Appendix 6

Performance Management Reporting NHS QIS Reviews:- (Condition Specific Standards)

Local Target: To achieve 100% compliance with ESSENTIAL criteria

Local Measure: Number of essential criteria met at time of review as a percentage (%) of total essential criteria possible

Title / Lead Executive / Clinical Lead / Review Date / %Essential Criteria
Met at Review Date / Assessment at June 2010 / Comments
Maternity / Alex McMahon
Acting Director of Strategic Planning and Modernisation/ Melanie Hornett
Nurse Director / Sandra Smith / Rona Hughes / Mar 2006 / 79%
(54/68) / 94%
(64/68) / Action plan in place and monitored by Maternity Services QIT/CMT
Breast Screening /

Alison MacCallum

Director of Public Health /

Lesley Smart

/ May 2006 / 93%
(62/67) / 94%
(63/67) / Remaining issues relate to data recording to provide evidence of achievement, which is being addressed.
Cervical Screening /

Alison MacCallum

Director of Public Health / Sue Payne / Aug. 2006 / 95%
(20/21) / No change / Standards have been reviewed due to significant change arising from implementation of SCCRS and now replaced by a set of KPIs. 1st report due autumn 2010.
Diabetes / Alex McMahon
Acting Director of Strategic Planning and Modernisation / Johnny McKnight/Mary Scott / Apr. 2007 / 86%
(31/36) / 97%
(35/36) / Action plan in place and monitored by LDSAG.
Outstanding criteria reliant on national electronic solution becoming available.
Blood Transfusion / Charles Swainson Medical Director / Charles Wallis / Sept. 2007 / 52%
(14/27) / 59%
(16/27) / Action plan in place and monitored by NHS Lothian Transfusion Committee (reports to UHD HCGRM operational group)
Majority of unmet criteriawill be addressed through 3 work streams which are well underway:
  • Revised transfusion policy
  • Implementation of patient identification policy
  • Implementation of single transfusion document

Asthma -
Children and Young People / Alex McMahon
Acting Director of Strategic Planning and Modernisation / Steve Cunningham / Dec. 2007 / 42%
(5/12) / No change* / Incorporating aspects of clinical governance and risk management standards as applied to asthma services. CQI scale used.
Action plan in place, being implemented and monitored Asthma services Clinical Reference group.
* Progress made in components of standard 2 particularly around partnership with school, referrals and education & training. Full EQIA completed and actioned.
Key national solution required re:data collection/extraction on GP systems.
Respiratory MCN will focus on asthma services in the autumn 2010 which will assist in taking forward this work.
Anaesthetics / Charles Swainson
Medical Director / David T Brown / 2005 / UHD 67%
(24/36)
WL 50%
(18/36) / 86%
(31/36) / Second round review of selected key criteria undertaken and report published 1 July 2010.
Action plan in place to address unmet criteria via Anaesthetics & Theatres CMT/QI team.
Learning Disabilities / Alex McMahon
Acting Director of Strategic Planning and Modernisation / Mike Jones/CHP Clinical Directors
Rona Laskowski / Aug.2005
Oct. 2008 / Adult
44%
(16/36)
Children 66%
(19/29)
77%
(13/17) / Adult
92%
(33/36)
Children
79%
(23/29)
88%
(15/17) / Phase 1 – Quality indicators 1,4,5&6
There has been significant development against these indicators. Remaining areas for activity includes capital investment to improve privacy in the in-patient units. For children's services - remaining areas include access to advocacy, and specific strategic planning.
October 2008 Review - Quality Indicators 2 and 3
Progress continues against agreed action plan. Specific progress against previously "not met" areas includes:
Primary Care Liaison Team established.
LD Acute Liaison Service - capacity increased by 50%.; Current pilot May - August 2010 of OOH/ A&E requirements from Liaison Service.
Webpage for professionals developed and launched, which includes a toolkit.
29 separate clinical leaflets developed in Easy Read formats and launched e.g. Diabetes Services; Asthma services.
Current study underway to understand LD Patient experience in Cancer services.
Health screening - joint reviews now undertaken by CLDT and GP practices
New policy in place and launched by Clinical Policy Group - Caring for Patients (aged 16+) with Learning Disabilities in a generic hospital setting.
Paediatric equivalent in development.
QIS Best Practice audit rolled out across UHD.
File Name: Condition Specific - Jul 2010 / Version: 1 / Date: July 2010
Produced By: NHS Lothian / Author: QAA Manager / Page 1 of 4 / Review Date/ Status: July 2011