10th June 2011 Mortality and harm reduction Mr Kamal Asaad – Interim Medical Director Cwm Taf Health Board Insert name of presentation on Master Slide

Improve information & communication Driver Diagram Review quality of coding data Review standard of record keeping Share Learning from mortality and Global Trigger tool (GTT) reviews Establish Quality Improvement & Safety Steering Group Improve information & communication Improving Leadership GTT each acute site monthly PCCT Pilot in 1 local GP practice Undertake 50 mortality reviews consecutively Take forward GTT findings for year 2009/10 with specific reference to quality of record keeping Pilot shared notes within community hospital setting Using Trend data to target mortality reviews to areas of apparent concern Expand mortality and GTT review teams Reduce Mortality & harm

Mortality Improved Quality of Coding Weekly reviews Using trend data to target areas of apparent concern Mortality Reviews taking place Working closely with coding and information Using trend data to target areas of concern by speciality and site Arrangements for feedback in place via Grand round Standing agenda item in Directorate Governance Groups Process for outcomes

Global Trigger Tool Weekly review – 10 notes per week Top Trigger – Readmission within 30 days Global Trigger Tool undertaken since October 2007. 10 sets of notes per week alternating between Prince Charles Hospital and the Royal Glamorgan Hospital Key issues relate to Differences in the structure of the clinical notes Inconsistencies in the quality of record keeping Investigation results not routinely filed in notes has been and continues to be robustly addressed (Key action from last presentation) Top triggers Readmission within 30 days – area of work to be progressed – linking in with Primary Care and work streams Complication in procedure or treatment – link to mortality trend data, infection rates and incidents (triangulate) The second top trigger was previously MEWS - this has improved considerably

Achievements Establishment of a Multi Professional Quality Improvement & Patient Safety Steering group Primary & Secondary Care Representation Includes Trainee & SAS Doctors Re-engineering of Anticoagulation out patient Clinics Development of Outreach teams on both district general hospital sites (previously one site) Reduction in Clostridium Difficile by 20% - started on a low base rate Roll out of skin bundle – 419 days pressure ulcer free Engagement with CHKS to understand fully our mortality data Reduction In Clostridium Difficile by 20%. Having achieved a reduction of 45% in 2009, the Health Board was already starting on a low base to achieve the 20% reduction. Rate for PCH 7.67, Rate for RGH 5.10. Roll out of skin bundle – a ward in Aberdare Community Hospital has achieved 419 days pressure ulcer free Engagement with CHKS – Training in relation to signposts, liaison and on going discussion in relation to specialist cases

Next Steps Expand Mortality and Global Trigger Tool Team (Medical & Nursing) Establish a local faculty of patient safety and improvement ambassadors Improve Communication & local ownership of the safety agenda Embedding of 1000 Lives to ensure integral to service delivery Link education and the service in relation to patient safety Development of 1000 Lives Webpage on Health Board Intranet