Quality report 2021-2022

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00 Quality Report cover	1
Quality report 2021-2022 vs 9 FINAL with feedback	2
Part 1: Statement on quality from the Chief Executive	2
Part 2: Priorities for improvement and statements of assurance from the board	4
2.1 Quality priorities for 2021/22	4
1. Improving Pressure Ulcer Management	4
2. Improving patient safety and experience during a national pandemic through the use of digital technology	4
3 Improving the Pharmacy Experience	4
2. Improving patient safety and experience during a national pandemic through the use of digital technology	6
Introduction	6
Future Developments	6
 Patient Communications	6
 Electronic Medications	7
 Electronic Referrals	8
2.2 Our quality ambitions for 2022/23	10
The Quality Improvements in the hospital are underpinned by our Quality Plan which was rolled over for 2021/22. A new quality plan is being developed for the coming year 2022/23. The driver diagram below sets out our overarching ambitions:	12
2.3.2 Participation in clinical audits and national confidential enquiries	13
2.3.3 Participation in clinical research	15
2.3.4 Quality goals and the CQUIN framework	15
2.3.5 Care Quality Commission	15
2.3.6 CQC Responsive Inspection	15
2.3.7 CQC Inspection Programme	15
2.3.8 Data Quality	15
2.3.9 Information Governance	16
2.3.10 Payment by Results / Information Governance	16
2.3.11 Data quality	16
2.3 Reporting against core indicators	18
Part 3: Other Information	23
Patient experience	23
PLACE Assessment	23
Patient experience stories to the Board	24
The Christie CODE	24
Quality Strategy 2017 – 2020	25
The Christie Quality Mark	26
Friends and Family Test	27
National inpatient survey 2020/21	27
Safer Staffing	29
3.1. Clinical Indicators - Patient Experience	30
Complaints	30
Complaints survey	31
The Christie has routinely sent complainants a questionnaire since August 2013 asking their views on how their complaint was handled and their opinion of the complaint response. The questionnaire was redesigned in August 2015 in line with The CQC repo...	31
Unfortunately, the complaints survey was temporarily put on hold during the covid-19 pandemic and therefore there is very little data this financial year to feedback from patients about the handling of their complaint and complaint response.	31
However, the feedback we have received has been positive overall with patients feeling that the Trust was understanding of their complaint and appropriate measures were put in place to resolve their issues and prevent them from happening again in the ...	31
As of 1st April 2022, the process for sending out complaints questionnaires has resumed.	31
Learning from Complaints 2021/22	31
3.3 Clinical indicators - Clinical Effectiveness	33
3.3.1 One and Five Year Cancer survival	33
3.3.2 Survival rates for 30 days post chemotherapy treatment, 90 days post radical radiotherapy treatment and 30 days post palliative radiotherapy treatment.	36
MRSA bacteremia	37
MRSA % appropriate elective patients	37
3.4.2 Healthcare acquired infections - Clostridium Difficile	37
3.4.3 Incidents Management	38
Patient Safety Incidences	39
3.4.4 Serious Incidents	39
3.4.5 Duty of Candour	39
3.4.6 Never Event	40
3.4.7 Pressure Ulcers	40
3.4.8 Local Clinical Audits	41
4. NHS Staff Survey	41
The Christie NHS Foundation Trust Wilmslow Road	51
www.facebook.com/TheChristieNHS	51

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