Quality Account 2010/11 - James Paget University Hospitals

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NHS number and GMC code validity James Paget University Hospitals NHS Foundation Trust submitted records during 2010/11 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included the patient’s valid NHS number was: 99.81% for admitted patient care; 99.80% for outpatient care; and 99.02% for accident and emergency care. The percentage of records in the published data which included the patient’s valid General Medical Practice Code was: 100% for admitted patient care; 100% for out patient care; and 98.40% for accident and emergency care. This data is based on the latest published figures up to Month 10. Information Governance Toolkit James Paget University Hospitals NHS Foundation Trust Information Governance Toolkit assessment score. Overall score for 2010/11 was 45/45. Information governance is a systematic approach to ensuring that all aspects of the processing of personal and sensitive information, both paper and electronic, meet prescribed standards. It aims to ensure that performance is subject to continuous improvement. The Information Governance framework has four dimensions: • Management: structures, policies, procedures, etc. • Systems: access controls, application security, validation, etc. • Processes: protocols, records management, data quality, etc. • People: education, training, development, guidance, etc. As a key part of the Information Governance agenda, the Department of Health and NHS Connecting for Health jointly produced an Information Governance Toolkit. The current version of the Toolkit is scored using a simple Red/Green (Satisfactory/Unsatisfactory) metric. The Toolkit is designed to assist organisations to achieve the aims of Information Governance and currently encompasses: • Information Governance Management • The NHS Confidentiality Code of Practice • The Caldicott Guidelines • Data Protection Act 1998 • Information Security Management NHS Code of Practice James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 28 of 62
• Information Quality Assurance • Records Management NHS Code of Practice • Freedom of Information Act 2000 It is the tool by which organisations can assess their compliance with current legislation, standards and national guidance. The Trust achieved a Level 2 score in 45 of the 45 requirements in the Toolkit Assessment, which is rated as ‘Satisfactory’ performance. Clinical Coding Error rate 5 James Paget University Hospitals NHS Foundation Trust was subject to the Payment by Results clinical coding audit during 2010/11 by D&A Clinical Coding Consultancy Limited. The error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were: • Primary Diagnoses Incorrect 9.5%; • Secondary Diagnoses Incorrect 13.8%; • Primary Procedures Incorrect 4.9%; and • Secondary Procedures Incorrect 4.5%. The table below shows the coding accuracy overall results in comparison to the 2010 audit. Please note different specialties were audited each year. Correct (%) 2009/10 Correct (%) 2010/11 Primary Diagnosis 92.50 90.50 Secondary Diagnosis 92.13 86.21 Primary Procedures 95.83 95.04 Secondary Procedures 88.89 95.52 The 2010 audit reviewed the following specialties: Gynaecology General Surgery Trauma and orthopaedics Ophthalmology General Medicine. 5 Please note: These results should not be extrapolated further than the actual sample audited. James Paget University Hospitals NHS Foundation Trust Quality Account 2010/11 Page 29 of 62
Page 1: James Paget University Hospitals NH
Page 4 and 5: Contents Page Foreword by Chief Exe
Page 6 and 7: The old and the very young are know
Page 8 and 9: Statement of directors' responsibil
Page 10 and 11: Current position: Patient Falls 120
Page 12 and 13: Priority 1b: Patient safety - Reduc
Page 14 and 15: Five work streams have been agreed
Page 16 and 17: No Commissioning for Quality and In
Page 18 and 19: No Commissioning for Quality and In
Page 20 and 21: The services provided by James Page
Page 22 and 23: Clinical Audits Audit Name Applicab
Page 24 and 25: (NHSBT UK Transplant Registry) Audi
Page 26 and 27: Case Study 2: Upper Gastrointestina
Page 28 and 29: The Trust has a dedicated lead for
Page 32 and 33: What others say about the Trust Car
Page 34 and 35: Current Position: Inpatient Pressur
Page 36 and 37: Metric 3 - Venous Thromboembolism (
Page 38 and 39: Monthly CVC BSI Rates 14 12 Rate of
Page 40 and 41: Metric 8 - Nutrition & Hydration Ma
Page 42 and 43: Patient Safety Incidents As at 18 t
Page 44 and 45: Never Events Never Events are serio
Page 46 and 47: Existing Commitments and National P
Page 48 and 49: Patient Experience National In-pati
Page 50 and 51: An action plan has been developed f
Page 52 and 53: Maternity National Survey The respo
Page 54 and 55: Question Area Conclusions Recommend
Page 56 and 57: Case Study: Health Service Ombudsma
Page 58 and 59: Patient Experience Measures Patient
Page 60 and 61: • 100 Key Scores Comparison 90% 8
Page 62 and 63: NHS Great Yarmouth & Waveney NHS Gr
Page 64: Glossary of Abbreviations A&E C dif

Quality Account 2010/11 - James Paget University Hospitals

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