NSS Information and Intelligence - ISD Scotland › Products-and-Services › ... · 4,000 records....

NationalServicesScotland

Assessment of SMR01 Data Scotland 2014-2015

NSS Information and Intelligence

Data Quality Assurance.

Data Quality Assurance Assessment of SMR01 Data Scotland 2014-2015

i

ContentsIntroduction ............................................................................................................................1

Executive Summary ...............................................................................................................2

Key Points ...............................................................................................................................................2

Summary of Recommendations .............................................................................................................2

Methodology ...........................................................................................................................2

Determining the Sample Sizes ..............................................................................................3

1. Results and Commentary ..................................................................................................5

1.1 Assessed data items National Accuracy ..........................................................................................6

1.2 Percentage Accuracy by Data Item and Hospital ...........................................................................7

2. Clinical Coding Accuracy ................................................................................................11

2.1 Clinical Coding Accuracy – 1992 to 2015 ....................................................................................... 11

2.2 Clinical Coding Accuracy – Main Condition ................................................................................... 14

2.3 Clinical Coding Accuracy – Main Operation/Procedure ................................................................ 19

2.4 Clinical Coding Accuracy within Defined Groups – Common Conditions (Adults) ....................... 24

3. Non-Clinical Coding Accuracy........................................................................................27

3.1 Non-Clinical Coding Accuracy – Admission Type .......................................................................... 27

3.2 Non-Clinical Coding Accuracy - Clinician Main Operation ............................................................29

3.3 Non-Clinical Coding Accuracy – Consultant / Health Care Professional Responsible for Care ... 31

3.4 Non-Clinical Coding Accuracy Continued – Date of Main Operation/Procedure .........................32

4. Additional Issues Identified ............................................................................................34

4.1 Examples of good practice .............................................................................................................34

4.2 Availability of Discharge Letters ......................................................................................................34

4.3 Clinical Coding Workforce by Health Board. ..................................................................................36

4.4 Findings from Additional Samples ..................................................................................................36

4.5 Conclusions .....................................................................................................................................36

4.6 Recommendations .......................................................................................................................... 37

Appendix 1 – Availability of Discharge Letters .................................................................38

Availability of discharge letters for all records assessed, discharges 2014-2015 ...............................38

Appendix 2 – Confidence Intervals ....................................................................................40

Accuracy of Main Condition .................................................................................................................40

Accuracy of Main Operation ................................................................................................................. 41

Appendix 3 – NHS Board Tracking Systems .....................................................................43

Contact ..................................................................................................................................44

Background Information .....................................................................................................44

Glossary of Data Definitions for Data Items Assessed ....................................................45


ii

Appendix 4: Additional Findings from Booster Samples - Epilepsy ...............................46

Objective ...............................................................................................................................................46

Key Findings ..........................................................................................................................................46

Background ...........................................................................................................................................46

Availability of Discharge Letters ............................................................................................................46

Clinical Findings .................................................................................................................................... 47

Recommendations ................................................................................................................................50

Further Information ................................................................................................................................ 51

Availability of Discharge Letters ........................................................................................................... 51

Appendix 5: Additional Findings from Booster Samples – Drugs Misuse ......................52

Objective ............................................................................................................................................... 52

Key Findings .......................................................................................................................................... 52

Background ........................................................................................................................................... 52

Clinical Findings ....................................................................................................................................53

Appendix 6: Additional Findings from Booster Samples - Aneurysms ..........................54

Objective ...............................................................................................................................................54

Key Findings ..........................................................................................................................................54

Background ...........................................................................................................................................54

Availability of Discharge Letters ............................................................................................................54

Clinical Findings ....................................................................................................................................55

Recommendations ................................................................................................................................58

Further Information ................................................................................................................................58


1

IntroductionThe quality assurance work carried out by Information Services Division (ISD) is an essential component of Information Governance and supports the meaningful use of nationally collated patient data in health care service planning. As part of ISD’s data quality assurance remit a National Assessment is carried out periodically, examining the quality of SMR01 data items (Inpatient and Day Case).

During 2014/15 the Data Quality Assurance (DQA) team at ISD carried out a quality assurance assessment of SMR01 (Acute Inpatient and Day Case) data submitted to ISD. This follow-up to the 2010/11 data quality assurance assessment aims to:

■ Ensure SMR01 data items are being recorded consistently to a high standard throughout NHSScotland.

■ Investigate the accuracy of recording for SMR01 clinical data items which stakeholders have identified as high interest.

■ Identify issues that may require further guidance and training across Scotland and share examples of best practice.

■ Highlight gaps in information being supplied to staff who record data items.


2

Executive SummaryThe DQA team has been assessing the quality of SMR01 data for over 25 years. Throughout this time the accuracy rate for recording of Main Condition and Main Operation/Procedure has remained relatively stable at around 89% and 94% respectively and this has not changed for this assessment.

Key Points ■ For Main Condition accuracy, 18 (50%) of the 36 hospitals assessed achieved the ISD

recommended minimum standard of 90%. ■ For Main Operation accuracy, 31 (89%) of the 35 hospitals assessed achieved the ISD

recommended minimum standard of 90%. ■ The overall Main Condition accuracy at 3-digit level was 89% nationally, which is consistent

with DQA assessments from 2010/11 and 2004/06. ■ The overall Main Operation accuracy at 3-digit level was 94% which is consistent with DQA

assessments from 2010/11 and 2004/06. ■ Almost half (44%) of the records assessed did not have a Final Discharge Letter (FDL). ■ All five non-clinical data items were recorded with above 90% accuracy.

Summary of Recommendations ■ Clinical staff should provide timely, high quality discharge letters with clear diagnostic and

procedural descriptions to enable accurate coding. ■ Local coding rules at health boards should conform to national standards and coding staff

should use all available information to record codes as specifically as possible. ■ Coding staff should take extra care to accurately code Main Condition. ■ There should be improved and increased recording of conditions identified as acute or

background conditions affecting the management of the patient.

MethodologyThe DQA team assessed records from hospitals in all mainland NHS Boards, Golden Jubilee National Hospital and one Island Board (Orkney). This amounted to 36 hospital sites and a total of 3,345 episodes in a random sample were assessed. Of the assessed episodes, 71% were inpatient and 29% were day case admissions.


3

Determining the Sample SizesA review of previous SMR01 National Assessments showed that given the number of staff available and the timeframe involved it was feasible to audit somewhere between 3,000 and 4,000 records. The decision had previously been made to include only one island hospital in the assessment, in this case, the Balfour Hospital in Orkney. Therefore, the Western Isles Hospital and the Gilbert Bain hospital were not included although an Informal assessment was carried out at Western Isles Hospital in March 2014 at their request. That meant a total of 36 hospitals with average available beds varying from over 1,000 to less than 20 were to be assessed.

The hospitals were stratified by hospital group and the average number of staffed beds was used to subdivide the A3 group (General Hospitals). Note that although Balfour hospital is classed as an A32 (small General Hospital), it was deemed appropriate to assess a minimum of 100 records, and reduce the confidence interval. The numbers of records assessed for each hospital were:

■ Teaching Hospitals (A1) – 140. ■ Large General Hospitals (A2) – 100. ■ General Hospitals (Medium) (A31) – 60. ■ General Hospitals (Small) (A32) – 40. ■ Children’s Hospitals (A4) – 75.

The system used to extract the samples ensured that a suitable proportion of records are drawn from each specialty.

The DQA team assessed selected data items submitted to the National Inpatient/Day case Scottish Morbidity Records (SMR01) database held at ISD. DQA compared the quality of submitted information against all patient information available at source, which includes assessing both the accuracy of coding and the quality of information available to coders.

For this assessment, DQA have utilised a new method of assessing, concentrating on the most used data items. This provides a more focused assessment and ensures the best use of DQA resources. In consultation with stakeholders it was agreed that the following would be assessed for accuracy:

Non-clinical: ■ Admission Type (to identify place of occurrence). ■ Consultant/HCP Responsible for Care (legally responsible for care). ■ Date of Main Operation (to determine whether admission date is used as a default). ■ Clinician Responsible for Main Operation (to determine if different from Consultant

Responsible for Care). ■ Specialty.

Clinical: ■ Main Condition (to 3 and 4-digit level). ■ Main Operation (to 3 and 4-digit level). ■ Groups of Common Conditions.


4

For those NHS Health Board areas which are deemed to be ‘Paper Light’ (the vast majority of patient information is held electronically), the assessment was carried out as much as possible utilising direct1 or remote2 access to hospital information systems.

The Western Infirmary, Victoria Infirmary, Southern General Hospital and Royal Hospital for Sick Children at Yorkhill were closed and services transferred to the new Queen Elizabeth University Hospital which was officially opened on 3rd July 2015. However, the time period being assessed related to discharges before the transfer, therefore the records from these individual hospital sites were assessed.

1 Aberdeen Royal Infirmary and the Royal Aberdeen Children’s Hospital were assessed directly i.e. firewall opened up to allow direct access to the server(s) which host the system(s).

2 NHS Greater Glasgow & Clyde, NHS Forth Valley and NHS Lothian were assessed via remote desktop connection.

Booster SamplesIn addition to the main random sample, the following booster samples were assessed to identify accuracy of coding to support areas of clinical interest or ISD statistical output:

■ 118 records with ICD-10 Codes G40.0-G40.9, R56.0 and R56.8 (Epilepsy or Seizures) in paediatric patients were assessed and support clinical interest nationally, (Appendix 4).

■ 76 records with ICD-10 Codes F11-F16, F18-F19 were assessed for Drugs related activity publications, (Appendix 5).

■ 70 records with ICD-10 Codes I71-I72 (Aneurysms) were assessed to support clinical interest nationally, with particular attention to admission type and aortic aneurysm repair operations. (Appendix 6).


5

1. Results and CommentaryFigure 1.1.1 shows the eleven data items assessed and compares nine of these with previous assessments in 2010/11 and 2004/06 where appropriate.

Of the total of 3,345 records assessed, there was insufficient evidence to assess accuracy in the following number of records:

■ Admission Type in 31 records. ■ Clinician Responsible for Main Operation in 115 records. ■ Consultant/HCP Responsible for Care in 398 records. ■ Date of Main Operation in 31 records and Specialty in 35 records. ■ Main Condition to a 3-digit level in five records. ■ Main Condition to a 4-digit level in one record. ■ Main Operation to a 3-digit level in eight records.

Data items with insufficient evidence to assess the accuracy of recording were excluded from the accuracy calculation.

Although the accuracy rate of Main Condition at 3-digit level has remained relatively stable over the years at around 89% it still falls below the ISD recommended minimum standard of 90%. However, this is not statistically significant from the 90% standard. For confidence intervals see Appendix 2.

The accuracy rate for Main Operation/Procedure at 3-digit level was 94% which was consistent with previous assessments in 2010/11 and 2004/06. For confidence intervals see Appendix 2.

There was a marked increase in the accuracy of Clinician Responsible for Main Operation from 80.3% to 94.2%. Where errors were found in this data item (180 errors), 42 were due to the corresponding operation being omitted and 17 were due to the corresponding operation being over-recorded.

There is a slight increase of 0.1% in the accuracy of Date of Main Operation. There were 125 errors for this data item 45 of which were due to corresponding operation being missed and 19 due to corresponding operation being over recorded. Of the remaining 61 errors, 56 were recorded incorrectly as admission date but evidence was available to find the correct date. Some coding departments default to admission date whether an operation date is available or not. Coding departments should always conform to official standards rather than using local defaults.


6

1.1 Assessed data items National Accuracy

Figure 1.1.1 - Accuracy of recording by data item – Scotland

81.0

84.0

87.8

90.9

93.2

80.5

91.8

80.0

88.0

88.3

90.4

93.6

94.3

80.3

96.1

99.6

80.4

82.3

88.1

89.0

90.1

90.2

90.3

93.8

94.2

96.2

99.1

0 10 20 30 40 50 60 70 80 90 100

Common Conditions (Adults) *

Common conditions (Paediatrics) *

Specialty

Date of Main Operation

Clinician Responsible for Main Operation

Main Operation (3-digit)

Admission Type

Consultant/HCP Responsible for Care


Main Condition (3-digit)


2014/15

2010/11

2004/06

* not comparable with 2010-11 or 2004/06. The accuracy of Common Conditions was not assessed in the previous two DQA assessments while Specialty and Admission Type were not assessed in 2004/06.


7

Table 1.1.2 shows that since the last assessment in 2010-11, three of the comparable data items have increased in accuracy and four data items have decreased in accuracy.

Table 1.1.2 - Summary of Assessed Data Items at Scotland Level

Data Item 2004-06 SMR01 % Accuracy Rate

2010-11 SMR01 % Accuracy Rate

2014-15 SMR01 % Accuracy Rates

% Point Difference from 2010-11

90-100%

Specialty .. 99.6 99.1 - 0.5

Date of Main Operation 91.8 96.1 96.2 + 0.1

Main Operation1 93.2 94.3 93.8 - 0.5

Admission Type .. 93.6 90.2 - 3.4


90.9 90.4 90.1 - 0.3


80.5 80.3 94.2 + 13.9

80-89%

Main Condition1 87.8 88.3 89.0 + 0.7

1 3-digit level* A comparison of common conditions is not possible as the assessment methodology was different from previous

assessments

1.2 Percentage Accuracy by Data Item and Hospital Table 1.2.1 shows the percentage accuracy, by hospital, for each data item assessed and the number of records assessed at each hospital. The number of records assessed depended on the size and type of hospital. Three hospitals had a Main Condition accuracy of below 70%.

For one of these hospitals (Arran War Memorial Hospital), a recurring issue was that GPs looking after inpatients had not been completing a discharge letter or summarising the patient’s diagnosis in the clinical history sheet. However, for nine out of the 15 Main Condition errors evidence was found in the IDL. Although operations/procedures are undertaken at Arran War Memorial Hospital, none of the 40 records assessed from the randomised sample contained a Main Operation/Procedure.

At Vale of Leven Hospital, for 19 of the 27 major Main Condition errors the evidence to code these correctly was found in an IDL or timely FDL. On three occasions, the correct code had been recorded but not placed in the Main Condition.

At Galloway Community Hospital, the evidence for the majority of Main Condition and Main Operation/Procedure errors was available in the FDL or IDL. Nearly half of the Main Condition errors had a symptom code recorded where there was sufficient information in the FDL to record a diagnosis.

Clinician Responsible for Main Operation is not a mandatory data item and is not recorded at the Golden Jubilee National Hospital.


8

Table 1.2.1 - Percentage accuracy by data item and Hospital

Hospital Hospital Type

Number Records

Assessed



Admission Type

Clinician Main

Operation

Consultant / HCP

Responsible

Date of Main

Operation

Specialty

Scotland 3345 89.0 93.8 90.2 94.2 90.1 96.2 99.1

Teaching Hospitals

Aberdeen Royal Infirmary

A1 140 86.2 95.0 75.7 97.0 84.0 91.7 99.3

Glasgow Royal Infirmary

A1 140 95.7 92.9 92.9 89.7 92.1 96.4 100.0

Ninewells Hospital

A1 140 86.3 92.1 99.3 95.0 76.1 97.9 97.9

Royal Infirmary of Edinburgh

A1 140 93.6 97.1 87.9 94.9 94.6 94.2 100.0

Southern General Hospital

A1 140 86.4 81.6 85.6 89.0 97.5 88.4 100.0

Western General Hospital, Edinburgh

A1 140 92.9 93.6 85.0 93.9 97.6 93.4 100.0

Western Infirmary/Gartnavel/Beatson Hospitals

A1 140 84.3 92.1 86.0 92.5 96.3 92.8 100.0

Large General Hospitals

Borders General Hospital

A2 100 86.0 95.0 99.0 94.8 92.0 97.0 100.0

Crosshouse Hospital

A2 100 95.0 100.0 98.0 96.9 89.4 100.0 100.0

Dumfries & Galloway Royal Infirmary

A2 100 80.8 94.0 100.0 92.9 78.7 98.0 100.0

Forth Valley Royal Hospital

A2 100 87.0 97.0 99.0 96.0 63.2 98.0 94.9

Golden Jubilee National Hospital

A2 100 96.0 97.0 97.0 - 93.9 100.0 100.0

Hairmyres Hospital

A2 100 93.0 97.0 56.4 92.9 89.4 99.0 99.0


9


Number Records

Assessed



Admission Type

Clinician Main

Operation

Consultant / HCP

Responsible

Date of Main

Operation

Specialty

Inverclyde Royal Hospital

A2 100 87.0 91.9 98.0 87.8 85.4 94.9 99.0

Monklands Hospital

A2 100 89.0 99.0 80.9 87.8 80.2 97.0 100.0

Perth Royal Infirmary

A2 100 93.0 95.0 100.0 97.0 93.0 98.0 99.0

Raigmore Hospital

A2 100 94.0 92.0 74.0 96.7 88.3 94.9 99.0

Royal Alexandra Hospital

A2 100 88.0 93.9 94.9 91.9 92.1 93.9 100.0

St John’s Hospital at Howden

A2 100 93.0 96.0 83.0 96.7 94.4 99.0 100.0

The Ayr Hospital

A2 100 89.0 95.0 98.0 92.0 91.0 94.0 100.0

Victoria Hospital, Fife

A2 100 93.0 94.0 97.0 94.8 82.1 94.0 98.0

Victoria Infirmary, Glasgow

A2 100 92.9 100.0 99.0 97.8 95.1 99.0 99.0

Wishaw General Hospital

A2 100 88.0 93.0 55.7 96.9 94.8 96.9 100.0

General Hospitals (Medium)

Dr Gray’s Hospital

A31 60 91.7 98.3 95.0 96.6 96.6 98.3 100.0

Queen Margaret Hospital

A31 60 93.3 100.0 100.0 98.1 96.2 100.0 98.3

Stracathro Hospital

A31 60 91.7 86.7 100.0 98.3 98.3 100.0 98.3

Vale of Leven District General Hospital

A31 60 55.0 90.0 90.0 88.1 98.0 96.7 100.0

General Hospitals (Small)

Arran War Memorial

A32 40 62.5 - 95.0 - 100.0 - 100.0

Belford Hospital

A32 40 90.0 87.5 85.0 95.0 92.3 95.0 100.0

Balfour Hospital

A32 100 96.0 92.0 99.0 91.8 89.6 97.0 99.0


10


Number Records

Assessed



Admission Type

Clinician Main

Operation

Consultant / HCP

Responsible

Date of Main

Operation

Specialty

Caithness General Hospital

A32 40 95.0 90.0 100.0 100.0 87.2 100.0 100.0

Galloway Community Hospital

A32 40 67.5 80.0 97.5 87.2 77.8 85.0 68.4

Lorn and Island District General Hospital

A32 40 82.5 95.0 100.0 100.0 97.5 100.0 100.0

Children’s Hospitals

Royal Aberdeen Children’s Hospital

A4 75 89.3 93.3 87.7 98.6 94.4 100.0 100.0

Royal Hospital for Sick Children, Edinburgh

A4 75 98.7 94.7 90.5 98.5 100.0 98.7 100.0

Royal Hospital for Sick Children, Yorkhill

A4 75 84.0 93.3 93.3 95.8 98.6 97.3 100.0


11

2. Clinical Coding Accuracy

2.1 Clinical Coding Accuracy – 1992 to 2015During the time period shown in Table 2.1.1 (1992 – 2015) there have been some significant changes that have impacted the recording of SMR01 data. COPPISH (Core Patient Profile Information in Scottish Hospitals) was introduced in 1996 and in 2007 it was recommended by the Strategic Review of Health and Care Statistics in Scotland that timescales for the receipt of SMR records by ISD should be reduced to six weeks. In addition to these changes, since late 2010 several NHS Boards have implemented a new Patient Management System (TrakCare).

Despite these significant changes there has been minimal impact on the 3-digit accuracy of either Main Condition or Main Operation.

Table 2.1.1 - Main Condition and Main Operation Accuracy (3-digit level) 1992 to 2015

Assessment Year 1992 1994 1996-97 2000-02 2004-06 2010-11 2014-15

Main Condition 88% 90% 89% 88% 88% 88% 89%

Main Operation 91% 94% 95% 95% 93% 94% 94%

Confidence Intervals:The Porta Dictionary of Epidemiology describes a confidence interval as:

“The conventional form of an INTERVAL ESTIMATE, computed in statistical analyses, based on the theory of frequency PROBABILITY. If the underlying statistical model is correct and there is no bias, a confidence interval derived from a valid analysis will over limited repetitions of the study, contain the true parameter with a frequency no less than its confidence level (often 95% is the stated level but other levels are also used)”.

The charts below show the accuracy scores for main condition and main procedure. The confidence interval applied was Wilson’s formula. This level was selected because it affords a narrower and more precise range of confidence.

The confidence interval tends to be wider at small hospitals where DQA assessed a small sample of records. The decision to assess small samples at these hospitals was taken due to technical and resource considerations and largely due to the fact that given the small amount of annual discharges at these hospitals a large range of possible results would not greatly affect the calculation of national accuracy.

Put simply, a confidence interval gives an indication of how much uncertainty there is around a figure. The uncertainty is due to the random variability created by using a small sample of records to draw conclusions about all records. Where the confidence interval is narrow, we are more certain about the value quoted, but where it is wide, there is much more uncertainty.


12

Figure 2.1.2 overleaf shows the proportion of discharges for each hospital assessed during the period 1st April 2014 to 31st March 2015. The five hospitals with the widest confidence intervals account for 1.5% of national discharges during the year 2014-15:

■ Arran War Memorial Hospital ■ Galloway Community Hospital ■ Vale of Leven Hospital ■ Lorn & Islands Hospital ■ Belford Hospital

Therefore, given the small proportion of overall discharges at these hospitals, National accuracy calculations can be relied upon.


13

Figure 2.1.2 - Proportion of discharges for hospitals assessed 1st April 2014 to 31st March 2015.

Western GeneralRoyal Alexandra

NinewellsRoyal Infirmary, Edinburgh

Aberdeen RIGlasgow RI

Western Infirmary/Gartnavel

0.040.150.200.270.330.340.37

0.650.860.90

1.151.161.23

1.881.90

2.102.44

2.592.88

3.043.14

3.493.61

3.834.08

4.244.294.314.35

4.534.55

4.895.67

6.106.61

7.82

0.00% 1.00% 2.00% 3.00% 4.00% 5.00% 6.00% 7.00% 8.00% 9.00%

Arran Belford

Galloway Lorn & Islands

Balfour CaithnessStracathro

RACH, AberdeenVale of Leven

Queen Margaret Dr Gray’s Perth RI

RHSC, EdinburghGolden Jubilee

Borders Inverclyde

RHSC, GlasgowD&GRI

St John’s Hairmyres

Ayr Southern General

RaigmoreForth ValleyMonklands

Crosshouse Wishaw

Victoria, Fife Victoria, Glasgow


14

2.2 Clinical Coding Accuracy – Main ConditionFigure 2.2.1 overleaf shows the 3-digit accuracy of Main Condition and Confidence Intervals.

Figure 2.2.2 overleaf shows the 3-digit accuracy of Main Condition in 2014-15 in comparison to 2010-11 and 2004-06 with hospitals grouped to allow peer comparison. (See Appendix 2 for Confidence Intervals).

Overall, the accuracy rate across Scotland has increased marginally by 0.7% to 89%. 15 of the hospitals were not assessed in the 2004/06 and 2010/11 audits. As a consequence, we are unable to compare the 2014/15 accuracy with previous performance.

Half of the 36 hospitals assessed achieved or exceeded the ISD recommended minimum standard of 90% for accuracy rate of Main Condition.


15

Figure 2.2.1 - Accuracy of Main Condition with Confidence Intervals

89.095.7

93.692.9

86.486.386.2

84.396.096.0

95.094.0

93.093.093.093.092.9

89.089.0

88.088.087.087.0

86.080.8

98.789.3

84.093.3

91.791.7

55.095.0

90.082.5

67.562.5

0 10 20 30 40 50 60 70 80 90 100

Scotland AverageGlasgow RI

Royal Infirmary EdinburghWestern General

Southern GeneralNinewells

Aberdeen RIWestern Infirmary/Gartnavel

BalfourGolden Jubilee

CrosshouseRaigmoreHairmyres

Perth RISt John's

Victoria, FifeVictoria, Glasgow

MonklandsAyr

WishawRoyal Alexandra

Forth ValleyInverclyde

BordersD&G RI

RHSC, EdinburghRACH, AberdeenRHSC, GlasgowQueen Margaret

Dr Gray'sStracathro

Vale of LevenCaithness

BelfordLorn & Island

GallowayArran


16

Figure 2.2.2 - Main Condition accuracy at 3-digit level

0 20 40 60 80 100

Dumfries &Galloway RI

Borders General

Forth Valley RH

Inverclyde RH

Royal Alexandra

Wishaw

Scotland

Monklands

Ayr

Hairmyres

Perth RI

St John's

Victoria Fife

Victoria, Glasgow

Raigmore

Crosshouse

Golden Jubilee

Percentage

Large general hospitals

2014/15

2010/11

2004/06

Minimum 90% Standard

Scotland 2014/15

Scotland 2010/11

Scotland 2004/06


17

0 20 40 60 80 100

Vale of Leven

Scotland

Dr Gray's

Stracathro

Queen Margaret

Percentage

2014/15 2010/11 2004/06


Scotland 2014/15 Scotland 2010/11 Scotland 2004/06

Medium general hospitals

Small general hospitals

0 20 40 60 80 100

Arran

Galloway

Lorn and Island

Scotland

Belford

Caithness

Balfour

Percentage


18

2014/15 2010/11 2004/06



Teaching hospitals

Children’s hospitals

0 20 40 60 80 100


Aberdeen RI

Ninewells

Southern General

Scotland

Western General

Royal Infirmary,Edinburgh

Glasgow RI

Percentage

0 20 40 60 80 100

RHSC,Yorkhill

Scotland

Royal Aberdeen CH

RHSC,Edinburgh

Percentage


19

2.3 Clinical Coding Accuracy – Main Operation/ProcedureFigure 2.3.1 overleaf shows the 3-digit accuracy for Main Operation and Confidence Intervals.

Figure 2.3.2 shows 3-digit accuracy for Main Operation/Procedure for 2014-15 compared with 2010-11 and 2004-06 where appropriate with hospitals grouped by size to allow for peer comparison.

For Arran War Memorial Hospital, none of the records assessed contained a Main Operation/Procedure and therefore the hospital is not included in this chart. 14 of the hospitals were not assessed in the 2004/06 and 2010/11 audits. As a consequence, we are unable to compare the 2014/15 accuracy with previous performance

Only four hospitals fell below the ISD recommended accuracy rate of 90% for Main Operation/Procedure.


20

Figure 2.3.1 - Accuracy of Main Operation/Procedure with Confidence Intervals

93.897.1

95.093.692.9

92.192.1

81.6100.0100.099.0

97.097.097.096.095.095.095.0

94.094.093.9

93.092.092.091.9

94.793.393.3

100.098.3

90.086.7

95.090.0

87.580.0

0 10 20 30 40 50 60 70 80 90 100

Scotland AverageRoyal Infirmary, Edinburgh

Aberdeen RIWestern General

Glasgow RINinewells

Western Infirmary/GartnavelSouthern General

CrosshouseVictoria, Glasgow

MonklandsForth Valley

Golden JubileeHairmyresSt John's

Perth RIAyr

D&G RIVictoria, Fife

Royal AlexandraWishawBalfour

RaigmoreInverclyde

RHSC, EdinburghRACH, AberdeenRHSC, GlasgowQueen Margaret

Dr Gray'sVale of Leven

StracathroLorn & Island

CaithnessBelford

Galloway

Borders


21

Figure 2.3.2 - Main Operation/Procedure accuracy at 3-digit level

2014/15

2010/11

2004/06


Scotland 2014/15

Scotland 2010/11

Scotland 2004/06

Large general hospitals

0 20 40 60 80 100

Inverclyde RH

Raigmore

Wishaw

Scotland

Dumfries & Galloway RI

Royal Alexandra

Victoria, Fife

Borders General

Perth RI

Ayr

St John's

Forth Valley RH

Golden Jubilee

Hairmyres

Monklands

Crosshouse

Victoria, Glasgow

Percentage


22

2014/15 2010/11 2004/06



Medium general hospitals

Small general hospitals

0 20 40 60 80 100

Stracathro

Vale of Leven

Scotland

Dr Gray's

Queen Margaret

Percentage

0 20 40 60 80 100

Galloway

Belford

Caithness

Balfour

Scotland

Lorn and Island

Percentage


23

2014/15 2010/11 2004/06



Teaching hospitals

Children’s hospitals

0 20 40 60 80 100

Royal Aberdeen CH

RHSC,Yorkhill

Scotland

RHSC,Edinburgh

Percentage

0 20 40 60 80 100

Southern General

Ninewells


Glasgow RI

Scotland

Western General

Aberdeen RI

Royal Infirmary,Edinburgh

Percentage


24

2.4 Clinical Coding Accuracy within Defined Groups – Common Conditions (Adults) DQA also assessed the quality of clinical coding for targeted groups of codes used in ISD statistical outputs e.g. F11-F19 for Drugs related activity publication, F10 for Alcohol related activity publication, I20-I25 and I60-I69, G45 for Heart Disease and Stroke publications.

For this assessment, DQA focussed on assessing the accuracy of 10 targeted groups of the most commonly present conditions to a 3-digit level whilst following traditional coding rules and principles. As Main Condition and Other Conditions have been combined, DQA are unable to provide a comparison with previous assessments.

Despite areas of good practice there is an under-recording of common conditions nationally. Over half of the 480 under-recorded conditions were found in sources other than IDLs or FDLs. These other information sources would still be available to coders and they should be scrutinised to identify other conditions which affect the patient’s care during the episode. 63 under-recorded conditions were found in late FDLs.

Figs 2.4.1 and 2.4.2 can be interpreted as follows:

■ Correctly recorded: number of codes where the Main Condition or Other Conditions were correctly recorded for that group of codes.

■ Over-recorded: code from one of the target groups has been coded incorrectly, due to the condition not being present or recorded in favour of acute/other conditions having a higher coding priority.

■ Under-recorded: code from one of the target groups should have been coded, but was omitted. This may be in place of a code that was not from a target group, or a blank space where nothing was coded.

■ Accuracy: percentage accuracy for Main Condition or Other Conditions recorded on SMR01 for that group of common conditions.

Table 2.4.1 shows the overall accuracy rate of selected common conditions for adults was 96.3%. The groups for Ischaemic Heart Disease, Chronic Lower Respiratory Conditions and Stroke have also been sub-divided to include accuracies for individual conditions within that group. Out of the total 480 under-recorded conditions, Ischaemic Heart Disease and Heart Failure represent just over a quarter. A further 21% of under-recorded conditions relate to Hypertensive Disease. Just over 30% of the drug misuse codes were also omitted. The percentage of the under recorded conditions was calculated by Under Recorded/Correct+Under Recorded e.g. in the case of Stroke there were 44 instances correctly recorded and 2 under recorded so the percentage under recorded is 2 expressed as a percentage of 46 (4.3%).


25

Table 2.4.1 - Types of errors for common conditions assessed (Adults)

Common Condition ICD-10 Codes

No. of conditions assessed

Insufficient Evidence*

Correct Over Recorded

Under Recorded

Accuracy

Stroke I61, I63-I64 44 0 44 0 4.3% (2) 97.1%

Subarachnoid Haemorrhage (SAH)

I60 6 0 6 0 0.0% (0) 98.6%

Transient Ischaemic Attacks (TIA)

G45 7 0 7 0 0.0% (0) 99.0%

Alcohol misuse F10 125 0 117 8 12.7% (17) 99.5%

Cerebrovascular disease

I60-I69, G45 118 0 109 9 12.8% (16) 98.0%

Diabetes mellitus E10-E14 252 0 245 7 13.7% (39) 95.6%

Chronic lower respiratory conditions

J00-J47 304 1 300 3 17.4% (63) 97.2%

Chronic Obstructive Pulmonary Disease (COPD)

J40-J44 193 0 192 1 14.7% (33) 96.0%

Asthma J45-J46 102 1 99 2 22.0% (28) 92.4%

Chronic kidney disease and unspecified renal failure

N18-N19 150 0 144 6 19.1% (34) 100.0%

Ischaemic heart disease

I20-I25 449 0 436 13 19.3% (104) 100.0%

Myocardial Infarction

I21-I22 69 0 68 1 6.8% (5) 100.0%

Heart failure I50 80 0 73 7 22.3% (21) 96.9%

Dementia F00-F03, G30

96 0 93 3 22.5% (27) 91.3%

Hypertensive disease

I10-I15 343 0 328 15 23.9% (103) 96.9%

Drug misuse F11-F19 131 0 127 4 30.6% (56) 93.6%

All Common Conditions

2048 1 1972 75 19.6% (480) 96.3%

*No evidence found on which to judge accuracy of code (excluded from accuracy calculation)


26

Table 2.4.2 shows the overall accuracy rate of selected common conditions for children was 94.2%. 14 common conditions were under recorded. A third of the sleep disorders and 20% of convulsions had not been recorded. However, the numbers involved are very small.

Table 2.4.2 - Types of errors for common conditions assessed (Paediatrics)

Common Condition

ICD-10 Codes


Correct Over Recorded

Under Recorded

Accuracy

Dental Caries K02 5 5 0 0 100.0%

Acute Upper Respiratory Infection

R06 30 27 3 2 90.0%

Viral Infection Unspecified Site

B34 24 24 0 1 100.0%

Abnormalities of Breathing

K21 19 15 4 3 78.9%

Epilepsy J00-J06 28 28 0 1 100.0%

Gastro-oesophageal Reflux Disease

J45 13 13 0 3 100.0%

Asthma G47 4 4 0 2 100.0%

Convulsions G40 12 11 1 1 91.7%

Sleep Disorders

R56 4 4 0 1 100.0%

All Common Conditions

139 131 8 14 94.2%


27

3. Non-Clinical Coding Accuracy

3.1 Non-Clinical Coding Accuracy – Admission TypeThe overall accuracy for Admission Type was 90.2% (Table 3.1). Although 99% of records had a correctly recorded Emergency Admission Type or Non-Emergency Admission Type, 90% of errors identified were caused by the wrong sub-type being allocated i.e. code 30 ‘Emergency Admission, no additional detail added’ or code 38 ‘Other Emergency Admission’ was recorded instead of a more specific code such as code 36, ‘Emergency Admission, patient non-injury’. This information is commonly selected by administrative staff who book patients into hospital and clinical coders are expected to correct any inaccuracies.

Tables 3.1.1 - 3.1.4 show hospitals with an accuracy rate for Admission Type of below 80%, (highlighted in grey in 3.1 below). However, within the respective groups, the accuracy rate is very high. There was insufficient evidence to assess the accuracy of Admission Type in 31 records. Where there is insufficient evidence, the data item is removed from the accuracy calculation.

Table 3.1 - Admission Type

Location Number Data Items Assessed

Insufficient Evidence

Accuracy

Aberdeen Royal Infirmary 140 - 75.7%

Arran War Memorial 40 - 95.0%

Balfour Hospital 100 - 99.0%

Belford Hospital 40 - 85.0%

Borders General Hospital 99 1 99.0%

Caithness General Hospital 40 - 100.0%

Crosshouse Hospital 99 1 98.0%

Dr Gray’s Hospital 60 - 95.0%

Dumfries & Galloway Royal Infirmary 100 - 100.0%

Forth Valley Royal Hospital 100 - 99.0%

Galloway Community Hospital 40 - 97.5%

Glasgow Royal Infirmary 140 - 92.9%

Golden Jubilee National Hospital 100 - 97.0%

Hairmyres Hospital 94 6 56.4%

Inverclyde Royal Hospital 100 - 98.0%


40 - 100.0%

Monklands Hospital 89 11 80.9%

Ninewells Hospital 140 - 99.3%

Perth Royal Infirmary 100 - 100.0%

Queen Margaret Hospital 60 - 100.0%

Raigmore Hospital 100 - 74.0%


28


Insufficient Evidence

Accuracy

Royal Aberdeen Children’s Hospital 73 2 87.7%

Royal Alexandra Hospital 99 1 94.9%


74 1 90.5%


75 - 93.3%

Royal Infirmary of Edinburgh 140 - 87.9%

Southern General Hospital 139 1 85.6%

St John’s Hospital at Howden 100 - 83.0%

Stracathro Hospital 60 - 100.0%

The Ayr Hospital 100 - 98.0%

Vale of Leven District General Hospital 60 - 90.0%

Victoria Hospital, Fife 100 - 97.0%

Victoria Infirmary, Glasgow 100 - 99.0%

Western General Hospital, Edinburgh 140 - 85.0%


136 4 86.0%

Wishaw General Hospital 97 3 56.7%

Scotland 3314 31 90.2%

Table 3.1.1 - Aberdeen Royal Infirmary

Data Item Number of Records

Errors Insufficient Evidence

Number Assessed

Percentage Accuracy

Number Benefit of Doubt

Admission Type 140 34 - 140 76

Emergency Admissions1

60 2 - 60 97

Non-emergency Admissions2

80 2 - 80 98

Table 3.1.2 - Hairmyres Hospital



Number Assessed

Percentage Accuracy


Admission Type 100 41 6 94 56


46 - 1 45 100


54 - 5 49 100


29

Table 3.1.3 - Raigmore Hospital



Number Assessed

Percentage Accuracy


Admission Type 100 26 - 100 74


36 - - 36 100


64 - - 64 100

Table 3.1.4 - Wishaw General Hospital



Number Assessed

Percentage Accuracy


Admission Type 100 43 3 97 56


49 1 49 98


51 - 3 48 100

1 Emergency admissions include Admission Type values 30-39. Percentage of emergency admissions submitted with any admission type value within this group.

2 Non-emergency admissions include Admission Type values 10-22. Percentage of non-emergency admissions submitted with any admission type value within this group.

3.2 Non-Clinical Coding Accuracy - Clinician Main OperationAlthough not a mandatory data item, the overall accuracy for Clinician Main Operation was 94.2% (Table 3.2.1). This has increased from 80% in the 2010/11 assessment.

For Golden Jubilee National Hospital, this data item is not recorded as there is nowhere on the Patient Management System (PMS) to capture the data. At Arran War Memorial Hospital, none of the records assessed contained a Main Operation/Procedure. These hospitals are not included in the table below.

42 of the 180 errors (23%) were due to the corresponding operation being omitted. A further 17 were over-recorded where the recorded procedure did not take place.

There was insufficient evidence to assess the accuracy of Clinician Main Operation in 115 records. Where there was insufficient evidence, the data item was removed from the accuracy calculation.


30

Table 3.2.1 - Clinician Main Operation


Insufficient Evidence Accuracy

Aberdeen Royal Infirmary 134 6 97.0%

Balfour Hospital 98 2 91.8%





Dr Gray's Hospital 59 1 96.6%

Dumfries & Galloway Royal Infirmary 99 1 92.9%


Galloway Community Hospital 39 1 87.2%

Glasgow Royal Infirmary 136 4 89.7%


Inverclyde Royal Hospital 98 2 87.8%

Lorn and Island District General Hospital 40 - 100.0%




Queen Margaret Hospital 54 6 98.1%

Raigmore Hospital 90 10 96.7%

Royal Aberdeen Children's Hospital 73 2 98.6%


Royal Hospital for Sick Children, Edinburgh 67 8 98.5%

Royal Hospital for Sick Children, Yorkhill 71 4 95.8%

Royal Infirmary of Edinburgh 136 4 94.9%


St John's Hospital at Howden 91 9 96.7%


The Ayr Hospital 88 12 92.0%

Vale of Leven District General Hospital 59 1 88.1%

Victoria Hospital, Fife 97 3 94.8%

Victoria Infirmary, Glasgow 93 7 97.8%

Western General Hospital, Edinburgh 132 8 93.9%


133 7 92.5%


Scotland 3090 115 94.2%


31

3.3 Non-Clinical Coding Accuracy – Consultant / Health Care Professional Responsible for CareThe overall accuracy for Consultant/HCP Responsible for Care was 90.1% which is broadly similar to previous assessments in 2010/11 and 2004/06.

There was insufficient evidence to assess the accuracy of Consultant/HCP Responsible for Care in 398 records. Where there was insufficient evidence, the data item was removed from the accuracy calculation. In one hospital there was not enough information to confirm this data item in 30 out of 39 records due to the patient’s care being transferred to a different consultant. For these records the discharging consultant’s name would be on the Immediate Discharge Letter (IDL) or FDL, with no evidence for the consultant responsible for care earlier in the admission.

This data item is usually recorded by other hospital staff but clinical coders endeavour to correct it when possible if they identify an inaccuracy.

Table 3.3.1 - Consultant/HCP Responsible for Care




Arran War Memorial 40 - 100.0%

Balfour Hospital 96 4 89.6%

Belford Hospital 39 1 92.3%


Caithness General Hospital 39 1 87.2%


Dr Gray's Hospital 58 2 96.6%


Forth Valley Royal Hospital 95 5 63.2%

Galloway Community Hospital 36 4 77.8%

Glasgow Royal Infirmary 101 39 92.1%

Golden Jubilee National Hospital 98 2 93.9%




40 - 97.5%


Ninewells Hospital 138 2 76.1%


Queen Margaret Hospital 53 7 96.2%





32




49 26 100.0%


71 4 98.6%





The Ayr Hospital 78 22 91.0%

Vale of Leven District General Hospital 50 10 98.0%

Victoria Hospital, Fife 84 16 82.1%




107 33 96.3%


Scotland 2947 398 90.1%

3.4 Non-Clinical Coding Accuracy Continued – Date of Main Operation/ProcedureThe overall accuracy for Date of Main Operation/Procedure was 96.2% which is similar to the 2010/11 assessment. However, some hospitals are defaulting to admission date and this accounted for 56 Date of Operation/Procedure errors. 45 errors were due to the corresponding operation being omitted. A further 19 were over-recorded where the recorded procedure did not take place.

There was insufficient evidence to assess the accuracy of Date of Main Operation/Procedure in 31 records. Where there is insufficient evidence, the data item is removed from the accuracy calculation.

Table 3.4.1 - Date of Main Operation/Procedure




Balfour Hospital 100 - 97.0%


Borders General Hospital 100 - 97.0%



33



Crosshouse Hospital 100 - 100.0%

Dr Gray's Hospital 60 - 98.3%



Galloway Community Hospital 40 - 85.0%

Glasgow Royal Infirmary 140 - 96.4%

Golden Jubilee National Hospital 100 - 100.0%




40 - 100.0%

Monklands Hospital 100 - 97.0%



Queen Margaret Hospital 60 - 100.0%





75 - 98.7%


75 - 97.3%





The Ayr Hospital 100 - 94.0%

Vale of Leven District General Hospital 60 - 96.7%

Victoria Hospital, Fife 100 - 94.0%




138 2 92.8%


Scotland 3274 31 96.2%


34

4. Additional Issues Identified

4.1 Examples of good practiceIn The Golden Jubilee National Hospital’s Cardiac Surgery unit the IDLs and FDLs list the consultant’s name after the name of the junior doctor who has dictated the letter.

Also, in The Golden Jubilee National Hospital’s Trauma and Orthopaedic FDLs the operation date is clearly stated in a section before the body of the text as well as the admission and discharge dates.

Caithness General Hospital produces a full chemotherapy discharge letter detailing admission date, discharge date, date of treatment, the cycle and type of chemotherapy the patient received. However, at the time of the assessment, this was not utilised by coders.

At Borders General Hospital the FDL frequently had the name of the admitting consultant and discharging consultant. If a patient’s admission covered more than one specialty, the FDL would name the consultant responsible for each specialty. The IDL template at Borders General Hospital has a field for Date of Main Operation.

At Royal Hospital for Sick Children, Edinburgh an electronic discharge letter template has been created for haematology patients. This has cut down significantly on the amount of confidential information being transported to the clinical coders.

At Royal Infirmary of Edinburgh the operation notes are available electronically. For some specialties the Date of Main Operation and Clinician Main Operation are available on the FDL.

In NHS Fife there were some very good day case proforma letters that detailed information for Clinician Main Operation, Date of Main Operation, Main Condition and Main Operation.

At Dr Gray’s Hospital the Oncology day case episodes each had an individual IDL.

4.2 Availability of Discharge LettersSince 2006, Scottish Government Guidelines and subsequent directives have advised NHS Boards to ensure that clinical teams produce a discharge summary within six weeks of the discharge date to allow clinical coding departments to submit their SMR returns within the six week deadline.

In addition to the 3,345 records assessed, there were a further 235 records that DQA could not assess due to a lack of information in the hospitals information systems. 49% of these were from the Haematology, Clinical and Medical Oncology specialties. Although DQA can exclude these records from the assessment, coding departments are expected to complete and submit SMR01 episodes irrespective of the quality of information available. Coders are dependent on receiving accurate and thorough clinical information. If this is not available then the quality of the SMR01 submission suffers.

1,876 records contained Final Discharge Letters (FDLs) of which 1,605 (86%) were available to clinical coders within the six week deadline.

http://webarchive.nationalarchives.gov.uk/20060515072154/http:/healthstatsreview.scot.nhs.uk/docs/StrategicReviewofStatisticsFinalReport_version9_12_2005.pdf


35

Figure 4.2.1 - Availability of Discharge Letters

No IDL or FDLIDL or FDL

FDLNo FDL

IDLNo IDL

FDLs completed within six weeks of dischargeFDLs not completed within six weeks of dischargeNo FDL

8.4%

91.6% 72.3%

27.7%

48.0%

8.1%

56.1%43.9% 43.9%

There were 281 (8%) records that did not contain an IDL or FDL but DQA were able to assess the accuracy of the records using other sources. Of these, 35% were from Haematology, Clinical and Medical Oncology and pertain to repeat chemotherapy sessions where coders often use documentation sent to them in the form of a clinic list. Good practice was found in Caithness General Hospital where a full chemotherapy discharge letter is produced which details admission date, discharge date, treatment date, cycle and type of chemotherapy the patient received. However, at the time of assessment this was not being utilised by clinical coders.

DQA recognise that for day case endoscopy admissions, only the endoscopy report may be available and is classed as an IDL in this instance.

Final Discharge Letters (FDLs) are normally completed by more senior medical staff and it is advised they be completed in a timely manner for all admissions to ensure the most accurate information is available to coding staff. The importance of timely and high quality discharge letters should be highlighted to clinical staff. Information and leaflets are available for download on the ISD website.

http://www.isdscotland.org/Products-and-Services/Terminology-Services/Information-for-Clinicians/

http://www.isdscotland.org/Products-and-Services/Terminology-Services/Information-for-Clinicians/Secondary-Care-clinicians/index.asp

Refer to Appendix 1 for availability of discharge letters by specialty.

http://www.isdscotland.org/Products-and-Services/Terminology-Services/Information

http://www.isdscotland.org/Products-and-Services/Terminology-Services/Information




36

4.3 Clinical Coding Workforce by Health Board.Some NHS Boards such as NHS Lanarkshire have centralised coding departments whereby coding staff at Wishaw General Hospital are responsible for Wishaw General, Hairmyres Hospital and half of Monklands Hospital coding. Similarly, NHS Tayside has recently improved the availability of information for clinical coding departments via electronic systems. The clinical coding workload will be centralised and coders have responsibilities for submitting SMR01 episodes for other NHS Tayside hospitals where required.

A full breakdown of clinical coding workforce by Health Board is available from the DQA team on request.

4.4 Findings from Additional SamplesIn addition to the random sample taken for this SMR01 Assessment, extra samples which targeted specific diagnoses were taken for the purpose of investigating the quality, accuracy and completeness of areas of clinical interest or statistical output.

■ Epilepsy and Convulsions in Paediatric Patients (ICD-10 codes G40.- and R56.0 and R56.8): See Appendix 4 for full report

■ Drugs Misuse (ICD-10 codes F11-F19): See Appendix 5 for full report ■ Aneurysms (ICD-10 codes I71.- and I72.-): See Appendix 6 for full report

These specific areas were assessed on request from ISD analysts and Consultants in Public Health Medicine (CPHMs).

4.5 ConclusionsCoding accuracy for Main Condition was good across most sites throughout Scotland. However, there were three outliers with low levels of accuracy. Action plans for two of these hospitals have since been put in place by the relevant NHS Boards to address the issues concerned. For the other, a new management team has been appointed to assess the processes and an action plan will follow. DQA will be in continuous contact with NHS Boards to offer assistance when required.

ISD’s Terminology Services and the DQA Team will work more closely with relevant Boards to ensure that national coding standards are adhered to. This will ensure that Boards cease using local coding rules which can lead to skewing of data and dramatic results in some areas e.g. ‘overdose’.

All findings were raised and discussed with hospital staff at the end of each hospital visit and individual hospital reports were issued to each site.


37

4.6 RecommendationsIssue Recommended Action

Clinical coders predominantly coding from Immediate Discharge Letters (IDLs). These can be vague and use non-code-able terms such as “suggestive of” and

“impression of” which mean only symptoms can be coded rather than diagnosis.

It is understood by DQA that an IDL may not always be followed up with an FDL. However, FDLs are normally completed by more senior medical staff and it is advisable they should be completed to ensure the most accurate clinical information is available to coding staff.

The importance of timely and high quality discharge letters should be highlighted to clinical staff. Information and leaflets are available for download on the ISD Terminology Services web pages ‘Information for Clinicians’ at: http://www.isdscotland.org/Products-and-Services/Terminology-Services/Information-for-Clinicians/

Clinical coders conforming to local rules instead of national standards.

It is accepted by DQA that local coding rules exist but it is recommended that these are reviewed regularly and instructions are obtained in writing. It should be noted that data items not coded to national standards will be marked in error.

Existing and new local rules must be submitted to Terminology Services to determine whether a national guideline is required i.e. areas which are being coded differently in many places because the coders are unsure or perhaps there isn’t a good code.

Under-recording of common conditions

Coders should ensure they are recording co-morbidities for inpatients according to the appropriate Scottish Clinical Coding Standard for co-morbidities– available on the Terminology Services website at:

http://www.isdscotland.org/Products-and-Services/Terminology-Services/Clinical-Coding-Guidelines/

Major errors in Main Condition resulting in an overall national average of 89% which falls below the ISD recommended minimum standard of 90%.

Clinical coding staff should ensure care is taken when recording Main Condition.

As a minimum, all coders are expected to undertake the ICD and OPCS Foundation Course, as provided by ISD Terminology Services. Refresher courses and specialty workshops are also available for experienced coders on request.

It is recommended that management consider the Certificate of Technical Competence (Clinical Coding) (CTC), for those coders with less than 12 months in the department. This award will ensure that all aspects of the post have been thoroughly explained and evidenced, leaving the coder with a work-based portfolio and confidence in their ability. The CTC is about to be piloted and should be available to sites from Autumn 2016.

For some Main Condition and Main Operation errors, the evidence was found in sources other than the Discharge Letters.

Clinical coders are encouraged to use all sources available in order to record codes as specifically as possible.

For 398 records, DQA assessors were unable to determine the accuracy of Consultant/HCP Responsible as there was no corroborating evidence in the casenotes.

Discharge letters are not always completed by the Consultant/HCP Responsible. Where a junior grade doctor completes the discharge letters, they should acknowledge who the responsible consultant is.

Many coding departments report problems with accuracy of non-clinical data as information is gathered by nursing or clinical staff who have competing demands.

Staff responsible for inputting non-clinical data items to be made aware of the importance of accurate selection of these data items. Clinical coding staff are reminded that they should amend any inaccuracies that are identified.






38

Appendix 1 – Availability of Discharge Letters

Availability of discharge letters for all records assessed, discharges 2014-2015 Specialty No. of Records No IDL or FDL IDL FDL FDLs completed

within 6 weeks of discharge

Accident & Emergency

39 4 18 24 23

Acute Medicine 50 5 28 34 28

Allergy 1 1 - - x

Anaesthetics 24 2 19 14 12

Cardiac Surgery 29 1 27 26 21

Cardiology 135 3 81 122 110

Cardiothoracic Surgery

1 - 1 - x

Clinical Oncology 51 21 26 12 12

Clinical Radiology 2 - 1 1 1

Community Dental Practice

11 5 6 1 1

Dermatology 5 1 3 3 2

Diabetes 2 1 - 1 1

Ear, Nose & Throat (ENT)

74 3 57 42 42

Endocrinology 1 1 - - x

Endocrinology & Diabetes

5 - 2 4 2

Gastroenterology 92 5 79 31 22

General Medicine 807 26 622 534 400

General Surgery 219 11 167 119 103

General Surgery (excl Vascular)

319 8 275 183 161

Geriatric Medicine

135 7 95 96 84

GP Other than Obstetrics

57 17 33 13 13

Gynaecology 104 5 70 68 64

Haematology 91 44 29 29 28

Infectious Diseases

10 - 10 4 4


39

Specialty No. of Records No IDL or FDL IDL FDL FDLs completed within 6 weeks of

discharge

Medical Oncology

67 34 26 15 14

Neurology 27 4 8 18 17

Neurosurgery 31 1 22 22 19

Ophthalmology 106 10 81 45 45

Oral and Maxillofacial Surgery

35 3 22 22 20

Oral Surgery 9 1 7 3 3

Paediatric Dentistry

5 - 5 - x

Paediatrics 156 7 141 35 35

Paediatric Surgery

34 33 10 10

Pain Management

16 1 10 12 12

Palliative Medicine

8 2 3 4 4

Plastic Surgery 57 4 40 21 20

Rehabilitation Medicine

6 1 5 3 2

Renal Medicine 20 3 12 9 6

Respiratory Medicine

59 4 47 27 21

Restorative Dentistry

1 - - 1 1

Rheumatology 14 8 3 4 4

Thoracic Surgery 15 - 15 12 7

Trauma and Orthopaedic Surgery

231 12 176 137 121

Urology 162 14 100 97 94

Vascular Surgery 22 1 13 18 16

Total: 3,345 281 2,418 1,876 1,605

- Null value- X FDLs not available for the sampled records within this specialtyNote: DQA recognise that for day case endoscopy admissions, only the endoscopy report may be available and is

classed as an IDL in this instance.


40

Appendix 2 – Confidence Intervals We have used 95% confidence intervals in our analysis of the random samples taken for the records assessed.

We can say that we are 95% confident that the true accuracy of the coded conditions and the true accuracy of the coded operations lie somewhere between the lower and upper accuracy intervals listed against each location below.

Accuracy of Main Condition

Location Lower Interval of Accuracy

Percentage Accuracy Upper Interval of Accuracy

Aberdeen Royal Infirmary 79.5% 86.2% 91.0%

Arran War Memorial 47.0% 62.5% 75.8%

Balfour Hospital 90.2% 96.0% 98.4%

Belford Hospital 76.9% 90.0% 96.0%

Borders General Hospital 77.9% 86.0% 91.5%

Caithness General Hospital 83.5% 95.0% 98.6%

Crosshouse 88.8% 95.0% 97.8%

Dr Gray’s Hospital 81.9% 91.7% 96.4%

Dumfries & Galloway Royal Infirmary 72.0% 80.8% 87.4%

Forth Valley Royal Hospital 79.0% 87.0% 92.2%

Galloway Community Hospital 52.0% 67.5% 79.9%

Glasgow Royal Infirmary 91.0% 95.7% 98.0%

Golden Jubilee National Hospital 90.2% 96.0% 98.4%

Hairmyres Hospital 86.3% 93.0% 96.6%

Inverclyde Royal Hospital 79.0% 87.0% 92.2%


68.0% 82.5% 91.3%

Monklands Hospital 81.4% 89.0% 93.7%

Ninewells Hospital 79.6% 86.3% 91.1%

Perth Royal Infirmary 86.3% 93.0% 96.6%

Queen Margaret Hospital 84.1% 93.3% 97.4%

Raigmore Hospital 87.5% 94.0% 97.2%

Royal Aberdeen Children’s Hospital 80.3% 89.3% 94.5%

Royal Alexandra Hospital 80.0% 88.0% 92.9%


92.8% 98.7% 99.8%


74.1% 84.0% 90.6%


41



Royal Infirmary of Edinburgh 88.2% 93.6% 96.6%

Scotland Average 87.9% 89.0% 90.1%

Southern General Hospital 79.8% 86.4% 91.1%

St John’s Hospital at Howden 86.3% 93.0% 96.6%

Stracathro Hospital 81.9% 91.7% 96.4%

The Ayr Hospital 81.4% 89.0% 93.7%


42.5% 55.0% 66.9%

Victoria Hospital 86.3% 93.0% 96.6%

Victoria Infirmary, Glasgow 86.1% 92.9% 96.5%

Western General Hospital, Edinburgh 87.4% 92.9% 96.1%

Western Infirmary/ Gartnavel/ Beatson Hospitals

77.4% 84.3% 89.4%

Wishaw General Hospital 80.2% 88.0% 93.0%

Accuracy of Main Operation



Aberdeen Royal Infirmary 90.0% 95.0% 97.6%

Balfour Hospital 85.0% 92.0% 95.9%

Belford Hospital 73.9% 87.5% 94.5%

Borders General Hospital 88.8% 95.0% 97.8%

Caithness General Hospital 76.9% 90.0% 96.0%

Crosshouse 96.3% 100.0% 100.0%

Dr Gray's Hospital 91.1% 98.3% 99.7%

Dumfries & Galloway Royal Infirmary 87.5% 94.0% 97.2%

Forth Valley Royal Hospital 91.5% 97.0% 99.0%

Galloway Community Hospital 65.2% 80.0% 89.5%

Glasgow Royal Infirmary 87.4% 92.9% 96.1%

Golden Jubilee National Hospital 91.5% 97.0% 99.0%

Hairmyres Hospital 91.5% 97.0% 99.0%

Inverclyde Royal Hospital 84.9% 91.9% 95.8%


83.5% 95.0% 98.6%

Monklands Hospital 94.6% 99.0% 99.8%

Ninewells Hospital 86.5% 92.1% 95.6%


42



Perth Royal Infirmary 88.8% 95.0% 97.8%

Queen Margaret Hospital 94.0% 100.0% 100.0%

Raigmore Hospital 85.0% 92.0% 95.9%

Royal Aberdeen Children's Hospital 85.3% 93.3% 97.1%

Royal Alexandra Hospital 87.4% 93.9% 97.2%


87.1% 94.7% 97.9%


85.3% 93.3% 97.1%

Royal Infirmary of Edinburgh 92.8% 97.1% 98.9%

Scotland Average 93.0% 93.8% 94.6%

Southern General Hospital 74.3% 81.6% 87.2%

St John's Hospital at Howden 90.2% 96.0% 98.4%

Stracathro Hospital 75.8% 86.7% 93.1%

The Ayr Hospital 88.8% 95.0% 97.8%


79.9% 90.0% 95.3%

Victoria Hospital, Fife 87.5% 94.0% 97.2%

Victoria Infirmary, Glasgow 96.3% 100.0% 100.0%

Western General Hospital, Edinburgh 88.2% 93.6% 96.6%

Western Infirmary/ Gartnavel/ Beatson Hospitals

86.4% 92.1% 95.5%

Wishaw General Hospital 86.3% 93.0% 96.6%

* The target for accuracy is 90% of records assessed are coded correctly; under this target value is deemed unsatisfactory for passing.

* The accuracy presented in the main body of the report should be deemed the accuracy percentage of the location. The confidence intervals shouldn’t be used to deem a pass/fail score.


43

Appendix 3 – NHS Board Tracking Systems

NHS Board Source Evidence

Ayrshire and Arran TrakCare and Casenotes

Borders TrakCare, Radiology, Sapphire, Shared Drives and Casenotes.

Dumfries and Galloway TOPAS, Labs and eCasenote

Fife OASIS, Clinical Portal, SCI Store and Casenotes

Forth Valley SCI Store, Clinical Portal, E-ward and Casenotes

Greater Glasgow &Clyde TrakCare, Clinical Portal, Chemocare.

Golden Jubilee Clinical Portal, Cathi, Casenotes

Grampian TrakCare, SCI Store, Op Note System, Casenotes

Highlands TrakCare, SCI Store, and Casenotes

Lanarkshire Clinical Portal and Casenotes

Lothian TrakCare, Clinical Portal, Lothian Surgical Audit and Casenotes.

Orkney TOPAS, SCI Store, Casenotes

Tayside Clinical Portal, TOPAS, EDD, ICE and Casenotes


44

ContactBarry Watson

Information Manager

[email protected]

0141 282 2268

Jean Harvey

Data Manager

[email protected]

0131 275 6367

Background InformationThe Data Quality Assurance (DQA) team is responsible for evaluating and ensuring that the Information Services Division’s (ISD) Scottish Morbidity Record (SMR) datasets are accurate, consistent and comparable across time and between sources. Evaluation of quality of data in any information system involves a comparison of data against an agreed set of standards. This is conducted retrospectively in order to support the credibility of ISD’s national patient based data.

The quality of national data is key to all those who use it both externally and internally at ISD as, without it, it would be impossible to interpret results with any accuracy or confidence. Without this assurance in the data it would undermine the use of information in a range of areas such as service planning, epidemiological research, contributions to evidence based medicine, generation of healthcare costs and the support of quality improvement and performance management. In particular, SMR01 data contributes to HEAT targets.

This report contains the findings on the quality of selected SMR01 data items at both a Scotland level and for individual hospitals.

Further information can be found on the Data Quality Assurance web pages ISD Data Quality Assurance.

mailto:[email protected]


http://www.isdscotland.org/Products-and-Services/Data-Quality/



45

Glossary of Data Definitions for Data Items AssessedAdmission Type An inpatient admission is categorised as an emergency, urgent or routine

inpatient admission except for Maternity and Neonatal admissions. The appropriate admission category depends on the clinical condition of the patient as assessed by the receiving consultant. The patient may or may not be on a waiting list.


The health professional responsible for care (HCP) is the clinician who has overall clinical and legal responsibility for a patient's healthcare during an episode. This is usually a medical consultant but may be another healthcare professional, for example a midwife, GP, nurse or Allied Healthcare Professional.

Date of Main Operation

The date the operation was performed


The identification code of the clinician responsible for the procedure. For a doctor, it is the GMC Registration Number; for other health care professionals, it is the unique identification number issued by the controlling authority of that discipline.

Groups of Common Conditions

In addition to the main condition, the record should, whenever possible, also list separately other conditions or problems dealt with during the episode of health care. Other conditions are defined as those conditions that co-exist or develop during the episode of healthcare and affect the management of the patient.

FDL Final Discharge Letter

IDL Immediate Discharge Letter

Main Operation Main Operation/Treatment/Investigative Procedure/Intervention are those aspects of clinical care carried out on patients undergoing treatment:

for the prevention, diagnosis, care or relief of disease

for the correction of deformity or deficit, including those performed for cosmetic reasons

associated with pregnancy, childbirth or contraceptive or procreative management

SMR Scottish Morbidity Record

Specialty A division of medicine or dentistry covering a specific area of clinical activity and identified within one of the Royal Colleges or Faculties.


46

Appendix 4: Additional Findings from Booster Samples - Epilepsy

2014/15 SMR01 National Assessment

Epilepsy & Convulsions in Paediatric Patients

ObjectiveThe main aim was to provide information on the accuracy of coding of Epilepsy and Convulsions in paediatric patients. This was carried out by assessing a booster sample of records with diagnosis of Epilepsy (ICD-10 codes G40.0 - G40.9) or Convulsion in any position, (ICD-10 codes R56.0 and R56.8).

Key Findings ■ Main Condition accuracy of Epilepsy at a 3-digit level was 94% and 76% to a 4-digit level (the

ISD recommended minimum target is 90%) ■ Main Condition accuracy for Convulsions at a 3-digit level was 81% and 71% to a 4-digit level

(the ISD recommended minimum target is 90%)

BackgroundThe Data Quality Assurance (DQA) team compare the quality of submitted information against all patient information available at source, which includes assessing both the accuracy of coding and the quality of information available to coders.

For this assessment, DQA assessed paediatric records with a main diagnosis of epilepsy or convulsion and records with epilepsy or convulsion codes in other conditions one to five.

There were 118 records assessed from the three main children’s Hospitals in Scotland (Royal Aberdeen Children’s Hospital, Royal Hospital for Sick Children Edinburgh and the Royal Hospital for Sick Children Glasgow) as well as records from three of the paediatric departments with the highest submissions of epilepsy/convulsion codes. These departments were within Crosshouse Hospital, Wishaw General Hospital and Ninewells Hospital.

From the main randomised National SMR01 assessment, an additional 17 patients were identified where either the main condition or the other conditions one to five contained a diagnosis of epilepsy or convulsion. These are also included in this report.

In total 135 records were assessed for the purpose of this report.

Availability of Discharge LettersSince 2006, NHS Boards have been advised to ensure that clinical teams produce a discharge summary within six weeks of the discharge date to allow clinical coding departments to submit their SMR returns within the six week target.


47

There was sufficient information available to DQA to assess all 135 records. However there were 10 records that had neither an Immediate Discharge Letter (IDL) nor a Final Discharge Letter (FDL).

Only 32 out of 135 records had Final Discharge Letters (FDL), of which 29 were available to clinical coders within the six week target.

Refer to Appendix A for availability of discharge letters by specialty.

Clinical Findings

Epilepsy in Main ConditionTable 1 shows the breakdown of errors by type and the percentage accuracy at a 3 and 4-digit level for Main Condition for those records with a Main Condition of Epilepsy (ICD-10 code G40.-)

Table 1: - Accuracy of submitted clinical data items for records with Main Condition G40.-, discharges between 1st April 2014 - 31st January 2015

Data item No evidence Major error Minor error 3-digit accuracy

(%)

4-digit accuracy

(%)B D M N P

Main Condition

- - - 2 6 94 76

B – Benefit of Doubt, no evidence found on which to judge accuracy of code (excluded from the accuracy calculation).

D – Benefit of Doubt at a 4-digit level, no evidence found on which to judge accuracy of the 4th character (excluded from the accuracy calculation at a 4-digit level).

M – Major error, code correct, but was not placed in the Main Condition or Main Operation position.N – Major error, code incorrect at a 3-digit level. P – Minor error, code correct at the 3-digit level, but the 4th character is incorrect.

33 records contained an Epilepsy code as a Main Condition.

There were two major errors where G40.3 Tonic Clonic Epilepsy had been recorded when it should have been R56.8 Seizure NOS. In each case the patients’ condition had been described as ‘tonic clonic seizure’ without the essential modifier ‘epilepsy’. This information was found in all IDLs and all occurred at the same hospital.

For four of the six minor errors it was found that G40.9 unspecified epilepsy had been recorded rather than a more specific type of epilepsy. The information was found in Discharge letters or from a Consultant letter to the GP.

The final two minor errors were due to an incorrect type of epilepsy being recorded and evidence was found in the IDL and Consultant to GP letter.

Epilepsy in Other Conditions 1 - 5Table 2 shows the breakdown of errors by type and the percentage accuracy at a 3 and 4-digit level for Other Conditions 1 - 5 for those records with a diagnosis of Epilepsy (ICD-10 code G40.-) in any position other than Main Condition.


48

Table 2: - Accuracy of submitted clinical data items for records with Other Conditions 1 - 5 G40.-, discharges between 1st April 2014 - 31st January 2015


(%)

4-digit accuracy (%)

B D E G P

Other Conditions 1-5

- - - 1 2 97 91


E – Excess code, the condition shouldn’t have been recorded, or another condition had a higher coding priority.G – Group error, Epilepsy was recorded instead of Convulsion or vice-versa. P – Minor error, code correct at the 3-digit level, but the 4th character is incorrect.

32 records contained an Epilepsy code in Other Conditions 1 - 5.

There was one major error and two minor errors found in epilepsy recording in Other Conditions 1 - 5.

The one major error was due to epilepsy being over-recorded. There was no mention of epilepsy in the patient’s IDL or FDL, only seizures.

The two minor errors were due to G40.9 Epilepsy unspecified being recorded where there was more information to code a more specific type. The information for these was found in the IDL and a Consultant to GP letter.

Convulsion in Main ConditionTable 3 shows the breakdown of errors by type and the percentage accuracy at a 3 and 4-digit level for Main Condition for those records with a Main Condition of Convulsion (ICD-10 code R56.-).

Table 3: - Accuracy of submitted clinical data items for records with Main Condition R56.-, discharges between 1st April 2014 - 31st January 2015


(%)


B D M N P

Mail Condition

- - 5 1 3 81 71


D – Benefit of Doubt at a 4-digit level, no evidence found on which to judge accuracy of the 4th character (excluded from the accuracy calculation at a 4-digit level).

M – Major error, code correct, but was not placed in the Main Condition or Main Operation position.N – Major error, code incorrect at a 3-digit level. P – Minor error, code correct at the 3-digit level, but the 4th character is incorrect.

31 records contained a Convulsion code as a Main Condition.


49

There were six major errors and three minor errors found in Main Condition.

For two of the six major errors it was found that R56.- Convulsion had been coded alongside Epilepsy G40.- but it is unnecessary to code this separately, as seizures are a symptom of epilepsy.

Three major errors were due to the convulsion being secondary to the main diagnosis. In all three instances the seizures had been correctly coded but should have been placed in Other Conditions 1 - 5 rather than Main Condition. For one record the IDL diagnosis was “febrile convulsion, likely secondary to viral illness” and for the other two the IDL stated diagnosis as

“febrile convulsion secondary to upper respiratory tract infection”.

The last major error was due to convulsion being over-coded in a record where it was stated in the FDL that the “seizure was queried”.

For the three minor errors evidence of a more accurate convulsion diagnosis was found in the IDL.

There was no pattern in which hospitals these errors occurred and all of the information was found in either the IDL or FDL.

Convulsion in Other Conditions 1 - 5Table 4 shows the breakdown of errors by type and the percentage accuracy at a 3 and 4-digit level for Other Conditions 1 - 5 for those records with a diagnosis of Convulsion (ICD-10 code R56.-) in any position other than Main Condition.

Table 4: - Accuracy of submitted clinical data items for records with Other Conditions 1 - 5 R56.-, discharges between 1st April 2014 and 31st January 2015

Data item No evidence Major error Minor error 3-digit accuracy (%)


B D E G P

Other Conditions 1-5

- - 4 - 1 86 82


E – Excess code, the condition shouldn’t have been recorded, or another condition had a higher coding priority.G – Group error, Epilepsy was recorded instead of Convulsion or vice-versa. P – Minor error, code correct at the 3-digit level, but the 4th character is incorrect.

28 records contained a Convulsion code in Other Conditions 1 - 5.

There were four major errors and one minor error found in Other Conditions 1 - 5.

For all four major errors, R56.- Convulsion was found to be over-recorded. Each had a correctly coded G40.- Epilepsy code in Main Condition meaning that coding ‘convulsion’ was in excess. Convulsion in this instance is part of the main diagnosis and is therefore not required.

One minor error was due to a more accurate diagnosis of ‘febrile convulsion’ being found in the patient’s Clinical Notes. This patient record had no IDL or FDL available making it more difficult to determine final diagnosis.


50

Epilepsy and Convulsion in Random Sample from SMR01 National AssessmentTable 5 shows the breakdown of number of records where Epilepsy or Convulsion was recorded in the random sample from the National SMR01 Assessment.

Table 5: - Accuracy of submitted clinical data items for records with Main Condition G40.- and R56.- and Other Conditions 1 - 5 G40.- and R56.-, discharges between 1st April 2014 – 31st March 2015

Data Item No. of Records Assessed

Correct Under Recorded

Over Recorded

Epilepsy in Main Condition 7 5 1 1

Epilepsy in Other Conditions 1 - 5

6 6 - -

Convulsion in Main Condition 3 2* - -

Convulsion in Other Conditions 1 - 5

1 1 - -

DQA found 17 records where Epilepsy and Convulsion were recorded in both Main Condition and Other Conditions 1 - 5.

In one record G40.- Epilepsy had been omitted as Main Condition the information found to code the term ‘infantile spasms’ was found in both the IDL and FDL.

In the record where Epilepsy was found to be over recorded, the term ‘generalised tonic clonic seizure’ was used to describe the patient’s discharge diagnosis on the IDL. Without the essential modifier ‘epileptic’ we cannot code G40.-.

*There was one major error found in the recording of Main Condition Convulsion. This occurred when R56.0 had been placed in Main Condition, but should have been in Other Conditions 1 - 5. The IDL stated the patient was diagnosed as having a “febrile convulsion secondary to viral illness”, so the viral illness should have been coded as Main Condition.

Recommendations

Issue Action

Incorrect coding of Main Condition

Coding staff should ensure that their training is up to date and follow the ICD-10 index and keep updated with any relevant coding standards.

Over-recording of conditions Coding staff should ensure that their training is up to date and follow the ICD-10 index and keep updated with any relevant coding standards.

Only 32 out of 135 records had an FDL with three of these not being completed within the six week target.

10 records out of 135 did not have an IDL or FDL.

Final Discharges Letters are normally completed by more senior medical staff and it is advisable they should be completed in a timely manner for all admissions to ensure the most accurate information is available to coding staff.

The importance of timely and high quality discharge letters should be highlighted to clinical staff. Information and leaflets are available for download on the ISD website

http://www.isdscotland.org/Products-and-Services/Terminology-Services/Useful-Links-and-Downloads/




51

Further Information

Hospitals assessed Royal Aberdeen Children’s Hospital, Royal Hospital for Sick Children Edinburgh, The Royal Hospital for Sick Children Glasgow, Crosshouse Hospital, Wishaw General Hospital and Ninewells Hospital

(The Victoria Hospital and St John’s Hospital at Howden were also included from the SMR01 National sample)

Assessors Simone Rattray and Nicola Young (Data Management Officers)

Assessment dates 15.12.2014 – 15.05.2015

No. records assessed 135

Contact for further information [email protected]

Website http://www.isdscotland.org/Products-and-Services/Data-Quality/

Availability of Discharge Letters

Table 4: - Availability of discharge letters for all records assessed, discharges between 1st April 2014 – 31st January 2015

Speciality No. of records

No. of records without

FDL or IDL

No. of records with IDL

No. of records with FDL

FDLs com-pleted within 6 weeks of discharge

Accident & Emergency 1 - - 1 1

Ear, Nose & Throat (ENT) 1 - 1 - -

Gastroenterology 1 - 1 - -

Medical Oncology 2 - 2 - -

Neurology 16 - 14 3 2

Oral and Maxillofacial Surgery

1 - 1 - -

Paediatrics 110 10 84 26 25

Respiratory Medicine 2 - 2 1 -

Trauma and Orthopaedic Surgery

1 - 1 1 1

Total 135 10 106 32 29

- Null valueX FDLs not available for the sampled records within this specialty




52

Appendix 5: Additional Findings from Booster Samples – Drugs Misuse


Drugs Misuse

ObjectiveTo investigate the accuracy of recording of drug misuse codes (ICD-10 codes F11-F19).

Key Findings ■ 90% of drug misuse codes were recorded correctly ■ 12 out of 241 drug misuse codes were over recorded, whilst 12 more had the incorrect drug

recorded ■ 65 drug misuse codes were under recorded

BackgroundDQA assessed ICD-10 drug misuse codes F11-F19 submitted to the National Inpatient/Day case Scottish Morbidity Records (SMR01) database held at Public Health and Intelligence (PHI). The accuracy was assessed to a 3-digit level.

As well as 123 records identified in the randomised national sample containing drug misuse codes, an additional booster sample of 76 records containing drug misuse codes was also assessed. From these 199 records, a total of 241 drug misuse codes were assessed.


53

Clinical Findings

Table 1: - Accuracy of submitted ICD-10 drug misuse codes F11-F19, discharges between 1st April 2014 – 31st March 2015

Drug ICD-10 Codes


Correct Incorrect Drug1

Over recorded2

Under recorded3

Opioids F11 45 40 2 3 2

Cannabinoids F12 18 16 1 1 1

Sedatives and Hypnotics

F13 14 14 - - 1

Cocaine F14 15 11 3 1 -

Other Stimulants inc. Caffeine

F15 14 12 1 1 3

Hallucinogens F16 4 2 2 - 1

Tobacco F17 109 105 - 4 57

Volatile Solvents F18 - - - - -

Multiple and Other Psycho active Substances

F19 22 17 3 2 -

All Drugs 241 217 12 12 65

1. Incorrect Drug – A different drug misuse code should have been recorded.2. Over recorded – The drug misuse code shouldn’t have been recorded, or another condition had a higher coding

priority.3. Under recorded – The drug misuse code should have been recorded.

Of the 241 drug codes recorded 90% were recorded correctly.

A drug misuse code was recorded in Main Condition on eight occasions, all of which were found to be correct by DQA. In four further records a drug misuse code was recorded correctly, but should have been placed in the Main Condition position.

There were 12 occasions when the drug misuse code was incorrect and a different drug should have been recorded in its place.

In three records where F19 was recorded, there was space and sufficient information available to record six specific drug codes individually: one F13, two F14, two F15 and one F16.

12 codes were found to be over recorded. For eight over recorded drug codes there was evidence that the patient wasn’t misusing drugs, and for three records it wasn’t documented that the patient was misusing drugs. In one record the drug misuse code was over recorded as a different condition had a higher priority.

There were 65 under recorded drug misuse codes, 57 of which were Tobacco (F17) codes. Evidence for 34 under recorded codes was found in documents other than the IDL or FDL, such as clinical notes, admission documents and consultant letters. Evidence for a further four was found in FDLs typed six weeks or later after discharge, so wouldn’t be available to the clinical coder.


54

Appendix 6: Additional Findings from Booster Samples - Aneurysms


Aortic and Other Aneurysms

ObjectiveTo investigate the accuracy of the recording of Aneurysms (ICD-10 codes I71.- and I72.-), related OPCS codes for aneurysm repair operations, and the accuracy of admission types being recorded.

Key Findings ■ Main Condition accuracy was 97% which exceeds the ISD minimum recommended target of

90% and is to be commended ■ Main Operation accuracy for aneurysm operations at a 3-digit level was 88% and 48% at a

4-digit level which does not meet the ISD minimum recommended target of 90% ■ Emergency Admission Type accuracy was 87%, whilst accuracy of recording Non-Emergency

Admission Type was 100%.

BackgroundThe Data Quality Assurance (DQA) team compare the quality of submitted information against all patient information available at source, which includes assessing both the accuracy of coding and the quality of information available to coders.

For this assessment, DQA assessed records with a main diagnosis of aneurysmal disease (ICD-10 codes I71.- and I72.-) submitted to the National Inpatient/Day case Scottish Morbidity Records (SMR01) database held at Public Health and Intelligence (PHI). In addition to the assessment of Main Condition and Main Operation to a 3 and 4-digit level, DQA also focused attention on the data item Admission Type.

There were 70 records assessed over six hospital sites with a date of discharge between 1st April 2014 to 31st January 2015. 58 of these records had Main Condition recorded as Aortic Aneurysm (I71.-) and 12 records had Main Condition recorded as Other Aneurysm (I72.-).

Availability of Discharge LettersSince 2006, NHS Boards have been advised to ensure that clinical teams produce a discharge summary within six weeks of the discharge date to allow clinical coding departments to submit their SMR returns within the six week target.

56 records had a Final Discharge Letter (FDL), 10 of which were not available within the six week target, and 52 records had an Immediate Discharge Letter (IDL). There were three records that didn’t contain an FDL or IDL, but DQA were able to assess the accuracy of the records using other sources available.


55

Clinical Findings

Aortic Aneurysms (ICD-10 Code I71.-) Main ConditionTable 1 shows the breakdown of errors by type and the percentage accuracy at a 3 and 4-digit level for Main Condition for those records with a Main Condition of aortic aneurysm.

Table 1: - Accuracy of Main Condition where I71.- is recorded, discharges between 1st April 2014 – 31st January 2015

Data item Major error Minor error 3-digit accuracy (%)


M N P

Main Condition - 2 1 97 95

M – Major error, code correct, but was not placed in the Main Condition or Main Operation position.N – Major error, code incorrect at a 3-digit level. P – Minor error, code correct at the 3-digit level, but the 4th character is incorrect

Main Condition accuracy at a 3-digit level was 97% which meets the ISD recommended minimum target of 90%.

There were two major errors and one minor error out of the 58 records assessed. One of the major errors was the result of an extremely complicated case history and should have been recorded as acute pancreatitis instead of aortic aneurysm. The information was found in the operation note.

The second major error resulted from the Immediate Discharge Letter stating that this was an aortic aneurysm but evidence from the operation notes and radiology reports showed that it should have been recorded as aneurysm of iliac artery (ICD-10 code I72.3).

Evidence for the minor error was found in the operation note and Final Discharge Letter.

Aortic Aneurysms (ICD-10 Code I71.-) Main OperationTable 2 shows the breakdown of errors by type and the percentage accuracy at a 3 and 4-digit level for Main Operation for aortic aneurysm repair operations.

Table 2: - Accuracy of Main Operation where I71.- has been recorded as Main Condition, discharges between 1st April 2014 – 31st January 2015

Data item Major error Minor error 3-digit accuracy (%)


M N P

Main Operation - 3 10 88 48

M – Major error, code correct, but was not placed in the Main Condition or Main Operation position.N – Major error, code incorrect at a 3-digit level. P – Minor error, code correct at the 3-digit level, but the 4th character is incorrect

There were 25 records assessed where the Main Operation was an aneurysm operation.


56

Main Operation accuracy at 3-digit level was 88% and 48% at 4-digit level which falls below the ISD recommended minimum standard of 90%.

There were three major errors, one of which was an omitted operation.

There were 10 minor errors. Six of these had omitted secondary codes and one had an incorrect secondary code.

Other Aneurysms (ICD-10 Code I72.-) Main Condition and Main OperationMain Condition accuracy for other non-aortic aneurysms was 92% at 3-digit level which meets the ISD minimum recommended target of 90%.

There was one major error which had been recorded as aneurysm of lower extremity instead of atherosclerosis of lower extremity. DQA found the correct information in operation notes.

There was also one minor error and DQA found the accurate information in the Immediate Discharge Letter

Main Operation accuracy at a 3-digit level was 29%.

There were seven records assessed where the Main Operation was an aneurysm operation.

There were five major errors which were completely random and mixed. DQA found the correct information for three major errors in the operation note, and the other two major errors in an imaging report.

There was one minor error due to an incorrect secondary code which DQA found in the operation note.

FDLs were not available to coders within the six-week deadline for four of the records that contained Main Operation errors.

Non-Clinical Findings

Admission Type

Table 3 shows the percentage accuracy of Admission Type for those records with a Main Condition of Aortic Aneurysm or Other Aneurysm (ICD-10 code I71.- or I72.-)

Table 3: - Accuracy of submitted Admission Type for records with a Main Condition I71.- or I72.-, discharges between 1st April 2014 – 31st January 2015

Admission Type Total No. of Records

C N Accuracy (%)

Emergency1 15 13 2 87

All other types (i.e. Non-Emergency)2

55 55 0 100

Overall 70 68 2 97

C – Code correctN – Code incorrect1 Emergency Admission types include codes 30-392 Non-Emergency Admission types include codes 10-12 and 18-22

Emergency Admission Type accuracy was 87%. There were two errors found in 15 records.


57

In one record, code 30 ‘Emergency Admission, no additional detail added’ was recorded where it should have been code 11 ‘Routine elective’ admission type. In one further record, code 36 ‘Patient Non-Injury’ was recorded where it should have been code 18 ‘Planned Transfer’. The information for these records was found in both IDLs.

All Other Admission Types (i.e. Non-Emergency) accuracy was 100%.

Admission Sub-TypeTable 4 shows the percentage accuracy of Admission Sub-Type for those records with a Main Condition of Aortic Aneurysm or Other Aneurysm (ICD-10 code I71.- or I72.-)

Table 4: - Accuracy of submitted Admission Sub-Type for records with a Main Condition I71.- or I72.-, discharges between 1st April 2014 – 31st January 2015

Admission Type Total No. of Records

C N Accuracy (%)

Emergency3 13 5 8 38

All other types (i.e. Non-Emergency)4

55 54 1 98

Overall 68 59 11 84

C – Code correctN – Code incorrect3 Emergency Admission types include codes 30-394 Non-Emergency Admission types include codes 10-12 and 18-22

Where the record had a correctly recorded Emergency Admission type, the Emergency Admission Sub-Type accuracy was 38%. There were 8 errors found in only 13 records.

In seven records, code 30 ‘Emergency Admission, no additional detail added’ was recorded instead of a more specific Emergency Admission code. Six should have been code 36 ‘Patient Non-Injury’ and one code 38 ‘Other Emergency’. All of the information to code the more specific Admission Type was found in either the IDL or FDL, although two of the FDL’s were provided outwith the six week target.

All Other Admission Sub-Types (i.e. Non-Emergency) accuracy was high at 98%. There was only one error found in 55 records.

This error occurred because the less specific code 10 ‘Routine Admission, no additional detail added’ was recorded instead of code 11 ‘Routine Elective’ and the information to code this was found in the IDL.


58

Recommendations

Issue Action

Complex aortic aneurysm surgery with evidence found in sources other than the IDL or FDL

Medical staff responsible for completing discharge letters are advised to include as much detail as possible.

As finer details of procedures are often found in documents other than the IDL or FDL, coders are encouraged to use all sources available in order to record OPCS-4 codes as specifically as possible.

Omitted and incorrect secondary/supplementary codes

Clinical coding staff should ensure care is taken when recording Main Operation and to seek guidance from Terminology Services if required.

Admission Type was recorded incorrectly in 11 records

Staff responsible for inputting Admission Type to be made aware of the importance of selecting a more specific option and coders to amend any admission types that are clearly not accurate.

Further Information

Hospitals assessed Aberdeen Royal Infirmary, Hairmyres Hospital, Ninewells Hospital, Royal Infirmary Edinburgh, Raigmore Hospital, Western Infirmary/Gartnavel General Hospital Glasgow

Assessors Morag Christie and Hazel Paterson (Data Management Officers)

Assessment dates 13.10.2014 - 05.06.2015

No. records assessed 70

No. records unable to be assessed -

Contact for further information [email protected]

Website http://www.isdscotland.org/Products-and-Services/Data-Quality/



NSS Information and Intelligence - ISD Scotland › Products-and-Services › ... · 4,000 records....

Documents

Transcript of NSS Information and Intelligence - ISD Scotland › Products-and-Services › ... · 4,000 records....