Programme of Work
ISD's quality improvement programme holds and maintains a growing range of projects in Scotland, summary information on the Quality Improvement work streams can be found here:
(For more information on each work stream, please click on the title to go to the work stream website.)
Quarterly HSMR
Since December 2009 Information Services Division (ISD) has produced quarterly hospital standardised mortality ratios (HSMR) for all Scottish hospitals participating in the Scottish Patient Safety Programme (SPSP). The aim of the SPSP is to reduce hospital mortality by 15% by December 2012.
Surgical Profiles
NHS Quality Improvement Scotland (NHS QIS) and the Information Services Division (ISD), together with a clinically led group, have developed a report called a surgical profile. The profile presents a suite of clinical indicators about the surgical care provided by an NHS Board, and is a tool designed to help the NHS Board monitor and continuously improve the quality, safety and effectiveness of surgical care.
Scottish Audit of Surgical Mortality SASM
The Scottish Audit of Surgical Mortality (SASM) is unique in the United Kingdom. SASM identifies all deaths that occur in hospital under the care of a surgeon, whether an operation has taken place or not. eSASM is to be launched on 5th January 2011.
Scottish Renal Registry SRR
The Scottish Renal Registry is a national registry of patients with renal failure and other renal disorders in Scotland.
All NHS Renal Units contribute fully.
Scottish Arthroplasty Project (SAP)
The aim of the Scottish Arthroplasty Project (SAP) is to encourage continual improvement in the quality of care provided to joint replacement surgery (arthroplasty) patients. This is currently achieved through the auditing of routinely collected SMR01 national data in Scotland.
Scottish Audit of Intracranial Vascular Malformations SAIVMs
SAIVMs is a national clinical audit, which is the result of a multicentre, multidisciplinary collaboration between representatives of the four Scottish neuroscience centres, other relevant specialists throughout NHS Scotland, patients, and general practitioners (GPs). SAIVMs evaluates health services for patients with IVMs.
The MS Register (MSR)
The aim of the MSR is to establish the incidence of MS in Scotland and so enable service evaluation and improvement for those newly diagnosed.
The Musculoskeletal (MSk) Audit
The Musculoskeletal (MSk) Audit provides data to complement the work of various hospital time-to-treatment teams by identifying rate-limiting steps for orthopaedic treatment. This will help orthopaedic departments meet their December 2011 Referral to Treatment target of patients waiting no longer than 18 weeks from receipt of a referral (e.g. from a GP) until starting treatment.
Scottish Trauma Audit Group (STAG)
The Scottish Trauma Audit Group (STAG) was set up in 1991 to audit the management of seriously injured patients in Scotland. It achieved its aims and stopped collecting trauma data in 2002. Since 2002, the team has worked on a range of national audit projects, most recently completing a SEPSIS Audit. The team are re-auditing trauma from January 2011.
Scottish Intensive Care Society Audit Group (SICSAG)
The aim of SICSAG is to improve the care of ICU AND HDU patients by systematic, comprehensive audit of their management and outcome.
Scottish ECT Accreditation Network (SEAN)
SEAN has taken a central role in ensuring that there is a continued process of clinical audit and monitoring of all NHS ECT sites in Scotland. All centres that administer ECT participate in on-site accreditation visits.
The Scottish Stroke Care Audit (SSCA)
SSCA was established in 2002 and now includes all hospitals managing acute stroke in Scotland. Since its inception, SSCA has helped to drive the improvements in stroke care which have contributed to the reduction in mortality rates and improved outcomes for stroke patients.
Statistical Process Control
The tutorial guide, which is available on the Clinical Indicators Website, provides an introduction to the application of run charts and control charts for identifying unusual behaviour in healthcare processes. SPC techniques are a tool for highlighting this unusual behaviour.
