1. Quality Accounts 2010/11: Looking back, looking forward Dr Patricia Bain Director of Quality & Standards 14 th September 2011

2. Quality Accounts 2011/12 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

3. Section 2: Looking back Quality Governance Strategy Quality Strategy Data Quality Strategy Business Intelligence Strategy Capabilities and Culture Training and development Quality focussed cultureLeadership Processes and structures Roles and accountabilitiesEscalating and managing performanceEngaging patients,staff,stakeholders Measurement Community to BoardPerformance reportsBusiness Intelligence

4. Section 2: Looking Back

5. Priority Improvement Programmes 2010/11 Priority One: Depth of Coding

6. Clinical Documentation

7. Priority 2: Infection control Urinary tract infection rates year on year2009/102010/11 Catheter related UTIs per 1,000 occupied bed days0.120.14 Non-catheterised UTIs per 1,000 occupied bed days0.080.24

8. Priority 3: VTE 90% target met

9. Priority 4: Fluid balance/Nutrition Assessment TypeQ1Q2Q3Q4YTD Fluid Balance Assessment68.70%63.60%63.90%62.70%64.70% Fluid Balance Calculated72.60%72.90%79.90%82.50%76.70% Fluid Balance Acted Upon98.50%97.60%100.00%99.50%98.90% Assessment TypeQ1Q2Q3Q4YTD Nutritional Assessment Completed89.20%93.00%89.00%92.60%91.10%

10. Quality at a Glance Improved on majority of indicators sustained our improvement of falls from height and the same level, quarter 4 saw an increase that impacted on the year to date target. We are reviewing our work related to the Falls Collaborative and will implement further measures during the coming year to reduce falls further. Medication errors continue to show limited improvement, we have therefore included them in next year’s Quality Account as requiring a specifically focused improvement programme. Unplanned re-admission rates within 14 and 28 days continue to show limited improvement, again we have included this for a specifically focused improvement programme as part of our involvement in the NHS QUEST initiative and is also included in our CQUIN payment framework for next year in relation to emergency admissions.

11. Section 2b: Statement of Assurance Service reviews CQUIN : £1.6/£2m National priorities Clinical Audit activity Research programmes, VTE Data Quality (new section) Information Governance

12. Section 3: Looking forward: 2011/12 Linked to Improvement programmes On-going : Mortality. Fluid balance and MUST tool CQUINs, National Priorities 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 Increasing responsiveness to our patients needs on composite indicator (PET) Increasing compliance to 95% of key measures of End of Life care pathway 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 Patient Safety Patient Experience KPIs Clinically Effective