Mortality Strategy 2018-19 - Wye Valley NHS Trust · The rest of the plan has been largely superseded by this document and the 2018/19 mortality improvement plan but the outline is

Mortality Strategy 2018-19

This strategy is designed to ensure that the organisation is learning from mortality though the

development of a strong mortality governance framework with a clear focus on improving the

quality of clinical care and preventing avoidable patient death

Mortality Strategy version 9.

Table of Contents 1. Executive Summary ......................................................................................................................... 3

2. Links to Trusts strategic objectives 18/19 ....................................................................................... 3

3. Introduction .................................................................................................................................... 3

4. Developments 2017/18 .................................................................................................................. 5

5. Review of patient outcomes ........................................................................................................... 8

6. Diagnosis Groups under Review. .................................................................................................. 12

7. Clinical Coding ............................................................................................................................... 16

8. Clinical Quality Monitoring ........................................................................................................... 17

9. Staffing Review ............................................................................................................................. 19

10. Strategy Objectives 2018/19 ..................................................................................................... 20

11. Coding ....................................................................................................................................... 24

12. Speciality Specific Plans ............................................................................................................ 24

13. Communication plan ................................................................................................................. 26

14. Evaluation, learning and review ................................................................................................ 26

15. References ................................................................................................................................ 27

16. Wye Valley NHS Trust associated documents .......................................................................... 27


1. Executive Summary 1.1 This strategy is designed to ensure that the organisation is learning from mortality though

the development of a strong mortality governance framework with a clear focus on improving the quality of clinical care and preventing avoidable patient death.

2. Links to Trusts strategic objectives 18/19 2.1 This strategy supports the delivery of the following Trust Strategic Objectives

3. Introduction 3.1 Over the last few years there has been increased scrutiny on mortality rates within

healthcare organisations with high profile investigations identifying failings in the governance of mortality review meetings (Francis report1). Around 50% of all deaths occur in hospital and most of these are inevitable, but around 3–5% of acute hospital deaths are thought to be potentially preventable2.

3.2. The launch of the Royal College of Physicians structured judgment review (SJR) into mortality cases commissioned by the National Mortality Case Record Review Programme3 (NMCRR), recognises these concerns and the importance of learning from mortality. The SJR approach to mortality reviews allows for both quantitative and qualitative information on care to be reviewed and uses a standardised way of reviewing the case records of adults who have died by improving understanding and learning about problems and processes in healthcare associated with mortality, and to share best practice. The Trust has actively adopted this system and adapted the previous mortality review form to incorporate this more structured review.

Reduce the variation in the quality of care we provide and avoidable death rates by delivering on our quality priorities

Reduce the financial deficit by delivering our financial plan

Improve urgent care by delivering the A & E standard and providing more services across seven days

Improve the quality and sustainability of our services by implementing our clinical strategy

Increase our productivity and deliver our elective activity plans to reduce patient waiting times and meet cancer standards

Care for people nearer to home by transforming our community services with our One Herefordshire partners

Ensure that we are equipped to deliver our plan by increasing staff recruitment and improving staff retention

Improve our effectiveness through the delivery of our Digital Strategy

Empower staff to deliver by improving staff engagement, increasing our leadership, capability and succession planning.


3.3 There is an associated increased drive for Trust Boards to be assured that deaths are reviewed and opportunities to improve care for future patients are not missed. The Care Quality Commission’s publication in December 2016 of a review into the way NHS Trusts review and investigate the deaths of patients, ‘Learning, candour and accountability’ builds on the need to maximise learning from deaths4.

3.4 The subsequent publication of the National Quality Board National Guidance on Learning from Deaths5 has further extended the recommendations made to Trusts on how undertaking clinical reviews and Learning from Deaths should happen to enable maximum learning takes place.

3.5 Concentrating attention on the factors that cause deaths through learning from mortality will impact positively on all patients, reducing complications, length of stay and readmission rates through improving pathways of care, reducing variability of care delivery, and early recognition and escalation of the deteriorating patient. There will also be an associated positive impact on the experience of patients’ families and carers through better support and opportunities for involvement in investigations and reviews.

3.6 This strategy will provide a framework for aligning systems, processes and quality improvement initiatives for the purpose of ensuring that the organisation is learning from mortality and engendering a culture of clinical excellence. It is a dynamic document which will be reviewed and developed over time.

3.7 This strategy outlines the Trusts commitment to improving the outcomes for its patients and details the initiatives already undertaken by the Trust in 2017/18 and is to be used as a framework for identifying systems, processes and quality improvement initiatives for the purpose of learning form mortality for 2018/19.

For several years the Trust has had high mortality indicators, both the Hospital Standardised Mortality Ratio (HMSR) and the Summary Hospital-level Mortality Indicator (SHMI) compared to its peers. Figure 1 and 2 Illustrate the variance of SHMI and HMSR among WVT peer group at the end of each fiscal year, other than 2017/18 when the financial year end position is not yet known.


Figure 1.

Figure 2.

4. Developments 2017/18 4.1 A significant amount of work has been undertaken in the year 17/18 to improve patient

outcomes and this section summarises the most important projects.

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Rolling HSMR, (basket of 56) by Peer : Fiscal Years (17/18 only until January 2018)Data Source: HED

RLQ - WYE VALLEY NHS TRUST RA3 - WESTON AREA HEALTH NHS TRUST

RA4 - YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST RBA - TAUNTON AND SOMERSET NHS FOUNDATION TRUST

RCF - AIREDALE NHS FOUNDATION TRUST RCX - THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST

RJC - SOUTH WARWICKSHIRE NHS FOUNDATION TRUST RJN - EAST CHESHIRE NHS TRUST

RKB - UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST RLT - GEORGE ELIOT HOSPITAL NHS TRUST

RWP - WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST

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RA3 - WESTON AREA HEALTH NHS TRUST RA4 - YEOVIL DISTRICT HOSPITAL NHS FOUNDATION TRUST

RBA - TAUNTON AND SOMERSET NHS FOUNDATION TRUST RCF - AIREDALE NHS FOUNDATION TRUST

RCX - THE QUEEN ELIZABETH HOSPITAL, KING'S LYNN, NHS FOUNDATION TRUST RJC - SOUTH WARWICKSHIRE NHS FOUNDATION TRUST

RJN - EAST CHESHIRE NHS TRUST RKB - UNIVERSITY HOSPITALS COVENTRY AND WARWICKSHIRE NHS TRUST

RLQ - WYE VALLEY NHS TRUST RLT - GEORGE ELIOT HOSPITAL NHS TRUST

RWP - WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST


4.1.1 Increased consultant staffing at weekends

Over the last decade, an increasing number of research studies have examined the association between weekend hospital admissions and poorer patient outcomes including higher rates of mortality. There is significant evidence demonstrating this ‘weekend effect’.

A range of potential causal links for the weekend effect have been identified; one of these is the availability of staff and services at weekends. It remains unclear how many deaths are avoidable and the Department of health identify that further work is required to understand the causal relationships6.

During the winter 2017/18 the Department of Health made available significant funds to help hospitals deal with the increase in acutely ill patients expected over this period. The Trust invested some of this money into providing speciality ward rounds at the weekend. The specialities included were Respiratory Medicine, Cardiology, Gastroenterology, Acute Medicine and Geriatrics. This increased cover meant that patients had access to speciality consultant opinion at times previously unavailable in the Trust.

The Trusts national audit result on 7 days services saw a significant rise in the number of patients that were reviewed within 14 hours of admission by a consultant at a weekend; from 56% in March 2017 to 88% in September 2017. The Trust anticipates that this value will increase further when re-audited as a direct result of increased Consultant leadership during weekends. Other than access to echocardiography at weekends the Trust offers access to diagnostic services 7 days a week. A business case to extend the provision of consultants available at weekends has been submitted to the Trust Management Board and agreed in April 2018. The business case identified that an additional 11 medical consultants were required to deliver 7 day urgent care. Further detail is included within section 10 of the ongoing actions required to implement the medical model.

4.1.2 Six point plan

The Associate Medical Director (AMD) for Governance, together with the Trust’s Deputy Medical Director implemented a mortality reduction six point plan. This plan was instrumental in delivering the increased frequency of consultant led weekend ward rounds and an improved “Learning from Deaths” process. The rest of the plan has been largely superseded by this document and the 2018/19 mortality improvement plan but the outline is included for completeness. The Trusts anticipates that the outcome of the next 7 day service audit will show an improvement as a result of point three of this six point plan.

1) Monitor use of COPD and Pneumonia bundles in all adult acute admission (medical and surgical).

2) Monitor the use of the sepsis bundle in all adult acute admissions (medical and surgical). 3) Additional weekend consultant ward rounds on Arrow/Lugg/GI medicine/Geriatric wards. 4) Attendance to the Mortality Review meetings in both Medicine and Surgery should be

regularly reviewed. 5) The Divisional minutes of meetings from defined Clinical Service Groups alongside the

minutes of any operational meetings are collocated on a WVT server with attendance of management teams being noted.

6) Deteriorating Patient Group attendance should be regularly reviewed.


4.1.3 Improved sepsis performance

Significant work has been undertaken within the Trust, led by the sepsis lead to improve our performance in caring for patients with sepsis. These include:

Sepsis screening and care bundle incorporated into emergency department (ED) electronic patient record (EPR) Symphony.

Detailed audit of sepsis bundle care in the ED with feedback to the ED “feedback Friday” forum.

Planned implementation of a Patient Group Directive (PGD) allowing nurse administration of first dose of antibiotic for red flag sepsis agreed and training being undertaken currently.

Raising the profile of sepsis through outreach education into the ED and by presentations to the medical grand round and medical audit meetings.

Trials of new ways of working including the “Perfect Week”, nurse led referral, single clerking, and introduction of ED board rounds to pull patients to medicine and facilitate early review of sick patients in ED by acute physicians.

Trial of ANP support of the ED sepsis process including practical support, education of nursing and medical staff of core sepsis care.

As a result of the increased awareness on sepsis the results of quarter 3’s (17/18) CQUIN has identified that of the percentage of patients who met the criteria of the local protocol for sepsis screening, 100% of its emergency department patients and 99% of all acute inpatients who were appropriate for screening were screened for sepsis; the target percentage was 90%.

The percentage of patients who were found to have sepsis and who received IV antibiotics within 1 hour has improved from 58% in quarter 1 (17/18) to 65% in quarter 3 (17/18); the target is 90%. Further work continues to analyse any themes for delays in patients not treated within an hour in order to further focus improvement efforts. Rolling 12 month sepsis SHMI with control lines to be added.

4.1.4 Improved “learning from deaths” process

WVT has invested in 5 Medical Examiners. These are consultant doctors from various specialities who have been funded to provide 1.25PA’s per week each to improve both the experience of bereaved relatives and to derive any learning from individual patient deaths.

These examiners will provide timely completion of Cremation Form 5 reducing delay for the family, and being a point of contact with the family allowing them to voice any concerns about the care provided to their relative in the final days before death. As part of their role the medical examiners will screen deaths to establish if more in-depth investigation may be required.

4.1.5 Improved “prior comorbidity” coding

The Trust has invested in an additional module of Medicode to improve our coding of patient co-morbidities which was implemented in April 2018. An additional algorithm has also been developed which allows the inclusion of irreversible co-morbidities, previously recorded in a patient’s clinical record, to be included in the coding for the index episode.


This will allow our coding to better reflect the true degree of illness suffered by patients admitted to the Trust.

4.1.6 Blended approach to managing patients in the emergency department.

The Trust has suffered from significant recruitment and retention problems in its emergency department (ED). Currently it has only 2 substantive consultants out of an establishment of 5 and 4.5 middle grade posts filled out of an establishment of 8. With the development of acute medicine in the Trust suitable patients can be offered the option at the point of triage of assessment by a member of the acute medicine team. This provides patient’s access to rapid, senior decision makers, a service which is proven to improve patient outcome.

5. Review of patient outcomes 5.1 Crude mortality

Overall crude mortality appears to be reducing at WVT. An unchanging or increasing trend in the standardised mortality statistics must stem from either:

1. An increase in the health of patients admitted to WVT- and therefore lower co-morbidity scores

2. A reduction in the quality of the coding of admitted patients – and therefore lower co-morbidity scores

3. A greater rate of improvement in our peer hospitals compared to WVT leading to a re-basing disadvantage at WVT.

Figure 3.

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Crude mortality Rate by Financial Year, all Diagnosis groupsData Source: HED

Crude rate (%) Average


5.2 Crude mortality by division

Figure 4 shows the trend in annual crude mortality rate from 2011/12 to 2017/18 for Medical Division. This also demonstrates a decreasing trend, disregarding a “spike”, in 2016/17.

Figure 4.

Figure 5 shows the trend in annual crude mortality rate from 2011/12 to 2017/18 for Surgical Division, overall this demonstrates a decreasing trend.

Figure 5.

8.20% 8.35% 8.15%7.63%

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Medical Division - Crude mortality Rate by Financial Year (from HSMR data, basket of 56) Data Source: HED

Crude rate (%) Average Linear (Crude rate (%))

1.97% 1.99%

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Surgical Division - Crude mortality Rate by Financial Year (from HSMR data, basket of 56) Data Source: HED

Crude rate (%) Average Linear (Crude rate (%))


5.3 Hospital Standardised Mortality Ratio (HMSR)

The HSMR is an indicator of healthcare quality that measures mortality rates for patients admitted to hospital and assesses the risk of death within a group of 56 diagnosis groups. The ratio compares the actual number of deaths with the expected number of deaths, and takes account a number of factors including age, sex, diagnosis, whether the admission was planned or emergency, and the length of stay. An HSMR of 100 means that the number of patients who died is exactly as it would be expected taking into account the standardisation factors. An HSMR above 100 means more patients died than would be expected, one below 100 means that fewer than expected died.

Periodically overall improvements in patient care nationally lead to a “rebasing process”. This leads to a change in the algorithm used to calculate the expected number of deaths for a condition, reducing the number. This has the effect of increasing the HMSR rate for an individual Trust.

The top 5 diagnosis codes which are triggering a high HMSR are; Septicaemia, Pneumonia, COPD, Acute Bronchitis and Congestive Heart Failure, further detail on each diagnosis is included in section 6. These groups remain the highest HMSR diagnosis codes for both weekday and weekend.

Data to be added showing weekend effect for top 5 diagnosis codes for SHMI/HMSR.

Figure 6 shows the total number of deaths against expected number of deaths and the rolling HMSR from 2012 until 2017 for WVT.

Figure 6.

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The rolling HMSR rate, taken each November from 2013 reveals essentially a static picture (table 2).

Table 2.

12 months rolling to: HMSR rate

11/2017 119.71

11/2016 118.9

11/2015 116.53

11/2014 110.69

11/2013 120.83

5.4 Summary Hospital-level Mortality Indicator

The SHMI is the ratio between the actual number of patients who die following hospitalisation at the Trust and the number that would be expected to die on the basis of average England figures, given the characteristics of the patients treated there. It covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge.

Additional data to be added to show the SHMI data for in-hospital deaths and deaths within 30 days of discharge with confidence intervals.

5.5 Cumulative summary (CuSum) control chart breeches

A cumulative sum control chart is a statistical process control (SPC) technique which provides focus on the outcome trend of a series of consecutive procedures. It is designed to allow prompt detection of changes in performance reflected by persistent deviation to an acceptable and expected rate of adverse outcomes. Table 3 identifies the diagnostic groups alerted in the last 12 months.

On a monthly basis the information department at WVT use the CuSum report to Identify if the Trust or diagnostic groups are likely to trigger CQC alerts. This information is then shared with the Trusts Mortality Committee and a proactive review of the diagnostic group triggered is commenced. The findings and ongoing actions from the review are monitored through the Mortality Committee.

Table 3. Identifies 5 of the recent diagnostic groups with a CuSum alert. Acute Bronchitis, Chronic Obstructive Pulmonary Disease and bronchiectasis, Pneumonia and Septicaemia are included in the Trusts ongoing quality improvement work identified in Section 12.


Table 3 Diagnostic Group Discharges Observed Expected HSMR CuSum

alerts Last Alert

Month

CuSum Value

Obs.-Exp.

Banding (PD2)

Skin and subcutaneous

tissue infections

593 17 8.93 190.44 1 Oct-17 3.12 8.07 As expected

Acute bronchitis 633 24 14.49 165.6 1 Jul-17 1.64 9.51 As expected

Chronic obstructive pulmonary disease and

bronchiectasis

582 36 22.89 157.27 2 Apr-17 0.48 13.11 Higher than

expected

Septicaemia (except in labour)

417 98 67.99 144.15 3 Jul-17 3.34 30.01 Higher than

expected

Acute myocardial infarction

220 27 19.8 136.36 1 Dec-16 1.42 7.2 As expected

Pneumonia (except that caused by

tuberculosis or sexually

transmitted disease)

982 155 133.2 116.37 2 Feb-17 0.19 21.8 As expected

6. Diagnosis Groups under Review. 6.1 Pneumonia

The overall rolling HMSR rate for November 2017 has reduced to 118 from 120 in November 2016. The actual ratio of observed over expected deaths improves from a mean of 1.3 for the months December to February 16/17 to 0.8 for May to July 17. Hypotheses to account for this include deteriorating system performance due to the increased numbers of patients admitted over the winter period or a more virulent form of pneumonia presenting in the winter months. These hypotheses will be tested in the coming year.


Figure 7.

6.2 Acute bronchitis

Figure 8.

Acute bronchitis and COPD show similar seasonal variation and will be investigated using the

same methodology as pneumonia.

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6.3 COPD

Figure 9.

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COPD, Expected and Actual deaths with HSMRData Source: HED

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6.4 Septicaemia

Septicaemia has been subject to a significant amount of quality improvement work over the last year as described in section 4.1.3. In April 2017 the National Clinical Coding Standards were updated and as a result this has altered the HMSR performance from a rolling HMSR for November 2016 of 118 compared to a HMSR of 145 for November 2017. However the Trust anticipates/expects a variation from April 2018 in that the HMSR rate could decrease as National Clinical Coding Standards change again and the recording of identified organs and their infections increases.

Figure 10.

6.5 Congestive heart failure

The HMSR rate has deteriorated from 112 for the 12 months to November 2016 to 130 for November 2017. Congestive heart failure will be subject to a separate mortality improvement action plan during 2018/19.

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Data Source: HED

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7. Clinical Coding The depth of coding at the Trust, as illustrated in table 4, is below the Trusts peer group and national figures, this is across all patient groups. The Trust recognises that the depth of coding of live patients is not optimal and therefore we are coding patients healthier than they may actually be which would affect the Trust SHMI rate. This is to be addressed in 2018/19 improvement plan as detailed in Section 11.

Table 4.

Coding Benchmarking all patients December 2016 -November 2017

WVT Peer National

Acute

Diagnosis Coding Depth 4.89 5.11 5.2

Procedure Coding Depth 2.56 2.66 2.72

Average Spell having different diag in 1st episode to last 2.8% 2.4% 2.2%

Comorbidity Score 2-20 4.25 4.68 4.31

Comorbidity Score 2-20 (deceased) 14.66 14.59 15.05

Palliative Care coding 1.1% 0.9% 1.1%

Palliative Care coding (deceased) 21% 23% 29%

Average Depth of Coding Elective/Non-Elective

All patients Deceased All Live

English Acute - Emergency 6.41 12.05 6.3

WVT -Emergency 6.02 12.64 5.85

English Acute-Elective 3.8 12.59 3.82

WVT -Elective 3.24 11.8 3.24

As part of the structured judgement review process the Trust included reviewing the clinical coding for the deceased patients and updated diagnosis codes where necessary. This meant that for a small cohort, ie deceased patients, the coding was being maximised but this was not the case for live patients. The Trust has therefore been in a position when comparing all our data that the depth of coding for deceased patients was greater. The reality is that this therefore had no impact on our mortality because we weren’t improving the denominator (ie expected number of deaths).

The Trust has identified two actions to be addressed to improve the depth of coding for live patients, the first being that more education is required for clinicians to document and record all relevant conditions in the notes and the second action was to implement the additional module for Medicode which would highlight previous comorbidities from previous spells. The Medicode module went live April 2018 and will improve the coding for all patients not just the deceased.


8. Clinical Quality Monitoring The systems for monitoring quality have developed during 2017/18. The information team collate key performance indicators for quality and performance at divisional level each month for review by the Clinical Quality Committee and Trust Board. On a quarterly basis divisions are requested to report on their data and give assurance to the Clinical Quality Committee on actions being undertaken on areas outside of normal reporting thresholds. Along with the KPI data the Clinical Quality Committee receive on a monthly basis updates on the Trusts quality priorities.

The Trust’s Quality & Safety team generates a governance information pack for divisions which includes data at directorate level on a monthly basis. The directorate teams are required to use this information to report and provide assurance to their divisions Quality & Safety Board meeting monthly. A quarterly inpatient ward dashboard has been introduced based primarily on the Trusts Nurse Sensitive Indicators, with the addition of appraisal and mandatory training. The intention is to bring together a picture of the indicators in the CQC domains, Safe, Effective, Caring, Well Led in an attempt to give, a holistic picture, across the indicators and over time.

The process of sharing and learning from outcomes following all external reviews and national survey’s, which includes quality assurance visits, patient and staff survey’s and ‘Getting It Right First Time’(GIRFT) reports has been adapted in 2017/18. This information is cascaded across all levels of the organisation highlighting areas of good practice and where there is a need for improvement. The Trusts Clinical Quality Committee seeks assurance from the divisions on improvement actions identified.

The use of expert panels to review all pressure ulcer incidents reported within the organisation has been embedded over the last twelve months. The purpose of the panel is to scrutinise incidents and determine the level of harm to the patient and whether more detailed investigations are required into the incident, in line with the Trusts serious incident pathway. Through the implementation of this panel approach to reviewing incidents, the Trust has seen a decrease in the number of serious incidents reports and that there is an improvement in the quality of incidents reported. A Falls expert panel has been introduced and is currently in its embryonic stage but the intention is that it follows a similar structure to that of the pressure ulcer panel, with representation from Herefordshire Clinical Commissioning Group.

8.1 VTE prophylaxis (VTE)

The monthly VTE assessment performance has reduced from 96% in April 2017 to 74% in February 2018 (Figure 12). On 31st July 2017 the Trust altered its risk assessment process from paper to electronic returns within the electronic patient record (EPR). Deterioration in assessment compliance can be seen around this time. It is recognised that there are a number of factors which have been identified where a focus for improvement is required, including variation in accessibility to complete the VTE assessment among a number of inpatient pathways which was not the case with the previous paper based system and challenges with getting junior medical staff to complete the assessment on the EPR system. Commitment has been made by the Trust to move to the electronic system, therefore VTE assessment continues to be an area of focus.


Figure 12.

Figure 13, illustrates the number of patients who developed a hospital associated VTE within 90 days of admission to hospital. The drop in assessment compliance is noted on the graph, notably this has not correlated with an increase in incidence of hospital acquired VTE. Periodic compliance checks are demonstrating that prophylaxis is being given to patients and that the issue is with completing the assessment. All junior doctors will be surveyed in May 2018 to determine the barriers to completion. The VTE Quality Improvement project will report into the Mortality Committee.

The overall trend for both VTE assessment and hospital associated VTE is shown as a dotted line on figure 13.

Figure 13.

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Number of Hospital Associated VTE v VTE Assessment

Hospital Associated VTE VTE assesment Linear (Hospital Associated VTE) Linear (VTE assesment)


8.2 Palliative Care

The Trust identifies that there is a gap in the coding of palliative care patients. An action to improve this has been included in the 2018/19 improvement plan.

Figure 14.

9. Staffing Review There is evidence reported that there is a relationship between low nurse and medical staffing levels and adverse patient outcomes, including higher mortality rates. The information in table 5 from the Model Hospital identifies the Trusts workforce numbers against peers. The Trust has a number of initiatives ongoing to increase workforce numbers, including nursing recruitment open days. The Trust has in April 2018 agreed to increase Consultant numbers by 11 to improve 7 day working.

Table 5 - All substantive staff - FTE and WAU per FTE

All substantive staff - FTE and WAU per FTE

Period FTE WAU per FTE

Total Actual

Peer Median

Trust Actual

Peer Median

All Substantive Staff 2016/17 2811.6 2991.78 16 18

Medical Staff 2016/17 307.57 325.96 148 157

Nursing and Midwifery 2016/17 1351.76 1370.8 34 41

Allied Health professional 2016/17 278.08 217.42 164 252

0

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Average Palliative Care Coding - Deceased patients onlyDate Source:HED

All Trusts Trust Comparators WVT


10. Strategy Objectives 2018/19 10.1 The key objective of this strategy is to ensure that the organisation is learning from mortality

which will impact positively on the quality of care and treatment delivered to patients. The Trust has identified 4 four areas where improvement focus will be delivered;

1. Improving the timeliness of care 2. Reducing the variation in care 3. Improving care through improved communication 4. Improving and co-ordinating a mortality improvement plan through the formation of

a Mortality Committee

10.2 Priorities for strategic change

The main areas where change is needed to enable us to achieve our key objectives is outlined below;

10.3 Improving the timeliness of care:

10.3.1 Develop an innovative Emergency Department recruitment strategy

WVT has had difficulty in recruiting to both consultant and middle grade posts in the ED. This has at times reduced access for patients to substantive, experienced ED practitioners as rota gaps are inevitably filled with locum staff. Networking with a national expert in ED recruitment has led to the proposal and initial development of an ED recruitment programme. The Trust will be working with NHSI in 2018/19 to explore the challenges the Trust encounters when recruiting and retaining consultants and establishing how NHSI and other national bodies can support the organisation.

Implementation in 2018/19

Lead – Clinical Lead and General Manager for A&E

Implementation objectives: To improve consultant recruitment WVT needs to develop the so-called 80/20 type

job plan where consultants work eighty percent of the time in the ED and twenty percent of the time in areas they find add richness to their career in emergency medicine such as teaching, pre-hospital care and providing medical support to mountain rescue teams.

To improve middle grade recruitment a similar job split is needed. However in this situation the twenty percent of non ED time is spent in other specialities to gain sufficient experience in pre-hospital care, intensive care, anaesthetics and paediatrics to allow application for the Certificate of Eligibility for Specialist Registration (CESR) and entry onto the specialist register.

Impact on key performance outcomes: Refer to Mortality Strategy improvement plan

10.3.2 Development of surgical and medical assessment unit assessment unit.

Surgical (SAU) and medical assessment units (CAU) have the benefit of reducing the time a patient waits for investigations and senior review by streamlining the assessment process and also reduce the numbers of patients admitted. Currently WVT does not have a dedicated SAU (a “virtual” SAU has been set up and demonstrated early benefit) and the CAU is often used as an escalation area in time of high numbers of admissions, negating its original purpose.



Lead – Associate Medical Director, Surgery and Clinical Lead Acute Medicine and Project Lead

Implementation objectives: A dedicated SAU/CAU complex.


10.3.3 Development of NEWS response team/whole patient pathway NEWS scoring

WVT already uses the National Early Warning Score in assessing patient’s clinical condition. However we have noted several areas in which we wish to improve.


Lead – Deputy Director of Clinical Governance and Clinical Lead for Deteriorating Patient Group

Implementation objectives: Implement NEWS 2 Improve responsiveness of nursing staff including escalation and the capacity to

respond to a high NEWS score. Introduce electronic recording and escalation software and a “NEWS” response

aspect to the proposed 24 hour critical care outreach team.


10.3.4 Strengthening the blended approach.

Bringing senior decision makers closer to the patient’s point of admission to acute secondary care is known to improve outcomes and improve the flow of patients through the hospital. This approach has been tested and proven in the “Perfect Week” trial of new working.


Lead – Associate Medical Director Medicine and Divisional Operational Director Medicine

Implementation objectives: WVT have already developed acute medical in-reach to ED and intend to increase

this blended approach to assessing patients by developing in-reach capability in the other medical specialities such as cardiology, respiratory medicine and gastroenterology. This development is supported by the “Acute Medical Model” business case presented at the Trust Management Board in April 2018 describing a significant increase in consultant numbers.



10.4 Reducing variation in care

10.4.1 Hospital at night

Medical cover out of hours at WVT currently follows a traditional model. All the acute specialties (medicine, general surgery, paediatrics, obstetrics and gynaecology) maintain separate out of hours rotas. In addition less acute specialities such as ophthalmology also maintain out of hours cover at the junior level. Particularly busy specialities, such as medicine, can find peaks in workload reduce their ability to respond to deteriorating patients in their areas when, potentially, there are other doctors on duty in the hospital who, given sufficient coordination, could support these specialities at such times. In addition, not all medical tasks need to be performed by a doctor. Nurses with extended training are able to provide reliable, high quality care within their sphere of competence.


Lead – To be confirmed

Implementation objectives: WVT has committed to establishing a “Hospital at Night” team in 2018/19. Initially

this will comprise a night-time co-ordinator supporting the current resident medical and surgical teams but will be extended to include critical care outreach as 24 hr capability is established.


10.4.2 Seven day consultant working

WVT, as other acute providers find an increase in mortality at the weekends. Whilst the cause of this increase is unknown and probably multifactorial there is an obvious reduction in the availability of specialist consultant input at this time. Individual speciality teams are small (commonly three) and to provide reliable input at the weekends as well as contributing to the general medical take, outpatient activity during the normal working week and consultant delivered, speciality specific, procedures (pacing, bronchoscopy, endoscopy etc) becomes impossible within an acceptable work pattern.


Lead – Associate Medical Director Medicine and Divisional Operational Director Medicine

Implementation objectives: Implement a staged approach to seven day working, dependent on recruitment,

such that, once fully established the “Acute Medical Model” will deliver speciality specific ward rounds both Saturday and Sunday as well as a separate acute medical and GI bleed rota.


10.4.3 24 hour critical care outreach

Currently WVT can only provide outreach by the critical care team from 8am -8pm, 7 days a week. The Trust feels this represents an unacceptable variation in the care certain particularly ill patients require.




Implementation objectives: Implement a 7 days a week 24 hours a day critical care outreach team.


10.4.4 Development of a High dependency unit (HDU)

WVT currently has no provision for patients requiring Level 2, high dependency, care. It has provision for six intensive care patients on the Intensive Care Unit (ITU) and an NIV bay on the respiratory ward. Patients who deteriorate on a general ward may not reach the threshold for care on ITU and therefore stretch medical and nursing resources on the general ward; this may lead to sub-optimal care. Equally patients no longer requiring care on the ITU may stay longer than necessary on ITU because of a lack of a stepdown bed provided by an HDU.



Implementation objectives: Provide provision for a flexible base of three HDU beds


10.5 Improving Care through Improved Communication

10.5.1 Development of a “whole patient pathway” NEWS communication protocol


Lead – Deputy Director of Clinical Governance and Herefordshire CCG Lead Nurse

Implementation objectives: WVT intends to work closely with its primary care and ambulance colleagues in

developing a “whole patient pathway” NEWS communication protocol so that unwell patients with high NEWS scores are recognised in primary care, communicated clearly to the ambulance teams who commence early supportive treatment and pre-alert the medical teams in ED and who then can respond in a timely fashion with definitive treatment.


10.6 Improving and co-ordinating a mortality improvement plan through the formation of a Mortality Committee


Lead – Operational Medical Director

Implementation objectives: Restructure the committee to provide more focus on mortality and to gain greater

clinical engagement. The “Reducing Harm Committee” will be replaced by the “Mortality Committee” chaired by the Operational Medical Director whose function, among others, will be to collate all CuSum alerts, pro-actively analyse crude mortality data on a monthly basis by diagnosis and develop and monitor all mortality specific improvement plans.


This activity will be summarised in a mortality report which will be provided to the Trusts Clinical Quality Committee, Trust Board and external bodies such as Herefordshire CCG and NHS Improvement.


11. Coding Co-morbidity coding at WVT currently scores the lowest amongst its peers. It also codes less than its peers for palliative care. This raises the possibility that patients cared for in the Trust have a higher number of co-morbidities and are more unwell which would therefore result in the patient having a higher mortality than our coding would suggest. It is important therefore in order to represent the Trusts mortality accurately that the coding depth is of high quality. Planned enhancements to improve clinical coding in 2018/19 include:

a. Development of a business case to provide dedicated, ward based coding support especially for our outlier groups. This would mean basing a coder on the coronary care unit and Arrow ward.

b. The production of regular “depth of coding” run charts to be produced as part of the monthly mortality report.

c. Enhanced education of clinicians through training on induction and education and audit days

d. The purchase of prior co-morbidity software which will automatically transfer previous, permanent, co-morbidities to the current hospital episode.

e. The development of a business case to purchase EMiS viewer. This will allow clinical teams to directly view the patient’s primary care record, accurately recording all co-morbidities.

12. Speciality Specific Plans In order to focus efforts in areas that will bring the greatest benefits the Trust will use the concept of “excess deaths”. Excess deaths are calculated by subtracting the observed number of deaths from the number expected when allowing for co-morbidities. It is important to emphasise that “excess” does not necessarily equate to preventable, it merely provides an indicator to areas where improvements in the patient pathway may see the greatest benefit. When looking at the list of diagnosis codes where observed deaths exceed expected deaths, in rank order, the top five (outlier groups) account for the majority (93) compared to 23 for diagnoses 6 to 9. The Trust will therefore focus efforts on improving outcomes for patients with these five diagnoses.


Date period : Feb 2017-Jan 2018, (Source HED - HSMR report )

CCS Group (of diagnosis) Number of observed deaths

Expected number of deaths

Obs.- Exp

2 - Septicaemia (except in labour) 121 87.45 33.55

122 - Pneumonia (except that caused by tuberculosis or sexually transmitted disease)

121 109.94 11.06

108 - Congestive heart failure; non-hypertensive

47 31.39 15.61

127 - Chronic obstructive pulmonary disease and bronchiectasis

30 20.01 9.99

125 - Acute bronchitis 23 13.61 9.39

153 - Gastrointestinal haemorrhage 15 12.4 2.6

The Trust will use similar methodology to examine each of these outlier groups and propose action plans to reduce the number of observed deaths compared to expected.

Methodology for reducing number of observed deaths in the outlier groups

The following methodology will be used:

1. Appoint clinical lead 2. Form multidisciplinary working group 3. Use “pyramid of investigation for special cause variation”7 4. Examine coding and co-morbidity depth 5. Benchmark for structure and resource 6. Benchmark patient pathway against national guidance 7. All variances will be subject to an action plan for improvement 8. The action plan will be monitored through the monthly Mortality Committee 9. The Mortality meeting will provide monthly updates to the Clinical Quality

Committee, the Trust Board, and the Trusts commissioners using a standardised monthly report.


In addition WVT will commission, at a minimum, an external pathway review from NHSI for pneumonia.

13. Communication plan 13.1. Wye Valley Trust is concerned about its longstanding high mortality index. A significant

amount of work has already taken place to address this and several plans are in train to implement Trust wide objectives which we feel will make a significant improvement. To achieve this. The Trust recognises that this strategy is communicated to all stakeholders to ensure shared objectives and understanding, timely implementation and feedback on progress.

The content of the strategy and on-going progress will therefore be communicated to the stakeholder groups listed below on a regular basis: o Divisional management teams o Speciality improvement groups o Trust Mortality Committee o Trust Clinical Quality Committee o Trust Board o Herefordshire Clinical Commissioning Group(HCCG) o NHS Improvement (NHSI)

14. Evaluation, learning and review 14.1 Progress against the improvement plan to implement this strategy will be monitored and the

strategic objectives reviewed through regular updates to the Mortality Committee. This will include:

On-going evaluation and review of the strategy throughout its life

Performance monitoring over the lifetime of the strategy to ensure that the objectives are being met and actions completed in a timely fashion.

Where required, additional action plans will be developed to maintain progress against the key performance results and/or take corrective action where performance is below expected levels.

Learning and innovation identified as a result of implementation of the strategy will be recorded, acted upon and shared widely to promote improvement.


15. References 1. Professor Sir Bruce Keogh (July 2013), Review into the quality of care and treatment

provided by 14 hospital trusts in England

2. Hogan H, Zipfel R, Neuberger J, Hutchings A, Darzi A, Black N. Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis. BMJ 2015;351:h3239.

3. Royal College of Physicians (2016) National Mortality Case Review Programme https://www.rcplondon.ac.uk/projects/national-mortality-case-record-review-programme

4. Care Quality Commission (December 2016), Learning, candour and accountability: a review of the way NHS trusts review and investigate the deaths of patients in England

5. National Guidance on Learning from Deaths. National Quality Board.

6. Department of Health (2015) Research into ‘the weekend effect’ on patient outcomes and mortality https://www.gov.uk/government/publications/research-into-the-weekend-effect-on-hospital-mortality/research-into-the-weekend-effect-on-patient-outcomes-and-mortality

7. Lilford R., Mohammed M. A., Spiegelhalter D., Thomson R. Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma. Lancet 2004; 363: 1147-54)

16. Wye Valley NHS Trust associated documents Trust Quality Account 2017/18

Wye Valley NHS Trust Mortality Review Policy

https://www.rcplondon.ac.uk/projects/national-mortality-case-record-review-programme

https://www.gov.uk/government/publications/research-into-the-weekend-effect-on-hospital-mortality/research-into-the-weekend-effect-on-patient-outcomes-and-mortality

https://www.gov.uk/government/publications/research-into-the-weekend-effect-on-hospital-mortality/research-into-the-weekend-effect-on-patient-outcomes-and-mortality

Documents

Mortality Strategy 2018-19 - Wye Valley NHS Trust · The rest of the plan has been largely superseded by this document and the 2018/19 mortality improvement plan but the outline is