The Annual Quality Statement
In line with the expectations set out in Together for Heath for absolute transparency on performance, action 10 of the Quality Delivery Plan for the NHS in Wales requires all NHS organisations to publish an Annual Quality Statement,beginning in 2012/13. This should form part of the organisation’s annual report.
Who and what is an Annual Quality Statement for?
The organisation’s Annual Quality Statement is first and foremost for the public. It provides an opportunity for the organisation to let its local population know in an open and honest way how it is doing to ensure all it services are meeting local need and reaching high standards. It should therefore bring together each year, a summary highlighting how the organisation is striving to continuously improve the quality of all the services it provides and commissions in order to drive both improvements in population health and the quality and safety of healthcare services. This provides a mechanism for Boards to routinely:
- assess how well they are doing across all services, including community, primary care and those where other sectors are engaged in providing services, including the third sector
- identify good practice to share and spread more widely
- identify areas that need improvement
- track progress, year on year
- account to the public and other stakeholders on the quality of its services and improvements made.
This needs to encompass all six domains of quality: safety, effectiveness, patient/user centredness, timeliness, equity and efficiency.
This approach should assist organisations in ensuring the quality of services are scrutinised and debated and areas for improvement are identified and prioritised in an open and transparent way. As well as service users, patients and citizens, other stakeholders and Government should be assured that the organisation is committed to continuously improving what it does.
What should a Statement look like?
It is important that the Annual Quality Statement is presented in a way that can immediately be understood by those who use the services and recognised by staff, primary care and other providers. To ensure national consistency in approach, some elements of the statement content are mandatory,but most should be determined locally to ensure that it fully captures local priorities. This is described in more detail in the next section. Overall the statement needs to provide an open and honest account of progress and priorities for improvement and provide assurance that the organisation is meeting standards, improving user experience and outcomes and reducing inequalities. It should signpost the reader to more detailed reports on service specific areas, including progress against individual service specific delivery plans as well as areas involving cross-cutting work with other partners.
What does it need to cover?
The Annual Quality Statement will combine an element of looking back at what has happened and been achieved with a forward look building on data and information used in that review. In looking back the Quality Delivery Plan suggests that Boards should seek to answer the following questions:
- Are we meeting standards and delivery requirements and are we improving outcomes?
- Are we genuinely seeking to understand the patient/user experience and is it improving?
- Are we meeting or exceeding our improvement goals?
- Are we being open and learning from error and concerns?
This exercise provides an opportunity for the organisation also to recognise and mitigate risk to achieving high quality care and be honest about performance. It should also enable Boards to identify and celebrate areas of local innovation in service delivery and transformation to ensure spread and sustainable improvement as well as areas where partnership working is key to success.
Boards should use the outcome of this exercise to determine the focus and priority for improvement in the coming year.
A suggested template, highlighting areas where a consistent approach needs to be adopted by all NHS Wales organisations is attached at annex 1.
Accessible to all
The Annual Quality Statement is a public document. It should therefore be presented in a way which is accessible to all.Organisations may want to consider using a number of ways to ‘tell their story’ It could include a mix of case studies, patient stories as well as quantitative date presented clearly and succinctly, signposting the reader to more detailed or technical information as required. It should provide a balance between positive information and acknowledgment of where services need to improve.
Publishing the Annual Quality Statement
Annual Quality Statements must be published electronically on the organisation’s website. However hard copies should be made available on request. Organisations should also take into account the needs of their local population and consider making the statement available in other formats or languages where there is a need to do so, considering going beyond meeting the legal requirements in such matters.
In 2012/13 the Annual Quality Statement should be published no later than 30 September 2013. In future years it is anticipated that the timing will be brought forward and in line with the annual accounting timetable and aligned with its governance statement. Updated guidance will be issued next year.
Organisations may choose to issue a baseline Annual Quality Statement for 2011/12.
Assuring the Annual Quality Statement
The Board is accountable for the organisation’s Quality Statement and must therefore assure itself through its internal assurance mechanisms, including internal audit, that the information published is both an accurate and representative picture of the quality of services it provides and the improvements that it is committing to. The Chair and Chief Executive will need to include a statement confirming this. Organisations may also wish to include endorsements from other stakeholders, such as the Community Health Council when agreeing their statement.
In future years the level of assurance may be subject to external scrutiny and audit by bodies such as Healthcare Inspectorate Wales
Review and next steps
As this is the first year that organisations are expected to publish a Quality Statement, Welsh Government will work with NHS organisations to evaluate the process and make improvements for future years. This process will be overseen by the National Quality and Safety Forum.
Annual Quality Statement
Statement from the Chair and Chief Executive
Part 1: Looking back
This should provide a summary of the achievements and challenges over the past year. As a minimum it should cover the following elements as well as any locally determined content.
The Standards for Health Services should be used as the framework to describe how the organisation knows that it is operating to the required standards across all it services including those provided in primary care, community settings and by other organisations on its behalf
i.e. is it doing the right thing, in the right place with the right staff at the right time etc
This should include a:
- summary of any external reviews/investigations of the organisation in the past year and actions taken
- description of the workforce profile and challenges e.g. actions taken in response to recruitment difficulties etc
- where relevant, a description of action taken in response to Quality Triggers
b)Providing high quality safe services and improving outcomes
To include a summary of:
- achievements and challenges across individual service delivery plans and local population health priorities, including health protection activities. This section may need to signpost to more detailed reports for some areas e.g. cancer, stroke, mental health, public health, primary care etc
- the organisation’s participation in national clinical audit and clinical outcome reviews and how the findings are driving improvement.
- achievements and challengesin meeting local improvement priorities , including learning from mortality and harm reviews, 1000 Lives Plus work streams etc
c)Improving patient /user experience
To include a summary of how the organisation:
- is user/patient centred, including actions to engage users/patients in their own health care decisions.
- is listening and responding to patient/user feedback, including Community Health Councils.
- is responding to local feedback through tools such as the fundamentals of care audits, GP quality outcome framework patient experience measures.
- learning from using patient stories
d)Being a learning organisation
This section should describe how the organisation listens and learns can demonstrate improvement in user/patient experience and staff satisfaction. This should include:
- Putting Things Right –
- summarise learning from concerns, including incidents and claims, Public Services Ombudsman Wales reports, Coroner rule 43 reports and signpost to their annual PTR report
- Compliance with patient safety alerts
- Details of any Never Events and action taken
- Using and enabling staff to participate inResearch and Innovation to drive improvement
- Responding to staff feedback and surveys.
Part 2: Looking forward
This section should set out how the organisationhas used this process to identify areas for focus and its improvement priorities for the coming year. It should also describe how it will track progress during the year and take action to mitigate risk where there may be areas giving cause for concern.
Seeking views and comments
The document should also be seen as a tool for engagement. Organisations may wish to engage with its stakeholders or partners in agreeing the final statement. This could include endorsements from others. It should also include details of how the reader can contact the organisation to comment on the statement or to seek further information