Summary Hospital-level Mortality Indicator (SHMI) data

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Objective for processing

Dr Foster (formerly Telstra Health UK UK) requires access to NHS England data for the purpose of providing the following services to clients in the health sector: [3 paragraphs unchanged] These services provided by Telstra Health UK Dr Foster involve: • Comparing Summary Hospital-level Mortality Indicator (SHMI) data with Telstra Health UK’s Dr Foster’s Hospital Standardised Mortality Ratio (HSMR). HSMR is a measure of mortality that is calculated by Telstra Health UK. Dr Foster. [1 paragraph unchanged] • Processing of this data to enable service users to uncover and [7 words unchanged] of differences between these indicators and to investigate variations compared to others. Telstra Health UK’s Dr Foster’s regular bespoke reports provide insight into where the areas of key variance lie. Subscribed authorised users in client NHS organisations can view data that relate [21 words unchanged] can view aggregated, small-number suppressed outputs relating to other organisations via the Telstra Health UK Dr Foster dashboard. This allows for benchmarking and peer analysis across a national scale, [8 words unchanged] diagnosis level. They cannot access record level data relating to other organisations. [1 paragraph unchanged] • Summary Hospital-level Mortality Indicator (SHMI) – necessary to obtain as complete a picture as possible of mortality information for Telstra Health UK Dr Foster to provide the above services to NHS organisations. [4 paragraphs unchanged] Telstra Health UK Dr Foster is the controller as the organisation responsible for ensuring that the data will only be processed for the purpose described above. [1 paragraph unchanged] Microsoft Ltd and Amazon Web Services (AWS) provide Cloud hosting services to Telstra Health UK Dr Foster and will store the data as contracted by Telstra Health UK. Dr Foster.

Processing activities

[1 paragraph unchanged] NHS England data will provide the relevant records from the SHMI dataset to Telstra Health UK. Dr Foster. The data will contain no direct identifying data items. The data will [6 words unchanged] reidentified through linkage with other data in the possession of the recipient. [1 paragraph unchanged] The data will be stored on servers at Telstra Health UK. Dr Foster. Telstra Health UK Dr Foster store data on the Clouds provided by Microsoft Ltd and AWS. [1 paragraph unchanged] NHS Trusts have record level access to the pseudonymised data relating to their organisation through their procurement of Telstra Health UK Dr Foster products and services. They also have access to small number suppressed, aggregated analysis relating to peer organisations. Telstra Health UK Dr Foster clients are authenticated through a cloud-based portal to access the cloud and on-premises output. [2 paragraphs unchanged] Access is restricted to employees of Telstra Health UK Dr Foster who have authorisation from Telstra Health UK Dr Foster management. [3 paragraphs unchanged] Analysts from Telstra Health UK Dr Foster will analyse the data for the purposes described above.

Expected output

Telstra Health UK Dr Foster provides healthcare data analytics and develops and refines methodologies for evaluating, monitoring, and improving performance within healthcare organisations. Telstra Health UK Dr Foster may also collaborate with other research groups by providing outputs to support [33 words unchanged] relevant disclosure rules for the dataset(s) from which the information was derived. [4 paragraphs unchanged] • Telstra Health UK Dr Foster website • Telstra Health UK Dr Foster Dashboard tool The Telstra Health UK Dr Foster Dashboard tool compares the SHMI and the HSMR. This is available to [31 words unchanged] to meet their internal target dates. The key outputs of this include: [12 paragraphs unchanged] Telstra Health UK Dr Foster provide NHS users with the option to take a paid-for service and [10 words unchanged] provide a more detailed and targeted level than is available within the Telstra Health UK Dr Foster Mortality Comparator tool or the NHS England data alone. They draw on the expertise and knowledge within the wider Telstra Health UK Dr Foster team to support organisations to understand where their focus should be.

Expected measurable benefits

[20 paragraphs unchanged] It is anticipated that patients within identified areas for improvement will benefit [14 words unchanged] which can ultimately lead to improved patient care. The service provided by Telstra Health UK Dr Foster is hoped to help patients within groups that are found to be [39 words unchanged] analysis. Earlier intervention for identified groups could lead to better survival rates.

Benefits reported

With the SHMI data provided, Telstra Health UK Dr Foster yield continuous benefits for their NHS customers through regular deliverables and by [80 words unchanged] the First Consultant Episode and potential concerns around their short-stay respiratory pathways. [8 paragraphs unchanged] The Head of Business Support, Information and Clinical Coding at The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust outlined the benefits of using Telstra Health UK’s Dr Foster’s service to investigate SHMI (August 2019): [1 paragraph unchanged] Trusts use their SHMI and HSMR comparisons to inform board reports and [57 words unchanged] preventable mortality and improving outcomes’ goal is hospital mortality. The Trust uses Telstra Health UK’s Dr Foster’s HSMR risk-adjusted mortality tool to monitor this". North West Anglia NHS Foundation Trust is a long-standing client of Telstra Health UK Dr Foster for clinical benchmarking tools and bespoke analytics projects. The Trust had identified [36 words unchanged] Governance & Compliance Manager, North West Anglia NHS Foundation Trust (November 2019): [1 paragraph unchanged] Telstra Health UK Dr Foster held a workshop in November 2019 to look at the emerging challenges [10 words unchanged] best practice. This was open to any interested Trusts and not just Telstra Health UK Dr Foster clients so that a greater number of practitioners within the health and [45 words unchanged] supporting Trusts to understand where to focus improvement work. By working together, Telstra Health UK Dr Foster aims to help increase the quality and accuracy of death certification and, [25 words unchanged] be expected to raise the overall standard of care for all patients.

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Unchanged: Objective for processing, Processing activities, Expected output, Expected measurable benefits, Benefits reported.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Objective for processing

The primary objective of processing is to produce and analyse statistics that NHS organisations can use to improve their understanding of mortality. Telstra Health UK requires access to NHS England data for the purpose of providing the following services to clients in the health sector: Telstra Health UK (formerly Dr Foster Limited) receive all SHMI fields monthly so that NHS organisations can benefit from a timely service with as complete a picture as possible of mortality and use this to improve outcomes for patients. • Online tools and services – analysis, dashboards, clinical benchmarking, and consultancy. Telstra Health UK provide its NHS customer organisations with the ability to drilldown into mortality data via its dashboard service at no additional cost. Telstra Health UK NHS customers cannot see small numbers relating to other organisations in this drilldown. These results are suppressed in line with the HES analysis guide. • Bespoke analytics – customised projects to meet individual client needs. SHMI data for all sites is requested, so that Telstra Health UK NHS customers can use the service to benchmark themselves against their peer organisations. It allows them to put their results into a national context. Telstra Health UK will surface site and trust level SHMI to provide a more complete service to customers. • Research for publication – thought leadership in the field of healthcare data analytics, with the aim of improving the planning, delivery and outcome of health and social care. The service allows comparison of the two leading mortality indicators in England, SHMI and Telstra Health UK’s Hospital Standardised Mortality Ratio (HSMR), and to interrogate SHMI in greater detail than is possible with the publicly available data. It provides the insight needed to embed SHMI and HSMR within mortality management programmes and to ensure that robust alerting/reporting systems are in place. These services provided by Telstra Health UK involve: (HSMR is calculated using data supplied under agreement number NIC-392201. Telstra Health UK provides the ability to compare these indicators but it does not link the data received under this agreement and NIC-392201.) • Comparing Summary Hospital-level Mortality Indicator (SHMI) data with Telstra Health UK’s Hospital Standardised Mortality Ratio (HSMR). HSMR is a measure of mortality that is calculated by Telstra Health UK. The processing enables users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations compared to others. • Embedding SHMI and HSMR within mortality management programmes to ensure that robust alerting/reporting systems are in place. The dashboard is on the same platform as Telstra Health UK’s other tools and creates an easy to consume, convenient and efficient service. It saves on administration time while providing an enhanced analysis that goes beyond the top level. • Processing of this data to enable service users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations compared to others. Telstra Health UK’s regular bespoke reports provide insight into where the areas of key variance lie. In addition to the dashboard tool, Telstra Health UK offers support, insight and analysis services so that NHS customers can exploit more of SHMI's potential and improve outcomes for patients. These services are: Subscribed authorised users in client NHS organisations can view data that relate to their organisation at a record level to help improve the quality of patient care and identify areas for improvement. They can view aggregated, small-number suppressed outputs relating to other organisations via the Telstra Health UK dashboard. This allows for benchmarking and peer analysis across a national scale, and trend tracking at NHS Trust, site, and diagnosis level. They cannot access record level data relating to other organisations. • Analysis from experienced and respected healthcare analytics professionals The following NHS England data will be accessed: • In-depth and detailed charts and visualisations • Summary Hospital-level Mortality Indicator (SHMI) – necessary to obtain as complete a picture as possible of mortality information for Telstra Health UK to provide the above services to NHS organisations. • Regular bespoke reports and insight into where the areas of key variance are, over and above what NHS Digital are currently able to do on the website • The SHMI is the ratio between the actual number of patients who have died following hospitalisation at each non-specialist acute NHS trust in England, and the number of patients that would be expected to die on the basis of average England figures. It includes deaths which occurred both in hospital and outside of hospital within 30 days (inclusive) of discharge. The SHMI indicates whether the observed number of deaths was 'higher than expected', 'as expected', or 'lower than expected' when compared to the national baseline. • Trend tracking at Trust, site and diagnosis level (Telstra Health UK NHS customers will not see small numbers relating to other organisations as a result of this trend tracking. These results will be suppressed in line with the HES analysis guide.) The level of the data will be pseudonymised. • An enhanced level of interpretation and insight The data will be minimised as follows: NHS organisations becoming aware of SHMI results that warrant further investigation may call upon the above services. They may see, for example, higher than usual instances of COPD and want to go beyond the headline figures. Telstra Health UK use its collective knowledge and insight, honed over 20 years, to produce analysis illuminated by informed narrative, charts and other visualisations. • Limited to data fields which are necessary to deliver products and services that benefit health and care in the UK. Telstra Health UK’s storage and processing locations are in the UK. Telstra Health UK do not transfer the data received under this agreement outside of the UK. Telstra Health UK is the controller as the organisation responsible for ensuring that the data will only be processed for the purpose described above. Telstra Health UK have identified the lawful bases of processing under General Data Protection Regulation (GDPR) as articles 6(1)(f) (legitimate interests) and 9(2)(j) (archiving in the public interest). Telstra Health UK have undertaken a legitimate interests assessment and a data protection impact assessment, and intend to maintain and update these documents where necessary. SHMI covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge; SHMI data does not include any data on living individuals. As such UK GDPR does not apply to data solely relating to deceased individuals. Telstra Health UK has a legitimate interest in being able to provide tools and services that healthcare organisations will find useful and that will benefit the health and social care system. Without processing NHS Digital data, Telstra Health UK would not be able to deliver these tools and services, this would be to the detriment of health professionals who use them. Telstra Health UK's customers can be assured that the tools and services are based on evidence provided by data from a trusted source. There is no viable alternative as relying on public domain data would lead to gaps and not allow the same support for decision making. Using pseudonymised data allows Telstra Health UK to deliver evidence-based insight and analysis while minimising intrusion into a patient's privacy. Microsoft Ltd and Amazon Web Services (AWS) provide Cloud hosting services to Telstra Health UK and will store the data as contracted by Telstra Health UK. The processing of this data is also necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) of GDPR. The processing is proportionate to its aims, respects data protection rights and provides suitable and specific measures to protect the rights and interests of individuals. It is necessary for reasons of public interest in public health, in particular to ensure high standards of quality and safety of health care. Although Telstra Health UK are not a public body, they provide services to help public healthcare organisations to monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare.

Processing activities

Telstra Health UK provide services to help public healthcare organisations monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare. The processing is within the scope of Telstra Health UK’s ISO 27001:2013 certified Information Security Management System (ISMS). Telstra Health UK processes are subject to internal and external audit. All staff receive initial information governance training followed by regular mandatory modules and awareness updates throughout the year. No data will flow to NHS England for the purposes of this Agreement. Telstra Health UK have identified the lawful bases of processing under General Data Protection Regulation (GDPR) as articles 6(1)(f) (legitimate interests) and 9(2)(j) (archiving in the public interest). Telstra Health UK have undertaken a legitimate interests assessment and a data protection impact assessment, and intend to maintain and update these documents where necessary. NHS England data will provide the relevant records from the SHMI dataset to Telstra Health UK. The data will contain no direct identifying data items. The data will be pseudonymised and individuals cannot be reidentified through linkage with other data in the possession of the recipient. The data are held securely on Telstra Health UK systems with access permissions only granted as necessary to specific roles. Data will be accessed by authorised employees of Telstra Health UK Limited where necessary to meet the requirements of their specific role and the purposes described in this agreement. The data will not be transferred to any other location. Microsoft Ltd and Amazon Web Services (AWS) supply Cloud Services for Telstra Health UK and are therefore listed as data processors. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. The data will be stored on servers at Telstra Health UK. Telstra Health UK will use the cloud for the benefit of its customers, increased resilience and flexibility for its services and to continue to maintain robust, proportionate security that takes into account the state of the art. Telstra Health UK store data on the Clouds provided by Microsoft Ltd and AWS. Telstra Health UK will use Microsoft Azure and AWS in addition to its existing on-premises data storage and processing solution. The data will be accessed by authorised personnel via remote access. The data will remain on the above servers at all times. Telstra Health UK is taking a hybrid and multi-vendor approach to make the best use of existing infrastructure, with the flexibility to meet security requirements and manage legacy applications that may perform more efficiently on-premises. There will be a transitionary period while Telstra Health UK move services to Azure and AWS, to ensure that customers are provided with business continuity and that services are not interrupted by immediate, wholesale change. NHS Trusts have record level access to the pseudonymised data relating to their organisation through their procurement of Telstra Health UK products and services. They also have access to small number suppressed, aggregated analysis relating to peer organisations. The core processing of the data is kept on-premises. Legacy applications and services will also remain on-premises during the first phase of this transition project. Telstra Health UK clients are authenticated through a cloud-based portal to access the cloud and on-premises output. Telstra Health UK will use Azure and AWS for inhouse application services, third party visualisation tools such as PowerBI and Tableau, and orchestration and automation services. These services will interact with processed output data. Personnel are prohibited from downloading or copying data to local devices. Azure and AWS offer different features, Telstra Health UK will use both to take full advantage of these and avoid vendor lock-in. The data will not leave England and Wales at any time. New services will be developed to be cloud native. Using a combination of these with an on-premises solution helps avoid complete dependency on a single cloud provider and will ensure that, if necessary, Telstra Health UK can migrate to another supplier with minimal disruption. Using two cloud vendors also increases availability allowing Telstra Health UK to operate normally in the event of one of the vendors experiencing an interruption to its services and would reduce the impact of such an event to end users within the NHS. The flexibility to avoid lock-in with a single supplier and to deploy easily to a new supplier means that Telstra Health UK can make best use of available technology and pricing, leading to better services and competitive rates for its customers. It can avoid the potential for being restricted to one service. Any change in cloud supplier will be requested by Telstra Health UK through an amendment request to this agreement. Access is restricted to employees of Telstra Health UK who have authorisation from Telstra Health UK management. Telstra Health UK’s backup solutions will take advantage of persistent cloud storage to achieve immutable backup and airgaps to protect against ransomware attacks similar to 'wannacry' or 'heartbleed'. This is to help ensure availability of data and services to NHS customers in the event of attempted cyberattacks. All personnel accessing the data have been appropriately trained in data protection and confidentiality. Telstra Health UK customers are authenticated through a cloud-based portal to access the cloud and on-premises output. The data will not be linked with any other data. The pseudonymised data is held securely on Telstra Health UK systems with access permissions only granted as necessary to specific roles. There will be no requirement and no attempt to reidentify individuals when using the data. Telstra Health UK download the pseudonymised SHMI data through NHS Digital’s Secure Electronic File Transfer (SEFT) and verify it against Telstra Health UK’s Data Landing Security Checklist. Data are recorded on the Telstra Health UK Data Asset Register (DAR) and allocated a unique asset tag, destruction date and record of acknowledgement requirements. Analysts from Telstra Health UK will analyse the data for the purposes described above. Data is then loaded into a secured database. An automated and documented process applies the published SHMI risk modelling methodology to the data, producing a dataset aggregated by CCS Group and Provider Site. Finally, this dataset is loaded into a database and quality checked, prior to being made available for analysis and onward consumption by Telstra Health UK services. SHMI data is shared in the dashboard via the secure portal with the NHS customers at aggregated level with small numbers suppressed in line with the HES analysis guide. Trusts can access their own unsuppressed data but small number suppression is applied to peer organisations’ SHMI data for all peer analysis. There will be no data linkage undertaken with NHS Digital data provided under this agreement.

Expected output

Telstra Health UK analysts and consultants analyse SHMI data to produce reports and insights for customers. Telstra Health UK provides healthcare data analytics and develops and refines methodologies for evaluating, monitoring, and improving performance within healthcare organisations. Telstra Health UK’s research provides healthcare data analytics and develops and refines methodologies for evaluating, monitoring, and improving performance within healthcare organisations. Telstra Health UK publish the outputs of research for the benefit of the NHS, health and social care, and the public. Publication may be through its website, news, or other media organisations or through academic journals. Telstra Health UK may also collaborate with other research groups by providing aggregate analyses to support publications expected to benefit the NHS and health and social care. Telstra Health UK use a certificated process to destroy the data using Blancco. Blancco has been certified by the National Cyber Security Centre (the UK's independent authority on cyber security). Telstra Health UK may also collaborate with other research groups by providing outputs to support publications expected to benefit and health and social care. 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. The Telstra Health UK Dashboard tool is available to NHS Acute Trusts, which compares the two leading mortality indicators in England – the SHMI and the Telstra Health UK Hospital Standard Mortality Ratio (HSMR). Trusts can access their own record level SHMI data but can only view aggregated and small-number suppressed analysis relating to peers. This is in line with the HES analysis guide and there are no links to any identifiers. It enables users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations against peers. The outputs will be communicated to relevant recipients through the following dissemination channels: Authorised users have continual access which allows them to meet their own internal target dates. • Journals Key outputs: • Press/media engagement • Overview of SHMI - summary charts, trends and breakdowns. • Board-level briefings to client NHS organisations to improve understanding of standardised mortality and the importance of monitoring and using both SHMI and HSMR. • Telstra Health UK website • Telstra Health UK Dashboard tool The Telstra Health UK Dashboard tool compares the SHMI and the HSMR. This is available to NHS Acute Trusts who have record level access to the pseudonymised data relating to their organisation, and aggregated analysis relating to peer organisations. Authorised users have continual access which allows them to meet their internal target dates. The key outputs of this include: • Overview of SHMI – summary charts, trends, and breakdowns. [1 paragraph unchanged] • Analyse Analysis of national position, regional comparisons comparisons, and custom peer groups. • The ability to drill down and investigate Investigation by SHMI supergroup, Clinical Classification System (CCS) group group, or user-defined basket of diagnoses. Typical end users: The typical end users include: [7 paragraphs unchanged] Telstra Health UK also deliver board level briefings to NHS customers to improve understanding of standardised mortality and the importance of monitoring and using both SHMI and HSMR. Telstra Health UK provide NHS users with the option to take a paid-for service and receive bespoke and regular mortality reports and analysis. These outputs provide a more detailed and targeted level than is available within the Telstra Health UK Mortality Comparator tool or the NHS England data alone. They draw on the expertise and knowledge within the wider Telstra Health UK team to support organisations to understand where their focus should be. Telstra Health UK provide its NHS users with the option to take a paid-for service and receive: • Bespoke and regular mortality reports and analysis • Additional charts and visualisations These outputs provide a more detailed and targeted level than is available within either the Telstra Health UK Mortality Comparator tool or the NHS Digital publication. They draw on the expertise and knowledge within the wider Telstra Health UK team to support organisations to understand where their focus should be.

Expected measurable benefits

Telstra Health UK's independent position is beneficial as it supports customer focus on information and data as opposed to anecdotal evidence. Benefits are achieved continually and a number are reliant on a range of factors outside of Telstra Health UK's control. However, whenever there are areas of concern about performance against key indicators, Telstra Health UK act immediately to alert relevant stakeholders to help in better understanding and addressing them. (All peer analysis is aggregated with small numbers suppression in line with the HES analysis guide). It is hoped that the expected benefits will involve: Expected benefits are: • Alerting client organisations with higher-than-expected mortality levels to encourage efforts to investigate and address these. Enabling customers to measure, compare and benchmark mortality. • Instigating clinical audit and informing investigations related to quality of care, such as highlighting poor clinical coding or quality/efficiency concerns. Alerting those who have higher than expected mortality levels to encourage efforts to investigate and address these. • Validating other mortality indicators – such as HSMR and crude mortality. Identifying mortality trends across hospitals. • Enhancing interpretation and insight around the SHMI data including root cause analysis. Instigating clinical audit and informing investigations related to quality of care, such as highlighting poor clinical coding or quality/efficiency concerns. • Informing the planning and design of services incorporating patient safety strategies and measures. Validating other mortality indicators – such as HSMR and crude mortality. • Tracking continual improvement and progress against action plans. Understanding and quickly visualising SHMI and HSMR indicators side by side. • Supporting the adoption of best practice principles. Enhancing interpretation and insight around the SHMI data including root cause analysis • Supporting client organisations in delivering their Learning from Deaths agenda and timely mortality reviews. Driving quality and operational productivity. • Providing monthly analysis at quality/mortality/patient safety meetings which inform decision making of relevant committees. These expected benefits are captured in the minutes of these meetings. Informing the planning and design of services incorporating patient safety strategies and measures. • Tracking changes in SHMI over time to identify which elements are driving improvement or deterioration, especially with post-discharge deaths. These expected benefits are reported in Trust board papers. Tracking continual improvement and progress against action plans. The value-added reporting service broadens the potential for SHMI to improve outcomes for patients and is hoped to lead to the following expected benefits: Supporting the adoption of best practice principles. • Improved understanding of where the key issues are within the SHMI and associated metrics. Supporting organisations in delivering their Learning from Deaths agenda and timely mortality reviews. • Identify mortality trends across sites. Providing monthly analysis at quality/mortality/patient safety meetings which inform decision making of relevant committees. The benefits are captured in minutes of these meetings. • Support clinical audit by identifying key cohorts of activity that could be investigated further at a local level. Tracking changes in SHMI over time and identify which elements are driving improvement/deterioration – especially post-discharge deaths. Generally reported in trust board papers. • Deeper understanding of SHMI and HSMR indicators with the option for further visualisations to supplement those in the tool. The value-added reporting service broadens the potential for SHMI to improve outcomes for patients and realise these additional benefits: • Availability of more informed evidence to instigate clinical audit and investigations related to quality of care. Improved understanding of where the key issues are within the SHMI and associated metrics • Evidence-rich analysis and insight to help build in 'patient safety by design' at the planning and design stages of services and throughout the project lifecycle. Identify mortality trends across sites • Support networking and the adoption of best practice principles by themed and targeted analysis at a regional or national level. Support clinical audit by identifying key cohorts of activity that could be investigated further at a local level • Enhanced support for organisations in delivering their Learning from Deaths agenda and timely mortality reviews. Deeper understanding of SHMI and HSMR indicators with the option for further visualisations to supplement those in the tool. It is anticipated that patients within identified areas for improvement will benefit when clinical teams use the analysis to plan resources more effectively and amend practices which can ultimately lead to improved patient care. The service provided by Telstra Health UK is hoped to help patients within groups that are found to be at a higher-than-expected risk by working with clinical teams to identify how the care pathway and documentation can be improved to benefit these patient groups. It is hoped that patients will benefit from changes that are informed by evidence-based analysis. Earlier intervention for identified groups could lead to better survival rates. Availability of more informed evidence to instigate clinical audit and investigations related to quality of care Evidence-rich analysis and insight to help build in 'patient safety by design' at the planning and design stages of services and throughout the project lifecycle Support networking and the adoption of best practice principles by themed and targeted analysis at a regional or national level Enhanced support for organisations in delivering their Learning from Deaths agenda and timely mortality reviews Patients within identified areas for improvement are expected to benefit when clinical teams use the analysis to plan resources more effectively and amend practices which can ultimately lead to improved patient care. The service will help patients within groups that are found to be at a higher than expected risk. Telstra Health UK will work with clinical teams to identify how the care pathway and documentation can be improved to benefit these patient groups. Patients will benefit from changes that are informed by evidence-based analysis. Earlier intervention for identified groups can lead to better survival rates.

Benefits reported

With the SHMI data provided, Telstra Health UK have been able to help their customers: With the SHMI data provided, Telstra Health UK yield continuous benefits for their NHS customers through regular deliverables and by Senior Consultants attending mortality meetings. For example, in May 2023 an NHS Foundation Trust was helped in understanding their SHMI outlier for gastrointestinal haemorrhage by triangulating methodologies with HSMR. The analysis indicated that the reason this diagnosis reported as “higher-than-expected” in SHMI was likely driven by out of hospital deaths. This customer was also provided analysis over the course of 2022/23 that discovered that they are likely having an issue with robustly catching the correct primary diagnosis and comorbidities in the First Consultant Episode and potential concerns around their short-stay respiratory pathways. • Uncover and investigate some of the potential root causes of differences between the various mortality indicators and to investigate variations against peers at Trust and diagnosis level. Regular continuous benefits include: • Track the SHMI over time to monitor trends at Trust level. • Uncovering and investigating some of the potential root causes of differences between the various mortality indicators, and to investigate variations against peers at Trust and diagnosis level. • Understand any variation between SHMI and HSMR at a summary level and what drives that variation. • Tracking the SHMI over time to monitor trends at Trust level. • Gain the insight they need to embed SHMI within their mortality management programme, alongside other mortality indicators, such as HSMR and Deaths after Surgery. • Understanding any variation between SHMI and HSMR at a summary level and what drives that variation. • Investigate and understand the impact of the inclusion of post-discharge mortality data (only available through the SHMI mortality indicator). • Gaining the insight needed to embed SHMI within mortality management programmes, alongside other mortality indicators, such as HSMR and Deaths after Surgery. • Gain the ability to drill down and investigate by SHMI supergroup, CCS group or user-defined basket of diagnoses. (Organisations reviewing peer data through the tool will only see SHMI data that has been aggregated with small number suppression applied.) • Investigating and understanding the impact of the inclusion of post-discharge mortality data (only available through the SHMI mortality indicator). Telstra Health UK encourages Trusts to make use of both metrics and monitor them together. Variations in results enables Trusts to begin to understand where it needs to investigate further and find out what is driving any differences. • Gaining the ability to investigate by SHMI supergroup, CCS group or user-defined basket of diagnoses. • An early warning for potential groups that may alert for SHMI in the future, allowing NHS customers to take action sooner. [1 paragraph unchanged] "Working with Telstra Health UK on SHMI is useful as the HSMR [44 words unchanged] in arrears it is important to be aware of the potential issues. Accessing both measures through a familiar portal is important for ease of use, we all have so many systems it is good to have a familiar product and feel confident about the results that are being viewed. Whilst the SHMI previewer is useful it doesn’t allow the same degree of interrogation as the Telstra Health UK products. Having a summary SHMI and HSMR together on the front page and comparative measures against other trusts is invaluable in assessing and understanding your own performance in context of others". "Accessing both measures through a familiar portal is important for ease of use, we all have so many systems it is good to have a familiar product and feel confident about the results that are being viewed. Whilst the SHMI previewer is useful it doesn’t allow the same degree of interrogation as the Telstra Health UK products. Having a summary SHMI and HSMR together on the front page and comparative measures against other trusts is invaluable in assessing and understanding your own performance in context of others." Trusts use their SHMI and HSMR comparisons to inform board reports and provide transparency for the public. Western Sussex Hospitals NHS Foundation Trust, for example, publish both together as key performance measures on their website. In their annual report and accounts for 2018-19, the Trust lists "Reducing preventable mortality and improving outcomes" as an internal priority. The Trust goes on to state that "The primary indicator for our ‘reducing preventable mortality and improving outcomes’ goal is hospital mortality. The Trust uses Telstra Health UK’s HSMR risk-adjusted mortality tool to monitor this". Trusts use their SHMI and HSMR comparisons to inform board reports and provide transparency for the public. Western Sussex Hospitals NHS Foundation Trust, for example, publish both together as key performance measures on their website. In their annual report and accounts for 2018-19, the Trust lists "Reducing preventable mortality and improving outcomes" as an internal priority. The Trust goes on to state that "The primary indicator for our ‘reducing preventable mortality and improving outcomes’ goal is hospital mortality. The Trust uses Telstra Health UK’s HSMR risk-adjusted mortality tool to monitor this." North West Anglia NHS Foundation Trust is a long-standing client of Telstra Health UK for clinical benchmarking tools and bespoke analytics projects. The Trust had identified an issue with its mortality ratio and wanted to understand and provide assurance to its executive board why it’s SHMI was high and ensure that it did not have any potential patient safety issues. Deputy Quality Governance & Compliance Manager, North West Anglia NHS Foundation Trust (November 2019): North West Anglia NHS Foundation Trust is a long-standing customer of Telstra Health UK for clinical benchmarking tools and bespoke analytics projects. The Trust had identified an issue with its mortality ratio and wanted to understand and provide assurance to its executive board why its Summary Hospital Mortality Indicator (SHMI) was high and ensure that it did not have any potential patient safety issues. “Telstra Health UK recently worked with us on a significant piece of work around the SHMI. We wanted to understand why our SHMI was high, so we worked closely with Telstra Health UK to examine each component and identify where there was a need for improvement. For example, we carried out an in-depth review of out of hospital activity across several diagnoses. Working with Telstra Health UK we then created a number of work streams focusing on the areas of most concern. Telstra Health UK’s analysis helped the trust dissect the SHMI, enabling us to focus our attention to drive effective improvement, and also provide the executive team with reassurance that there were no developing patient safety issues. This in turn has had an impact on the care we provide for patients”. “Telstra Health UK recently worked with us on a significant piece of work around the SHMI. We wanted to understand why our SHMI was high, so we worked closely with Telstra Health UK to examine each component and identify where there was a need for improvement. For example, we carried out an in-depth review of out of hospital activity across several diagnoses." Telstra Health UK held a workshop in November 2019 to look at the emerging challenges facing medical examiners and how to capture, share and implement best practice. This was open to any interested Trusts and not just Telstra Health UK clients so that a greater number of practitioners within the health and social care system could benefit from the insights. The use of the HSMR and SHMI with learning from deaths national guidance was mentioned and discussed by all the Trusts represented at the workshop. Learning from deaths is seen as an initiative that complements mortality data supporting Trusts to understand where to focus improvement work. By working together, Telstra Health UK aims to help increase the quality and accuracy of death certification and, as a result, mortality data. This information allows Trusts to identify areas in need of change and inform improvement which, in the long term, can be expected to raise the overall standard of care for all patients. “Working with Telstra Health UK we then created a number of work streams focusing on the areas of most concern. Telstra Health UK’s analysis helped the trust dissect the SHMI, enabling us to focus our attention to drive effective improvement, and also provide the executive team with reassurance that there were no developing patient safety issues. This in turn has had an impact on the care we provide for patients.” Deputy Quality Governance & Compliance Manager, North West Anglia NHS Foundation Trust (November 2019) Telstra Health UK held a workshop in November 2019 to look at the emerging challenges facing medical examiners and how to capture, share and implement best practice. This was open to any interested Trusts and not just Telstra Health UK customers, so that a greater number of practitioners within the health and social care system could benefit from the insights. The use of the hospital standardised mortality ratio (HSMR) and summary hospital-level mortality indicator (SHMI) with learning from deaths national guidance was mentioned and discussed by all the Trusts represented at the workshop. Learning from deaths is seen as an initiative that complements mortality data supporting Trusts to understand where to focus improvement work. By working together, Telstra Health UK aims to help increase the quality and accuracy of death certification and, as a result, mortality data. This information allows Trusts to identify areas in need of change and inform improvement which, in the long term, can be expected to raise the overall standard of care for all patients. Providing Covid-19 assistance has affected opportunities for the formal recording of additional benefits. Telstra Health UK continues to engage regularly with its NHS customers’ staff from operational to board level, providing the benefit of its expertise through interactive sessions as well as its tools and reports. Informal feedback at the meetings and interactive sessions reinforces the value that Telstra Health UK brings to its NHS customers.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Objective for processing

[1 paragraph unchanged] Telstra Health UK (formerly Dr Foster Limited) receive the data monthly to provide NHS organisations with the data and insight they require on a timelier basis. All all SHMI fields are required monthly so that NHS organisations can benefit from a timely service with as complete a picture as possible of mortality and use this to improve outcomes for patients. Dr Foster processes the data received under this agreement to Telstra Health UK provide Dr Foster’s its NHS customer organisations with the ability to drilldown into mortality data via a free of charge its dashboard service. Dr Foster service at no additional cost. Telstra Health UK NHS customers cannot see small numbers relating to other organisations in this drilldown. These results are suppressed in line with the HES analysis guide. This service is not available to non-NHS organisations. SHMI data for all sites is requested, this is so that Dr Foster Telstra Health UK NHS customers can use the service to benchmark themselves against any other organisation. their peer organisations. It allows them to put their results into a national context. Dr Foster Telstra Health UK will surface site and trust level SHMI to provide a more complete service to customers. The service allows comparison of the two leading mortality indicators in England, SHMI and Dr Foster’s Telstra Health UK’s Hospital Standardised Mortality Ratio (HSMR), and to interrogate SHMI in greater detail than is possible with the publicly available data. (HSMR is calculated using data supplied under agreement number NIC-68697. Dr Foster It provides the ability insight needed to compare these indicators but it does not link the data received under this agreement embed SHMI and NIC-68697.) HSMR within mortality management programmes and to ensure that robust alerting/reporting systems are in place. The processing enables users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations compared to others. NHS customers can use the service to benchmark their performance. (HSMR is calculated using data supplied under agreement number NIC-392201. Telstra Health UK provides the ability to compare these indicators but it does not link the data received under this agreement and NIC-392201.) The service allows users to understand variation between SHMI and HSMR at a summary level and what drives that variation. It enables inspection and investigation with rapid drilldown to specific areas of interest, such as diagnosis groups, and provides the insight needed to embed SHMI and HSMR within mortality management programmes. The processing enables users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations compared to others. The free of charge dashboard is on the same platform as Dr Foster’s Telstra Health UK’s other tools and creates an easy to consume, convenient and efficient service. It saves on administration time while providing an enhanced analysis that goes beyond the top level. By including a tool to allow comparison of HSMR and SHMI side by side, this allows Trusts to track both mortality metrics side by side to ensure that they have a robust alerting/reporting system in place. Dr Foster receive the data monthly. Monthly data means that the results in their tool match the SHMI data published nationally by NHS Digital. It will improve the free of charge service to ensure that users are provided with timely analysis, so that they can act on results quicker and work to cut delays to improvements. The monthly supply of data will support organisations in delivering their Learning from Deaths agenda and timely mortality reviews with the benefit of up to date and detailed analysis. In addition to the dashboard tool, Telstra Health UK offers support, insight and analysis services so that NHS customers can exploit more of SHMI's potential and improve outcomes for patients. These services are: Dr Foster wish to renew their application to continue to receive monthly SHMI data. Access to the SHMI data through Dr Foster tools will remain free of charge to Dr Foster's NHS customers, but Dr Foster would also offer additional support, insight and analysis as a commercial service. This will enable NHS customers to exploit more of SHMI's potential to improve outcomes for patients. The SHMI data is used to provide additional: [3 paragraphs unchanged] • Trend tracking at Trust, site and diagnosis level (Dr Foster (Telstra Health UK NHS customers will not see small numbers relating to other organisations as [6 words unchanged] These results will be suppressed in line with the HES analysis guide.) [1 paragraph unchanged] SHMI covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge; SHMI data does not include any data on living individuals. NHS organisations becoming aware of SHMI results that warrant further investigation may call upon the above services. They may see, for example, higher than usual instances of COPD and want to go beyond the headline figures. Telstra Health UK use its collective knowledge and insight, honed over 20 years, to produce analysis illuminated by informed narrative, charts and other visualisations. NHS customers of Dr Foster becoming aware of SHMI results that warrant further investigation will be able to call upon the service. They may see, for example, higher than usual instances of COPD and want to go beyond the headline figures. Dr Foster would use its collective knowledge and insight, honed over 20 years, to produce analysis illuminated by informed narrative, charts and other visualisations. Telstra Health UK’s storage and processing locations are in the UK. Telstra Health UK do not transfer the data received under this agreement outside of the UK. Dr Foster will also use the SHMI data to create articles and infographics to broaden public understanding of hospital mortality rates. These will be freely available on the Dr Foster website. Telstra Health UK have identified the lawful bases of processing under General Data Protection Regulation (GDPR) as articles 6(1)(f) (legitimate interests) and 9(2)(j) (archiving in the public interest). Telstra Health UK have undertaken a legitimate interests assessment and a data protection impact assessment, and intend to maintain and update these documents where necessary. The Care Quality Commission (CQC) and NHS Improvement (NHSi) continue to track and monitor HSMR and SHMI. NHSi’s Single Oversight Framework lists both SHMI and HSMR in its appendices as quality of care metrics that they will use ‘to supplement Care Quality Commission (CQC) information to identify where providers may need support under the quality of care theme.’ Telstra Health UK has a legitimate interest in being able to provide tools and services that healthcare organisations will find useful and that will benefit the health and social care system. Without processing NHS Digital data, Telstra Health UK would not be able to deliver these tools and services, this would be to the detriment of health professionals who use them. Telstra Health UK's customers can be assured that the tools and services are based on evidence provided by data from a trusted source. There is no viable alternative as relying on public domain data would lead to gaps and not allow the same support for decision making. Using pseudonymised data allows Telstra Health UK to deliver evidence-based insight and analysis while minimising intrusion into a patient's privacy. CQC review both SHMI and HSMR when inspecting providers. The processing of this data is also necessary for archiving purposes in the public interest, scientific or historical research purposes or statistical purposes in accordance with Article 89(1) of GDPR. The processing is proportionate to its aims, respects data protection rights and provides suitable and specific measures to protect the rights and interests of individuals. It is necessary for reasons of public interest in public health, in particular to ensure high standards of quality and safety of health care. Although Telstra Health UK are not a public body, they provide services to help public healthcare organisations to monitor and improve their services. Processing is designed to benefit patients and society as a whole through better healthcare. Dr Foster has provided objective insight and analysis of healthcare data since 1999. Dr Foster has been processing SHMI data since 2011. Dr Foster process the minimum necessary to meet the purpose and build privacy into their designs. Dr Foster’s Information Security Management System (ISMS) is certified to ISO 27001:2013, the international information security standard. Regular audits and independent assessment are used by Dr Foster to maintain compliance with the standard and provide assurance that information security is always built in to their work. Dr Foster are the sole data controller who also processes the data. No outputs produced for Dr Foster customers will contain pseudonymised record level data.

Processing activities

Dr Foster Telstra Health UK provide services to help public healthcare organisations monitor and improve their services. [9 words unchanged] a whole through better healthcare. The processing is within the scope of Dr Foster’s Telstra Health UK’s ISO 27001 27001:2013 certified Information Security Management System (ISMS). Dr Foster Telstra Health UK processes are subject to internal and external audit. All staff receive initial information governance training followed by regular mandatory modules and awareness updates throughout the year and simulated phishing exercises to measure the effectiveness of training and awareness. year. The data are held securely on Dr Foster systems with access permissions only granted as necessary to specific roles. Data will be accessed by authorised employees of Dr Foster Limited where necessary to meet the requirements of their specific role and the purposes described in this agreement. Telstra Health UK have identified the lawful bases of processing under General Data Protection Regulation (GDPR) as articles 6(1)(f) (legitimate interests) and 9(2)(j) (archiving in the public interest). Telstra Health UK have undertaken a legitimate interests assessment and a data protection impact assessment, and intend to maintain and update these documents where necessary. Landing The data are held securely on Telstra Health UK systems with access permissions only granted as necessary to specific roles. Data will be accessed by authorised employees of Telstra Health UK Limited where necessary to meet the requirements of their specific role and the purposes described in this agreement. All downloaded files are checked to ensure that they comply with Dr Foster’s Data Landing Security Checklist. Microsoft Ltd and Amazon Web Services (AWS) supply Cloud Services for Telstra Health UK and are therefore listed as data processors. They supply support to the system, but do not access data. Therefore, any access to the data held under this agreement would be considered a breach of the agreement. The data is recorded on the Dr Foster Data Asset Register (DAR) upon landing. Entries on the DAR are allocated a unique asset tag and a date for destruction. The DAR also records any acknowledgement requirements. Telstra Health UK will use the cloud for the benefit of its customers, increased resilience and flexibility for its services and to continue to maintain robust, proportionate security that takes into account the state of the art. Processing Telstra Health UK will use Microsoft Azure and AWS in addition to its existing on-premises data storage and processing solution. Data will flow to Dr Foster Ltd only. Telstra Health UK is taking a hybrid and multi-vendor approach to make the best use of existing infrastructure, with the flexibility to meet security requirements and manage legacy applications that may perform more efficiently on-premises. There will be a transitionary period while Telstra Health UK move services to Azure and AWS, to ensure that customers are provided with business continuity and that services are not interrupted by immediate, wholesale change. Once logged on the Data Asset Register, the data is picked up by a data landing process which loads the data into a database on a secure Master Data Server. An automated ‘SHMI’ process (documented) is then run to apply the published SHMI risk modelling methodology to the data, producing a dataset aggregated by CCS Group and Provider Site. Finally, this dataset is loaded into a database and quality checked, prior to being made available for analysis and onward consumption by the Dr Foster Mortality Service. The core processing of the data is kept on-premises. Legacy applications and services will also remain on-premises during the first phase of this transition project. SHMI data is shared via the secure portal with the NHS customers at aggregated level with small numbers suppressed in line with the HES analysis guide. Trusts can access their own unsuppressed data but for all peer analysis, small number suppression is applied to peer organisations’ SHMI data. Telstra Health UK will use Azure and AWS for inhouse application services, third party visualisation tools such as PowerBI and Tableau, and orchestration and automation services. These services will interact with processed output data. Dr Foster analysts and consultants will analyse SHMI data to produce reports and insights for customers. This will be part of the proposed paid-for service available to NHS customers of Dr Foster only. Azure and AWS offer different features, Telstra Health UK will use both to take full advantage of these and avoid vendor lock-in. Publication New services will be developed to be cloud native. Using a combination of these with an on-premises solution helps avoid complete dependency on a single cloud provider and will ensure that, if necessary, Telstra Health UK can migrate to another supplier with minimal disruption. Using two cloud vendors also increases availability allowing Telstra Health UK to operate normally in the event of one of the vendors experiencing an interruption to its services and would reduce the impact of such an event to end users within the NHS. The flexibility to avoid lock-in with a single supplier and to deploy easily to a new supplier means that Telstra Health UK can make best use of available technology and pricing, leading to better services and competitive rates for its customers. It can avoid the potential for being restricted to one service. Any change in cloud supplier will be requested by Telstra Health UK through an amendment request to this agreement. SHMI data, which has been available to Dr Foster since 2011, will only be made available to NHS Trusts via the Dr Foster Dashboard Tool. Telstra Health UK’s backup solutions will take advantage of persistent cloud storage to achieve immutable backup and airgaps to protect against ransomware attacks similar to 'wannacry' or 'heartbleed'. This is to help ensure availability of data and services to NHS customers in the event of attempted cyberattacks. This tool is provided free of charge to all NHS Trusts who are already customers of Dr Foster, with the option of including a value-added service for an additional charge. Telstra Health UK customers are authenticated through a cloud-based portal to access the cloud and on-premises output. NHS customers of Dr Foster taking the value-added service will be able to requests reports and analysis. All published outputs will be in line with NHS guidance. The pseudonymised data is held securely on Telstra Health UK systems with access permissions only granted as necessary to specific roles. High-level analysis and infographics will be published by Dr Foster on its website and via social media channels to broaden public understanding of hospital mortality rates. Telstra Health UK download the pseudonymised SHMI data through NHS Digital’s Secure Electronic File Transfer (SEFT) and verify it against Telstra Health UK’s Data Landing Security Checklist. Data are recorded on the Telstra Health UK Data Asset Register (DAR) and allocated a unique asset tag, destruction date and record of acknowledgement requirements. Destruction Data is then loaded into a secured database. An automated and documented process applies the published SHMI risk modelling methodology to the data, producing a dataset aggregated by CCS Group and Provider Site. Finally, this dataset is loaded into a database and quality checked, prior to being made available for analysis and onward consumption by Telstra Health UK services. The monthly destruction review process identifies data for destruction on the DAR using the unique assets tags and destruction dates. Dr Foster use a certificated process to destroy the data using Blancco. Blancco has been certified by the National Cyber Security Centre (the UK's independent authority on cyber security). SHMI data is shared in the dashboard via the secure portal with the NHS customers at aggregated level with small numbers suppressed in line with the HES analysis guide. Trusts can access their own unsuppressed data but small number suppression is applied to peer organisations’ SHMI data for all peer analysis. Any data provided will only be used by Dr Foster for the purposes, activities, and outputs defined in this agreement. All organisations party to this agreement must comply with the Data Sharing Framework Contract requirements, including those regarding the use (and purposes of that use) by “Personnel” (as defined within the Data Sharing Framework Contract i.e. employees, agents and contractors of the Data Recipient who may have access to that data). [1 paragraph unchanged]

Expected output

The Dr Foster Dashboard tool is available to NHS Acute Trusts, which compares the two leading mortality indicators in England – the SHMI and the Dr Foster Hospital Standard Mortality Ratio (HSMR). Trusts can access their own record level SHMI data but can only view aggregated and small-number suppressed analysis relating to peers. Telstra Health UK analysts and consultants analyse SHMI data to produce reports and insights for customers. Peer analysis data is aggregated with small numbers suppressed in line with the HES analysis guide and there are no links to any identifiers. It enables users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations against peers. Telstra Health UK’s research provides healthcare data analytics and develops and refines methodologies for evaluating, monitoring, and improving performance within healthcare organisations. Telstra Health UK publish the outputs of research for the benefit of the NHS, health and social care, and the public. Publication may be through its website, news, or other media organisations or through academic journals. Telstra Health UK may also collaborate with other research groups by providing aggregate analyses to support publications expected to benefit the NHS and health and social care. Telstra Health UK use a certificated process to destroy the data using Blancco. Blancco has been certified by the National Cyber Security Centre (the UK's independent authority on cyber security). This is only available to NHS Acute Trusts within England and Wales which are customers of Dr Foster Ltd. The Telstra Health UK Dashboard tool is available to NHS Acute Trusts, which compares the two leading mortality indicators in England – the SHMI and the Telstra Health UK Hospital Standard Mortality Ratio (HSMR). Trusts can access their own record level SHMI data but can only view aggregated and small-number suppressed analysis relating to peers. This is in line with the HES analysis guide and there are no links to any identifiers. It enables users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations against peers. Authorised users have continual access which allows them to meet their own internal target dates. Processing monthly data allows users a greater opportunity to meet internal target dates, with information based on the most up to date data available. [4 paragraphs unchanged] • The ability to drill down and investigate by SHMI supergroup, Clinical Classification System (CCS) group or user-defined basket of diagnoses. Organisations reviewing peer data through the tool will only see SHMI data that has been aggregated with small number suppression applied. [8 paragraphs unchanged] All peer analysis will contain only data that is aggregated with small numbers suppressed in line with the HES Analysis Guide. The host hospital will be able to access its own unsuppressed data. Telstra Health UK also deliver board level briefings to NHS customers to improve understanding of standardised mortality and the importance of monitoring and using both SHMI and HSMR. Dr Foster also deliver board level briefings to NHS customers to improve understanding of standardised mortality and the importance of monitoring and using both SHMI and HSMR. Telstra Health UK provide its NHS users with the option to take a paid-for service and receive: Dr Foster provide its NHS users with the option to take a paid-for service and receive: [2 paragraphs unchanged] These outputs provide a more detailed and targeted level than is available within either the Dr Foster Mortality Comparator tool or the NHS Digital publication. This enhances the free of charge Mortality Comparator (SHMI) tool which is updated at each publication date and offered for free (with the option to request the value-added service for a charge). Dr Foster NHS customers do not see small numbers relating to other organisations. Small numbers are suppressed in line with the HES analysis guide. No outputs produced for Dr Foster customers will contain pseudonymised record level data. These outputs provide a more detailed and targeted level than is available within either the Telstra Health UK Mortality Comparator tool or the NHS Digital publication. They draw on the expertise and knowledge within the wider Telstra Health UK team to support organisations to understand where their focus should be. These value-added services are available for a charge and utilises the expertise and knowledge within the wider Dr Foster team to support organisations to understand where their focus should be.

Expected measurable benefits

Dr Foster provides its NHS customers, free of charge, with a tool to allow them to monitor and improve the quality and safety of care they provide by comparing the two leading mortality indicators in England: SHMI and HSMR. It enables their customers to perform a root cause analysis of their SHMI, in line with the requirements of the NHS Operating Framework. Telstra Health UK's independent position is beneficial as it supports customer focus on information and data as opposed to anecdotal evidence. Benefits are achieved continually and a number are reliant on a range of factors outside of Telstra Health UK's control. However, whenever there are areas of concern about performance against key indicators, Telstra Health UK act immediately to alert relevant stakeholders to help in better understanding and addressing them. (All peer analysis is aggregated with small numbers suppression in line with the HES analysis guide). “All hospital trusts, regardless of whether they are outliers, need to examine, understand and explain their SHMI and identify and act where performance is falling short. Should a trust be an outlier on any mortality measure it should scrutinise the underlying data to understand the reason and take appropriate action.” Expected benefits are: The Operating Framework for the NHS in England 2012/13 Enabling customers to measure, compare and benchmark mortality. Expected measurable benefits are: Alerting those who have higher than expected mortality levels to encourage efforts to investigate and address these. • Enable customers to measure, compare and benchmark mortality and alerting those who have higher than expected mortality levels to encourage efforts to investigate and address these. Dr Foster's independent position is beneficial as it supports customer focus on information and data as opposed to anecdotal evidence. Identifying mortality trends across hospitals. • Identify mortality trends across hospitals. Instigating clinical audit and informing investigations related to quality of care, such as highlighting poor clinical coding or quality/efficiency concerns. • Instigate clinical audit and inform investigations related to quality of care, such as highlighting poor clinical coding or quality/efficiency concerns. Validating other mortality indicators – such as HSMR and crude mortality. • Validate other mortality indicators – such as HSMR and crude mortality. Understanding and quickly visualising SHMI and HSMR indicators side by side. • Understand and quickly visualise SHMI and HSMR indicators side by side. Enhancing interpretation and insight around the SHMI data including root cause analysis • Compare organisations nationally to support the reduction of clinical variation across the care pathway. Driving quality and operational productivity. • Provide an enhanced level interpretation and insight around the SHMI data Informing the planning and design of services incorporating patient safety strategies and measures. • Providing evidence to instigate clinical audit and investigations related to quality of care Tracking continual improvement and progress against action plans. • Drive quality and operational productivity and track continual performance improvement. Supporting the adoption of best practice principles. • Inform the planning and design of services incorporating patient safety strategies and measures Supporting organisations in delivering their Learning from Deaths agenda and timely mortality reviews. • Support networking and the adoption of best practice principles Providing monthly analysis at quality/mortality/patient safety meetings which inform decision making of relevant committees. The benefits are captured in minutes of these meetings. • Supporting organisations in delivering their Learning from Deaths agenda and timely mortality reviews Tracking changes in SHMI over time and identify which elements are driving improvement/deterioration – especially post-discharge deaths. Generally reported in trust board papers. Customers can identify areas of variation against peers which means they can develop action plans to address potential quality of care issues The value-added reporting service broadens the potential for SHMI to improve outcomes for patients and realise these additional benefits: • Provision of monthly analysis at quality/mortality/patient safety meetings which inform decision making of relevant committees. The benefits are captured in minutes of these meetings Improved understanding of where the key issues are within the SHMI and associated metrics • Enables customers to track trends and monitor progress against action plans Identify mortality trends across sites • Enables customers to understand the different components of SHMI meaning that other mortality metrics can be validated and action plans addressed Support clinical audit by identifying key cohorts of activity that could be investigated further at a local level • Ability to track changes in SHMI over time and identify which elements are driving improvement/deterioration – especially post discharge deaths. Generally reported in trust board papers. Deeper understanding of SHMI and HSMR indicators with the option for further visualisations to supplement those in the tool. • Identify cohorts of spells for further investigation to support the learning from deaths agenda and local patient safety initiatives Availability of more informed evidence to instigate clinical audit and investigations related to quality of care • Benchmarking performance enables trusts to identify other organisations with whom they may be able to share best practice Evidence-rich analysis and insight to help build in 'patient safety by design' at the planning and design stages of services and throughout the project lifecycle The value-added reporting service broadens the potential for SHMI to improve outcomes for patients. These benefits are in addition to those listed above: Support networking and the adoption of best practice principles by themed and targeted analysis at a regional or national level • Better understanding of where the key issues are within the SHMI and associated metrics Enhanced support for organisations in delivering their Learning from Deaths agenda and timely mortality reviews • The provision of detailed analysis by SHMI supergroup or user-defined basket of diagnoses. Patients within identified areas for improvement are expected to benefit when clinical teams use the analysis to plan resources more effectively and amend practices which can ultimately lead to improved patient care. • Identify mortality trends across sites (small numbers will be suppressed in any peer analysis) The service will help patients within groups that are found to be at a higher than expected risk. Telstra Health UK will work with clinical teams to identify how the care pathway and documentation can be improved to benefit these patient groups. • Support clinical audit by identifying key cohorts of activity that could be investigated further at a local level Patients will benefit from changes that are informed by evidence-based analysis. Earlier intervention for identified groups can lead to better survival rates. • Deeper understanding of SHMI and HSMR indicators with the option for further visualisations to supplement those in the free of charge tool. • Compare and track organisations nationally to support the reduction of clinical variation across the care pathway. (Small numbers will be suppressed in any peer analysis.) • Availability of more informed evidence to instigate clinical audit and investigations related to quality of care • Drive quality and operational productivity and track continual performance improvement. • Evidence-rich analysis and insight to help build in 'patient safety by design' at the planning and design stages of services and throughout the project lifecycle • Support networking and the adoption of best practice principles by themed and targeted analysis at a regional or national level (small numbers will be suppressed in line with the HES analysis guide) • Enhanced support for organisations in delivering their Learning from Deaths agenda and timely mortality reviews • Patients within identified areas for improvement are expected to benefit when clinical teams use the analysis to plan resources more effectively and amend practices which can ultimately lead to improved patient care. • The service will help patients within groups that are found to be at a higher than expected risk. Dr Foster will work with clinical teams to identify how the care pathway and documentation can be improved to benefit these patient groups. • Patients will benefit from changes that are informed by evidence-based analysis. Earlier intervention for identified groups can lead to better survival rates. Dr Foster holds regular review meetings with its customers to monitor action plans and track agreed actions to assess their impact on SHMI and other quality metrics such as crude rates and length of stay. It is not possible to outline a specific target date for achievement of the benefits outlined above as they are reliant on a range of factors outside of Dr Foster’s immediate control. However, whenever there are areas of particular concern about performance against key indicators, Dr Foster acts immediately to make their customers aware and offers assistance in better understanding and addressing them. In addition, benefits are ongoing as these outputs are used within NHS Trusts’ internal monthly reporting and quality processes.

Benefits reported

With the SHMI data provided, Dr Foster Telstra Health UK have been able to help their customers: [6 paragraphs unchanged] Dr Foster Telstra Health UK encourages Trusts to make use of both metrics and monitor them together. [11 words unchanged] needs to investigate further and find out what is driving any differences. The Head of Business Support, Information and Clinical Coding at The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust outlined the benefits of using Dr Foster’s Telstra Health UK’s service to investigate SHMI (August 2019): "Working with Dr Foster Telstra Health UK on SHMI is useful as the HSMR and SHMI have differing categories [39 words unchanged] in arrears it is important to be aware of the potential issues. "Accessing both measures through a familiar portal is important for ease of [29 words unchanged] is useful it doesn’t allow the same degree of interrogation as the Dr Foster Telstra Health UK products. Having a summary SHMI and HSMR together on the front page [7 words unchanged] invaluable in assessing and understanding your own performance in context of others." Trusts use their SHMI and HSMR comparisons to inform board reports and [57 words unchanged] preventable mortality and improving outcomes’ goal is hospital mortality. The Trust uses Dr Foster’s Telstra Health UK’s HSMR risk-adjusted mortality tool to monitor this." North West Anglia NHS Foundation Trust is a long-standing customer of Dr Foster Telstra Health UK for clinical benchmarking tools and bespoke analytics projects. The Trust had identified [26 words unchanged] and ensure that it did not have any potential patient safety issues. “Dr Foster “Telstra Health UK recently worked with us on a significant piece of work around the SHMI. We wanted to understand why our SHMI was high, so we worked closely with Dr Foster Telstra Health UK to examine each component and identify where there was a need for [5 words unchanged] out an in-depth review of out of hospital activity across several diagnoses." “Working with Dr Foster Telstra Health UK we then created a number of work streams focusing on the areas of most concern. Dr Foster’s Telstra Health UK’s analysis helped the trust dissect the SHMI, enabling us to focus our [23 words unchanged] turn has had an impact on the care we provide for patients.” [1 paragraph unchanged] Dr Foster Telstra Health UK held a workshop in November 2019 to look at the emerging challenges [10 words unchanged] best practice. This was open to any interested Trusts and not just Dr Foster Telstra Health UK customers, so that a greater number of practitioners within the health and [53 words unchanged] supporting Trusts to understand where to focus improvement work. By working together, Dr Foster Telstra Health UK aims to help increase the quality and accuracy of death certification and, [25 words unchanged] be expected to raise the overall standard of care for all patients. Providing Covid-19 assistance has affected opportunities for the formal recording of additional benefits. Dr Foster Telstra Health UK continues to engage regularly with its NHS customers’ staff from operational to [18 words unchanged] Informal feedback at the meetings and interactive sessions reinforces the value that Dr Foster Telstra Health UK brings to its NHS customers.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Objective for processing

[7 paragraphs unchanged] The free of charge dashboard is on the same platform as Dr [30 words unchanged] including a tool to allow comparison of HSMR and SHMI side by side side, this allows Trusts to track both mortality metrics side by side to ensure that they have a robust alerting/reporting system in place. [15 paragraphs unchanged] Dr Foster are the sole data controller who also processes the data. [1 paragraph unchanged]

Processing activities

Processing [7 paragraphs unchanged] Once logged on the Data Asset Register Register, the data is picked up by a data landing process which loads [28 words unchanged] the data, producing a dataset aggregated by CCS Group and Provider Site. Finally Finally, this dataset is loaded into a database and quality checked, prior to being made available for analysis and onward consumption by the Dr Foster Mortality Service. SHMI data is shared via the secure portal with the NHS customers [13 words unchanged] guide. Trusts can access their own unsuppressed data but for all peer analysis analysis, small number suppression is applied to peer organisations’ SHMI data. [11 paragraphs unchanged]

Expected output

[18 paragraphs unchanged] Outputs for the hospital mortality rate service: Dr Foster also deliver board level briefings to NHS customers to improve understanding of standardised mortality and the importance of monitoring and using both SHMI and HSMR. Dr Foster provide its NHS users with the option to take a paid-for service and receive: [1 paragraph unchanged] • Charts Additional charts and visualisations These outputs will provide a more detailed and targeted level than is currently available within either the Dr Foster Mortality Comparator tool or the NHS Digital publication. This will enhance enhances the current free of charge Mortality Comparator (SHMI) tool which is envisaged will continue to be updated at each publication date and offered for free (with the option to request the value-added service for a charge). Dr Foster NHS customers will do not see small numbers relating to other organisations. Small numbers will be are suppressed in line with the HES analysis guide. No outputs produced for Dr Foster customers will contain pseudonymised record level data. This analysis These value-added services are available for a charge and reporting will be a value added service utilising utilises the expertise and knowledge within the wider Dr Foster team to support organisations to understand where their focus should be. Dr Foster are currently developing this additional service and will make it available for a charge.

Expected measurable benefits

Dr Foster provides all of its NHS customers customers, free of charge charge, with a tool to allow them to monitor and improve the quality [29 words unchanged] their SHMI, in line with the requirements of the NHS Operating Framework. [15 paragraphs unchanged] Customers are able to can identify areas of variation against peers which means they can develop action plans to address potential quality of care issues [20 paragraphs unchanged] • Patients will benefit from changes that are informed by evidence based evidence-based analysis. Earlier intervention for identified groups can lead to better survival rates. How will these be measured: [1 paragraph unchanged] When will these be achieved: [1 paragraph unchanged] In addition addition, benefits are ongoing as these outputs are used within NHS Trusts’ internal monthly reporting and quality processes.

Benefits reported

[8 paragraphs unchanged] The Head of Business Support, Information and Clinical Coding, Coding at The Queen Elizabeth Hospital Kings Lynn NHS Foundation Trust outlined the benefits of using Dr Foster’s service to investigate SHMI (August 2019): [4 paragraphs unchanged] “Dr Foster recently worked with us on a significant piece of work [35 words unchanged] carried out an in-depth review of out of hospital activity across several diagnoses. diagnoses." [1 paragraph unchanged] Hayley Topping, Deputy Quality Governance & Compliance Manager, North West Anglia NHS Foundation Trust (November 2019) [1 paragraph unchanged] The additional outputs approved in December 2019 are under development. Dr Foster will work with its customers to record examples of yielded benefits as the new services are made available. Providing Covid-19 assistance has affected opportunities for the formal recording of additional benefits. Dr Foster continues to engage regularly with its NHS customers’ staff from operational to board level, providing the benefit of its expertise through interactive sessions as well as its tools and reports. Informal feedback at the meetings and interactive sessions reinforces the value that Dr Foster brings to its NHS customers.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Objective for processing

[9 paragraphs unchanged] Dr Foster wish to amend their application to provide additional services to NHS customers, for which there will be a charge. Access to the SHMI data through Dr Foster tools will remain free of charge to Dr Foster's NHS customers, but Dr Foster would also offer additional support, insight and analysis as a commercial service. This will enable NHS customers to exploit more of SHMI's potential to improve outcomes for patients. Dr Foster wish to renew their application to continue to receive monthly SHMI data. The proposed additional services would use the SHMI data to provide: Access to the SHMI data through Dr Foster tools will remain free of charge to Dr Foster's NHS customers, but Dr Foster would also offer additional support, insight and analysis as a commercial service. This will enable NHS customers to exploit more of SHMI's potential to improve outcomes for patients. The SHMI data is used to provide additional: [12 paragraphs unchanged]

Expected output

The Dr Foster Dashboard tool is available to NHS Acute Trusts, which [8 words unchanged] – the SHMI and the Dr Foster Hospital Standard Mortality Ratio (HSMR). All Trusts can access their own record level SHMI data is but can only view aggregated with small numbers and small-number suppressed in line with the HES analysis guide and there are no links relating to any identifiers. It enables users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations against peers. Peer analysis data is aggregated with small numbers suppressed in line with the HES analysis guide and there are no links to any identifiers. It enables users to uncover and investigate some of the potential root causes of differences between these indicators and to investigate variations against peers. [1 paragraph unchanged] Authorised users have continual access which allows them to meet their own internal target dates. Processing monthly data will allow allows users a greater opportunity to meet internal target dates, with information based on the most up to date data available. [14 paragraphs unchanged] Outputs for the proposed new hospital mortality rate service: [4 paragraphs unchanged] Dr Foster expect to offer are currently developing this additional service and will make it available for a charge by January 2020. charge.

Expected measurable benefits

[23 paragraphs unchanged] The value-added reporting service is expected to broaden broadens the potential for SHMI to improve outcomes for patients. Dr Foster expect the These benefits of this service to add are in addition to those above. The expected benefits are: listed above: [19 paragraphs unchanged]

Benefits reported

[8 paragraphs unchanged] The Head of Business Support, Information and Clinical Coding, at The Queen [5 words unchanged] Foundation Trust outlined the benefits of using Dr Foster’s service to investigate SHMI: SHMI (August 2019): [6 paragraphs unchanged] Hayley Topping, Deputy Quality Governance & Compliance Manager, North West Anglia NHS Foundation Trust (November 2019) Dr Foster held a workshop in November 2019 to look at the emerging challenges facing medical examiners and how to capture, share and implement best practice. This was open to any interested Trusts and not just Dr Foster customers, so that a greater number of practitioners within the health and social care system could benefit from the insights. The use of the hospital standardised mortality ratio (HSMR) and summary hospital-level mortality indicator (SHMI) with learning from deaths national guidance was mentioned and discussed by all the Trusts represented at the workshop. Learning from deaths is seen as an initiative that complements mortality data supporting Trusts to understand where to focus improvement work. By working together, Dr Foster aims to help increase the quality and accuracy of death certification and, as a result, mortality data. This information allows Trusts to identify areas in need of change and inform improvement which, in the long term, can be expected to raise the overall standard of care for all patients. The additional outputs approved in December 2019 are under development. Dr Foster will work with its customers to record examples of yielded benefits as the new services are made available.

Unchanged: Processing activities.

Text removed is struck through; text added is underlined. Unchanged paragraphs are summarised rather than repeated.

Objective for processing

[1 paragraph unchanged] Dr Foster are requesting an amendment receive the data monthly to their application for SHMI data, so that they can receive it monthly instead of quarterly, and provide NHS organisations with the data and insight they require on a more timely timelier basis. All SHMI fields are required so that NHS organisations can benefit [5 words unchanged] as possible of mortality and use this to improve outcomes for patients. [6 paragraphs unchanged] Dr Foster wish to amend their application to receive the data monthly. Monthly data will mean means that the results in their tool match the SHMI data published nationally [52 words unchanged] mortality reviews with the benefit of up to date and detailed analysis. Dr Foster wish to amend their application to provide additional services to NHS customers, for which there will be a charge. Access to the SHMI data through Dr Foster tools will remain free of charge to Dr Foster's NHS customers, but Dr Foster would also offer additional support, insight and analysis as a commercial service. This will enable NHS customers to exploit more of SHMI's potential to improve outcomes for patients. The proposed additional services would use the SHMI data to provide: • Analysis from experienced and respected healthcare analytics professionals • In-depth and detailed charts and visualisations • Regular bespoke reports and insight into where the areas of key variance are, over and above what NHS Digital are currently able to do on the website • Trend tracking at Trust, site and diagnosis level (Dr Foster NHS customers will not see small numbers relating to other organisations as a result of this trend tracking. These results will be suppressed in line with the HES analysis guide.) • An enhanced level of interpretation and insight SHMI covers all deaths reported of patients who were admitted to non-specialist acute trusts in England and either die while in hospital or within 30 days of discharge; SHMI data does not include any data on living individuals. NHS customers of Dr Foster becoming aware of SHMI results that warrant further investigation will be able to call upon the service. They may see, for example, higher than usual instances of COPD and want to go beyond the headline figures. Dr Foster would use its collective knowledge and insight, honed over 20 years, to produce analysis illuminated by informed narrative, charts and other visualisations. Dr Foster will also use the SHMI data to create articles and infographics to broaden public understanding of hospital mortality rates. These will be freely available on the Dr Foster website. [3 paragraphs unchanged] No outputs produced for Dr Foster customers will contain pseudonymised record level data.

Processing activities

Processing [9 paragraphs unchanged] Dr Foster analysts and consultants will analyse SHMI data to produce reports and insights for customers. This will be part of the proposed paid-for service available to NHS customers of Dr Foster only. [2 paragraphs unchanged] This tool is provided free of charge to all NHS Trusts who are already customers of Dr Foster. Foster, with the option of including a value-added service for an additional charge. NHS customers of Dr Foster taking the value-added service will be able to requests reports and analysis. All published outputs will be in line with NHS guidance. High-level analysis and infographics will be published by Dr Foster on its website and via social media channels to broaden public understanding of hospital mortality rates. [5 paragraphs unchanged]

Expected output

The Dr Foster Dashboard Tool Online application tool is available to NHS Acute Trusts, which compares the two leading mortality [50 words unchanged] causes of differences between these indicators and to investigate variations against peers. This is only available to NHS customers Acute Trusts within England and Wales. Wales which are customers of Dr Foster Ltd. [6 paragraphs unchanged] Typical end users users: [8 paragraphs unchanged] Outputs for the proposed new hospital mortality rate service: • Bespoke and regular mortality reports and analysis • Charts and visualisations These outputs will provide a more detailed and targeted level than is currently available within either the Dr Foster Mortality Comparator tool or the NHS Digital publication. This will enhance the current free of charge Mortality Comparator (SHMI) tool which is envisaged will continue to be updated at each publication date and offered for free (with the option to request the value-added service for a charge). Dr Foster NHS customers will not see small numbers relating to other organisations. Small numbers will be suppressed in line with the HES analysis guide. No outputs produced for Dr Foster customers will contain pseudonymised record level data. This analysis and reporting will be a value added service utilising the expertise and knowledge within the wider Dr Foster team to support organisations to understand where their focus should be. Dr Foster expect to offer this additional service for a charge by January 2020.

Expected measurable benefits

[18 paragraphs unchanged] • Enables customers to track trends and moniitor monitor progress against action plans [1 paragraph unchanged] • Ability to track changes in SHMI over time and identify which elements are driving improvement/detioration improvement/deterioration – especially post discharge deaths. Generally reported in trust board papers. • Identify cohorts of spells for further investigation to support the learning from deaths agenda and local patient safety intiatives initiatives [1 paragraph unchanged] The value-added reporting service is expected to broaden the potential for SHMI to improve outcomes for patients. Dr Foster expect the benefits of this service to add to those above. The expected benefits are: • Better understanding of where the key issues are within the SHMI and associated metrics • The provision of detailed analysis by SHMI supergroup or user-defined basket of diagnoses. • Identify mortality trends across sites (small numbers will be suppressed in any peer analysis) • Support clinical audit by identifying key cohorts of activity that could be investigated further at a local level • Deeper understanding of SHMI and HSMR indicators with the option for further visualisations to supplement those in the free of charge tool. • Compare and track organisations nationally to support the reduction of clinical variation across the care pathway. (Small numbers will be suppressed in any peer analysis.) • Availability of more informed evidence to instigate clinical audit and investigations related to quality of care • Drive quality and operational productivity and track continual performance improvement. • Evidence-rich analysis and insight to help build in 'patient safety by design' at the planning and design stages of services and throughout the project lifecycle • Support networking and the adoption of best practice principles by themed and targeted analysis at a regional or national level (small numbers will be suppressed in line with the HES analysis guide) • Enhanced support for organisations in delivering their Learning from Deaths agenda and timely mortality reviews • Patients within identified areas for improvement are expected to benefit when clinical teams use the analysis to plan resources more effectively and amend practices which can ultimately lead to improved patient care. • The service will help patients within groups that are found to be at a higher than expected risk. Dr Foster will work with clinical teams to identify how the care pathway and documentation can be improved to benefit these patient groups. • Patients will benefit from changes that are informed by evidence based analysis. Earlier intervention for identified groups can lead to better survival rates. [5 paragraphs unchanged]

Benefits reported

[6 paragraphs unchanged] • The Gain the ability to drill down and investigate by SHMI supergroup, CCS group or [13 words unchanged] see SHMI data that has been aggregated with small number suppression applied.) [2 paragraphs unchanged] ‘Working "Working with Dr Foster on SHMI is useful as the HSMR and SHMI [42 words unchanged] in arrears it is important to be aware of the potential issues. ‘Accessing "Accessing both measures through a familiar portal is important for ease of use, [60 words unchanged] is invaluable in assessing and understanding your own performance in context of others.’ others." Trusts use their SHMI and HSMR comparisons to inform board reports and [22 words unchanged] website. In their annual report and accounts for 2018-19, the Trust lists ‘Reducing "Reducing preventable mortality and improving outcomes’ outcomes" as an internal priority. The Trust goes on to state that ‘The "The primary indicator for our ‘reducing preventable mortality and improving outcomes’ goal is hospital mortality. The Trust uses Dr Foster’s HSMR risk-adjusted mortality tool to monitor this.’ this." North West Anglia NHS Foundation Trust is a long-standing customer of Dr Foster for clinical benchmarking tools and bespoke analytics projects. The Trust had identified an issue with its mortality ratio and wanted to understand and provide assurance to its executive board why its Summary Hospital Mortality Indicator (SHMI) was high and ensure that it did not have any potential patient safety issues. “Dr Foster recently worked with us on a significant piece of work around the SHMI. We wanted to understand why our SHMI was high, so we worked closely with Dr Foster to examine each component and identify where there was a need for improvement. For example, we carried out an in-depth review of out of hospital activity across several diagnoses. “Working with Dr Foster we then created a number of work streams focusing on the areas of most concern. Dr Foster’s analysis helped the trust dissect the SHMI, enabling us to focus our attention to drive effective improvement, and also provide the executive team with reassurance that there were no developing patient safety issues. This in turn has had an impact on the care we provide for patients.” Hayley Topping, Deputy Quality Governance & Compliance Manager, North West Anglia NHS Foundation Trust