Part 2
Looking forward.
Priorities for Improvement for 2010/2011
Year on year the hospital identifies a number of quality drivers to ensure that a quality
improvement focus is maintained. For the years 2010 to 2012 Quality takes priority in the
Hospital’s three year Business Plan as follows:
•
Enhance the patient experience by improving all aspects of communication
•
Exceed national clinical standards in at least two services when compared to
available benchmark
•
Meet all regulatory standards
•
Undertake Customer Care Training for all staff
In addition to the Quality objectives, a number of other priorities are identified as follows,
which the Hospital Management Board believes will influence the Quality of Service
provision at the hospital:
•
To review all existing services provided at Benenden Hospital in line with the
strategic business plan, enhancing where appropriate and discontinuing where
necessary.
•
Investigate new service opportunities
•
Meet all performance standards
•
Ensure our people are “fit for purpose” by introducing methods to support our
performance culture by the development of Vision, Values, Goals and including the
development of a Consequences framework and Reward Strategy.
•
Develop a plan for the Hospital Site
Stakeholder Feedback
This years quality improvement priorities are the Boards response to both external and
internal stakeholder feedback from: Patient Satisfaction Surveys; Chief Executive
unannounced visits; the Care Quality Commission response to the Hospital’s annual self
assessment; Benenden Healthcare Society Members Annual Conference; Hospital Board
Member visibility and Health and Safety walkabout visits around the site; Board of
Governor rota visits and patient complaints and incident reports.
A recent meeting with our Commissioners confirmed that they are satisfied with the quality
of service provided for NHS patients.
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Multidisciplinary Audit
Building on the successful programme developed in 2008, the 2009 programme
incorporated a wider number of specialties, including some non-clinical specialties. A total
of 13 audits and a number of Clinical update sessions were delivered during the year. The
range of specialties that presented their audits included General Surgery, Gynaecology,
Gastroenterology, Ear Nose & Throat, Anaesthetics, Radiology, Microbiology and
Haematology and Infection Control. There were also sessions on Patient Safety, Clinical
Coding and Accountability. The Hospital has also continued to undertake a number of
Endoscopy Service audits as part of the requirement of the Global Rating Scale, an NHS
initiative that the Hospital has signed up to in order to ensure best practice in the delivery
of our Endoscopy Service.
The following are examples of how we have learnt from feedback by listening to our
stakeholders or as a result of findings from audits or from reported incidents and
complaints. They are reported under one of 3 categories: Patient Safety, Clinical
Effectiveness and Patient Experience.
Patient Safety
Informed consent
As part of the informed consent process, patients are advised about the rates of surgical
complications nationally in relation to their planned procedure and or condition. We
acknowledge that local data may not be readily available to our patients and we will work
with our clinicians to develop the reporting of all surgical complications and outcomes of
surgery in order to provide this information to our patients.
Specialty outcomes will be reported through the Patient Safety Committee and thus to
Integrated Governance and the Hospital Management Board in the quarterly Governance
reports. Benenden Hospital is also signed up to the Independent Healthcare Advisory
Service initiative to report outcome measures and benchmark against other Independent
Sector hospitals.
Surgical checklist
Following the successful introduction of the surgical safety checklist within the operating
theatre, work is ongoing to improve compliance and efficacy of this valuable patient safety
tool. Further specific safety checklists are being developed and introduced nationally. With
this in mind, we will work alongside stakeholders to ensure further patient safety tools are
introduced in a timely way to provide assurance that patient safety remains at the top of
the hospital agenda.
All work related to Patient Safety will be reported to the Patient Safety Committee for
discussion, agreement and monitoring. Minutes of the meeting will be forwarded to
Integrated Governance and so to the Hospital Management Board.
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Clinical Effectiveness
Pain relief
An audit of pain scores following laparoscopic cholecystectomy showed that the scores
were higher than expected. Action taken has resulted in routine liver bed infiltration with
local anaesthetic solution peri-operatively and this has improved postoperative pain
scores.A repeat audit will be undertaken during the next six months and the results
reported to the Pain Team
Following two written complaints relating to pain during EVLT (Endo Venous
Laser Treatment) an audit was undertaken. This is a modern treatment for varicose veins.
This supported the patient perspective and action has now been taken to improve the pain
scores by administering Intra Venous Paracetamol before the procedure and also
administering a sedative as required. Patient Information was also reviewed and amended.
A repeat audit will be undertaken during the next six months and the results reported to the
Pain Team
Post op Incident
As part of the learning process, all incidents and complaints reported are reviewed and
investigated where necessary and learning points identified. If relevant in order to reduce
further risks to patients, changes are made to clinical and non clinical practice. Learning
however does not always necessitate change in practice but they all involve reflection and
discussion.
One incident that required Root Cause Analysis led to a review of positioning of patients
for specific surgical procedures and further staff training in this regard.
Training updates for all theatre staff were carried out and alternative surgical drapes
trialled to facilitate a clearer view of patient limb positioning. No further incidents have
occurred.
Patient Experience
Patient Feedback survey
The 2009 In-Patient and Day Case Patient Survey demonstrated a very high quality of
care, however there are always some areas for improvement. The most important
feedback being that In Patients were waiting too long from admission to time going to
theatre. Work is ongoing to introduce staggered admissions to reduce the waiting time to
Theatre. This process will be monitored via a number of routes such as audits and patient
satisfaction feedback and reported to Integrated Governance quarterly.
Comfort Audit
As the result of a comparative audit undertaken as part of the Global Rating Standards
(GRS) for assessing 3 levels of comfort during endoscopy, (comfortable, moderate
discomfort and extreme discomfort) action was taken to improve pre investigation
communication between staff and patient resulting in a decrease in those reporting
extreme discomfort and an increase in those reporting that they were either comfortable or
had moderate discomfort.
The audit will be repeated six monthly to monitor continuous improvement in comfort
during endoscopy.
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Research
Benenden Hospital is unique within the Independent Sector in that it supports appropriate
research on site involving consenting members in order to improve practice and strive to
inform medical advances in those specialties undertaking the research. Currently, the
research being undertaken is within Gynaecology and General Surgery. The work
undertaken is supported by a Research Advisor and Research Committee.
Following Research undertaken during 2009, some changes to clinical practice have been
made in both specialties.
Part 3 Looking back and review of performance
One of the best ways to progress in any organisation is to review the past to identify the
successes and to highlight the areas where there is need for improvement. In looking at
our successes we are proud to say that Benenden Hospital is accredited for Information
Security Organisation (ISO) 27001 and Investors in People.
Integrated Governance
In order to assure the Board of Governors and the Hospital Management Board of safety
and effectiveness in all aspects of risk management, an Integrated Governance approach
has been developed. The purpose is to:
•
Inform all stakeholders including; staff, members of Benenden Healthcare Society
and all users of our services of the principles underpinning Governance
arrangements within the hospital including Committee structures, Policies and
reporting.
•
Detail the systems of control and assurance adopted by the Hospital’s Board of
Governors and Management Board to ensure that the hospital operates in
accordance with legal and national requirements including:
- Ethical principles
- Regulatory Framework
- Sound Risk Management standards
A schematic of the Committee structure is set out over the page, highlighting the
importance of such risk components as; Patient Safety; Infection Control; Occupational
Health and Safety; Resuscitation and Research.
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The Integrated Governance Committee (IGC) oversees all business and actions of the
Risk Committee’s for assurance and the minutes of the IGC taken the Management Board
on a quarterly basis for information, discussion and assurance along with a number of
other reports as follows:
• Integrated Governance Quarterly and Annual Reports
• Complaints Quarterly and Annual Reports
• Clinical Indicator Reports
• High Level Risk Register
• Financial Reports and Key Performance Indicators
The following extract is taken from the 2009 Integrated Governance Annual Report.
The information contained in this report has been compiled using data and feedback
obtained from both external and internal stakeholders as identified earlier in the report.
INCIDENT REPORTING
The tables and graphs below show total numbers of incidents, both clinical and non clinical
reported and total incident by type and severity.
Reported Incidents by Type 2005 - 2009
Information Security
Clinical Complications
1400
Clinical - adverse
1200
Clinical - non adverse
1000
Personal accident - staff
800
Personal accident - patients
600
Personal accident - others
400
Ill health
Fire incident
200
Security/vehicle/property incident
0
2005
2006
2007
2008
2009
Abuse/harassment
Other incidents
Incidents by Severity - 2009
119
12.6%
LOW
4
0.4%
MINOR
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820
87.0%
MEDIUM
The severity of incidents remains reassuringly low as illustrated by the graph above, with
no high risk incidents of any kind. Rating is based on a risk management matrix that is
commonly used throughout healthcare. High risk incidents would be those that cause
death, life threatening injury or permanent disability. Benenden Hospital encourages the
reporting of all incidents and recognises high reporting as a positive trend rather than
negative. The Hospital Management Board are assured that all incidents are reported and
reviewed.
High Level Risk Register
The Hospital has a well developed High Level Risk Register that is regularly considered by
the Hospital Management Board and the Board of Governors that identifies our significant
risks. Rates those risks, identifies controls in place and any required actions to reduce the
risk.
Root Cause Analysis (RCA)
Any incident identified as medium or above or any trends identified would have a detailed
investigation undertaken by the manager and supported by the Governance Team.
A one-day risk management study day on RCA for managers was provided during the
year.
Clinical Complications
The table below shows the recording of clinical complications and their causes for 2009.
Clinical Complications 2009
2
2
2
4
1
Allergic Reaction
Blood/Fluid Loss
Unexpected Deterioration
0
Infection
0
Other Physical Injury
None
10
5
Other
Pain
Puncture of Organ
Unknown
4
1
3
2
Return to Theatre
Collapse
Gastro Disturbance
Patient Safety Alerts
Work towards compliance with National Patient Safety Agency Alerts has continued
throughout the year with great achievements across the Hospital.
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COMPLAINTS
Benenden Hospital records all complaints whether verbal or written. Trends vary as can
be seen in the graph below.
Trend Comparisons of Verbal and Written Complaints 1Q07 – 4Q09
70
Ve rbal
Writte n
60
50
40
30
20
10
0
1Q07
2Q07
3Q07
4Q07
1Q08
2Q08
3Q08
4Q08
1Q09
2Q09
3Q09
4Q09
Risk Rating of Complaints for 2009
Risk Rating of Complaints Received During 2009
13%
(18 verbal, 15 w ritten)
87%
(169 verbal, 56 w ritten)
High Risk
Medium Risk
Low Risk
The top three complaints received during 2009 where Communication/ information, clinical
care and waiting times/delays/cancellation of outpatient appointments. The Hospital
Management Board takes complaints very seriously and in particular the issue of
communication and as a result, the first objective of the 2010-2012 Business Plan is to
identify specific communication issues and take formal action to improve them. We are
also undertaking a review of all patient related documentation to ensure that the patient
receives accurate and timely communication.
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CLINICAL INDICATORS.
Clinical indicators play an important part in the monthly review by the Hospital
Management Board and the hospital uses a traffic light system to focus attention on those
indicators that are of concern. A number of the following indicators are reported to the
Care Quality Commission on a quarterly basis as required.
Clinical Indicators 2009
Risk
Rating
Clinical Indicator
As a Percentage of
Annual Discharges
Unplanned Re-admission Within 29 Days of Discharge
0.3%
Day Case In-patient Conversion
4.6%
Returns to Theatre
0.2%
Deaths
0.0%
Reported Adverse Clinical Incidents
0.1%
Post-operative Venous Thrombo Embolism
0.0%
Surgical Site Infections ( orthopaedic)
0.0%
Unplanned Admissions to HDU
0.09%
Blood Usage
0.84%
Length of Stay 14 Days and Over
0.87%
Reported Clinical Complications
0.51%
Clinical Complaints (Written)
0.5%
Number of MRSA Bacteraemias
0.0%
Number of MSSA Cases
0.0%
Number of C. Difficile Cases
0.0%
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INFECTION CONTROL
Benenden Hospital is committed to ensuring that Healthcare Acquired Infections are kept
to a minimum and the Management Board have signed up to an agreement identifying
what it will do to ensure this. This agreement is on display in the Reception area for all
patients and visitors to see. The hospital has appointed a Director for Infection Prevention
and Control as a demonstration of its commitment.
Total number of Infection Rates 2009 by Specialty
Comparison of Reported Post-Operative Inections by Specialty
1Q09 - 4Q09
5
4
3
2
1
no reported blood
infections during 2009
0
1Q09 2Q09 3Q09 4Q09 1Q09 2Q09 3Q09 4Q09 1Q09 2Q09 3Q09 4Q09 1Q09 2Q09 3Q09 4Q09
Urine Infections
Gynaecology
Wound Infections
General Surgery
Vaginal Infections
Urology
ENT
Blood Infections
Orthopaedics
Others
There have been no reported outbreaks of MRSA, Clostridium Difficile or any other
Hospital
associated
infection
at
the
Hospital
during
2009.
The hospital is fully compliant with the Department of Health requirement to report all rates
of MRSA, Clostridium Dificille and MSSA, to the Health Protection Agency (HPA) and
reports during 2009 showed no such infections. The Hospital Management Board made
the decision that all patients attending the hospital for a surgical procedure (with the
exception of cataract surgery, paediatrics and endoscopy) would be screened for MRSA.
During 2009 the Hospital undertook a Patient Environment Action Team (PEAT)
assessment of all clinical areas, looking at the environment from the patient’s perspective.
The results of this assessment were submitted to the National Patient Safety Agency as
required by the Department of Health and identified only minor areas for improvement.
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STANDARDS
Patient Feedback
In 2009 the Hospital concentrated on obtaining patient feedback on Inpatient and Day
Case services. The report revealed a 99.2% overall satisfaction rate. This survey was
undertaken by an independent company to eliminate bias.
Care Quality Commission (CQC) Annual Assessment
At the end of July 2009 the Hospital successfully completed and submitted the detailed
CQC Self Assessment. Following the submission the Hospital received an excellent report
from the Commission which did not identify any non-conformities on the standards
assessed.
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