Commercial work by L2S2 Ltd to support NHS England, CQC, ICBs and NHS Trusts.

CRAB Clinical Informatics Limited (C2-Ai) is responsible for developing and marketing CRAB (Copeland Risk Adjusted Barometer). Designed by the former National Director for Clinical Audit, CRAB is a web-based tool and reporting platform to evaluate quality and outcomes in a way which accurately reflects the clinical profile and case-mix complexity of patients treated.

C2-Ai is the sole Data Controller. L2S2 Ltd is the sole data processor acting under the instructions of C2-Ai. Whilst C2-Ai undertake analysis for the Care Quality Commission (CQC) and intend to undertake work for a variety of organisations, neither C2-Ai nor any of its customer organisations have access to or process the raw Hospital Episode Statistics (HES) data provided by NHS England. Only L2S2 have access to and process the raw HES data, with customers having sight of aggregate (small number suppressed) outputs only.

The HES data set is being obtained to support the Care Quality Commission (CQC) and NHS Trusts/ Independent Sector Providers offering NHS services only. The data processed is the same for both purposes, and the data outcomes are the same.

HES Admitted Patient Care (HES APC) and HES Critical Care (HES CC) are the only data sets required as C2-Ai only look at inpatient avoidable harm from admission to discharge/death <30 days.

The C2-Ai reports are specifically to:

- assist in objective benchmarking of organisations and sites/ departments within Trusts/ Independent Sector Providers offering NHS services

- expedite quality analysis on behalf of the CQC and NHS Trusts/ Independent Sector Providers offering NHS services, notably quarterly national/ monthly local horizon scanning of hospitals with high levels of morbidity as an early-warning and targeting tool for inspections.

This is designed to provide a granular local dashboard to help the CQC and NHS Trusts/ Independent Sector Providers offering NHS services to interpret and understand safety in relation to avoidable harm, morbidity and areas for improvement.

Where mentioned; “anonymised data and anonymised reports” refer to reports that do not contain any identifiable data, other than the name of the hospital trust with whom the report is being shared directly.

C2-Ai will only identify and share the hospital provider’s name for the hospital provider that the report is being shared with.

No patient identifiable data is shared within the reports.

To clarify, Consultant information is only shared where untoward harm is identified and requires investigation based on data provided by the hospital and not NHS England.

All of the data fields provided by NHS England are processed by L2S2 using CRAB algorithms on its own dedicated server and are not aggregated or amalgamated with any other data received from other sources.

Data is presented in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Accordingly, the latest HES data is required by C2-Ai from NHS England in order for this analysis to be contemporary, accurate and reliable to make a worthwhile analysis. C2-Ai require a maximum of 3 years of finalised NHS England data at any time. To be clear, the data set requested and currently held is the minimum breadth of data fields required to undertake the CRAB analysis robustly, therefore the data fields cannot be minimised further.

C2-Ai only require pseudonymised data from NHS England– algorithms developed require all hospital activity coding relating to comorbidities, procedure and diagnoses in order to facilitate analysis. These algorithms are reviewed semi-annually to ensure they use the minimum data set required for the algorithms to work.

Furthermore, analysis is required to be down to the consultant level by general medical council (GMC) code in order to verify speciality of clinical practice within a specific NHS Trust/ Independent Sector Providers offering NHS services as is required by the CQC to provide targeted, key lines of enquiry for their on-site inspection teams.

In the past, the C2-Ai analysis provided to the Keogh review team in 2013 was based on a bulk extract of HES & mortality data supplied by NHS England for the 14 hospitals concerned. A similar exercise was also conducted using HES data on behalf of Monitor, and again as a research project investigating emergency laparotomy practice with Royal United Bath Hospital NHS Trust. With the extension of this system following the Keogh Review and the newly defined roles of the CQC, the CQC has commissioned C2-Ai on an ongoing quarterly basis to analyse HES data for all hospitals providing NHS services in England.

C2-Ai, the Data Controller for this application, have developed an analytical tool to evaluate the quality of healthcare and associated outcomes. This was developed for use by health-related national bodies and NHS Trusts, and other NHS organisations; it was not developed purely for the CQC for example. C2-Ai already has other customers (NHS Trusts) using the tool for analysis of their own Trust data (i.e. not the HES data). Therefore, C2-Ai have developed their service and analytical tool for a range of customers, and C2-Ai determine the nature of processing, aligned to customer needs. This is why C2-Ai is the sole Data Controller.

C2-Ai only processes data where absolutely necessary to perform the clinical audit as requested by the client. A Data Privacy Impact Assessment (DPIA) and Legitimate Interest Assessment (LIA) is carried out before the processing of data to ensure it is necessary to create a new client database.

The lawful basis for processing personal data under the UK GDPR is Article 6(1)(f) processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child.

Processing personal data is necessary for C2-Ai's legitimate interests, which are to process data to improve care for patients by providing clinicians, managers and regulators with analysis of risk adjusted clinical quality and benchmarking analysis. The data to which access is requested are proportionate and necessary to achieve those interests. C2-Ai has completed a legitimate interests assessment (LIA) and is satisfied that the interests of the data subjects do not override C2-Ai’s legitimate interests; that they would reasonably expect the processing and it would not cause unjustified harm.

C2-Ai believe in order to improve care standards it is a reasonable expectation for a patient receiving care to have their pseudonymised details and treatment prescribed included in an aggregate dataset to be processed as part of an assessment of care-giver’s performance for the future benefit of that patient and all other patients.

C2-Ai also believe that in order to improve care standards it is a wholly reasonable expectation for a care giver/ consultant providing care to have their prescribed treatment assessed and processed.

Where C2-Ai happens to notice a potential risk to patient safety, C2-Ai, without any charge, provide this information to the regulator in aggregate form to act upon to prevent further untoward harm to patients.

The lawful basis for processing special category data under the UK GDPR is Article 9(2)(j) processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject;

The analysis C2-Ai undertakes on behalf of Health regulators and organisations providing NHS services serves the broader societal public interest of ensuring standards of quality and safety are maintained in hospitals and to help inform performance ratings to help people choose care.

REPORTS FOR CQC

Reports are produced for the CQC with the objective of providing an early warning analysis in order to focus their inspections, identify poor hospital performance, improve patient safety and help reduce avoidable harm to patients.

C2-Ai analysis is made available to the CQC in the context of inspections and improvement projects, but under no circumstances will the CQC be given access to the raw data. Analysis is shared with the CQC in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Without C2-Ai processed national HES from NHS England, CQC inspectors would have no quantitative (risk adjusted) analysis of morbidity in particular to benchmark hospitals providing NHS services and by specialty. This would restrict their ability to undertake inspections based on informed data and identification of poorly performing hospitals early (prior to avoidable mortality becoming an issue). Hospital outliers might be missed and untoward harm may occur to patients where it could potentially be avoided.

REPORTS FOR NHS TRUSTS AND INDEPENDENT SECTOR PROVIDERS OFFERING NHS SERVICES

Following requests from NHS Acute Trusts/ Independent Sector Providers offering NHS services, C2-Ai will supply anonymised (aggregate, small number suppressed) reports of other NHS Trusts/ independent sector providers (e.g. private hospitals contracted to provide NHS overspill elective surgery, or NHS Trusts and Integrated Care Systems who are outsourcing some elective recovery work to the local private sector providers) to benchmark the individual organisation's clinical performance as reported by C2-Ai regionally and nationally against other anonymised hospitals. These reports will be shared directly with the named organisation only to support their quality improvements. The NHS Trusts/ independent sector providers can only view their own named data, benchmarked against the anonymised results of other hospitals nationally and regionally.

C2-Ai’s established regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives will be supported with the regional and national quarterly reports. These C2-Ai reports aim to demonstrate where improvements have been made and identify where remedial measures are required. This can be seen in the Academic Health Science Network ‘Limiting patient harm due to Acute Kidney Injury: A Patient Safety Initiative', where C2-Ai would like to support Hospitals Trusts with similar projects. By the end of the Acute Kidney Injury (AKI) intervention, AKI incidence on surgical wards had fallen by 36%. In addition to the reduction in patient harm, the Hospital Trust estimates the AKI programme has allowed the trust to reallocate £533,000 per year to other services.

NHS Trusts have explicitly requested regional and national benchmarking reports. Thereby, NHS Trusts can implement remedial and preventative actions. Improvements initiatives to improve care standards are also highlighted and can be implemented.

C2-Ai is a private company and as such healthcare providers of NHS services and regulator organisation clients will be charged for CRAB analysis, software services, expert support in application and interpretation of reports and access to their bespoke database reporting. C2-Ai works on behalf of NHS organisations to whom C2-Ai provide the outputs of the C2-Ai Analysis (generating a profit from the work outlined in this application) and continue to maintain the relevance of these tools that utilise NHS England data inputs.

The provision of the C2-Ai products benefit the health and social care system in England and Wales through identification of variance in clinical practice based on algorithms developed to provide case mix specific risk adjusted clinical outcomes trends, regional and national benchmarking and avoidable harm identification to support quality improvement and horizon scanning in terms of early warning for NHS providers and regulators. The analysis has supported the elective recovery programmes in dozens of NHS Trusts and ICSs in support of patient risk stratification and prehabilitation.

The benefits to the recipients (see benefits section) include patient level case mix risk adjusted clinical outcomes and triggers of avoidable harm (including quality of care of the deteriorating patient) analysis for all NHS hospitals and providers of NHS services – which can only be determined through C2-Ai's proprietary speciality specific risk adjustment algorithms.

There are a number of historic and recent independent publications by NHS as to the clinical benefits from quality improvement programmes and related cost efficiency savings to the NHS, which have been supported by the C2-Ai analysis.

The expected outputs of the processing will be:

• A report of risk adjusted health outcomes to the Care Quality Commission (CQC) on a quarterly basis, at Trust/ hospital provider and specialty levels

• A report of findings to individual NHS Trusts/ Independent Sector Providers offering NHS services on request to assist in benchmarking and quality analysis

• Maintenance of regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives, supported by quarterly regional and national reports

The outputs will not contain NHS England data and will only contain aggregated information with small numbers suppressed as appropriate in line with the relevant disclosure rules for the dataset(s) from which the information was derived.

Reviews and scheduled reports of acute care and performance of an organisation are for that organisation only, unless being reviewed for a national body such as the CQC.

CQC:

The CQC have used C2-Ai reports to drill into more detailed analysis of organisational performance where appropriate, particularly in relation to morbidity and avoidable harm - to support CQC inspection activity and elective recovery by NHS England.

NHS Trusts:

The CRAB web-based tool has supported hospital organisations when wanting to review certain procedures and their outcomes to monitor performance. The Observatory is used to help Trust Boards and clinical leaders target their improvement efforts in the right areas and identify areas of excellence. As a result, Trusts have been able to:

- put in place appropriate governance and monitoring systems

- receive early warning of problems or deterioration in practice quality so this could be rapidly investigated

- monitor and improve quality from the perspective of avoidable harm

- better understand the clinical risks or possible complications for individual patients, to enable informed conversations and higher quality care.

C2-Ai (CRAB) is now deployed in over 25 NHS Trust including 2 ICB region-wide deployments to support mutual aid and health equity assurance

C2-Ai was able to demonstrate to South Tees NHS Trust that it saved on average £4,700 per Acute Kidney Injury episode avoided. Acute Kidney Injury episodes have reduced by over 36% since this intervention, saving the Trust over £85,000/year. This success has since been shared with other NHS Trusts.

C2-Ai was able to undertake analysis across the Cheshire and Merseyside Integrated Care System for all acute NHS Trusts. C2-Ai analysis saved over £200,000 per Trust in administration efficiencies; reduced length of stay by 125 bed days per 1,000 patients on the patient tracking list and reduced emergency admissions by over 8% (of note, in 2020 prior to introduction of C2-Ai patient tracking list risk stratification 100% of patients listed for elective femoral hernia repairs presented as emergencies at one of the pilot Trusts). Reducing emergency admissions and length of stay tends to improve patient experiences and patient safety.

Furthermore, the analysis has been used to create waiting well pathways of care to prehabilitate patients with modifiable risk factors to improve their health risks ahead of surgery. Preliminary data has shown a greater than 6 fold reduction in expected complications such as hospital acquired pneumonia, conversion of inpatient to day-case in a number of procedures  and reduction in length of stay by 2-3 days per patient recruited onto the programme. This work has been published and forms part of the NHS England Blueprinting programme.

GIRFT

The risk stratification analysis provided by CRAB has been included in the GIRFT best practice guidance for elective recovery.

The Keogh Review:

The Keogh Review used C2-Ai reports to assess risk-adjusted harm in 14 hospital Trusts. The Keogh review identified inadequate numbers of nursing staff as a key issue, and subsequently developed plans to address safety and quality changes in each of the Trusts identified by the C2-Ai reports

Darzi Review

CRAB contributed to and was named in the most recent Lord Darzi report on the state of the NHS. Recommendations are in line with the services CRAB provides NHS Trusts and ICB regards actionable insights and transparency through case mix adjusted clinical outcomes relevant to the case-mix complexity of the NHS Providers populations

BiG Carbon Index

Linking risk adjusted clinical outcomes to sustainability costs associated with carbon usage, fresh water and waste and how these track over time to support the ICB and NHS Trust Net Zero goals and accountabilities with NHS England

CRAB Clinical Informatics Limited (C2-Ai) is responsible for developing and marketing CRAB (Copeland Risk Adjusted Barometer). Designed by the former National Director for Clinical Audit, CRAB is a web-based tool and reporting platform to evaluate quality and outcomes in a way which accurately reflects the clinical profile and case-mix complexity of patients treated.

C2-Ai is the sole Data Controller. L2S2 Ltd is the sole data processor acting under the instructions of C2-Ai. Whilst C2-Ai undertake analysis for the Care Quality Commission (CQC) and intend to undertake work for a variety of organisations, neither C2-Ai nor any of its customer organisations have access to or process the raw Hospital Episode Statistics (HES) data provided by NHS England. Only L2S2 have access to and process the raw HES data, with customers having sight of aggregate (small number suppressed) outputs only.

The HES data set is being obtained to support the Care Quality Commission (CQC) and NHS Trusts/ Independent Sector Providers offering NHS services only. The data processed is the same for both purposes, and the data outcomes are the same.

HES Admitted Patient Care (HES APC) and HES Critical Care (HES CC) are the only data sets required as C2-Ai only look at inpatient avoidable harm from admission to discharge/death <30 days.

The C2-Ai reports are specifically to:

- assist in objective benchmarking of organisations and sites/ departments within Trusts/ Independent Sector Providers offering NHS services

- expedite quality analysis on behalf of the CQC and NHS Trusts/ Independent Sector Providers offering NHS services, notably quarterly national/ monthly local horizon scanning of hospitals with high levels of morbidity as an early-warning and targeting tool for inspections.

This is designed to provide a granular local dashboard to help the CQC and NHS Trusts/ Independent Sector Providers offering NHS services to interpret and understand safety in relation to avoidable harm, morbidity and areas for improvement.

Where mentioned; “anonymised data and anonymised reports” refer to reports that do not contain any identifiable data, other than the name of the hospital trust with whom the report is being shared directly.

C2-Ai will only identify and share the hospital provider’s name for the hospital provider that the report is being shared with.

No patient identifiable data is shared within the reports.

To clarify, Consultant information is only shared where untoward harm is identified and requires investigation based on data provided by the hospital and not NHS England.

All of the data fields provided by NHS England are processed by L2S2 using CRAB algorithms on its own dedicated server and are not aggregated or amalgamated with any other data received from other sources.

Data is presented in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Accordingly, the latest HES data is required by C2-Ai from NHS England in order for this analysis to be contemporary, accurate and reliable to make a worthwhile analysis. C2-Ai require a maximum of 3 years of finalised NHS England data at any time. To be clear, the data set requested and currently held is the minimum breadth of data fields required to undertake the CRAB analysis robustly, therefore the data fields cannot be minimised further.

C2-Ai only require pseudonymised data from NHS England– algorithms developed require all hospital activity coding relating to comorbidities, procedure and diagnoses in order to facilitate analysis. These algorithms are reviewed semi-annually to ensure they use the minimum data set required for the algorithms to work.

Furthermore, analysis is required to be down to the consultant level by general medical council (GMC) code in order to verify speciality of clinical practice within a specific NHS Trust/ Independent Sector Providers offering NHS services as is required by the CQC to provide targeted, key lines of enquiry for their on-site inspection teams.

In the past, the C2-Ai analysis provided to the Keogh review team in 2013 was based on a bulk extract of HES & mortality data supplied by NHS England for the 14 hospitals concerned. A similar exercise was also conducted using HES data on behalf of Monitor, and again as a research project investigating emergency laparotomy practice with Royal United Bath Hospital NHS Trust. With the extension of this system following the Keogh Review and the newly defined roles of the CQC, the CQC has commissioned C2-Ai on an ongoing quarterly basis to analyse HES data for all hospitals providing NHS services in England.

C2-Ai, the Data Controller for this application, have developed an analytical tool to evaluate the quality of healthcare and associated outcomes. This was developed for use by health-related national bodies and NHS Trusts, and other NHS organisations; it was not developed purely for the CQC for example. C2-Ai already has other customers (NHS Trusts) using the tool for analysis of their own Trust data (i.e. not the HES data). Therefore, C2-Ai have developed their service and analytical tool for a range of customers, and C2-Ai determine the nature of processing, aligned to customer needs. This is why C2-Ai is the sole Data Controller.

C2-Ai only processes data where absolutely necessary to perform the clinical audit as requested by the client. A Data Privacy Impact Assessment (DPIA) and Legitimate Interest Assessment (LIA) is carried out before the processing of data to ensure it is necessary to create a new client database.

The lawful basis for processing personal data under the UK GDPR is Article 6(1)(f) processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child.

Processing personal data is necessary for C2-Ai's legitimate interests, which are to process data to improve care for patients by providing clinicians, managers and regulators with analysis of risk adjusted clinical quality and benchmarking analysis. The data to which access is requested are proportionate and necessary to achieve those interests. C2-Ai has completed a legitimate interests assessment (LIA) and is satisfied that the interests of the data subjects do not override C2-Ai’s legitimate interests; that they would reasonably expect the processing and it would not cause unjustified harm.

C2-Ai believe in order to improve care standards it is a reasonable expectation for a patient receiving care to have their pseudonymised details and treatment prescribed included in an aggregate dataset to be processed as part of an assessment of care-giver’s performance for the future benefit of that patient and all other patients.

C2-Ai also believe that in order to improve care standards it is a wholly reasonable expectation for a care giver/ consultant providing care to have their prescribed treatment assessed and processed.

Where C2-Ai happens to notice a potential risk to patient safety, C2-Ai, without any charge, provide this information to the regulator in aggregate form to act upon to prevent further untoward harm to patients.

The lawful basis for processing special category data under the UK GDPR is Article 9(2)(j) processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject;

The analysis C2-Ai undertakes on behalf of Health regulators and organisations providing NHS services serves the broader societal public interest of ensuring standards of quality and safety are maintained in hospitals and to help inform performance ratings to help people choose care.

REPORTS FOR CQC

Reports are produced for the CQC with the objective of providing an early warning analysis in order to focus their inspections, identify poor hospital performance, improve patient safety and help reduce avoidable harm to patients.

C2-Ai analysis is made available to the CQC in the context of inspections and improvement projects, but under no circumstances will the CQC be given access to the raw data. Analysis is shared with the CQC in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Without C2-Ai processed national HES from NHS England, CQC inspectors would have no quantitative (risk adjusted) analysis of morbidity in particular to benchmark hospitals providing NHS services and by specialty. This would restrict their ability to undertake inspections based on informed data and identification of poorly performing hospitals early (prior to avoidable mortality becoming an issue). Hospital outliers might be missed and untoward harm may occur to patients where it could potentially be avoided.

REPORTS FOR NHS TRUSTS AND INDEPENDENT SECTOR PROVIDERS OFFERING NHS SERVICES

Following requests from NHS Acute Trusts/ Independent Sector Providers offering NHS services, C2-Ai will supply anonymised (aggregate, small number suppressed) reports of other NHS Trusts/ independent sector providers (e.g. private hospitals contracted to provide NHS overspill elective surgery, or NHS Trusts and Integrated Care Systems who are outsourcing some elective recovery work to the local private sector providers) to benchmark the individual organisation's clinical performance as reported by C2-Ai regionally and nationally against other anonymised hospitals. These reports will be shared directly with the named organisation only to support their quality improvements. The NHS Trusts/ independent sector providers can only view their own named data, benchmarked against the anonymised results of other hospitals nationally and regionally.

C2-Ai’s established regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives will be supported with the regional and national quarterly reports. These C2-Ai reports aim to demonstrate where improvements have been made and identify where remedial measures are required. This can be seen in the Academic Health Science Network ‘Limiting patient harm due to Acute Kidney Injury: A Patient Safety Initiative', where C2-Ai would like to support Hospitals Trusts with similar projects. By the end of the Acute Kidney Injury (AKI) intervention, AKI incidence on surgical wards had fallen by 36%. In addition to the reduction in patient harm, the Hospital Trust estimates the AKI programme has allowed the trust to reallocate £533,000 per year to other services.

NHS Trusts have explicitly requested regional and national benchmarking reports. Thereby, NHS Trusts can implement remedial and preventative actions. Improvements initiatives to improve care standards are also highlighted and can be implemented.

C2-Ai is a private company and as such healthcare providers of NHS services and regulator organisation clients will be charged for CRAB analysis, software services, expert support in application and interpretation of reports and access to their bespoke database reporting. C2-Ai works on behalf of NHS organisations to whom C2-Ai provide the outputs of the C2-Ai Analysis (generating a profit from the work outlined in this application) and continue to maintain the relevance of these tools that utilise NHS England data inputs.

The provision of the C2-Ai products benefit the health and social care system in England and Wales through identification of variance in clinical practice based on algorithms developed to provide case mix specific risk adjusted clinical outcomes trends, regional and national benchmarking and avoidable harm identification to support quality improvement and horizon scanning in terms of early warning for NHS providers and regulators. The analysis has supported the elective recovery programmes in dozens of NHS Trusts and ICSs in support of patient risk stratification and prehabilitation.

The benefits to the recipients (see benefits section) include patient level case mix risk adjusted clinical outcomes and triggers of avoidable harm (including quality of care of the deteriorating patient) analysis for all NHS hospitals and providers of NHS services – which can only be determined through C2-Ai's proprietary speciality specific risk adjustment algorithms.

There are a number of historic and recent independent publications by NHS as to the clinical benefits from quality improvement programmes and related cost efficiency savings to the NHS, which have been supported by the C2-Ai analysis.

The expected outputs of the processing will be:

• A report of risk adjusted health outcomes to the Care Quality Commission (CQC) on a quarterly basis, at Trust/ hospital provider and specialty levels

• A report of findings to individual NHS Trusts/ Independent Sector Providers offering NHS services on request to assist in benchmarking and quality analysis

• Maintenance of regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives, supported by quarterly regional and national reports

The outputs will not contain NHS England data and will only contain aggregated information with small numbers suppressed as appropriate in line with the relevant disclosure rules for the dataset(s) from which the information was derived.

Reviews and scheduled reports of acute care and performance of an organisation are for that organisation only, unless being reviewed for a national body such as the CQC.

CQC:

The CQC have used C2-Ai reports to drill into more detailed analysis of organisational performance where appropriate, particularly in relation to morbidity and avoidable harm - to support CQC inspection activity and elective recovery by NHS England.

NHS Trusts:

The CRAB web-based tool has supported hospital organisations when wanting to review certain procedures and their outcomes to monitor performance. The Observatory is used to help Trust Boards and clinical leaders target their improvement efforts in the right areas and identify areas of excellence. As a result, Trusts have been able to:

- put in place appropriate governance and monitoring systems

- receive early warning of problems or deterioration in practice quality so this could be rapidly investigated

- monitor and improve quality from the perspective of avoidable harm

- better understand the clinical risks or possible complications for individual patients, to enable informed conversations and higher quality care.

C2-Ai (CRAB) is now deployed in over 25 NHS Trust including 2 ICB region-wide deployments to support mutual aid and health equity assurance

C2-Ai was able to demonstrate to South Tees NHS Trust that it saved on average £4,700 per Acute Kidney Injury episode avoided. Acute Kidney Injury episodes have reduced by over 36% since this intervention, saving the Trust over £85,000/year. This success has since been shared with other NHS Trusts.

C2-Ai was able to undertake analysis across the Cheshire and Merseyside Integrated Care System for all acute NHS Trusts. C2-Ai analysis saved over £200,000 per Trust in administration efficiencies; reduced length of stay by 125 bed days per 1,000 patients on the patient tracking list and reduced emergency admissions by over 8% (of note, in 2020 prior to introduction of C2-Ai patient tracking list risk stratification 100% of patients listed for elective femoral hernia repairs presented as emergencies at one of the pilot Trusts). Reducing emergency admissions and length of stay tends to improve patient experiences and patient safety.

Furthermore, the analysis has been used to create waiting well pathways of care to prehabilitate patients with modifiable risk factors to improve their health risks ahead of surgery. Preliminary data has shown a greater than 6 fold reduction in expected complications such as hospital acquired pneumonia, conversion of inpatient to day-case in a number of procedures  and reduction in length of stay by 2-3 days per patient recruited onto the programme. This work has been published and forms part of the NHS England Blueprinting programme.

GIRFT

The risk stratification analysis provided by CRAB has been included in the GIRFT best practice guidance for elective recovery.

The Keogh Review:

The Keogh Review used C2-Ai reports to assess risk-adjusted harm in 14 hospital Trusts. The Keogh review identified inadequate numbers of nursing staff as a key issue, and subsequently developed plans to address safety and quality changes in each of the Trusts identified by the C2-Ai reports

Darzi Review

CRAB contributed to and was named in the most recent Lord Darzi report on the state of the NHS. Recommendations are in line with the services CRAB provides NHS Trusts and ICB regards actionable insights and transparency through case mix adjusted clinical outcomes relevant to the case-mix complexity of the NHS Providers populations

BiG Carbon Index

Linking risk adjusted clinical outcomes to sustainability costs associated with carbon usage, fresh water and waste and how these track over time to support the ICB and NHS Trust Net Zero goals and accountabilities with NHS England

CRAB Clinical Informatics Limited (C2-Ai) is responsible for developing and marketing CRAB (Copeland Risk Adjusted Barometer). Designed by the former National Director for Clinical Audit, CRAB is a web-based tool and reporting platform to evaluate quality and outcomes in a way which accurately reflects the clinical profile and case-mix complexity of patients treated.

C2-Ai is the sole Data Controller. L2S2 Ltd is the sole data processor acting under the instructions of C2-Ai. Whilst C2-Ai undertake analysis for the Care Quality Commission (CQC) and intend to undertake work for a variety of organisations, neither C2-Ai nor any of its customer organisations have access to or process the raw Hospital Episode Statistics (HES) data provided by NHS England. Only L2S2 have access to and process the raw HES data, with customers having sight of aggregate (small number suppressed) outputs only.

The HES data set is being obtained to support the Care Quality Commission (CQC) and NHS Trusts/ Independent Sector Providers offering NHS services only. The data processed is the same for both purposes, and the data outcomes are the same.

HES Admitted Patient Care (HES APC) and HES Critical Care (HES CC) are the only data sets required as C2-Ai only look at inpatient avoidable harm from admission to discharge/death <30 days.

The C2-Ai reports are specifically to:

- assist in objective benchmarking of organisations and sites/ departments within Trusts/ Independent Sector Providers offering NHS services

- expedite quality analysis on behalf of the CQC and NHS Trusts/ Independent Sector Providers offering NHS services, notably quarterly national/ monthly local horizon scanning of hospitals with high levels of morbidity as an early-warning and targeting tool for inspections.

This is designed to provide a granular local dashboard to help the CQC and NHS Trusts/ Independent Sector Providers offering NHS services to interpret and understand safety in relation to avoidable harm, morbidity and areas for improvement.

Where mentioned; “anonymised data and anonymised reports” refer to reports that do not contain any identifiable data, other than the name of the hospital trust with whom the report is being shared directly.

C2-Ai will only identify and share the hospital provider’s name for the hospital provider that the report is being shared with.

No patient identifiable data is shared within the reports.

To clarify, Consultant information is only shared where untoward harm is identified and requires investigation based on data provided by the hospital and not NHS England.

All of the data fields provided by NHS England are processed by L2S2 using CRAB algorithms on its own dedicated server and are not aggregated or amalgamated with any other data received from other sources.

Data is presented in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Accordingly, the latest HES data is required by C2-Ai from NHS England in order for this analysis to be contemporary, accurate and reliable to make a worthwhile analysis. C2-Ai require a maximum of 3 years of finalised NHS England data at any time. To be clear, the data set requested and currently held is the minimum breadth of data fields required to undertake the CRAB analysis robustly, therefore the data fields cannot be minimised further.

C2-Ai only require pseudonymised data from NHS England– algorithms developed require all hospital activity coding relating to comorbidities, procedure and diagnoses in order to facilitate analysis. These algorithms are reviewed semi-annually to ensure they use the minimum data set required for the algorithms to work.

Furthermore, analysis is required to be down to the consultant level by general medical council (GMC) code in order to verify speciality of clinical practice within a specific NHS Trust/ Independent Sector Providers offering NHS services as is required by the CQC to provide targeted, key lines of enquiry for their on-site inspection teams.

In the past, the C2-Ai analysis provided to the Keogh review team in 2013 was based on a bulk extract of HES & mortality data supplied by NHS England for the 14 hospitals concerned. A similar exercise was also conducted using HES data on behalf of Monitor, and again as a research project investigating emergency laparotomy practice with Royal United Bath Hospital NHS Trust. With the extension of this system following the Keogh Review and the newly defined roles of the CQC, the CQC has commissioned C2-Ai on an ongoing quarterly basis to analyse HES data for all hospitals providing NHS services in England.

C2-Ai, the Data Controller for this application, have developed an analytical tool to evaluate the quality of healthcare and associated outcomes. This was developed for use by health-related national bodies and NHS Trusts, and other NHS organisations; it was not developed purely for the CQC for example. C2-Ai already has other customers (NHS Trusts) using the tool for analysis of their own Trust data (i.e. not the HES data). Therefore, C2-Ai have developed their service and analytical tool for a range of customers, and C2-Ai determine the nature of processing, aligned to customer needs. This is why C2-Ai is the sole Data Controller.

C2-Ai only processes data where absolutely necessary to perform the clinical audit as requested by the client. A Data Privacy Impact Assessment (DPIA) and Legitimate Interest Assessment (LIA) is carried out before the processing of data to ensure it is necessary to create a new client database.

The lawful basis for processing personal data under the UK GDPR is Article 6(1)(f) processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child.

Processing personal data is necessary for C2-Ai's legitimate interests, which are to process data to improve care for patients by providing clinicians, managers and regulators with analysis of risk adjusted clinical quality and benchmarking analysis. The data to which access is requested are proportionate and necessary to achieve those interests. C2-Ai has completed a legitimate interests assessment (LIA) and is satisfied that the interests of the data subjects do not override C2-Ai’s legitimate interests; that they would reasonably expect the processing and it would not cause unjustified harm.

C2-Ai believe in order to improve care standards it is a reasonable expectation for a patient receiving care to have their pseudonymised details and treatment prescribed included in an aggregate dataset to be processed as part of an assessment of care-giver’s performance for the future benefit of that patient and all other patients.

C2-Ai also believe that in order to improve care standards it is a wholly reasonable expectation for a care giver/ consultant providing care to have their prescribed treatment assessed and processed.

Where C2-Ai happens to notice a potential risk to patient safety, C2-Ai, without any charge, provide this information to the regulator in aggregate form to act upon to prevent further untoward harm to patients.

The lawful basis for processing special category data under the UK GDPR is Article 9(2)(j) processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject;

The analysis C2-Ai undertakes on behalf of Health regulators and organisations providing NHS services serves the broader societal public interest of ensuring standards of quality and safety are maintained in hospitals and to help inform performance ratings to help people choose care.

REPORTS FOR CQC

Reports are produced for the CQC with the objective of providing an early warning analysis in order to focus their inspections, identify poor hospital performance, improve patient safety and help reduce avoidable harm to patients.

C2-Ai analysis is made available to the CQC in the context of inspections and improvement projects, but under no circumstances will the CQC be given access to the raw data. Analysis is shared with the CQC in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Without C2-Ai processed national HES from NHS England, CQC inspectors would have no quantitative (risk adjusted) analysis of morbidity in particular to benchmark hospitals providing NHS services and by specialty. This would restrict their ability to undertake inspections based on informed data and identification of poorly performing hospitals early (prior to avoidable mortality becoming an issue). Hospital outliers might be missed and untoward harm may occur to patients where it could potentially be avoided.

REPORTS FOR NHS TRUSTS AND INDEPENDENT SECTOR PROVIDERS OFFERING NHS SERVICES

Following requests from NHS Acute Trusts/ Independent Sector Providers offering NHS services, C2-Ai will supply anonymised (aggregate, small number suppressed) reports of other NHS Trusts/ independent sector providers (e.g. private hospitals contracted to provide NHS overspill elective surgery, or NHS Trusts and Integrated Care Systems who are outsourcing some elective recovery work to the local private sector providers) to benchmark the individual organisation's clinical performance as reported by C2-Ai regionally and nationally against other anonymised hospitals. These reports will be shared directly with the named organisation only to support their quality improvements. The NHS Trusts/ independent sector providers can only view their own named data, benchmarked against the anonymised results of other hospitals nationally and regionally.

C2-Ai’s established regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives will be supported with the regional and national quarterly reports. These C2-Ai reports aim to demonstrate where improvements have been made and identify where remedial measures are required. This can be seen in the Academic Health Science Network ‘Limiting patient harm due to Acute Kidney Injury: A Patient Safety Initiative', where C2-Ai would like to support Hospitals Trusts with similar projects. By the end of the Acute Kidney Injury (AKI) intervention, AKI incidence on surgical wards had fallen by 36%. In addition to the reduction in patient harm, the Hospital Trust estimates the AKI programme has allowed the trust to reallocate £533,000 per year to other services.

NHS Trusts have explicitly requested regional and national benchmarking reports. Thereby, NHS Trusts can implement remedial and preventative actions. Improvements initiatives to improve care standards are also highlighted and can be implemented.

C2-Ai is a private company and as such healthcare providers of NHS services and regulator organisation clients will be charged for CRAB analysis, software services, expert support in application and interpretation of reports and access to their bespoke database reporting. C2-Ai works on behalf of NHS organisations to whom C2-Ai provide the outputs of the C2-Ai Analysis (generating a profit from the work outlined in this application) and continue to maintain the relevance of these tools that utilise NHS England data inputs.

The provision of the C2-Ai products benefit the health and social care system in England and Wales through identification of variance in clinical practice based on algorithms developed to provide case mix specific risk adjusted clinical outcomes trends, regional and national benchmarking and avoidable harm identification to support quality improvement and horizon scanning in terms of early warning for NHS providers and regulators. The analysis has supported the elective recovery programmes in dozens of NHS Trusts and ICSs in support of patient risk stratification and prehabilitation.

The benefits to the recipients (see benefits section) include patient level case mix risk adjusted clinical outcomes and triggers of avoidable harm (including quality of care of the deteriorating patient) analysis for all NHS hospitals and providers of NHS services – which can only be determined through C2-Ai's proprietary speciality specific risk adjustment algorithms.

There are a number of historic and recent independent publications by NHS as to the clinical benefits from quality improvement programmes and related cost efficiency savings to the NHS, which have been supported by the C2-Ai analysis.

The expected outputs of the processing will be:

• A report of risk adjusted health outcomes to the Care Quality Commission (CQC) on a quarterly basis, at Trust/ hospital provider and specialty levels

• A report of findings to individual NHS Trusts/ Independent Sector Providers offering NHS services on request to assist in benchmarking and quality analysis

• Maintenance of regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives, supported by quarterly regional and national reports

The outputs will not contain NHS England data and will only contain aggregated information with small numbers suppressed as appropriate in line with the relevant disclosure rules for the dataset(s) from which the information was derived.

Reviews and scheduled reports of acute care and performance of an organisation are for that organisation only, unless being reviewed for a national body such as the CQC.

CQC:

The CQC have used C2-Ai reports to drill into more detailed analysis of organisational performance where appropriate, particularly in relation to morbidity and avoidable harm - to support CQC inspection activity and elective recovery by NHS England.

NHS Trusts:

The CRAB web-based tool has supported hospital organisations when wanting to review certain procedures and their outcomes to monitor performance. This has typically been done as a one-off exercise to help Trust Boards and clinical leaders target their improvement efforts in the right areas. As a result, Trusts have been able to:

- put in place appropriate governance and monitoring systems

- receive early warning of problems or deterioration in practice quality so this could be rapidly investigated

- monitor and improve quality from the perspective of avoidable harm

- better understand the clinical risks or possible complications for individual patients, to enable informed conversations and higher quality care

C2-Ai was able to demonstrate to South Tees NHS Trust that it saved on average £4,700 per Acute Kidney Injury episode avoided. Acute Kidney Injury episodes have reduced by over 36% since this intervention, saving the Trust over £85,000/year. This success has since been shared with other NHS Trusts.

C2-Ai was able to undertake analysis across the Cheshire and Merseyside Integrated Care System for all acute NHS Trusts. C2-Ai analysis saved over £200,000 per Trust in administration efficiencies; reduced length of stay by 125 bed days per 1,000 patients on the patient tracking list and reduced emergency admissions by over 8% (of note, in 2020 prior to introduction of C2-Ai patient tracking list risk stratification 100% of patients listed for elective femoral hernia repairs presented as emergencies at one of the pilot Trusts). Reducing emergency admissions and length of stay tends to improve patient experiences and patient safety.

Furthermore, the analysis has been used to create waiting well pathways of care to prehabilitate patients with modifiable risk factors to improve their health risks ahead of surgery. Preliminary data has shown a 100% reduction in expected complications such as hospital acquired pneumonia, conversion of inpatient to day-case in a number of procedures  and reduction in length of stay by 2-3 days per patient recruited onto the programme.

The Keogh Review:

The Keogh Review used C2-Ai reports to assess risk-adjusted harm in 14 hospital Trusts. The Keogh review identified inadequate numbers of nursing staff as a key issue, and subsequently developed plans to address safety and quality changes in each of the Trusts identified by the C2-Ai reports

CRAB Clinical Informatics Limited (C-Ci) is responsible for developing and marketing CRAB (Copeland Risk Adjusted Barometer). Designed by the former National Director for Clinical Audit, CRAB is a web-based tool to evaluate quality and outcomes in a way which accurately reflects the clinical profile of patients treated.

C-Ci is the sole Data Controller. L2S2 Ltd is the sole data processor. Whilst C-Ci undertake analysis for the CQC and intend to undertake work for a variety of organisations, neither C-Ci nor any of its customer organisations have access to or process the raw HES data provided by NHS Digital. Only L2S2 have access to and process the raw HES data, with customers having sight of aggregate (small number suppressed) outputs only.

C-Ci has been re-branded and is now known as Copeland Clinical Ai (C2-Ai). C-Ci remains the name used for the organisation as a legal entity, and so this name will be used throughout the application when referencing the organisation.

HES data set is being obtained to support the Care Quality Commission (CQC) and NHS Trusts only. The data processed is the same for both purposes, and the data outcomes are the same.

HES Admitted Patient Care (HES APC) and HES Critical Care (HES CC) are the only data sets required as C-Ci only look at inpatient avoidable harm from admission to discharge/death <30 days.

The CRAB reports are specifically to:

- assist in objective benchmarking of organisations

- expedite quality analysis on behalf of the CQC and NHS Trusts, notably quarterly national horizon scanning of NHS Trusts high levels of morbidity as an early-warning and targeting tool for inspections.

This is designed to provide a granular local dashboard to help the Care Quality Commission and NHS Trusts to interpret and understand safety in relation to avoidable harm, morbidity and areas for improvement.

Where mentioned; “anonymised data and anonymised reports” refer to reports that do not contain any identifiable data, other than the name of the hospital trust with whom the report is being shared directly.

For example, although not currently developed, the national and regional benchmarking reports are expected to be provided in the format of line graphs or similar, where all hospitals are benchmarked by C-Ci. Only the hospital trust that is in contact with C-Ci will have their Organisation’s information made available to them. The hospital trust will have their own hospital report made available to them.

C-Ci will only identify and share the hospital trust’s name for the hospital trust that the report is being shared with.

No patient identifiable data is shared within the reports.

Consultant information is only shared where untoward harm is identified and requires investigation.

All of the data fields provided by NHS Digital are processed by CRAB algorithms on its own dedicated server and are not aggregated or amalgamated with any other data received from other sources.

Data is presented in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Accordingly, the latest HES data is required by C-Ci from NHS Digital in order for this analysis to be contemporary, accurate and reliable to make a worthwhile analysis. To be clear, the data set requested and currently held is the minimum breadth of data fields required to undertake the CRAB analysis robustly, therefore the data fields cannot be minimised further.

CRAB only require pseudonymised data – algorithms developed require all hospital activity coding relating to comorbidities, procedure and diagnoses in order to facilitate analysis. These algorithms are reviewed semi-annually to ensure they use the minimum data set required for the algorithms to work.

Furthermore, analysis is required to be down to the consultant level by GMC code (CONSULT field) in order to verify speciality of clinical practice within a specific NHS Trust as is required by the CQC to provide targeted, key lines of enquiry for their on-site inspection teams.

Historically, C-Ci has an established record of receiving and handling data from the HSCIC/NHS Digital, and successfully passed a compliance audit by NHS Digital in January 2017. The analysis provided to the Keogh review team in 2013 was based on a bulk extract of HES & ONS data supplied by the HSCIC (now NHS Digital) for the 14 hospitals concerned. A similar exercise was also conducted using HES data on behalf of Monitor, and again as a research project investigating emergency laparotomy practice with Royal United Bath Hospital NHS Trust. With the extension of this system following the Keogh Review and the newly defined roles of the CQC, the CQC has commissioned C-Ci on an ongoing quarterly basis to analyse HES data for all NHS Trusts in England.

CRAB Clinical Informatics, the Data Controller for this application, have developed an analytical tool to evaluate the quality of healthcare and associated outcomes. This was developed for use by health-related national bodies and NHS Trusts, and other NHS organisations; it was not developed purely for the CQC for example. In fact, C-Ci already has other customers (NHS Trusts) using the tool for analysis of their own Trust data (i.e. not the HES data). Therefore, C-Ci have developed their service and analytical tool for a range of customers, and C-Ci determine the nature of processing, aligned to customer needs. This is why C-Ci is the sole Data Controller.

REPORTS FOR CQC

Reports are produced for the CQC with the objective of providing an early warning analysis in order to focus their inspections, identify poor hospital performance, improve patient safety and help reduce avoidable harm to patients.

C-Ci analysis in the form of static reports (either pdf or excel, the latter for CQC to incorporate into their own template reports) is made available to the CQC in the context of inspections and improvement projects, but under no circumstances will the CQC be given access to the raw data. Analysis shared with the CQC in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

C-Ci undertake data privacy impact assessments (DPIA) and a legitimate interest assessment (LIA) before creating any new databases, as part of C-Ci's governance and ISO9001 framework, before working with any new Agents as approved by NHS Digital Auditors in January 2017.

The legitimate interests relied upon by C-Ci for this use of data are that C-Ci have been commissioned by the CQC to undertake NHS Trust level analysis of pseudonymised quarterly national HES data from NHS Digital using CRAB’s proprietary algorithms to identify risk adjusted outcomes aggregated by Trust and specialty for mortality and complications. The LIA for the CQC has been completed and has already been shared with NHS Digital.

The legal basis for processing is:

EU GDPR Article 6: “Lawfulness of processing”.

1.(f) processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child.

L2S2, on behalf of C-Ci, process NHS Trust level analysis of pseudo-anonymised HES data sourced from NHS Digital and SUS data sourced directly from NHS trusts to identify risk adjusted outcomes aggregated by Trust (HES data) and specialty for mortality and complications (HES and SUS data). Thereby, with NHS HES data the CQC can identify outlying NHS Trusts as the basis for risk-based inspections, and remedial and preventative actions by the NHS Trusts being inspected. NHS Trusts can review their CRAB processed SUS data to the same effect. CRAB processed data enables the review of any cause and effect improvement measures that may have been implemented to improve the standard of patient care. Without CRAB processed national HES from NHS Digital, CQC inspectors would have no quantitative analysis of morbidity in particular to benchmark NHS trusts. This would restrict their ability to undertake inspections based on informed data and identification of poorly performing NHS Trusts early (prior to avoidable mortality becoming an issue). Hospital outliers might be missed and untoward harm may occur to patients where it could potentially be avoided.

And

EU GDPR Article 9:

"Processing of special categories of personal data"

2.(j) processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject;

The analysis CRAB undertakes on behalf of Health regulators and NHS organisations serves the broader societal interest of ensuring standards of quality and safety are maintained in hospitals and to help inform performance ratings to help people choose care.

- The CRAB analysis cannot be achieved without access to the pseudo-anonymised data.

- All information is pseudonymised when received and analysed data is at an aggregate level (i.e. Trust or speciality level, meaning there are no small volumes) with no patient specific reference.

C-Ci only processes data where absolutely necessary to perform the clinical audit as requested by the client. A Data Privacy Impact Assessment (DPIA) and Legitimate Interest Assessment (LIA) is carried out before the processing of data to ensure it is necessary to create a new client database.

C-Ci believe in order to improve care standards it is a reasonable expectation for a patient receiving care to have their fully anonymised details and treatment prescribed included in an aggregate dataset to be processed as part of an assessment of care-giver’s performance for the future benefit of that patient and all other patients.

C-Ci also believe that in order to improve care standards it is a wholly reasonable expectation for a care giver/ consultant providing care to have their prescribed treatment assessed and processed.

Where C-Ci happens to notice a potential risk to patient safety, C-Ci, without any charge, provide this information to the regulator in aggregate form to act upon to prevent further untoward harm to patients.

REPORTS FOR NHS TRUSTS

Following requests from NHS Trusts, C-Ci will supply anonymised (aggregate, small number suppressed) reports of other NHS Trusts to benchmark the individual NHS Trust's clinical performance as reported by CRAB regionally and nationally against other anonymised hospital trusts. These reports will be shared directly with the named NHS Trust only to support their quality improvements. The NHS Trusts can only view their own named data, benchmarked against the anonymised results of other NHS Trusts nationally and regionally.

C-Ci’s established regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives will be supported with the regional and national quarterly reports. These CRAB reports aim to demonstrate where improvements have been made and identify where remedial measures are required. This can be seen in the Academic Health Science Network ‘Limiting patient harm due to Acute Kidney Injury: A Patient Safety Initiative', where C-Ci would like to support Hospitals Trusts with similar projects. By the end of the Acute Kidney Injury (AKI) intervention in July 2016, AKI incidence on surgical wards had fallen by 36%. In addition to the reduction in patient harm, the Hospital Trust estimates the AKI programme has allowed the trust to reallocate £533,000 per year to other services.

NHS Trusts have now explicitly requested regional and national benchmarking reports and a separate LIA has been shared with NHS Digital. Thereby, NHS Trusts can implement remedial and preventative actions. Improvements initiatives to improve care standards are also highlighted and can be implemented.

Outputs of the C-Ci work to CQC in relation to use of the HES data provided by NHS Digital are:

- CQC (quarterly reporting since 2017 and ongoing):

- Quarterly risk adjusted outcomes and NHS Trust outlier reports on behalf of the Care Quality Commission (CQC) at Trust and clinical speciality levels based on C-Ci's proprietary analysis of operative surgical care using mortality and morbidity risk adjusted for case mix complexity in addition to ward based medical care using triggers of potential avoidable harm (based on the IHI Global Trigger Tool).

- Training of CQC inspectors on use of C-Ci analysis

CQC Reports specifically include the following quantitative metrics: Top 20 NHS trusts (quarterly basis since March 2017):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) 20 NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

++++

Outputs of the C-Ci work to NHS Trusts in relation to use of the HES data provided by NHS Digital will be:

- NHS Trusts' regional and national reports (quarterly reporting)

- assist in objective benchmarking of organisations

- expedite quality analysis on behalf of the NHS Trust

- quarterly risk adjusted outcomes reports on behalf of the Trust and clinical speciality levels based on C-Ci's proprietary analysis of operative surgical care using mortality and morbidity risk adjusted for case mix complexity (based on the IHI Global Trigger Tool).

- training of NHS staff on use of C-Ci analysis

- regional hub for trusts to network with each other and share learning from improvement initiatives. C-Ci is able to demonstrate where improvements have been made and support where remedial measures are required.

NHS Trust Reports specifically include the following quantitative metrics: Anonymised NHS Trusts, with only the NHS Trusts requesting assistance to be identified within the report (quarterly basis):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide

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CQC:

C-Ci has been commissioned by to undertake a quarterly national review of NHS medicine and surgery outcomes of all NHS hospitals in England on behalf of the Care Quality Commission (CQC) - commenced March 2017 and continues to present.

Reviews and scheduled reports of acute care and performance of an organisation are for that organisation only, unless being reviewed for a national body such as the CQC or Monitor, with timescales determined by the executives.

In relation to the interactive databases, the reporting can be made available to individual patient level, subject to restricted permissions, enabling organisations to conduct detailed audits and investigations where necessary (e.g. critical incident & SUI reporting). However, in any given case, the raw data itself is not accessed, and in relation to the reports, these are only accessible to the organisation and staff concerned, being hosted in a dedicated, encrypted environment and subject to IG-compliant processes for log-in and individualised permissions.

Hospital, regional and national benchmarking:

• COVID Mortality risk by hospital

• O/E risk adj mortality and morbidity by surgical specialty/ hospital – regional

• 4 or more triggers of avoidable harm by specialty

• Mortality rate for patients with 4 or more triggers by specialty

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C-Ci are involved in delivery of the regional support for elective recovery work sponsored by NHSE. This will involve both risk stratification of the patient tracking list and risk adjusted surgical outcomes for Integrated Care Systems (ICSs) and Trusts included in the analysis.

NHS Trusts –

Bespoke investigations. For example:

Supporting investigation of high hospital standard mortality ratio (HSMR) at hospital site. C-Ci carried out a mortality and morbidity review of the hospital and disclosed the causes of the high HSMR.

As a result, the trust is able to target and carry out remedial and improvement initiatives, which will potentially have a direct improvement on the quality of care the public receives, along with an improved profile for the hospital.

Hospitals providing NHS services:

CRAB has also supported and continues to support hospital organisations when wanting to review certain procedures and their outcomes to monitor performance. This is typically done as a one-off exercise, again to help Trust Boards and clinical leaders target their improvement efforts in the right areas. The benefit of CRAB to clinicians, managers and Board members at hospital Trusts includes the ability to:

- understand quality of care on an ongoing basis, and to set in place appropriate governance and monitoring systems.

- receive early warning of problems and monitor trends for deterioration in practice quality - rapidly investigate and interpret SHMI results (and other mortality data such as HSMR), to understand root cause and underlying patterns in relation to mortality, in accordance with DH policy guidance that provider organisations should have their own localised clinical dashboards for this purpose.

- monitor quality beyond basic mortality: assessing morbidity and avoidable harm, as a fundamental move towards continuous quality improvement

- generate appraisal documentation for clinical staff
- improve accuracy of coding

- understand the clinical risks (or mortality and complications) for each individual patient and have frank and open discussions with them.

These benefits can also be aggregated to a national level, in so far as the DH and regulatory bodies (Monitor and CQC) can use the information to drill into more detailed analysis of organisational performance where appropriate, particularly in relation to morbidity and avoidable harm - as is envisaged to support CQC inspection activity and quality base-lining by Monitor.

In essence this will provide CQC inspectors with an early warning analysis at a Trust and Department level based on a more in-depth view of medical and ward-based care alongside clinically risk-adjusted surgical practice than may otherwise be possible with standard mortality and statistical analysis. The focus in particular is on understanding morbidity as well as mortality, and areas where morbidity may be just as much the result of omission to treat/failure to rescue as it may be the result of active error.

C-Ci continue to work with the CQC, NHS Trusts and PWC, with yielded benefits as at 2021 including:

CQC (Commenced March 2017 - present)

- successfully providing Rapid Reviews of hospital care originally for the previous Chief Inspector of Hospitals as and when requested for supporting the CQC Inspections, and since then;

- quarterly NHS Trust reporting for the CQC as a horizon scanning tool for early identification of outlying NHS Trusts which may perform acceptably for mortality, but potentially have underlying problems in relation to morbidity which have hitherto gone unnoticed and may easily escalate, with an impact on avoidable mortality. This may include: problems with failure to rescue deteriorating patients; or recovering seriously ill patients who have deteriorated as a result of poor care, which has impacted upon cost and capacity to treat others.

- within the above, which specific areas of an organisation are most problematic, in order that any subsequent enquiry or inspection can be effectively targeted.

- outlying/improving organisations at the good end of the spectrum, to highlight where the NHS is developing a learning culture, in line with CQC recommendations.

- quarterly list of the top 20 NHS trusts:

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) 20 NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice

- adoption of CCI produced metrics by CQC inspectors to enable targeted inspections based on risk of avoidable harm and risk adjusted health outcomes performance by Trust down to individual medical and surgical specialities

- inclusion of CCI metrics into CQC standard dashboards for distribution to all NHS Trusts (awaiting sign off for general publication)

PWC - Keogh Review (Completed 2013)

- The Keogh Review used CRAB and PWC to do the detailed assessment of what was really going on in hospitals because mortality indicators simply don’t provide the insights and accuracy of C-Ci's approach. C-Ci reports on risk-adjusted harm as well as just mortality.

- 14 hospital trusts were analysed including: Basildon and Thurrock in Essex; United Lincolnshire; Blackpool; The Dudley Group, West Midlands; George Eliot, Warwickshire; Northern Lincolnshire and Goole; Tameside, Greater Manchester; Sherwood Forest, Nottinghamshire; Colchester, Essex; Medway, Kent; Burton, Staffordshire; North Cumbria; East Lancashire; and Buckinghamshire Healthcare.

- The Keogh review found frequent examples of inadequate numbers of nursing staff. All 14 trusts subsequently carried out “urgent reviews of safe staffing levels”.

- Eleven of the 14 hospital providers investigated because of high mortality ratios were placed in “special measures”.

- After reviewing each of the trusts, the teams found that having less nursing staff was linked to higher in-patient mortality rates.

- There were additional plans to address safety and quality changes in each of the trusts identified by C-Ci's analysis.

AHSN/ICS - (commenced 2021 to present)

- C-Ci is working with the AHSNs and ICSs to support regional benchmarking of clinical outcomes and support risk stratification of the patient treatment list for elective surgery in order to reduce referral to treatment times and prioritise patients at greatest risk of deterioration. A pilot was successfully undertaken in February 2021 and is being rolled out to a number of NHS Trusts across the north west and other parts of England.

NHS Trust - South Tees (completed 2017)

- C-Ci was able to demonstrate to the Trust that it saved on average £4700 per AKI episode avoided and over the period since intervention AKI has reduced by over 36%, which has resulted in a saving to the Trust of over £85,000 per year.

- This successful programme has shared the pathway and been consulted by other NHS Trusts, who have been made aware of C-Ci's AKI project through their links to CRAB Clinical Informations (including 9 other NHS Trusts including: Imperial, Frimley Park, Wexham Park, North Devon, St Helen's, and Southend NHS Trusts).

- Published research papers on cost savings from health quality improvement based on data analysed by C-Ci on behalf of South Tees NHS Trust: http://atlas.ahsnnetwork.com/limiting-patient-harm-due-to-acute-kidney-injury/

- Initiative was recognised at national health innovations awards as highly commended in July 2017 at the HSJ National Patient Safety Awards and winner in the health innovation category at the AHSN awards in September 2017.

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C-Ci has been shortlisted for 2 health service journal awards for patient safety and elective recovery in partnership with NHS trusts in recognition of the improvements in clinical outcomes and cost savings to both NHS trusts.

CRAB Clinical Informatics Limited (C-Ci) is responsible for developing and marketing CRAB (Copeland Risk Adjusted Barometer). Designed by the former National Director for Clinical Audit, CRAB is a web-based tool to evaluate quality and outcomes in a way which accurately reflects the clinical profile of patients treated.

C-Ci is the sole Data Controller. L2S2 Ltd is the sole data processor. Whilst C-Ci undertake analysis for the CQC and intend to undertake work for a variety of organisations, neither C-Ci nor any of its customer organisations have access to or process the raw HES data provided by NHS Digital. Only L2S2 have access to and process the raw HES data, with customers having sight of aggregate (small number suppressed) outputs only.

C-Ci has been re-branded and is now known as Copeland Clinical Ai (C2-Ai). C-Ci remains the name used for the organisation as a legal entity, and so this name will be used throughout the application when referencing the organisation.

HES data set is being obtained to support the Care Quality Commission (CQC) and NHS Trusts only. The data processed is the same for both purposes, and the data outcomes are the same.

HES Admitted Patient Care (HES APC) and HES Critical Care (HES CC) are the only data sets required as C-Ci only look at inpatient avoidable harm from admission to discharge/death <30 days.

The CRAB reports are specifically to:

- assist in objective benchmarking of organisations

- expedite quality analysis on behalf of the CQC and NHS Trusts, notably quarterly national horizon scanning of NHS Trusts high levels of morbidity as an early-warning and targeting tool for inspections.

This is designed to provide a granular local dashboard to help the Care Quality Commission and NHS Trusts to interpret and understand safety in relation to avoidable harm, morbidity and areas for improvement.

Where mentioned; “anonymised data and anonymised reports” refer to reports that do not contain any identifiable data, other than the name of the hospital trust with whom the report is being shared directly.

For example, although not currently developed, the national and regional benchmarking reports are expected to be provided in the format of line graphs or similar, where all hospitals are benchmarked by C-Ci. Only the hospital trust that is in contact with C-Ci will have their Organisation’s information made available to them. The hospital trust will have their own hospital report made available to them.

C-Ci will only identify and share the hospital trust’s name for the hospital trust that the report is being shared with.

No patient identifiable data is shared within the reports.

Consultant information is only shared where untoward harm is identified and requires investigation.

All of the data fields provided by NHS Digital are processed by CRAB algorithms on its own dedicated server and are not aggregated or amalgamated with any other data received from other sources.

Data is presented in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Accordingly, the latest HES data is required by C-Ci from NHS Digital in order for this analysis to be contemporary, accurate and reliable to make a worthwhile analysis. To be clear, the data set requested and currently held is the minimum breadth of data fields required to undertake the CRAB analysis robustly, therefore the data fields cannot be minimised further.

CRAB only require pseudonymised data – algorithms developed require all hospital activity coding relating to comorbidities, procedure and diagnoses in order to facilitate analysis. These algorithms are reviewed semi-annually to ensure they use the minimum data set required for the algorithms to work.

Furthermore, analysis is required to be down to the consultant level by GMC code (CONSULT field) in order to verify speciality of clinical practice within a specific NHS Trust as is required by the CQC to provide targeted, key lines of enquiry for their on-site inspection teams.

Historically, C-Ci has an established record of receiving and handling data from the HSCIC/NHS Digital, and successfully passed a compliance audit by NHS Digital in January 2017. The analysis provided to the Keogh review team in 2013 was based on a bulk extract of HES & ONS data supplied by the HSCIC (now NHS Digital) for the 14 hospitals concerned. A similar exercise was also conducted using HES data on behalf of Monitor, and again as a research project investigating emergency laparotomy practice with Royal United Bath Hospital NHS Trust. With the extension of this system following the Keogh Review and the newly defined roles of the CQC, the CQC has commissioned C-Ci on an ongoing quarterly basis to analyse HES data for all NHS Trusts in England.

CRAB Clinical Informatics, the Data Controller for this application, have developed an analytical tool to evaluate the quality of healthcare and associated outcomes. This was developed for use by health-related national bodies and NHS Trusts, and other NHS organisations; it was not developed purely for the CQC for example. In fact, C-Ci already has other customers (NHS Trusts) using the tool for analysis of their own Trust data (i.e. not the HES data). Therefore, C-Ci have developed their service and analytical tool for a range of customers, and C-Ci determine the nature of processing, aligned to customer needs. This is why C-Ci is the sole Data Controller.

REPORTS FOR CQC

Reports are produced for the CQC with the objective of providing an early warning analysis in order to focus their inspections, identify poor hospital performance, improve patient safety and help reduce avoidable harm to patients.

C-Ci analysis in the form of static reports (either pdf or excel, the latter for CQC to incorporate into their own template reports) is made available to the CQC in the context of inspections and improvement projects, but under no circumstances will the CQC be given access to the raw data. Analysis shared with the CQC in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

C-Ci undertake data privacy impact assessments (DPIA) and a legitimate interest assessment (LIA) before creating any new databases, as part of C-Ci's governance and ISO9001 framework, before working with any new Agents as approved by NHS Digital Auditors in January 2017.

The legitimate interests relied upon by C-Ci for this use of data are that C-Ci have been commissioned by the CQC to undertake NHS Trust level analysis of pseudonymised quarterly national HES data from NHS Digital using CRAB’s proprietary algorithms to identify risk adjusted outcomes aggregated by Trust and specialty for mortality and complications. The LIA for the CQC has been completed and has already been shared with NHS Digital.

The legal basis for processing is:

EU GDPR Article 6: “Lawfulness of processing”.

1.(f) processing is necessary for the purposes of the legitimate interests pursued by the controller or by a third party, except where such interests are overridden by the interests or fundamental rights and freedoms of the data subject which require protection of personal data, in particular where the data subject is a child.

L2S2, on behalf of C-Ci, process NHS Trust level analysis of pseudo-anonymised HES data sourced from NHS Digital and SUS data sourced directly from NHS trusts to identify risk adjusted outcomes aggregated by Trust (HES data) and specialty for mortality and complications (HES and SUS data). Thereby, with NHS HES data the CQC can identify outlying NHS Trusts as the basis for risk-based inspections, and remedial and preventative actions by the NHS Trusts being inspected. NHS Trusts can review their CRAB processed SUS data to the same effect. CRAB processed data enables the review of any cause and effect improvement measures that may have been implemented to improve the standard of patient care. Without CRAB processed national HES from NHS Digital, CQC inspectors would have no quantitative analysis of morbidity in particular to benchmark NHS trusts. This would restrict their ability to undertake inspections based on informed data and identification of poorly performing NHS Trusts early (prior to avoidable mortality becoming an issue). Hospital outliers might be missed and untoward harm may occur to patients where it could potentially be avoided.

And

EU GDPR Article 9:

"Processing of special categories of personal data"

2.(j) processing is necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) based on Union or Member State law which shall be proportionate to the aim pursued, respect the essence of the right to data protection and provide for suitable and specific measures to safeguard the fundamental rights and the interests of the data subject;

The analysis CRAB undertakes on behalf of Health regulators and NHS organisations serves the broader societal interest of ensuring standards of quality and safety are maintained in hospitals and to help inform performance ratings to help people choose care.

- The CRAB analysis cannot be achieved without access to the pseudo-anonymised data.

- All information is pseudonymised when received and analysed data is at an aggregate level (i.e. Trust or speciality level, meaning there are no small volumes) with no patient specific reference.

C-Ci only processes data where absolutely necessary to perform the clinical audit as requested by the client. A Data Privacy Impact Assessment (DPIA) and Legitimate Interest Assessment (LIA) is carried out before the processing of data to ensure it is necessary to create a new client database.

C-Ci believe in order to improve care standards it is a reasonable expectation for a patient receiving care to have their fully anonymised details and treatment prescribed included in an aggregate dataset to be processed as part of an assessment of care-giver’s performance for the future benefit of that patient and all other patients.

C-Ci also believe that in order to improve care standards it is a wholly reasonable expectation for a care giver/ consultant providing care to have their prescribed treatment assessed and processed.

Where C-Ci happens to notice a potential risk to patient safety, C-Ci, without any charge, provide this information to the regulator in aggregate form to act upon to prevent further untoward harm to patients.

REPORTS FOR NHS TRUSTS

Following requests from NHS Trusts, C-Ci will supply anonymised (aggregate, small number suppressed) reports of other NHS Trusts to benchmark the individual NHS Trust's clinical performance as reported by CRAB regionally and nationally against other anonymised hospital trusts. These reports will be shared directly with the named NHS Trust only to support their quality improvements. The NHS Trusts can only view their own named data, benchmarked against the anonymised results of other NHS Trusts nationally and regionally.

C-Ci’s established regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives will be supported with the regional and national quarterly reports. These CRAB reports aim to demonstrate where improvements have been made and identify where remedial measures are required. This can be seen in the Academic Health Science Network ‘Limiting patient harm due to Acute Kidney Injury: A Patient Safety Initiative', where we would like to support Hospitals Trusts with similar projects. By the end of the Acute Kidney Injury (AKI) intervention in July 2016, AKI incidence on surgical wards had fallen by 36%. In addition to the reduction in patient harm, the Hospital Trust estimates the AKI programme has allowed the trust to reallocate £533,000 per year to other services.

NHS Trusts have now explicitly requested regional and national benchmarking reports and a separate LIA has been shared with NHS Digital. Thereby, NHS Trusts can implement remedial and preventative actions. Improvements initiatives to improve care standards are also highlighted and can be implemented.

Outputs of the C-Ci work to CQC in relation to use of the HES data provided by NHS Digital are:

- CQC (quarterly reporting since 2017 and ongoing):

- Quarterly risk adjusted outcomes and NHS Trust outlier reports on behalf of the Care Quality Commission (CQC) at Trust and clinical speciality levels based on C-Ci's proprietary analysis of operative surgical care using mortality and morbidity risk adjusted for case mix complexity in addition to ward based medical care using triggers of potential avoidable harm (based on the IHI Global Trigger Tool).

- Training of CQC inspectors on use of C-Ci analysis

CQC Reports specifically include the following quantitative metrics: Top 20 NHS trusts (quarterly basis since March 2017):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) 20 NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

++++

Outputs of the C-Ci work to NHS Trusts in relation to use of the HES data provided by NHS Digital will be:

- NHS Trusts' regional and national reports (quarterly reporting)

- assist in objective benchmarking of organisations

- expedite quality analysis on behalf of the NHS Trust

- quarterly risk adjusted outcomes reports on behalf of the Trust and clinical speciality levels based on C-Ci's proprietary analysis of operative surgical care using mortality and morbidity risk adjusted for case mix complexity (based on the IHI Global Trigger Tool).

- training of NHS staff on use of C-Ci analysis

- regional hub for trusts to network with each other and share learning from improvement initiatives. C-Ci is able to demonstrate where improvements have been made and support where remedial measures are required.

NHS Trust Reports specifically include the following quantitative metrics: Anonymised NHS Trusts, with only the NHS Trusts requesting assistance to be identified within the report (quarterly basis):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

All outputs will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide

+++

v 12.3

CQC:

C-Ci has been commissioned by to undertake a quarterly national review of NHS medicine and surgery outcomes of all NHS hospitals in England on behalf of the Care Quality Commission (CQC) - commenced March 2017 and continues to present.

Reviews and scheduled reports of acute care and performance of an organisation are for that organisation only, unless being reviewed for a national body such as the CQC or Monitor, with timescales determined by the executives.

In relation to the interactive databases, the reporting can be made available to individual patient level, subject to restricted permissions, enabling organisations to conduct detailed audits and investigations where necessary (e.g. critical incident & SUI reporting). However, in any given case, the raw data itself is not accessed, and in relation to the reports, these are only accessible to the organisation and staff concerned, being hosted in a dedicated, encrypted environment and subject to IG-compliant processes for log-in and individualised permissions.

Hospital, regional and national benchmarking:

• COVID Mortality risk by hospital

• O/E risk adj morality and morbidity by surgical specialty/ hospital – regional

• 4 or more triggers of avoidable harm by specialty

• Mortality rate for patients with 4 or more triggers by specialty

CQC (Commenced March 2017 - present) - successfully providing Rapid Reviews of hospital care originally for the previous Chief Inspector of Hospitals as and when requested for supporting the CQC Inspections, and since then, - a national horizon-scanning process on an ongoing, quarterly basis for the current Chief Inspector of Hospitals - ongoing - identification of outlying organisations at a Trust and clinical speciality levels, some of which have historically performed acceptably from a mortality perspective, but have been found to have underlying problems in relation to morbidity which have hitherto gone unnoticed and may easily escalate, with an impact on avoidable mortality. - inclusion of C-Ci metrics into CQC standard dashboards for distribution to all NHS Trusts (awaiting sign off for general publication) - C-Ci have trained the CQC inspectors to use the CRAB reports to identify outlying NHS Trusts based on robust risk-based analysis using the quarterly national review of NHS medicine and surgery outcomes of all NHS hospitals in England on behalf of the Care Quality Commission (CQC) - commenced March 2017.

NHS Trusts –

Bespoke investigations. For example:

Supporting investigation of high hospital standard mortality ratio (HSMR) at hospital site. C-Ci carried out a mortality and morbidity review of the hospital and disclosed the causes of the high HSMR.

As a result, the trust is able to target and carry out remedial and improvement initiatives, which will potentially have a direct improvement on the quality of care the public receives, along with an improved profile for the hospital.

Although not using NHSD data (but equivalent data from client trusts), C-Ci have successfully defended several clinicians who had been criticised (in one instance suspended) on the basis of high mortality and complication rates. In all three cases, these high rates were actually justified by the extreme complexity of work they were undertaking, and their risk-adjusted outcomes were excellent.

On other occasions, C-Ci were able to respond to the Chief Inspector of Hospitals immediately whilst he was on site during an inspection with analysis as to whether a staff complaint about a surgeon’s complication rates was justified. C-Ci were able to show that the surgeon in question had had problems on first arriving at the trust, due to being unfamiliar with prostheses in use at the organisation, but his outcomes had improved over the 2 subsequent years and were currently good.

In a converse example, C-Ci identified a surgeon who had seemingly excellent results but was “too good to be true”. Further investigation revealed he was operating on only very simple cases and rejecting other patients as inoperable (when this was clearly not the case), causing harm to patients who deteriorated without an operation and who then had to be retrieved by other surgeons with, by then, more aggravated symptoms. By agreement with the Trust concerned, the surgeon has since ceased practising.

Benefits of the monthly extract to date include:

- successfully providing Rapid Reviews of hospital care for the Chief Inspector of Hospitals as and when requested for supporting the CQC Inspections, and since then,

- a national horizon-scanning process on an ongoing, quarterly basis for the current Chief Inspector of Hospitals, which is designed to identify:

- outlying organisations at a Trust and clinical speciality levels, which may perform acceptably for mortality, but potentially have underlying problems in relation to morbidity which have hitherto gone unnoticed and may easily escalate, with an impact on avoidable mortality.

- This may include:

o problems with failure to rescue deteriorating patients

o recovering seriously ill patients who have deteriorated as a result of poor care, which has impacted upon cost and capacity to treat others

- within the above, which specific areas of an organisation are most problematic, in order that any subsequent enquiry or inspection can be effectively targeted.

- outlying/improving organisations at the good end of the spectrum, to highlight where the NHS is developing a learning culture, in line with CQC recommendations.

Hospitals providing NHS services:

CRAB has also supported and continues to support hospital organisations when wanting to review certain procedures and their outcomes to monitor performance. This is typically done as a one-off exercise, again to help Trust Boards and clinical leaders target their improvement efforts in the right areas. The benefit of CRAB to clinicians, managers and Board members at hospital Trusts includes the ability to:

- understand quality of care on an ongoing basis, and to set in place appropriate governance and monitoring systems.

- receive early warning of problems and monitor trends for deterioration in practice quality - rapidly investigate and interpret SHMI results (and other mortality data such as HSMR), to understand root cause and underlying patterns in relation to mortality, in accordance with DH policy guidance that provider organisations should have their own localised clinical dashboards for this purpose.

- monitor quality beyond basic mortality: assessing morbidity and avoidable harm, as a fundamental move towards continuous quality improvement

- generate appraisal documentation for clinical staff
- improve accuracy of coding

- understand the clinical risks (or mortality and complications) for each individual patient and have frank and open discussions with them.

These benefits can also be aggregated to a national level, in so far as the DH and regulatory bodies (Monitor and CQC) can use the information to drill into more detailed analysis of organisational performance where appropriate, particularly in relation to morbidity and avoidable harm - as is envisaged to support CQC inspection activity and quality base-lining by Monitor.

In essence this will provide CQC inspectors with an early warning analysis at a Trust and Department level based on a more in-depth view of medical and ward-based care alongside clinically risk-adjusted surgical practice than may otherwise be possible with standard mortality and statistical analysis. The focus in particular is on understanding morbidity as well as mortality, and areas where morbidity may be just as much the result of omission to treat/failure to rescue as it may be the result of active error.

C-Ci provides the CQC inspectors with a list of the top 20 NHS trusts (quarterly basis since March 2017 to present):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) 20 NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

PWC:

The Keogh Review used CRAB and PWC to do the detailed assessment of what was really going on in hospitals because mortality indicators simply don’t provide the insights and accuracy of our approach. C-Ci reports on risk-adjusted harm as well as just mortality.

C-Ci continue to work with the CQC, NHS Trusts and PWC, with yielded benefits as at 2021 including:

CQC (Commenced March 2017 - present)

- quarterly NHS Trust reporting for the CQC as a horizon scanning tool for early identification of outlying NHS Trusts

- adoption of CCI produced metrics by CQC inspectors to enable targeted inspections based on risk of avoidable harm and risk adjusted health outcomes performance by Trust down to individual medical and surgical specialities

- inclusion of CCI metrics into CQC standard dashboards for distribution to all NHS Trusts (awaiting sign off for general publication)

PWC - Keogh Review (Completed 2013)

14 hospital trusts were analysed including: Basildon and Thurrock in Essex; United Lincolnshire; Blackpool; The Dudley Group, West Midlands; George Eliot, Warwickshire; Northern Lincolnshire and Goole; Tameside, Greater Manchester; Sherwood Forest, Nottinghamshire; Colchester, Essex; Medway, Kent; Burton, Staffordshire; North Cumbria; East Lancashire; and Buckinghamshire Healthcare.

- The Keogh review found frequent examples of inadequate numbers of nursing staff. All 14 trusts subsequently carried out “urgent reviews of safe staffing levels”.

- Eleven of the 14 hospital providers investigated because of high mortality ratios were placed in “special measures”.

- After reviewing each of the trusts, the teams found that having less nursing staff was linked to higher in-patient mortal

CRAB Clinical Informatics Limited (C-Ci) is responsible for developing and marketing CRAB (Copeland Risk Adjusted Barometer). Designed by the former National Director for Clinical Audit, CRAB is a web-based tool to evaluate quality and outcomes in a way which accurately reflects the clinical profile of patients treated.

HES data set is being obtained to support the CQC and NHS Trusts only.

The data processed is the same for both purposes, and the data outcomes are the same.

The CRAB reports are specifically to:

- assist in objective benchmarking of organisations

- expedite quality analysis on behalf of the CQC and NHS Trusts, notably quarterly national horizon scanning of NHS Trusts high levels of morbidity as an early-warning and targeting tool for inspections.

This is designed to provide a granular local dashboard to help the Care Quality Commission and NHS Trusts to interpret and understand safety in relation to avoidable harm, morbidity and areas for improvement.

Where mentioned; “anonymised data and anonymised reports” refer to reports that do not contain any identifiable data, other than the name of the hospital trust with whom the report is being shared directly.

For example, although not currently developed, the national and regional benchmarking reports are expected to be provided in the format of line graphs or similar, where all hospitals are benchmarked by CRAB. Only the hospital trust that is in contact with C-Ci will have their Organisation’s information made available to them.

C-Ci will only identify and share the hospital trust’s name for the hospital trust that the report is being shared with.

No patient identifiable data is shared within the reports.

Consultant information is only shared where untoward harm is identified and requires investigation.

All of the data fields provided by NHS Digital are processed by CRAB algorithms on its own dedicated server and are not aggregated or amalgamated with any other data received from other sources.

Data is presented in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Accordingly, the latest HES data is required by C-Ci from NHS Digital in order for this analysis to be contemporary, accurate and reliable to make a worthwhile analysis. To be clear, the data set requested and currently held is the minimum breadth of data fields required to undertake the CRAB analysis robustly, therefore the data fields can not be minimised further. Furthermore, analysis is required to be down to the consultant level by GMC code (CONSULT field) in order to verify speciality of clinical practice within a specific NHS Trust as is required by the CQC to provide targeted, key lines of enquiry for their on-site inspection teams.

Historically, C-Ci has an established record of receiving and handling data from the HSCIC/NHS Digital, and successfully passed a compliance audit by NHS Digital in January 2017. The analysis provided to the Keogh review team in 2013 was based on a bulk extract of HES & ONS data supplied by the HSCIC (now NHS Digital) for the 14 hospitals concerned. A similar exercise was also conducted using HES data on behalf of Monitor, and again as a research project investigating emergency laparotomy practice with Royal United Bath Hospital NHS Trust. With the extension of this system following the Keogh Review and the newly defined roles of the CQC, the CQC has commissioned C-Ci on an ongoing quarterly basis to analyse HES data for all NHS Trusts in England.

CRAB Clinical Informatics, the Data Controller for this application, have developed an analytical tool to evaluate the quality of healthcare and associated outcomes. This was developed for use by health-related national bodies and NHS Trusts, and other NHS organisations; it was not developed purely for the CQC for example. In fact, CRAB already has other customers (NHS Trusts) using the tool for analysis of their own Trust data (i.e. not the HES data). Therefore, CRAB have developed their service and analytical tool for a range of customers, and CRAB determine the nature of processing, aligned to customer needs. This is why CRAB is the sole Data Controller.

REPORTS FOR CQC

Reports are produced for the CQC with the objective of providing an early warning analysis in order to focus their inspections, identify poor hospital performance, improve patient safety and help reduce avoidable harm to patients.

C-Ci analysis in the form of static reports (either pdf or excel, the latter for CQC to incorporate into their own template reports) is made available to the CQC in the context of inspections and improvement projects, but under no circumstances will the CQC be given access to the raw data. Analysis shared with the CQC in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

C-Ci undertake data privacy impact assessments (DPIA) and a legitimate interest assessment (LIA) before creating any new databases, as part of C-Ci's governance and ISO9001 framework, before working with any new Agents as approved by NHS Digital Auditors in January 2017.

The legitimate interests relied upon by C-Ci for this use of data are that C-Ci have been commissioned by the CQC to undertake NHS Trust level analysis of pseudonymised quarterly national HES data from NHS Digital using CRAB’s proprietary algorithms to identify risk adjusted outcomes aggregated by Trust and specialty for mortality and complications. The LIA for the CQC has been completed and has already been shared with NHS Digital.

REPORTS FOR NHS TRUSTS

Following requests from NHS Trusts, C-Ci will supply anonymised (aggregate, small number suppressed) reports of other NHS Trusts to benchmark the individual NHS Trust's clinical performance as reported by CRAB regionally and nationally against other anonymised hospital trusts. These reports will be shared directly with the named NHS Trust only to support their quality improvements.

C-Ci’s established regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives will be supported with the regional and national quarterly reports. These CRAB reports aim to demonstrate where improvements have been made and identify where remedial measures are required. This can be seen in the Academic Health Science Network ‘Limiting patient harm due to Acute Kidney Injury: A Patient Safety Initiative', where we would like to support Hospitals Trusts with similar projects. By the end of the Acute Kidney Injury (AKI) intervention in July 2016, AKI incidence on surgical wards had fallen by 36%. In addition to the reduction in patient harm, the Hospital Trust estimates the AKI programme has saved the Trust £533,000 per year.

NHS Trusts have now explicitly requested regional and national benchmarking reports and a seperate LIA has been shared with NHS Digital.

The legitimate interests relied upon by C-Ci for this use of data are that C-Ci, using CRAB’s proprietary algorithms, are able to identify risk adjusted outcomes aggregated by Trust and specialty for mortality and complications. Thereby, NHS Trusts can implement remedial and preventative actions. Improvements initiatives to improve care standards are also highlighted and can be implemented.

Outputs of the C-Ci work to CQC in relation to use of the HES data provided by NHS Digital are:

- CQC (quarterly reporting since 2017 and ongoing):

- Quarterly risk adjusted outcomes and NHS Trust outlier reports on behalf of the Care Quality Commission (CQC) at Trust and clinical speciality levels based on C-Ci's proprietary analysis of operative surgical care using mortality and morbidity risk adjusted for case mix complexity in addition to ward based medical care using triggers of potential avoidable harm (based on the IHI Global Trigger Tool).

- Training of CQC inspectors on use of C-Ci analysis

CQC Reports specifically include the following quantitative metrics: Top 20 NHS trusts (quarterly basis since March 2017):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) 20 NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

++++

Outputs of the C-Ci work to NHS Trusts in relation to use of the HES data provided by NHS Digital will be:

- NHS Trusts' regional and national reports (quarterly reporting)

- assist in objective benchmarking of organisations

- expedite quality analysis on behalf of the NHS Trust

- quarterly risk adjusted outcomes reports on behalf of the Trust and clinical speciality levels based on C-Ci's proprietary analysis of operative surgical care using mortality and morbidity risk adjusted for case mix complexity (based on the IHI Global Trigger Tool).

- training of NHS staff on use of C-Ci analysis

- regional hub for trusts to network with each other and share learning from improvement initiatives. CRAB is able to demonstrate where improvements have been made and support where remedial measures are required.

NHS Trust Reports specifically include the following quantitative metrics: Anonymised NHS Trusts, with only the NHS Trusts requesting assistance to be identified within the report (quarterly basis):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

CQC (Commenced March 2017 - present) - successfully providing Rapid Reviews of hospital care originally for Prof Sir Mike Richards, Chief Inspector of Hospitals as and when requested for supporting the CQC Inspections, and since then, - a national horizon-scanning process on an ongoing, quarterly basis for Prof Ted Baker (the current Chief Inspector of Hospitals) - ongoing - identification of outlying organisations at a Trust and clinical speciality levels, some of which have historically performed acceptably from a mortality perspective, but have been found to have underlying problems in relation to morbidity which have hitherto gone unnoticed and may easily escalate, with an impact on avoidable mortality. - inclusion of C-Ci metrics into CQC standard dashboards for distribution to all NHS Trusts (awaiting sign off for general publication) - C-Ci have trained the CQC inspectors to use the CRAB reports to identify outlying NHS Trusts based on robust risk based analysis using the quarterly national review of NHS medicine and surgery outcomes of all NHS hospitals in England on behalf of the Care Quality Commission (CQC) - commenced March 2017.

NHS Trusts –

Bespoke investigations. For example, C-Ci's most recent one:

Supporting investigation of high hospital standard mortality ratio (HSMR) at hospital site. C-Ci carried out a mortality and morbidity review of the hospital and disclosed the causes of the high HSMR.

As a result, the trust is able to target and carry out remedial and improvement initiatives, which will potentially have a direct improvement on the quality of care the public receives, along with an improved profile for the hospital.

Although not using NHSD data (but equivalent data from client trusts), C-Ci have successfully defended 3 individuals who had been criticised (in one instance suspended) on the basis of high mortality and complication rates. In all three cases, these high rates were actually justified by the extreme complexity of work they were undertaking, and their risk-adjusted outcomes were excellent.

On a separate occasion, C-Ci were able to respond to the Chief Inspector of Hospitals immediately whilst he was on site during an inspection with analysis as to whether a staff complaint about a surgeon’s complication rates was justified. C-Ci were able to show that the surgeon in question had had problems on first arriving at the trust, due to being unfamiliar with prostheses in use at the organisation, but his outcomes had improved over the 2 subsequent years and were currently good.

In a converse example, C-Ci identified a surgeon who had seemingly excellent results but was “too good to be true”. Further investigation revealed he was operating on only very simple cases and rejecting other patients as inoperable (when this was clearly not the case), causing harm to patients who deteriorated without an operation and who then had to be retrieved by other surgeons with, by then, more aggravated symptoms. By agreement with the Trust concerned, the surgeon has since ceased practising.

CRAB Clinical Informatics Limited (C-Ci) is responsible for developing and marketing CRAB (Copeland Risk Adjusted Barometer). Designed by the former National Director for Clinical Audit, CRAB is a web-based tool to evaluate quality and outcomes in a way which accurately reflects the clinical profile of patients treated.

HES data set is being obtained to support the CQC and NHS Trusts only.

The data processed is the same for both purposes, and the data outcomes are the same.

The CRAB reports are specifically to:

- assist in objective benchmarking of organisations

- expedite quality analysis on behalf of the CQC and NHS Trusts, notably quarterly national horizon scanning of NHS Trusts high levels of morbidity as an early-warning and targeting tool for inspections.

This is designed to provide a granular local dashboard to help the Care Quality Commission and NHS Trusts to interpret and understand safety in relation to avoidable harm, morbidity and areas for improvement.

Where mentioned; “anonymised data and anonymised reports” refer to reports that do not contain any identifiable data, other than the name of the hospital trust with whom the report is being shared directly.

For example, although not currently developed, the national and regional benchmarking reports are expected to be provided in the format of line graphs or similar, where all hospitals are benchmarked by CRAB. Only the hospital trust that is in contact with C-Ci will have their Organisation’s information made available to them.

C-Ci will only identify and share the hospital trust’s name for the hospital trust that the report is being shared with.

No patient identifiable data is shared within the reports.

Consultant information is only shared where untoward harm is identified and requires investigation.

All of the data fields provided by NHS Digital are processed by CRAB algorithms on its own dedicated server and are not aggregated or amalgamated with any other data received from other sources.

Data is presented in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

Accordingly, the latest HES data is required by C-Ci from NHS Digital in order for this analysis to be contemporary, accurate and reliable to make a worthwhile analysis. To be clear, the data set requested and currently held is the minimum breadth of data fields required to undertake the CRAB analysis robustly, therefore the data fields can not be minimised further. Furthermore, analysis is required to be down to the consultant level by GMC code (CONSULT field) in order to verify speciality of clinical practice within a specific NHS Trust as is required by the CQC to provide targeted, key lines of enquiry for their on-site inspection teams.

Historically, C-Ci has an established record of receiving and handling data from the HSCIC/NHS Digital, and successfully passed a compliance audit by NHS Digital in January 2017. The analysis provided to the Keogh review team in 2013 was based on a bulk extract of HES & ONS data supplied by the HSCIC (now NHS Digital) for the 14 hospitals concerned. A similar exercise was also conducted using HES data on behalf of Monitor, and again as a research project investigating emergency laparotomy practice with Royal United Bath Hospital NHS Trust. With the extension of this system following the Keogh Review and the newly defined roles of the CQC, the CQC has commissioned C-Ci on an ongoing quarterly basis to analyse HES data for all NHS Trusts in England.

CRAB Clinical Informatics, the Data Controller for this application, have developed an analytical tool to evaluate the quality of healthcare and associated outcomes. This was developed for use by health-related national bodies and NHS Trusts, and other NHS organisations; it was not developed purely for the CQC for example. In fact, CRAB already has other customers (NHS Trusts) using the tool for analysis of their own Trust data (i.e. not the HES data). Therefore, CRAB have developed their service and analytical tool for a range of customers, and CRAB determine the nature of processing, aligned to customer needs. This is why CRAB is the sole Data Controller.

REPORTS FOR CQC

Reports are produced for the CQC with the objective of providing an early warning analysis in order to focus their inspections, identify poor hospital performance, improve patient safety and help reduce avoidable harm to patients.

C-Ci analysis in the form of static reports (either pdf or excel, the latter for CQC to incorporate into their own template reports) is made available to the CQC in the context of inspections and improvement projects, but under no circumstances will the CQC be given access to the raw data. Analysis shared with the CQC in aggregate form (trend lines/bulk period analyses) in line with the HES Analysis Guide; small numbers are suppressed and there is no reference to record-level data.

C-Ci undertake data privacy impact assessments (DPIA) and a legitimate interest assessment (LIA) before creating any new databases, as part of C-Ci's governance and ISO9001 framework, before working with any new Agents as approved by NHS Digital Auditors in January 2017.

The legitimate interests relied upon by C-Ci for this use of data are that C-Ci have been commissioned by the CQC to undertake NHS Trust level analysis of pseudonymised quarterly national HES data from NHS Digital using CRAB’s proprietary algorithms to identify risk adjusted outcomes aggregated by Trust and specialty for mortality and complications. The LIA for the CQC has been completed and has already been shared with NHS Digital.

REPORTS FOR NHS TRUSTS

Following requests from NHS Trusts, C-Ci will supply anonymised (aggregate, small number suppressed) reports of other NHS Trusts to benchmark the individual NHS Trust's clinical performance as reported by CRAB regionally and nationally against other anonymised hospital trusts. These reports will be shared directly with the named NHS Trust only to support their quality improvements.

C-Ci’s established regional hubs for NHS Trusts to network with each other and share learning from improvement initiatives will be supported with the regional and national quarterly reports. These CRAB reports aim to demonstrate where improvements have been made and identify where remedial measures are required. This can be seen in the Academic Health Science Network ‘Limiting patient harm due to Acute Kidney Injury: A Patient Safety Initiative', where we would like to support Hospitals Trusts with similar projects. By the end of the Acute Kidney Injury (AKI) intervention in July 2016, AKI incidence on surgical wards had fallen by 36%. In addition to the reduction in patient harm, the Hospital Trust estimates the AKI programme has saved the Trust £533,000 per year.

NHS Trusts have now explicitly requested regional and national benchmarking reports and a seperate LIA has been shared with NHS Digital.

The legitimate interests relied upon by C-Ci for this use of data are that C-Ci, using CRAB’s proprietary algorithms, are able to identify risk adjusted outcomes aggregated by Trust and specialty for mortality and complications. Thereby, NHS Trusts can implement remedial and preventative actions. Improvements initiatives to improve care standards are also highlighted and can be implemented.

Outputs of the C-Ci work to CQC in relation to use of the HES data provided by NHS Digital are:

- CQC (quarterly reporting since 2017 and ongoing):

- Quarterly risk adjusted outcomes and NHS Trust outlier reports on behalf of the Care Quality Commission (CQC) at Trust and clinical speciality levels based on C-Ci's proprietary analysis of operative surgical care using mortality and morbidity risk adjusted for case mix complexity in addition to ward based medical care using triggers of potential avoidable harm (based on the IHI Global Trigger Tool).

- Training of CQC inspectors on use of C-Ci analysis

CQC Reports specifically include the following quantitative metrics: Top 20 NHS trusts (quarterly basis since March 2017):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) 20 NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

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Outputs of the C-Ci work to NHS Trusts in relation to use of the HES data provided by NHS Digital will be:

- NHS Trusts' regional and national reports (quarterly reporting)

- assist in objective benchmarking of organisations

- expedite quality analysis on behalf of the NHS Trust

- quarterly risk adjusted outcomes reports on behalf of the Trust and clinical speciality levels based on C-Ci's proprietary analysis of operative surgical care using mortality and morbidity risk adjusted for case mix complexity (based on the IHI Global Trigger Tool).

- training of NHS staff on use of C-Ci analysis

- regional hub for trusts to network with each other and share learning from improvement initiatives. CRAB is able to demonstrate where improvements have been made and support where remedial measures are required.

NHS Trust Reports specifically include the following quantitative metrics: Anonymised NHS Trusts, with only the NHS Trusts requesting assistance to be identified within the report (quarterly basis):

a) with the highest rate (percentage) of patients with 4 or more triggers of avoidable harm in general medicine and general surgery; and

b) with the highest mortality rate for patients experiencing 4 or more triggers.

c) with risk adjusted mortality trends at an organisation and clinical speciality levels

d) with risk adjusted morbidity trends at an organisation and clinical speciality levels

e) NHS trusts with the lowest rates of avoidable harm as exemplars of best and safest practice.

CQC (Commenced March 2017 - present) - successfully providing Rapid Reviews of hospital care originally for Prof Sir Mike Richards, Chief Inspector of Hospitals as and when requested for supporting the CQC Inspections, and since then, - a national horizon-scanning process on an ongoing, quarterly basis for Prof Ted Baker (the current Chief Inspector of Hospitals) - ongoing - identification of outlying organisations at a Trust and clinical speciality levels, some of which have historically performed acceptably from a mortality perspective, but have been found to have underlying problems in relation to morbidity which have hitherto gone unnoticed and may easily escalate, with an impact on avoidable mortality. - inclusion of C-Ci metrics into CQC standard dashboards for distribution to all NHS Trusts (awaiting sign off for general publication) - C-Ci have trained the CQC inspectors to use the CRAB reports to identify outlying NHS Trusts based on robust riskbased analysis using the quarterly national review of NHS medicine and surgery outcomes of all NHS hospitals in England on behalf of the Care Quality Commission (CQC) - commenced March 2017.

NHS Trusts –

Bespoke investigations. For example, C-Ci's most recent one:

Supporting investigation of high hospital standard mortality ratio (HSMR) at hospital site. C-Ci carried out a mortality and morbidity review of the hospital and disclosed the causes of the high HSMR.

As a result, the trust is able to target and carry out remedial and improvement initiatives, which will potentially have a direct improvement on the quality of care the public receives, along with an improved profile for the hospital.

Although not using NHSD data (but equivalent data from client trusts), C-Ci have successfully defended 3 individuals who had been criticised (in one instance suspended) on the basis of high mortality and complication rates. In all three cases, these high rates were actually justified by the extreme complexity of work they were undertaking, and their risk-adjusted outcomes were excellent.

On a separate occasion, C-Ci were able to respond to the Chief Inspector of Hospitals immediately whilst he was on site during an inspection with analysis as to whether a staff complaint about a surgeon’s complication rates was justified. C-Ci were able to show that the surgeon in question had had problems on first arriving at the trust, due to being unfamiliar with prostheses in use at the organisation, but his outcomes had improved over the 2 subsequent years and were currently good.

In a converse example, C-Ci identified a surgeon who had seemingly excellent results but was “too good to be true”. Further investigation revealed he was operating on only very simple cases and rejecting other patients as inoperable (when this was clearly not the case), causing harm to patients who deteriorated without an operation and who then had to be retrieved by other surgeons with, by then, more aggravated symptoms. By agreement with the Trust concerned, the surgeon has since ceased practising.