1. National Learning Session - 10th June 2011
Improving Care, Delivering Quality Dr Graham Shortland - Reliable Processes Cardiff & Vale University Health Board
Insert name of presentation on Master Slide

2. Driver Diagram WalkRounds/Patient Safety Fridays Leadership for QI
Mortality & Harm Reviews
Build Skills Capacity & Capability
Ventilator acquired Pneumonias
Ventilator bundle
Clostridium Dificile
Clostridium Dificile Bundle
Blood stream infections
Central & Peripheral Line Insertion & Maintenance Bundles
Hospital Acquired Infections
Catheter Associated UTI
Urine Catheter insertion & maintenance bundles
Surgical site infections
Early Warning Scores & Rapid Response
Sepsis/RRAILS
SSI Bundle
Reduce Mortality, Harm, Variation and Waste
Surgical Errors
WHO Checklist
VTEs
HAT assessment, prevention and treatment
Medicines Management
Reconciliation
First episode psychosis
Mental Health
High risk medications
Depression
Dementia
Pathways and Bundles
Heart Failure
Stroke care
Falls Prevention
Pressure Ulcers
SKIN Bundle
Transforming Care

3. Risk Adjusted Mortality - Cardiff and Vale UHB

4. RAMI Weekly Deaths Review Group established
Led by Medical Director, supported by Assistant Medical Directors (x2); Assistant Director Patient Safety & Quality; Improvement Advisor and Clinical Coding Manager, Clinical Coder in rotation to inform learning
Data extracts generated weekly via Clinical Governance Data Analyst from CHKS, patients whose RAMI suggests least likely to die (RAMI less than 0.25)
On average 18 of 45 weekly deaths case notes reviewed
If triggers identified Medical Director generates letter for lead Consultant to undertake case review and feedback
Key learning to date
Coding Quality improving
Raising the profile and importance of clinical coding with clinicians and making some operational changes to working arrangements to strengthen coder / clinician interface.

5. Leadership – WalkRounds
Patient Safety Fridays introduced during 2009 – 2 WalkRounds per week – all areas of the organisation covered.
Database for actions – completion monitored.
Recurring themes are staffing and estates/ environments of care issues
Planned ward refurbishment programme underway
Good practice observed and share
Next steps
Maintain the focus on Q&S organisational priorities
Outcomes reported and scrutinised at Board and Quality & Safety Committee
Further develop relationships with estates to agree and monitor actions

7. Falls Prevention
Significant achievement for CELT: no re-referrals for falls
On-going review and development of documentation in progress
73% of patients referred to CELT for Falls Prevention received a full assessment.(27% declined or were admitted to hospital etc)

8. Safer Surgery

9. Summary Wide range of initiatives
Various stages of Development - process reliability
Constant vigilance with outcome measures as programmes mature