1. Measuring harm in healthcare

2. Our demographics are changing…

3. Our tolerance is changing…. The burden is growing…….

4. Measurement is complex

5. Hospital Episode Statistics

7. http://www.nrls.npsa.nhs.uk/ http://www.nrls.npsa.nhs.uk/resources/?EntryId45=135153

9. Are we improving? The 6 million dollar question

11. MRSA Infection Rates Data sourced from the Health Protection Agency (mandatory surveillance of MRSA, Trust apportioned cases based on 167 NHS Acute Trusts in England) and HES online (calculated hospital bed days), calculated for the period April 2007 – October 2012. The data is presented as a rate (U Prime Chart) of MRSA bacteraemia per 1,000 hospital bed days (based on HES number of episodes). The mean rate for the latest re-based period is 0.01 per 1,000 FCE’s, an 86% decrease from the first period centre line. During the reported period there has been a decrease (before and after, first (Aug-Oct) and last three data points) of 2,558,522 bed days. 0.07 to 0.01 per 1000 bed days = 86% 

12. C.Diff Infection Rates Data sourced from the Health Protection Agency (mandatory surveillance of Clostridium Difficile, Trust apportioned cases based on 167 NHS Acute Trusts in England) and HES online (calculated hospital bed days), calculated for the period April 2007 – October 2012. The data is presented as a rate (U Prime Chart) of C.Diff per 1,000 hospital bed days (based on HES number of episodes). The mean rate for the latest re- based period is 0.17 per 1,000 FCE’s, a 75% decrease from the first period centre line. During the reported period there has been a decrease (before and after, first (Aug-Oct) and last three data points) of 2,558,522 bed days. 0.79 to 0.17 per 1000 bed days = 78% 

13. The proportion of patients who die in hospital Data sourced from Hospital Episode Statistics (HES) for the period April 2007 – October 2012. The data is presented in proportion (p prime chart) of patients in England that die within hospital (both emergency and elective), excluding non-elective/non-emergency e.g. maternity and blank codes. The denominator is the number of hospital admissions. The mean crude rate for the latest rebased period is 1.51%, although this does not take into account seasonal peaks. This data does not highlight the wide variation in mortality rates between organisations. During the reported period monthly admissions have remained stable at approximately 1 million per month. However between 2007 (Aug-Oct) and 2012 (Aug-Oct) there has been an increase in admission of 15% (a difference of 427,691). Months Proportion of patients who die (%) Seasonal Adjustment 1.88%1.52% 19% 

14. The proportion of patients who die in hospital – NHS QUEST network Data sourced from Hospital Episode Statistics (HES) for the period April 2007 – October 2012. The data is presented in proportion (p prime chart) of patients in England that die within hospital (only emergency admissions), excluding non-elective/non-emergency e.g. maternity and blank codes. The denominator is the number of hospital admissions.

15. QIPP Safe Care What about these harms?

19. Pre-work Safety Express PolicyCQUIN CQUIN implemented

20. Scale up to a national data collection

22. How many patients have a pressure ulcer?

23. How many people have a new pressure ulcer?

24. Is there a difference between settings?

25. What category is causing the highest burden?

26. How much variation is there?

28. Number of patient affected by a New Pressure (Cat 2-4) Number of patient affected by New Pressure Ulcer (Cat 3-4 only) Organisation Incident Reporting Safety Thermometer** Incident Reporting Safety Thermometer The Newcastle Upon Tyne Hospitals NHS Foundation Trust 8001844---491 Sheffield Teaching Hospitals NHS Foundation Trust 2432098---270 Central Manchester University Hospitals NHS Foundation Trust 8421215---273 Oxford University Hospitals NHS Trust 2481948---209 Imperial College Healthcare NHS Trust 22*1041---38 Cambridge University Hospitals NHS Foundation Trust 153629---55 University College London Hospitals NHS Foundation Trust 222428---142 Guy's and St Thomas' NHS Foundation Trust *** 80613---68 King's College Hospital NHS Foundation Trust 1471328---189 University Hospitals Birmingham NHS Foundation Trust 501*-266--- Percentage of patients affected by a New Pressure Ulcer (Cat 2-4) Percentage of patients affected by a New Pressure Ulcer (Cat 3-4 only) Incident Reporting Safety Thermometer Incident Reporting Safety Thermometer 0.6%1.4% --- 0.4% 0.2%1.6% --- 0.2% 0.6%0.9% --- 0.2% 1.6% --- 0.2% 0.0%0.8% --- 0.0% 0.2%0.6% --- 0.1% 0.3%0.5% --- 0.2% 0.1%0.6% --- 0.1% 0.2%1.3% --- 0.2% 0.7%0.3% --- Hospital Group New Pressure Ulcers * Cat 2 Pressure Ulcers not included *- Cat 1 Pressure Ulcers included ** Extrapolated figures based on full years HES (2011/12) admissions (inpatient spells) for Shelford group organisations and NHS ST national data for financial year 2012/13 *** Community reporting of pressure ulcers is proportionally higher than Acute reporting (Acute 80 & Community 717) --- No data available

29. What does all of this really mean?

30. 186, 617 People harmed from pressure ulcers developing in Hospital in England alone 149, 293 Could be avoided Tweet ideas #notonmywatch No national reduction in 2012… Commit to Act Now

31. What are we learning from the evaluation? Issues common to data collection systems: Connection to purpose Data collection systems Use of data

32. http://harmfreecare.org

33. Thank you