Document Number:
Sponsors: / Medical Director/DON
Author: / Associate Director of Clinical Governance/IP&C
Created date: / 15/0210
Version: / 1.0
Status: / Approved by Trust Board
Approved date: / April 2010
Next Review date: / March - 2013
To be approved by: / Trust Board

1

TABLE OF CONTENTS

1Document Definition

1.1Revision History

1.2Review and Approval History

1.3References

1.4Glossary/Definitions

1.5Purpose

1.6Scope

1.7Regulatory Position – Strategic Drivers

1.8Special Cases

1.9Comments

2Quality Account (QA) and Quality Improvement Plan (QIP) – Aims and Objectives

2.1 Introduction

2.2 Quality Account and Quality Improvement Plan

2.3 Aim

2.4 Objectives

3Quality Account (QA) and Quality Improvement Plan (QIP) – Framework and Content

3.1 The key aims of Quality Account are to:

3.2 The Framework for the Quality Account

3.3 Content of the Quality Account

4Priorities for Quality Improvement

4.1The Trust defines 4 priorities for quality improvement:

4.2Consultation

5Responsibilities8

6Monitoring and Reporting Arrangements and Quality Assurance – Quality Account and Improvement Plan 10

7CQUIN10

1Document Definition

1.1Revision History

Version / Status / CR No. or Reason for change / Date / Author
1.1 / Draft / New document entitled Quality Account and Improvement Plan April 2010 – March 2013. / 15/02/10 / Associate Director Clinical Governance/IP&C
1.11 / Draft / Incorporated Initial review comments / Feb/March 2010 / Associate Director Clinical Governance/IP&C
1.12 / Issued / After Final Review / June 2010 / Associate Director Clinical Governance/IP&C

1.2Review and Approval History

Version / Reviewer/Approver / R/A / Scope / Date
1.2 / Medical Director/DON/CE / Context completeness and accuracy / 28/02/10
1.21 / Patient Safety and Quality Committee / R / Context completeness and accuracy / 02/03/10
16/03/10
1.22 / External
Stakeholders
  • LINKs
  • Overview Scrutiny Committees
  • Commissioning PCTs
  • Governors
  • LINKs
/ A / Consultation and Agreement / 07/03/10
1.23 / Trust Board / A / Final Approval / 25/03/10

1.3References

Ref Number / Document title / Document Reference/Location
Trust Business Plan and Core Objectives / Intranet
Corporate and Directorate Risk Registers / Intranet
Quality Account 2009/10 / Intranet

1.4Glossary/Definitions

ADCQ – Associate Director of Clinical Quality

AMDs – Associate Medical Directors

CQC - Quality Commission

PSQC – Patient safety and Quality Committee

CSS – Clinical Support Services

CGS – Clinical Governance Services

DH – Department of Health

DIPC – Director for IP&C

EFM – Estates and Facilities Management

GWHFT – Great Western Hospitals NHS Foundation Trust

IMT – Information, Management, Technology

IP&C – Infection Prevention and Control

MRSA – Methicillin-Resistant Staphylococcus Aureus

NHS – National Health Service

NHSLA – NHS Litigation Authority

NICE – National Institute for Clinical Excellence

NPSA – National Patient Safety Agency

PALS – Patient Advisory and Liaison Service

PCT – Primary Care Trust

PEAT – Patient Environment Action

PICKER – Picker Institute Report (Patient Experiences)

PSQC – Patient safety and Quality Committee

QA – Quality Account

QIP – Quality Improvement Plan

QRP – Quality and Risk profile

1.5Purpose

The purpose of the Quality Strategy is:

To set out the Great Western Hospitals NHS Foundation Trust’s key priorities for quality improvement over the next 3 years (2010 – 2013) and how the improvements will be delivered.

  • To provide assurances that structures and systems are in place to promote patient safety at all times. Providing excellent quality of care for patients is integral to the Trust’s mission statement and objectives as described below:

The Trusts vision is to be

“The provider of choice by delivering high quality services, within the resources available, which delight our patients and commissioners and to establish sound, viable business partnerships by forming strategic alliances with our primary care trusts and other key partners”.

The Trust’s vision is underpinned by fourkey strategic aims:

  1. To provide safe, high quality care which patients are satisfied with and staff are proud to provide and ensuring our services are embedded in and valued by our communities
  2. To maintain and strengthen relationships in our core markets in the communities of Swindon and adjoining parts of Wiltshire and further develop market share in the other areas of Wiltshire, Gloucestershire, Oxfordshire and Berkshire through:
  • Market growth (increase existing referrals).
  • Providing community services that we don’t currently provide.
  • Tendering for (appropriate) services
  • Repatriation of tertiary services, where clinically safe and appropriate and we can make a profit or repatriated services would meet our strategic aims
  1. In all services we will perform in the top 20% of similar sized hospitals and there will be a focus on productivity in all areas of our business
  2. We will work in partnership in all we do to ensure delivery of the best healthcare for our patients, commissioners and communities.

The Trust’s business objectives are:

To deliver care that is at all times safe, high quality, productive and focused on delivering patient satisfaction

To ensure all our activities are delivered within the available financial envelope

To deliver innovative effective Clinical Services

To work together across our organisation, breaking down professional and clinical barriers to deliver excellence now and in the future

To develop our workforce

To use innovation and new ways of workingas an integral part of growing the Trust’s future success

1.6Scope

The scope of the work described in the Quality Account (QA) applies to:

  • All staff employed by the GWHFT
  • Carillion Health
  • The Hospital Company
  • All staff working within the Trust who may not be Trust employees eg volunteers, PCT staff, agency and locum staff
  • Other sub contractors as applicable ie GWAS, Prospect
  • NBThe scope of this document does not refer to or address the non clinical, financial or workforce quality improvement strategies. It does refer to associated quality improvements to enable the Trust to achieve its regulatory obligations within its QIP and to improve its Quality and Risk Profile (QRP) published by the CQC. The CQC advise that the QRP will inform the Trust’s quality assessment as part of its registration process and the annual health check

Consultation on the QA be with and agreed by:

  • The Trust’s Governors
  • The Trust’s Risk and Governance Committees and Management Committee
  • External stakeholders including LINKs and local OSCs.
  • Commissioning PCTs

The QIP and QA will be approved by Trust Board

1.7Regulatory Position – Strategic Drivers

The QA addresses the Trust’s legal and contractual obligations and incorporate guidance on the QA framework, contents, validity and reliability as directed by its regulators, Monitor and the CQC and the DH which is responsible for the development of NHS policy. The regulations, guidance and assessment frameworks include:

  • CQC – Essential Standards for Quality and Patient Safety – December 2009
  • CQC – Quality and Risk Profile
  • Monitor Compliance and Assurance Framework
  • Commissioning Quality Contract PCT
  • Safer Patients Initiative
  • Leading Improvements in Patient Safety (LiPS)
  • Releasing Time to Care (productive ward)
  • NHS Next Stage Review “High Quality Care For All”
  • Commissioning for Quality Improvement and Innovation (CQUIN)
  • Patient Reported Outcome Measures – PROMs
  • National Patient Safety First Campaign
  • NHSLA Standards (acute and maternity)
  • Essence of Care DH 2001
  • Patient Experience Survey Reports (Internal and External- PICKER ), formal and informal complaints
  • Health Act - 2008, DH
  • National service frameworks
  • National priorities – performance indicators
  • MRSA and Clostridium difficile targets – DOH
  • Reports and actions arising from internal and external audits and reviews – learning from the best.
  • Actions arising from incidents, serious case and litigation reviews.
  • Actions arising from Safety Alerts Bulletins including Pharmaceutical Alerts.
  • The Trust’s corporate risk register
  • Mental Health Act
  • Safeguarding Vulnerable adults and children
  • Annual PEAT Survey
  • Staff satisfaction Survey

1.8Special Cases

There are no exceptions to the implementation of this strategy for quality improvement

1.9Comments

Any comments on this document should, in the first instance, be addressed to the author (referenced at end of document)

2Quality Account (QA) and Quality Improvement Plan (QIP) – Aims and Objectives

2.1 Introduction

Within its business plan, the Great Western Hospitals NHS Foundation Trust sets out that the provision of safe, high quality patient care is its number one priority.

This quality and safety strategy explains the key measures against which the Trust will assess that this objective is met and the detailed plans for how these measures will be delivered...

2.2 Quality Account and Quality Improvement Plan

Delivery of this strategy will provide both internal and external assurances that robust clinical governance structures and systems are in place, monitored and appropriately managed and that there is a continuous drive to improve the quality of care provided for our patients.

2.3 Aim

To set out a clear quality improvement plan building on current local and national quality improvement initiatives to meet the Trust’s patient quality and safety objectives and provide the safest and most effective care to enhancing the patient experience.

2.4 Objectives

  1. To set out clear and progressive annual quality and safety improvement indicators for the period 2010 – 2013
  1. To ensure the quality improvement plan is driven by the needs of our local population whilst also addressing contractual, national, and local and obligations.
  1. To provide a framework through which the quality improvement plan will be achieved and learning from audits, complaints and incidents is demonstrated
  1. To identify leads responsible for ensuring each of the quality improvement indicators are owned and progressed and developing work streams to ensure their delivery.
  1. To identify a clear pathway for the leads to report associated risks and to provide solutions to those risks through the Governance and Risk Committees through to Trust Board.
  2. To determine the specific responsibilities at clinical and operational levels for leading and implementing each of the elements within the quality improvement plan.
  1. To clearly define the Clinical Governance reporting structures and responsibilities within the Trust.
  1. To define the reporting, monitoring, and assurance processes for the quality improvement plan
  1. To ensure that approval of the QIP and priorities are directed approved and monitored at Board level.
  1. To meet all the requirements of our regulators

3Quality Account (QA) Framework and Priorities

3.1 The key aims of the Quality Account are to:

  • Improve the quality of healthcare services
  • To improve the experiences of our patient’s journeys
  • Improve accountability to our governors and the public
  • Ensure the Board ownership for the improvement of quality
  • Allow clinical teams to assess and improve quality
  • Provide a framework to support discussions with Commissioners about local priorities for improvements

3.2 The Framework for the Quality Account

The DH consultation on the framework for Quality Accounts ran from 17th September 2009 to 10th December 2009. In addition, Monitor outlined additional requirements for Foundation Trusts in its consultation document for the Annual Reporting Requirements for 2009/10 which closed on 25th January 2010. These additional requirements include a report on progress against those priorities identified in the 2008/09 Quality Report.

The overriding principles are that quality accounts should be short, readable documents, accessible to all members of the local community. They will be published by the end of June 2010 and will be made publicly available on the NHS Choice website.

In Year 1, 2009/10, NHS Foundation Trusts were required to produce Quality Accounts. In Year 2, 20010/11, Quality Accounts will be introduced for primary and community care sectors. It is proposed that there will be an exemption for small providers with less than 100 NHS patients or with NHS contract worth less than £100, 000.

Boards are responsible for the accuracy and completeness of Quality Accounts and ensuring compliance with related regulations and guidance.

3.3 Content of the Quality Account

The content is nationally mandated and must include:

  • Signed statement from the Board
  • Between 3 and 5 priorities for improvements, similar to those identified in the Trust Quality Objectives
  • A measurable report of quality performance in 9 areas (3 Patient Experience, 3 Patient Safety, 3 Clinical Effectiveness). These priorities need to be agreed in consultation with the Board, local commissioners and local stakeholders
  • Information regarding participation in Clinical Audit and Research and innovation
  • What others say about the provider including the CQC, Governors, PCTs, LINks, Commissioning PCTs need to endorse Trust Quality Accounts as one mechanism of providing assurance about the content of the report.
  • Data Quality - 4 scores comprising: valid NHS number for patients, error rate for clinical coding, valid GP registration code, overall score received from the information governance toolkit

4Priorities for Quality Improvement

4.1The Trust defines 4 priorities for quality improvement:

  • To improve patient safety and reduce harm
  1. Reduce Hospital Acquired Infections
  2. Reduce hospital mortalities
  3. Reduce pressure ulcers
  4. Reduce harm associated with patient falls and medication errors
  5. To deliver effective, evidence based care
  1. Increase patient nutritional and VTE risk assessments on admission to hospital
  2. Compliance with the Stroke care pathway and action plan
  3. Monitor numbers of patients who return to theatres and who are re admitted to hospital
  4. Compliance with NICE guidance and CAS alerts
  5. To improve the patient experience
  1. Involve patients more about decisions about their care
  2. improve information to patients about their medication on discharge
  3. Improve information to patients about who to contact after discharge
  • To comply with governance and regulatory obligations
  1. Compliance with CWC regulations
  2. NHSLA and CNST – minimum Level 1
  3. Compliance with the Mental Health Capacity Act
  4. Compliance with Safeguarding Children

The above quality improvement priorities will inform the annual quality improvement plans over the next 3 years and progress reported upon within the annual Quality Accounts (See separate annual improvement plans and annual reports).

4.2Consultation

The above priorities for quality improvement have been agreed with our key internal and external stakeholders (defined on page 3).

5.0Responsibilities

The management structure, lines of communication and organisational structure associated with the implementation of this strategy are set out below.

5.1Trust Board

Trust Board is responsible for:

  • Ensuring the Trust provides high quality and safe clinical care to patients
  • Approving the key priorities for quality improvement following recommendations from the Executive team
  • Ensuring sufficient resources are available for the management team who are responsible for the delivery of the quality objectives.
  • Providing a named non executive to have delegated responsibility for the Quality Account and Improvement Plan

5.2Chief Executive

The Chief Executive (CE) is accountable to Trust Board for the delivery of the Quality Account and Quality Improvement Plan

5.3Medical Director (MD)

The MD is the executive lead for Clinical Governance and Infection Prevention and Control (DIPC) and thus has devolved accountability from the CE for the overall delivery of the quality improvement plan. The MD works closely with the management team to ensure effective delivery.

The MD is responsible for:

  • Presenting monthly and quarterly Quality and Clinical Governance and IP&C reports to Management Committee and Trust Board.
  • Managing the quality performance against the quality improvement plan within the Trust’s directorates.
  • Chairing the Patient Safety and Quality Committees
  • Managing the Associate Director for Clinical Governance, the Director of Operations and the Associated Medical Directors.

5.4Executive Team

  • Individual executives are responsible for the delivery of core elements of the Quality Improvement Plan.
  • The executive team are responsible for identifying designated clinical and operational leads to progress the deliver the quality improvement plan.

5.5Associate Director for Clinical Governance (ADCG)

The ADCG/IP&C reports directly to the MD

The ADCG/IP&C is responsible for:

  • Leading and managing Clinical Governance Support Services (CGSS) comprising IP&C, Clinical Risk, Clinical Audit, and the Clinical Governance co coordinator.
  • Ensuring organisational support, advice and expertise is provided by the CGSS
  • Developing the Quality Account, Improvement Plan and monitoring process.
  • To lead on the assessment, monitoring and reporting of all external quality regulatory requirements
  • Supporting the MD with the delivery of the Quality agenda including the provision of reports, monitoring tools, plans, service reviews and development of policy documents.
  • Ensuring close working and integration with all clinical and none clinical teams from whom delivery of the clinical governance agenda is required
  • Monitoring and reporting on progress with the Quality Improvement Plan to relevant internal and external stakeholders including the CQC, Monitor and the commissioning PCTs
  • Working closely with the Associate Director for Performance and Planning and Head of Corporate Governance on the monitoring of performance, risks annual health check and trust wide quality assurance

5.6Clinical Support Services

Clinical Support services are responsible for:

  • Providing, advice, policies and education and undertaking audits for directorate teams to support their delivery of the Quality Improvement Plan.
  • Collecting, collating and analysing clinical data to identify ward and organisational risks and informing the CGRC and IGRC accordingly.
  • Providing monthly, quarterly and annual reports to the Patient Safety and Quality Committee

5.7Associate Medical Directors (AMDs)

The AMDs are accountable for the safe delivery of high quality care to patients within the directorates that they manage. They are responsible for:

  • Ensuring their management, departmental leads and nursing teams are aware of their responsibilities within the Quality Improvement plan and for its full delivery.
  • Optimising resources to prevent, reduce and manage all clinical risks.
  • Engaging with the CGSS to seek advice and support with the delivery of the Clinical Governance Plan

5.8Carillion

Carillion are responsible for the delivery of cleaning services to the Trust in line with their sub contract with The Hospital Company and hence contribute to associated elements of the QIP. Hence, Carillion with directorate teams have responsibility for ensuring environmental cleanliness is monitored, reported upon and delivered to an excellent PEAT standard.