Annual Report Structure - Table of Contents
The following table details the outline structure for the Quality Account/Report 2014/15
Received
Confirmed as in progress
Not received
Section
Account
able
Person
PART 1: Statement on Quality from the chief executive of the NHS Foundation Trust
Statement on quality by the Chief Executive and introduction
Naomi
Blackwell
/Jennie
Hall
Dashboard - our priorities from last year
Naomi
Blackwell
PART 2: Priorities for improvement and statements of assurance from the board
Priorities for improvement in 2015/2016
Our 10 year strategy
Naomi
Blackwell
(Draft)
Naomi
Blackwell
Staff FFT
Liz
Woods
Developing the Quality Account
Naomi
Blackwell
London Quality Standards
Simon
McKenzie
Learning from other organisations
Jennie
Hall
Review of services
Directors
Research
Dan
Forton
Participation in clinical audits
Kate Hutt
Use of CQUIN payment framework
Imran
Hussain
Statement from CQC
Sal
Maughan
Data Quality
Tom
Dewar
Information governance toolkit attainment levels
Lech
Clinical coding error rate
Statements of assurance from the board
Tom
Dewar
Jennie
Hall
Part 3: Improving Patient Safety
Medication errors
Chris
Evans
Patient safety incidents
Maria
Prete
Patient falls
Yvonne
Connolly
Patient Safety thermometer
Yvonne
Connolly
Offender healthcare
Alison
Ludlam
Summary hospital-level mortality indicator
Kate Hutt
% patient deaths with palliative care coded at either diagnosis or specialty level
Kate Hutt
Risk assessed for venous thromboembolism
Imran
Hussain
C.difficile
Matt
Laundy
Patient safety incidents reported
Yvonne
Connolly
Part 4: Improving Patient Experience
Community learning disability referrals
Alison
Ludlham
Complaints
Sarah
Duncan
Responding to Patients Needs
End of Life Care (new for 2015/2016)
Imran
Hussain/
Tom
McGill
David
Flood/
Anneliese
Weichart
Part 4: Improving patient outcomes
Sexual health in secondary schools
Alison
Ludlham
Clinical outcome measures in community services
Alison
Ludlham
Patent Reported Outcomes Measures (PROMS)
Groin hernia surgery
Kate Hutt
Varicose vein surgery
Kate Hutt
Hip replacement surgery
Kate Hutt
Knee replacement surgery during the reporting period.
Kate Hutt
Clinical Records (new for 2015/2016)
28 days readmission
Jennie
Hall/Evon
Wheeler
Imran
Hussain
Part 5: Performance
Maximum time of 18 weeks from point of referral to treatment in aggregate - admitted C)
Martin
Wilson
Maximum time of 18 weeks from point of referral to treatment in aggregate - non-admitted C)
Martin
Wilson
Maximum time of 18 weeks from point of referral to treatment in aggregate - patient on an
incomplete pathway C)
Martin
Wilson
A&E: maximum waiting time of four hours form arrival to admission/transfer/discharge (D)
Martin
Wilson
All cancers: 62-day wait for first treatment (E) from:
Urgent GP referral for suspected cancer
Imran
Hussain
NHS Cancer Screening Service referral
Imran
Hussain
All cancers: 31-day wait for second or subsequent treatment (F), comprising:
Imran
Hussain
Radiotherapy
Imran
Hussain
Anti-cancer drug treatments
Imran
Hussain
Surgery
Imran
Hussain
PART 6 - Annex 1: Statements from commissioners, local Healthwatch organisations and
Overview and Scrutiny Committees
Wandsworth CCG (on behalf of local CCGs)
Sandra
Iksander
Wandsworth Council (OSC) Richard Wiles
Richard
Wiles
Healthwatch Wandsworth
Healthwa
tch
Healthwatch Merton
Healthwa
tch
Healthwatch Lambeth
Healthwa
tch
Statement to confirm stakeholders engaged with and internal assurance processes achieved
Naomi
Blackwell
PART 6 - Annex A : Clinical Audits
Participation in clinical audits
Kate Hutt
National clinical audits undertaken
Kate Hutt
Local clinical audits undertaken
Kate Hutt
PART 6 - Annex B : Assessment of compliance against London Quality Standards
Simon
Mackenzi
e