Data Management, Audit and Outcomes

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1 Data Management, Audit and Outcomes Providing Accurate Outcomes and Activity Data The Trust has in place robust mechanisms for capturing and reporting on all oesophago-gastric cancer surgery activity and associated clinical outcomes. We have a full time permanent Clinical Audit Officer who proactively maintains our upper GI surgical database which contains ten years worth of experience. The purpose of this role is to ensure all activity and outcome data is both accurate and valid. The quality of our data has been confirmed in both national and regional audits. The database currently holds data on over 647, and has been a vital tool in understanding trends and realising the impact of increased experience and improved practice on long term survival rates. Regular checks of the validity of the data are performed by the surgeons in collaboration with the Clinical Audit Officer, who also automatically validates the data against that held in the patient administrative system. Once checked, the data are subsequently submitted to the NHS Connecting for Health secondary uses service. The Trust has received significant assurance for data quality and the systems and processes supporting it. As part of the external assurance supporting the production of the Quality Account, the Audit Commission recently undertook a review of the management of the 62 day cancer pathway; it was noted that there had been significant improvements made in data management and therefore, no recommendations were made. The Trust have successfully implemented the Somerset Cancer Register to aid the collection of activity and waiting time data and also support clinical audits and reporting. Clinical Coding at LHCH has been recognised as being of the highest standard within the north west of England; being the only Trust in the region to achieve Level 3 in the Information Toolkit requirements and achieving excellent results in their PbR Assurance Framework Audit undertaken by the Audit Commission. This achievement has been nationally recognised with the Trust receiving a CHKS overall winner award in the Specialist Trust category for data quality and clinical coding for both 211 and 212. We are not complacent about our approach to data quality, recognising that there is always an opportunity to improve. As such, the Trust welcomes the opportunity to receive external feedback regarding the quality and validity of data submitted. This feedback will be used to re-engineer our systems and processes. The Trust has started developing a new electronic patient record which will integrate the totality of its data sources. This will provide new and substantial opportunities to scrutinise and improve the quality of its data yet further.

2 Participation in National Audits We are committed to submitting accurate and valid data to all national audits that fall within our remit as determined by the National Clinical Audit and Patient Outcomes Programme (NCAPOP) list. This is reported each year within our quality accounts in order to demonstrate transparency in our full compliance. In addition to the NOGCA, LHCH contributes to all National Audit projects pertaining to cardiology, respiratory medicine and cardiothoracic surgery. The Clinical Audit programme at LHCH seeks to improve the outcomes of patient care through structured peer review where by clinicians examine their practice and outcomes against agreed standards and modify their practice where indicated. A Comprehensive clinical audit forward plan is drawn up each year for each service line as part of the Trusts overall annual plan. The Clinical Quality Department work with the clinicians and management staff in the service lines to ensure delivery of the plan and realisation of outcomes for the benefit of patients. The AUGIS 21 national report served to confirm the excellent practice and outcomes of LHCH (see Outcomes). Supporting Clinical Governance Operative activity and outcomes are analysed for the Unit and individual surgeon with benchmarking against national data. This is presented on a regular basis at monthly clinical audit days and as part of consultant appraisal. With respect to Upper GI surgery process control charts are created for in-hospital mortality, anastomotic leak, return to ITU and return to theatre. The hospital has a policy for the monitoring of Thoracic and Upper GI surgical performance, with a detailed description of outcomes being measured and how variations from agreed standards are dealt with. Outcomes from local and national audit are discussed at Directorate Governance meetings on a monthly basis and any relevant action plans are incorporated in the governance work plan for ongoing review. Overall clinical governance is the responsibility of the Clinical Quality Committee, chaired by the Trust Medical Director.

3 Adjusted Mortality Rate LHCH uses a variety of statistical techniques for its Consultant appraisal process including funnel plots and cumulative summation (CUSUM) charts shown below. Example of funnel plots used at LHCH for Consultant appraisals in-hospital mortality by Consultant after pulmonary lobectomy for cancer Number of Cases Upper 9% CI Lower 9% CI Upper 95% CI Lower 95% CI Upper 99% CI Lower 99% CI Unit Average % Operator This plot tells us that each operator falls within acceptable limits of performance with respect to mortality taking into account volume of activity. This is a static plot and is useful for ensuring lower volume operators are not disadvantaged when performance is assessed. For CUSUM charts, each patient in a given experience (we use a three year moving window, such that each surgeons most recent three years of activity is subject to scrutiny) is allocated a sequential number (x axis). The outcome of each patient is plotted (y axis) relative to their sequence number; each in-hospital death is reflected in a unit increase in the number observed (observed mortality). Ninety-five per cent confidence limits surround observed mortality to facilitate visual significance testing. All patients have their expected risk calculated using appropriate risk models. Expected risk is accumulated across the experience in parallel with observed mortality. Differences therefore reflect variations in performance between what is achieved (observed) and what is predicted (expected) in a time related way. This is the principal difference with funnel plots, and is especially useful in detecting periods of underperformance that might otherwise go undetected in a static plot. We plan to develop a risk model for Upper GI surgery and have considerable experience in developing and publishing such models in other cardiothoracic specialties. The figure below shows acceptable performance, as both estimates of risk lie well within the 95% confidence limits. This surgeon has experienced a relative increase in the number of deaths in the second half of his experience relative to the first, without

4 change in case mix (evidenced from the straightness of the line plotting the expected number of deaths). Should the estimates of expected risk cross the lower bound confidence limit, unacceptable performance would be inferred. Estimates of expected risk crossing the upper bound confidence limit signify excellent performance. This method of displaying results has visual appeal and is easy to comprehend. Example of CUSUM curves used at LHCH for Consultant appraisals Observed deaths Upper confidence limit Lower confidence limit Expected deaths EXCELLENT No. Dead ACCEPTABLE Patient Sequence No UNACCEPTABLE

5 Adjusted 3-day Mortality (%) Outcomes Mortality The crude 3-day mortality for oesophagectomy and gastrectomy was.7% and % respectively between April 29 and March 212. Adjusted 3-day mortality rates, from the recent National Oesophago-Gastric Cancer Audit for 21 (national audit 1st October 27 to 3th June 29), for LHCH and other NHS Trusts in the north west of England, including the rate for England and Wales, are shown in the figure below. Adjusted 3-day mortality after surgical resection in oesophago-gastric cancer patients 12% 1% Adjusted 3-day Mortality England and Wales Performance 8% 6% 4% LHCH 2% % North West NHS Trusts

6 Adjusted 9-day Mortality (%) Adjusted 9-day mortality rates, from the recent National Oesophago-Gastric Cancer Audit for 21, for LHCH and other NHS Trusts in the north west of England, including the rate for England and Wales, are shown in the figure below. Adjusted 9-day mortality after surgical resection in oesophago-gastric cancer patients 16% 14% Adjusted 9-day Mortality England and Wales Performance 12% 1% 8% 6% 4% LHCH 2% % North West NHS Trusts

7 Percentage The overall in-hospital mortality between April 29 and March 212 for oesophagogastric cancer surgical patients is shown in the figure below. In-hospital mortality after surgical resection in oesophago-gastric cancer patients 5% 4% 3% LHCH In-hospital Mortality 2% 1% % All Upper GI Surgery Oesophagectomy Gastrectomy

8 LHCH continually monitors its in-hospital mortality rates using Statistical Process Control (SPC) charts as shown below for both for oesophagectomy and gastrectomy.

9 Adjusted Anastomotic Leak (%) Anastomotic Leak The crude anastomotic leak rate for oesophagectomy and gastrectomy was 6.3% and 2.6% respectively between April 29 and March 212. Adjusted post-operative anastomotic leak rates, from the recent National Oesophago-Gastric Cancer Audit for 21, for LHCH and other NHS Trusts in the north west of England, including the rate for England and Wales, are shown in the figure below. Adjusted post-operative anastomotic leak rate after surgical resection in oesophagogastric cancer patients 3% 25% Adjusted Anastomotic Leak England and Wales Performance 2% 15% 1% 5% LHCH % North West NHS Trusts

10 As with in-hospital mortality, SPC charts are used routinely to monitor anastomotic leaks as shown below for oesophagectomy.

11 Survival The latest three-year survival statistics for oesophagectomy and gastrectomy are 61% and 59% respectively for the period April 29 to March 212. The survival curves for both oesophagectomy and gastrectomy are shown in the figures below. The survival statistics are obtained on a routine basis from the Demographics Batch Service (DBS, formerly the National Strategic Tracing Service) and are linked to over 1-years worth of clinical data held on upper GI and thoracic surgery.. This survival data is produced by collecting information on patients undergoing an oesophagectomy for cancer which has been entered prospectively onto the LHCH upper GI/thoracic surgical database over the last 1 years. The long-term outcomes for the patients are identified from the DBS. We are very proud of these figures which are as good as survival data published anywhere else in the Western world. These results justify our high surgical resection rate (28%, compared with the National OG Audit figure of 24%) indicating that a pro-active approach to patients with marginal fitness suffering from oesophageal cancer when combined with excellent peri-operative outcomes can lead to a high cure rate. The routine collection of survival status for our patients enables the Trust to have robust intelligence on long-term survival as shown below stratified by pathological stage.

12 Readmissions The 3-day readmission rate for upper GI surgery at LHCH between April 21 and March 212 has been %; with no reported unplanned readmissions. LHCH has a robust readmission process in place with information provided on a monthly basis by Commissioners on all readmissions associated with the Trust; this includes readmissions back to LHCH and also those readmitted to another Hospital within 3-days. This information is used to monitor readmission performance abd supports an on-going Service Improvement Project aimed at reducing such events.

13 Patient Surveys and Quality of Life LHCH has an embedded patient and family experience vision with monthly questionnaires undertaken to assess 6 core domains: arrival, patient contract, stay, treatment, after stay and reputation. This is in conjunction with participation in all relevant national patient surveys. This information is collated electronically and can be provided in hard copy. The latest information for 212/13 continues to demonstrate excellent results in this area as shown below. Patient Survey Results for 6 Core Domains 212/13 Target 211 National In-patient Survey 212/13 In-House Survey YTD (n=1126) AFTER STAY: Q13. Did you feel you were involved in 95% decisions about your discharge from hospital? 95% REPUTATION: Q18. Would you recommend this hospital to your family and friends? 1% 99% 93% 9% 8% 7% 99% 96% 99% ARRIVAL: Q1. Did you feel the hospital staff were 99% expecting you? 98% 6% 94% TREATMENT: Q16. Would you agree, the staff really 92% knew what they were doing? 88% 92% 82% 87% 85% PATIENT CONTRACT: Q4. Did you feel that your care was planned with you and for you? 96% 95% STAY: Q15. Did you feel you were treated with compassion? On the back of the processes already in place, we are implementing the new Department of Health's NHS Friends and Family which aims to compare all NHS Trusts on whether patients would recommend friends and family to receive similar care or treatment from the provider. With respect to PROMS, as a specialist Trust, LHCH was not involved in the initial project. However, LHCH is the lead organisation for PROMS for coronary revascularisation and has responsibility for analysing all of the initial pilot data which has been collated from 11 Hospitals.

14 LHCH has a long history of undertaking quality of life assessments through it's work as the host centre for the North West Quality Improvement Prgramme in Cardiac Interventions as demonstrated below which used EQ5D (which is the primary tool used within PROMS. Example of Quality of Life assessments before and after intervention 1 9 p<.5 p<.1 p<.1 p<.1 NS NS NS p<.5 Mean (SE) EQ5D (lower=worse quality of life) At follow-up At baseline Score Scale Score Scale Score Scale Score Scale PTCA N=86 CABG Only N=69 Valve(s) Only N=11 CABG+ Valve(s) N=7 18-weeks, Cancer Waits and Infection Rates LHCH continues to show excellent performance with respect to 18-weeks, cancer waiting times, and infection rates. This is demonstrated by the current Monitor Governance Risk Rating of Green as illustrated on the following page (as of November 212).

15 Governance Risk Rating Q1 Q2 Q3 Q4 YTD Amber Green Green Green Green Indicators - Weighted 1 Threshold Weighting Monitoring Period Plan Q1 Q2 9 Q3 9 Q4 YTD Clostridium Difficile - meet trajectory 12 1 Quarterly MRSA - meet trajectory 6 1 Quarterly 1 All Cancers: 31 day wait for second or subsequent treatment (surgery) 94% 1 Quarterly 94% 1% 1% 1% 1% All Cancers: 62 day wait for first treatment from urgent GP referral to treatment 79% 1 Quarterly 79% 75.6% 81.5% 8.3% 79.2% Referral to treatment waiting times - Admitted pathway compliance - Measured aggregate; failure in month is a fail for the quarter 9% 1 Quarterly 9% 93.% 92.3% 9.7% 92.1% Referral to treatment waiting times - Non admitted pathway compliance - Measured aggregate; failure in month is a fail for the quarter 95% 1 Quarterly 95% 97.1% 97.1% 95.3% 96.6% Referral to treatment waiting times - Incomplete pathways compliance - Measured aggregate; failure in month is a fail for the quarter 92% 1 Quarterly 92% 93.8% 93.7% 93.3% 93.3% Indicators Weighted.5 Threshold Weighting Monitoring Period Plan Q1 Q2 9 Q3 9 Q4 YTD All Cancers: 31 day wait from diagnosis to first treatment 96%.5 Quarterly 96% 98.8% 98.2% 98.6% 98.9% Cancer: 2 week wait from referral to date first seen (all cancers) 93%.5 Quarterly 93% 1% 1% 1% 1% Data Completeness Community Services Indicators Weighted 1 Threshold Weighting Monitoring Period Plan Q1 Q2 9 Q3 9 Q4 YTD Referral Information 5% 1 Quarterly 5% 99.1% 98.8% 98.6% 98.9% Treatment activity information 5% 1 Quarterly 5% 1% 1% 1% 1%

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