopatientsover

thewholecourseoftheirillness.Excitingly,theCoalitionGovernmentseemscommitted

tonallyaddressingthisissue,andthe2010guideisinpartacaseformoreandbetter

information.MoreonthisfromRogerTayloronpage6.

TheHospitalGuidehasalsochangedoverthepast10years,althoughsomeconstants

remain.WecontinuetopublishHospitalStandardisedMortalityRatios(HSMRs)but,in

additiontothis,havenowintroducedtwootherwaysoflookingatmortality.Youcannd

theresultsonpages16-17.

Forthe2010guidewehaveteamedupwithleadingcliniciansandanalyststoshinethe

spotlightonthreeareasimportanttomanypatients:stroke,orthopaedicsandurology

(seepages18-25).Andwehavereturnedtothethornysubjectofsafety.Thepublicity

aroundlastyearssafetyindextooksomebysurprise,butraisedawarenessoftherisks

facingpatients.Thisyearwelookbacktoseewheretherehasbeenimprovementand

whereproblemsremain.The2009guidepromptedsomechanges,includingaDepartment

ofHealthtaskforceonmeasuringmortalityandnewrulesaroundthereportingofsafety

incidents.However,westillhavesomewaytogotogetreliabledataaboutadverseevents.

Wearealsotryingoutsomenewwaysofpresentinginformationonourwebsite.Visitors

towww.drfosterhealth.co.ukcannowspecifywhichaspectsofpatientexperiencemattermosttothemandthenndoutwhichhospitaltrustsperformbestontherelevantcriteria.

Asever,thanksmustgotoallthosewhohavehelpedmakethisyearsguidecometolife,

especially the experts whose commentaries and opinions you will nd throughoutthe

report.ThankyoualsotothoseindividualsineachNHStrustwhocoordinatedactivity

aroundtheHospitalGuide,notleastinrespondingtoourannualsurvey,towhich99per

centoftrustsreturneddata.

Thechallengewesetourselvesistoproduceareportwhichisaccessibleforpatientsand

thepublicandvalidforcliniciansandmanagers.Thisguidehasbeen10yearsinthemaking

andwehopeyounditstimulatingandinformative.

Editors letter

Alex Kafetz


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What we can tell you:

the good news

1.Deathsinhospitalcontinuetofall,dropping7percentbetween2008/09and

2009/10incrudeterms.Seepage11.

2.ThegapbetweenthehighestandlowestHospitalStandardisedMortalityRatios(HSMRs)

hasnarrowed,witheightfewertrustsHSMRsabovetheexpectedrange.Seepage10.

3.Safetystandardshaveimproved,withhigherratesofcompliancewithsafetyalerts

andbetterreportingoferrors.Seepage27.

4.Airedaleisoursmalltrustoftheyearforaremarkablefourthtime,withverygood

performanceinclinicaloutcomes,safetyandpatientexperience.Seepage9.

5.RoyalFreeHampsteadandIpswichHospitalhavewonlargeandmediumtrustofthe

year,whileEastKentHospitalsisrecognisedforthersttimeasfoundationtrustofthe

yearwithexcellentoutcomesinarangeofclinicalareas.Seepages7-9.

What we can tell you:areas of concern

1.Variationsinmortalityratiospersist,with19trustshavinghighHSMRs.Seepage10.

2.Fourtrustshavehighratiosforthedeathsaftersurgeryindicator.Twoofthesetrusts

alsohavehighHSMRs.Seepages12-13.

3.Ratesofemergencyreadmissionsvarywidely,asdorevisionsandmanipulations

followingcommonoperations,wherethreetrustshavehighrates.Seepages22-23.

4.In2009/10over27,000potentialadverseeventswererecordedinhospitaldata.

Thisisalmostcertainlyanundercountduetoinconsistentrecording.Seepage30.

5.Standardsinthetreatmentoflife-threateningconditionssuchasstrokeandbroken

hipsvarywidely.Manytrustsfallshortofbestpractice.Seepages18-23.

What we cannot tell you

but would like to know

1.Howmanypeoplesufferpotentiallylife-threateningbloodclotsfollowingtreatment?

DespitebeingaDepartmentofHealthpriority,thisinformationisnotbeingrecorded

properly.Seepage30.

2.Thequalityofcareforpatientsafterleavinghospital.Informationaboutcommunity

andprimarycareservicesforpeoplewithlong-termconditionsisnotavailablefor

analysisinthewaythathospitaldatais.Seepage19.

3.Thelevelofmedicalerrorstakingplace.Recordingisinconsistentandtrustswithhigh

ratesofadverseeventscanoftenbebestatkeepingaccuraterecords.Seepages30-31.

4.HowNHScareforcommonproceduresinprivatehospitalscompareswiththecare

giveninNHStrusts.Seepages22-23.

5.Moredetailedinformationabouthowindividualclinicalteamstreatpatients(heldon

databasessuchastheNationalJointRegistryorCancerRegistry).Seepage23.

How good is my

hospital?


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Introductory message

Roger Taylor

Co-founder of Dr Foster

The aims of the rst Dr Foster Hospital Guideweresimple. We wanted to put more

informationandmorepowerintothehandsofpatientsandthepublicbygivingthem

anindependentviewonwherehealthcarewasworkingandwhereitwasnot.Wewanted

toendtheofcialmonopolyondataaboutNHSperformance.Wewantedtoseeapublicdebateaboutwhatitlooksliketohavequalityinhealthcare.

Inthedecadesincetherstguide,DrFosterhasgrownfromasmallpublishingcompany

intoabusinessthatworkswithmosthospitalsinEngland.Thedebatehasalsoshifted:

everyone now accepts that delivering good healthcare means measuring performance

andbeingtransparentaboutthatmeasurement.Thereis muchmoreinformationtoday

aboutclinicaloutcomesandaboutwhatpatientsthinkabouttheirservicesthanthere

was10yearsago.

Wehaveseenimprovementsasaresult.Thewidevariationsinhospitalmortalityratioshave

narrowedsincewerstpublishedthedata,andthereisgreaterfocusonimprovingclinical

outcomesandsafety.Inthisguideyouwillndmanyexamplesofwhereimprovementsin

qualityhavebeendrivenbybetterinformation.Buthowhavewedoneonouroriginalaims

ofgivinggreaterpowertopatientsandhavingamoreopendebateaboutquality?Thefact

is,thereisstillalongwaytogo.

Athirdofpatientsstillsaytheyarenotsufcientlyinvolvedindecisionsabouttheircare.

Asapatient,itisstilltoodifculttondoutaboutthetreatmentoptionsavailableto

you, the standards ofcareyou should expect and whether ornot the service you are

receivingmeetsthese.TryndingoutwhattoexpectfromyourGPandotherlocalservices

followingadiagnosisofdepression.Tryndingouthowthatcompareswithbestpractice.Tryndingoutwhatotherpatientsthinkabouttheseservices.Youwillnotgetfar.TheNHS

collectsvastamountsofdatabuttoolittleofitisturnedintousefulinformation.Where

informationisavailable,itisrarelyprovidedtopatientsorthepublicinwaysthathelp

themmakedecisions.

Inthisguidewehavetriedtoanswerafewquestionsabouthospitalcare:wheredoes

itappearthatstrokecareisdeliveredwell?Whichhospitalswouldwerecommendfor

treatmentofpelviccancers?Wheredohighmortalityratiosraisequestionsaboutcare?

Buttherearemanymorequestionswherewewouldliketogiveanswersbutcannot.

TheCoalitionGovernmenthasrecognisedthattheNHScannotbemanagedfromWhitehall.Itiscommittedtogreatertransparencyandgivingpatientsmoresayoverwhathappensto

them.Wewelcometheseambitionsandhopethat,beforeanother10yearsareup,wewill

beabletoaddresssomeoftheunansweredquestionsinthisguide.


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East Kent Hospitals University NHS Foundation Trust

Trustsof the year

Each year Dr Foster celebrates the achievements and successes

of the NHS by naming our foundation, small, medium and large trusts

of the year, as well as one overall winner. This year we have related

the awards to the Coalition Governments Outcomes Framework.1

On the next pages

See the best performing trustsin each category


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Preventing premature death Result Trust score National average

Thesearefourmortalityratios,

comparingtheactualnumbersof

deathswithourestimates.100isthenationalaverage.Lowerscores

aredesirable.Seepages10-17.

HospitalStandardisedMortalityRatio(HSMR) 79 100

Basketoffivestandardisedmortalityratios 81 100

Deathsaftersurgery 89 100

Deathsinlow-riskconditions 77 100

Quality of life despite long-term conditions Result Trust score National average

Infocusingonstrokewehave

selectedsixindicatorsfollowing

patientsalongahospitalpathway.

Seepages18-21.

Strokepatientsscannedonthesameornextday 54% 47%

Thrombolytictreatmentwhenappropriate 6% 3%

Pneumoniaduetoswallowingproblems 3% 5%

Dischargehomewithin56days 78% 73%

Readmissionswithin28days 114 100

In-hospitalmortality 71 100

Helping recovery from ill health or injury Result Trust score National average

Wehavemeasuredtrustsacross

orthopaedicsandurology,looking

atreadmissionsandoperations

whichneedtobedoneagain.

Seepages22-25.

Re-doratesfortransurethralresectionoftheprostate 6% 5%

Kneerevisionsandmanipulationswithinoneyear 0.04% 1%

Hiprevisionsandmanipulationswithinoneyear 1% 5%

Hipreplacementreadmissions 118 100

Kneereplacementreadmissions 124 100

Hipfractureoperationswithintwodays 71% 67%

Hipfracturestandardisedmortalityratio 89 100

Positive experiences of care Result Trust score National average

Alltrustsarefocusingonthese

vequestionsfromthenational

patientsurveyandtheycan

receivenancialrewardsfor

performingwell.Seepages34-35.

Sufficientlyinvolvedincaredecisions? 68% 70%

Staffavailabletotalktoaboutworries? 57% 59%

Enoughprivacywhendiscussingcare? 80% 81%

Medicationside-effectsexplainedpre-discharge? 49% 45%

Givenacontactforpost-dischargeconcerns? 74% 74%

Safe environment and avoiding harm Result

Wehaverevisitedanumberof

measuresofpatientsafetythat

werehighlightedinlastyears

HospitalGuide.Mostofthe

informationisfromoursurvey.

Seepages26-31.

Trusthasaboardleadforpatientsafety? 4

Patientsafetyisonboardsmonthlyagenda? 4

Inpatientswithtrackandtriggersystemsinplace? 100%

Trustcomplieswithselectedsafetyalerts? 4

Allsurgicalpatientsgivenclot-preventiondevices? 4

Patientsrisk-assessedforbloodclotsonadmission? 31-60%

Reportedrateofsafetyevents?

East Kent Hospitals University NHS Foundation Trust

Scorecards for all trusts are available at www.drfosterhealth.co.uk/hospital-guide

Key

Exceedsexpectation

Meetsexpectation4Yes


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Our2010overalltrustoftheyearisEastKent

Hospitals University NHS Foundation Trust,

which has shown dedication to putting the

patient rst. In fact, across all the winners

thereisacommonthemeofdeliveringservices

closertothepeoplewhoneedthem.Thistype

of reorganisation has been proven to benet

patientsand,inthesetougheconomictimes,

savemoney.

On the previous page,the scorecardfor East

Kent gives anoverviewof thecategories and

datathatweusedtodetermineourtoptrusts.

These measures are explored in more detail

throughouttheguide.ScorecardsforallEnglish

acutetrustscanbefoundonourwebsite.

Foundation trust of the year

and overall winner

East Kent Hospitals University

NHS Foundation Trust

Asdemonstratedbyitsscorecard,EastKent

HospitalsUniversityNHSFoundationTrusthas

becomeourwinningtrustthisyearbyperforming

consistently well across our chosen criteria.

Indoingso,ithassucceededinmeetingthe

particularchallengesofbeingoneofthelargest

trustsinthecountryanetworkofthreedistrict

generalhospitals,twocommunityhospitalsand

several satellite sites serving a population of

750,000people.

ItsmottoofPuttingpatientsrsthasbeena

driving force behind recent changes to make

keyspecialistservicesavailablelocallyandina

timelymanner.Newtechnologyisalsohelping

toimprovecare,notleastinthehyper-strokeservicewheretheinnovative,award-winninguse

oftelemedicinehasenabledthedevelopment

ofa24/7service.Thetrustoffersaroutine

radiologyservicesevendaysaweek,ensuring

thatallpatientsreceivethescansatthetime

theyneedthem,andrecentlybecamethelead

trust for delivering primary angioplasty for

heartattackpatientsacrossthewholeofKent.

In commenting on the award, chief executive

StuartBainexplainedthatthesuccessofthe

trustcanbeputdowntoacombinationofvery

highambitionbytheboard,goodplanning,and

the dedication of the 7,000 staff who always

gotheextramilefor theirpatients.Headded,

Safety and effectiveness have been the key

drivers in directing our investment in service

changeandthisisreectedinourexceptionally

lowHSMRandgoodinfectionpreventionrates.

Large trust of the year

Royal Free Hampstead NHS Trust

RoyalFreeHampsteadNHSTrustisknownfor

itspioneeringsurgery,beingtherstinEurope

toofferkeyholemastectomyandoneofthefew

centresofferingkeyholesurgeryforpancreatic

cancer.Itevenhasethicalapprovaltoperform

whatwouldbethecountrysrstfacetransplant.

Butdespitethecomplexityofitscaseload,itsmortality ratios have been among the lowest

inthecountry for manyyears, and this high-

qualityperformanceisrecognisedinbecoming

DrFosterslargetrustoftheyear.

Thisachievementisdowntotheeffortsofour

workforcewhoaimtoofferthebestclinicalcare,

thebestpatientexperienceand whopioneer

newandeffectivehealthcareapproaches,said

DavidSloman,thetrustschiefexecutive.

Reectingitseffortstoputpatientsatthecentre

ofeverythingitdoes,thetrustisparticipating

in a programme to improve staff-to-patient

interactions,aswellasprovidingcarecloserto

patients homesthrough its network of Royal

Freeclinics.Inanotherinnovativemove,ithas

been the rst acutetrustto appoint a public

healthlead.

Medium trust of the year

Ipswich Hospital NHS Trust

IpswichHospitalNHSTrustisavibrantgeneral

hospital that provides a range of services on

site,many of themspecialised. These include

vascular surgery, spinal surgery, radiotherapy

and gynaecological cancer surgery, which are

capable ofbeingprovided toa population of

morethan500,000.Italsooffersmidwiferyin

thecommunity,andindeedisworkingclosely

withlocalGPstofurtherincreasetherangeof

communityservices.

Inadditiontobeingoneof10hospitalsintheUK

leadinganationalprogrammeofimprovements

fororthopaedicpatients,thetrustpridesitself

on having low rates of healthcare-acquired

infectionsandhasbeenrapidlyreducingrates

ofavoidableharmsuchasfrompatientfallsand

pressuresores.

ChiefexecutiveAndrewReedsaid,Iamvery

proudthat Ipswich Hospital has beennamed

medium-sizedtrustoftheyear.Everyoneatthe

hospitalplaysapartinthequalityofcarewe

provide,but itis aparticular accoladeto our

doctors, nurses and all clinical professionals

whohavemaintainedanunrelentingfocuson

thesafetyandexperienceofourpatients.

Small trust of the year

Airedale NHS Trust

Supportingmorethan200,000peopleacross

Yorkshire andLancashire, Airedale NHSTrust

has been our best performing small trust on

severalpreviousoccasions.

WeareextremelypleasedtowintheDrFoster

awardagainforthefourthtimeinveyears,

especiallyasitisinthesameyearthatwe

achieved foundation trust status, explained

BridgetFletcher,formerdirectorofnursingand

nowchiefexecutive.2

It isnot only a fantastic achievementfor our

staffbutalsorecognitionforthehardworkthey

doeverydaytomakesureweprovidehigh-

quality,safe,compassionate,personalcarefor

allourpatients.

The trust provides services from the main

hospitalsiteandalsofromcommunityhospitalsandhealthcentres,aswellastoanumber

of prisons throughout England through its

pioneeringtelemedicineservice.Overthenext

12monthsitisplanningtoinstalltelemedicine

equipmentintosomepatientshomes,nursing

homes,GPpracticesandotherremotelocations.

Theaimistoprovide integratedhealthcare to

patientsintheirownhomesorasclosetohome

aspossible.

To categorise trusts,we used the Healthcare

Commissionsdenitions(basedonthenumber

of beds perhospital). Foundation trusts are

automaticallyinthatcategory.

Full results are available at www.drfosterhealth.co.uk/hospital-guideTRUSTS OF THE EAR


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10 of the 19 are new additions

102 meet expectation

26 exceed expectation

2 of the 19 have been high for 6 years

19 are below expectation

ofa

ll147

trusts

Trust mortality

An overview of HSMRs in 2009/10.

Measuring

mortalitya key step to ensuring qualityHSMRs are decreasing

across the NHS. Only 19 of the

147 hospital trusts now have

signicantly high HSMRs,

compared with 27 last year,

whereas 26 trusts have HSMRs

that are signicantly low,

down from 32 a year ago.

The overall improvement

suggests greater consistency

across trusts, both in terms of

data-recording and perhaps inthe quality of care.


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Full results are available at www.drfosterhealth.co.uk/hospital-guide

Preventingpeoplefromdyingduetoillnessor

injuryis,perhaps,themostfundamentalaimof

healthcare.Sometimesitisnotpossible.Butby

alwaysdeliveringthebestcare,itispossibletoreducethechancesofdeath.Lowermortality

ratiosareonemarkerofgoodqualitycare.

Thisguide compares themortality ratios at

Englishtrustsaftertakingintoconsiderationthe

differencesinthepatientstreated.Wedothis

tosee ifthe number ofpatients who survive

followingtreatmentisinlinewiththenumber

wewouldexpect,giventheircondition.

In this section we look at threemeasures,

comparing thenumber ofdeaths atthe trust

withthenumberweestimatewouldhappenif

mortalityratioswereinlinewiththenational

average. This takes into account a patients

diagnosis, age,admission method and other

characteristics.Ifatrusthasthesamenumberof

deathsasestimated,wegiveascoreof100.Ifit

has10percentmoredeaths,wegiveascoreof

110,orfor10percentfewerdeathsascoreof90.

TheHSMRisoneofthemostcommonlyused

measuresofoverallmortalityfortrusts.Itlooks

atthoseconditionswhichaccountforthevast

majorityofdeathsinhospital(80percent).

This yearthere continues tobe a variation

in mortality ratios,rangingfrom 18 percent

higherthanexpectedto28percentlowerthan

expected.Justbychancethereisboundtobe

somedisparity. Weidentifytrusts as having

highorlowHSMRsifthevariationisextreme;

inotherwords,thelikelihoodofitoccurringby

chanceislessthanoneinathousand.

Whenatrusthasahighmortalityratio,we

cannot be sure of the reason why; itmaybebecauseofinaccuratedataoraresultof

particularly unusual circumstances at that

trust.However,itisausefulscreeningtoolthat

warrantsinvestigation,andwebelievethatthe

publicshouldbemadeawareofit.Thisyears

HSMRresultscanbeseenonpage16.

Nosinglemeasurecan tell thewholestory,

soitisimportanttolookatmortalityandthe

outcomesoftreatmentinmanydifferentways.

MORTAIT

1 Hospital StandardisedMortality Ratios (HSMRs)

Hospital Standardised Mortality Ratios (HSMRs), or death rates as they

have become known in the media, are an important outcome measure for

patients. Imperial College London developed HSMRs in the 1990s.

However, it was the 2001 Bristol Inquiry report, which recommended

transparency of hospital data for patients, that acted as a catalyst for DrFoster to rst publish them.1 Dr Foster was responding to the lack of clinical

information available to the public during the Bristol Inquiry.

In April 2010 the Department of Health stated, A high HSMR is a trigger

to ask hard questions. Good hospitals monitor their HSMRs actively and

seek to understand where performance may be falling short, and action

should not stop until the clinical leaders and the board at the hospital

are satised that the issues have been effectively dealt with.2 I strongly

support this position and welcome the continued publication of HSMRs by

Dr Foster and NHS Choices (www.nhs.uk).

Putting the data into the public domain is an essential way to focusclinicians and managers on investigating outcomes. High HSMRs, together

with concerns in other measures of mortality, prompted the Healthcare

Commissions investigation at Mid Staffordshire NHS Foundation Trust.3

It is possible that, without the alarm being raised, the problems that were

found could have continued unrecognised by the system.4

Professor Sir Brian Jarman is emeritus professor at Imperial College London

Why the

HSMR resultsmatter

Prof Sir Brian Jarman

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Youwillseearangeofthesethroughoutthe

HospitalGuide.Withinthischapter,inaddition

toHSMRs,wealsolookatmortalityintwo

otherways:mortalityinhigh-riskconditionsanddeathsaftersurgery.

Itisimportanttolookatmortalityforspecic

conditions(seealsopages19and23),especially

those where treatment can have the biggest

impact.HerewehaveselectedfromtheHSMR

abasketofveconditionswhichaffectalarge

number of people and where mortality is

acceptedasanindicatorofthequalityofcare

inhospital.Bycreatingabasketofconditions,

we can identify variations in mortality more

effectively than if we only look at diagnoses

individually. Restricting thebasketmeanswe

canbe more focusedinmeasurementthan

withtheHSMR.Theconditionsinourbasket

areheartattack,pneumonia,stroke,congestive

heartfailureandbrokenhips.

Theresultscanbeseenonpage17.Theyincludesometrustswhoseoverallmortalityratiosarelow

orasexpected,butwhichnonethelesshaveareas

ofhighmortality.Individualtrustsmaydecide

tomonitortheirperformanceusingdifferent

basketsrelevanttothecaretheyprovide.

Conventionallyknownasfailuretorescue,this

isthersttimethisindicatorhasbeenusedin

theUK,thoughitiscurrentlypublishedinthe

US.5ImperialCollegeLondonandKingsCollege

LondonhavedevelopeditalongsideDrFoster.

MORTAIT

DID OU KNOW? Eight hospital trusts do not have a policy

to notify GPs on the death of a patient.

Sadly, some deaths in hospital are inevitable. Much of the difference in

mortality ratios between hospitals has little to do with differences in the

quality of care that people receive. Instead it is related to the sort of people

who are treated and how vulnerable they are. Measures like the HSMR try

to account for this using statistical techniques, but no statistical adjustment

can ever be perfect.

The ratio of avoidable deaths among surgical patients with treatable

complications gives another way of exploring how a hospital performs,

one which relates to a specic group of people and which offers some

advantages. For people undergoing surgery, the chance of developing a

complication such as bleeding or pneumonia depends very much on their

age, underlying conditions and other factors. But while complications are

often a result of patient characteristics, a hospitals ability to successfully

treat it is strongly related to the quality of care provided. Staff must be

vigilant and act promptly to ensure the right treatment is given.

By looking at the ratio of death only among those people who experience

complications, this indicator allows for the fact that some hospitals will treat

more people who are at risk of complications than others. The indicator is

intended to show how well they perform once the complications occur.

Hospitals performing poorly on this indicator should consider whether they

have proper systems in place for identifying and responding to patients who

deteriorate after their operation.

Professor Peter Grifths is director of the National Nursing Research Unit

at Kings College London

Why look atdeaths after surgery?

Prof Peter Grifths

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2 Mortality in high-riskconditions

3 Deathsafter surgery


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Theindicatorlooksatsurgicalpatientswhohad

asecondarydiagnosissuchasinternalbleeding,

pneumoniaorabloodclot,andsubsequently

died. Eitherthe patients hadthiscondition

alreadyortheydevelopeditasaconsequence

ofthesurgery.Intheformercase,operating

onapatientinthesecircumstancesmayhave

increasedtheriskofdeath.

Deathamongthisparticulargroupofpatients

will sometimes be inevitable. But trusts with

highratiosshouldmakesurethatappropriate

proceduresareinplacetominimisetheriskof

deathfollowingsurgery.

Acrossthe147acutehospitaltrustsinEngland,

fourhavesignicantlyhighratiosfordeathsaftersurgery,twoareperformingsignicantly

better, and the rest are performing within

theestimatedrange.However,thereislarge

variationinperformance,withratiosfrom26

to179.AswithHSMRs,theresultsmaybe

affectedbytheaccuracyoftheunderlyingdata.

Againtheresultsaredisplayedonpage17.

This measure uses a very different approach

fromtheHSMR,sotruststhathavehighratios

onbothofthemeasuresUniversityHospitals

Birmingham NHS Foundation Trustand Hull

andEastYorkshireHospitalsNHSTrust will

wanttounderstandthepossiblecauses.

Measurementsofhospitalmortalityratiosare

only as good as the data they are based on.

Hospitaltrustsarerequiredtodocumentin

detail the care they provide topatients usingdenedsystemsofcoding.Onthewholethis

codingisrobust,buttherecanbesomevariation

betweentrusts.

Inrecentyears,becauseofthecontinuedfocus

onmortalityratios,sometrustshavereviewed

thewaytheycodepatientsandhaveincreased

thenumberidentiedasbeinginpalliativecare.

Ifthesepatientsdie,theyhaverelativelylittle

effecton the trusts HSMR,becausedeath is

theexpectedoutcome.

Afocusonmoreaccuratecodingiswelcome.

However,wehaveseengreaterinconsistency

inthewaythattrustsarecodingpalliativecare

The safety of a patients stay in hospital depends on the level of accuracy invested in

the monitoring, recording, measuring and decision-making around crucial changes

in their vital signs. Any delay in picking up patient deterioration can have an obvious

and tragic human cost. Also, it often means a return to critical care, which incurscosts and prevents trusts from using resources efciently.

Trusts need to know their standardised mortality ratios so that crucial work can be

done to improve them. The predominantly nurse-led critical care outreach teams

have been integral to improvements in reducing complications, speeding recovery

and enabling a quicker discharge for patients. This must not detract, however, from

the need for wards to have correct stafng levels and accurate skill-mixes; we must

ensure the best care at all times.

The Royal College of Nursings training packages and nursing practice principles

are giving staff the expert help they need to guide their actions before patients get

worse. The obvious key to success is empowering nurses to work closely with otherhealthcare professionals to get basic care right.

Dr Peter Carter is chief executive and general secretary of the Royal College of Nursing

A view from the front lineby the Royal College of Nursing

MORTAIT

4 Is the dataaccurate?

Deaths after surgery

Anoverviewoftrustsresultsfor2009/10.

4high

2low

141asexpected

all147trusts


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Full results are available at www.drfosterhealth.co.uk/hospital-guideMORTAIT

DID OU KNOW? All hospital trusts now use the World Health

Organisations Safer Surgery Checklist.

patientsinrecentyears.Sometrustsaremore

likelythanotherstocodeparticular patientsas

palliativecareand,asaresult,theirHSMRsare

lowerthantheywouldbeifalldatawascodedinthesameway.

OnaveragethiscanreduceatrustsHSMR

byuptoaboutvepoints.Therefore,inthe

interests of transparency, we have started

topublishthepercentagesofdeathsateach

trustwhicharecodedaspalliativecare.These

rangefromlessthan1percentinsometrusts

toover 40per cent inothers, with 45.5 per

centatBasingstokeandNorthHampshireNHS

FoundationTrustand44.5percentatMedway

NHSFoundationTrust .

Transparency around outcomes depends on

hospitals coding information accurately and

consistently.Withincreasingfocusonaccurate

measurementofoutcomes,itisessentialthat

clear guidelines are issued on howpatients

shouldbeclassied,andthathighstandardsof

data-recordingaremaintained.

The real value ofmeasuring mortality is inprompting trusts to take practicalactions that

helpdeliverbettercare.Herearesomeexamples.

Forming a successful action plan

TamesideHospitalNHSFoundationTrust

Tamesides HSMR has improved from high

toasexpectedin2010.Accordingtomedical

director Tariq Mahmood, this is theresult of

the development and systematic application

of a detailed mortality action plan with the

full support of the trust chief executive, the

endorsementoftheboardandtheinvolvement

ofclinicalandmanagerialstaff.

Thetrusthasbeenfocusingoncontinuingto

improveclinicalcare,suchasbysignicantly

increasingthenumberofitsconsultantsand

nursingstaff,andbyenhancingthecriticalcare

outreachteamandintensivetherapyunit(ITU).

Ithasalsobeenimplementingcarebundlesfor

certainhigh-riskconditions.

Goodclinicaldocumentationunderpinseffective

clinicalcareandappropriatecoding,andthereby

affectstheHSMR.Tofacilitatethisthetrusthas

undertakenaperiodofeducationandtraining

forbothitsclinicalandcodingstaff.Inaddition,

itconductsregularreviewsofallunexpected

deathsinhospitalinordertoidentifyanyissues

withcaremanagementordocumentation.

Qualityend-of-lifecareisimportantforensuring

adignieddeathinanappropriatesetting,soit

isvitaltoincreaseawarenessofthesubjectand

haveanintegratedapproachacrossprimaryand

secondarycare.Thisalsohelpstoreducethe

5 How are trustsresponding?

Patients need meaningful information, delivered in everyday language, so that they

can make an informed choice of hospitals and services. However, it is essential that

the information is accessible, readable and clear. We hear from patients phoning

our helpline about how confused they are by the medical terminology used when

delivering information, or that the information is in a format, such as online, that they

nd hard to access. It is not an informed choice if patients are unable to engage or

access the information presented to them.

Although mortality ratios are an important measure for patients when comparing

hospital services, they do not tell the whole story of quality of care in a hospital and

do not apply to large areas of care. To get to the heart of hospital care, patients

need other information: infection rates and the staff-to-patient ratio for a ward or

department, and the performance and outcomes for consultants and their teams.

The information revolution is a key part of the proposed changes to the NHS

outlined in the White Paper, but it is essential that this data is meaningful and

truly representative of the quality of care in hospital wards and departments. The

information needs to be easily accessible through a range of media, consistent

between hospitals, up to date and explained in plain English, avoiding the need for

complex statistics that leave patients confused.

Katherine Murphy is chief executive of The Patients Association

What else dont we know?by The Patients Association


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HSMRasmorepeoplearesupportedindying

outsidehospital,ifthatistheirchoice.

Thetrust hasbeenvisitingother organisations

withlowHSMRsandisalsoamemberofthe

NorthWestReducingMortalityCollaborative

(seebelow),whichhelpstounderstandand

addressthereasonsforparticularlyhighHSMRs

acrosstheregion.

Regional cooperation to improve care

NorthWestReducingMortalityCollaborative

Ninetrustsinthenorth-westhavebeenworking

togethercloselyoverthepastyeartobringabout

improvementsinpatientmortalityratios.Thisisallpartofawiderstrategytoraisestandardsof

carethroughoutthearea.

FacilitatedbytheAdvancingQualityAlliance

(AQuA), this breakthrough collaborative is

onlypartwaythroughitsrstyear,butallthe

trustshavealreadymadeimprovements.Each

onehasmadeacommitmenttoseeafallinits

HSMRofatleast10pointsovera12-month

period.Some,suchasTamesideHospitalNHS

Foundation Trust and Royal Bolton Hospital

NHSFoundationTrust,havesignicantlyreduced

theirratiosfromahighstartingpoint.

Thecollaborativeinvolvesa series of learning

events,bothforfront-lineteamsandhospital

executives. In between the eventsthey test

out ideas for improvementsand measure the

impactofthechangestheyaremaking.Sixsets

ofinterventionsarebeingpursued:

Reducingharm,suchasbytacklinghealthcare-

acquiredinfectionsormedicationerrors.Usingcarebundlestoensurethateverypatient

hasthemosteffectivecare,everytime.

Improvingthecareofdeterioratingpatientsby

spottingwarningsignsearlyandactingquickly.

Improvingend-of-lifecaretogivepatientsand

familiesmorechoiceandcontrol.

Ensuringeffectiveleadershipandmanagement

fromboardsthroughtofront-linestaff.

Tacklingallarisingissuestodowithcodingand

dataanalysis.

AQuA,whichissupportingtheinitiative,isa

membership organisation funded by primary

caretrustsandacutetrustsinthenorth-westto

improvequalityandspreadbestpractice.

Improving HSMRs through cultural changeSouthLondonHealthcareNHSTrust

SouthLondonHealthcareNHSTrustwascreated

inApril2009fromthemergerofthreehospitals.

Itiscurrentlyintheprocessofmajorcultural

changes:mergingdepartments,reconguring

services,re-engineeringpatientpathwaysand

introducingmodernworkingpractices.

Thetrusthasrecentlyintroducedthefollowing,

whichitbelieveswillhaveapositiveimpacton

itsHSMR:

Board-levelfocusonsafetyasthetrustgoes

throughthisperiodofchange.

The introduction of new models of care,

specicallytheintroductionanddevelopmentoftheacutemedicalunitmodelofcare.

Newlydevelopedprocesses,ledbythemedical

director, for regular analysis of the Dr Foster

data, internal investigation of any alerts, and

review of all low-risk deaths. These reviews

bring front-lineclinicians into the process,

enhancingpartnershipwithcoders.

Insistence that thecoding of deaths isonly

undertakenbythemostseniorclinicalcoders,

as well as introducing an internal quality

assuranceprocess for thecoding of deaths

priortosubmission.Asaresult,theproportion

oflow-riskdeathswhichonanalysisrequire

re-codinghasdecreasedfrom45to14percent

onthemostrecentaudit.

MORTAIT

Why measuring

mortalityis important

Avoiding unnecessary deaths is an important objective for health services in

all countries. People should not die early where medical intervention could

make a difference. As far back as 1863, Florence Nightingale recognised

that uniform hospital statistics would enable us to ascertain the relative

mortality of different hospitals.

Initial interest in standardised mortality data was muted, but some in the NHSrecognised that HSMRs could help trusts to identify where improvements

needed to be made. The recent association of persistently high HSMRs with

shockingly poor clinical care in a few trusts has focused fresh interest on

the use of mortality statistics in local accountability arrangements.

Important caveats need to be made. In particular, there is no gold standard

or single indicator which can be deemed as having most power in discerning

good or poor quality care. As with most indicators, its use for all audiences

is subject to caution. It is not appropriate to use HSMR data for league

tables of hospitals. Any inferences drawn from HSMR data should be

corroborated (or investigated) by other comparative measures before

conclusions are drawn about the quality of care.

Further development and understanding of the use of standardised mortality

statistics across the NHS will bring greater quality and consistency in terms

of the way we monitor mortality associated with hospitalisation. This will be

of benet to the public at large.

Dr Robert Winter is medical director at NHS East of England

Dr Robert Winter

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Hospital Standardised Mortality Ratios (HSMRs) Thisisabroadmeasureacrossthemajorityofactivityinahospitalwhereriskofdeathis

signicant.Becauseitcoverssomuchactivity,itisanexcellentscreeningtoolforidentifyingwheretheremaybeproblemswithavoidablemortality.

ower than expected mortality Ratio Higher than expected mortality Ratio

AintreeUniversityHospitalsNHSFoundationTrust 85 Barking,HaveringandRedbridgeUniversityHospitalsNHSTrust 116

AshfordandStPetersHospitalsNHSTrust 90 BuckinghamshireHospitalsNHSTrust 118

BarnetandChaseFarmHospitalsNHSTrust 88 CityHospitalsSunderlandNHSFoundationTrust* 1 14

BartsandTheLondonNHSTrust 89 DerbyHospitalsNHSFoundationTrust 112

BradfordTeachingHospitalsNHSFoundationTrust 81 EastSussexHospitalsNHSTrust* 110

CambridgeUniversityHospitalsNHSFoundationTrust 81 GeorgeEliotHospitalNHSTrust* 113

EastKentHospitalsUniversityNHSFoundationTrust 79 HullandEastYorkshireHospitalsNHSTrust 117

EpsomandStHelierUniversityHospitalsNHSTrust 90 IsleofWightNHSPCT* 115

FrimleyParkHospitalNHSFoundationTrust 85 MidCheshireHospitalsNHSFoundationTrust 1 14

ImperialCollegeHealthcareNHSTrust 80 NorthamptonGeneralHospitalNHSTrust* 112

LeedsTeachingHospitalsNHSTrust 91 PennineAcuteHospitalsNHSTrust 110

MaidstoneandTunbridgeWellsNHSTrust 92 RoyalBoltonHospitalNHSFoundationTrust 116

MidStaffordshireNHSFoundationTrust 87 ShrewsburyandTelfordHospitalNHSTrust* 117

NorthBristolNHSTrust 90 SouthLondonHealthcareNHSTrust* 109

NorthWestLondonHospitalsNHSTrust 87 SouthportandOrmskirkHospitalNHSTrust* 113

PlymouthHospitalsNHSTrust 86 TheDudleyGroupofHospitalsNHSFoundationTrust 115

RoyalFreeHampsteadNHSTrust 72 TheRoyalWolverhamptonHospitalsNHSTrust* 116

SalfordRoyalNHSFoundationTrust 84 UniversityHospitalsBirminghamNHSFoundationTrust 109

ShefeldTeachingHospitalsNHSFoundationTrust 92 WesternSussexHospitalsNHSTrust* 107

StGeorgesHealthcareNHSTrust 84

TauntonandSomersetNHSFoundationTrust 89

TheNewcastleuponTyneHospitalsNHSFoundationTrust 90

TheWhittingtonHospitalNHSTrust 84

UniversityCollegeLondonHospitalsNHSFoundationTrust 72

UniversityHospitalsBristolNHSFoundationTrust 86

WestMiddlesexUniversityHospitalNHSTrust 86

Results for the three mortality indicators

*DenotestrustswhichdidnothavehighHSMRslastyear

DenotestrustswithhighHSMRsforthepastsixyears

MORTAIT



16/38



Standardised mortality ratiosThisbasketcontainsveofthe56conditionsthatcomprisetheHSMR:heartattacks,stroke,pneumonia,

congestiveheartfailureandbrokenhips.


AshfordandStPetersHospitalsNHSTrust 83 CountyDurhamandDarlingtonNHSFoundationTrust 113

BradfordTeachingHospitalsNHSFoundationTrust 87 DerbyHospitalsNHSFoundationTrust 115

EastKentHospitalsUniversityNHSFoundationTrust 81 EastandNorthHertfordshireNHSTrust 118

FrimleyParkHospitalNHSFoundationTrust 84 GreatWesternHospitalsNHSFoundationTrust 117

ImperialCollegeHealthcareNHSTrust 83 HullandEastYorkshireHospitalsNHSTrust 115

MidStaffordshireNHSFoundationTrust 74 RoyalBoltonHospitalNHSFoundationTrust 118

NorthWestLondonHospitalsNHSTrust 88 ShrewsburyandTelfordHospitalNHSTrust 117

PlymouthHospitalsNHSTrust 87 SouthLondonHealthcareNHSTrust 112

RoyalFreeHampsteadNHSTrust 79 SurreyandSussexHealthcareNHSTrust 121

StGeorgesHealthcareNHSTrust 87 TheRoyalWolverhamptonHospitalsNHSTrust 121


UniversityHospitalsBristolNHSFoundationTrust 84

WestMiddlesexUniversityHospitalNHSTrust 78

Deaths after surgery Thisindicatorlooksatunexpecteddeathsamongsurgicalpatients.


ChelseaandWestminsterHospitalNHSFoundationTrust 26 HullandEastYorkshireHospitalsNHSTrust 166

WinchesterandEastleighHealthcareNHSTrust 46 TheNewcastleuponTyneHospitalsNHSFoundationTrust 137

UniversityHospitalsBirminghamNHSFoundationTrust 157

UniversityHospitalofNorthStaffordshireNHSTrust 153


Look back at pages 11-13

Why did we choosethese indicators?

MORTAIT

Results for all trusts are available at www.drfosterhealth.co.uk/hospital-guide

Source:SecondaryUsesService(SUS)data2009/10


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Strokeisahighnationalprioritybutthereisa

markedvariationinstandardsofcare.Thiswas

highlightedbytheNationalAuditOfce(NAO)

in2005andrecentlyin2010.1

AstheUKsthirdbiggestkiller,stroketakes

thelivesofmorewomenthanbreastcancer.

There are 110,000 strokes in England each

year,andalmostathirdofeveryonewhohas

onediesfromit.2Thosewhosurviveoftenhave

permanentdisabilities.TheNAOestimatedthat

thedirectcostofcaringforpeoplewhohavea

strokeis3bnayearandthewidereconomic

costsare8bn.3

Under pressure to improve

TheDepartmentofHealths2007StrokeStrategy

recognised thescaleof theproblemand set

outtomakeimprovementsapriority. 4Butwhat

impacthasthestrategyhadintermsofhelping

hospitalstoadheretobestpracticeandimprove

patientoutcomes?

Inthis years HospitalGuidethe DrFoster

teamhasfocusedonkeyindicatorsofquality

and outcomes that stretch across the stroke

carepathway,inotherwordsacrossthemany

differentstagesoftreatmentandcareforthis

particularcondition.

Strokeexcellence across a care pathwayTo understand quality, you need to measure the aspects of care that

patients are most concerned about. This often boils down to looking

at the detail around individual conditions. Here we focus on the care

that patients receive when they have a stroke.

The key to providing high-quality stroke care is making sure that everyone who

has a stroke is admitted directly to a stroke unit and spends all of their time there.

The evidence is strong that these units, staffed with a multi-disciplinary team of stroke

specialists, improve outcomes and reduce stroke mortality.

Recent years have seen a dramatic improvement in the number of stroke units, the

number of patients treated there and the length of time they stay. Stroke patients

and their families will want to assess these different aspects of care, as well as the

quality of specic units.

The Sentinel Stroke Audit, which is carried out every two years by the Royal College

of Physicians, provides a wealth of data about stroke unit provision. New, real-time

measurement of the hyper-acute phase of stroke care is also coming on stream with

the introduction of the Stroke Improvement National Audit Programme. Both of

these are important measures for clinicians and commissioners, but they are also

vital tools for helping patients to assess their care.

Just as vital is data about post-hospital stroke provision, and this is much thinner

on the ground. The Care Quality Commission (CQC) is carrying out a one-off review

of post-hospital stroke provision to be published later this year, but in future we

will need to see more systematic measurement of the quality and quantity of stroke

services in the community, building on the baseline provided by the CQC.

Joe Korner is director of communications at The Stroke Association

The information we needby The Stroke Association


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Full results are available at www.drfosterhealth.co.uk/hospital-guideSTROKE

Taking action early

Ofthesixperformanceindicators,thersttwo

measuredinterventionsthatshouldtakeplacein

thecriticalperiodofcarestraightafterastroke:

Theproportionofpatientsreceivingabrain

scanonthesameornextday.

Theproportionofpatientsgiventhrombolytic

orclotbustingdrugswithin24hours.

Receiving a brain scan promptly is thebest

way tocorrectly diagnosethe nature ofthe

stroke.Withoutthis information itmaynot

bepossibletostartappropriatetreatmentas

soonasrequired.In2009/10thehighestrateofpatientshavingabrainscanbythenextday

was87percentatNorthMiddlesexUniversity

HospitalNHSTrust.Elsewheretherateswere

aslowas42percent.

Thrombolysiscanmakea bigdifferenceto the

patientsrecoverybutthisrequiresskilledteams

onsite.Notalltrustsaresetuptoprovidethis

care.Insomeareas,networksarebeingsetup

sothat,ifahospitalcannotprovidetreatment,

patientsaretransferredquicklytonearbyunits

whichcan.Thrombolysisratesvariedfrom0. 2

to17percent.Youcanseeallthescanningand

thrombolysisresultsonourwebsite.

Quality care from start to nish

The following four indicators were chosen to

helpdemonstratethequalityofoutcomes:

Theproportionofstrokeadmissionsthatlead

topneumoniaduetoswallowingproblems,

whichshouldnothappenifcareteamshavecarriedoutastandardcheck.Ratesvariedfrom

2to12percent.

Theproportionofpatientsreturningtotheir

usual place of residence following hospital

treatmentwithinaperiodof56days,which

impliessuccessfulrehabilitation.Ratesvaried

from55to85percent.

Therateofemergencyreadmissionstohospital

aftertreatmentforastroke,whichhighlights

returnvisitsthatcouldpossiblybeavoided.

Ratesvariedfrom44percentbelowaverage

to58percentaboveaverage.

Thestandardisedmortalityratio,whichcan

highlightpreventabledeaths.Ratesvariedfrom

34belowaverageto66aboveaverage.

No room for complacency

Tobuildapictureofoverallperformance,wehave identied trusts that have performed

signicantly better or worse than expected

acrossallsixindicators.

Tobeinourbestperformersbasket,trusts

hadtodoverywellintwoormoreofoursix

indicators, and not be below average on any

oftheothers.Likewiseourworstperformers

are belowaverage onat leasttwo indicators,

without doing particularly well on any ofthe

rest.Youcanseetheresultsforthesetrustson

pages20-21,whilethefulllistingsforallother

trustsareavailableonourwebsite.

It is clear that there have been measurable

improvementsinthewaytheNHSdealswith

strokesandthattheStrokeStrategyismaking

a difference tothe number ofdeaths.In fact

theNAO estimated that, since 2006, stroke

patientschancesofdyingwithin10yearshave

fallenfrom71to67percent.5Butthereisstilla

worryinglevelofvariationincare.Yourchance

ofsurvivaloryourqualityoflifeifyoudo

survivestillvariesaccordingtowhichhospital

youareadmittedto.

DID OU KNOW? 97% of trusts have a specialist stroke unit.

The stroke data in the 2010 Hospital Guide provides an invaluable means

of comparing performances across all English acute services for stroke.

Two relevant outcomes for stroke are readmissions and standardised

mortality and it is very encouraging that most hospitals perform well on these

two measures. A move towards measuring in- and out-of-hospital mortality

would be a further advance given that many stroke patients now benet from

early supported discharge, sometimes within 72 hours of admission.

The landscape of acute stroke care is changing dramatically in the UK,

and the data presented here is unlikely to reect this. For instance, this

year a new model of care in London has already helped to increase rates

of intravenous thrombolysis to 12 per cent for February to July 2010,

compared with 3.5 per cent for the same period in 2009.

Of course thrombolysis rates are only a small part of the story. There is also

a need to demonstrate improved outcomes of functional recovery following

treatment, improvement in the percentage of patients returning to their

previous life roles, and patient satisfaction with the care provided. It is to behoped that the 2011 Hospital Guide looks across the whole stroke pathway,

rather than just acute care.

Dr Charles Davie is consultant neurologist at the Royal Free Hampstead NHS Trust,

stroke lead for University College London Partners and clinical stroke lead for the North

Central London Cardiac and Stroke Network

What happens

to patients after theyleave hospital?

Dr Charles Davie

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The care pathway:best and worst performing trusts

across six indicators

DIAGNOSIS

AND PREENTION

URGENT

TREATENT

Performing

brain scans the same

or next day

Providing

thrombolytic drugs

within 24 hours

EastKentHospitalsUniversityNHSFoundationTrust

DerbyHospitalsNHSFoundationTrust

NorthumbriaHealthcareNHSFoundationTrust

SouthendUniversityHospitalNHSFoundationTrust

SouthTeesHospitalsNHSFoundationTrust

TheQueenElizabethHospitalKingsLynnNHSTrust

Barking,HaveringandRedbridgeUniversityHospitalsNHSTrust

BasildonandThurrockUniversityHospitalsNHSFoundationTrust

Blackpool,FyldeandWyreHospitalsNHSFoundationTrust

GeorgeEliotHospitalNHSTrust

IsleofWightNHSPCT

LeedsTeachingHospitalsNHSTrust

NottinghamUniversityHospitalsNHSTrust

WestMiddlesexUniversityHospitalNHSTrust


Key

Exceedsexpectation Meetsexpectation BelowexpectationNotapplicable

Bestperformers

Worstperformers

Continuedo

ver


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ACUTE TREATENT HOSPITAL DISCHARGE SECONDAR

PREENTION

Pneumonia due

to swallowing problems

Standardised

mortality ratio for stroke

Discharge home

within 56 days

Emergency

readmissions for stroke

Source:SUSdata2009/10


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With an ageing population, the demand fororthopaedic services has grown steadily over

thepast20years.Thisisparticularlytruefor

hip and knee replacements: 125,000 took

placeinEnglandin2009/10.Theannualcost

formedicalandsocialcareintheUKforhip

fracturesaloneisabout2bn,settoriseto

2.2bnby2020.1Forthesereasonswehave

focusedonorthopaedicsasakeyspecialty.

Avoiding readmissions

First we identied all patients who were

readmittedwithin28daysafterahiporknee

replacement. For both these outcomes, the

majority oftrusts performed to theexpected

standard in 2009/10. However, for hips,two

trusts had high readmission rates Leeds

Teaching Hospitals NHS Trust (75 per cent

aboveaverage)andTheNewcastleuponTyne

HospitalsNHSFoundationTrust(63percent).

Incontrast,twotrustshadlowrates Northern

Devon Healthcare NHS Trust (67 per cent

below average) and Royal Devon and ExeterNHSFoundationTrust(35percent).

Reducing the need for revisions

In2009/10morethan2,000patientshadto

havetheirhiporkneereplacementrevisedor

manipulated. Wear and tear does mean that

replacementswillnotlastforever.Butformost

patientstheydolastfor15to20years.

Hip revision rates varied from 0 to 3.5 per

cent,andkneerevisionsfrom0to2.1percent.

Twotrusts had high rates for hip revisions

Frimley Park Hospital NHS Foundation Trust

andNorthumbriaHealthcareNHSFoundation

Excellence in

orthopaedicsa team approachWhen measuring clinical effectiveness, it is essential to look at

the overall performance of care teams, not just hospitals, so that

the results are meaningful to patients. This year we have assessed

a basket of six indicators for the quality of orthopaedic care.


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Trustandonewashighforkneerevisions

GuysandStThomasNHSFoundationTrust.

Sixteen trusts have done particularly well on

this indicator. Visit www.drfosterhealth.co.uk

toseethefulllistofresults.

Death following a hip fracture

Hipfractures(orfracturedneckoffemur)also

representamajorexpensefortheNHSand

arethemostcommonreasonforadmissionto

anorthopaedicward.Morethan70,000hip

fractureshappeneachyearintheUK,whichis

likelytoincreaseto101,000by2020.2

Moreover, patients who suffer a hip fracture

haveahighmortalityratio:about10percentof

peoplewithahipfracturediewithinonemonth,

andaboutathirdwithin12months.In2009/10

nearly6,000peoplediedinhospital.However,

when examining standardised mortality ratios,

all trusts performed as well as expected, and

CambridgeUniversityHospitalsNHSFoundation

Trust had an especially lowratio(46 per cent

belowaverage).

Operating straightaway

Patientswho falland break theirhips should

havethemoperatedonwithintwodays.Thisis

acrucialtimeframe,notonlyasitisacceptedbest practice from the National Institute for

HealthandClinicalExcellence(NICE),butalso

asthereisaprovenlinkbetweenadelayin

theoperationandanincreasedriskofdeath.3

Worryingly, in our analysis, 21 per cent of

trustshadratesthatweresignicantlylow.The

percentageoperatedonwithintwodaysvaried

from34to94percent.Againthefullresults

areshownonourwebsite.

Forapictureoftrustsoverallperformance,we

have identied those performing signicantly

wellorpoorlyacrossthesixindicators(using

the same criteria asfor stroke, see page 19).

Thesetrustsareshownintheboxtotheright.

ORTHOPAEDIS

Joining up

the dataTom WainwrightRobert Middleton

Best performers AiredaleNHSTrust

NorthernDevonHealthcareNHSTrust

RoyalDevonandExeterNHSFoundationTrust

RoyalSurreyCountyNHSFoundationTrust

UniversityHospitalsCoventryandWarwickshireNHSTrust

WestSuffolkHospitalNHSTrust

Worst performer LeedsTeachingHospitalsNHSTrust

Combining the indicators

Truststhathaveperformedsignicantlywellorpoorlyacrossthesixindicators:

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Understanding more about the effect of our orthopaedic interventions is

imperative, so there is great value in tracking the data we see on these pages.

There have also been recent developments in the way that we can assess the

quality of hip and knee replacements. In September 2010, the rst data on

Patient Reported Outcome Measures (PROMs) was published by The NHS

Information Centre for health and social care. PROMs use ve different

questionnaires to evaluate patients health. The initial data is termed

experimental but shows us that 96 per cent of hip replacement patients

and 91 per cent of knee replacement patients recorded a joint-related

improvement after their operation.

Benchmarking is a hugely powerful tool in helping hospitals to identify

areas where improvements are needed, as well as increasing transparency

for the general public so they can make choices about where to be treated.

It should be noted that the variation in outcomes across providers and

therefore the inferred difference in quality is often greater than we might

imagine. For example, case-mix-adjusted average length of stay varies by

over seven days across hospitals for knee replacement. We would like to

see more sensitive and discriminative data; at present the data we have

does not provide patients with enough detail to choose between different

hospitals by making meaningful judgements about quality.

A step towards more meaningful data could happen by bringing together

the various databases that we already have. While the Dr Foster data is very

useful in isolation, it would be strengthened further by aggregation with the

other major databases such as PROMs, the National Joint Registry and the

national hip fracture audit.

Robert Middleton is consultant orthopaedic surgeon and Tom Wainwright

is clinical researcher in orthopaedics, both at The Royal Bournemouth

and Christchurch Hospitals NHS Foundation Trust


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Urologyexcellence in operations

Guidelines recommend that

surgery for urological cancer

be carried out in specialist

centres to improve quality.1

Simon Carter, consultant

urologist at Imperial College

Healthcare NHS Trust,

shows how the guidelines

are being implemented

and identies leading trusts

for these types of operation.

Urologicalcancers,suchasthosefoundinthebladder,prostateorkidney,affectmorepeople

thanbreastcancereachyear. 2Itisrecommended

practice to carry out operations for these

conditionsinlargerorganisationswherethe

oftencomplexproceduresareperformedmore

frequently.Inthissectionwelistsomeofthe

leadingtrustsinthetreatmentoftheseillnesses.

Operationstotreatbenignprostatediseaseare

performedinawidernumberofunits;wehave

comparedhowoftentheprocedureneedstobe

redonewithinthreeyears.

Surgery for pelvic cancer

Therearegoodreasonstobelievethatcentres

whichcarry outlarge numbers ofsurgery for

prostateand bladdercancerhave consistently

highstandards.Wehave thereforeidentiedthe19truststhatperformedhighnumbersof

operationsonpeoplewithprostateorbladder

cancerfrom2007/08to2009/10(seepage25).

Inaddition,wehaveidentiedwhichofthose

trusts alsoperformed a signicant numberof

laparoscopicprostatectomyoperationsduring

2009/10.Theseoperationsoffer considerable

benetstothepatientintermsofthespeedof

operatingandthespeedofrecovery.However,

notalltrustshavesurgeonswhoareexpertin

thesetechniques.

The2002guidelinesfromNICEdemandedthat

pelvic urological cancer surgeryshouldonly

beundertaken in units where morethan 50

proceduresareperformedeveryyear.

%l

aparoscopic

2006/07

10%

20%

30%

40%

50%

60%

2007/08 2008/09 2009/10

Financial year

Large Medium Small All

0%

ore prostatectomies are now being performed by laparoscopic techniqueSource: SUS data 2006/07 to 2009/10.


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Full results are available at www.drfosterhealth.co.uk/hospital-guideUROO

Toagreatextent,theguidelinesarenowbeing

achieved.Over3,500prostatectomyoperations

are being performed in the large trusts each

year (dened as trusts doing more than 50

operationsayear).Fewerthan1,000arebeing

performedinsmallormedium-sizedtrusts.The

useoflaparoscopicorkeyholetechniqueshas

also increased dramatically, predominantly in

thelargercentres.

Prostatecancersurgeryisontheincrease.The

totalnumberofoperations(bothlaparoscopic

and open)has risenby 33per cent between

2005/06and2009/10.Largetrustshaveseen

ariseof166percentduringthattime,while

mediumtrustsactivityhasfallenby61percent.

In2006/07only15percentofprostatectomies

werecodedasbeingalaparoscopicprocedure;

this rate has increased each year and by

2009/10 stood at44per cent.The upward

trendistrueofbothlargeandmediumtrusts

(showninthegraphonpage24).

Removalofthebladder,knownasacystectomy,

isanothermajorsurgicalprocedurewithmany

potential complications, and it is probably

best performed by surgical teams with great

experience.In2005/06largetrusts(thosedoing

more than 25 operations a year) performed

only21percentofcystectomies(304intotal).

Bycontrast,by2009/10largetrustsaccounted

for63percentofcystectomies(1,005).

Isitpossibletosaythatthequalityofoperative

urologicalcarehasimproved?Whencomparing

truststhatperformmanyprocedureswiththose

thatonlydoamodestnumber,simplemeasures

haveshownthattheirratesofreadmissionsand

lengthofstayareverysimilar.

However,theincreasinguseofsophisticated

surgicaltechniquesisconcentratedinasmall

numberoftrusts,andpatientsaremorelikelyto

getthefullrangeofoptionsinthelargercentres.

Surgery for benign conditions

Conventionalurologicalproceduresforlower

urinary tract symptoms and acute retention

of urine both benign conditions continue

tobeundertakeninawiderangeofhospitals,

with varying quality. One such procedure is

transurethralresectionoftheprostate(TURP).

Measuringthe need torepeatthis operation

withinthreeyearscouldbe a novelway of

lookingatquality,especiallyasthedatacanbeusedtoseewhenoperationsareperformedin

anytrustinEngland.

TrustswithlowratesforrepeatTURPoperations

withinathree-yearperiod:

AintreeUniversityHospitals

NHSFoundationTrust

Barking,HaveringandRedbridgeUniversity

HospitalsNHSTrust

DerbyHospitalsNHSFoundationTrust

GeorgeEliotHospitalNHSTrust

IpswichHospitalNHSTrust

LutonandDunstableHospital

NHSFoundationTrust


RoyalBoltonHospitalNHSFoundationTrustShrewsburyandTelfordHospitalNHSTrust

SouthportandOrmskirkHospitalNHSTrust

UniversityHospitalsofLeicesterNHSTrust

WarringtonandHaltonHospitals

NHSFoundationTrust

YeovilDistrictHospitalNHSFoundationTrust

TrustswithhighratesforrepeatTURPoperations

withinathree-yearperiod:

MidEssexHospitalServicesNHSTrust

NorthernLincolnshireandGooleHospitals

NHSFoundationTrust

TheQueenElizabethHospitalKingsLynn

NHSTrust

Trusts performing high numbers of urological operations

on pelvic cancer patients.Source: SUS data 2007/08 to 2009/10.

Number of cases

NorthBristolNHSTrust* 391

GuysandStThomasNHSFoundationTrust* 376

CambridgeUniversityHospitalsNHSFoundationTrust* 330

TheNewcastleuponTyneHospitalsNHSFoundationTrust* 279

ShefeldTeachingHospitalsNHSFoundationTrust* 268

NorfolkandNorwichUniversityHospitalsNHSFoundationTrust 230

ImperialCollegeHealthcareNHSTrust* 225

LeedsTeachingHospitalsNHSTrust 201

HullandEastYorkshireHospitalsNHSTrust 193

CityHospitalsSunderlandNHSFoundationTrust 189

RoyalBerkshireNHSFoundationTrust* 182

NottinghamUniversityHospitalsNHSTrust* 179

SouthTeesHospitalsNHSFoundationTrust 168

RoyalDevonandExeterNHSFoundationTrust 150


PlymouthHospitalsNHSTrust 132

AshfordandStPetersHospitalsNHSTrust 128

MedwayNHSFoundationTrust 125

CentralManchesterUniversityHospitalsNHSFoundationTrust 106

*Trustswithmorethan40laparoscopicprostatectomiesin2009/10


25/38


Wherever medicine is practised in the world, unsafe treatment results in

errors and harm to patients. A key part of efforts to improve safety is to

accurately measure and monitor the way in which it is being addressed.

Saetythe foundation for quality

See pages 7-9

Who have we named ourtrusts of the year?


26/38



Ayearagoweratedhospitaltrustsonarangeofaspectsofpatientsafety.Thisyearweseeif

thesituationhasimproved.Forallthemeasures

below,fullresultsareavailableonourwebsite

atwww.drfosterhealth.co.uk.

Complying with safety alerts

Inour2009surveyweaskedallNHShospital

trustswhethertheyweremeetingbasicsafety

requirements.Thesearealertsissuedbythe

NationalPatientSafetyAgency(NPSA)which

warnhospitalsofpotentiallydangerouspractice

andadvisethemwhattodotoavoidharmto

patients.Seventruststoldusthat,foroneor

moreofthesealerts,itwouldtakethematleast

sixmonthstobecomecompliant.

Thisyearweaskedaboutalertsthatwereissued

in2009/10.Notrustsaiditwouldtakelonger

thansixmonthstobecomecompliantwiththese

alerts.Thisisaclearimprovementonlastyear.

However, threetrusts saidthey werestill notcompliantwithatleastoneofthealertsand

requiredafurtherthreemonthstodothis.The

alertsincluded:reducingtheriskofoverdosing

thedrugmidazolam,andinappropriateuseof

oralbowel-cleansingsolutionspriortosurgery.

Thethreetrustswere:

SouthendUniversityHospital

NHSFoundationTrust

StGeorgesHealthcareNHSTrust

WesternSussexHospitalsNHSTrust

ThesedelayscomedespitetheNPSAclearly

stating that its guidance should be acted on

immediately.Adateforcompletionisalsogiven.

Track and trigger systems

InlastyearsHospitalGuidewereportedabout

trackandtriggersystems.Theseareregularobservationsmadebynurses,designedtopick

updeteriorationinapatientscondition.

Lastyear64percentoftrustssaidtheyhadthis

systeminplaceforallacutepatients,andthis

yearwearepleasedtoseethishasrisento79

percent.Butthismeansthatoneinvetrusts

stilldonothaveatrackandtriggersystemin

place.Tondouttheresultsforyourlocaltrust

gotowww.drfosterhealth.co.uk.

Commitment by hospital boards

Weaskedalltrustswhethertheyhaveaboard

representativeresponsible for patientsafety,

whether they discuss patients safety at all

board meetings, and whether theyhave clear

denitionsthatenableittobemonitored.This

year,aslastyear,100percentoftrustsconrmed

thattheydid.

Infection control

Againweaskedalltrustswhethertheyhavean

antibioticpharmacist(whohasakeyrolefor

managing infection risks), whether they have

pre-assessmentclinics to screenall patients

forinfectionspriortoadmission,andwhether

theytreatthose patientscarrying aninfection

beforeadmittingthem(bytreatmentthrough

adecolonisationroutine).

Lastyear86percentoftrustssaidthattheydid

allthesethings.Thisyearithasrisento97percent.However, Walsall HospitalsNHS Trust

and UniversityHospitalsof MorecambeBay

NHSTrusttoldusthattheydonotemployan

antibioticpharmacist.

Reporting incidents when they happen

Disclosingpatientsafetyincidentsthroughthe

NationalReportingandLearningServiceisanimportantelement ofmanagingsafety. After

last years guide, this voluntary system now

includessomemandatoryreportingamove

wewelcome.In2008/09,trustsonaverage

reportedveincidentsper100admissions.This

hasrisento5.7in 2009/10.Ahigherrateis

generallyregardedasapositivesignbecauseit

showsawarenessoferrorsandnear-missesand

acultureoffreedomtoreport.Thetrustswith

thelowestratesofreportingare:1

MidYorkshireHospitalsNHSTrust

(2.1incidentsper100admissions)

JamesPagetUniversityHospitals

NHSFoundationTrust(2.7)

WinchesterandEastleighHealthcare

NHSTrust(2.7)

We have looked at how many patient safetyincidentswererecordedateachhospitaltrust

in2009/10usingroutinedata.Weknowthat

this underestimatesthe scaleof theproblem

becausetherecordingofdataisstillnotaccurate

enoughtogiveatruepicture.However,wecan

saythefollowing:

Pressure sores Approximately6,000patients

wererecordedashavingpressuresoreswhile

inhospital.Unfortunatelywedonotknowhow

manypatientsdevelopedthese after arriving,ratherthanbeforehand.Butwecansaythat,

inthetrustswiththehighestrates,morethan

3.5percentofpatientswererecordedashaving

pressuresores.

PATIENT SAFET

1 Is patient safetyimproving?

2 Measuring patient safety how big is the problem?

99% of all trusts responded to the Hospital Guide survey.

Only George Eliot Hospital NHS Trust and University HospitalsBirmingham NHS Foundation Trust failed to submit a response.


27/38


Full results are available at www.drfosterhealth.co.uk/hospital-guidePATIENT SAFET

Pulmonary embolisms (PEs)Morethan30,500

admissionswererecordedashavingPEswhile

inhospitalin2009/10.Thislife-threatening

conditionisapotentialcomplicationfollowingastayinhospital,andthereismuchthathospitals

candotoreducetheriskofitoccurring.We

found that the rate of recorded PEs varied

widelybetweentrusts(seethediagramonpage

29),withthehighestratesover3.5timesgreater

thanthelowest.

Obstetric tears Tearingduringchildbirthcan

resultinincontinenceandtheneedforfurther

treatment.Risksoftearing,however,canbe

reducedthroughsafemanagementofpatients.

More than 13,000 women were recorded as

havingexperiencedanobstetrictearin2009/10

(with a delivery that was not assisted with

forceps)andthehighestratesweremorethan

sixtimesgreaterthanthelowest.Pleasevisit

www.drfosterhealth.co.uktondoutifyour

localtrusthasahighorlowrate.

Accidental punctures or lacerations Almost

10,000 hospital patients were recorded as

having sufferedfrom an accidental puncture

orlacerationin2009/10.Thisgureisalmostcertainlyanunder-recording,andeachoneof

theseeventscouldhavebeenavoided.

Post-operative haemorrhagesMorethan2,000

patientswererecordedashavingsufferedfrom

post-operative intestinal bleeding. This often

requiresfurthersurgerytotreatandcanbea

life-threateningcomplication.Again,thelevels

recordedarelikelytobeanunderestimate.

Post-operative sepsisThisisanotherpotentially

life-threatening complication. Around 1,300

patientsundergoingsurgerywererecordedas

alsohavingsepsis.Itmustbeassumedthatin

mostcasesthesepsiswastheresultofsurgery.

The information we needby Lifeblood: The Thrombosis Charity

Deep vein thrombosis is hard to spot. It does not always cause any physical swelling

or redness as the textbooks say, so it is often clinically silent. We know from the

many calls and stories we receive in the Lifeblood ofce that many people have their

symptoms ignored by health professionals as they do not t the textbook description.

Knowing how many PEs are actually occurring allows us to monitor how well the

condition is being prevented in hospital. We are grateful to Dr Foster for its work in

trying to establish the numbers admitted with a diagnosis of PE, and we are just as

disappointed that the data is so poor due to the coding system around DVT and PE.

2010 has been a watershed, with the Department of Health setting nancial incentives

for hospitals in England to assess the VTE risk of all adult admissions. Now, thanks to

the Dr Foster team, there is added proof that coding in this area must be improved.

Here is just one of many stories about the serious harm from hospital-acquired clots:

The risk of a blood clot wasnt even mentioned

Amy was diagnosed with juvenile arthritis aged six, had her rst hip replacement at

15 and has now had seven new hips. At her last operation in 2005, aged 32, she did

not receive routine thromboprophylaxis pre or post-operatively. Afterwards she was on

crutches and not allowed to bear any weight, increasing her risk of developing a blood

clot. But this wasnt mentioned and she was sent home without any information.

A month later her leg swelled up. At rst she put it down to her arthritis and the strain

of hopping about, but it got worse and one day her leg had trebled in size. She called

her GP, who lifted her legs, asking if they hurt; she said they did not and he left saying

nothing was wrong. But the pain became so severe that her friend took her to hospital.

She was diagnosed with a DVT (a large clot in her thigh), given drugs and kept in bed for

two weeks. After being sent home with compression stockings, her leg returned to its

normal size in a fortnight. Then she was given three months warfarin and discharged.

After one DVT, the risk of a second increases. Amy developed a clot two years laterafter a long-haul ight and is now on life-long warfarin. She has frequent pain and

swelling, but her GP only gave her stockings when she showed him a Lifeblood leaet.

Professor Beverley Hunt is medical director at Lifeblood: The Thrombosis Charity


28/38


Patients assessed for VTE No. of trusts

100% 6

91-99% 7

61-90% 59

31-60% 36

1-30% 24

0% 1

Didnotanswerthequestion 14

3 Preventing blood clotsin hospital

Recognition of the burden of hospital-acquired VTE in England has been

consigned to the too difcult box for too many years. In 2005, when

we rst became involved in the VTE prevention journey in the NHS in

England, there was little appetite for exploring routine data in any detail or

for considering the data in new ways.

However, under the leadership of Sir Liam Donaldson and now Sir Bruce

Keogh, it has become clear that improving coding can provide insight into

the number of people each year who develop a hospital-acquired thrombosis.

We have been working with the Dr Foster team to create an evidential

basis on which to dene hospital-acquired thrombosis. This approach was

endorsed recently by the Academy of Medical Royal Colleges through the

work of the National Quality Boards VTE sub-group. We are also working

with trusts in the south-west to try to improve consistency in coding.

We are still some way from understanding the true incidence of hospital-

acquired VTE, and use of discharge coding remains difcult. Post-mortem

studies suggest that, in a third of patients where death is caused by a PE,

the correct diagnosis is not even suspected beforehand.

Highlighting PEs in this years Hospital Guide is a welcome contribution to

our understanding of the size of the VTE issue. Just as important, though,

is the impetus that this published data may provide in stimulating the NHS

to locally discuss, publish, use and improve local data on VTE.

Dr Anita Thomas OBE is national clinical director for VTE and Tim Brown

is national VTE prevention programme lead, both for the Department of Health

Measuringblood clots moreaccurately

Tim BrownDr Anita Thomas

E

PE

R

T

O

P

I

N

I

O

N

Avenousthromboembolism(VTE)isablood

clot which develops in a part of the body,

usuallythe leg.Deep veinthrombosis (DVT)

isacommontypeofthiscondition.Partof

aclotmaybreakoffandlodgeinthearteries

thatsupplythelungs,resultinginapulmonary

embolism(PE).Thiscanoftenbefatal.

TheDepartmentofHealthhasmadesurethat

thepreventionofVTEisamajorpriority,and

it isa key component of the CQUIN scheme

(CommissioningforQualityandInnovation).

All adult patients admitted to hospital mustnow be risk-assessed for VTE,and trusts will

berequiredtodoaroot-causeanalysisofall

conrmedcasesofhospital-acquiredVTE.2

Theriskofpatientsdevelopingabloodclotis

increasedby mostsurgicaland somemedical

treatmentsandconditions.In2001,forexample,

JohnHeitfromtheMayoClinicintheUSreported

thatincidence of VTEis morethan 100-fold

higheramong hospitalised patients compared

withcommunityresidents.3Inaddition,in2005

theHealthSelectCommitteereportedthatVTEs

couldaccountfor 25,000 preventabledeaths

eachyear.4

Weaskedtrustsinourquestionnaire,What

percentageofpatientsarerisk-assessedforVTE

onadmission?Theytoldusthefollowing:

Themajorityoftrustswereabletoreporthow

manypatientswererisk-assessed.However,itis

aconcernthat15trustseithertoldustheywere

notassessing any patientsor were unable to

providetheinformation.Also,mosttrustsneed

toincreasetheirassessmentratessignicantly

inordertoprotectpatientsfromrisk.Seeour

websiteforfulllistings.

Variation in the rates of pulmonary embolismSource:SUSdata2009/10,99.8%controllimits.

ofall147trusts

22exceedexpectation 98meetexpectation 27arebelowexpectation



29/38



Why we cannot tell you which trusts

are best at preventing blood clots

Fromthehospitaldatarecords,weidentiedallpatientswhowererecordedashavingsuffered

fromaPE.Wethentookthosepatientsforwhom

itwasrecordedasasecondarydiagnosisafter

admissionforadifferentconditionorprocedure.

Wealsotookthosepatientswhowereadmitted

tohospitalwithaprimarydiagnosisofPEwho

had been treated in hospital for a different

conditionwithinthepreviousthreemonths.This

isbecausetheriskofdevelopinganembolism

following hospital treatment continues for up

to90days.5

Our analysis revealed approximately 30,500

PEsduring2009/10.Weknowthatthisisan

undercount because many patients with PEs

arenotcodedassuch,andinsteadarerecorded

ashavinghadunspeciedcomplicationscaused

bytheirtreatment.

Asthediagramonpage29shows,thereiswide

variation in the number of PEs recorded at

eachtrust.Thisrangesfrom47percentbelow

averageto174percentaboveaverage.However,wedonotknowthetruerateofPEsforeach

trust. We are also uncertain about the exact

numberofPEscausedbyinappropriatecare

or inadequatepre-treatment riskassessment.

Nevertheless,allhospitaltrustsmustchange

their coding systems where necessary and

ensurethattheycomplywiththemandateto

systematicallyinvestigateallunexpectedPEs.

We are approaching The NHS Information

Centreforhealthand social care,askingit toissueexplicitguidancearounduniformcoding

practices.DrFosterhopestorevisitthistopic

earlynextyearandbeabletoidentifytrustsand

theirrates.

Formorethanadecade,successivereportshaveattemptedtoquantifythenumberofmedical

mistakes(oradverseevents)thattakeplacein

ourhospitals.In2000theDepartmentofHealth

estimated that harm is caused to patients in

around10percentofadmissions,orataratein

excessof850,000ayear.6

Tenyearslaterwearestillquotingguresbased

onresearchestimates.TheNHScannotstate

categorically how many medical errors take

place in its hospitals.Not all hospital chief

executivesknowexactlyhowmanypatientsare

harmedintheirunitseachyear,thereforethey

cannotknowexactlyhowtheirorganisationwill

preventharmtoallfuturepatients.

DrFosterhasexaminedroutinedatatotryto

gain a picture of the medical mistakes being

recorded.IntheUS,theAgencyforHealthcare

ResearchQuality(AHRQ)hasbeendeveloping

waysofmeasuringtheseforseveralyears,and

inparalleltheDrFosterUnitatImperialCollege

Londonhasbeentranslatingthemethods.Thesehave been featured inpastHospital Guides.

The AHRQ has also introduced a composite

indicator,aggregatingthiscollectionofmeasures

intoan overall hospital score.7 TheUnit has

reproducedthiscompositeindex,usingsixofthe

20indicators:

Pressuresores(decubitusulcer).

Deathsaftersurgery(seepages12-13for

adenition).

Bleedsorbruisesaftersurgery(post-operative

haemorrhageorhaematoma).

Post-operativerespiratoryfailure.

Post-operativesepsis.

Accidentalpunctureorlaceration.

OtherindicatorsrecommendedbytheAHRQ

wereexcludedduringtheresearch,eitherasthe

reportednumbersweretoosmallortherewas

notenoughcondenceinthecoding(iehowwelltheinformationwasrecorded).

In2009/10,acrossthesesixindicators,more

than27,000 potentialadverse events were

reported.Again,thisdatadoesnotgiveusa

completepicturebecausesometrustsarebetter

atrecordingtheinformationthanothers.Infact

we cansee that, in general,trustswith high

ratesofincidentsarethosethattendtohave

more complete records about their patients.

Itisnotthattheyhavehigherratesofmedical

errors,theyaresimplybetteratrecordingwhat

happens.Whatismore,truststhatarebetterat

recordinginformationarelikelytobebetterat

managingtheproblems.

On page 31 we list the trusts that are

good at recording data, as well as those

that are relatively poor at it.

4 Preventing adverseevents in hospitals

DID OU KNOW? Trusts reported 56 incidents of wrong site

surgery, as well as 150 foreign objects that were left inside patients

after an operation.

Its clear that all trust

boards should have thesafety of their patients as

the number one priority.

No matter how dedicated

and professional the

nursing staff are, things

do go wrong and we need

to work even harder at

tackling avoidable mortality

and adverse events.

DrPeterCarter,ChiefExecutiveandGeneralSecretary,RoyalCollegeofNursing


30/38



Good data-recording and high adverse events

What this may mean:Thecodingismoreaccuratethanmany

othertrusts.Thoselistedbelowhaveahighrateofadverseevents

whencomparedwiththerestoftheNHSandthis,coupledwith

theaccuratecoding,meansthattheremaybepotentialproblems

here.Thedatashouldbeinvestigatedtorulethisout.

CentralManchesterUniversityHospitalsNHSFoundationTrust

DoncasterandBassetlawHospitalsNHSFoundationTrust

LancashireTeachingHospitalsNHSFoundationTrust

LutonandDunstableHospitalNHSFoundationTrust

NorthBristolNHSTrust


PlymouthHospitalsNHSTrust

RoyalDevonandExeterNHSFoundationTrust

SalfordRoyalNHSFoundationTrust

SherwoodForestHospitalsNHSFoundationTrust

SouthendUniversityHospitalNHSFoundationTrust

StGeorgesHealthcareNHSTrust

TheNewcastleuponTyneHospitalsNHSFoundationTrust

UniversityHospitalsofLeicesterNHSTrust

WarringtonandHaltonHospitalsNHSFoundationTrust

WestHertfordshireHospitalsNHSTrust

WesternSussexHospitalsNHSTrust

Good data-recording and low adverse events

What this may mean: Thecodingismoreaccuratethanmany

othertrusts.The low rates are promising because theysuggest

thatfewermedicalerrorsareoccurringinthesetrusts.However,

ofcourse,allerrorsshouldbeinvestigated.

BedfordHospitalNHSTrust

RoyalCornwallHospitalsNHSTrust

RoyalLiverpoolandBroadgreenUniversityHospitalsNHSTrust

SandwellandWestBirminghamHospitalsNHSTrust

SouthDevonHealthcareNHSFoundationTrust

UniversityHospitalofSouthManchester

NHSFoundationTrust

Wrightington,WiganandLeighNHSFoundationTrust

Poorer data-recording and high adverse events

What this may mean:Codingratesarelowcomparedwithother

trusts,yetincidentsarehigh.Thissuggeststhatthetruerateof

incidentsmaybeevenhigher,asnotallarebeingrecorded.The

recordedincidentsshouldbeinvestigated,andthereshouldalso

beanassessmenttoseeifmoreshouldhavebeenreported.

CambridgeUniversityHospitalsNHSFoundationTrust

LeedsTeachingHospitalsNHSTrust

MidEssexHospitalServicesNHSTrust

NorthCumbriaUniversityHospitalsNHSTrust

OxfordRadcliffeHospitalsNHSTrust

Poorer data-recording and low adverse events

What this may mean:Codingratesarelowcomparedwithother

trusts. This maybe thereasonfor the lowratesof incidents.

Areviewmayneedtotakeplacetoensurethatadverseeventsare

beingrecorded.

AiredaleNHSTrust

Ba

Documents

Hospital Guide 2010