Highgate Private Hospital. Quality Account April 2016 March 2017

Transcription

1 Highgate Private Hospital Quality Account April 2016 March

2 Contents Welcome to Aspen Healthcare 4 Statement on Quality from Aspen Healthcare s Chief Executive 7 Introduction to Highgate Private Hospital s Quality Account 9 Statement on Quality 10 Accountability Statement Quality Priorities for Patient Safety Clinical Effectiveness Patient Experience Statement of Assurance 14 Review of NHS Services Provided Participation in Clinical Audit Participation in Research Goals Agreed with Commissioners Statement from the Care Quality Commission Statement on Data Quality Quality Indicators Review of Quality Performance for Patient Safety Clinical Effectiveness Patient Experience External Perspectives on Quality of Service 26 3

3 Welcome to Aspen Healthcare Highgate Private 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 specialist 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 Eye, 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 19 theatres, in 2016 alone Aspen has delivered care to: over 45,000 patients who were admitted into our facilities for surgery 300,000 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. 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, comprising nearly 45% of our patient numbers. 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 2016 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 they 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. Aspen Healthcare Hospitals and Clinics locations: Cancer Centre London The Chelmsford Claremont Hospital The Edinburgh Clinic Highgate Private Hospital The Holly Private Hospital Midland Eye Nova Healthcare Parkside Hospital 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. MidlandEye Specialists in complete eye care 5

4 Statement on Quality from Aspen Healthcare s Chief Executive Thank you for the wonderful treatment I received. All the staff were very kind and helpful. Ms ES (September 2016) Welcome to the Quality Account, which describes how we did this year against our quality and safety standards. On behalf of Aspen Healthcare I am pleased to provide the annual Quality Account for Highgate Private Hospital. This report focuses on the quality of services we provided over the last year (April 2016 to March 2017) and importantly, looks forward and sets out our plans for further quality improvements in the forthcoming year. At Aspen Healthcare we aim to excel in the provision of the highest quality healthcare services and work in partnership with the NHS to ensure that the services delivered result in safe, effective and personalised care for all our patients. Each year we review the quality priorities we agreed in the previous year s Quality Account. Our quality priorities form part of Aspen s overall quality framework which centres on nine drivers of quality and safety, helping to ensure that quality is incorporated into every one of our hospitals/ clinics and that safety, quality and excellence remain the focus of all we do, whilst delivering the highest standards of patient care. This is underpinned by Aspen s Quality Strategy, which focuses on the three dimensions of quality: patient safety, clinical effectiveness and patient experience. The past year has seen nearly all our hospitals/clinics externally inspected by the Care Quality Commission (CQC), England s health and social care regulator. These comprehensive inspections have provided external validation of the quality and safety of care we deliver and I am pleased to report that all our hospitals/clinics to date have been rated as Good, with our staff commended for their kind and compassionate care. This Quality Account presents our achievements in terms of clinical effectiveness, safety and patient experience, and demonstrates that our managers, clinicians and staff at Highgate Private Hospital are all committed to providing the highest standards of quality care to those patients we treat. The Account aims to provide a balanced view of what we are good at and where additional improvements can still be made. In addition, our quality priorities for the coming year ( ), as agreed with the Aspen Senior Management Team, are outlined within this report. In we saw further improvements made to our patient safety and experience, with patients consistently telling us the experience they have at our hospital/clinics is of the highest standard. We will remain committed to monitoring all aspects of our patients experience within Highgate Private Hospital, ensuring this feedback is effectively utilised to continue to drive quality improvements. I would like to thank all the staff who everyday show commitment to our high standards and contribute to the continuous improvements we make to our patients care and experience. The majority of information provided in this report is for all the patients we have cared for during both NHS and private. Des Shiels Chief Executive, Aspen Healthcare 7

5 Introduction to Highgate Private Hospital Situated in the heart of North London, Highgate Private Hospital has been established for more than thirty years and has been a part of Aspen Healthcare Group since Highgate Private Hospital prides itself on high standards of nursing care, a friendly atmosphere, and continual investment in medical technology, staff, training and facilities. The hospital consists of forty three luxury en-suite patient bedrooms, four fully-equipped operating theatres, a minor operating room, endoscopy unit, eleven outpatient consulting rooms, Private GP services and an on-site pharmacy for both in-patient and outpatient dispensing. Highgate Private Hospital is proud to build on its legacy of serving patients with first class private healthcare for over thirty years and welcomes all patients, whether NHS, insured or paying for their own treatment. During , 34,731 patients attended for outpatient care, 5,356 came for day case surgery and 1,780 were treated as in-patients. Vital Statistics Total beds 43 In-patient and day case beds 41 Enhanced care level 1 beds 2 Total theatres 4 Consulting rooms 11 Endoscopy suite Pathology Physiotherapy Pharmacy Private GP services MRI CT Ultrasound X-ray Parking Recognised by all major insurers 24/7 Resident Medical Officer or Doctor onsite Highgate Private Hospital participates in the NHS e-referral Service, allowing patients to choose their healthcare provider ShockwaveTM therapy available WorldHost Business Status in customer service Association of Perioperative Practice accreditation LaingBuisson 2016 Awards Finalist Nursing Practice. 9

6 Statement on Quality Quality Priorities for Highgate Hospital is proud to present its fourth Quality Account report for the financial year Our commitment to quality is evidenced by our high quality performance and aspiration to continually improve all outcomes and experiences for our patients. Highgate Private Hospital strives to provide effective leadership to all staff in the hospital, to ensure that all services provided are Accountability Statement Directors of organisations providing hospital services have an obligation under the 2009 Health Act, National Health Service (Quality Accounts) Regulations 2010 and the National Health Service (Quality Accounts) Amendment Regulation (2011) to prepare a Quality Account for each financial year. Mark Hawken Hospital Director This report has been reviewed and approved by: both safe and compliant with regulatory requirements while meeting our customers expectations. This report has been prepared based on the guidance issued by the Department of Health setting out these legal requirements. To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate. Date: 2nd May 2017 Dr Voi Shim Wong, Medical Advisory Committee Chair, Highgate Private Hospital Christine Etherington, Quality Governance Committee Chair, Highgate Private Hospital Des Shiels, Chief Executive Officer, Aspen Healthcare Judi Ingram, Group Clinical Director, Aspen Healthcare. 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 for These priorities were agreed with 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 regularly reviewed by our Aspen Quality Governance Committee which meets quarterly to monitor, manage and improve the processes designed to ensure safe and effective service delivery. Highgate Private Hospital is committed to delivering services that are safe, of a high quality & 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. 1. Patient Safety Improving and increasing the safety of our care and services provided. 2. Clinical Effectiveness Improving the outcome of any assessment, treatment and care our patients receive to optimise patients health and well-being. 3. Patient Experience Aspiring to ensure we exceed the expectations of all our patients. The key quality priorities identified for are as follows: Patient Safety Involving patients in monitoring hand hygiene The hands of healthcare workers and other staff working in clinical areas can become contaminated with micro-organisms during the course of their duties. Hand hygiene by healthcare workers (HCW s) is the leading measure in preventing the transmission of healthcare acquired infections. Inviting patients to report on staff hand hygiene will be a useful intervention in assuring compliance. A proforma will be developed for patients to complete to record staff compliance with hand hygiene practice and the results fed back to staff. This initiative will complement our existing hospital-based hand programme and develop further our patient-centred safety initiatives. Patient Safety Survey Our patients experience is essential to understanding the impact of harm and how we would work together to improve safety. Building upon the work we developed last year in providing patients with information on how to keep safe whilst an in-patient/day case, we plan to introduce a patient survey that will explore their perceptions of safety, as we know little about 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. 11

7 Clinical Effectiveness Improve Practical Training Compliance Ensuring our staff have undertaken training to support them in their roles is a priority. In order to ensure that the care delivered is at its most efficient and effective, we aim to increase our focus on training compliance of face-to-face practical training sessions for all our staff, to complement our comprehensive elearning suite of training programmes. Highgate Private Hospital will develop an annual practical training programme and report quarterly back on this to its senior management team and Governance committee. Implementation of Cosmetic Clinical Quality Indicators (CQIs)/Q-PROMs (Patient Reported Outcome Measures) As a cosmetic surgery provider we will work towards collecting clinical outcome measures developed by the Royal College of Surgeons. CQI s will be routinely collected for all cosmetic surgical procedures and help provide outcome measures for cosmetic surgery that can be published at individual surgeon and provider levels. Capturing more accurate information about the demographics of patients having cosmetic surgical procedures will enable more consistent audit and quality improvement, permitting activity and outcomes to be monitored whilst supporting improved patient choice and informed decision-making. Cosmetic surgery-specific PROMs, called Q-PROMs, will be completed by patients pre- and post-operatively allowing for a measurement of change in how patients feel, which is then attributable to the surgical intervention. As well as providing patients with information, Q PROMs will be able to be utilised to benchmark outcomes at a service and clinician level against national averages and will help us improve our services and standardise care. Patient Experience Implement Online Patient Survey Data Collection Patient satisfaction is at the heart of our business, with patient feedback being very important to us in informing how we are doing and highlighting areas that require further focus to enhance our patients experience. In 2017 we will move to complement our paper surveys with online electronic surveys that will permit timely capture of this information, permitting real time monitoring and the ability to respond to patient feedback more promptly. Implement Patient Post Discharge 48-hour Telephone Calls To further enhance our patients experience of discharge from our hospital, we will continue with follow-up telephone calls. These calls should support patients and their families after discharge from the hospital, improve patient and family satisfaction and decrease hospital re-admission rates. Patients identified will be called 48-hours after discharge by a member of the clinical staff. These phone calls will review each patient s health status and arrangements for follow up appointments, as well as permit clarification of any further/new questions. 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 Commissioning for Quality and Innovation (CQUIN) initiatives so they become business as usual, and work to implement any locally agreed CQUINs with our commissioners Meet and exceed the Quality Schedule of our NHS Contracts. I have just come home from the best hospital experience with The Highgate Hospital. From the moment I arrived I was put at ease Ms R.B (Feburary 2017) Quality Priorities for

8 Statements of Assurance Review of NHS Services Provided During April 2016 to March 2017, Highgate Private Hospital provided and/or subcontracted 3,067 patients in the following specialty NHS services: Speciality Anaesthetics (Pain Management) ENT Endoscopy General Surgery Gynaecology Orthopaedic (spinal) Podiatry Trauma and Orthopaedics Urology Highgate Private 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 represents 100% of the total income generated from the provision of NHS services by Highgate Private Hospital for April 1st 2016 to March 31st There have been 0 healthcare associated infections at Highgate. Participation in the Aspen Safety STEPup to Safety campaign, including Human Factors training by all staff, will assist in compliance on all aspects of the WHO Surgical Safety Checklist. Review all Consultants with practising privileges and ensure compliance with Aspen s practising privileges criteria. Review of physiotherapy service at Highgate Private Hospital to ensure a consistent quality service is maintained and provided to our patients. Develop an annual plan for Hand Hygiene audit and ensure all Infection Prevention & Control (IPC) Links have received training. AUDIT Average % Compliance April March 2017 Patient Falls 100% Venous Thrombosis Embolism (VTE) 100% Patient Consent - consent process accurately completed and recorded 98.5% Record Keeping 98% Controlled Drugs 95.5% Surgical Safety 100% Surgical Safety Observational 100% Participation in Clinical Audit National 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. The national clinical audits and national confidential enquiries that The Highgate NATIONAL CLINICAL AUDITS Private Hospital was eligible to participate in, and for which data collection was completed during April 2016 to March 2017, is as listed below. This national clinical audit was reviewed by the provider in April 2016 to March The Highgate Private Hospital responded to any statistical anomalies and no further action was required. National Early Warning Score (NEWS) Chart 99% Practising Privileges 89.5% Consultant Visits 100% Traceability 99.6% Resuscitation 98.75% Safeguarding 100% Information Governance 98.5% Intentional Rounding 99.5% Diagnostics 96% Imaging Safety 97.5% Name of Audit Participation Number of cases submitted National Joint Registry Yes 63 Physiotherapy 92.5% Transfusion Compliance 98.75% Local Audits The reports of twenty five local clinical audits were reviewed by the provider for April 1st 2016 to March 31st 2017 and Highgate Private Hospital intends to take the following actions to further improve the quality of healthcare provided: Continue with clinical emergency scenario training to ensure staff maintain their skills in this area. Work towards 100% compliance in intentional patient rounding (planned checks by nursing staff) with regular spot checks of in-patient records by the clinical management team. Ensure each patient receives a copy of their consent form by making it a routine step in the patient s preparation for theatre. Infection Prevention and Control (IPC) Standards 100% Surgical Site Infection Audit 100% IPC Environment & Clinical Practice Audit 100% Urinary Catheter Audit 92% Peripheral Vascular Devices Audit 92% Hand Hygiene Audit 88% 15

9 Participation in Research There were no NHS patients recruited during the reporting period for this Quality Account to participate in research approved by a research ethics committee. Goals Agreed with Commissioners A proportion of Highgate Private Hospital income in was conditional on achieving quality improvement and innovation goals agreed between Highgate Private Hospital and their NHS Commissioners, through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for 2016/2017 and for the following 12 month period are available electronically at cquin/cquin-16-17/. The hospital put a strong emphasis on providing safe, effective and quality care for patients and launched a number of initiatives to support staff in providing safe care. Statements of Assurance Statement from the Care Quality Commission Highgate Private Hospital is required to register with the Care Quality Commission (CQC) and its current registration status is able to provide the following activities: Treatment of disease, disorder or injury; Surgical procedures; Diagnostic and screening procedures. The Care Quality Commission has not taken any enforcement action against Highgate Private Hospital during April 2016 to March 2017 and has not participated in any special reviews or investigations by the CQC during the reporting period. Highgate Private Hospital was last inspected by the CQC in December 2016 and awarded the hospital an overall rating of Good. We received an Outstanding rating in the Wellled domain and Good for the Safe, Effective, Caring and Responsive domains. Areas noted for outstanding practice were: There was a clear statement of vision and values, driven by safety and quality. The hospital had a well-defined strategy underpinned by the vision and values. The hospital had a clear and robust governance structure. Governance focused on improving patient safety, learning from patients experience, improving clinical effectiveness and patient experience There was a good incident reporting culture, with a robust investigation and learning from incidents process The hospital monitored patient safety on a day-to-day basis Feedback from patients who use the service was consistently positive and people received care at the service without delay. The CQC found the culture within the hospital to be one of openness, transparency and willingness to learn and improve. Staff reported they were happy and proud to work for the hospital. Areas noted for improvement were: Address the nursing staff vacancies in the outpatients and diagnostic imaging Ensure there is an effective system for checking that consultants with approved practising privileges underwent the appropriate checks when working at the hospital Ensure cleaning products are stored in locked cupboards as required by the Control of Substances Hazardous to Health Regulations 2002 (COSHH). An improvement plan is in place to ensure these areas are addressed. Statement on Data Quality Highgate Private Hospital recognises that good quality information underpins the effective delivery of patient care and is essential if improvements in quality of care are to be made. We ensure that our Information Governance policies guide and inform our standards of record keeping, supporting the delivery of care and treatment and that accuracy, completeness and validity of these records are monitored on a monthly audit basis to continually improve data quality. Highgate Private Hospital will be taking the following actions to further improve data quality: Use of a professional accredited Clinical Coder to meet the requirements of the NHS contract. Regular reviews of the data reports submitted to the Secondary Uses Service to correct omissions and/or errors in data. Introduction of a specific role within the Contracts department dedicated to cross checking all NHS tracker data to ensure accuracy. To maintain the latest release of our Patient Administration System (APAS) software ensuring all upgrades and new fields are readily available to our staff to enter required information. Continue to offer technical support to our Consultants in the on-line use of the APAS patient administration system secure view of clinic and operating lists, when they are not at the hospital site. Regularly review all aspects of patient administration processes to ensure patient data is accurately captured at all times. Information Governance Toolkit attainment levels: The Information Governance Toolkit is a performance assessment tool, produced by the Department of Health, and is a set of standards the organisations providing NHS care must complete and submit annually by 31 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 effectively. Aspen Healthcare s Information Governance Assessment Report overall score for was 76% and graded satisfactory, meeting national Level 2 requirements. Secondary Uses System (SUS) Highgate Private Hospital submitted records during 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: 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. Clinical Coding Error Rate Highgate Private Hospital was not subject to the Payment by Results clinical coding audit during by the Audit Commission. 17

10 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 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. Highgate Private Hospital considers that this data is as described in this section as it is Number of Patient Safety Incidents, including Never Events Source: From Aspen Healthcare s incident reporting system: % of patient contacts collated on a continuous basis and does not rely on retrospective analysis. Highgate Private Hospital has taken action 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 % of patient contacts Serious Incidents % Serious Incidents % Serious Incidents % Serious Incidents % resulting in harm or death resulting in harm or death Never Events % Never Events % Total % Total % NB. All Never Events are also recorded as serious incidents so there is a duplication as reported above. Serious Incidents are events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant a comprehensive investigation to be completed. Never Events are a sub set of serious incidents that have been classified by NHS England. They have the potential to cause serious patient harm or death and are deemed largely preventable if comprehensive safety safeguards had been effectively put in place. Incident reporting is a key element of Highgate Private Hospital s patient safety programme. There is a real commitment to learn from any actual (or potential) error to reduce the likelihood of the incident reoccurring, and of any future harm to our patients. Recognising and reporting any incident (or near miss) is the first step to learning and all our staff are encouraged to report these. Incidents are classified by degree of harm (or potential to harm). We undertake robust investigations of all serious incidents (using a human factors and system-based approach), and also investigate those incidents that have resulted in low or no harm if they had the potential to cause harm. These investigations are undertaken in an open and transparent approach with our patients. We take our responsibility to be honest with our patients (Duty of Candour) very seriously and are committed to acknowledging, apologising and explaining when things do go wrong. The key learnings from the above serious incident(s) were: Improvement in the method of theatre staff allocations to ensure the person completing the allocations is trained to complete the task and has all the required information at their disposal to complete this task. Requirement for a system to be in place in relation to the set-up of instruments and consumables in theatre in the days prior to an operating list. The importance of outlining a process and engaging theatre staff in the development and implementation of the implant verification process. The safety culture has been improved through further education and awareness regarding following procedure, importance of prompt time and attendance, and challenging practice. Theatre scheduling to be formalised to ensure that staffing levels can be planned accordingly, reducing the reliance on staff to complete overtime. This also assists in planning shift patterns to meet operating schedules. 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 calculate the health gains after surgical treatment using pre and post-operative surveys. Patient Reported Outcome Measures [PROMs] Hip replacement surgery: % of respondents who recorded an increase in their EQ-5D PROMs index score following operation Knee replacement surgery: % of respondents who recorded an increase in their EQ-5D PROMs index score following operation No Data 100% (89.4% nationally) No Data 100% (81.4% nationally) Groin hernia surgery: No Data 72.7% (50.9% nationally) Statements of Assurance 19

11 Other Mandatory Indicators All performance indicators are monitored on a monthly basis at key meetings and then reviewed quarterly by both local and corporate level Quality Governance Committees. Any significant anomaly is 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. Friends and Family Test - patients Friends and Family Test - staff Patient satisfaction survey rated extremely likely/likely Staff satisfaction survey 97% 98.3% Emphasis on improving intentional rounding on patients to ensure regular contact between the clinical staff and the patient. 68% N/A Survey staff once every two years and review response 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 Source CQC performance indicator Clinical audit report Actions to improve quality 6 16 All re-admissions are reported, investigated and reviewed through the hospital s incident reporting system. Trend analysis is undertaken each quarter and if any trends are found these are addressed with the specific Consultant by the Medical Advisory Committee (MAC) Chair and the Hospital Director. All data is shared at the local and corporate Governance Committee and MAC. CQUIN data 100% 100% Emphasis placed on maintaining the standard set in the previous year. VTE risk assessment and education commenced at pre-admission assessment and completed as a routine part of the admission process. From national Public Health England/Scotland returns 0 0 Continue regular Infection Prevention & Control audits of the clinical environment quarterly. Any episodes of suspected or confirmed infections are escalated and investigated with an appropriate root cause analysis. Infection Prevention and Control A robust structure is in place at Highgate Private Hospital for monitoring Infection Prevention and Control (IPC) in the hospital environment. A clinical IPC Lead oversees all processes relating to IPC, with a local IPC Committee meeting held quarterly. This is led by the IPC Lead and a Consultant Microbiologist, reporting directly to the Group Nurse Consultant for IPC, and into the Aspen Group IPC Committee. Trained IPC Link Practitioners are based in every clinical area, and are proactive in managing the environment to ensure that cleanliness, sterility and clinical practice is optimised at all times. Activity and monitoring includes regular inspections of the clinical and non-clinical environment, auditing processes for clinical practice, and also investigation into occasions when infections or other IPC issues have been identified. Hand hygiene is a key element of IPC, with hand hygiene training and audits completed regularly. Other IPC audits include monitoring of surgical site infections, urinary catheter-associated infections, peripheral vascular devices and wound surveillance for joint replacement procedures. Identified actions that resulted from audits include improved documentation for peripheral vascular devices, and environmental improvements to clinical areas (improved storage). Infection MRSA positive blood culture 0 0 MSSA positive blood culture 0 0 E. Coli positive blood culture 0 0 Clostridium difficile hospital acquired infections 0 0 Number of patient safety incidents which resulted in severe harm or death From hospital incident reports (Datix) 0 0 No incidents that resulted in severe harm or death during the reporting period. Reporting of all incidents and near misses is actively encouraged with a focus on completing thorough investigations to ensure processes and systems are reviewed and changes made where appropriate. Responsiveness to personal needs of patients Patient satisfaction survey data for overall level of care 96% 97.5% Continued monitoring of visits to patients (intentional nurse rounding) to ensure regular contact between clinical staff and the patient. Review of all patient complaints and in-patient surveys at quarterly Governance meetings with action plans formulated to address improvement areas identified. Statements of Assurance 21

12 Complaints Highgate Private Hospital seeks to ensure that every opportunity is taken to make changes following all feedback, concerns and complaints to improve the care and services received by patients, users and their representatives. When a complaint is received by the Hospital Director it is his responsibility to establish whether any immediate and/or remedial action(s) should be taken prior to the investigation - in the interest of safeguarding safety and quality. All complaints are shared with the department/individual/head of Department named in the complaint to ensure full investigation/learning/remedial actions can be put in place as appropriate. Indicator Number of Complaints % per 100 admissions 1.8% 1.7% Key learning and changes made as a result of complaints: Complaint reports are regularly developed and taken to the Senior Management Team, Medical Advisory Committee, Head of Department and local governance meetings as well as the Patient Experience meeting & Focus Panel in order that staff constructively discuss complaints received in their areas of responsibility as part of our clinical governance processes. This encourages the sharing of any lessons that are learned and an improved understanding of the impact the experience has had on individual patients. Changes have been made throughout the year in response to issues raised and these include: Changes to the responsibilities of booking pre-assessment appointments has resulted in the clinical team having greater oversight of the patient pathway and has led to better pre-planning for surgery. This has resulted in decreased surgery cancellations for preventable reasons. A daily operational meeting is now scheduled each morning for all key services to attend. At this, all departments discuss the current day and the forecasted days ahead to ensure all departments have the appropriate staffing levels for the predicated work load. This also provides an opportunity for the core services to discuss any issues relating to the current day. The hospital has clarified its admission and exclusion criteria to ensure that all Consultants referring patients to the hospital refer patients that are clinically suitable. Providing this clear guidance has prevented patients starting a pathway through the hospital when they are not clinically suitable, and thus will improve their health care experience. The Hospital Director and the Director of Nursing, Clinical Services & Governance have met with all Consultants in relation to feedback received from patients about their Consultant s conduct. Consultants are reminded that they must demonstrate behaviours in line with the Aspen s organisational values. Pain management issues, including pharmacological and nonpharmacological, have been discussed at the hospital Practice Development Group meeting, with plans in place to improve staff education on pain management. The new staff orientation programme on the ward is being reviewed to ensure all new staff are competent in pain management techniques prior to independently taking a patient case load. Complaints regarding the hospital s facilities often mentioned the poor Wi-Fi service, especially for in-patients. As a result the hospital has now upgraded the ageing Wi-Fi system. I was very impressed by the staff,... I felt at ease and made to feel very comfortable. Patient feedback survey April 2016 Statements of Assurance 23

13 Review of Quality Performance This section reviews our progress with the key quality priorities we identified in last year s Quality Account. Patient Safety STEP-up to Safety Programme Aspen s aim is for all our facilities to be recognised as having an outstanding standard of patient safety and in 2016 we implemented a new training programme for all staff called STEP-up to Safety. This innovative programme explores safety behaviours and engages staff in helping them understand their own role in our safety culture. Progress: Our staff attended a Safety Culture training session centred on human factors led by the Group Medical Director and Group Clinical Director. Heads of Department, Team Leaders and clinical staff also attended further training to support our aim that, by working together to establish a robust safety culture, we can come closer to our goal of eliminating all avoidable harm. Using our Patients Experience to Improve Safety This involved working in partnership with our patients to improve their safety. An improved understanding of our patients perceptions of safety would help to inform any improvements required & support co-production of changes to service delivery and our safety. Progress: A patient information leaflet Making your stay with us safe: simple steps to keep yourself safe has been developed, outlining some steps that patients can take to help contribute to assuring their own safety with us. The leaflet includes information on aspects of care such as correct identification; preventing infections; medicines safety and discharge advice. The senior team at Highgate Private Hospital have agreed on how to best disseminate the leaflet to ensure all patients have the opportunity to review the leaflet at the beginning of their admission. The leaflet was launched in early 2017 and will be followed up with a patient survey exploring their perceptions of safety. Clinical Effectiveness Develop an Audit Tool to Review Cardiac Arrests/Calls Although there are a very low number of cardiac arrests in our hospital we commenced collecting audit data to permit us to identify and promote improvements in the prevention, care delivery and outcomes from cardiac arrest. Progress: We have developed and implemented a new audit tool to ensure we utilise every opportunity to review and analyse any cardiac arrests and cardiac arrest calls to inform and further improve practice and policy. We have also added a bi-annual audit of cardiac arrests to our audit programme. Due to the low number of cardiac arrests, regular scenarios are carried out by the Resuscitation Officer to ensure all staff remain competent. Staff are encouraged to report any incidents where the crash team is called, even if it is in error, so that effective monitoring of the cardiac arrest procedure can take place. Patient Experience Implement a Dementia Awareness Strategy With an ageing population, the number of people in the UK living with, or at risk of, dementia is continuing to rise and we wished to review our practice to ensure this supported the quality, safety and experience of our care to patients and families/carers who are affected by dementia. Progress: We have developed and implemented a Dementia Strategy across all our hospitals and clinics and worked to raise staff awareness to ensure they have an improved perception and understanding of dementia, to enhance the care they provide. This has included the introduction of Dementia Champions in each hospital/clinic, staff training, awareness information leaflets, dementia resource folders, overview at staff induction, and the implementation of a Dementia Care pathway. We have also registered with the Alzheimer s Society s Dementia Friends programme and Review and Improve Patients Fluid and Hydration Pathway In ensuring the provision of optimum hydration to our patients, we aimed to review our policies to ensure these reflected best practice guidance. Progress: We have reviewed and updated how we assess and record the hydration status of our patients. We have also updated our intravenous (IV) fluid therapy practice and fasting guidance, including the provision of information for patients on IV therapy and when to fast. Our fluid management recording has been enhanced by the implementation of revised documentation of all fluid intake and output for all patients This has helped nurses to ensure that all patients are routinely assessed for fluid management, and helps to make sure that patients are not starved for too long prior to surgery, which can cause delays in discharge afterwards. We now regularly audit the outcome of these changes via our integrated audit programme. asked as many of our staff as possible to learn a little bit about what it s like to live with dementia and turn that understanding into making a difference to people living with the condition by watching a range of videos. By the end of 2016, 50% of our permanent staff had already watched these videos. A registered nurse is the hospital s Dementia Champion. She has developed a resource folder which is accessible to all staff, and is able to source support and equipment to ensure that patients with dementia will be safely and appropriately cared for within our hospital environment. All ward nursing staff have embraced this learning, and have access to the resources available. On International Nurses Day in 2016 the hospital planted forget-me-nots in the hospital garden, and had a tea party in support of the Alzheimer s Society s Dementia Friends initiative. 25

14 Develop Ways to Improve Meaningful Patient Involvement and Engagement Patients are at the centre of the services we provide and we wished to explore how we could improve their involvement and have meaningful engagement with our patients. Progress: We have developed a Patient Involvement and Engagement Strategy to support our hospitals and clinics in developing meaningful initiatives. This is in a toolkit format and provides a route map of engagement ideas, as applicable to the services we provide, aiming to promote the involvement of our patients in the planning and improvement of our services. This has included making it easier for our patients to feedback on their experience with the development of on-line surveys that will be launched in The majority of focus has been on establishing and including patients in new Patient Forums, improving their inclusion in any complaints & incident investigations, and inviting them to participate in the design, planning and delivery of any new services. This will be an on-going process of ensuring a truly patient focused approach and a culture of engagement and involvement. Throughout Highgate focused on inviting patients to the hospital to discuss their experience when they provided any negative feedback to the hospital. This helped the hospital better understand the patient s specific experience and increased the patient s satisfaction that their complaint was taken seriously. All patient feedback was investigated thoroughly and action plans were developed as a result of each complaint investigation to ensure meaningful change was made as a result of patient feedback. Patients involved in serious incidents were asked to provide either written or verbal feedback in relation to their experience of the incident. Patient opinion and feedback was seen as an important element of the evidence gathering investigation process due to the unique view point patients have in relation to an incident. External Perspective on Quality of Services What others say about our services: Highgate Private Hospital invited Healthwatch Haringey, Haringey Clinical Commissioning Group and Islington Clinical Commissioning Group to comment on this Quality Account. Prior to publication no comments had been received. Really happy with my consultation They were very caring and very careful with the investigation they had to do. They were very gentle, kept my dignity, were very thorough and made sure I had all the appropriate tests in the following weeks. I know I m under great care. NHS Choices review, January 2017 Review of Quality Performance

15 Thank you for taking the time to read our Quality Account. Your comments are always welcome and we would be pleased to hear from you if you have any questions or wish to provide feedback. Please contact us via our websites: Or call us on: Highgate Private Hospital Head Office, Aspen Healthcare Write to us at: Highgate Private Hospital View Road Highgate London N6 4DJ Aspen Healthcare Limited Centurion House (3rd Floor) 37 Jewry Street London EC3N 2ER