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8.1 
LOTHIAN NHS BOARD 
 
Board Meeting 
22 September 2010 
 
Medical Director 
 
QUALITY IMPROVEMENT REPORT 
 

Purpose of the Report 
 
1.1 
This report presents the updated Quality Report for September 2010 including the 
measures introduced to date. 
 
 

Recommendations 
 
The Board is asked to: 
 
2.1 
Review the quality measures presented. 
 
2.2 
Review and comment on quality improvement matters
 
 

Introduction 
 
3.1 
The Quality Dashboard was introduced in a previous paper to the Healthcare 
Governance & Risk Management Committee in February 2010 and to the Board in 
March 2010 as the Quality Matrix.  The title has been changed to Quality 
Improvement Report to reflect the terminology set out in the Quality Strategy (2010) 
launched on 10th May 2010. 
 
3.1.1  The quality improvement report includes a suite of measures which, at a system 
level, will allow monitoring of the quality of care provided by NHS Lothian. 
 
3.1.2  This paper presents the updated quality improvement report for September 2010.  
Table 1 shows each of the individual measures, their data source, and what 
questions they answer about the care we deliver.  
 
Table 1 
 
Measure How 
good 
is 
Is our care 
How do we 
Data Source 
our care? 
getting 
compare? 
better? 
HSMR 


 ISD 
 
Adverse Events 


 
IHI Global Trigger 
Tool Review 
Hospital Acquired 



Infection Control 
Infection(HAI) 
Team 
Incidents 


 Datix 
System 
Complaints 


 Datix 
System 
HSMR: Hospital Standardised Mortality Ratio 
 
 
 

 
 
 
3.2 
Links to the Quality Strategy 
 
3.2.1  The NHSScotland Healthcare Quality Strategy launched in May 2010 included a 
three level Quality Measurement Framework (QMF). Level 1 is national reporting 
towards the quality ambitions, level 2 contains HEAT targets and level 3 is for other 
local or national measures required for quality improvement. An update from the 
Scottish Government on progress in developing potential level 1 Quality Outcome 
Measures as part of the QMF was received in August and is appended to this 
report (Appendix 1). Feedback is currently being sought from Boards on the 
potential measures. 
 
3.2.2  The ‘core’ measures HAI, adverse events and HSMR presented in the NHS Lothian 
Quality Improvement Report are already aligned with the Quality Strategy level 1 
measures. Similarly, HSMR, HAI, complaints and incidents also feature in the draft 
NHS Scotland Quality Strategy Scorecard (which is envisaged as spanning levels 
1-3). 
 
3.3 
Quality of Care Measures 
 
Hospital Standardised Mortality Rate (HSMR) 
  
Hospital Standardised Mortality Ratio (HSMR) is calculated by Information Services 
Division and used by the Scottish Patient Safety Programme (SPSP). There is an 
SPSP target reduction in HSMR of 15% by 2011.  HSMR is the ratio of observed 
deaths to expected deaths within 30 days of admission to hospital.  If the HSMR for 
a hospital is less than 1, then fewer hospital deaths within 30 days of admission are 
occurring than expected.  HSMRs have therefore been used as system level 
‘warnings’ for areas for further investigation. There is some controversy about their 
use, but they remain widely used in this way. 
 
Figures 1a-c show the number of observed and expected deaths at Royal Infirmary 
Edinburgh (RIE), St John’s and Western General Hospital (WGH) each quarter 
from October 2006 to December 2009.  The HSMRs in each case for the last 
reported quarter are RIE=0.93, St John’s=1.0 and WGH=0.72.  These are all less 
than 1, indicating that the number of observed deaths is fewer than the expected 
number, with the exception of St. John’s whose observed deaths match the 
expected number. 
 
It must be emphasised that the quarter to quarter changes should be interpreted 
with caution.  HSMRs cannot be compared between hospitals or boards. 
 
 
 
 
 
 
 
 
 
 

 
2

 
 
 

Quarterly Hospital Standardised Mortality Ratios in Royal Infirmary of Edinburgh 
Figure 1a - Number of observed and expected deaths; October 2006 – December 2009 
  
500
450
400
350
hs
300
Observed
 deat
deaths (30
250
days)
ber of
200
Expected
um
N
deaths   (30
150
days)
100
50
0
Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec
2006
2007
2007
2007
2007
2008
2008
2008
2008
2009
2009
2009
2009
 
 
Quarterly Hospital Standardised Mortality Ratios in St John’s Hospital 
Figure 1b – Number of observed and expected deaths; October 2006 – December 2009 
 
500
450
400
350
s
h
300
Observed
 deat
deaths (30
250
r of
days)
be
200
Expected
um
N
deaths   (30
150
days)
100
50
0
Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec
2006
2007
2007
2007
2007
2008
2008
2008
2008
2009
2009
2009
2009
 
 
Quarterly Hospital Standardised Mortality Ratios in Western General Hospital 
Figure 1c – Number of observed and expected deaths; October 2006 – December 2009 
 
500
450
400
350
hs
at
300
Observed
f de
deaths (30
250
 o
days)
ber
200
Expected
um
N
deaths   (30
150
days)
100
50
0
Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec Jan-Mar Apr-Jun Jul-Sep Oct-Dec
2006
2007
2007
2007
2007
2008
2008
2008
2008
2009
2009
2009
2009
 
 
 
3



 
 
3.4 
Adverse Events  
 
Adverse events are currently measured at the three main acute sites using 
retrospective case note review using the ‘Global Trigger Tool’.  At present, the 
baseline has not stabilised, as illustrated by Figure 2. This is because the review 
process is subject to constant improvement (of both the sampling procedure and 
the review itself). This applies to all boards across Scotland.  At present therefore, 
no comparison with other Boards is possible. 
 
The Institute of Health Improvement (IHI), who are advisors to the Scottish Patient 
Safety Programme, advise that in a health care system of NHS Lothian’s size and 
complexity an expected baseline would be approximately 89-90 adverse events per 
1000 patient days. NHS Lothian is now starting to achieve this. If this rate is 
sustained, NHS Lothian will be expected to achieve a 30% reduction against this by 
2011.   
 
Rate of Adverse Events per 1000 patient days. 
Figure 2 – Jun 2007 to November 2009 
 
 NHS Lothian
Rate of Adverse Events per 1000 patient days
 RIE, WGH & SJH
100
 
 
90
80
70
ays
60
t D
en
ati

50
 1000 p
40
er
p

9 data points over 
30
base line  median from 
Oct 08 - Jun 09 = 
20
sustaine d shift in the 
Baseline median 29.0 
data. New me dian of 47.2 
(based on first 16 data 
is based on this time  
10
points)
period
0
07
7
7
7
7
8
8
8
8
8
9
9
9
9
-0
07
08
08
08
08
08
09
09
09
09
09
g-0
p-0
-0
-0
ct-07
c-0
b-08 ar-
pr-
g-0
ct-08
c-0
b-09 ar-
pr-
ct-09
Jun-
Jul
ov-
ay-0
ep-0
ov-
ay-0
ug-0 ep-0
ov-
Au
Se
O
N
De
Jan- Fe
M
A
M
Jun-
Jul Au S
O
N
De
Jan- Fe
M
A
M
Jun-
Jul A
S
O
N
Month of Discharge
3.5 
Healthcare Associated Infections 
 
3.5.1  S.aureus Bacteraemia (SAB) 
NHS Lothian’s HEAT target for SAB reduction is 49% by March 2011.  In the 
quarter to July 2010, there has been an increase in the SAB rate.  Infection Control 
within NHS Lothian is working closely with the Scottish Patient Safety Programme 
in Lothian, Health Protection Scotland and Quality Improvement Scotland to 
address the issue of SABs. 
 
 
 
 
 
 
4





 
 
Figure 3a – Progress against HEAT Target for S.aureus Bacteraemia (SAB) 
   
 
Source: Lothian Infection Control Team 
 
3.5.2  C.difficile Infection (CDI) 
In June 2010 the Scottish Government Health Department (SGHD) issued a new 
HEAT Target for CDI to all NHS Boards, increasing the target from a 30% to a 50% 
reduction by March 2011. 
 
NHS Lothian has put in place an extensive CDI programme which is fully integrated 
with the Patient Safety Programme.  This has resulted in an improved performance 
that has outstripped the HEAT target requirements, which is illustrated in Figure 3b. 
 
Figure 3b – Progress against HEAT Target for C.difficile Infection (CDI) 
      
 
Source: Lothian Infection Control Team 
 
 
3.5.3 Hand 
Hygiene 
There has been a significant and sustained improvement in compliance since 
October 2007.  NHS Lothian continues to surpass the 90% compliance rate 
(HEAT), currently achieving 93% as of July 2010. 
 
 
 
5


 
 
3.6 
Reported Incidents  
 
Incidents are reported through out NHS Lothian using the DATIX system, whereby 
staff record incidents that affect patients and also incidents that affect staff. The 
category and degree of harm associated with each incident is also recorded by 
staff.  There are improvements to be made in the degree of standardisation in this 
process and actions to improve standardisation are being led by the Risk 
Management Team in conjunction with clinical management teams.  
 
Figures 4a, 4b and 4c show a sustained increase in incident reporting up to June 
2010.  This is considered a positive indicator of an organisation’s safety culture.  
Factors which may have influenced reporting are shown in the figures below.  
 
Figure 4a: Number of incidents reported per month in NHS Lothian (August 2008-June 2010) 
 
NHS Lothian Incident Reporting Trends
Reported Incidents
Median
All unexpected 
Deaths to be reported 
on DATIX  

3000
DATIX Web fully 
implemented 

2500
2000
C diff reported on DATIX  
(coded as major harm) 

1500
1000
500
0
8
9
0
08
9
09
09
09
10
10
10
g-08 -08
-09
-09
-10
p
t-08 v-0
n-0 b-09
r-
l-09
r-
ar
ay-
n-0
g-09 p
t-09 v-09
n-
r-10
ay-
n-1
Au
ec-
ec-
Se
Oc No D
Ja
Fe
M
Ap M
Ju
Ju Au Se Oc No D
Ja
Feb Ma
Ap M
Ju
Month
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
6



 
 
Figure 4b: Number of incidents reported per month in primary care (August 2008-June 2010) 
 
Primary Care Incidents
1200
All unexpected deaths 
1000
to be reported on Datix
800
s
nt

C.Diff reported on Datix 
(coded as major harm) 
ide
c
n

600
 I
o of
N

400
200
0
08
09
10
10
g-08 p-08
t-08 v-08
-09
r-09
l-09
t-09
-10
r-
r-10
ec-
b-09 ar-
y-09 n-09
g-09 p-09
v-09 c-09
b-10
ay-
n-10
Au
Se
Oc
No
D
Jan
Fe
M
Ap
Ma
Ju
Ju
Au
Se
Oc
No
De
Jan
Fe
Ma
Ap
M
Ju
Month
 
 
In Figure 4c the incident rate for Lothian University Hospitals Division is given per 
1000 occupied bed days. 
 
Figure 4c: Rate of incidents per 1000 bed days per month in LUHD in NHS Lothian (August 2008-
June 2010) 
 
 
LUHD Rate of incidents per 1000 bed days 
3 consecutive hand 
hygiene audit results 
30
< 75% reported on 
Datix 
Upgrade to Datix Version 9
25
20
ays
 d

All unexpected deaths 
d
e

to be reported on Datix 
 b
d

Hand hygiene audit results < 
ie
p

95% reported on Datix
15
ccu
 o

000
r 1
e
 p
te

10
Ra
5
0
8
09
09
9
09
9
10
10
0
g-0
-08
-09
-09
l-09
-09
-10
r-10
-10
-1
ep
ct-08
ov-08
c-08
ar-0
pr
ug
p-0
ct-09
v-09
ec-09
Au
S
O
N
De
Jan-
Feb-
M
A
May
Jun-
Ju
A
Se
O
No
D
Jan-
Feb-
Mar
Ap
May
Jun
Month
 
 
 
 
 
 
 
7



 
 
 
Figures 4d, 4e and 4f show an increase in incidents reported associated with major 
or moderate harm.  This is understood to be a result of a change in incident 
reporting; for example, the Medical Director instructed that all unexpected deaths 
are reported on Datix.  Similarly, there has also been an increase in the reporting of 
Clostridium Difficile infections on Datix, most of which have been coded as major 
harm.  
 
Figure 4d: Number of incidents associated with moderate or major harm or death reported per 
month in NHS Lothian (August 2008-June 2010) 
 
 
 
Figure 4e: Number of incidents associated with moderate or major harm or death reported per 
month in primary care in NHS Lothian (August 2008-June 2010) 
 
 
8



Primary Care Incidents with Moderate or Major Harm or Death
80
All unexpected deaths 
70
to be reported on Datix 
60
m
ar

50
 H
ith

40
ts w
n
e
d

30
ci
C.Diff reported on Datix 
In
(coded as major harm) 
20
10
0
08
09
09
10
10
g-08
-08
p-08
v-08
r-09
r-
l-09
r-10
r-10
ec-
n-09 b-
y-09
g-09 p-09 ct-09 v-09 c-09 n-10 b-
y-
n-10
Au
Se
Oct No
D
Ja
Fe
Ma
Ap
Ma
Jun-09 Ju
Au
Se
O
No
De
Ja
Fe
Ma
Ap
Ma
Ju
Month
 
 
 
 
Figure 4f: Rate of incidents per 1000 bed days per month in LUHD associated with moderate or 
major harm or death 
 
LUHD incidents reported with moderate or major harm or death per 1000 occupied bed days
2
All unexpected deaths to 
be reported on Datix
ays
 d
ed
 b

ied
p
cu

1
c
0 o
C Diff reported 
 100
er

on Datix 
 p
e

(coded as 
at
R

major harm)
0
08
09
09
09
09
09
10
g-08
p-08
t-08
v-
-08
b-
r-
r-09
y-09
-09
g-
p-09
t-09
-09
c-
r-10
r-10
y-10
-10
Au
Se
Oc
No
Dec
Jan-09
Fe
Ma
Ap
Ma
Jun-
Jul
Au
Se
Oc
Nov
De
Jan-10
Feb-
Ma
Ap
Ma
Jun
Month
 
 
3.7 
Complaints 
 
NHS Lothian received a total of 243 formal complaints during the period April to 
June 2010, as illustrated in Figure 5a.  This represents a decrease on the previous 
quarter.  The main reason for the decrease is due to the improvement in car parking 
facilities at St John’s and Western General Hospitals. In addition improvements in 
the reporting of complaints figures to ensure consistency in counting across the 
divisions has lead to a decrease in the number of complaints logged as board 
complaints. 
 
9






 
Figure 5a – Formal Complaints across NHS Lothian? 
 
 
 
NHS Lothian has achieved an average 20 day response time of 81% in respect of 
the target of 85% as illustrated in figure 5b, with some directorates achieving 100%. 
Improvement in the accuracy of reporting of complaints has seen a decrease in the 
number of formal complaints recorded. The centralisation of the NHS Lothian 
complaints team will bring improvements in standardisation of process and sharing 
of lessons learned, however some difficulties were encountered in the weeks 
following the transfer, and it is hoped that the performance will improve in the next 
quarter.  
 
Figure 5b – 20 Day Response Target 
 
100%
90%
80%
70%
60%
t
n
lia
p

50%
m
o
 c
%

40%
30%
20%
10%
0%
April - June '09
July - Sept '09
Oct - Dec '09
Jan - Mar '10
Apr - June '10
Time Periods
 
 
Table 2 shows the ISD figures for NHS Lothian for formal complaints from April 
2009 to June 2010.  The top three consistent themes are clinical treatment, staff 
 
10

attitude and communication.  ISD will produce board by board national comparisons 
in September 2010. 
 
Table 2 – ISD Figures for Complaints 1 April to 30 June 2009 and 2010  
 
1 April 2009 to 30 June 2009 (Total:  355)  
1 April 2010 to 30 June 2010 (Total: 212 ) 
Clinical Treatment 
70 
20% 
Clinical Treatment 
76 
36% 
Staff Attitude 
39 
11% 
Staff Attitude 
33 
16% 
Communication Oral 
25 
7% 
Date for appointment 
19 
9% 
Communication Written 
22 
6% 
Communication Oral 
13 
6% 
Admission/ Transfer/Discharge 
17 
5% 
Admission/ Transfer/Discharge 
13 
6% 
 
3.7.1  Scottish Public Services Ombudsman Reports: There have been three reports 
published by the Ombudsman’s office in respect of the University Hospitals Division 
of NHS Lothian with a further two reports published in respect of GP services. In 
addition the Ombudsman’s office has investigated three complaints which have 
been resolved without need to progress to full report 
 
3.8 
Effectiveness Measures 
 
3.8.1  In the July board paper, the rationale for including a small number of system-level 
measures of the effectiveness of care in the Quality Improvement Report was 
explained. Since this time, work has taken place to agree the timetable of these 
measures. This is included in Appendix 2. This timetable aims to synchronise as far 
as possible with data releases that already occur; it may be subject to some change 
over the year if there are changes to these releases or if additional local analyses 
or work is required to better inform reporting to the Board. 
 
3.8.2  The detail of which measures will be included for each topic will be agreed during 
2010/11. This will be informed by updates from the Scottish Government as 
outlined above and as a result of on-going discussion with the clinical and/or 
strategic leads for these areas. 
 
3.8.3  The first set of measures for critical care is presented below, as are findings from 
the recently published UK Audit of Vascular Surgical Services and Carotid 
Enarterectomy.  Additional measures will be presented for vascular surgery as part 
of the surgical measures due to be reported next year. 
 
3.8.4  Critical Care 
 
3.8.4.1 
The data below shows outcomes in Scottish Intensive Care Units (ICU) and 
High Dependency Units (HDU) for 2009.  This data is taken from the annual 
report of the Scottish Intensive Care Society Audit Group (SICSAG) which is a 
national audit funded through Information Services Division (ISD).   
 
3.8.4.2 
The outcome measure used by SICSAG is the patient’s survival status when 
they leave hospital (even if this is not the original hospital).  Patients admitted to 
ICU are at significant, but varied, risk of death.  Comparing the proportion of 
patients who die in each unit can give a misleading impression because the 
severity of their illness is different.  To overcome this, the APACHE II system is 
used to adjust for case-mix.  This is a validated scoring system, which takes 
account of both the patient’s acute condition and their chronic health.  APACHE 
II produces an expected mortality rate for a unit, which can be compared to the 
 
11


actual observed mortality rate to give a Standardised Mortality Ratio (SMR).  An 
SMR significantly greater than 1 suggests that mortality is higher than expected, 
and a value of less than 1 that it is lower than expected. 
 
3.8.4.3 
To show the differences between units, a funnel plot is shown.  This has curved 
lines on it to represent two standard deviations (inner curves) and three 
standard deviations (outer curves) from the Scottish mean. For SICSAG, the 
general understanding is that if an ICU is outside the inner curves then it ‘might 
be different’ from the Scottish mean. If an ICU is outside the outer curves then it 
‘is different’ from the Scottish mean. It should be recognised that comparison of 
25 ICUs/HDUs has a considerable chance of detecting a unit that ‘might be’ 
different.  
 
3.8.4.4 
Figure 6 sets out the Standardised Mortality Rates in ICU and combined units 
(2009) below. The SMR for all 3 Lothian ICUs (units M,R,X) is well below the 
Scottish mean on the SMR funnel plots. 
 
 
 
 
The Scottish SMR has been decreasing steadily over recent years: 2006 = 0.93, 
2009 = 0.84.   
 
Figure 6 
 
 
3.8.5  Vascular Surgery 
 
3.8.5.1 
UK Carotid Endarterectomy Audit 
NHS Lothian participates in the UK Vascular Surgery Audit which is delivered 
by the Royal College of Physicians in London and the Vascular Society.   The 
audit runs continuously with reports published approximately every two years, 
and this is an update on the last audit published in 2008.   
 
 
Carotid Endarterectomy can prevent stroke in patients with coronary artery 
narrowing who present with an ischemic event or a previous stroke.  Both SIGN 
and NICE have produced guidance for clinicians and national standards for the 
 
12

services.    NHS Lothian operated on 153 patients, 2% of the UK total.  99% of 
patients had symptomatic disease.  Indications for operation were completely 
consistent with recommended criteria.  No patients were operated on with minor 
narrowing or complete occlusion (both relative contra-indications for successful 
operation).  Further imaging to confirm a diagnosis was required in about 85% 
of patients.  The national strategy suggests a target of 48hrs from symptom to 
operation for high risk patients.  Mean referral time in the UK is 19 days and 9 
days in NHS Lothian.  This is a considerable improvement from over 20 days in 
2008.  There have been consequent improvements in time from admission to 
imaging and to surgery, and these steps along the pathway are measured and 
acted on quarterly.  
 
 Surgery is consultant led and the audit recommends and increase in the use of 
carotid patching which is the most effective type of operation.  26% of patients 
are now treated with a local anaesthetic plus a nerve block, which has 
considerably decreased the time for recovery to less than 4 hours.  Length of 
stay is now only 3 days.  98% of patients attended follow up and were assessed 
by the surgeon.  One recommendation is that assessment should also be 
undertaken by a physician with an interest in stroke, in order to detect minor 
complication.  
 
 Outcomes:  There were no in-patient deaths reported in this audit, and only 2 
patients died within 30 days of operation, one from a heart attack, and one from 
a stroke.  Overall mortality was 1.6% which is less than that reported in 
randomised control trials, and not significantly different from 0.8% reported 
across the UK.   The full report is available from the Medical Director.  
 
3.8.5.2 
Organisational Audit of Vascular Surgical Services 
The Organisational Audit is undertaken less frequently and is based on a 3 
month snapshot between December 2009 and February 2010.  NHS Lothian 
reports high levels of data compliance (more than 94%) which is better than the 
majority of units in England.  NHS Lothian is one of the busiest units in the UK 
for some aspects of vascular surgery, reporting over 100 cases per year for 
arterial reconstruction and leg amputation.  This is in the top quartile of UK 
services for operating on emergency leakage of abdominal aortic aneurysms.  
Overall, the standards of staffing and facilities in NHS Lothian are comparable to 
the best in the UK but the individual surgeons are amongst the busiest in the UK 
in terms of case load per consultant.  Unlike other vascular surgeons in the UK 
the surgeons in NHS Lothian also undertake additional work with specialist 
management of difficult varicose veins.  Using a weighted index, surgeons in 
NHS Lothian undertake 1.33 completed procedures per week versus the UK 
average of 0.98 with an inter-quarter IQ range of 0.72-1.27.  NHS Lothian 
surgeons are therefore in the 95% percentile, i.e. the busiest surgeons in the 
UK.  NHS Lothian also has a better ratio of trainees to consultants than many 
other vascular units, and is well supported with specialist nurses and vascular 
technicians.  There are no particular areas of concern in this report other than 
monitoring the workload and capacity of vascular surgical services.  The full 
report is available from the Medical Director. 
 

Impact on Health Inequalities 
 
4.1 
The work set out by this paper, which incorporates existing data and the 
development and monitoring of new indicators, will have a positive impact on 
 
13

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. 
 

Resource Implications 
 
5.1 
There are no resource implications associated with this report. 
 
 
Professor Charles Swainson/ Jo Bennett / Dr Elizabeth Bream 
Medical Director/ Clinical Governance Manager / Public Health Consultant 
14 September 2010 
 
 
List of Appendices 
 
Appendix 1: Quality Measurement Framework (QMF) Update 
Appendix 2: Proposed Effectiveness Measures Timetable 
 
14

APPENDIX 1 
 
The Quality Measurement Framework (QMF) – Update from Scottish Government 
 
 
Introduction 
 
The NHSS Healthcare Quality Strategy was officially launched in May 2010. This new 
approach is about putting people at the heart of everything we do, delivering measureable 
improvement and creating confidence that NHSScotland is delivering the highest quality 
healthcare.  
 
As an action identified by the Quality Strategy, a Quality Measurement Framework is 
being developed. This will provide a structure for alignment of all measurement work to the 
three Quality Ambitions, and include a set of Quality Outcome Measures to indicate 
national progress towards these Ambitions.   
 
This paper sets out to further explain and clarify: 
•  What is meant by the Quality Measurement Framework 
•  The significance of the Quality Ambitions 
•  The three levels of the Quality Measurement Framework 
•  How the three levels relate to each other 
•  What the Quality Outcome Measures will be used for and by whom 
•  How the 12 potential Quality Outcome Measures were chosen 
•  How the Quality Scorecard (developed in response to the Mid Staffs situation) 
relates to the Measurement Framework  
•  The work that is underway to develop the Quality Outcome Measures 
•  How this relates to the National Performance Framework  
•  How the Single Outcome Agreements (SOAs) fit into this framework 
 
 
What is the Quality Measurement Framework? 
 
The Quality Measurement Framework provides a structure for understanding and aligning 
the wide range of measurement that goes on across the NHS in Scotland for different 
purposes.  By showing how all of this work leads towards the Quality Ambitions – which 
are illustrated by 12 potential Quality Outcome Measures – we have a basis for 
prioritisation and the ability to demonstrate improvement both locally and nationally. 
 
The measurement framework is NOT a new set of measures on top of everything else, 
rather it is a way of demonstrating how all existing work fits together towards the aim of 
improving quality.   
 
A pictorial description of the framework is included in Appendix (a) for reference. 
 
 
What is the significance of the Quality Ambitions? 
 
The Quality Strategy and the shared vision of healthcare quality for Scotland is based 
upon the Institute of Medicine’s six dimensions of healthcare quality, together with the 
priorities of healthcare quality identified by people in Scotland as: caring and 
 
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link to page 16 link to page 16 compassionate; clearly communicating conditions and treatment; effective collaborative 
working between clinicians, patients and others; continuity of care; and clinical excellence.  
 
At the national quality measures consultation event in March 20101, the development of 
measures for the six quality dimensions was discussed.  It was apparent that clear 
statements of what these meant was required, and that there were overlaps between the 
dimensions. The development of the three Quality Ambitions was the outcome of these 
discussions.  The Quality Ambitions combine all of the above aspects of quality.   
 
The Quality Measurement Framework supports the vision for NHSS as described by the 
Quality Ambitions.  All measurement will be aligned to these Quality Ambitions. 
 
 
What are the three levels in the framework? 
 
The three levels described by the framework provide a simplified structure for thinking 
about the intended use of sets of measures.  The framework is intended as a 
representation to highlight that all measurement should align towards the quality 
ambitions.   It is possible for certain measures to appear at more than one level, or that 
they may change use over time, with future developments.  It should therefore be 
recognised that there is a degree of fluidity between the levels and that there is not an 
intention to determine a rigid unchangeable landscape.  In summary: 
 
•  Level 1 is for national reporting on long term progress towards the quality ambitions  
•  Level 2 contains the HEAT targets, which are for shorter term Central Government 
performance management of NHS Boards 
•  Level 3 is for all other measures required for quality improvement, either by national 
programmes or locally.   
 
Level 1 
These Quality Outcome Measures will be illustrative of the Quality Ambitions, 
and will indicate progress towards these three Quality Ambitions over time at 
the national (Scotland) level.  These will not be targets and they will not state 
when progress will be achieved by.  The 12 potential Quality Outcome 
Measures that were originally proposed in the Quality Strategy are listed in 
appendix (b). These measures are currently undergoing further investigation 
and development by the Quality Measures Technical Group (QMTG)2, and 
some suggestions for changes have already been put forward – for example 
that the workforce related measures should be on staff engagement and staff 
development. 
 
Level 2 

HEAT targets are performance management targets which are planned and 
agreed with NHSScotland via the LDP process as the priority areas for 
progress each year.  These are short term targets (1-3 years).  Over time the 
HEAT targets will be aligned to the Quality Ambitions.  The HEAT targets that 
are developed will not need to correspond specifically to the Quality Outcome 
Measures, but will reflect the priorities for the NHS in terms of moving towards 
the Quality Ambitions.  
 
Level 3 
There are many existing national and local measurement systems to drive 
improvement across primary and secondary care, all of which can be 
                                            
1 See section ‘How were the 12 potential Quality Outcome Measures chosen’ for details of this event 
2 See section ‘What work is being undertaken to develop the Quality Outcome Measures’ for membership of this group 
 
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considered as part of level 3.  Examples include the measures used in the 
Scottish Patient Safety Programme, the Quality Outcomes Framework (QOF), 
the Mental Health Quality Measures Framework and clinical indicators used in 
secondary care departments, e.g. the CQIs developed through the Senior 
Charge Nurse Review. Where future aggregation to NHS Board or national 
level is anticipated, attention would need to be given to consistency of 
definitions.  In other cases, where measurement is required that is meaningful 
locally for quality improvement, measures might be locally defined.   
 
 
How do the three levels relate to each other?  
 
Figure 1: the three levels of measurement 

Quality Outcome Measures
HEAT
Local and national quality measures
 
 
Level 1 and level 2 
The HEAT measures will not simply be targets for the Quality Outcome Measures, but will 
be measures that reflect movement towards the Quality Ambitions.  In some cases it will 
be easier to directly link HEAT to the Quality Outcome Measures than in others. 
 
Level 1 and level 3 
Level 3 measures may be combined to national level to form Quality Outcome Measures.  
For example, this could be the case for HSMR.  In some cases, there is a link between 
local and national levels in terms of improvement - for example, a Level 3 quality indicator 
such as local use of the CARE measure to improve patient consultations would be 
expected to have an impact on the Quality Outcome Measure for patient experience. 
 
 
Level 2 and level 3 
Some measures that are used locally will end up as HEAT targets.  Not every level 3 
measure will be represented in HEAT, but they will usually still be important for local 
performance management/ improvement and also for some national programmes. 
 
 
What will the Quality Outcome Measures be used for and by whom? 
 

 
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The Quality Outcome Measures will reflect progress towards the three Quality Ambitions 
but will not be subject to specific targets. They will include a combination of patient-based, 
staff-based and system-based measures to cover the three main levers for change and 
will provide a line of sight to the National Performance Framework.  
 
The Quality Outcome Measures will be used to describe and challenge the pace of 
progress towards the Quality Ambitions. They will be used by all those with an interest in, 
and responsibility for, delivering the vision set out in the Quality Strategy. This includes 
everyone working with and for NHSScotland, Scottish Government Health Directorates, 
and all those working in Local Authorities and the Third Sector who work in partnership 
with NHSScotland throughout each patient's journey.    
 
 
How were the 12 potential Quality Outcome Measures chosen? 
 
In March 2010, a national measures event was held in Dundee. Chief Executives were 
asked to nominate a Quality Lead for each Board to join a national quality measures 
network. Each Lead was asked to invite any other interested parties to the network 
measures event.   
 
In preparation for this measures event in March 2010, Health Boards were asked to 
feedback to the Scottish Government all the ways in which they measure quality. These 
were mainly level three measures which were mapped against the Institute of Medicine’s 
six dimensions of quality (person-centred, safe, effective, efficient, equitable and timely) 
and the seven ‘Cs’ (caring, compassionate, clear communication, collaboration, clean, 
continuity of care, clinical excellence). In addition, other Scottish measures were also 
mapped including the National Performance Framework, Single Outcome Agreement, 
Community Care Outcomes, Staff Governance, Scottish Patient Safety Programme, 
Equality, Patient Focus and Public Involvement, Complaints data, Local Delivery Plan – 
HEAT targets, Scottish Ambulance Service, NHS24, State Hospital and the proposed 
Quality Scorecard. Some international measures were examined including the Institute of 
Healthcare Improvement’s Whole System Measures. 
 
At this event, groups were formed to look at each of the six dimensions of quality and 
examine which existing measures and international measures could be used for level one 
potential Quality Outcome Measures. From the discussions it became clear that there was 
some overlap and interaction between the six dimensions of quality and the seven ‘Cs’ 
and it would be helpful to combine them into the three Quality Ambitions. 
 
The Measures network were then asked to comment on a draft version of the 
Measurement Framework in April 2010 and the twelve potential measures were 
developed. 
The aim was to produce a balanced set of measures which reflect the three Quality 
Ambitions and are patient, staff and system based. 
 
 
How does the developing “Quality Scorecard” fit into the measurement framework? 
 
Prior to the development of the Quality Measurement Framework, a project was initiated to 
produce a tool that could be used centrally to indicate any potential quality and 
governance concerns in Scottish hospitals.  This was a response to the Mid Staffs 
situation.   
 
 
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The tool – which has been sometimes known as the Quality Dashboard or Quality 
Scorecard, but could also be thought of as a Quality Early Warning System - is being 
developed in conjunction with Information Services Division (ISD).  Many Boards are 
already looking at these indicators, but the tool provides an additional comparison with the 
Scottish average so that outliers can be spotted.  
 
This work is part of the measures landscape, but is important to note that it is not the 
same thing as the Quality Measures Framework. The indicators used in the scorecard will 
be selected so that they provide an overall picture for comparison of hospital systems.  
The indicators will be drawn from different levels of the framework, as illustrated in figure 
2.  It may be considered that there is conflict between the use of the same measures for 
longer term progress at level 1, and for shorter term monitoring in the scorecard.  This will 
be explored further but it may be that these uses are compatible. 
 
Figure 2 

 
Quality Ambitions 
Level 1 
Quality 
Scorecard 
Level 2 
Level 3 
 
 
What work is being undertaken to develop the Quality Outcome Measures? 
 
To progress development of the Quality Outcome Measures (level 1), the Quality 
Measures Technical Group met for the first time on 16th June. Members of the group 
represented the Scottish Government, ISD, Quality Improvement Scotland (QIS) and the 
wider NHS. 
 
At this preliminary meeting the membership and role and remit of the group were agreed. 
Small working parties will be taking forward the 12 potential measures to fully investigate 
them for use. A paper will be produced and shared for consultation for each measure.  
These will detail information such as: 
•  the rationale for the measure 
•  how the measure will show improvement in quality   
•  definition and methodology  
• data 
issues 
•  past trends/current position 
•  other systems which include the measure 
•  direct links to HEAT 
• international 
linkages 
• equalities 
information 
•  better value and financial implications 
 
 
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Each measure has an analyst (technical) lead (SGHD, ISD or QIS), a policy lead and a 
clinical lead to take forward the development of the Quality Outcome Measure and to 
make sure that each of these key areas of expertise are available to consider all aspects 
of using the measure. 
 
Consultation on the papers for each of the Quality Outcome Measures will take place with 
the Measures network and the designated Measures Lead for each Board.  
 
Wider engagement will take place with SG directorates, national ACF chairs, clinicians 
involved in the NHS Leadership Development programme (Delivering the Future) and 
others to be confirmed. Internationally, the Health Foundation, the Institute for Healthcare 
Improvement and Jonkoping will be consulted. 
 
Based on the work to develop the measures papers, and the consultation, the 12 potential 
measures may change over the course of development or some may be dropped or 
added. 
 
It is expected that by October, a position statement will be available for each of the 
measures. A number of the measures will be fully worked through with supporting 
technical notes, whereas some will require further development. 
 
How does this relate to the National Performance Framework (NPF)? 
 
Scotland Performs measures and reports on the Scottish Government's progress towards 
its Purpose of creating a more successful country, with opportunities for all to flourish 
through increasing sustainable economic growth.  Within the Purpose there are five 
strategic objectives, of which Healthier is the one most relevant to the NHS.  However 
innovation in the NHS also contributes to Smarter Scotland, and consideration of 
environmental issues to Greener.   
 
Of the 15 national outcomes, there are several that improved quality in the NHS will 
support.  The main ones are: 
 
•  We live longer, healthier lives 
•  We have tackled the significant inequalities in society 
•  Our public services are high quality, continually improving, efficient and 
responsive to local peoples needs. 
 
Within Scotland Performs there are 45 national indicators, which represent progress 
towards the outcomes.  Some of these are already reflected in HEAT, and some (for 
example improved patient experience) will be reflected in the Quality Outcome Measures. 
 
How do the Single Outcome Agreements (SOA) fit into this framework? 
 
NHS Boards need to work closely with Local Authority and Community Planning partners 
towards their Single Outcome Agreements.  In the context of the Quality Measurement 
Framework, these could be considered at level 3 as they are locally agreed measures.  
However in some cases, the SOA outcome measures used may also be in HEAT or 
potentially even at level 1 acknowledging the current variation in tiers of measures used 
across Community Planning Partnerships. 
 
Scottish Government, August 2010 
 
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Appendix (a) – The Quality Measurement Framework 
 

 
 
 
 

 
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Appendix (b) – Potential National Quality Outcome Measures as specified in draft 
Quality Strategy – some are likely to change 

Potential measure 
Rationale 
Healthcare experience 
People’s experience of our services is important. This is also an 
indicator in the National Performance Framework for which 
methodology has still to be developed. Ideally, this measure would 
include feedback from both patients and carers. Patient experience 
of various aspects of quality can be assessed from current surveys. 
Further consideration around how to capture the experience of 
carers will be required and existing information sources will be 
explored. 
Staff experience 
Staff survey results provide another angle on the person-
centredness of the NHS. Survey questions relate to several of the 
quality dimensions. Again, these could be separate measures or 
combined into one measure. 
Staff attendance 
This indicator supports several dimensions, including efficiency and 
person-centredness. In addition, a reduction of staff absence could 
be expected to contribute to improved safety, timeliness and 
effectiveness. 
Healthcare Associated Infections 
Key priority within the strategy. Indicates a cleaner environment and 
reduction in avoidable harm. Infections can result in longer stays in 
hospital, reducing clinical effectiveness, efficiency and affecting 
timeliness. 
Emergency admissions 
This outcome indicator should represent a shift in the balance of 
care. It could demonstrate effectiveness of anticipatory and planned 
care. Patients are supported to remain at home where safe and 
appropriate. This measure should, therefore, reflect improved 
partnership working with social care, carers and the voluntary sector. 
Adverse events 
This directly contributes towards the aim of no avoidable injury or 
harm. Adverse events result in poorer clinical outcomes and less 
effective use of resources. Therefore, this measure supports 
effectiveness and efficiency as well as safety. 
Hospital Standardised Mortality 
National reduction in HSMR should reflect work in individual 
Rate (HSMR) 
hospitals to review mortality under the Scottish Patient Safety 
Programme and reflect reduction in serious adverse events and 
infections 
Proportion of people who live 
This outcome is intended to reflect the range of improvements right 
beyond 75 years 
through the healthcare system from prevention to treatment.  
Patient Reported Outcomes 
Indicates whether interventions have been effective from the point of 
view of patients. It is proposed that there is potential for, through 
time, an aggregated measure of PROMS based on local feedback to 
be developed. A project is being initiated by NHS QIS, working in 
partnership with the Universities of Stirling and Dundee & The 
Alliance of Self Care, to develop a national toolkit for this. As part of 
this project, the potential for this type of measure will be 
investigated. This is therefore a longer-term aim. 
Patient experience of access 
Shows the patient point of view as to whether they have been able 
to access the care they needed, when they needed it.  
Self Assessed General Health 
Self-assessed health will be a longer-term measure that will allow us 
to assess the effectiveness of a wide range of initiatives. Will reflect 
all quality outcomes including person-centred, timeliness, efficient, 
clinical effectiveness and safe.  
Percentage of last 12 months of 
Captures the outcomes of Living and Dying Well (a national action 
life spent in preferred place of 
plan for palliative and end of life care in Scotland) i.e. use of tools to 
care 
identify and assess people with palliative and end of life care needs; 
delivery and coordination of care across care settings to address 
those needs by consistent access to, and review of, anticipatory 
care plans (including palliative care summary and Do Not Attempt 
Cardio-pulmonary Resuscitation (DNACPR).  
 
 
 
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APPENDIX 2 
 
Proposed timetable for reporting effectiveness measures to the NHS Board 
 
This is an indicative timetable and additional areas may be included and the schedule may 
change in light of additional analyses and/or local work being required. The timetable will 
also be adapted as additional national data become available. For example medicine, 
which is covered across many of the topics already listed, may have an additional report 
as a medical profile is scheduled to be released by QIS at the end of 2011. 
 
Board 
Proposed 
Example of measure to be used 
Meeting  effectiveness measure 
report on 
Nov 
Mental Health 
Number of people recorded on Dementia 
2010 
 
Registers 
Respiratory 
 
 
Re-admission rates (7 and 28 days) for 
Chronic Obstructive Pulmonary Disease 
 
Jan 
Cancer 
Breast screening percentage uptake for 
2011 
 
women aged 50-70 
 
 
Sexual health 
Proportion of women of reproductive age  
using Long Acting Reversible Contraception 
(LARC) 
 
Mar  
Coronary Heart Disease 
Proportion of Coronary Heart Disease 
 
patients on register having an annual review 
 
May  
Renal  
Survival (from given time period when renal 
 
replacement therapy first started) 
 
 
July  
Diabetes 
Diabetes mortality 
 
 
 
 
Child & maternal health  
Percentage of pregnancies correctly identified 
 
by Down’s Syndrome screening test 
 
 
Surgery  
Surgical mortality  
 
 
Sep  
Stroke 
Percentage of patients admitted to a stroke 
 
unit on the day of admission 
 
 
Substance Misuse 
In development 
 
 
Blood Borne Viruses 
Percentage of patients who complete 
treatment for Hepatitis C infection 
 
Nov  
Palliative care 
In development 
 
 
Learning Disabilities 
In development 
 
 
Older People 
In development 
 
 
 
 
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Document Outline