Mid CHP Governance Committee 28 October 2011

Mid Highland CHP SMR Return Rate Monitor % of SMR01 returns received (2 month lag averaging over 3 month period). National target is 95% complete in 6 wks from end of discharge

1 CURRENT POSITION

° SMRO1 coding report as at 09 September 2011 based on average SMRO1 returns for the 3 months (May 11 – July 11) indicates the overall return rate for Mid Highland CHP is 89.1% which indicates an increase of 4% completeness from the previous report.

° Mackinnon Memorial Hospital, Skye - the % of completed returns is 90% and the team were on track to meet the 95% completeness target for future returns. However, long term absence within the admin team has impacted on the availability of coders and therefore % completeness.

° Fort William – the % of completed returns for this period had increased from 75.6% to 86.2%. Long term absence and annual leave had been the major contributing factor in the decrease in SMRO coding in Belford Hospital at the last report date.

° Ross Memorial Hospital – reporting a slight decrease in % completeness, due to annual leave. There is only one person who undertakes coding in this Hospital. (9 outstanding records)

° The remaining 2 community hospitals in the area, report an increase in % completeness from the last report and continue to achieve the 95% target or above. ( and County Community Hospital Invergordon)

2 ACTION PLANS TO ADDRESS

° E-Health Senior Information Officer continues to provide weekly reports to CHP Business Manager to allow performance monitoring

° Training for ISD Coders has a more structured approach across NHS Highland, with NHS Highland’s E-Health Senior Information Officer leading on this.

° SMR02 Coding (maternity) is up to date, with all current coding being completed on time and meeting the 95% completion standard. Midwifery staff continue to concentrate on the backlog. At present there are 7 outstanding cases to be coded within Mackinnon Memorial Hospital, Skye.

° Belford Hospital – From beginning of October a member of staff has been identified to undertake coding following departure of previous member of staff, this will actively manage and clear the coding backlog whilst ensuring that recent discharges are coded within required timescale. The member of staff concerned has been provided with access to Results Reporting to facilitate

ongoing timely coding.

° Belford Hospital – Ongoing work with Ward Clerks to ensure that ‘Ward Attenders’ are recorded correctly, these episodes were previously recorded as inpatients thus creating an additional episode to code.

° Ross Memorial Hospital - Plan in place to ensure contingency arrangements from County Community Hospital, Invergordon, should the one member of staff who undertakes the coding, be absent for any reason.

° MacKinnon Memorial Hospital, Skye – Action Plan to be put in place when staffing back to full complement, which will allow outstanding coding to be brought up to date.

3 EXPECTED IMPACT OF ACTIONS ON PERFORMANCE

° Action Plan to be implemented to monitor continued improvement for Belford Hospital, Fort William to ensure that they meet the agreed standard of % completeness. Recent actions have resulted in backlog being addressed therefore would expect to see significant improvement in the next report.

° Ross Memorial Hospital – Contingency plan in place to ensure coding is processed within the 6 week timescale and % completeness achieved and maintained.

° Mackinnon Memorial Hospital, Skye – Continued performance monitoring and implementation of Action Plan will ensure any backlog of coding is processed and remainder of coding completed within timescale.

° ISD Coding Training has now been completed across the CHP. Systems are in place to ensure that the SMR01/SMR02 coding is processed within the 6 week timescale, as per the NHS Standard.

4 FORECAST OF RETURN TO PLANNED PERFORMANCE (ie Trajectory)

° The CHP will continue to monitor SMR01 and SMR02 submissions across all the hospitals within the CHP to ensure we are meeting the agreed standard.

Fiona Matheson Mid Highland CHP Business Manager

14th October 2011

‘SMR’ – Scottish Morbidity Records