1. 10th June 2011
Mortality and harm reduction Mr Kamal Asaad – Interim Medical Director Cwm Taf Health Board
Insert name of presentation on Master Slide

2. 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

3. 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

4. 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

5. 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

6. 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