As part of an initiative to improve the quality of care within the North West Strategic Health Authority, five ‘quality markers’ (QMs) were measured in all adult admissions with pneumonia in all 23 Acute Trusts in the North West Region. Results for discharges for 30 months from October 2008 are presented. Data reporting was changed to match the financial year in 2009 so cohorts from October 2008-September 2009, October 2009-March 2010 and April 2010-March 2011 are presented. Only adults who fulfilled a prescribed definition of ‘pneumonia’ were included.

QMs were taken from a USA initiative and adapted for UK use. Patient identification was based on clinical coding. Data was recorded in each individual Trust and centrally collated.

Data on 31,972 pneumonia episodes were included (11,127, 6,683, 14,162 in each time period respectively). Mean results of % compliance for each variable for each Trust, together with standard deviation as a measure of variability across hospital sites, are presented in the Table for each cohort.

Initial compliance was worst for administration of smoking cessation advice and best for oxygenation assessment. While variability between hospitals was least for oxygenation it was greatest for the performance of blood cultures prior to antibiotic administration. Over the 3 cohorts overall compliance with QM assessment steadily improved for all QMs and variability between Trusts declined for all but smoking cessation advice.

Conclusions The Advancing Quality Programme has resulted in improved quality of pneumonia care as assessed by both the improvement in overall compliance and the reduction in inter-hospital variability.