Quality Accounts 2010/11:
Looking back, looking forward
Dr Patricia Bain
Director of Quality & Standards
14th September 2011
Quality Accounts 2011/12
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Legal requirement to produce quality account
Statement of assurance – new requirement
Audited: KPMG and PWC – moderate assurance
Section 1: Chief Executive commentary
Section 2: Looking back, Statement of
Assurance
• Section 3 :Looking forward
• Annex:
Statements from stakeholders
Section 2: Looking back
Quality Strategy
Strategy
Data Quality Strategy
Business Intelligence Strategy
Training and development
Capabilities and Culture
Quality
Governance
Quality focussed culture
Leadership
Roles and accountabilities
Processes and structures
Escalating and managing performance
Engaging patients,staff,stakeholders
Community to Board
Measurement
Performance reports
Business Intelligence
Section 2: Looking Back
100
National Inpatient Survey: CQUIN results 2010 vs 2009
90
80
70
60
50
40
30
20
10
0
Did a member of staff
tell you about
medication side
effects to watch for
when you went
home?
Did hospital staff tell Did you find someone
Were you given
Were you involved as
you who to contact if on the hospital staff to enough privacy when much as you wanted
you were worried
talk to about your
discussing your
to be in decisions
about your condition worries and fears?
condition and
about your care and
or treatment after you
treatment?
treatment?
left hospital?
National Inpatient survey 2009
National Inpatient survey 2010
Local PET Inpatient survey 2010
Priority Improvement Programmes 2010/11
• Priority One: Depth of Coding
2008/09
2009/10
2010/11
2010/11 vs
previous year
Trust
2.3
2.6
3.0
15%
Accident & Emergency
Child Health
HCOP
General Medicine
Specialist Medicine
Ear, Nose & Throat
General Surgery
Ophthalmology
Obstetrics & Gynaecology
Oral (Maxfax) surgery
Urology
Trauma & Orthopaedics
2.8
1.7
4.1
2.9
2.0
1.5
2.3
1.6
1.6
2.3
2.3
2.0
3.2
1.7
4.7
3.4
2.4
1.9
2.7
1.9
1.8
2.3
2.7
2.5
4.0
1.7
5.2
3.9
3.3
2.7
3.2
2.5
2.0
2.4
3.2
2.9
25%
0%
11%
15%
38%
42%
19%
32%
11%
4%
19%
16%
Clinical Documentation
Row Labels
Quarter 1
Nursing entries in chronological order
99.5%
Entries on the record initialled
98.0%
Entries with time recorded
95.0%
Pages with forename and surname
111.5%
Entries with date recorded
93.0%
Pages with unique patient identifier
113.7%
Entries on the record with legible printed name
92.9%
Predicted discharge date recorded
52.3%
Number of deletions or alterations countersigned 36.6%
*Red indicates data quality issues
Quarter 2
99.9%
96.5%
96.2%
85.8%
85.4%
83.8%
79.0%
64.0%
46.1%
Quarter 3
99.6%
98.5%
93.0%
80.3%
92.9%
78.4%
74.6%
63.7%
56.5%
Quarter 4
99.8%
93.2%
91.3%
90.7%
94.8%
88.9%
77.3%
68.0%
50.2%
YTD
99.7%
96.4%
93.9%
91.3%
91.2%
90.3%
80.2%
62.7%
47.3%
Priority 2: Infection control
Urinary tract infection rates year on year
2009/10
2010/11
Catheter related UTIs per 1,000 occupied bed days
0.12
0.14
Non-catheterised UTIs per 1,000 occupied bed days
0.08
0.24
Priority 3: VTE
90% target met
Priority 4: Fluid balance/Nutrition
Assessment Type
Q1
Q2
Q3
Q4
YTD
Fluid Balance Assessment
68.70%
63.60%
63.90%
62.70%
64.70%
Fluid Balance Calculated
72.60%
72.90%
79.90%
82.50%
76.70%
Fluid Balance Acted Upon
98.50%
97.60%
100.00%
99.50%
98.90%
Assessment Type
Nutritional Assessment Completed
Q1
Q2
Q3
Q4
YTD
89.20%
93.00%
89.00%
92.60%
91.10%
Section 2b: Statement of Assurance
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Service reviews
CQUIN : £1.6/£2m
National priorities
Clinical Audit activity
Research programmes, VTE
Data Quality (new section)
Information Governance
Section 3: Looking forward: 2011/12
• 95% high risk prescriptions,
opiates, anticoagulants,
antibiotics prescribed as per
protocol
• Reduce number of
communication incidents :
handover/hand-off
• Continue to have zero Never
Events
• Increasing
Patient
Safety
Clinically
Effective
Patient
Experience
responsiveness to our
patients needs on
composite indicator
(PET)
• Increasing compliance
to 95% of key measures
of End of Life care
pathway
KPIs
• Reducing 30day re-admission
rates
•Continue to achieve month on
month 90% VTE risk assessment
•Ensure 90% of VTE prophylaxis
prescribed as per national
guidance
•Linked to Improvement
programmes
•On-going :
Mortality. Fluid balance and
MUST tool
• CQUINs, National Priorities