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6.6 
LOTHIAN NHS BOARD 
 
Board Meeting 
24 March 2010 
 
Medical / Nurse Director 
 
 
QUALITY IMPROVEMENT REPORT 
 
 

Purpose of the Report 
 
1.1 
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. 
 
 

Recommendations 
 
The Board is asked to: 
 
2.1  Support the introduction of a system-wide quality of care indicators and 
 
reporting structure.   
  
2.2 
Note the update on patient experience actions.   
  
 

Summary of the Issues 
 
3.1 
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 
  
improvement 
•  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. 
 
3.2 
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 
care. 
 
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   
infections; 
• 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. 
 
3.3 
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 
 
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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 
Safe Care 
 
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: 
 
Royal Infirmary 
 
0.79 
Western General    
0.76 
St Johns Hospital 
 
0.92 
 
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 
Sep 07) 
baseline 
Royal Infirmary 
0.88 
0.79 
0.75 
Western 
0.73 0.76 
0.62 
General 
St Johns 
0.89 0.92 
0.76 
Hospital 
 
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.  
 
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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 
track progress. 
 
 Chart 1 - Lothian Overall Rate/1000 pt days 
NHS Lothian
Rate of Adverse Events per 1000 patient days
80
ys
a

70
t D
n

60
ie
48
50
 pat
40
00
39
30
 10
20
 per
te
a

10
R
0
07
8
08
08
9
v-07
-08
-08
-09
n-08
r-0
ay
r-0
ov-
n-09
ay
Sep-
No
Ja
Ma
M
Jul
Sep-
N
Ja
Ma
M
Month
 
 
 
3.5 
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 
completeness. 
 
3.6 
Incidents 
 
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. 
 
 
4

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.   
 
 Chart 
1  
 
 
NHS Lothian Incident Reporting Trends Jan-Dec 09 
 
Reported Incidents
Harm to Person
 
 
2500
 
2250
2000
 
1750
 
1500
 
1250
 
1000
750
      
500
  250
 
0
 
Jan- Feb- Mar- Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec-
09
09
09
09
09
09
09
09
09
09
09
09
 
 
 
Chart 2 
 
NHS Lothian Incidents with Harm to Persons - Jan-Dec 2009
Incident reported with harm 
 
2009: 
 
550
Severity of harm
500
 
450
 
400
Minor harm 78% 
 
350
 
300
Moderate harm 17% 
250
 
200
 
150
Major harm 3% 
 
100
 
50
Death 2% 
0
 
Jan- Feb- Mar- Apr- May- Jun-
Jul- Aug- Sep- Oct- Nov- Dec-
 
09
09
09
09
09
09
09
09
09
09
09
09
 
 
 
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3.7 
Clinical Effectiveness 
 
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. 
 
3.8 
Person-Centred Care 
 
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 
being progressed. 
 
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. 
 
Chart 3 
Formal Complaints
400
374
350
300
283
267
271

250
er
NHS Lothian Totals
b
m

211
UHD
u
200
191
 N
CHP / REAS
tal
o

150
Board
T
100
68
50
47
48
25
28
35
0
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. 
 
6

 
Chart 4 
3 day Acknowledgements
120%
100%
80%
t
n

NHS Lothian Totals
lia
UHD
60%
mp
o

CHP / REAS
% c
LHB
40%
20%
0%
Oct - Dec '09
July - Sept '09 April - June '09
Time Periods
 
 
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. 
 
Chart 5 
20 Day Response Target
100%
90%
80%
70%
t
n

60%
NHS Lothian Totals
lia
UHD
50%
mp
o

CHP / REAS
40%
% C
LHB
30%
20%
10%
0%
Oct - Dec '09 July - Sept '09
April - June
'09
Time Periods
 
 
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. 
 
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3.9 
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 
monitoring.  
 
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 
 
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•  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 
and improvement 
•  Corporate Governance – robust governance arrangements are in place for 
involving people, founded on mutuality, equality, diversity and human rights 
principles.      
 
 
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 
 
9

 
3.13  Summary 
 
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 
 
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. 
 
 

Resource Implications 
 
5.1 
There are no resource implications associated with this report. 
 
 
 
Pat Dawson
Jo Bennett
Elizabeth Bream
Carol Crowther
 
 
 
 
Associate Nurse 
Clinical Governance  
Consultant 
Chief Nurse 
Director 
Manager
Public Health
Quality & 
 
 
Strategic 
Professional 
Development
Standards, UHD
 
 
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 
 
 
 
 
 
10


6.6 
 
 


 
13

APPENDIX 3 
 
 
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. 
 
 
 
 
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