LOTHIAN NHS BOARD
24 March 2010
Medical / Nurse Director
QUALITY IMPROVEMENT REPORT
Purpose of the Report
The purpose of this report is to inform the Board of current work in quality
improvement including measuring patient experience and set out an approach to
establishing, developing and reporting system-wide quality of care indicators.
The Board is asked to:
2.1 Support the introduction of a system-wide quality of care indicators and
Note the update on patient experience actions.
Summary of the Issues
Measuring The Quality of Care Provided by NHS Lothian
NHS Lothian aspires to be at the level of Scotland’s best performing NHS Boards
and a world top 25 healthcare organisation in terms of outcomes and value. To
deliver this strategic intent, and to provide data to key stakeholders, a balanced
set of system measures are required to:
• show performance over time
• allow the organisation to see performance relative to strategic plans for
• allow comparisons to other similar organisations; and
• assist quality improvement planning.
3.1.1 In April 2010, the Quality Strategy for NHS Scotland will be launched. A central
tenet of this strategy is the need to have in place objective indicators and
measures of quality to inform decision making and support frontline
improvement. In the first instance, the national strategy is focussing on three of
the six dimensions of quality: safe, effective and person-centred care. These
dimensions are the focus of the indicators proposed here.
It is accepted that other dimensions of quality (timeliness, efficiency, equity) are
important and that the dimensions are inter-related; these are partly reported
through HEAT, however, further development work is required to robustly report
measures in these areas on a routine basis.
3.1.2 This approach also supports the delivery of NHS Scotland Efficiency &
Productivity Programme – Delivery Framework 2009.
3.1.3 There is increasing national and local focus on data and measurement, which is
reflected in the current number of improvement programmes which require timely
data for improvement and for performance. These include the Scottish Patient
Safety Programme, Leading Better Care, Lean in Lothian and the Healthcare
Associated Infection programme.
Approach to Measuring Quality of Care
The English Institute of Health Improvement and the King’s Fund both
recommend a ‘less is more’ approach with scrutiny of a small number of
indicators which are integrated into the organisation’s measures in a balanced
dashboard approach (Getting The Measure of Quality 2010
). The approach
described in this paper aims to achieve this by aligning currently used indicators
and recommending a reporting framework, to ensure a consistent robust
approach to the measurement and reporting of safe, effective, person-centred
3.2.1 In addition to the system-level measures, it is also necessary to establish
measures at a CHCP/CMT level, reported at the appropriate level. These
additional measures help to provide context for changes in the system measures.
3.2.2 A Worked example of System and Local Measures :-
NHS Lothian has received its first quarterly Hospital Standardised Mortality Ratio
(HSMR) for Hospital sites from Information Services Division (ISD). NHS
Lothian improvement goal aligned to the Patient Safety Programme is to reduce
HSMR by 15% by 2011. To achieve this goal, cross-department improvements
will be required. These include:
• The Surgical Directorate being tasked to eliminate surgical site infections;
• Critical Care reducing ventilator-associated pneumonias and central line
• Accident & Emergency reducing death in patients who arrive in the
emergency department with acute myocardial infarction;
• A whole system approach to rescuing deteriorating patients.
Clinical and Management Teams supported by the Quality Improvement Teams
and modernisation team will utilise data on local measures to inform
improvement activity and demonstrate improvement over time. These local
measures will then roll up to affect the system measures for HSMR.
Quality of Care Indicators
This report builds on system-wide measures which are currently in use in Lothian
but are reported to different committees at different levels across the
organisation (see Appendix 1). Through consultation with senior personnel with
responsibility for safe, effective, person-centred care and with the chair of the
Healthcare Governance & Risk Management Committee, a range of indicators
are proposed for routine reporting, along with an aligned reporting framework.
Appendix 2 sets out the proposed indicators and reporting mechanisms, and
illustrates how the data would be presented.
3.4.1 Hospital Standardised Mortality Ratio (HSMR)
ISD has published Hospital Standardised Mortality Ratios on a quarterly basis
beginning October to December 2006. The most recent data are for
January/March 2009. The next publication in April 2010 is expected to only be
one quarter behind.
The Scottish Patient Safety Programme aims to achieve a 15% reduction by
2011 against a baseline of October 2006 to September 2007.
For the latest quarter available (January to March 2009 the Standardised
Mortality Ratios were as follows:
St Johns Hospital
These figures represent the ratio of actual deaths to expected deaths within 30
days of admission to hospital. Therefore for each of the 3 sites, fewer deaths
than expected are occurring (if the HMSR for a hospital is less than 1 then fewer
hospital deaths within 30 days of admission are occurring than expected).
These figures suggest good performance by UHD, but the Board should be
aware that only the Royal Infirmary appears to be demonstrating any downward
trend in SMR. This is illustrated by the baseline figures and the 15% reduction,
calculated over a one year period, as shown below:
Baseline (Oct 06-
Jan 09-Mar 09
15% reduction from
It is suggested that when the figures are next published that the trajectory for
each hospital is assessed and this is used to help identify areas for improvement.
3.4.2 Adverse Event Rate
The second SPSP goal is to see by end of 2011 a 30% reduction in the Adverse
Event Rate. This is measured by an assessment Tool called the Global Trigger
Tool (GTT). Case notes are reviewed for these triggers and the adverse events
then recorded and categorised by harm i.e. minimum or no harm to death.
The Institute of Health Improvement, drawing on international evidence, would
expect an adverse event rate of between 80-90 per 1000 patient days. NHS
Lothian was one of 2 Boards where experts from IHI visited to shadow and test
how the assessment tool is used. Doctors, nurses, allied health professionals
and pharmacists all contribute to this work and it is important that the definitions
and baseline measures are used consistently.
The IHI were impressed with the quality of the process and the health records in
Lothian. Their review found an Adverse Event Rate of 64.3 events per 1000
patient days. This is consistent with the best hospitals in the USA and sits well
with our progress towards being one of the world’s top 25 healthcare systems.
Work continues across Scotland to get a reliable process in place to achieve a
baseline in each Board. The rates of individual hospitals or Boards are not
intended to be used for benchmarking but illustrate an organisation’s trends to
Chart 1 - Lothian Overall Rate/1000 pt days
Rate of Adverse Events per 1000 patient days
Healthcare Associated Infection (HAI)
This is currently robustly and routinely reported within and outwith NHS Lothian,
and remains a strategic priority, data will be captured in the matrix on HAI for
Assessment of incident reporting is internationally used as a proxy measure for
‘safety culture’. It is increasingly recognised that the higher the incident rate the
stronger the reporting and local learning culture (National Patient Safety Agency
2009). The aim therefore should be to see an increase in incidents reported and
a reduction in harm.
NHS Lothian has seen an increase in reporting during 2009, and a survey on
Patient Safety Culture is underway. During 2010 the focus will be on how to
reduce the harm caused by incidents as well as improving reporting.
3.6.1 Incident Trends:
6738 incidents were reported during the period of October to December 2009.
Falls continues to be the highest reported incident = 2168 (32%) of which 16 can
be attributed to major harm or death. Violence/abuse incidents account for 981
(15%) of which 2 can be attributed to major harm or death and medication 549
(8%) of which 2 can be attributed to major harm or death, of reported incidents
for this quarter. This is consistent with reporting throughout the year. For the
next report, we will provide benchmark data to provide context for these figures
based on preliminary work being undertaken by ISD based on incidents per
thousand patient contacts.
Charts 1 and 2 highlight general incident reporting trends, specifically for
incidents involving harm.
NHS Lothian Incident Reporting Trends Jan-Dec 09
Harm to Person
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec-
NHS Lothian Incidents with Harm to Persons - Jan-Dec 2009
Incident reported with harm
Severity of harm
Minor harm 78%
Moderate harm 17%
Major harm 3%
Jan- Feb- Mar- Apr- May- Jun-
Jul- Aug- Sep- Oct- Nov- Dec-
NHS Lothian currently monitors clinical effectiveness in a number of ways, from
compliance with NHS Quality Improvement Scotland standards to annual reports
on surgical and maternal deaths. There is however no agreed routine reporting
of effectiveness outcomes. This is an area for development, and will be informed
by the national Quality Strategy. It is proposed that during 2010 we develop
these indicators, by working with colleagues at CMT/CHCP level.
A central component of the Quality Strategy is to measure patient experience
and demonstrate continuous improvement. Current indicators such as
complaints will be added to with a systematic, fast frequent feedback process.
This was the recommendation of one of the 5x5x5 projects and implementation is
3.8.1 Quarterly Complaints Trends – NHS Lothian received a total of 283 formal
complaints during the period October to December 2009. This represents a small
increase on the previous quarter. The main reason for this increase is a large
number of complaints to facilities due to car parking and traffic management at St
John’s and Western General Hospital.
NHS Lothian Totals
CHP / REAS
Oct - Dec '09
July - Sept '09
April - June '09
There is a national target of acknowledging all formal complaints within 3 working
days. For this quarter, NHS Lothian has acknowledged 99% of formal complaints
within 3 working days. The breakdown is detailed in the bar chart 4 below.
3 day Acknowledgements
NHS Lothian Totals
CHP / REAS
Oct - Dec '09
July - Sept '09 April - June '09
3.8.2 Working towards the national target to respond to formal complaints within 20
working days has been a challenge for most NHS Boards across Scotland. The
current quantitative data on the ISD website (2007/8) demonstrates that NHS
Scotland is 67.1% compliant with this target. NHS Lothian’s performance for the
same period was above the Scottish average at 73.4%. Work continues to
improve performance of this target and the line chart 5 below demonstrates NHS
Lothian’s current performance.
20 Day Response Target
NHS Lothian Totals
CHP / REAS
Oct - Dec '09 July - Sept '09
April - June
3.8.3 In his recent commentaries, the Ombudsman has published 2 case reports which
relate directly to NHS Lothian. The issues that have arisen from these cases
include: consent process prior to surgery, lack of information, clinical treatment
and incorrect reporting of X-Rays. As a result of these cases a number of actions
have been put in place across the organisation to reduce the risk of recurrence.
An Infrastructure to collect quality measures
To deliver improvements and provide timely and efficient assurance reporting, a
mechanism for data capture from ward level through to the Board has been
identified. A business case for a generic solution to capturing quality indicators
has been approved by eHealth and will be progressed during the 2nd quarter of
2010. This would provide rapid feedback of data to ward level to support
continuous improvement and produce reports at all levels of management within
NHS Lothian for performance management and assurance reporting.
3.9.1 It is acknowledged that these indicators are only one tool for assessing quality of
care, and this needs to be recognised by those who are applying and interpreting
them. The ability to make informed inferences from these indicators requires an
understanding of their origins and limitations. It is recommended that key
stakeholders should be trained in the interpretation and application of quality
indicators to support a systematic approach to identifying areas of concern and
the intervention required.
3.10 Reporting Quality of Care Indicators
It is proposed, and has been supported by Healthcare Governance and Risk
Management Committee and the Executive Management Team, that this Quality
Indicators report brings together reporting on Safe Person Centred Effective
Care. This will replace the separate reports on complaints, SPSP and previous
quality papers. It would be submitted quarterly to the Board.
Future reporting will also be influenced by the National Quality Strategy for NHS
Scotland due to be launched later in April 2010. NHS Lothian is an active partner
in informing what the quality indicator matrix will look like nationally. That
however does not limit NHS Lothian in having more ambitious reporting and
3.11 Better Together Scotland’s Patient Experience Programme
3.11.1 There are currently two major surveys underway. The GP practices survey of
nearly 500,000 people in Scotland, closes end March. The adult inpatient survey
of around 3,600 people in Scotland will close mid April 2010. Results of these
surveys will be available in the summer and be reported through a number of
groups and to the Board.
3.11.2 Scottish Renal Patient Experience Survey Transplant and Dialysis Reports:
These surveys were published by NHS Quality Improvement Scotland in January
2010. They included NHS Lothian specific evidence from patients receiving
dialysis and transplantation services. The Renal Services Quality Improvement
Team will progress the detailed consideration and resulting improvement plans.
Significant plans are also in place to expand capacity and infrastructure.
Some key findings include:
• Good response rates to postal survey – 62% dialysis, 70% transplant
• For people receiving dialysis, comfort, cleanliness and privacy and choice of
time for dialysis could be improved.
• For transplant patients, RIE was mid-range for compared to other units and
general recommendations include: - better information and liaison with GP’s
and multi-disciplinary team.
3.11.3 Participation Standard
The Scottish Health Council is finalising a Participation Standard for NHS
Boards for 2010-2011. This will replace current assessment methods and is set
to introduce a systematic collection of comparable data on involving people in
the work of NHS Lothian. The work will cover three areas of participation:
• Patient Focus –
responsive, person centred care which involves people;
treating individuals with respect and dignity
• Public Involvement –
effective involvement of people in service planning
• Corporate Governance –
robust governance arrangements are in place for
involving people, founded on mutuality, equality, diversity and human rights
The current Patient Focus and Public Involvement assessment process will be
reported to a future Board meeting.
3.11.4 Patients’ Rights Bill
The development of the Bill is underway for introduction into the Scottish
Parliament in Spring 2010. Key proposals include:
• A 12-week waiting time guarantee from agreement to treatment to the start of
that treatment for day cases and inpatients.
• Patients Rights Officers for NHS Health Board areas.
• Reinforcement of existing rights to make a complaint and strengthening of the
support to patients through the complaints process.
• Better clarity about responsibilities for patients – for example attending
agreed appointments and offering feedback on health services.
3.12 New Development - Health Economics Research Unit (HERU)
The HERU at the University of Aberdeen has evaluated projects assessing the
cost effectiveness of automated diabetic retinopathy grading in Scotland.
Systematic screening for diabetic retinopathy is already in place with national
screening programmes based on high quality digital photography. The three-
level manual grading system is currently used in Scotland. HERU have now
investigated automated algorithms to improve the sensitivity of image grading
with no loss of specificity. New automated algorithms cost approximately the
same as the original and detect slightly increased numbers of referable cases.
The result of this work is that automated grading should now be implemented
across NHS Scotland. This will be taken up by the Ophthalmology services and
the Diabetes Managed Clinical Network
There is evidence that focussing on quality and patient safety can impact on the
care we provide and reduce costs (Health Foundation 2009). It is of critical
importance there is senior management engagement and support in the
development and application of quality of care indicators. The indicators set out
in this paper are the start of this process, and will develop over time, including
the presentation of data and commentary, but are required if we are to deliver
the Board’s strategic objectives.
Impact on Health Inequalities
The work proposed by this paper, which incorporates existing data and the
development and monitoring of new indicators, will have a positive impact on
inequality. A Rapid Impact Assessment (RIA) was carried out on the Scottish
Patient Safety Programme on 5 May 2009, which has significant overlap with
elements of this paper. This identified communication with patients and staff,
and improved monitoring, as key issues. The plan proposed by this paper will be
developed during 2010 and will incorporate a further RIA to determine the impact
of increased monitoring and collation and use of quality and safety data. Actions
arising from this RIA will be incorporated into the diversity monitoring action plan,
a key part of NHS Lothian Quality & Human Rights Scheme to be published in
There are no resource implications associated with this report.
17 March 2010
List of Appendices
Appendix 1: Quality of Care Indicators
Appendix 2: Quality of Care Reporting Matrix
Appendix 3: RMIS Lessons Learned October to December 2009
1. Examples of Lessons Learned and Changes in Clinical Practice Initiated to
Improve Patient Safety from Reported Incidents
Some examples of incidents where there has been learning and changes made:
1. An out of date medication was kept in-house and dispensed by a member of
staff. The patient was advised not to take further tablets. The GP was contacted
and they issued another prescription and visited the patient to check all was well.
The patient was advised to take medication to the pharmacy for safe disposal.
Procurement procedures have now been reviewed and are ongoing. Staff
training has been commenced and implemented. The incident has been shared
in the weekly staff bulletin to share lessons learnt and a regular procedure for
checking stock control has been implemented.
2. Blue bags were inappropriately used for confidential waste, as white bags were
not available. The blue bag was uplifted but not treated as confidential waste.
An action plan has been initiated. All blue bags have been removed for use as
confidential waste and a supply of white bags has been replenished. All staff
have been reminded to follow Waste Management Policy and escalate any
deviations through the Datix reporting system.
3. The handle of a piece of equipment used in surgery disintegrated while being
used by the surgeon. This resulted in a slightly more invasive procedure and a
greater risk of infection for the patient. The incident initiated a system wide
review of this type of instrument. Hospital Sterilisation and Decontamination Unit
(HSDU) have been replacing devices of this type where their suitability for
purpose is been questioned. Under the replacement programme, new devices
have been purchased and a build up of stock is underway. The Incident
Reporting and Investigation Centre (IRIC) were promptly informed and they, in
turn, reported it to the Medicines and Healthcare Products Regulatory Agency
(MHRA), in case a national alert was required, so far this has not been required.
The incident review demonstrates collaboration between Theatres directorate,
HSDU, Medical Physics and Risk Management.
4. As the Paediatric Intensive Care Unit (PICU) in Edinburgh was full, but patients
required beds, PICU contacted the unit in Newcastle to see if they had beds, but
were told there were none. It was later discovered there were four beds in
Newcastle. Staff in Edinburgh were unaware that Newcastle had more than one
PICU. An important lesson has been learned; that Newcastle has 3 PICU’s but
one central switchboard. Staff have been advised that if there is an
inappropriate response, they are to check who the call has been put through to.
A laminated notice with a single point of contact direct dial line for Newcastle
General has been placed for staff information.
- LOTHIAN NHS BOARD
- List of Appendices
- Quality Improvement Report.pdf
- LOTHIAN NHS BOARD
- 1 Purpose of the Report
- 2 Recommendations
- 3 Summary of the Issues
- 4 Impact on Health Inequalities
- 4.1 The work proposed by this paper, which incorporates existing data and the development and monitoring of new indicators, will have a positive impact on inequality. A Rapid Impact Assessment (RIA) was carried out on the Scottish Patient Safety Programme on 5 May 2009, which has significant overlap with elements of this paper. This identified communication with patients and staff, and improved monitoring, as key issues. The plan proposed by this paper will be developed during 2010 and will incorporate a further RIA to determine the impact of increased monitoring and collation and use of quality and safety data. Actions arising from this RIA will be incorporated into the diversity monitoring action plan, a key part of NHS Lothian Quality & Human Rights Scheme to be published in June 2010.
- 5 Resource Implications
- List of Appendices