1
Contents
Introduction
Welcome to Optegra
Page 3
Optegra Pledge
Page 4
Welcome to Optegra Yorkshire Eye Hospital
Page 5-6
Part 1:
1.1
1.2
Statement of Commitment, Rory Passmore,
Optegra UK Managing Director
Statement of Quality, Sue Boyes,
Yorkshire Eye Hospital Director
Page 8-9
Page 10
Part 2:
Priorities for Improvement 2015 / 2016
Page 11-20
Statement of Assurance
Page 21
Statement of Quality Delivery
Page 24-26
Part 3:
Review of our Quality Performance 2014
“A Look Back”
Page 27-28
Glossary
Page 29
2
Introduction.
Welcome to Optegra
Optegra was founded with the aim of creating world-class centres for excellence in eye care in
the UK and international markets.
This didn’t just mean providing the very best treatments available. We wanted to create a
completely new premium kind of experience: one that offers superb levels of care and attention
for everyone, every step of the way.
Optegra brings together the most advanced treatments, technology and 5 star patient facilities.
Our specialist Consultant led teams deliver the highest standards in world class, ultra modern
hospitals which have been designed with every detail in mind to make sure your experience is
pleasant and stress free.
Our Consultant Ophthalmic Surgeons are among the most well respected and renowned
practitioners in their field who are NHS trained and members of the Royal College of
Ophthalmologists (RCO).
With such expertise and specially designed, dedicated eye hospitals, we are completely
committed to providing individually, tailored eye care solutions.
We aim to deliver outstanding results, a speedy recovery – a whole new quality of life.
3
Optegra Pledge
Optegra provides personalised eye
care by expert clinical teams at our
specialist hospitals dedicated to eyes,
to deliver the optimum outcome for
you.
With our care, its not just eye care, its
complete care.
4
Optegra Yorkshire Eye Hospital
In the UK we have 6 hospitals and are currently in the process of opening a Hospital in central
London.
Optegra Yorkshire Eye Hospital is a private hospital situated between Leeds and Bradford. The
hospital offers care to NHS patients, patients with private medical insurance and patients who
wish to fund their own treatments.
The hospital provides a full range of Ophthalmic services, including outpatient consultations,
diagnostics and surgery, through to follow-up care.
During the period January 2014 – December 2014 the hospital has had 33,165 patients through
its doors, and approximately 30 % were treated under the care of the NHS.
There are 23 specialist Ophthalmic Consultants working in the hospital who are amongst the
best in the world: highly recognised in their field and completely committed to providing our
patients with first class treatments. They are all NHS trained and Fellows of the Royal College of
Ophthalmologists (RCO).
Our Consultants have many years ophthalmic experience and have undertaken thousands of
eye procedures. They are regulated and approved by Optegras Medical Director and Medical
Advisory Committee.
All have made outstanding contributions to the research, development and practise to new
techniques.
5
21 clinical staff including the Clinical Services Manager, Nurses and Healthcare Technicians
support the Consultants. There is also a skill mix of Optometrists and Orthoptists as well as a
fundal photographer, a 17 strong Administration team managed by our Patient Service
Manager, along with dedicated Facilities and Housekeeping support, supports the hospital.
The Hospital is also supported by a Regional Business Manager.
The hospital has built an excellent relationship with Leeds Teaching Hospital Trust, Bradford
Teaching Hospitals and Airedale Foundation Trust to deliver a collaborative approach to patient
care.
Our field-based Professional Partnership Managers provide vital links to the Optometry
community and GP’s to ensure their needs and expectation are managed through a partnership
referral process and streamlined patient choice referrals.
What Our Optometry Community Say About us
“Optegra provide wide range of specialist ophthalmic services and receive the majority of our
private referrals. Patient feedback is consistently high and clinical outcomes are excellent.
Optegra seem to ensure that all the tests required by the specialist are done together and
patients really appreciate this because it avoids additional appointments.”
Mike Procter. Harrogate, HG1 2QZ
Paul Verity, Paul Verity Opticians, West Yorkshire
“As a group of three West Yorkshire independent optometry practices we feel blessed to have
such an excellent resource as the Optegra Yorkshire Eye Hospital on our doorstep.
It enables us to refer patients in the complete confidence that they will receive highest quality
treatments from excellent specialists, using the latest equipment in pleasant, relaxed
surroundings. We have developed a close working relationship with Optegra through their local
Business Development Manager which means referrals are always actioned quickly and
effectively. I would recommend Optegra to both my patients and my professional colleagues.”
6
Robert Foulds, Donovan Smith Opticians, Brighouse
“We refer our patients to Optegra in total confidence they will see the chosen Ophthalmologist
who specialises in the appropriate field and receive the very best clinical care in a modern and
comfortable environment embracing the very latest available technology. Our referrals are
always processed efficiently with excellent feedback at each stage of the patient journey.”
Giles Price, Christopher Nixon Optometrists, Harrogate
“When referring my patients to the specialist ophthalmologists at Optegra Yorkshire Eye
Hospital I am assured that they will receive first class medical treatment. Moreover, the entire
team at Optegra ensure that our patients experience the very best care throughout their journey
from initial referral to discharge.”
7
Part 1
1:1 Statement of Commitment
Optegra UK Ltd is totally committed to fostering an organisational culture that puts the patient at
the centre of everything the Optegra Yorkshire Eye Hospitals does.
The Optegra Yorkshire Eye Hospital was established by its founding surgeons specifically to
demonstrate the highest levels of patient safety, clinical outcomes and customer satisfaction. It
is that vision that remains at the heart of our dedication to the highest levels of quality and
reflected in the Optegra mission statement - “To be the worlds most trusted choice for eye care"
The hospital was acquired in February 2010 by Optegra UK, who specialise in Ophthalmology
services across the country and is one of six hospitals based in the UK, with the others being
situated in Surrey, Solent, Manchester, Birmingham and London. As Managing Director of
Optegra UK, I am passionate about ensuring that high quality patient care is at the centre of all
we do and how we operate in all our facilities. This relies not only on excellent medical and
clinical leadership in our hospitals but also upon our overall continuing commitment to drive year
on year improvement in clinical outcomes.
Following the appointment of our Head of Eye Sciences role in 2011, we have expanded the
use of Medisoft, the UK's only Ophthalmology specific patient pathway system that records
patient clinical data from onset to discharge. It has a comprehensive audit element that records
both pre and post-surgical outcomes and also surgical and anaesthetic complications. For the
first time Optegra UK now generates consistent and high quality surgical outcome data for all of
its hospitals. Our Head of Eye Sciences, in conjunction with our consultant Ophthalmologist
Medical Director are instrumental in approving any new procedures and technologies into
Optegra hospitals and will also provide us with the capability to participate in a wide range of
research projects.
As a provider of ophthalmic healthcare, we have continued to work hard in 2014 to further
develop a structured clinical governance framework and risk management system across all our
hospitals and we continually review our performance so we can drive improvements to the
benefit of all our patients. I believe that delivering clinical excellence depends upon everyone in
the organisation; everyone is responsible for ensuring that are delivering high levels
performance and constantly seeking to improve.
The requirement to ensure clinical excellence is the role of everyone in the organisation and is
not about reliance upon one or two people. Across Optegra we nurture teamwork and
professionalism, we value our people and set our targets high, and we work hard in every
aspect of our services to provide facilities of a high order. We believe in investing substantially
in our people, our hospitals and our equipment to ensure care is delivered in a consistent and
safe manner at all times.
8
The Optegra Yorkshire Eye Hospital is accustomed to the disciplines of regulatory and
contractual requirements to assure health commissioners of our clinical performance and to
report complaints and serious incidents accordingly. The hospital maintains a Risk Register and
reviews specific actions to achieve risk reduction.
To the best or my knowledge as requested by the regulations governing the publication of this
document, the information in this report is accurate.
Rory Passmore
Uk Managing Director
9
1:2 Statement of Quality:
This is the fifth quality account issued by the Optegra Yorkshire Eye Hospital and it reflects on
performance in the last financial year.
A great deal was achieved by clinical and administration teams during 2014/15, in partnership
with patients, our commissioners and our professional referring community
We are especially proud of our improved performance in our patient satisfaction survey
reaching a world class net promoter score of 84.
.
We delivered on our CQUIN goals… Section 1.1 of the CQUIN was to continue with the Friends
and family test at Optegra Yorkshire Eye Hospital. This part of the CQUIN has been achieved
with the returns being higher in quarter 1 and quarter 4.
Section 1.2 of the CQUIN was to improve performance on the staff Friends and Family Test.
The goal was to achieve a better result in 2014/15 compared with the 2013/14 result. This part
of the CQUIN has been achieved with an increase of the staff recommending Optegra.
Our research and surgical outcome profile remains strong and we continue to audit and
evaluate to continually improve our services.
We recently successfully completed a clinical evaluation of a new intraoperative imaging system
and were delighted that we were able to invite NHS and private patients attending Optegra
Yorkshire Eye Hospital for cataract surgery, to take part in the study.
Working with our CCG programme for 2015/16 we look forward to continuing to provide a
quality service to all our patients
Sue Boyes
Hospital Director
10
Part 2
Priorities for Improvement 2015/2016
Through a process of audit and feedback, we strive to make the patients experience the best it
can be. This is through a process governed by clinical effectiveness, safety, national guidance
and recommendations. The Hospitals priorities for improvement have and will continue to be
determined by evaluating and acting upon our governance processes and learning from our
patients and staff.
Patient Safety
Never Events are serious and largely preventable patient safety incidents that should not occur
if preventable measures have been implemented.
The full ‘never events’ list for reference is:
(www.gov.uk/government/news/never-events.list)

























wrong site surgery (appropriate to Optegra)
wrong implant/prosthesis (appropriate to Optegra)
retained foreign object post-operation (appropriate to Optegra)
wrongly prepared high-risk injectable medication
maladministration of potassium-containing solutions
wrong route administration of chemotherapy
wrong route administration of oral/enteral treatment
intravenous administration of epidural medication
maladministration of Insulin
overdose of midazolam during conscious sedation (appropriate to Optegra)
opioid overdose of an opioid-naive patient
inappropriate administration of daily oral methotrexate
suicide using non-collapsible rails
escape of a transferred prisoner
falls from unrestricted windows
entrapment in bedrails
transfusion of ABO-incompatible blood components
transplantation of ABO-incompatible organs as a result of error
misplaced naso- or oro-gastric tubes
wrong gas administered
failure to monitor and respond to oxygen saturation
air embolism
misidentification of patients
severe scalding of patients
maternal death due to post partum haemorrhage after elective Caesarean section.
11
There are 4 core ‘never events’ which will continue to form part of our measurement of patient
safety during 2015/16.

Wrong site surgery
Optegra Yorkshire Eye Hospital continues as standard practice to use the World Health
Organisation (WHO) recommendations for safer surgery checklist. It is a tool used
throughout cataract surgery to improve safety through effective communication and
setting out safety checks throughout the perioperative period.
As part of the of the pre operative checking protocol the surgery site is marked and
checked with the patient and consent form as part of the day care nurses duties. This
safety check is carried out again by the anaesthetic/escort nurse and then a further time
by the scrub nurse, before surgery is commenced.
The hospital has consistently achieved compliance throughout 2014 for completion of the
checklist and it has now become standard in the patient surgical pathway. It will continue
to be audited and evaluated throughout 2015/16.
Due to its success in maintaining safety measures, the checklist has now been adapted,
and is used for all types of surgery, moving forward for the year 2015/16.

Wrong Implant / prosthesis
“Wrong intraocular lens implant; learning from reported patient safety incidents” (SP
Kelly Feb 2011) showed that a large percentage of incidents of wrong implantation of
Intra Occular Lens, were due to wrong lens selection. Optegra Yorkshire Eye Hospital
have worked hard to raise awareness of this never event, through education,
communication and robust audit processes. Through this process we have achieved
100% compliance throughout 2014 with the Lens Checking Protocol. This best practice
and cycle of audit will continue during 2015/16.
The WHO Surgical Safety Checking audit is now completed monthly in conjunction with our
Lens Checking Protocol audit, as these 2 audits have enhanced the Safety of our Patients
during the Perioperative period. These audits are carried out by a different member of the
clinical team every month and we have found that this responsibility has helped to instill
confidence, pride and a sense of achievement within the team.
12
Clinical Audit Matrix 2014
Area
Jan
Feb
Mar
April
May
June
July
Aug
Sept
Oct
Nov
Dec
Lens Checking Protocol Audit
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
WHO Surgical Safety for Cataract Surgery Audit
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
Documentation Audit
Decontamination Audit
Hand Hygiene Audit
Clinical Waste Pre-Acceptance Audit
Consent Audit
Medicines Management Audit
Prescribing Audit
(Local)
Environmental – Clinical YEH – OPD
Pre/post op/theatre
Environmental – Leeds Site
Antimicrobial Prescribing Audit (Local)

Retained Foreign Object Post Operation
The association for pre operative practice (AFPP 2011) and the association of pre
operative registered nurse (AORN 201) state ‘ a count must be taken for all procedures
where countable objects are used, eg swabs, instruments and sharps.
However guidance has been taken from the WHO guidelines for safe surgery 2009,
which states ‘specific low risk procedures, such as cystoscopy and cataract surgery can
be exempted for the counting protocols.
Retained foreign objects rarely occur due to the nature of our surgery but extra vigilance
is undertaken due to the tiny microscopic sutures used sometimes, and needle counts
are be carried out when they are used.
13

Overdose of Midazolam during conscious sedation
Few procedures require the need for sedation at the Optegra Yorkshire Eye Hospital.
There is always a Consultant Anaesthetist on site for this process and you will be
closely monitored. You will always be fully informed of what to expect pre and post
operatively.
VTE Risk Assessment (Venous Thrombo-Embolism)
From 1 June 2010, the Department of Health (DoH) requires that VTE risk assessments take
place for every patient, and that results are closely monitored in order to reduce the 25,000
preventable deaths that occur in UK hospitals every year. All nurses and health care assistants
need to understand VTE prevention procedures, and the reasons why these procedures take
place.
The National Institute for Clinical Excellence (NICE 2010) recommends that all patients should
be assessed for risk of developing thrombosis (blood clots) on a regular basis, as follows:

every patient should be assessed on admission to hospital

every patient should be assessed again, 24 hours after admission to hospital

every patient should be assessed again, whenever their medical condition changes

every patient should be assessed again before discharge

every patient should receive information on how to continue preventative measures at
home.
Due to the nature of our surgery, operation time is less than 90 minutes and therefore the need
to assess VTE risk is minimal. (anaesthetic and surgical time greater than 90 minutes increases
the risk of developing a VTE)
However, at Optegra Yorkshire Eye Hospital, we adhere to the NICE guideline CG92 by asking
a series of elimination questions at pre assessment to determine any likely risk, and therefore
100% of all patients undergoing surgical intervention are assessed using the DoH assessment
tool. (2010)
Education and Training
During 2015/16 we aim to improve skill mix and enhance staff clinical skills, through education
and training. This will in turn enhance the patient experience and pathway. We will offer a
phlebotomy service for consultant to use and all staff will be trained on visual field examination
and bandage contact lens removal.
14
Infection Control
Infection prevention and control measures aim to ensure the protection of those who might be
vulnerable to acquiring an infection both in the general community and while receiving care due
to health problems, in a range of settings. The basic principle of infection prevention and control
is hygiene. The World Health Organisation
Optegra Yorkshire Eye Hospital understands that ‘good infection prevention and control are
essential to ensure that people who use health and social care services receive safe and
effective care. Effective prevention and control of infection must be part of everyday practice
and be applied consistently by everyone’. The Social Care Act 2008 (updated Jan 2011)
The Infection Prevention & Control Team (IPC)
Tanith Turner-Lumb. Clinical Services Manager
Jackie Mann. RGN. IPC Link Nurse
Dr Miles Denton. Consultant Microbiologist. Leeds
Teaching Hospital (Advisor Capacity)
Michael Horsley. IPC Nurse. Bradford CCG.
(Advisor Capacity)
Optegra Yorkshire Eye Hospital appreciates that effective infection prevention and control is
integral to monitoring risk management. This is not only in maintaining the quality of patient care
but also in the protection of staff and improved attendance in the workplace.
The hospitals infection control processes are coordinated by an experienced senior nurse, who
has support from a Consultant Microbiologist and an Infection Prevention and Control Link
Nurse from Bradford CCG.
The hospital has quarterly Infection Prevention Committee meetings and an updated annual
plan has been submitted and approved for 2015.
The hospital staff has access to up to date infection control policies including one that involves
patients with Ebola and have been involved in a rolling programme of updating on training.
An infection control audit programme has been maintained throughout 2014 and will continue
for the future year. This will include hand hygiene, environmental and decontamination of waste.
15
Infection Control Audits that were undertaken in 2014:
Infection Control audits undertaken and average scores for 2014 were:
Hand Hygiene 99.9% - this was due to a member of staff wearing a wrist watch and wearing a
long sleeved shirt. Further training has been given to staff members about the importance of
‘bare below the elbows’.
Environmental 88.46% - this was due to some areas being missed, and not being dusted.
House keeping did have some staff shortages in 2014. Facilities manager is aware of this issue.
Decontamination 99.9% - this was due incorrect disposal. Paper waste was found in a sharps
bin.
Benchmarking
It is seen that benchmarking or the collection of performance information or measures and
making comparisons with other compatible organisations is maintaining our transparency within
the independent sector providers.
Benchmarking, is now recognised as an essential technique for achieving continuous
improvement, by allowing us to analyse and improve key care processes, eliminate waste, and
improve performance. Benchmarking's strength is that it allows us to make decisions based on
facts, not intuition or 'gut feeling.
Callisto Study – Clare O’Donell. Head of Eye Sciences
We recently successfully completed a clinical evaluation of a new intraoperative imaging system
and were delighted that we were able to invite NHS and private patients attending Optegra
Yorkshire Eye Hospital for cataract surgery, to take part in the study.
In summary, an imaging system was being evaluated that projects a video overlay onto a live
image of the eye that can be seen through the surgical microscope during cataract
surgery. The overlay displays surgical assistance tools including templates for rhexis creation
and reference/target axis templates for toric IOL alignment.
Appropriate approvals were naturally obtained and 72 patients who met the inclusion criteria
(significant corneal astigmatism and undergoing phacoemulsification and intraocular lens
surgery) took part.
Study participants received a commercially available CE-marked Zeiss monofocal toric
intraocular implant (versus a spherical IOL) and the surgeon utilised the intraoperative imaging
system during the surgery on the test group.
The benefits to participants were potentially a better visual and refractive clinical outcome
(through correction of the corneal astigmatism with a toric IOL). Participants were offered a
contribution to expenses incurred.
16
The ophthalmologist investigators (all Consultant Ophthalmic Surgeons) included Yorkshire’s Mr
Shafiq Rehman, who has extensive experience in research and cataract surgery.
The results of this study are being finalised at present and it is envisaged that these will be
submitted for publication in peer reviewed scientific journals in due course. Interim data have
been presented at an international research meeting.
CQUIN Scheme
From April 2013 the Optegra Yorkshire Eye Hospital, entered into a contract with NHS Airedale
Bradford and Leeds for the provision of NHS services, through the Commissioning of Quality &
Innovation Payment Framework (CQUINS). Payment is conditional on achieving quality
improvement in the following area.

Introduction of the Friends and family Test – to improve the experience of patients in
line with domain 4 of the NHS outcomes framework. The friends and family test will
provide timely, granular feedback from patients about their experience.

Goal 1 – to increase the response rate

Goal 2 – improve performance on the staff, friends and family test
Our CQUIN scheme for 2015/16.
The scheme agreed with our commissioners is:


To continue with the Friends and Family Test – to improve the experience of patients
in line with domain 4 of the NHS outcomes framework. Providing timely, granular
feedback from patients about their experience.
Shift from day case to out patient procedure – to reduce the number of procedures
performed as a day case with a corresponding increase in the number of these
procedures performed as an out patient procedure, therefore improving patient
experience.
17
350
300
250
200
150
100
50
0
Ye
arl
JA FE M AP M JU JUL AU SE OC NO DE
y
N B AR RIL AY NE Y G PT T V C
Tot
al
Extremely Likely
Extremely Likely
44 46 29 17 41 31 38 7 18 28 19 6 324
Extremely Unlikely
Likely
14 7
2
0
7
7
7
3
1
7
3
2 60
Neither Likely nor unlikely 0
2
1
0
1
0
0
0
0
1
0
0
5
Unlikely
0
0
0
0
0
0
0
0
0
0
0
0
0
Extremely Unlikely
0
0
0
0
0
0
0
0
0
0
0
0
0
Don’t Know
0
0
0
0
0
0
0
0
0
0
0
0
0
Total
58 55 32 17 49 38 45 10 19 36 22 8
0
Likely
Neither Likely nor unlikely
Unlikely
Don’t Know
Total
Actual Patient Comments:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Excellent professional service, already recommended several people, all members
of staff friendly & give you plenty of time.
Quality treatment.
Location, excellent facilities.
Excellent service, efficient courteous staff, usually no delay except today.
The staff are friendly & welcoming, it makes it a pleasure to visit. If only everyone
was like this ; the world would be a better place! Well Done! 5 *
A high standard of care given in good surroundings.
Good consultant, good waiting room, good staff.
I have found the practice very efficient & helpful.
Extremely likely because of the care & attention I received last time I was here a
month ago.
Friendly staff, treated with respect, clean environment.
Every member of staff polite & efficient. Very good, nice to have a drink too!
Good service & very helpful. Gave me all the info I needed & very good advice for
the future. Would definitely tell friends & family to come here.
"Private" treatment on the NHS.
Very happy with every aspect of care given.
Convenient for me, very relaxing atmosphere, staff very pleasant & extremely
helpful.
Excellent care & attention. Very professional.
I have been happy with my treatment here.
So much nicer than other hospitals!
Good efficient service.
Very pleased with the service.
I think this hospital is excellent & very well run.
Extremely efficient, local to where i live, pleasant surroundings without having to
walk for miles with a hospital. Quality care & service.
Good service & nice people.
Convenience, pleasant surroundings & excellent treatment.
Friendly, efficient & happy atmosphere.
18
•
•
Good care, pleasant environment, good communication, punctual appointments - no
waiting!
Excellent care & treatment & very kind, caring staff.
Patient Experience
Patient feedback in 2014 has shown that the waiting time in the clinic areas for their
appointments has improved on last year and that also on the previous year patients feel more
adequately prepared for their procedure.
Patient evaluation and feedback has and will always continue to be important to us here at
Optegra Yorkshire Eye Hospital, as we strive to make the patients experience the best it can be,
for the moment they walk through the door.

We continue to use the role of Nurse Coordinator for the Day. This is not only for
communicating any outpatient delays but also as a valuable resource when patients
telephone the hospital for any clinical advice.

The reception team, also continue to inform the patients at point of arrival of any clinic
delays. We have found this also works well and reduces anxieties and assists in the
management of patients expectations.

On the day of surgery the patients have access to an emergency telephone number, to
ring to speak to a nurse if they are worried. This has been well received and also helped
in managing the patients post operative recovery phase.

All patients post operative instructions have been reviewed and the patient is now better
informed following their procedure.
Our patient experience survey in 2014
85% of our patients are ‘highly likely to recommend’ our services to their family and friends, this
is an improvement on the 2013 score of 71%.
19
Slide from Optegra Wide Patient Survey
A net promoter score is a
measurement of quality by asking
the patients to score on a scale of
1-10 how likely they would be to
recommend Optegra to their family
and friends.
Staff continue, to encourage patients to comment on their experience and Patient Liaisons and
Consultants continue to receive regular thank you cards.
Clinical Effectiveness
Optegra Yorkshire Eye Hospital has an Integrated Governance committee that meets on a
quarterly basis throughout the year to monitor quality and effectiveness of care. All incidents,
near misses, patient and staff feedback are reviewed to determine any trends that may require
further analysis or investigation. Recommendations for action and improvement are escalated to
the Integrated Governance Steering Committee where lessons learned and actions are shared
and disseminated to all Optegra hospitals. This process re-enforces our open and honest
culture of patients safety incident reporting and aids in disseminating lessons learnt and aligning
best practice at all times.
Quality Data and Audit
Optegra Yorkshire Eye Hospital continues using its NHS N3 connectivity; this enables our NHS
team to communicate securely and safely via the NHS.net email account. This also allows our
activity and financial data to be received via the Service Users System (SUS).
Staff use the NHS Choose and Book system, which enables patients to access our services
with ease and helps our clinical team triage the patients referral for the best possible care.
During 2015/16 reporting via this system will be monitored with our commissioners to ensure
accuracy and financial payments are made in line with the Payment by Results Framework
2014/15.
20
Optegra Yorkshire Eye Hospital will improve on its Quality data reporting and submit the agreed
quality and performance reports to the commissioners on a monthly basis during 2015/16.
Statements of Assurance on Quality
In accordance with The National Health Service (Quality Accounts) Regulations 2010 Optegra
Yorkshire Eye Hospital makes the following statements of assurance:

During 2014/15 the Optegra Yorkshire Eye Hospital provided Ophthalmology
services to the NHS through the NHS Standard Acute Contract. It did not
subcontract out any of those services.

The Optegra Yorkshire Eye 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 2014/15 represents 100 per cent
of the total income generated from the provision of NHS services by the Optegra
Yorkshire Eye Hospital for 2014/15.

During 2014/15 no national clinical audits or national confidential enquiry covered
NHS services that the Optegra Yorkshire Eye Hospital provides.
National Clinical Audits for this period was 0 out of the 51of the inclusion criteria (o%) as they
were not pertinent to the ophthalmic speciality.
The National Confidential Enquires (NCEPOD) for this period was 1/1 of the inclusion criteria
(100%).
The Optegra Yorkshire Eye Hospital carried out the following hospital clinical audits:
21
Clinical Audit Matrix 2014
Jan
Area
Feb
Mar
May
Jun
July
93%
Documentation Audit
Aug
Sep
Oct
Nov
Dec
100
%
99.8
%
Decontamination Audit
Hand Hygiene Audit
Apr
100
%
100
%
98%
100
%
Clinical Waste Pre-Acceptance Audit
Lens Checking Protocol Audit
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
WHO Surgical Safety for Cataract
Surgery Audit
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
100
%
Consent Audit
Medicines Management Audit
94%
(Local)
Prescribing Audit
98%
(Local)
100
%
97.6
%
Environmental – Clinical YEH – OPD
Pre/post op/theatre
95.5
%
72%
Environmental – Leeds Site
Antimicrobial Prescribing Audit (Local)
90%
90%
Optegra Yorkshire Eye Hospital intends to continue with the following actions to improve,
maintain quality and patient safety of the healthcare provided.



Continue to monitor adherence to the Lens checking protocol - monthly
Adhere to the WHO recommendations on Safer Cataract Surgery and continue
with the implementation for other surgery.
Ensure audits are relevant and comply with National guidance and standards
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The number of patients receiving NHS services provided by the Optegra
Yorkshire Eye Hospital in 2014/15 that were recruited during that period to
participate in research approved by a research ethics committee was nil.
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The Optegra Yorkshire Eye Hospital income in 2014/15 was conditional on
achieving quality improvement and innovation goals through the Commissioning
for Quality and Innovation (CQUIN) payment framework.

The Optegra Yorkshire Eye Hospital is required to register with the Care Quality
Commission and its current registration status is registered. The Optegra
Yorkshire Eye Hospital has the following conditions on registration: None

The Care Quality Commission has not taken enforcement action against
Yorkshire Eye Hospital during 2014/15.

The Optegra Yorkshire Eye Hospital was registered during this period under the
Health and Social Care Act 2008
Care Quality Commission (CQC)
The Optegra Yorkshire Eye Hospital is subject to periodic reviews by the Care Quality
Commission and the last review was 23rd September 2013. The CQC’s assessment of the
Optegra Yorkshire Eye Hospital following the review was full compliance achieved against
outcomes;
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Respecting and involving people who use the services
Care and Welfare of people who use the services
Cleanliness and infection control
Supporting workers
Assessing and monitoring the quality of service provision
The CQC also reviewed Optegra Yorkshire Eye hospital Leeds Laser Site on 12 th December
2013. The CQC’s assessment of the site following the review was full compliance achieved
against outcomes;
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Consent to care and treatment
Care and welfare of people who use the services
Safety, availability and suitability of equipment
Requirements relating to workers
Assessing and monitoring the quality of service provision.
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Optegra Yorkshire Eye Hospital are working hard with all its staff to prepare for the new 5 key
areas of inspection:
Safety
Caring
Well Led
Responsive
Effectiveness
Statement of Quality Delivery
The Optegra Yorkshire Eye Hospital operates a quality framework to ensure it is
accountable for improving the quality of its services and safeguarding the highest
standards in creating an environment where clinical care will excel.
National Institute for Clinical Excellence. N.I.C.E. Guidelines
At Optegra Yorkshire Eye Hospital, all our Consultant practice in accordance with NICE
guidance and all have a practising privileges contract. All our clinical staff practise, within CQC
and NICE guidelines and within the NMC code of conduct. All our nurses and ODPs are
registered with the NMC and HcPc.
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Relevant guidelines for practice include:
https://www.nice.org.uk/guidance
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Aflibercept solution for injection for treating wet age‑related macular degeneration.
TA294. September 2013
Implantation of multifocal (non-accommodative) intraocular lenses during cataract
surgery. IPG264. June 2008.
Implantation of accommodating intraocular lenses for cataract. IPG209. February 2007.
Ranibizumab for the treatment of age-related macular degeneration. TA155. May 2012
Glaucoma quality standard. QS7. March 2011
Patient group directions. MPG2. August 2013
Pre operative testing for elective surgery. CG3. June 2003
Surgical site infections. QS49. October 2013
Risk assessment for Venous Thromboembolism (VTE). CG92. March 2010
Safeguarding Adults and Children
The Optegra Yorkshire Eye Hospital undertook a local programme of education for its clinical
staff members for the safeguarding of vulnerable adults during 2014.
Following several reports and enquiries into safeguarding (such as the Winterbourne View,
Francis Enquiry and Saville Enquiry) Optegra Yorkshire Eye Hospital has recognised the
importance of working closely with relevant safeguarding boards, for both children and adults.
With this in mind further safeguarding training has been attended and policies put in place to
protect patients accessing our services.
There are two link nurses on site, one for adults and paediatric trained nurse for children, both
also have had extra training on recognising and responding to domestic abuse and
radicalization of minors and are both government registered to deliver WRAP training. All staff,
including administrative, have had access to training on the mental capacity act, deprivation of
liberties and safeguarding children.
We have a comprehensive up to date resource file for staff to access, and now have policies on
restraint and safeguarding children to protect those who may be vulnerable.
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Return to Theatre
The Optegra Yorkshire Eye Hospital treats between 300 and 400 patients for surgery each
month. This is planned surgery, and monitoring the numbers of patients who return to theatre is
very important. The value is to identify any trends in either the surgical procedure or a specific
surgical team.
The Optegra Yorkshire Eye rate of return is very low, in 12 years the Optegra Yorkshire Eye
Hospital has undertaken over 25,000 surgical procedures with only 6 returns to theatre.
During 2014 we had no patient requiring a return to theatre.
Staffing in the Work place
The Optegra Yorkshire Eye Hospital has a dedicated team of clinical staff with extensive
knowledge and experience in Ophthalmology.

Sickness, absence rates and staff turnover rates for 2014 are 5% turnover and
4.9% absence
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Staff appraisals are undertaken annually, and reviewed at 6 months, these directly
link to Optegra UK's performance and training systems. The following work has
been undertaken again in 2014, to improve on training and development,
communication and reward and recognition.
 Talent Management
 Communication
 Reward & Recognition
Long Service Awards
Shared Values Recognition
Raffle ticket awards for exceptional work
The number of significant staff injuries was none for the period 2014/ 2015
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Part 3
Review of our Quality Performance 2014
“A Look Back”
The following are the areas for improvement that were highlighted in the Optegra Yorkshire Eye
Hospital Quality Accounts for the period 2014 and will remain on our agenda for 2015

To continue to evaluate and audit the Lens checking protocol.
The Optegra Yorkshire Eye hospital continued with the lens checking protocol audit on a
monthly basis. This audit is carried out by a different member of the clinical team every month
and we have found that this responsibility has helped to instill confidence, pride and a sense of
achievement within the team. We have achieved 100% compliance in this process during 2014.
Due to the success and recognised significance in safety, it has been introduced moving
forward into 2015, for all surgical interventions.
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Patient communication
Patient feedback in 2014 has shown that the waiting time in the clinic areas for their
appointments has improved on last year and that also on the previous year patients felt more
adequately prepared for their procedure.
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We introduced the role of Nurse Coordinator for the Day, which has continued and has
been used for communicating any outpatient delays as well has being used as a valuable
resource when patients telephone the hospital for any clinical advice.
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The reception team began to inform the patients at point of arrival of any clinic delays.
We have found this worked well and reduce anxieties and assisted in the management of
patient’s expectations.
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On the day of surgery the patients had access to an emergency telephone number, to
ring to speak to a nurse if they are worried. This has been well received and also helped
in managing the patients post operative recovery phase.

All patients post operative instructions have been reviewed and the patient is now better
informed following their procedure.
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Eliminating Mixed Sex Accommodation (EMSA)
The Optegra Yorkshire Eye Hospital has an EMSA plan in place and has submitted its monthly
report to the commissioner during 2014/15
There were no breaches during this period.
The Optegra Yorkshire Eye Hospital displayed on its website a declaration of compliance to
EMSA as set out by the DOH.
Complaints
The Optegra Yorkshire Eye Hospital has received No formal complaints during 2014.
We believe that listening to our patients and acting upon their suggestions has helped with
continual improvement throughout 2014 and is fundamental in providing the highest quality
ophthalmic care, which we know, is high on our patient and commissioners agenda.
Quality patient care is at the heart of all staff work at Optegra Yorkshire Eye Hospital and we all
strive to make the patients experience the best it can be, for the moment the walk through our
doors.
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Glossary of Abbreviations.
CQC
Care Quality Commission
CQUINS
Commissioning for Quality and Innovation
DOH
Department of Health
EMSA
Eliminating Mixed Sex Accommodation
EU
European Union
IOL
Intra ocular lens
IPC
Infection Prevention and Control
VTE
Venous Thromboembolism
WHO
World Health Organisation
TDTL. CSM. May 2015. OYEH Quality Accounts Report
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