1. Insert name of presentation on Master Slide Annual Quality Framework 2011-2012 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 with organisational purpose –Assessment of progress on specific improvement programmes.

3. 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

4. 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 Deliver Effective care pathways & pro- active community orientated care Depression Rapid Response to acute illness Reduce harm and variation 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 Deliver timely access to services Improve end of life care Improve clinical leadership BBV hepatitis action plan

5. Measurement for assurance vs 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 Both approaches are required, but there is potential for tension unless there is clarity about the balance between them at each organisational level …

6. Balancing measurement for improvement and assurance at different organisation levels Focus on process measures Focus on outcomes Board levelFrontline 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

7. Building accountability for improvement at mid-organisation levels Provide organisational level assurance Manage local improvement Spread & sustainBuild leadership and accountability Divisional Teams Directorate/locality Teams Exec Team

8. 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

9. Examples of report 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.

10. Examples of effective reporting (2) Acute Stroke Care

11. Examples of effective reporting (3) Critical Care

12. Next steps A populated version of the template needs to be…… (where, when) The 1000 Lives Plus team will review the review the report with you to identify any changes or refinements needed before the next submission. For further support or advice, contact….