Annual Report and Accounts - The Great Western Hospital

Steps which have been put in place to assure the Board that the Quality Report presents a balanced
view and that there are appropriate controls in place to ensure the accuracy of data include the
following: -
• The Medical Director is the Executive lead for the Quality Account and there is a named Non
Executive Director with designated personal leadership for patient safety and quality on behalf
of the Trust Board. The Trust has a 3 year Quality Improvement Strategy which provides
details on roles and responsibilities for quality and safety and defines the key focus for the
Annual Quality Accounts.
• The Annual Quality Account Report 2011/12 provides a narrative of progress toward
achieving the quality improvement indicators agreed by the Executive Committee, the Patient
Safety and Quality Committee and the Trust Board.
• The Quality Account is compiled by a Clinical Governance Administrator following both
internal and external consultation to inform the improvement indicators. Data is provided by
nominated leads in the Trust. These leads are responsible for scrutinising the data they
provide to ensure accuracy. Once compiled the Quality Account Report is scrutinised by the
Associated Director of Quality and Patient Safety for challenging the veracity of data. The
Medical Director is ultimately accountable to Trust Board and its committees for the accuracy
of the Quality Account Report.
• The Quality Account is subject to robust challenge at a Patient Safety and Quality Committee
on both substantive issues and also on data quality. Where variance against targets is
identified the leads for individual metrics are held to account by the Patient Safety and Quality
Committee. Following scrutiny at that committee, the Quality Account is reported to Trust
Board which is required to both attest to the accuracy of the data and also ensure that
improvements against the targets are maintained.
• Directors’ responsibilities for the Quality Account Report are outlined separately in this report.
• The Quality Account Report has been prepared in accordance with Monitor’s annual reporting
guidance as well as the standards to support data quality for the preparation of the Quality
Report. No material weaknesses in the control framework associated with Quality Accounts
have been identified.
14.7 Review of effectiveness
As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal
control. My review of the effectiveness of the system of internal control is informed by the work of the
internal auditors, clinical audit and the executive managers within the NHS foundation trust who have
responsibility for the development and maintenance of the internal control framework. I have drawn
on the content of the quality report attached to this Annual report and other performance information
available to me. My review is also informed by comments made by the external auditors in their
management letter and other reports. I have been advised on the implications of the result of my
review of the effectiveness of the system of internal control by the Board and the Audit, Risk and
Assurance Committee and a plan to address weaknesses and ensure continuous improvement of the
system is in place.
The processes that have been applied in maintaining and reviewing the effectiveness of the system
of internal control include the following: -
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