Cwm Taf Morgannwg University Health Board (CTUHB) continues to work collaboratively with colleagues across NHS Wales to establish better ways of measuring clinical performance & outcomes and to learn & improve the quality of care. In addition, all mortality data for the CTMUHB is subject to regular/continuous internal analysis. Our analysis has not found any evidence of systematic failure in health care leading to excess mortality. The analysis reports are regularly submitted to and scrutinised by the Quality & Safety Committee, the Executive Board and the Health Board and most recently a report was submitted to the Health Board meeting in November 2015.
The Crude mortality data for CTUHB remains high due primarily to:
- The lack of alternative end of life care arrangements for many patients just prior to death (in 2015, 62.4% of deaths in Cwm Taf Morgannwg area occurred on hospital sites compared with 54.6% average for Wales as shown in Mortality Indicator Reference No. 20).
- The population high rate of co-morbidities linked to higher rates of Deprivation as shown in Mortality Indicator reference No. 21). This is also linked to the higher than Wales average crude deaths rate per 1,000 population as shown in Mortality Indicator reference No. 2).
Cwm Taf Morgannwg UHB has established an effective system of scrutiny to monitor patient safety and mortality which also provides a rich environment for multi-professional learning leading to improving quality of care. This process was referenced in the Summary Findings & Recommendation of Professor Stephen Palmer Independent Review – Recommendation No. 26 “Cwm Taf Morgannwg Health Board has an impressive and high visibility clinical case notes mortality review process in place giving considerable reassurance to the Board that high Risk Adjusted Mortality Indicator (RAMI) are not indicators of poor care”. Professor Stephen Palmer report
Cwm Taf Morgannwg’s approach to monitoring safety and quality of care is based on the recommendations of Professor Stephen Palmer Report and include:
- Establishing a systematic mortality review process
- Progressive improvement is being achieved
- Cwm Taf Morgannwg is expected to submit performance reports regularly to Welsh Government regarding the timescales for the reviews
- Monitoring and benchmarking of condition-specific mortality
- Participation in National Audits
- Improving data quality via improved clinical engagement
What are we doing in Cwm Taf Morgannwg University Health Board?
Within Cwm Taf Morgannwg UHB, we do not rely solely on mortality indices we are provided with to tell us about safety for those patients who die in our hospitals.
However, they may guide us to those areas of variance, which require further scrutiny and investigation to establish whether there are failings in service delivery and/or quality improvements that can be made. They are not a substitute for the more valuable process of examining in detail the clinical record and circumstances in which a patient dies in hospital. This process is known as case-note mortality review and it serves two purposes. Firstly to provide reassurance that the majority of deaths are expected and unavoidable, and secondly, to identify areas within our services where we can do better.
From April 2013, the hospital notes of every in-patient dying in either Prince Charles or Royal Glamorgan Hospitals has been or is in the process of being reviewed by a team of senior clinical staff including General Practitioners, hospital specialists and senior nursing staff. As of April 2014 we extended this process to other hospital sites across Cwm Taf Morgannwg. There is wide support from, and engagement with our doctor and nurse teams around this process. Our aim is not just to prevent avoidable death but to prevent any harm to patients, especially that which results in long-term suffering or disability.
We do not rely on sampling i.e. that some deaths should be reviewed and others not. Death is a natural and expected process most of the time but we believe that every death deserves the attention that comes from an independent assessment (i.e. by staff who did not treat the patient during life) to offer that reassurance. Equally, where concerns are raised we believe it is right and proper to ensure that we are in a position to learn any lessons in order to improve the care we give to patients.
In terms of the reassurance we have sought, we have found from case-note mortality review that the vast majority of patients who have died in our hospitals were coming to the end of their natural lives and that we have been particularly effective in recording conversations staff have had with relatives about this.
However, the process has been valuable in highlighting areas where we think we could improve care provided and learn lessons. For example, we have put into place more effective measures to reduce the risk of patients developing blood clots and significant infection during hospital admission. In the small number of cases where we have found, for example, evidence of delays in communication between staff or delays in treatment, we have notified the senior doctor or nurse responsible to seek clarity and evidence of learning for the purposes of improvement.
More generally Cwm Taf Morgannwg UHB also collects and scrutinises a wide range of objective safety measures to inform our quality improvement plan, examples include:
- Infection rates: Cwm Taf Morgannwg Health Board continues to have the lowest rate of C Difficile infection in Wales
- There is a sustained improvement over the past 2 years in mortality rates in Cwm Taf Morgannwg from heart attacks, stroke, following hip fractures, and crude in hospital mortality rates which reflect the progress made in developing the stroke unit, improving pathways with neighbouring health boards and quality improvement processes. These services continue to be monitored and scrutinised to facilitate further quality improvement processes.
- Pressure ulcer rates: we have made significant improvements in the methodology for recording the incidents of pressure ulcer development and improving management.
Together with mortality indices and case-note mortality review this suite of information gives us a far more meaningful picture of the safety and quality of healthcare provided to patients who are admitted to our hospitals.
A note about interpreting mortality index data
The Measuring Inequalities (2016) report shows that at a population level people are living longer and longer in good health in Wales as a whole. However, the report also indicates at a national level that the difference between life expectancy between the most and least deprived areas of Wales shows no sign of reducing. This is called the Slope Index of Inequalities (SII).(1)
The graph above compares life expectancy and healthy life expectancy for Cwm Taf Morgannwg. It provides a comparison between the time periods 2005/09 and 2010/14 and the variation in the Slope Index of Inequalities (SII). In Cwm Taf Morgannwg, it is a very positive sign that life expectancy and healthy life expectancy (2010-2014) have improved since the previous report (2005-2009). The inequality gap between the most and least deprived has narrowed across all of the parameters and this has not been seen in other parts of Wales. However, we still remain below the Wales averages and for male life expectancy in Rhondda Cynon Taff, the inequality gap has increased since the previous report from 7.4 years to 7.8 years demonstrating the variations within Cwm Taf Morgannwg.
- Cwm Taf Morgannwg serves the most deprived communities in Wales and has a large older population suffering from long-term, often multiple and complex health conditions
- The deprivation and associated co-morbidities is highest in Merthyr Tydfil and Rhondda Cynon Taff (Next to Blaenau Gwent) as shown in mortality indicator 21.
- Rhondda Cynon Taff and Merthyr Tydfil (Together with Neath Port Talbot and Bridgend) Has the lowest life expectancy at birth which is more obvious in females as shown in mortality indicator 1.
- A greater proportion of patients are admitted and treated as emergencies in Cwm Taf Morgannwg hospitals (as opposed to being brought into hospital on a planned basis). Many of these admissions are likely to reflect the severity and progression in their illness.
- The percentage of people dying in hospital as opposed to at home or in a nursing home is also greater in the population Cwm Taf Morgannwg serves and underlies the crude mortality figures for Cwm Taf Morgannwg UHB. This is often a matter of culture and/or limited choice about admission to hospital as part of their end-of-life care. This is demonstrated in mortality indicator 20.
The Association of Public Health Observatories has produced a very helpful technical briefing document called Dying to Know which contains further information about interpreting mortality data, which is available via this link.