Sunday, 30 June 2013

Coding, once more.

This section of the Board meeting covering May is just a bit less reassuring than it should be:

“1 Executive Summary

The Trust is mindful of the need to increase its efforts to improve quality performance, in particular its in-hospital mortality and the experience of patients using its emergency services.

The Board’s attention is therefore drawn to three key issues discussed in the paper.

1. The challenge of reducing the amount of people who die in hospital;

Mortality reviews are being carried out at Divisional level but not on 100% of deaths as per the Trust’s aspiration. Therefore the performance of 97 deaths in hospital against a month’s target of 76 is disappointing. However, at a more Trust-wide level, the Clinical Outcomes Steering Group continues to provide in-depth analysis of the mortality data. There is more to be done to get all deaths reviewed in a standardised way and this is being tracked by the Integrated Governance and Assurance Committee.”

That’s 21 more deaths in one month than the target – how can we work to improve that figure, to improve patient outcomes?

I know, let’s have another look at the figures:

“The Medical Director and Chief Nurse introduced the Quality Report. This presented the quality dashboard with associated commentary on exceptions and the best care dashboard.

The following points in the report were highlighted:

The SHMI and RAMI target should be 73 which represented the proportion of in-hospital deaths. The RAMI had gone up to 83 in the month but on further investigation this was due to 30 patients who had not been coded appropriately;

Crude mortality for the month was 2.06% with a year to date figure of 1.66%. The increase towards the end of the year was a common seasonal peak with the year to date figure slightly above the planned 1.6%”

‘Coding’: I’ve had a bit to say about that in this Blog before – here’s an article I wrote which quotes from ‘Private Eye’ and The Daily Telegraph on this subject;


One section, ‘Change the diagnosis’, deals with how a hospital can change the cause of death from an illness which shows up in a category that rings alarm bells to one that doesn’t. You cook the books by altering cause of death so it doesn’t show up in the standardised mortality rates.

So, if someone comes in with a broken femur (that’s very treatable) but dies later of pneumonia (that’s not good) resulting from the break, you record it as caused by pneumonia and not the break. Then it doesn’t show up as a death that should have been prevented by better treatment.

So, the ‘Eye’ shows that in 2009 Mid Staffs Hospitals patients with hip fractures were 5 times less likely to die from that cause than the English average, even though the Hospital was losing far more patients with hip fractures than it should have done. It was credited as being one of the 5 ‘most improved’ trusts in 2009 as a result.

Well, they are all at it again!

Check out this Daily Telegraph report;

Wednesday 27 February

The head of an NHS trust has "stepped aside" amid fears that staff tried to mask high mortality rates by recording the wrong cause of death for patients. Dr Jackie Bene, medical director and acting chief executive of the trust, has 'stepped aside'

By Stephen Adams, Medical Correspondent6:30PM GMT 27 Feb 2013

2011, Bolton NHS Foundation Trust recorded a large spike in septicaemia deaths, which are not included in official mortality figures, at the Royal Bolton Hospital in Greater Manchester. During the same year, it also recorded a significant improvement in death rates and was given an award for the “most improved” trust.

But a recent audit demanded by local doctors has unearthed evidence that these improvements may have been fictional. On Monday staff were told that Dr Jackie Bene, medical director and acting chief executive of the trust, had “stepped aside” to “allow a fully independent view to be taken". The report is expected to be completed by March 6.

Professor Sir Bruce Keogh, medical director of the NHS, last night (Wed) said hospitals “must behave openly and honestly about their performance”, while campaigner Julie Bailey said: “It’s fraud in my mind.”

Until 2011 the Bolton trust had been one of the worst performing hospital trusts in England, with death rates well above the national average. But that year its mortality rate plummeted, leading to the award. Last December it was ranked as having death rates that were “better than expected”. Yet between April 2011 and March 2012 some 800 deaths from septicaemia were recorded at Bolton - four times the number one would expect in a trust of that size. A septicaemia coding also means the hospital would have received more money for that patient.

Dr Wirin Bhatiani, lead GP for the Bolton Clinical Commissioning Group, said he first became aware of the "unusually high" number of septicaemia cases in October. The group has commissioned the hospital rating firm Dr Foster to carry out an independent audit looking at 200 cases. Dr Bhatiani said interim findings based on 50 cases showed “cause for concern”. He said: “While we are keen to wait for the final report, we are sufficiently concerned by the interim findings to commence further investigations.”

David Wakefield, chairman of the trust, said it wanted to "rule out any serious issues as soon as possible" and make sure the way patients were coded met the"highest quality standards". He was brought in by Monitor, which regulates semi-autonomous foundation trusts, after it put Bolton in the highest risk rating for governance and finance.

A trust spokesman emphasised the issue was solely with the way “some causes of death were recorded”, and did not change the number of people who had died. Neither did it mean patients’ death certificates were inaccurate, she added. Julie Bailey, founder of the Stafford group Cure the NHS, said the Bolton situation showed “each and every hospital” should be vetted to find out “just how many unnecessary deaths there have been”. She said: “We are hearing more and more instances of people apparently ‘gaming’ the data to mask high death rates. If that’s what’s been going on here, it’s fraud in my mind.”

Professor Keogh said: "If we're to have an open and accountable NHS, where patients and the public know how NHS hospitals are doing, those hospitals must behave openly and honestly about their performance. "These allegations have been picked up by the local NHS working together and scrutinising what has been going on - with support from the Care Quality Commission and Monitor. As yet, there is no evidence that any patient has been harmed. But we will be monitoring the situation and learning any lessons." Bolton is not one of the 14 trusts currently being examined for apparent high death rates. However, a Department of Health spokesman said Prof Keogh “reserves the right” to call it in if he felt it necessary.


Why get told off for failing patients when you can just move a few figures around, get out of trouble and get paid more money as well?

How many more ‘trusts’ are doing this?

Probably all of them.


That’s how I ended the Blog back in February.

30 deaths re-coded – that really worries me.


Neil Harris

(a don’t stop till you drop production)

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