The performance of the Trust against its financial and activity targets is outlined in the bi-monthly Finance and Performance Report, which has already been mentioned in Class 3 of this Publication Scheme. As indicated in Class 4 of the scheme, the minutes of the Finance and Planning Sub-Committee are available.

A full report is made to the Trust Board midway through the financial year and at the end of each financial year on how the Trust is performing against its Corporate Objectives and this will be made available on the Trust's website at www.wirralhealth.org.uk.

The Department of Health annually (usually in July) produces a range of performance indicators against which every Trust is measured. There are 9 key targets to be achieved and 36 "balanced scorecard" targets that focus on clinical and patient related issues as well as capacity and capability. The performance indicators for the current financial year can be found on the Department of Health's website at www.chi.nhs.uk Wirral Hospital Trust has achieved the highest 'three star' rating for two consecutive years, 2002 & 2003.

Clinical Governance - Maintaining and Measuring Quality within the Trust
Wirral Hospital Trust aims to provide high quality health care services at all times and we are doing this through the introduction of a framework called Clinical Governance. Clinical Governance is designed to help organisations and individuals constantly monitor and improve standards of care through a number of agreed Clinical Governance Standards (some of which are identified in Class 8 as well as details on how to obtain copies of them) and quality assurance systems:

Clinical Audit
The Trust has a Clinical Audit Strategy, the aim of which is to promote cross Directorate multi-disciplinary audits which will lead to improved patient outcomes. A copy of the strategy can be obtained from the Clinical Practice Research Unit Co-ordinator*. Directorates within the Trust undertake a large number of audits on a regional and national level and these are recorded on a trust-wide database to enable the sharing of good practice. An annual report is produced which gives details of all the audits conducted within the Trust. A copy of this can be obtained from the CPRU Co-ordinator*.

Patient Confidentiality
The Caldicott Guardian, currently the Medical Director* plays an active role in ensuring that the aims of the Trust do not put patient confidentiality at risk. A Code of Conduct has been developed to encourage consistency and uniformity in the way information is generally handled across the NHS organisations in Wirral. A copy of this document can be obtained from the Caldicott Support Officer*.

Further developments of Caldicott within the Trust include the production of a patient information leaflet focusing on the proposed uses of information and a copy of this leaflet can be obtained from the Caldicott Support Officer*.

Benchmarking
The Trust is involved with a number of benchmarking sources designed to allow comparisons of performance in relation to other similar Trusts. The Trust works mainly with the Department of Health National Clinical Indicators and an external company CHKS Benchmarking that provides the Trust with information relating to workload and clinical indicators.

Controls Assurance
Controls Assurance is designed to ensure the protection of any patients, staff or visitors against harm. The Trust has a Controls Assurance Executive Committee who meet to discuss progress against the Controls Assurance Standards and to produce action plans. Minutes of these meetings can be obtained by contacting the Head of Risk Management*.

The table below represents the arrangements that the Trust has in place to address issues of corporate and clinical governance.

Ensuring Patient Safety
The Trust has a legal and moral duty to the patients in its care to ensure their safety and well being is not compromised as a result of hospital activities, processes or procedures. The Trust is committed at all times to this and has a Risk Management Department that deals with issues around potential risks. The Trust has a Risk Management Policy and a Health & Safety Policy but the cornerstone of risk management is the incident reporting system, which allows for the collection and analysis of incident data designed to alert the Trust to any specific problem areas. The system is supported by an Incident Reporting Policy that is available to all staff and training sessions and seminars are provided for all medical and support staff. Details on how to obtain copies of the policies mentioned can be obtained in Class 8 and any further information on the role of risk management is available from the Head of Risk Management*.

As referred to in Class 6, the Trust has a comprehensive cleaning service and works with Patient Environment Action Teams (PEAT) to continually improve the cleanliness and environment of its hospital sites through audit and inspection processes and self-assessment. The Trust has a PEAT Inspection Working Group who meet to discuss any issues related to agreed quality control standards. More information on PEAT and the performance of Wirral Hospital against the standards can be obtained by visiting the PEAT website at www.cleanhospitals.com

Clinical Negligence Scheme for Trusts
The Trust is a member of the Clinical Negligence Scheme for Trusts (CNST), which is operated by a Special Health Authority called the NHS Litigation Authority. Their website can be found at www.nhsla.com. The Scheme pools the financial risk of clinical negligence claims across all NHS Trusts in membership. Discounts on premiums can be achieved if the Trust complies with the various risk management standards of the scheme and currently Wirral Hospital has achieved Level Two compliance. For more information about CNST you can contact the Head of Risk Management*.