Claremont Private Hospital. Quality Account April March 2016

Transcription

1 Claremont Private Hospital Quality Account April March 2016

2 Contents Welcome to Aspen Healthcare 4 Statement on Quality from the Chief Executive Aspen Healthcare 7 Introduction to Claremont Hospital 9 Vital Stats Statement on Quality 10 Accountability Statement Quality Priorities for Patient Safety Clinical Effectiveness Patient Experience Statements of Assurance 16 Review of NHS Services provided Participation in Clinical Audit Local Audits Participation in Research Goals agreed with Commissioners Statement from the Care Quality Commission Statements on Data Quality Quality Indicators Review of Quality Performance for Patient Safety Clinical Effectiveness Patient Experience External Perspective on Quality of Service 31

3 Welcome to Aspen Healthcare Aspen Healthcare Hospitals and Clinics locations: Claremont Hospital is part of the Aspen Healthcare Group. Aspen Healthcare was established in 1998 and is a UK-based private healthcare provider with extensive knowledge of the healthcare market. The Group s core business is the management and operation of private hospitals and other medical facilities, such as day surgery clinics, many of which are in joint partnership with our Consultants. Aspen Healthcare is the proud operator of four acute hospitals, two cancer centres, and three day-surgery hospitals in the UK. Aspen Healthcare s current facilities are: Cancer Centre London Wimbledon, SW London The Chelmsford Private Day Surgery Hospital, Chelmsford, Essex The Claremont Hospital, Sheffield The Edinburgh Clinic, Edinburgh Highgate Private Hospital Highgate, N London The Holly Private Hospital Buckhurst Hill, NE London Midland, Solihull Nova Healthcare, Leeds Parkside Hospital Wimbledon, SW London Aspen Healthcare s facilities cover a wide range of specialties and treatments providing consulting, diagnostic and surgical services, as well as state of the art oncological services. Within these nine facilities, comprising over 250 beds and 17 theatres, in 2015 alone Aspen has delivered care to: Over 42,000 patients who were admitted into our facilities Nearly 36,000 patients who required surgery More than 350,000 patients who attended our outpatient and diagnostic departments We have delivered this care always with Aspen Healthcare s mission statement underpinning the delivery of all our care and services: Our aim is to provide first-class independent healthcare for the local community in a safe, comfortable and welcoming environment; one in which we would be happy to treat our own families. Aspen is now one of the main providers of independent hospital services in the UK and through a variety of local contracts we provided nearly 20,000 NHS patient episodes of care last year. We work very closely with other healthcare providers in each locality including GPs, Clinical Commissioning Groups and NHS Acute Trusts to deliver the highest standard of services to all our patients. It is our aim to serve the local community and excel in the provision of quality acute private healthcare services in the UK and we are pleased to report that in 2015 our patient satisfaction ratings continued to be high with 99% of our inpatients rating their overall quality of their care as excellent, very good or good, and 97% responding that they were extremely likely or likely to recommend the Aspen hospital visited. Across Aspen we strive to go beyond compliance in meeting required national standards and excel in all that we endeavour to do. Although every year we are happy to look back and reflect on what we have achieved, more importantly we look forward and set our quality goals even higher to constantly improve upon how we deliver our care and services. Cancer Centre London The Chelmsford Claremont Hospital The Edinburgh Clinic Highgate Private Hospital The Holly Private Hospital Midland Eye Nova Healthcare Parkside Hospital MidlandEye Specialists in complete eye care 4 5

4 Statement on Quality from the Chief Executive Aspen Healthcare On behalf of Aspen Healthcare I am pleased to provide this Quality Account for Claremont Hospital - this is our annual report to the public and other stakeholders and focuses on the quality of services we have provided over the last year (April 2015 to March 2016). It also importantly looks forward and sets out our plan of quality improvements for the forthcoming year. Aspen Healthcare is committed to excelling in the provision of the highest quality healthcare services and in working in partnership with the NHS to ensure that the services delivered result in safe, effective and personalised care for all patients. Each year we review a set of quality priorities that we agreed we would focus on in the previous year s Quality Account. Our quality priorities form part of our quality framework which centres on nine drivers of quality and safety, helping ensure that quality is incorporated into every one of our hospitals/clinics and that safety, quality and excellence remains the focus of all we do whilst delivering the highest standards of patient care. This is underpinned by our Quality Strategy, centred on the three dimensions of quality: patient safety, clinical effectiveness, and patient experience. Over the past year there has been a change in the way healthcare organisations are externally monitored with the Care Quality Commission (CQC), England s health and social care regulator, introducing a new comprehensive inspection regime aimed at raising standards. We will continue to work closely with the CQC to ensure we continue to strive for excellence and continual improvement in the services we provide. This Quality Account presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience, and demonstrates that our managers, clinicians and staff at Claremont Hospital are all committed to providing continuous, evidence based, quality care to those people we treat. It provides a balanced view of what we are good at and where additional improvements can be made. In addition our quality priorities for the coming year, 2016/17, have been agreed with the Aspen Senior Management Teams and will be outlined within this report. The experience that patients have in all our hospital/clinics is of the utmost importance to Aspen and we are committed to establishing an organisational culture that puts the patient at the centre of everything we do. We are committed to monitoring all aspects of the patients journey within Claremont Hospital, providing our staff with the results of our patient feedback questionnaires so that they can drive improvement for the department they work in and for Aspen. I would like to thank all the staff who continually show commitment to the continuous improvements we have made to our patients care and experience. The majority of information provided in this report is for all the patients we have cared for in 2015/16 NHS and private. Des Shiels Chief Executive, Aspen Healthcare 6 7

5 Introduction to Claremont Hospital Claremont Hospital has been at the heart of the South Yorkshire community providing first class healthcare for 60 years. The hospital is situated in large landscaped grounds to the South West of Sheffield. The hospital was originally founded by the Sisters of Our Lady of Mercy, a religious institute which relocated from Ireland to Sheffield in The original hospital was opened in 1921 on a different site in Sheffield and moved to its current location in Claremont Hospital has been a proud part of Aspen Healthcare Group since January 2012 during which time significant investment has already supported extensive refurbishments and improvements to be made to patient and staff facilities. This work continues with 2015/16 attracting an additional 1.7M of investment to:- Open a new 6 bedded suite to provide dedicated accommodation for patients having day case surgery Refurbish a further 10 patient bedrooms to a high standard which is conducive to recovery as part of a rolling programme to refurbish all patient bedrooms Upgrading of the Radiology reception area to enhance the environment for patients attending diagnostic imaging Install a new hospital wide state of the art nurse-call system Remodel the Pharmacy department and upgrade the surrounding out-patient department area Refurbish consulting rooms to enhance the experience of patients attending out-patient appointments. Enhance the main car park entrance and increase car parking facilities. With just under 200 staff employed and 230 consultants with Practising Privileges [admitting rights], Claremont Hospital specialises in elective short stay surgery, welcoming both NHS funded patients and privately funded patients. The main surgical specialities we offer include orthopaedics, general surgery, plastic surgery, ophthalmology, gynaecology, urology and ENT. Our patients stay in hospital an average of 1 day and whilst we see a wide age range of adult patients the average age of our patients is 58yrs. Vital Stats Total beds 41 Enhanced care beds 4 Operating theatres 3 Consulting Rooms 13 Endoscopy Suite Pathology laboratory Physiotherapy Pharmacy MRI CT Ultrasound X-ray Private GP service Satellite clinics Choose and Book Free parking Accept all major insurers Consultant delivered service 24/7 Resident Medical Officer During 2016/17 we will continue to work hard to protect our reputation for safe, high quality care delivery and outcomes. Our organisational development ambitions for the forthcoming year, as detailed in this report, will continue to challenge us, driving us towards ensuring safety and quality is incorporated into everything we do. 8 9

6 Statement on Quality For the third consecutive year I welcome this opportunity to share with the public an honest account of our performance during the reporting period 2015/16, and to outline the future improvements we aim to make during 2016/17. With ongoing national attention on safety and quality failings in both the public and private healthcare sectors, we have invested heavily in our quality and patient safety agenda s during the course of the past few years. From the moment our patients arrive with us they become part of a long-standing community of people who have benefitted from more than sixty years of high quality diagnosis, treatment and care provided at Claremont Hospital. Today, as proud members of the Aspen Healthcare Group, we remain committed to the pursuit of excellence in all that we do and in continuing to develop and future-proof our services and premises in keeping with our organisation-wide culture of sustainable continuous improvement. Central to our success is our proactive and dynamic quality governance framework which we update each year to ensure it stays current and reflects best practice. We remain committed to providing our patients with the best possible treatment and outcomes within a clean and safe environment where evidence based care and practice is delivered at the right time, in the right way, by the right people. We continue to grow and develop our systems robustly to aid in demonstrating our accountability for continuously monitoring and improving the quality of our care and service delivery. Rejecting complacency has allowed us to have an enviable record on quality and safety. Weaknesses are identified and responded to promptly and openly so that we may maximise our learning from them. As we continue to learn more about the different ways in which we can improve, we place ourselves in a better position than ever before to critically analyse and apply realistic sustainable improvements through balanced investment. Our most important objective is to ensure our patients have a good outcome combined with a safe and positive experience when coming to our hospital. Listening to the experiences of our patients, their relatives and carers, is very important to us. Their feedback is valued and assists us in our drive to improve the quality, safety and clinical effectiveness of the services we provide services which we consistently strive to ensure are patient centred, accessible, focused on recovery, and services in which our patients are involved in their treatment and care enabling them to reach their full potential when they return home. Our outcomes, as published throughout this annual report, demonstrate our achievements and how we plan to keep improving. Our successes are only possible with the hard work, pride, skill and compassion of our staff together with their support and commitment to our vision and core values. Promoting quality at an operational level by empowering our staff to lead impactful safety and quality improvements is integral to improving patient experiences. Our staff work together collaboratively to address tangible issues for those we care for and it rewards us enormously to frequently be able to personally thank them when patients praise them for the care and attention they have received. During the coming year we will continue to build on the strong foundations we have laid whilst further embedding our shared organisational values and introducing new priorities to challenge us to maintain our practices beyond the minimum regulatory requirement. Accountability Statement To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate. Andrew Davey Hospital Director, Claremont Hospital Date: 30 th April 2015 This report has been reviewed and approved by: Chris Blundell, Medical Advisory Committee Chair, Claremont Hospital Robert Kerry, Quality Governance Committee Chair, Claremont Hospital Des Shiels, Chief Executive Officer, Aspen Healthcare Judi Ingram, Group Clinical Director, Aspen Healthcare I would like to thank the hospital for the way in which my health needs have been handled. The level of information provided about the procedure and the subsequent care and advice have all been exemplary. In my view, everything that a modern health service should provide. Mr S. Sheffield 10 11

7 Quality Priorities For National Quality Account guidelines require us to identify at least three priorities for improvement. Aspen s quality strategy outlines how we will progress a number of quality and safety initiatives for the forthcoming years and the following information provided focuses on our main priorities. These have been determined by our senior management team and are informed by feedback from our patients and staff, audit results, national guidance and recommendations from the various hospital/clinic teams across Aspen Healthcare. Our quality priorities are reviewed at our Aspen Quality Governance Committee which meets quarterly to monitor, manage and improve the processes designed to ensure safe and effective service delivery. Regular reporting on these priorities will also be provided to the Group Quality Governance Committee, to Aspen s Executive Team and Board of Directors, and also the commissioners of NHS services. Claremont Hospital is committed to delivering services that are safe, of a high quality, and clinically effective and we constantly strive to improve our clinical safety and standards. The priorities we have identified will, we believe, drive the three domains of quality - patient safety, clinical effectiveness and patient experience: Patient Safety This is about improving and increasing the safety of our care and services provided Clinical Effectiveness This is about improving the outcome of any assessment, treatment and care our patients receive to optimise patients health and well-being Patient Experience This is about aspiring to ensure we exceed the expectations of all our patients. Clinical Effectiveness Develop an Audit Tool to Review Cardiac Arrests/Calls Although we have very low numbers of cardiac arrests in our hospitals and clinics we wish to ensure that we utilise every opportunity to review and analyse all inhospital cardiac arrests and cardiac arrest calls so that we can use this information to inform and improve practice and policy. This new audit tool will assist us in collecting data and permit us to identify and promote improvements in the prevention, care delivery, and outcomes from cardiac arrest. Review and Improve Patients Fluid and Hydration Pathway The provision of optimum fluid is fundamental to good health. We aim to review our policies and procedures and ensure these support and reflect best practice guidance. This will include reviewing the assessment of the hydration status of our patients, intravenous (IV) fluid therapy practice, and the fasting of our patients prior to surgical procedures. We will ensure that there are robust processes in place to record all fluid intake and output for all patients who require this by developing our fluid recording charts and by providing staff training. We will audit the outcome of the changes we make via our integrated audit programme. The key quality priorities identified for are as follows: Patient Safety STEP- up to a Culture of Safety Programme We want all our Aspen hospitals and clinics to be recognised as having an outstanding standard of patient safety. As part of that ambition, we are starting a new programme in 2016 directed at all our staff and consultants which will invite us all to STEPup to a culture of safety. This will involve all our staff undergoing a training session in human factors which encompass all those factors which impact on our staff such as environmental, organisational and job factors, and individual characteristics that can influence people and their behaviour at work. The amount of training will be dependent on job role but our aim is that by working together we can come closer to our goal of eliminating all avoidable harm. Using our Patients Experience to Improve Safety Our patients experience is essential to understanding the impact of harm and how we would work together to improve safety. We plan to use various mechanisms, including a survey for patients. The survey will explore the perceptions of safety from a patient perspective, as we know little about how our patients actually feel about their treatment and if on occasions patients have felt unsafe and the reasons for this. With an improved understanding of our patients perceptions of safety we can use this to inform changes we need to make and support co-production of changes to service delivery. Every member of staff with whom I came into contact with was pleasant, cheerful and a pleasure to be looked after by. I would congratulate them all on the way that their demeanour positively influences the getting better feeling and is one of great encouragement. Mr B. Sheffield 12 13

8 Patient Experience Implement a Dementia Awareness Strategy With an aging population, the number of people in the UK living with, or at risk of, dementia is continuing to rise. We will implement a dementia awareness strategy across all our hospitals and clinics to foster staff awareness and an improved perception of dementia to help enhance the quality, safety and experience of our care to patients and families/carers affected by dementia. This will include a series of improvement projects, training for our staff, implementation of a dementia care pathway and developing ways in which we can assure those suffering from dementia, and their family/carers, that we provide dementia appropriate care. Ways to Improve Meaningful Patient Involvement and Engagement Patients are at the centre of the services we provide and we wish to explore how we can improve their involvement and have meaningful engagement with our patients. To achieve this we will implement a broad range of initiatives to encourage patient involvement. These will include reviewing how we can make it easier for our patients to feedback on their experience, improving patient information, including them in patient forums with our staff and inviting them to participate in the design, planning and delivery of any new services. While targeting the areas above, we will also continue to: Strive to further improve upon all our quality and safety measures Continue with our programme of development relating to other quality initiatives Continue to develop our workforce to ensure they have the skills to deliver high quality care in the most appropriate and effective way Embed our 2016/17 Commissioning for Quality and Innovation (CQUIN) initiatives so they become business as usual, and work to implement any locally agreed CQUIN s with our commissioners Meet and exceed the Quality Schedule of our NHS Contracts. Thoroughly professional hospital offering exceptional standards of care. Mr H. Sheffield 14 15

9 Statements of Assurance Review of NHS Services Provided This section of our Quality Account provides the mandatory information for inclusion as determined by Department of Health regulations, and reviews our performance over the last year between April 2015 and March 2016 but reported in June as required by the guidelines. Between April 2015 and March 2016, Claremont Hospital provided the following NHS services: Service Activity Ear Nose and Throat 401 General Surgery 3845 Gynaecology 929 Neurosurgery [spinal] 5101 Service Activity Ophthalmology 179 Orthopaedics 4740 Urology 200 Claremont Hospital has reviewed all the data available to them on the quality of care in all of these NHS services. The income generated by the NHS services reviewed in 2015/16 represents 100% of the total income generated from the provision of NHS services by Claremont Hospital for the year April 2015 to March Participation in Clinical Audit National clinical audits are a set of national projects that provide a common format by which to collect audit data. National confidential enquiries aim to detect areas of deficiencies in clinical practice and devise recommendations to resolve them. During April 2015 to March 2016, 1 national clinical audit and 2 national confidential enquiries covered services that Claremont Hospital provides. During that period Claremont Hospital participated in 100% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. The national clinical audits and national confidential enquiries that Claremont Hospital was eligible to participate in during April 2015 to March 2016 are as follows: National Joint Registry Sepsis Care of Patients with Mental Health Problems in Acute General Hospitals The national clinical audits and national confidential enquiries that Claremont Hospital participated in, and for which data collection was completed during April 2015 to March 2016, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry. National Confidential Enquiry Name of Audit Participation Number of cases submitted Sepsis Yes No case submissions were made as this was an organisational questionnaire. The organisational questionnaire was completed and submitted Care of Patients with Mental Health Problems in General Hospitals [Adult] Organisational Questionnaire Yes No case submissions were made as this was an organisational questionnaire. The organisational questionnaire was completed and submitted National Clinical Audits Name of Audit Participation Number of cases submitted National Joint Registry Yes 667 The reports of 2 national confidential enquiry reports were reviewed by the provider in April 2015 to March 2016 and Claremont Hospital has taken/intends to take the following actions to improve the quality of healthcare provided: A formal protocol for the early identification and immediate management of patients with Sepsis has been implemented and is supported with a Sepsis Six Pathway poster displayed in clinical rooms. Whilst Claremont Hospital is unable to accept emergency patient admissions resulting from gastrointestinal bleeding, consideration is being given to a protocol/pathway for the care of patients who may develop a gastrointestinal bleed whilst an inpatient having unrelated, planned surgery. All the staff were extremely efficient, friendly and caring. My room was lovely, clean, light and airy. I felt great support throughout what could have been a very stressful time. Miss P. Sheffield 16 17

10 Local Audits The following local clinical audits were reviewed by Claremont Hospital during April 2015 and March Most of the audits were undertaken at least 2 or 3 times within the reporting period, some more frequently: Audit Average % Compliance April 2015 March 2016 Venous Thromboembolism (VTE) patient risk assessments fully documented 88% Record Keeping documentation in clinical records compliant with national and 92% local standards and requirements Practicing Privileges documentation supporting the granting of practicing 91% privileges to consultants is accurate and up to date e.g. appraisal documentation Intentional Rounding documenting that patients are routinely visited by 68% 1 nursing staff each hour during the day and every 2 hours at night Early Warning System observations fully recorded to aid early detection of 94% potential deteriorating conditions Patient Falls patient risk assessments fully documented 97% Health Records Access Request a clear audit trail to monitor the progress and 67% 2 completion of Health Record Access requests Controlled Drugs (CD) accuracy of associated documentation and recording 93% Patient Consent consent process fully and accurately completed and recorded 79% 3 as per Aspen policy standards Safeguarding [Adults and Children] staff training completed 83% [WHO] Surgical Safety Checklist process accurately undertaken for every 94% patient having a surgical procedure Operating Theatre Traceability accurate recording of all equipment, 94% prostheses, and implants. 1 Of the 5 audits completed 2 scored over 80% 2 One audit has been completed. All the information was available but at the time it was not in a clearly auditable trail. This has since been rectified 3 100% of patients are consented prior to surgery Audit Consultant Visits consultants document their visits to review inpatients on a daily basis Pathology national and local standards met 87% Blood Transfusion Compliance national and local standards met 89% Physiotherapy- national and local standards met 92% Diagnostics national and local standards met 99% Resuscitation equipment checks fully and accurately recorded 92% Information Governance national and local standards met 96% Patient Led Assessment of the Care Environment [PLACE] see page 22 90% Patient Privacy and Dignity Audit interviews with randomly selected patients to understand if each patient believes they have been treated with dignity and respect and their privacy protected 15 Steps Challenge an observational study to understand how patients and visitors perceive the hospital environment within 15 footsteps of entering the facility Sit and See a comprehensive observational study to consider the approach by staff to the general care of patients, the level of patient/visitor engagement, and the environmental factors within patient reception areas Infection Prevention cleanliness of the hospital environment compliant with national standards Hand Hygiene hand washing facilities and practices compliant with national standards Average % Compliance April 2015 March % There is no compliance score associated with this audit There is no compliance score associated with this initiative 96% 96% 98% Surgical Site Infection preventative practices compliant with national standards 100% Peripheral Intravenous Devices practice compliant with national standards and 93% best practice Urinary Catheter practice compliant with national standards and best practice 99% Prophylactic Antimicrobial Prescribing and Usage 86% The service, treatment and care was more than excellent from first entering the hospital, during, and up to my leaving. My stay was made to run very smoothly, efficiently, with dignity, and without worries by everyone concerned. Mr P. Rotherham 18 19

11 The reports of 83 local clinical audits were reviewed by the provider in April 2015 to March 2016 and Claremont Hospital has taken/intends to take the following key actions to improve the quality of healthcare provided: Intentional Rounding - The Lead Nurse Inpatients has continued to give Intentional Rounding a high profile at ward level so as to increase the consistency of completion of the documentation by the ward nursing staff as this relatively new initiative continues to bed into daily practice culture Participation in Research The number of patients receiving NHS services provided or sub-contracted by Claremont Hospital in April 2015 to March Goals Agreed With Commissioners Claremont Hospital income in April 2015 to March 2016 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Statement from the Care Quality Commission All standards were being met when we inspected the service Claremont Hospital is required to register with the Care Quality Commission (CQC) and its current registration status is fully compliant and Claremont Hospital has no conditions imposed against registration. The Care Quality Commission has not taken Statement on Data Quality Claremont Hospital takes Data Quality very seriously and recognises that good quality information is fundamental to the effective delivery of patient care and is essential if Health Records Access Requests - The Medical Records Supervisor has developed a dedicated spreadsheet with which to capture data pertaining to the progress of access to health record requests where this information is not captured on the hospital s Patient Administration System Consent - An aide memoire was provided to all consultants when using the outpatient consulting rooms reminding them of the two stage consent process. As a result compliance scores improved from 69% to 93% during the course of the reporting period 2016 that were recruited during that period to participate in research approved by a research ethics committee was zero. Quality and Innovation payment framework because the hospital worked within different contracting arrangements. enforcement action against Claremont Hospital during April 2015 to March Claremont Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. improvements in quality of care and value for money are to be realised. We have voluntarily commenced submitting non-identifiable data to the Private Health Information Network [PHIN] an independent Information Organisation with a mandate to ensure that by 2017 patients using independent healthcare facilities will be able to access comparative performance measures including activity levels, length of stay, patient satisfaction, and rates of unplanned readmission, for both hospitals and individual consultants. This is another useful tool by which we can demonstrate Information Governance Toolkit attainment levels: The Information Governance Toolkit is a performance assessment tool produced by the Department of Health. It is a set of standards that organisations providing NHS care must complete and submit annually by 31st March each year. The toolkit enables organisations to measure their compliance with a range of information handling requirements, thus ensuring that confidentiality and security of personal information is managed safely and securely. Aspen Healthcare s Information Governance Toolkit Assessment Report overall score for 2015/16 was 75%, and was graded green, achieving level 2 in all categories and meeting national requirements Claremont Hospital has/will be taking the following actions to improve data quality: To maintain the latest release of our Patient Secondary Uses System (SUS) Claremont Hospital submitted records during April 2015 to March 2016 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included the patient s valid NHS number was: Clinical Coding Error Rate Claremont Hospital was not subject to the Payment by Results clinical coding audit the quality of our services and identify opportunities for improvement. Our data quality compliance with PHIN is 99.8%. Our Information Governance policies continue to inform our standards of record keeping which support and evidence the delivery of care and treatment. Records are regularly monitored for accuracy, completeness, and legibility, providing timely identification of quality issues and any remedial steps required. Administration System [PAS] software ensuring all upgrades and new fields are readily available to our staff to enter required information To install user friendly kiosks and handheld tablets enabling patients to enter Patient Satisfaction and PROMS data electronically. Further development of management reports to provide timely information to support and inform managers and to identify data quality issues as they arise To continue to review administrative procedures, particularly those conducted at reception desks, to ensure patient data is accurately captured at the right time To continue expanding our text messaging service to all of our inpatients and outpatients facilitating additional SMS Messages for improved patient information and reminders to complete and return post discharge questionnaires. 100% for admitted patient care; 100% for outpatient care. And which included the patient s valid General Medical Practice Code was: 100% for admitted patient care; 100% for outpatient care. during April 2015 to March 2016 by the Audit Commission

12 Quality Indicators In January 2013, the Department of Health advised amendments had been made to the National Health Service (Quality Accounts) Regulations A core set of quality indicators were identified for inclusion in the quality account. Not all indicator measures that are routinely collated in the NHS are currently available in the independent sector and work will continue during 2016/17 on improving the consistency and standard of quality indicators reported across Aspen Healthcare. A number of metrics have been chosen to summarise our performance against key quality indicators of effectiveness, safety and patient experience. Claremont Hospital considers that this data is as described in this section as it is collated on a continuous basis and does not rely on retrospective analysis. Claremont Hospital has taken the following actions to improve our data collection submissions, and the quality of its services, by working with the Private Healthcare Information Network (PHIN) which was launched in April Data is collected and published about private and independent healthcare, which includes quality indicators. Aspen Healthcare is an active member of PHIN and is working with other member organisations to further develop the information available to the public. See: When anomalies arise, each one of the indicators is reviewed with a view to learning why an event or incident occurred so that steps can be taken to reduce the risk of it happening again. The key learning from the above serious incident(s) includes: To revise the hospital protocol for the localisation of the intended level of spinal surgery To cascade Human Factors training to all levels and disciplines of staff To reinforce the importance of adherence to the National Early Warning Score [NEWS] escalation referral pathway To review fluid balance charts and ensure staff know how to always accurately record a patients hydration status Hospital Level Mortality Indicator and Percentage of Patient Deaths with Palliative Care Code This indicator measures whether the number of people who die in hospital is higher or lower than would be expected. This data is not currently routinely collected in the independent sector. Patient Reported Outcome Measures (PROMs) Patient Reported Outcome Measures (PROMs) assess general health improvement from the patient perspective. These currently cover four clinical procedures in the NHS and one clinical procedure in the independent sector and calculate the health gains after surgical treatment using pre and post-operative surveys. Number of Patient Safety Incidents, including Never Events Source: From Aspen Healthcare s incident reporting system: % of patient contacts % of patient contacts Serious Incidents 0 0% Serious Incidents % Serious Incidents resulting in harm or death 0 0% Serious Incidents resulting in harm or death % Never Events 0 0% Never Events % Total 0 0% Total % Patient Reported Outcome Measures [PROMs] [*presentation of the data is different for each year due to a change in the provider of the information] Hip replacement surgery: respondents who recorded an increase in their EQ-5D index score following operation Oxford Score Knee replacement surgery: respondents who recorded an increase in their EQ-5D index score following operation Oxford score 2014/15 [mean increase]* [Nationally = 0.437] 22.6 [Nationally = 21.4] 0.33 [Nationally = 0.31] 17 [Nationally = 16.1] Statistically insufficient data Statistically insufficient data Statistically insufficient data 2015/16 [percentage increase]* 97.3% Data not available 73.1% Data not available NB. All Never Events are also recorded as serious incidents. Complete satisfaction with my treatment and totally confident with the standard of care and attention I received. Groin hernia surgery: Varicose vein surgery: Cataract Surgery: Statistically insufficient data Statistically insufficient data Statistically insufficient Mr C. Derbyshire 22 23

13 Indicator Number of people aged 15 years and over readmitted within 28 days of discharge Number of admissions risk assessed for VTE Number of Clostridium difficile infections reported Number of patient safety incidents which resulted in severe harm or death Responsiveness to personal needs of patients Friends and Family Test - patients Friends and Family Test - staff Other Mandatory Indicators All performance indicators are monitored on a monthly basis at key meetings and then reviewed quarterly at both local and corporate level Quality Governance Committees. Any significant anomaly is Complaints Source CQC performance indicator Clinical audit report Patient experience is central to all our services and Claremont Hospital ensures that the information provided by patient s in letters of complaint is used as a valuable part of understanding and improving our carefully investigated and any changes that are required are actioned within identified time frames. Learning is disseminated through various quality forums in order to prevent similar situations occurring again. Actions to improve quality Whilst all three readmissions were clinically appropriate, strengthening of the discharge process has commenced and is soon to be supported by a dedicated Discharge Co-ordinator. HSIC data 99.5% 100% Maintain current process and practise From national Public Health England returns From hospital incident reports (Datix) Patient satisfaction survey data for overall level of care Patient satisfaction survey rated extremely likely/ likely Staff satisfaction survey % 98% 98% 97% 85% 83% Maintain current infection prevention and control measures The incident has been thoroughly and robustly investigated with a monitored action plan to implement supportive changes to prevent a similar situation occurring. To continue listening to our patients and striving to ensure that all our patients receive what they believe to be a high standard of good quality care To continue evolving our practices and service delivery to maintain our provision of first-class healthcare in a safe, comfortable and welcoming environment To continue working with our staff helping them to develop their ideas to support sustainable continuous improvement which benefit both patients and staff. patient s experience. Our aspiration is to ensure that letters of complaint are not simply viewed as a process to be managed but as a genuine opportunity to reflect, learn and improve our services further. Summary of complaints received Total of formal [written and verbal] complaints received 40 Number of complaints as a percentage of total patient contacts 0.06% Number of complaints upheld 20 [46%] Number of complaints partially upheld 10 [23%] Number of complaints not upheld 10 [23%] Complaints referred to the Independent Sector Complaints Adjudication Service [ISCAS] / Commissioners / Care Quality Commission /Ombudsman When complaints are received they are categorised in line with the national NHS KO41 categories. The content of many Summary of complaints received letters of complaint will often fall into more than one category. The breakdown from the complaints received is tabled below. Admission, discharge, transfer 10 All aspects of clinical treatment 23 Appointments/delay/cancellation 6 Attitude of staff 4 Communication, information 11 Personal records 1 The key trends arising from the complaints received include: Discharge process Nursing care Clinics running late Lack of patient information Key learning points and changes in practice which have resulted from the information contained in letters of complaint include: The review of some out-patient clinic times Non-slip socks provided for patients attending for Endoscopy An EIDO patient information leaflet has been amended to include post-operative urinary retention as a risk following spinal surgery The housekeeping team ensure the nurse call system is fully functioning in each patient room when cleaned on patient discharge A revised Discharge Checklist has been implemented In additional support to the actions already taken, as listed above, our key priorities during 2016/17 include: The appointment of a Discharge Nurse to co-ordinate and oversee the safe and efficient discharge of patients ensuring required home/community services are in place The introduction of post-discharge telephone calls to patients to ensure they are managing to optimise their continuing recovery at home Strengthening the proactive management of out-patient clinics to ensure patients are informed at an early stage if clinics are running late. An annual complaints report is produced each year and is available on request

14 Review of Quality Performance 2015/2016 This section reviews our progress with Aspen Healthcare s key quality priorities as identified in last year s Quality Account [2014/2015]. Patient Safety Safety Leadership Walkabouts Leadership walkabouts have been demonstrated to have a significant impact on safety culture and are a way of ensuring that senior management teams are informed first hand of any safety concerns by their own frontline staff. Progress: An Aspen toolkit and guide was developed to support the implementation of safety leadership walkabouts. Safety Leadership Walkabouts have now been completed by the Hospital Director and Director of Nursing and Clinical Services in six clinical departments across the hospital. Using a template of questions to ensure similar themes are addressed in each department, visits were planned at regular intervals throughout the year and were well received by staff. The aim of the Walkabouts is to capture concerns regarding any aspect of Safety which the staff may not have addressed through any other forum, and also to capture good news particularly relating to staff members who have gone the extra mile in executing their day to day duties. From the Safety Leadership Walkabouts the following changes have been, or are being, made: A newsletter produced by the Hospital Director called Dr s Orders is now regularly published to all staff to improve communication and help staff to keep abreast of changes and new initiatives The rate of pay for bank operating theatre staff was reviewed to continue ensuring consistent and safe staffing of the operating department in a consistent and safe manner An internal audit has commenced to facilitate a review of the operating theatre finish times. This will help to ensure staff are not routinely required to work at exceptionally late hours Computer network and connectivity issues have been resolved Some equipment replacement programmes have been brought forward Some aspects of fabric maintenance have been brought forward. The impact of Safety Leadership Walkabouts on the safety culture across the hospital has been realised and further Walkabouts are scheduled throughout the coming year Patient Safety Newsletter These newsletters aim to provide a vehicle to share best practice and learning across our hospitals, further improving our clinical safety and promoting a culture of safety and continuous learning. Progress: This priority was fully achieved with three editions of the newsletter published in 2015/16. These patient safety newsletters included topical issues, reinforced safety messages to our staff, and importantly shared the learning from serious incidents that had occurred across the Aspen group. Positive feedback was received from staff and the newsletters will continue to be published 3-4 times a year. The newsletters are forwarded electronically to each member of staff and also printed and displayed on each departments Hotboard where all key performance indicator information is also displayed and is updated monthly. The Hotboards are visually accessible to patients, relatives, visitors and staff. Datix Risk Register Rollout An effective risk management framework requires the identification of risks, their prioritisation, and actions required to reduce the likelihood of recurrence. The aim of implementing the Datix system risk register module was to support the recording and monitoring of risks more effectively. Progress: The Datix system risk register module was rolled out to all Aspen hospitals and clinics and now enables us to robustly record and track the risks at Claremont Hospital and the principal business objectives they threaten. Although this module still requires some embedding into practice great progress has been made with an improved oversight of identified risks now available. The risk register is reviewed at the Aspen Quality Governance and Quality Board meetings with the aim to now further develop this into an effective Board Assurance Framework. We currently have 40 risks identified in the register module and this is continually being added to. Heads of Departments review and report their top three risks at their monthly review meetings with the senior management team. The risk register is now an integral part Clinical Effectiveness Ward and departmental Datix Dashboards rollout The aim of this quality priority was to provide staff with near time meaningful information on reported clinical indicators to help inform their daily decisions on the quality of patient care. Progress: Ward and department based Datix dashboards of measures have been developed and these are now available to provide information on the effectiveness of care and key quality metrics. Each month we publish key performance indicator information on Hotboards displayed in each department. These boards are visually of the hospitals Senior Management Team annual assurance programme and has been particularly useful in aiding the prioritisation of capital spending. Implement a VTE Root Cause Analysis Toolkit Venous thromboembolism (VTE), which includes deep vein thrombosis and pulmonary embolism, is a recognised complication in patients admitted into hospital. A root cause analysis (RCA) approach will help to ensure an understanding of any factors that led to an incidence of pulmonary embolism/deep vein thrombosis. Progress: An Aspen VTE root cause analysis toolkit was developed and launched last year and now supports a systematic and evidence based approach to undertaking investigations of all confirmed cases of VTE. There was only one episode of VTE (pulmonary embolism) last year and the toolkit was used to guide the investigation. Staff awareness of this toolkit has been raised via our electronic policy and procedure system Netconsent and also via meeting fora. accessible to patients, relatives, visitors and staff. The monthly display of information includes a table of all adverse incidents reported during the previous month. Currently the hotboard displays help us to identify trends but we also plan to start using this information more dynamically now that the concept is more embedded within our culture. Not only will trend analysis continue but we will begin to apply realistic improvement goals to relevant key performance indicators to continue driving quality and safety improvements. We will also be asking our patients and visitors if they find the displayed information to be an effective method of communicating with them

15 Core Clinical Training Programme Our clinical staff need to be supported to develop and maintain their skills to provide the best possible care to our patients. Progress: We developed and implemented a new core training programme comprised of key modules and seminars to support our frontline clinical staff in developing and building upon their clinical skills and knowledge. This included competency based foundation training in critical care, clinical skills updates, training in the professional context of care delivery and a clinical leadership four day programme. These evaluated extremely well and the programme will continue in 2016/17. To date a total of 17 members of our clinical staff have attended one or more modules and more staff are scheduled to attend forthcoming training dates. Arising from the Clinical Leadership programme one of the changes we have implemented in practice is the introduction of the Serious Adverse Blood Reactions and Events [SABRE] tool. This is an on-line system supporting haemovigilance across the UK by allowing submission of notifications and confirmations of blood transfusion related adverse events and adverse reactions PROMs to Private Patients Patient Reported Outcome Measures (PROMS) collect information on the effectiveness of care delivered to patients as perceived by the patients themselves, based on responses to questionnaires before and after surgery. The NHS PROMs programme is well established and in we planned to roll out PROMS to all our patients (NHS and private) for certain surgical procedures to complement our existing information on the quality of services and patient outcomes. Progress: PROMS to private patients was successfully extended to include private patients for cataract, knee replacement, hip replacement and groin hernia surgical procedures. Data on PROMS is included in this Quality Account. This has extended our existing information on the quality of services and patient outcomes. We have plans in place to begin collecting information from patients by providing them with access to electronic tablets in individual kiosks where they will be able to securely enter their information in private with technical help and support from staff if needed. We are also continuing to work closely with three consultants who have been involved at a national level in setting up PROM s data registry s for patients having spinal surgery and ankle surgery. We look forward to including these specialities within our PROM s collection in the near future. From reception to departure I was treated with respect and professionalism. The treatment and support was exceptional at every level. Mr A. Derbyshire Patient Experience Embedding our Values Improving our Patients Experience After developing our values [Beyond Compliance; Personalised Attention; Investing in Excellence, Partnership and Teamwork; Always with Integrity] with our staff, we planned in 2015/16 to further embed these into our hospital culture in order to distinguish ourselves from other healthcare organisations. Progress: We have now successfully launched Our Values Workshops that aim to engage, inform and train our staff how they should go about their work always demonstrating positive behaviours and attitudes that truly reflect our values. In 2015 we successfully recruited 25 Values Partners from across the business, representing each Aspen facility and then as a collaboration developed a one day bespoke workshop centred around living our values day in day out. Our target is for all staff, regardless of their level or role in the organisation to attend a workshop. Our first aim is to achieve 85% attendance in 2016 across Aspen Healthcare and we are well on the journey to achieve this. To date a total of 75 members of staff at Claremont Hospital have attended an Our Values Workshop. This represents 41.5% of our hospital staff. Further workshops are scheduled during We anticipate that we will easily reach and surpass our 85% attendance goal. Implement Practice Observational Tools In wishing to assure ourselves that our patients have an excellent experience of care in our hospital and understand what good quality care looks and feels like from a patient s perspective we proposed to introduce tools to support us in observing clinical practice so that we could capture those elements of care that make such a difference to our patients. Progress: Using the sit&see TM and Fifteen Steps Challenge tools all Aspen facilities undertook regular sessions observing the care environment and interactions with our patients. These have proven to provide excellent examples of care delivery and also permitted us to make recommendations on where to improve certain aspects of care based on the observational findings. Staff (including our non-clinical staff) were trained in the use of the observational tools and these have really provided us with insight information from our patients perspective providing important insights into the difference staff interactions can make to patient care, compassion, dignity and respect. We have now completed two Fifteen Step Challenges. The assessors in the most recent assessment of the care environment included our Hospital Director, Director of Nursing and Clinical Services, Lead Nurse Inpatients and two non-clinical people from separate partner organisations. The assessment covers four domains: Welcoming, Safe, Caring and Involving, and Well organised and calm. Overall, the team were very impressed with the calm and friendly atmosphere and commented that this belied the fact that the ward area was fully occupied and busy with three operating lists in progress. From all the positive comments made, four required further action which have now all been completed: 28 29

16 the Patient Information Guide has been completely re-formatted, updated, and professionally printed and is located in each patient room. It now includes information relating to visiting times which was previously not included hand hygiene sanitisers located around the hospital site for use by relatives, visitors and staff now have instructions for use beneath the company logo printed on them a Welcome to the Ward sign has been installed at the entrance to the ward area as part of an ongoing programme to refresh signage across the hospital site Hotboards, displaying key performance information, and Staff on Duty information boards are now prominently displayed adjacent to the main reception area in the ward and can be easily viewed by patients, relatives, visitors and staff. We have also completed two sit&see TM observational studies, one in our main hospital reception area and one in our outpatient reception area. The study acknowledges all interactions between staff, patients and visitors, as well as the environmental ambience created by the reception staff. In both studies the environment was pleasant, clean and tidy with a relaxed and calm atmosphere. A good number of positive actions and interactions were noted during both studies. The overall percentage score from both audits was 96% with the individual reception areas scoring 97% and 95% respectively. As these tools provide such valuable information and feedback we are actively increasing our numbers of trained observers so that we can undertake additional practice observation sessions throughout the coming year. Increase Friends and Family Test Response Rates The national Friends and Family Test (FFT) is a feedback measure of our patient experience and asks if people would recommend the services they have used to their friends and family if they needed similar care or treatment. It can be used alongside other data to continuously improve the services we offer, reinforce exemplary standards of care, and improve care where improvement is needed. We worked to improve our response rates to try and ensure this really was a representative reflection of our patient s experience. Progress We worked to encourage our patients to complete our surveys stressing how important their feedback was to us and in assisting us in improving our services. We aimed for at least 15% of our eligible patients to respond. Our response rates at the end of 2015 compared well with those at the end of 2014, with nearly 25% of our inpatients responding. This now helps us in ensuring that the feedback obtained is representative and, having added an additional text box seeking the reason for giving the response they have to the FFT question this permits us to act in confidence on the results in making positive changes that improve our patients experience. In encouraging our patients to complete our surveys we reformatted the wording and presentation of our welcome letter which is in every patient room prior to admission and which includes reference to our survey. We also engaged our nursing staff, ward clerks, and ward hostesses to remind our patients of the value we place on their feedback. Our newly appointed Discharge Co-ordinator will also have a role to play in highlighting the importance of our surveys to patients just prior to their discharge. In the very near future we also plan to be able to provide patients with electronic tablets with which to complete our survey. Over the past two years our response rate has remained consistent, ranging between 23% and 26%. Our aim is to strive to improve these figures year on year. External Perspective on Quality of Services Statement from NHS Sheffield Clinical Commissioning Group For a number of years NHS Sheffield Clinical Commissioning Group (CCG) has had contact with Claremont Hospital in relation to the provision of NHS elective care, managed under the conditions of the NHS Standard Contract. This has been and continues to be a very positive business relationship where we have been able to constructively discuss any issues that have arisen and practically resolve in a timely manner. The Director of Clinical Services has provided the clinical support to the contract and again has worked in a very positive way to respond to clinical issues according to the contract requirements. NHS Sheffield CCG has had the opportunity to review and comment on the information in this quality account prior to publication. Claremont Hospital has considered our comments and made amendments where appropriate. The CCG is confident that to the best of its knowledge the information supplied within this account is factually accurate and a true record, reflecting the Hospital s performance over the period April 2015 March The CCG supports the work areas involved within the Hospital s identified three Quality Improvement Priorities for 2016/17 Patient Safety, Clinical Effectiveness and Patient Experience. Submitted by Beverly Ryton on behalf of: Tim Furness Director of Delivery and Rachael Hague Contracting Lead NHS Sheffield Clinical Commissioning Group 13th May

17 Statement from NHS Hardwick Clinical Commissioning Group NHS Hardwick CCG has completed its review statement in accordance with the National Health Service (Quality Accounts) Amendment Regulations 2012 and is pleased to confirm that the necessary data requirements have been included and as far as can be determined the commentary and data presented are an accurate and honest reflection of progress made at Claremont Hospital in improved service delivery and patient outcomes. This is a clear and wellstructured Quality Account and outlines the key service areas and achievements and developments across the year. Commissioners welcomed the performance improvements within Claremont Hospital during 2015/16 and are pleased to see how well services within Aspen Healthcare are performing overall. We commend the organisation on their continued work in improving outcomes and communicating with service users, careers and the public. The 2015/16 priorities Claremont Hospital exceeded or excelled in were: Datix Risk Register Rollout and the rollout of Ward and department based Datix dashboards: implementation of a risk management framework to identify risks, their prioritisation and actions required to reduce the likelihood of recurrence. The aim of implementing the Datix system risk register module was to support the recording and monitoring of risks more effectively. Core Clinical Training Programme: development and implementation of a new core training programme comprised of key modules and seminars to support frontline clinical staff in developing and building upon their clinical skills and knowledge. Implement Practice Observational Tools: Use of the sit&see TM and Fifteen Steps Challenge tools to understand what good quality care looks and feels like from a patient s perspective. There were no national or local Commissioning for Quality and Innovations (CQUIN) in April 2015 to March 2016 due to the hospital working within different contracting arrangements. 2016/17 Quality Priorities Hardwick CCG supports the quality improvement priorities identified by Claremont Hospital for the coming year. The six objectives for 2016/17 are aligned with the five key lines of enquiry as defined by the Care Quality Commission. These are: Patient Safety STEP- up to a Culture of Safety Programme Using our Patients Experience to Improve Safety Clinical Effectiveness Develop an Audit Tool to Review Cardiac Arrests/Calls Review and Improve Patients Fluid and Hydration Pathway Patient Experience Implement a Dementia Awareness Strategy Develop Ways to Improve Meaningful Patient Involvement and Engagement In conclusion, Hardwick CCG can see that the organisation puts the patient at the forefront of its service provision and proactively ensures that quality is a key priority area. The CCG thanks the organisation for the opportunity to comment on this document and supports Aspen Healthcare s quality priorities for 2016/17 which aims to further improve the quality and experience of services for patients, carers and their families and staff. Yours sincerely Phil Sugden Deputy Director of Quality NHS Hardwick CCG I am over the moon about the treatment I have received and more than happy to come back to have my other hip replaced. Mr L. Sheffield 32 33