The Chelmsford Private Day Surgery Hospital. Quality Account April 2016 March 2017

Transcription

1 The Chelmsford Private Day Surgery 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 The Chelmsford Private Day Surgery Hospital 9 Statement on Quality 10 Accountability Statement Quality Priorities for Patient Safety Clinical Effectiveness Patient Experience Statements 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 The Chelmsford Private Day Surgery 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 Hospitals and Clinics locations: Cancer Centre London The Chelmsford 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. 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 Friendly and efficient service in lovely surroundings making it overall a very pleasant experience. Patient Survey Feedback December 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 The Chelmsford Private Day Surgery 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 The Chelmsford 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 The Chelmsford, 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 The Chelmsford Private Day Surgery Hospital Located in the heart of Chelmsford, Essex, The Chelmsford Private Day Surgery Hospital is an elite private diagnostic and ambulatory surgery centre first established in February The facility comprises of a Theatre suite, several outpatient consultation rooms, an on-site physiotherapy and gym, MRI, Ultrasound, X-ray and excellent surgical facilities. We aspire to ensure the personalised care our patients receive is the best in the vicinity. During , 13,352 patients attended for outpatient care and 1,266 patients were admitted for day case surgery. The Chelmsford Private Day Surgery Hospital provides the following: General consulting rooms 4 Specialist ophthalmology consulting rooms 2 ODP treatment room 1 Theatre room 1 Procedure room 1 GA recovery - first stage 1 Procedure admission and discharge lounge 1 Private GP services Free parking All major insurers are accepted Choose and Book Diagnostics suite comprising: MRI; Ultrasound; X-ray This has been a great, wonderful experience and much better than expected. Every member of staff made me feel at ease and welcome. Such a friendly, relaxed atmosphere. Patient Survey Feedback March

6 Statement on Quality Quality Priorities for The Chelmsford Private Day Surgery Hospital is proud to present our fourth Quality Account in which we will demonstrate our commitment to quality and safety. We have measured our progress objectively, identifying where we aspire to improve in centred on the areas of patient safety, clinical effectiveness and patient experience. The Quality Account is actively owned by all the teams at The Chelmsford Private Day Surgery (The Chelmsford), and we have a genuine desire to drive forward our quality initiatives over the next year, modelled on our Quality Governance Framework and Quality Strategy. This Quality Account also helps us to openly report on what we do well and what we need to improve upon. Our local Quality Governance Committee meets quarterly and provides information, outcomes and quality Accountability Statement Directors of organisations providing hospital services have an obligation under the 2009 Health and Social 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. Director of Clinics, Aspen Healthcare This report has been reviewed and approved by: data on all aspects of our patients pathway, including feedback from patients. This committee feeds into the Aspen Group Quality Governance Committee which is chaired by Aspen s CEO. The committee provides assurance to the Aspen Executive Team and Board that we are responsive to any changes in values, expectations, perceptions and to ensure that services provided to our patients are based on best practice. This report has been prepared based on 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 Louise Teare, Medical Advisory Committee Chair, The Chelmsford Mrs Jill Norman, Quality Governance Committee Chair, The Chelmsford Mr Des Shiels, Chief Executive Officer, Aspen Healthcare Mrs Judi Ingram, 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. The Chelmsford 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 care I received was second to none. I was thoroughly looked after from the second I arrived until the moment left. Patient Survey Feedback March 2017 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 and tips on how to keep safe whilst in our care, 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. Statement on Quality 11

7 Clinical Effectiveness Patient Experience 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. The Chelmsford is to develop an annual practical training programme and report regularly 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. 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 hospitals and clinics, we will introduce 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. Mystery Shopper - Assuring the Best Patient Experience In seeking to ensure and improve upon our patients experience and assess our customer care standards, we will develop mystery shopper mechanisms to measure the quality of service and interaction when a patient books an appointment by telephone, or attends for an outpatient appointment. The mystery shoppers will pose as normal patients and gather information about their actual service experience. This information will provide a clear understanding of real patient experiences and help us to further explore how we can improve our standards further. Quality Priorities for 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. The Hospital staff were very professional in everything they did and I felt very comfortable with all the staff around me, absolutely brilliant team! Patient Survey Feedback December

8 Statements of Assurance This section provides mandatory information for inclusion in a Quality Account, as determined by the Department of Health regulations, and reviews our performance over the last year, running from April 2016 to March 2017 but reported in June as required by the guidelines. Review of NHS Services Provided During , The Chelmsford provided and/or subcontracted the following nine NHS services: NHS e-referral Service: Pain Management Ophthalmology Cataract Surgery Orthopaedics Diagnostics Spot Contracts Ophthalmology Cataracts & Ocular Plastics Orthopaedics Pain Management Plastics/Cosmetics Ongoing Contracts Podiatry The Chelmsford 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 The Chelmsford for April 2016 March 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 Chelmsford Private Day Surgery Hospital participated in the following National Clinical Audit in which it was eligible to participate in: National PROMs (Patient Reported Outcome Measures) Programme for cataracts. Local Audits The reports of 16 local clinical audits were reviewed by The Chelmsford from April 2016 to March 2017 and The Chelmsford intends to take the following actions to further improve the quality of healthcare provided: Whilst there has been significant improvement in resuscitation management, we shall continue to ensure that all clinical teams participate in resuscitation practical scenarios, to embed knowledge and ensure skills retention AUDIT We will aim to ensure that all clinical staff receive face-to-face training for pain management in This will not only ensure staff competency and knowledge, but also enhance our patients experience and satisfaction for post-operative pain management Improve awareness of the documentation standards required for actual times (24 hour clock), dates and signatures in all medical record entries. Outcome Infection, Prevention and Control (IPC), hand hygiene and environmental 97% audits Resuscitation management 90% Surgical safety (WHO) checklist completion 100% Falls risk assessment compliance 100% Consent form completion 97% Safeguarding adults and children 100% Controlled drugs 99% Theatre traceability audit 100% Consultant practising privileges 98% Information governance 85% VTE 100% Medical records 97% Pain 83% Fasting 95% Imaging safety 97% NEWS (National Early Warning Scores) 94% 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 The Chelmsford Private Day Surgery Hospital s income in April 2016 to March 2017 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation (CQUIN) payment framework because this was not applicable to the commissioning contracts of The Chelmsford Private Day Surgery. 15

9 Statement from the Care Quality Commission Statement on Data Quality The Chelmsford Private Day Surgery Hospital is required to register with the Care Quality Commission (CQC) and its current registration status is to provide the following regulated activities: Treatment of disease, disorder or injury Diagnostic and screening procedures Surgical procedures. The Care Quality Commission has not taken any enforcement action against The Chelmsford during the period April 2016 to March 2017 and The Chelmsford has not participated in any special reviews or investigations by the CQC during the reporting period. The Chelmsford was last inspected by the CQC in September In January 2017 the CQC published its inspection report of The Chelmsford Day Surgery Hospital and awarded an overall rating of Good. The Chelmsford was rated as Good in the Safe, Effective, Caring and Wellled domains and rated as Outstanding in the Responsive domain. The Chelmsford was rated as Outstanding in the responsive domain because: The service was planned and delivered to meet the needs of patients. Statements of Assurance The hospital did not have a waiting list and there were no issues with patient flow. The hospital consistently achieved above 97% Referral To Treatment (RTT) within eighteen weeks for NHS patients for surgery and outpatients. There was a complaints procedure and staff had feedback about complaints received. The CQC also identified a few areas for improvement and these were: Improve the quality and completion of patient records. This was addressed with service users and audits conducted show immediate improvement. Ensure that risk assessments on moving and handling are undertaken prior to surgery. Although The Chelmsford is recognised as an ambulatory surgical facility, for which there is a general risk assessment, the inspectors advised on specific risk assessments where restricted mobility is identified. Ensure medicines within outpatients are consistently and accurately recorded and maintained to prevent discrepancies in the medicines records. Immediate action was taken to clarify reporting and audit sheets. The Chelmsford Private Day Surgery Hospital recognises that good quality information underpins the effective delivery of patient care. This is essential if improvements in quality of care and value for money are to be made. Information Governance is high on our Quality Agenda and robust policies and procedures are in place to support the Information Governance process. This includes standards for record keeping and storage, continuous audits of records to ensure accuracy, completeness and validity. Regular team meetings are scheduled to improve audit outcomes and address responses to our patient satisfaction and staff safety surveys. 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 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 effectively. Aspen Healthcare s Information Governance Assessment Report overall score for was 76% and was graded satisfactory. The Chelmsford will be taking the following actions to further improve data quality: Continuation of monthly audit of patients medical records Quarterly audits of office environments and data management Review of storage facilities for medical records with a view to a more robust archiving schedule Ensuring 100% of our staff complete the elearning modules related to record keeping and Information Governance. Secondary Uses System (SUS) The Chelmsford submitted records during April 2016 March 2017 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 outpatient care And which included the patient s valid General Medical Practice Code was: 100% for outpatient care. Clinical Coding Error Rate The Chelmsford was not subject to the Payment by Results clinical coding audit during April 2016 March 2017 by the Audit Commission. 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. The Chelmsford 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. The Chelmsford 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. The Chelmsford currently only submits adverse incidents and patient satisfaction data to PHIN. 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. 17

10 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 0 0 Serious Incidents 0 0 Serious Incidents 0 0 resulting in harm or death resulting in harm or death Never Events 0 0 Never Events 0 0 Total 0 0 Total 0 0 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 currently not routinely collected in the independent sector. Patient Reported Outcome Measures [PROMs] Cataract Surgery (private patients only): Number of cases submitted % of respondents who recorded an increase in their Catquest rating following operation 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. The Chelmsford currently only submits cataract data for private patients (due to the case mix of patients treated) N/A % Indicator Source 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 CQC performance indicator Clinical audit report Actions to improve quality 0 0 Continue to monitor data. Review any readmission at Quality Governance and Medical Advisory Committees. Investigate each one and provide learning and action plans where appropriate CQUIN data 100% 100% 100% of those who required assessment From national Public Health England/ Scotland returns From hospital incident reports (Datix) Patient satisfaction survey data for overall level of care Patient satisfaction survey rated extremely likely/likely 0 0 Continue to monitor 0 0 Continue to monitor 99% 98% Training for all staff in WorldHost Customer Care and also on the Aspen Values training programme. 98% 100% Continue to monitor 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 - staff Staff satisfaction survey Infection Prevention and Control The Chelmsford s vision is that no person is harmed by a preventable infection. Monthly audits and surveillance identifies risks which are reported in the Quarterly Infection Prevention and Control (IPC) Doctor reports, along with measures taken to reduce those risks. Auditing and regular local compliance monitoring takes place to ensure that Health Care Workers are practicing competently. Our patients can have confidence that their care at The Chelmsford will be associated with minimal risk of Healthcare Associated 98 % N/A Survey staff once every two years and review response Statements of Assurance Infections (HCAI). The Chelmsford s clinical areas are compliant with the requirements of the Hygiene Code. The IPC Doctor presents quarterly and annual reports to The Chelmsford s Medical Advisory Committee and is on the Integrated Governance Committee. The IPC Lead Nurse produces a quarterly report for Governance meetings and monitors infection surveillance, as well as: leading on the investigation of any infection control incidents (such as needlestick injuries or 19

11 outbreaks), meets with the IPC Nurse Advisor, submits the IPC Annual Report and Annual Programme, represents IPC at the quarterly Quality Governance Meeting, and provides appropriate IPC advice whilst taking into account national guidance. The IPC Lead Nurse covers day-to-day IPC activities as appropriate, and works with the IPC doctor to deliver full compliance with the Hygiene Code at The Chelmsford. She ensures completion of monthly audits of infection prevention and control key performance indicators. She also provides appropriate infection prevention and control information to staff on a day-to-day basis. The IPC assurance process involves a monthly audit of IPC key performance indicators. During the year there were no outbreaks or infection control incidents. Healthcare Associated Infections The following are effectively developed at The Chelmsford: Generic mandatory training is in place for all staff and includes IPC IPC training and development Link nurse hand hygiene training is mandatory on induction and annually Implementation of safety devices and compliance with EU directives Influenza staff vaccine campaign - 50% of the Chelmsford staff requested the vaccination. The Chelmsford places IPC as a high priority to ensure patient safety, patient experience and in gaining and maintaining public confidence. We work to sustain a culture in which every staff member takes responsibility and is accountable for IPC. The Chelmsford has been successful in controlling infection during 2016; staff engagement and understanding being the key component of our success. 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 Complaints Complaints, both written and verbal, including any immediate red alerts from our patient satisfaction surveys, are entered onto the Datix system. In addition to recording the number of formal complaints (excluding red alerts), all relevant associated documents are uploaded to the Datix system. This system provides a comprehensive record of each complaint, responses, evidence of actions undertaken and resulting outcomes arising from complaints. All concerns and complaints are categorised to enable more detailed analysis of themes, in line with the national NHS KO41 categories. These include categories such as: admission and discharge, care and treatment (medical and nursing), the attitude of staff, patients privacy and dignity, communication and consent to treatment. Once patients have been discharged, they Statements of Assurance 0 0 are asked to complete a Giving feedback form by either the reception or outpatient staff. The form is used to evaluate individual patient experiences to ensure action is taken from any comments or concerns the patient may have. This information allows us to improve our services going forward. This form can also be found on our website for patients to complete electronically and reviews can be left on our social media pages. The feedback is regularly reviewed by The Chelmsford staff and all feedback (concerns, complaints, red alerts) is incorporated into the complaints review process. All complaints are reviewed and actioned by the Hospital Manager. Complaints are discussed with the relevant departments and reviewed at the local quarterly Medical Advisory and Quality Governance meetings and also at the facility bi monthly team briefs to establish learning outcomes. Indicator Number of Complaints 3 7 % per 100 admissions 0.02% 0.04% The Chelmsford 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. Forward planning and checking processes are followed up prior to a patient s admission, and staff are aware of the need that correct administration and processes are followed to ensure patient safety and an overall positive experience. Information shared (both written and verbal) must be accurate so there is no cause for confusion. As soon as a complaint is received by the Hospital Manager, it is their 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. Regular complaint reports are developed and taken to quarterly Quality Governance meetings and individual departmental meetings. This ensures that staff constructively discuss complaints received in their areas of responsibility as part of the clinical governance process. This encourages the sharing of any lessons learned and an improved understanding of the impact the experience has had on individual patients. Despite the small number of complaints received, changes have been made throughout the year in response to issues raised and these include: Review of letters sent to patients from the Bookings Office, which now includes details on what the procedure payment includes Consultant secretaries sent a reminder of the lower age limit for procedures, and all staff advised to check the year of birth for individual patients All staff (especially chaperones) to be reminded of the importance of addressing patient concerns at the time they arise. Patients should be encouraged to discuss any concerns with a senior staff member to prevent the need for escalation A full review of the medication ordering process with additional stock lists and check lists now in place. Audits undertaken as a result of complaints: Patient satisfaction audits are continually reviewed to ensure that learning takes place from the comments received from patients. The patient experience is monitored by satisfaction questionnaires and 14 day post-procedure outcome audits If complaints are received concerning the general facility (governed by the landlord), this is raised at the quarterly Tenants meeting (e.g. parking availability). Pre-assessment training has undertaken by the clinical team throughout the year, which has greatly improved risk management and communication with patients, prior to their admission. The team have embraced timely communication of any dissatisfaction expressed by patients, so that the Hospital Manager can address concerns on the day thus reducing formal complaints received. The Chelmsford has embraced a culture of safety across both clinical and administrative departments. Further focus for : Quarterly review of patient information. Streamline of our pre-assessment processes and use of an on-line anaesthetic assessment to ensure timely and appropriate clinical investigations. Quality impact assessments for any new services/procedures to ensure safe implementation. 21

12 Review of Quality Performance This section reviews our progress with the key quality properties we identified in last year s Quality Account. Patient Safety STEP-up to Safety Programme Aspen s aim is for all our hospital and clinics 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. Following the initial training session for all staff, each team was asked to identify an area where they considered they have improved their communication and processes to enhance the safety of the patient s pathway. The theatre team have undertaken specific human factors training for their area as part of their Association for Perioperative Practice (AfPP) standards audit. This proved to be very motivating and we plan to extend this training to include both administrative and clinical teams. Two STEP-up Safety Ambassadors have been identified (one clinical and one non clinical) to undertake further training to cascade to the whole team and embed further safety initiatives locally. 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 leaflet was launched in early 2017 and will be followed up with a patient survey exploring their perceptions of safety. Various improvements have been taken following the results of our last Patient Safety Survey, including the planned modernisation of outpatient chairs (for patients with restricted movement and the elderly) and the introduction of a Privacy room for patients and Consultants to use, prior to surgery, to ensure privacy and confidentiality for general procedure discussions, confirmation of consent and surgical site marking. If I could give 11/10 I would. Patient Survey Feedback March 2017 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 collected 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. Fortunately, as an ambulatory day surgery facility we have not had any cardiac arrests in However, we ensure that apart from annual resuscitation training we also have regular unannounced practice scenarios which assist skills and knowledge retention and also enable audit and reflection of emergency procedures. 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 record of fluid management has been enhanced by the implementation of revised documentation of all fluid intake and output for patients. We now regularly audit the outcome of these changes via our integrated audit programme. As a day surgery facility and in line with our fasting policy, it is essential that patients are hydrated sufficiently pre-operatively to enable a full and fast recovery. Admission staff are trained to fully inform patients during their preoperative assessment about the importance of appropriate hydration and adhering to the fasting guidelines. They have attended clinical skills updates to facilitate both pre and postoperative assessment and the management of dehydration. Review of Quality Performance

13 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 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. The Chelmsford Dementia Lead has compiled a Dementia Information folder which is available for all staff to read. This is in addition to the mandatory on-line awareness modules. Many staff members have now become Dementia Friends and are more sensitive when exploring capacity and tailoring patient care according to an individual s needs. 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 ongoing process of ensuring a truly patient focused approach and a culture of engagement and involvement. The Chelmsford has adapted areas to streamline the patient journey and patients who have visited the facility regularly have been asked to participate in projects enabling a more patient-focused approach. Review of Quality Performance

14 External Perspective on Quality of Services What others say about our services: Statement provided by Elizabeth Podd (Deputy Director of Commissioning, Mid Essex Hospitals Trust) Mid Essex Hospitals Trust (MEHT) sub-contracts a limited range of NHS activity to The Chelmsford Private Day Surgery Hospital including imaging, outpatient and day-case activity. MEHT carried out a Quality Assessment of the Hospital before sub-contracting the services and maintains a close managerial relationship with the Hospital, which ensures that patient care is kept at an optimum level. Statement provided by Petra Steiner (RTT Outsourcing Project Lead, Barking, Havering and Redbridge University Hospital NHS Trust) There are no complaints with adherence to the turnaround times and contractual assurance. Statement provided by Jason Nandlal (Consultant Podiatric Surgeon, South Essex Contract) Essex University Partnership Foundation Trust (EPUT) has undertaken outpatient clinics and day case surgery sessions at Chelmsford Private Day Hospital for some considerable time. The continuous high standards that the hospital has always maintained are reflected in their recent Care Quality Commission (CQC) report; the best in the Chelmsford area. This encourages us to continue to take advantage of this excellent facility. The high standards maintained by theatre and radiology staff combined with on-site MRI, X-ray, and ultrasound, in conjunction with high quality Consultant Radiologists have proven to be the ideal for our work. The nursing staff are caring, friendly, and conscientious. Our feedback is always very good for patients who have visited this hospital. We have an excellent relationship with the management staff and feel confident that we can provide a high standard of care now and in the future. External Perspective on Quality of Services I was kept informed at all stages and the process was efficient and smooth. The facility was clean and the staff were excellent Patient Survey Feedback March

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: Head Office, Aspen Healthcare The Chelmsford Private Day Surgery Write to us at: The Chelmsford Private Day Surgery Hospital Fenton House New London Road Chelmsford CM2 0PP Aspen Healthcare Limited Centurion House (3rd Floor) 37 Jewry Street London EC3N 2ER