1. Insert name of presentation on Master Slide Quality & Safety improvement Reporting

2. National context A move towards quality and outcomes to drive improvement. A new relationship for governance by Welsh Government -assesses risk and capability but builds local ownership. A reduction in requirements for performance information which meet specific central government strategies or departmental needs. This change in focus requires a transparent and consistent way for Boards to provide assurance that includes: –A shift to a focus on outcomes that are underpinned by reliable. processes –Clear alignment of improvement priorities and organisational purpose –Assessment of progress on specific improvement programmes.

3. Quality & Safety Improvement Reports - One essential component of quality assurance Quality & Safety Committee Are we making progress on our improvement programmes? Are we learning from mistakes and responding appropriately when things go wrong? Are we using Standards for Health Services effectively ?

4. Transform services to achieve the five year vision for NHS Wales Protect and improve health for all Integrate services Deliver and sustain excellent services that meet the needs of patients and maximise clinical outcomes Transform internal systems AIM Primary Drivers Corporate requirements Secondary Drivers Interventions Aligning 1000 Lives Plus with the AQF

5. Deliver and sustain excellent services that meet the needs of patients and maximise clinical outcomes. Treat patients well and help them with their problems Deliver safe, high quality services Provide timely access to services. Primary Driver Secondary Drivers Improve stroke care Transforming Theatres (reducing surgical complications) Deliver Effective care pathways & pro- active community orientated care Depression Rapid Response to acute illness Reduce harm and variation & deliver timely access to services Enhanced recovery after surgery Zero tolerance of HCAI Hospital acquired pressure ulcers Reducing HCAI Improving critical care Hospital acquired thrombosis Improving medicines management Falls prevention in the community Dementia Stroke rehab Improve cardiac services Acute cardiac/CHF TIA’s Acute stroke Transforming maternity Services Improve mental health care Improve cancer care ‘Focus on’ pathways Transforming Care Improve major trauma & Acute illness services Improve elective care Engage workforce Leading the way to quality and safety improvement Zero tolerance of pressure ulcers Improve end of life care Improve clinical leadership BBV hepatitis action plan

6. Measurement for assurance and measurement for improvement AimImprovementAssurance Method of testingSmall sequential testsNo testing – simply evaluate performance Sample sizeSmall sequential samplesGather all relevant information Analysis and presentationRun charts or SPC chartsAchievement of target, league tables There is potential for tension unless there is clarity about the aims of measurement.

7. Balancing measurement for improvement and assurance at different levels Focus on process measures Focus on outcomes Board level Frontline team level Core system-wide assurance measures RAMI GTT Harm rates Programme specific outcome measures: Condition specific mortality rates Incidence of specific categories of avoidable harm. Improvement measures Process reliability Care bundle compliance Uptake of evidence-based practice Focus on outcomes National level Division/ Directorate levels

8. Understanding the improvement journey Improvement programmes start with baseline setting and small scale tests of change. Reliable process implementation needs to be achieved in the pilot area before spread is started Spreading is not a simply a matter of “rolling out” change, it requires active testing. Boards and Executive teams need to know if they are on track.

9. A scoring scale for assessing improvement programme progress ScoreNarrative 10 Reliable implementation has been achieved in all relevant areas/populations. 9 Reliable implementation has been achieved in half of all relevant areas/populations 8 Reliable implementation has been achieved outside the initial pilot area/ population. 7 A plan to spread reliable implementation is in place and spread is underway beyond the pilot area/population. 6 Reliable implementation has been achieved in the pilot area / population 5 Changes have been fully tested using multiple PDSA cycles in the pilot area and we are now in the process of implementation 4 Testing of changes is underway in the pilot area / population. Data collection has commenced and baseline information is available 3 The Local implementation and data collection strategy for the programme has been agreed. 2 A programme team has been set up 1 An organisation lead has been appointed for the programme

10. Completing your report You can use standard narrative relating to programme improvement scores in your report. Charts can be selected as appropriate to your progress score. You should include only sufficient explanatory narrative to highlight key progress achievements, barriers and next steps.

11. Completing your report: Examples of narrative (1) Mortality and harm We have set specific target to achieve a Risk Adjusted mortality Index (RAMI) in line with top performing UK organizations by 2013. The control chart shows an average RAMI of 80.7. We will need to show 6 consecutive months with a score below 80 before we can be confident of a reducing trend towards the target. We will report on themes our first 6 months of structured mortality reviews in next quarter. This information may highlight further priority areas for improvement that will support reduction in RAMI. Our target for system-wide harm reduction is to reduce hospital adverse event rates (as measured by the Global Trigger Tool) to 10 per 1000 patient days. The control chart shows that we have only met our target in 2 of the past 9 months and that the average adverse event rate over the period is 23.3. However, robust GTT assessment arrangements are in place. The profile of triggers identified so far is consistent with existing improvement programmes, but indicates a particular need for greater focus on the spread Hospital Acquired Thrombosis interventions.

12. Completing your report: Examples of report narrative (2): Hospital acquired pressure ulcers) Progress score 6 Changes have been fully tested on the test ward and we have consistently achieved over 95% compliance with the ‘SKIN’ bundle. Incidence of a pressure ulcer last month has adversely affected the outcome ‘time between’ measure, but we remain confident that implementation is robust. A spread plan to introduce this intervention on all surgical wards on both acute sites will be finalised by the end of this month.

13. Next steps Assess your current reporting mechanisms and either incorporate the necessary requirements into existing reports, or use the template provided. Use the summary of measures and Excel spreadsheet tool to ensure that relevant data is collected and available for inclusion in reports or for scrutiny purposes. Send a copy of the report to the Welsh Government by emailing improvingpatientsafety@wales.gsi.gov.uk. improvingpatientsafety@wales.gsi.gov.uk Contact Sara.Harley2@wales.nhs.uk or telephone 02920 827653 to arrange further support or provide feedback.Sara.Harley2@wales.nhs.uk