Quality Account 2010/11 - James Paget University Hospitals

No
Commissioning for
Quality and Innovation
(CQUIN)
CQUIN GOAL
CQUIN INDICATOR
Achieving
Not Currently Achieving
On Plan to Achieve
Area of Concern
1
2 Dementia
3 Patient Responsiveness
4 End of Life - choice
5
Maternity Services user
responsiveness
8 Day Case Basket
9 Reduce falls in hospital
10 Case note audits
Reduce avoidable death, disability and
chronic ill health from Venousthromboembolism
(VTE)
Development and implementation of an
integrated Dementia Pathway across
mental health & learning disability,
community and acute sectors:
Improve response to personal needs of
patients
Provide Palliative and End of Life care
using the nationally defined end of life
care tools
Maternity user responsiveness
Improve rate for Audit Commission
basket of 25 procedures performed as a
day case
Reducing Falls whilst in Hospital
Mortality audits and case note reviews
for harm events
1. % of all adult inpatients
who have had a VTE risk
assessment on admission
to hospital using the
national tool
2. % of inpatient &
obstetric patients excluding
non obstetric day cases
who have had appropriate
thrombopropyhlaxis
Leading and working on
Acute Trust elements of
the pathway in partnership
with all key stakeholders.
The indicator will be a
composite, calculated from
5 survey questions. Each
describes a different
element of the overarching
theme: “responsiveness to
personal needs"
1. Provision of palliative
and EOL care using the
nationally defined EOL
care tools
2. Reduction in the number
of palliative/EOL patients
dying in the acute care
setting
Introduction of ongoing
user survey and
subsequent audit/response
to improve patient
experience.
% of all operations from
the Audit Commission
basket of 25 procedures
performed as a day case
Reduce in-patient falls by
20% compared to 2009/10
baseline.
1. Baseline review:
Mortality 100 sets of notes
& Harm events, 40 sets of
notes
2. Ongoing monthly
reviews: Mortality 20 sets
of notes & Harm events, 20
sets of notes.
James Paget University Hospitals NHS Foundation Trust
Quality Account 2010/11 Page 14 of 62