Contents Part 1 Introduction – Page Overview Chief Executive’s 3  introduction What we do the services we provide 4  – Our vision and values 8  Part 2 Priorities for improvement and statements of assurance – from the board Review of Quality Account 2017/2018 Introduction 10 Priorities for Improvement 10 Review of Quality Priorities 2017/2018 and our performance 10 Quality Priorities for 2018/2019 and how we will achieve them 20 Participation in Clinical Audits 29 NICE Quality Standards 31 Research 33 CQUINS 35 Care Quality Commission Inspection and action delivery 37 Hospital Episode Statistics 38 Information Governance Toolkit attainment levels 39 Data quality 39 Learning from patient deaths 40 Patient Activity 42 Mandated quality indicators 45 Patient Reported Outcome Measures (PROMs) 47 Reducing harm from infection 49 Mortality outcomes SHMI 52 – Venous Thromboembolism (VTE) 53 Friends and Family Test Patients 54 – Friends and Family Test Staff 55 – Part 3 Other Information – Patient Safety Falls 56 Pressure Ulcers 57 Preventing deterioration 59 Sepsis 61 Medicines Management 63 Managing patient safety incidents and duty of candour 65 Seven Day Service 68
Contents Part 1 – Introduction Page Overview  Chief Executive’s introduction 3  What we do – the services we provide 4  Our vision and values 8 Part 2 – Priorities for improvement and statements of assurance from the board Review of Quality Account 2017/2018 Introduction 10 Priorities for Improvement 10 Review of Quality Priorities 2017/2018 and our performance 10 Quality Priorities for 2018/2019 and how we will achieve them 20 Participation in Clinical Audits 29 NICE Quality Standards 31 Research 33 CQUINS 35 Care Quality Commission Inspection and action delivery 37 Hospital Episode Statistics 38 Information Governance Toolkit attainment levels 39 Data quality 39 Learning from patient deaths 40 Patient Activity 42 Mandated quality indicators 45 Patient Reported Outcome Measures (PROMs) 47 Reducing harm from infection 49 Mortality outcomes – SHMI 52 Venous Thromboembolism (VTE) 53 Friends and Family Test – Patients 54 Friends and Family Test – Staff 55 Part 3 – Other Information Patient Safety Falls 56 Pressure Ulcers 57 Preventing deterioration 59 Sepsis 61 Medicines Management 63 Managing patient safety incidents and duty of candour 65 Seven Day Service 68