UKSH SOUTH WEST
QUALITY ACCOUNT
2009–2010
Emersons Green
NHS Treatment Centre
Devizes
NHS Treatment Centre
Cirencester
NHS Treatment Centre
Contents
Executive summary
About UKSH South West
About this report
Part 1 Statement by the chief executive
Part 2 Quality objectives and mandatory statements
Objectives for quality improvement
Reducing cancellations on the day
Increasing VTE risk assessments
Improving VTE prophylaxis
Improving MEWs documentation
Antibiotic surgical prophylaxis
Mandatory statements
Review of services
Audits
Research
CQUIN framework
Statements from the Care Quality Commission
Data quality
Safeguarding statement from the UKSH Board
Part 3 Review of quality performance in 2009−10
Patient experience and feedback
Clinical quality and outcomes
Monitoring quality performance - regular clinical review
Statements from NHS South Gloucestershire and South Gloucestershire Health Scrutiny Select Committee
2
UK SPECIALIST HOSPITALS
UKSH takes pride in providing the best
possible service to patients throughout
their care, from first appointment to our
follow-up contact with them after treatment.
QUALITY ACCOUNT 2009–2010
3
Explanation of terms used in this report
CQC
CQUIN
DH
DVT
MEWS
IRMA
PCT
PE
PROMs
UKSH
UKSH SOUTH WEST
VTE
4
Care Quality Commission
Commissioning for Quality and Innovation
Department of Health
Deep-vein thrombosis
Modified Early Warning Score
Image Retrieval in Medical Applications
Primary Care Trust
Pulmonary embolism
Patient-Reported Outcome Measures
UK Specialist Hospitals
The three centres opened in 2009: Cirencester / Devizes / Emersons Green
Venous thromboembolism
UK SPECIALIST HOSPITALS
Executive summary
UK Specialist Hospitals (UKSH) has opened
three new NHS treatment centres in the
South West during 2009-10. All have
delivered excellent clinical outcomes and
quality of care to NHS patients, building
on the outstanding five-year track record of
their sister site at Shepton Mallet.
These achievements mean we are able
to set ambitious targets for the coming
year across all our sites. Our key priority
for improvement is to ensure the highest
standards in patient safety, thereby paving
the way for the best clinical outcomes.
Our specific targets for 2010−11 are:
Ensure the rate of cancellations on the
day of surgery is no more than 4%
Carry out risk assessments for VTE
(blood clots) for at least 95% of
patients
During 2009-10 – in the five months
since opening in November 2009 – the
three UKSH South West sites have already
produced results which compare favourably
with established healthcare organisations.
Patient satisfaction is 98.5%,
waiting times are low, lengths of
stay are better than the national
average and clinical outcomes
are excellent.
We have had no cases of hospitalacquired MRSA bacteraemia or
C. difficile.
This Quality Account shows our determination
to build on these strong foundations –
continually seeking to improve clinical
outcomes and patient experience.
Ensure that 100% of patients identified
as being at risk of VTE receive the
appropriate preventative measures
Carry out documented MEWS (Modified
Early Warning Score - a system for
detecting changes in a patient’s
condition) measurements for at least
95% of patients
Ensure that 100% of patients receive
appropriate antibiotic surgical
prophylaxis according to protocol
QUALITY ACCOUNT 2009–2010
5
About UKSH South West
UKSH South West operates three treatment
centres in the South West. The main
facility is situated in North Bristol at
Emersons Green and the other two centres
are in Devizes, Wiltshire and Cirencester,
Gloucestershire.
UKSH South West works with its local
NHS partners, including seven Primary
Care Trusts, to offer high-quality, rapid
access to planned treatments across a
range of specialties for NHS patients.
These PCTs are NHS Bristol, NHS South
Gloucestershire, NHS North Somerset,
NHS Swindon, NHS Wiltshire, NHS
Gloucestershire and Bath, and North East
Somerset NHS.
All three centres opened in November
2009. The centres at Emersons Green
and Devizes are new, purpose-built
surgical hospitals. The centre in
Cirencester is housed in a refurbished
section of the existing Cirencester Hospital.
UK Specialist Hospitals (UKSH), the
parent company of UKSH South West, also
operates the Shepton Mallet NHS Treatment
Centre in Somerset. This site opened in
July 2005 and has treated over 40,000
NHS patients to date. We employ over
300 skilled clinicians and support staff
at our centres across the South West.
We treat a broadly similar patient population
to that of a typical district NHS hospital,
including elderly patients with stable
chronic conditions such as diabetes.
6
UK SPECIALIST HOSPITALS
Because of its setting and clinical mission, UKSH does not undertake unplanned
surgery. Also, any patients with unstable
co-morbidities discovered at the time of
pre-admission are referred elsewhere for
management of their condition. Similarly,
because there is no post-operative critical
care unit, any patients expected to need
this degree of support would be rerouted
to an acute district general or specialist
hospital.
Emersons Green NHS Treatment Centre
At Emersons Green in Bristol NHS
patients can access planned procedures
including joint replacements, minor
orthopaedics, ophthalmology, endoscopy,
general surgery, dental extractions,
gynaecology, ear, nose and throat treatments,
urology and diagnostic services.
Emersons Green offers day case and
inpatient treatment through its 33-bed
facility. It has four operating theatres, an
endoscopy suite, a day surgery facility, a
comprehensive diagnostic department and
physiotherapy services.
Devizes NHS Treatment Centre
The centre at Devizes delivers a
comprehensive range of day case
procedures. It also offers convenient
outpatient appointments for procedures
such as joint replacements, for which the
surgery is then undertaken at Emersons
Green.
More information about UK Specialist
Hospitals and its treatment centres in the
south west are available on the website
www.uk-sh.co.uk
Devizes NHS Treatment Centre
offers services to NHS patients in the
following areas: ophthalmology, minor
orthopaedics, ear, nose and throat
procedures, gynaecology, urology, dental
extractions, endoscopy, general surgery
and diagnostic services.
Cirencester NHS Treatment Centre
The Cirencester NHS Treatment Centre
specialises in day case procedures in
several specialty areas: minor orthopaedics,
ear, nose and throat procedures, gynaecology,
urology, dental extractions, general surgery
and diagnostic services.
As at Devizes, patients can have their
outpatient appointment at Cirencester
and then the surgery at Emersons Green
hospital.
More information about UK Specialist
Hospitals and its treatment centres in the
South West is available on the website
www.uk-sh.co.uk
QUALITY ACCOUNT 2009–2010
7
About this report
UKSH is pleased to participate in the
Department of Health’s new Quality
Accounts reporting system.
UKSH has previously produced regular
reports on performance data such as
numbers of operations and the success
of the outcomes for its facility in Shepton
Mallet. These are published on our website
(www.uk-sh.co.uk) and will be replicated
for our new sites in the South West on an
annual basis starting in November 2010.
Quality Accounts complement this
information by placing particular focus
on the quality of patient experience. They
allow for comparability across providers
and also give us the opportunity to identify
areas for future improvement and to
monitor our success in delivering on these.
The structure of our report follows the
guidelines from the Department of Health
and is arranged as follows:
8
UK SPECIALIST HOSPITALS
Part 1
Statement by the chief executive
Part 2.1Priorities for future improvements and details on how we plan to achieve them
Part 2.2Information on areas common to all providers, following detailed guidelines set by the Department of Health
Part 3
Performance report for 2009−10 on the quality of care provided at UKSH South West NHS
Treatment Centres
This Quality Account relates to our facilities
in Emersons Green (Bristol), Cirencester
and Devizes. A separate Quality Account
is available for our sister site at Shepton
Mallet.
As the UKSH South West sites only
opened in November 2009 this report
relates to the five months of 2009–10
during which we were operational.
The model of focused care which underpins
the service we provide across our centres has
enabled us to deliver excellence in clinical
outcomes.
QUALITY ACCOUNT 2009–2010
9
Part 1
Statement by the chief executive
UK Specialist Hospitals (UKSH) welcomes
the introduction of Quality Accounts into
the NHS. Meaningful data provision is
a cornerstone of our model of care and
UKSH has always given patients and
commissioners detailed information about
clinical outcomes and patient experience.
We believe this is crucial to enable
patients to exercise proper choice and to
hold NHS service providers to account.
The focus on quality of care which is at
the heart of this new reporting system is
important to us. UKSH takes pride in
providing the best possible service to
patients throughout their care, from first
appointment to our follow-up contact with
them after treatment.
The model of focused care which underpins
the service we provide across our centres
has enabled us to deliver excellence in
clinical outcomes. The six principles
governing our approach are: insistence on
clinical best practice; extremely careful
recruitment; ongoing staff training; intensive
monitoring of performance; extensive
reporting on patient satisfaction and
clinical data; and full implementation
of patient safety guidelines. These are
implemented so that care is responsive
to individual needs with flexible patientfocused pathways.
This approach has led to some outstanding
clinical results. For example, we have
a zero rate of hospital-acquired MRSA
bacteraemia and low rates of re-admission
and clinical complications at all our sites.
The baseline from which we start in
2010−11 is therefore high. This Quality
Account now sets us the challenge to
further improve our performance, and in
response we have identified areas where
we can take specific measures to attain the
very highest standards in patient experience,
patient safety and clinical effectiveness.
Our priorities for improvement in the
coming year arise from patient feedback,
our own insight into where we can further
refine clinical success, and from wider
national healthcare objectives to which we
contribute. We will be seeking to exceed
local, regional and national NHS targets
and to respond directly to what patients
tell us is important to them.
We will take initiatives to reduce the number
of cancelled operations, minimise the risk
of blood clots and improve recognition of
early warning signs during treatment so
that action can be taken to ensure patient
safety and excellent clinical outcomes.
I am confident that through the commitment
of our staff and the support and advice
from our independent Clinical Advisory
Board and UKSH Board we will deliver on
these objectives and continue to provide
high-quality patient care.
I confirm that to the best of my knowledge
the information presented in this document
is accurate.
Fiona Calnan Chief Executive
10
UK SPECIALIST HOSPITALS
Part 2
Quality objectives
In 2010−11 UKSH South West NHS
Treatment Centres aim to improve quality
of care in five areas:
Cancellations on the day of surgery
Risk assessments for VTE (blood clots)
Measures to prevent VTE for at-risk
patients
Documentation for MEWS – the early
warning system for detecting changes
in a patient’s condition
Our specific targets for 2010−11 are:
Ensure the rate of cancellations on the
day of surgery is no more than 4%
Carry out risk assessments for VTE
(blood clots) for at least 95% of
patients
Ensure that 100% of patients identified
as being at risk of VTE receive the
appropriate preventative measures
Correct use of antibiotics
Carry out documented MEWS
measurements for at least 95% of patients
These priorities will ensure higher standards
across all the key factors that make up
successful healthcare: patient experience,
patient safety and clinical effectiveness.
Ensure that 100% of patients receive
appropriate antibiotic surgical
prophylaxis according to protocol
QUALITY ACCOUNT 2009–2010
11
As part of our ongoing commitment to
providing the best possible service to our
patients, we will prioritise these objectives
to ensure the quality of care at our centres
is of the highest standard over the next
twelve months.
This is in part due to our insistence on
minimising unnecessary risk to patients.
Building on this strong foundation we are
able to focus on areas where we believe we
can continue to improve our clinical
effectiveness.
In selecting these objectives we have
considered each of the key aspects of
healthcare as determined by the
Department of Health: patient experience,
patient safety and clinical effectiveness.
Some of our commitments will address
more than one of these areas: for example,
our priorities for improving patient safety
during operations will also improve the
clinical outcomes of those procedures.
Progress on achieving these goals will
be monitored on a monthly basis by the
Board of UK Specialist Hospitals and the
Clinical Advisory Board and we will report
back to you on this in next year’s Quality
Account. More information about our
monitoring processes and monthly clinical
review is given in part 3 below.
UKSH has an exceptionally strong record
on clinical quality and outcomes.
12
Our objectives and the initiatives we will
take to achieve them can be summarised
as follows:
Objective
Target
Key healthcare
area
Initiatives planned
for 2010-11
Low rate of
cancellations on
the day
Ensure on the
day cancellation
is no more than 4%
Patient
experience
•
•
•
Increase risk
assessments for
VTE (blood clots)
At least 95% of
patients receive
risk assessment
Patient safety
& Clinical
effectiveness
• Staff training in new VTE e-learning tool
• All patients to receive literature on
VTE prevention
Improve VTE prophylaxis
(measures to prevent
at-risk patients
developing blood clots)
100% of patients
receive appropriate
preventative
measures
Patient safety
& Clinical
effectiveness
• VTE prevention part of mandatory,
ongoing staff training
• Involve more staff in review of VTE audits
Improve MEWS
documentation
MEWS documentation for
at least 95% of patients
Patient safety &
Clinical effectiveness
• Quarterly audits to ensure increased staff training is effective
Safe use of antibiotics
100% of patients receive
appropriate antibiotic
prophylaxis
Patient safety
• Quarterly audits
• New training if necessary
UK SPECIALIST HOSPITALS
Check patients’ understanding of
pre-operation guidance
New staff guidelines on pre-operative
tests
Better training for booking staff
Reducing cancellations on the day
– for a better patient experience
We take pride in our ability to offer dates
for surgery where all parties have confidence
that the procedure will go ahead on the
planned date. Over 92% of procedures
take place as anticipated on the day of surgery.
While this is a strong record, we want
to address that remaining 8% of cases,
because we know that cancellation on
the day of a planned operation is not only
inefficient, but also causes distress and
inconvenience to the individuals affected.
Patient feedback has alerted us to this
concern, and we have explored the issue
in focus groups.
We can identify both clinical and non-clinical
ways to address cancellations on the day:
Clinical:
Ensure pre-operative guidance for
patients is followed
Take appropriate actions following
test results
Non-clinical:
Ensure specific equipment needed
is available
Communicate fully with patients to reduce cases of DNA (‘does not attend’)
UKSH has a series of systems and processes
already in place to reduce these occurrences,
including a dedicated team of clinical
staff who contact all patients prior to
surgery.
Although some cancellations are not
preventable, for example those due to
patient illness or adverse weather conditions
making travel difficult, we believe we can
be even more successful in minimising the
remaining number.
Target:
Reduce cancellations on the day of surgery
to no more than 4%, so that at least 96%
of operations go ahead on the planned date
This will be measured as the average
on-the-day cancellation rate for the last
6 months of next year, allowing the first
6 months as a period to implement the
improved protocols. The measurement
will include all cancellations, even those
caused by events which are beyond our
control.
As a first step we have examined the
implementation of the internal written
guideline on the management of preoperative tests for Resident Medical
Officers that we have had in place since
opening. This identifies patients whose
test results have either not been returned
or that reveal additional actions need to be
taken. It ensures timely and appropriate
action is taken wherever possible to
prevent cancellation.
We plan to supplement the implementation
of this guideline with a series of initiatives
that will help us achieve our target to
reduce cancellations on the day, including:
QUALITY ACCOUNT 2009–2010
13
Immediate actions
Staff in the Outpatient department to
check each patient’s understanding of
the pre-operative guidance before they
leave the treatment centre.
All patients to receive reminder
notifications prior to surgery, and
UKSH to measure success rates of
contacting patients.
To be implemented within three months
Implementation of procedures to ensure
that social care or home equipment
packages are delivered and verified
prior to surgery.
Train booking staff in the completion of
booking forms which highlight specific
equipment requirements to ensure
equipment availability.
Monitoring the time elapsed between
outpatient appointments and surgery
to ensure that tests such as MRSA
swabs are still current.
14
UK SPECIALIST HOSPITALS
Increasing VTE risk assessments
– to improve patient safety and clinical
effectiveness
Our second objective relates to the
nationwide drive to reduce the risk to
patients from blood clots (VTE) – one of
the NHS’s Commissioning for Quality and
Innovations (CQUIN) goals for 2010−11.
This national initiative is supported by
new guidelines published by the National
Institute for Clinical Excellence (NICE) in
January 2010: ‘CG92 Venous
Thromboembolism − Reducing the Risk’.
Venous thromboembolism (VTE) is the
formation of a blood clot in the veins. It
most commonly occurs in the deep veins
of the leg or pelvis, when it is known as
deep-vein thrombosis (DVT). An embolism
occurs if all or part of the clot breaks off
from the site where it forms and travels
through the venous system. If it lodges in
the lungs, this is called pulmonary embolism
(PE). Deep-vein thrombosis (DVT) and
pulmonary embolism (PE) are the most
common manifestations of VTE and are a
significant complication of surgery, with an
associated incidence of mortality.
With approximately 25,000 people dying
of preventable VTE every year in the UK,
it is clear that this is a crucial area for
improvement nationally. At UKSH we have
an excellent record on the prevention of
VTE, with no VTE-related mortality, and we
will continue to play our part in raising the
standards across the country.
At UKSH we have already implemented
much of what is set out in the new NICE
guidelines: we have incorporated a VTE
risk-assessment tool into the clinical care
pathway for our patients, and regular
internal audits are undertaken to monitor
compliance with this tool. In 2010−11
we will adopt the revised VTE risk-assessment
tool which has been produced by the
Department of Health, and we will comply
with the new reporting framework.
We currently carry out risk assessments
for all our patients except those undergoing
ophthalmic treatments and endoscopy,
where the risk of VTE is low because the
procedures are relatively non-invasive.
However, in line with the new guidelines,
going forward we will include all patients
in the risk assessments.
In order to make a real contribution to
this national initiative, our own target for
increasing VTE risk assessments will be
higher than the target set nationally, to
reflect the high baseline we have already
achieved across all our centres.
Target:
At least 95% (national target 90%) of
patients admitted to our centres will be
assessed for risk of VTE
Because UKSH South West opened during
2009−10, a complete set of audited
baseline data for last year is not available.
QUALITY ACCOUNT 2009–2010
15
New initiatives in 2010−11 will include:
Training in use of the new VTE e-learning
tool from the Department of Health for
all staff. This will be incorporated as
part of the induction and mandatory
training programme for staff.
Provision of patient literature on VTE
prevention for all patients, irrespective
of their need for preventative measures
(prophylaxis). Currently UKSH provides
patient literature to all patients
receiving prophylaxis.
The implementation of these initiatives will
be led through our Clinical Governance
committee and will be monitored on a
monthly basis.
16
UK SPECIALIST HOSPITALS
99.7% of our patients say they would
recommend our treatment centre to a friend.
QUALITY ACCOUNT 2009–2010
17
Improving VTE prophylaxis
– to maximise patient safety and
clinical effectiveness
In addition to implementing the new
NICE guidance on risk assessments for
VTE, UKSH will ensure that every patient
identified as being at increased risk of VTE
receives appropriate preventative measures
(prophylaxis).
The 2010 national guideline on VTE
published by NICE includes specific
recommendations for VTE prophylaxis
for different kinds of operation. We have
already incorporated these recommendations
into our VTE policy. The recommended
preventative measures include giving
patients compression stockings,
special pressure boots during and after
the procedure and prescribing
antithromboembolytic medication (to thin
the blood temporarily).
Target:
100% of patients identified as being at
increased risk of VTE receive the
recommended mechanical and
pharmacological prophylaxis at the right
time and for the appropriate duration
Because UKSH South West opened during
2009−10, a complete set of audited
baseline data for last year is not available.
18
UK SPECIALIST HOSPITALS
New initiatives in 2010−11
VTE assessment/prevention updates as
part of standard mandatory training to
ensure all staff are aware of the
significance of this initiative on an
ongoing basis.
Review of VTE audits at specialtybased clinical meetings in addition to
the standard review at clinical
governance meetings to ensure that
clinicians and all members of the
multidisciplinary team understand
their responsibility for delivering the
initiative.
We will carry out internal audits on a
quarterly basis to ensure that all patients
at risk of developing VTE are receiving the
appropriate prophylactic measures.
Improving MEWS documentation
– to maximise patient safety and clinical
effectiveness
The Modified Early Warning Score (MEWS)
is a method of monitoring patients that
allows changes in their condition to be
recognised in time for action to be taken.
This can be crucial in ensuring successful
clinical outcomes.
The MEWS system is based on routine
observations and is sensitive enough
to detect subtle changes in a patient’s
physiology. All patients have their vital
signs measured and these are converted
into a score. If the scores reach above a
certain threshold, a doctor must be called
to assess the patient. This process will
identify patients who may need transfer to
an acute hospital for timely and
appropriate interventions.
UKSH will therefore focus on ensuring
that its staff carry out and document
MEWS checks.
Target:
Carry out documented MEWS
measurements for at least 95% of patients
Because UKSH South West opened during
2009−10, a complete set of audited
baseline data for last year is not available.
Quarterly audits will be undertaken to
assess compliance and will continue to
be monitored at our Clinical Governance
meetings.
For the MEWS system to work it is vital
that the measurements are taken routinely
and properly documented. This ensures
that a baseline status for each patient
is established and any deterioration is
quickly recognised.
QUALITY ACCOUNT 2009–2010
19
Antibiotic surgical prophylaxis
– to improve patient safety
Our final objective is to ensure the safe
use of antibiotics at our treatment centres,
in order to fight infections effectively.
While rates of both hospital-acquired
MRSA bacteraemia and C. difficile are
currently nil at our new facilities, we are
keen to participate in nationwide initiatives
to reduce all healthcare-associated infections
in healthcare settings.
Antibiotics are an important tool in treating
patients and preventing infections. At the
same time, the inappropriate use of
antibiotics can in some cases leave
patients more exposed to other infections.
Nationally, while significant reductions
have been achieved in recent years in the
occurrence of MRSA bacteraemia and C.
difficile infections, new guidelines now
show that better-targeted antibiotics can
prevent a wider range of infections.
Current evidence demonstrates that the
use of broad-spectrum antibiotics makes
patients more susceptible to harmful
antibiotic-resistant bacteria such as
Extended-Spectrum Beta-Lactamase
(ESBL) gram negative bacteria.
Broad-spectrum antibiotics should
therefore be avoided unless there are clear
indications for their use. We have updated
our Antimicrobial Surgical Prophylaxis
protocol in 2009 in line with this national
guidance.
Monitoring the use of antibiotics within
the healthcare setting is a key initiative in
the NHS Saving Lives campaign.
20
UK SPECIALIST HOSPITALS
To ensure that all patients are receiving
appropriate prophylaxis but not receiving
unnecessary antibiotic treatment, UKSH
will audit quarterly the prescribing and
administration of antibiotic use against
the agreed protocols.
Target:
100% of patients are prescribed and
receive the appropriate antibiotic surgical
prophylaxis according to protocol
This means:
100% of patients receive one dose of
antibiotic(s) pre-operatively on induction
of anaesthesia or within 60 minutes prior
to incision
The clinical indication of additional use of
antibiotic is recorded in 100% of cases
Because UKSH South West opened during
2009−10, a complete set of audited
baseline data for last year is not available.
New initiatives in 2010−11:
Sharing of this audit at all specialtybased meetings as well as Infection
Control meetings
If we find non-compliance we will
introduce update training for staff to
rectify this
We are keen to participate in nationwide
initiatives to reduce all healthcare-associated
infections in healthcare settings.
Mandatory statements
The following section contains the
mandatory statements common to all
Quality Accounts as required by the
regulations set out by the Department
of Health.
Review of services
During 2009−10 UKSH South West NHS
Treatment Centres provided the following
NHS services:
• Orthopaedics surgery
(Joint replacements and Minor)
• General Surgery
(including colonoscopy)
• Ophthalmic Surgery
(including cataracts and minor
eyelid procedures)
• Oral Surgery
• Minor Urology including cystoscopy
• Gynaecology
• Ear Nose and Throat Surgery
• Imaging (X-ray and Ultrasound)
UKSH South West has reviewed all
available data on the quality of care in
these NHS services.
Audit
During 2009−10, two national clinical
audits and no national confidential
enquiries covered NHS services that
UKSH South West provides.
During that period UKSH South West
participated in 100% of the national
clinical audits and 100% of the national
confidential enquiries in which it was
eligible to participate.
The national clinical audits and national
confidential enquiries that UKSH South
West participated in during 2009−10
are as follows:
• PROMs (4 specialties)
• NJR Hip and knee replacements
The national clinical audits and national
confidential enquiries that UKSH South
West participated in, and for which
data collection was completed during
2009−10, are listed below alongside the
number of cases submitted to each audit
or enquiry as a percentage of the number
of registered cases required by the terms
of that audit or enquiry.
The income generated by the NHS services
reviewed in 2009−10 represents 100% of
the total income generated from the
provision of NHS services by UKSH South
West for 2009−10.
National
Specialty
QUALITY ACCOUNT 2009–2010
21
National
Specialty
clinical audit
PROMs
Hip replacements
98.7%
PROMs
Knee replacements
97.2%
PROMs
Hernias
97.3%
PROMs
Varicose veins
100%
NJR
Hip replacements
100%
NJR
Knee replacements
100%
The reports of 2 national clinical audits
were reviewed by the provider in 2009−10
and UKSH South West intends to take the
following actions to improve the quality of
healthcare provided.
PROMs (Patient Reported Outcome
Measures) measure how patients perceive
their health has improved following
treatment. From 1 April 2009, all
providers of NHS-funded care have
collected PROMs information. So far,
the NHS Information Centre has published
only pre-operative data. Post-operative
information will be published during the
summer of 2010 and this will allow the
effect of treatment to be assessed.
Because we are waiting for the results of
this ongoing audit, no action has yet been
taken, except for discussions at board level
about the completeness of PROMs data.
22
Cases submitted as
percentage of cases required
UK SPECIALIST HOSPITALS
The National Joint Registry (NJR) is a
monitoring database which tracks joint
replacement procedures carried out
throughout England and Wales. Since
opening in November 2009 Emersons
Green NHS Treatment Centre has submitted
100% of its hip and knee procedures
to the NJR. As newly opened facilities,
UKSH South West will not receive data
back from the NJR until next year, when it
will review the results.
Results on all procedures, including hip
and knee replacements, are routinely
monitored through our internal clinical
governance processes. These show
excellent clinical outcomes.
The reports of 8 local clinical audits were
reviewed by the provider in 2009−10,
and UKSH took all appropriate actions to
improve the quality of healthcare provided.
The local clinical audits carried out were:
Audit
Action
Monitoring results
Hand hygiene
Comply with HPA
requirements
Quarterly
Infection prevention
& control
Comply with HPA
requirements
All positive results audited,
identifies any organism trends
Waste − clinical
& non-clinical
Comply with: HPA Health
& Safety requirements
Quarterly
Sterile Services
Ensure ongoing compliance
with QMS 13485
Monthly tray list
Information
Governance
Ensure ongoing compliance
with: ISO 27001 IGSOC
Six-monthly external audits.
Rotational internal audit
plan in place
World Health Organisation
(WHO) surgery checklist
Comply with WHO
guidelines
Monthly audit
Medical staff
Comply with skills, experience
and competency standard as
set by the External Clinical
Advisory Board
Start of engagement; then
at 3 months; then annual
or as required
Resuscitation
Ensure best practice in
resuscitation technique
Bi-monthly audit
Pharmacy including
Controlled Drugs audits and
Prescription chart audit
Comply with National Policy
& Legislation
Monthly
Record keeping
Ensure best practice in
record keeping
Monthly Audit
QUALITY ACCOUNT 2009–2010
23
Research
The number of patients receiving NHS
services provided by UKSH South West in
2009−10 that were recruited during that
period to participate in research approved
by a research ethics committee was nil.
CQUIN (Commissioning
for Quality and Innovation)
Framework
UKSH South West income in 2009−10
was not conditional on achieving quality
improvement and innovation goals
through the Commissioning for Quality
and Innovation payment framework
because this is not included in the
contractual arrangements currently
in place.
Statements from the Care
Quality Commission (CQC)
Each of our South West sites − Emersons
Green, Devizes and Cirencester − are
required to register separately with the
Care Quality Commission. Their current
registration status dates from November
2009.
The Care Quality Commission has not
taken enforcement action against any
of the three centres during 2009−10.
All three sites will be subject to periodic
reviews by the Care Quality Commission;
there were no reviews during the first five
months of operation to the end of 2009–10.
24
UK SPECIALIST HOSPITALS
UKSH South West has not participated in
any special reviews or investigations by
the CQC during the reporting period.
Data quality
All UKSH South West sites have
submitted records during 2009−10 to the
Secondary Uses service for inclusion in
the Hospital Episode Statistics which are
included in the latest published data.
The percentage of records in the
published data:
-which included the patient’s valid NHS
number was:
100% for admitted patient care;
and 100% for out patient care.
-which included the patient’s valid
General Medical Practice Code was:
100% for admitted patient care;
and 100% for out patient care.
UKSH’s score for 2009−10 for Information
Quality and Records Management,
assessed using the Information
Governance Toolkit, was 68%.
As a result of a continuing improvement
programme on Information Governance,
UKSH has identified that for the forthcoming year 2010−11 this assessment is
likely to be 80+%.
UKSH was not subject to the Payment
by Results clinical coding audit during
2009−10 by the Audit Commission.
Safeguarding statement from
the UKSH Board
The Board is satisfied that UKSH is
compliant with the following safeguarding
requirements:
UKSH meets the statutory requirement
with regard to the carrying out of CRB
checks on all staff.
Safeguarding policies and systems for
Children and Vulnerable Adults are up
to date and robust.
All eligible staff have undertaken and
are up to date with safeguarding
training at Level 1. This is included
in Induction and mandatory training.
A review of other training arrangements
is ongoing, taking account of emerging
messages from the national review of
safeguarding training.
Named professionals are clear about
their roles and have sufficient time
and support to undertake them.
There is a Board level Executive
Director lead for safeguarding. The
Board reviews safeguarding across the
organisation at least once a year.
QUALITY ACCOUNT 2009–2010
25
Part 3
Review of quality performance
in 2009–2010
Since our new centres opened in
November 2009 we have maintained the
excellent record established by Shepton
Mallet NHS Treatment Centre on infection
prevention, with no cases of hospitalacquired MRSA bacteraemia or C. difficile
in 2009−10 at any of our facilities.
Our commitment to clinical best practice,
careful recruitment and ongoing training is
translating into outstanding clinical
effectiveness. The new sites have achieved
low rates of re-admission and returns to
theatre.
Patient surveys carried out by UKSH at
the new sites already demonstrate high
patient satisfaction.
Patient experience & feedback
At our sister site in Shepton Mallet, UKSH
has always paid careful attention to the
quality of patient experience and sought
feedback and opinions from patients. The
understanding of patient needs gained in
this way has meant the new South West
sites have been able to offer an
exceptional service from the outset.
26
UK SPECIALIST HOSPITALS
Examples include:
• Good travel directions with free and ample car parking
• One-stop outpatient visits
(ie all diagnostics taken on the same day)
• Timed visits so patients do not wait for outpatient visits diagnostics or
surgery once they enter the facility
• On-site kitchen preparing healthy
cuisine with fresh ingredients
• Single-sex accommodation
• Ensuite facilities to patient rooms
• Free WiFi access and phone calls
A key factor in patient satisfaction is the
overall waiting time for patients from
referral to receiving surgery. UKSH strives
to provide the shortest possible waiting
times for patients with options to attend
on a variety of dates and times.
Total waiting times for surgery at the new
sites are on average below ten weeks, and
we expect to reduce this futher during
2010-11.
UKSH undertakes a monthly patient satisfaction survey in which all patients attending
for surgery are asked their views on their experience at the UKSH South West treatment
centres.
In 2009−10 we achieved a high satisfaction rate across all aspects of our service,
with 99.7% of patients saying they would recommend our treatment centre to a friend.
Patients reply to 10 questions on a scale of 1 (bad) to 5 (excellent). UKSH measures
satisfaction as including all responses graded 4 and 5. Responses between November
2009 and March 2010 (777) indicate the following:
Question
% Satisfied
Q1 How long did you wait after you had chosen to come to the treatment centre?
87.2%
Q2 Were our booking staff helpful and efficient?
98.0%
Q3 Was it easy for you to get to and park at the treatment centre?
87.2%
Q4 How long did you have to wait before you were seen at Out Patients?
86.2%
Q5 Did the Out Patient staff meet your expectations?
96.8%
Q6 How long did you wait on the day of surgery?
84.4%
Q7 Did the surgical staff meet all your expectations?
98.2%
Q8 Did you experience any problem post discharge?
97.8%
Q9 Did the ward staff (nurses, physios) meet your expectations?
97.8%
Q10Did the catering meet your expectations?
92.8%
Q11Was the treatment centre welcoming and clean?
99.2%
Would you recommend the treatment centre to a friend? (yes)
99.7%
Any negative comments received either in surveys or by letter are followed up by a
dedicated team. The patients are contacted, where a contact address is supplied, and
their concerns are addressed through the Clinical Governance process chaired by the
Medical Director of UKSH.
UKSH has placed further emphasis on the role of patient feedback by incorporating
patient satisfaction questionnaires into the review of medical staff during their
probationary period.
QUALITY ACCOUNT 2009–2010
27
Clinical quality and outcomes
Achieving clinical quality and high patient
satisfaction are not add-on programmes
at UKSH but are fundamental to our
approach to care. This is based on a
model of focused care, where a high
volume of specialty care is carried out
in small, focused facilities.
The teams that perform these high-volume
specialties have undergone intensive
training to arrive at extremely high levels
of clinical quality and productivity. The
whole administrative structure, support
staff and facility are designed around this
model, with a focus on delivering the best
patient experience throughout the patient
pathway: from one-stop assessment and
diagnostics to early, intensive physiotherapy
as required, early, healthy discharge home,
and follow-up care.
Supporting and building on the focused
care model are the following six principal
elements of UKSH’s approach:
A. Clinical best practice: Extensive
identification and use of international best practice clinical guidelines
embedded in clinical pathways and protocols. UKSH believes it has the most detailed and comprehensive pathways and protocols in place for the
procedures it offers of any provider in
the UK and insists on uniform
application of proven approaches.
28
UK SPECIALIST HOSPITALS
B. Recruitment: Extremely careful recruiting
and credentialing of doctors who have long-term experience in the specialties UKSH performs. UKSH has excellent consultant staff from the UK,
Scandinavia, the United States and other countries.
C. Ongoing training: A commitment to in-service clinical staff training. UKSH expects and pays for all clinical staff to engage in ten days of training every year.
D. Performance monitoring: Intensive monitoring of performance to spot and deal with anomalies with very
responsive turnaround times.
E. Transparency: UKSH has published on
its website one of the most extensive
array of clinical and patient satisfaction data of any clinical provider in England.
F.
Safety: Full implementation of patient
safety guidelines, including ‘time outs’
for the surgical team just before
operations.
The performance data for the three UKSH
South West sites demonstrate our
excellent clinical effectiveness:
A high daycase rate – where we
complete a procedure within one
day so that patients do not have to
stay overnight
Zero rates of deep-vein thrombosis
(DVT)
One incidence of pulmonary embolism
(PE) within the context of 2,367
procedures
A very low rate of wound infection
Low rates of unplanned returns to
theatre and re-admissions
2009−2010
Clinical Effectiveness
Mortality
0.00%
Length of stay (Joint)
4.1days
Daycase rate (excl. Joint
replacement surgery)
94.00%
DVT
0.00%
PE
0.04%
Unplanned returns to theatre
0.17%
Emergency re-admissions
0.67%
Regional/local anaesthetic rate 74.00%
UKSH is committed to providing data to
enable its performance across its treatment
streams to be compared with other
organisations, national indices and
contractual performance indicators.
We have commissioned independent
research to compare our performance with
other UK health providers but at present
there is a lack of substantial data
elsewhere to allow clear case-mix
adjusted comparisons.
We are actively working to improve this
situation, but at the moment, this means
we cannot provide clear benchmark data
for the figures listed above. However, from
the information that we do have available,
we are confident that these figures compare
very favourably with other providers of
similar care in the UK.
UKSH intends to play its full part in
establishing quality indices that measure
quality throughout the patient pathway as
the health quality agenda progresses in
the UK.
QUALITY ACCOUNT 2009–2010
29
Monitoring performance
– regular clinical review
UKSH undertakes a robust integrated
clinical governance and risk management
programme which monitors clinical quality
and outcome performance by individual
surgeons every month.
This includes a detailed review of
clinical outcomes at a subspecialty level
for each surgeon examining factors such
as returns to theatre, DVT or PE rates. It
also includes taking action in response to
any trends or variances.
As part of our commitment to transparency,
UKSH has published annual reports of
DVT and PE rates for its hospitals which
were far more detailed than those
published by many other organisations
before the introduction of Quality
Accounts. Going forward, we will
incorporate this process into the Quality
Account framework. We also provide
referrers with detailed scorecards of each
surgeon’s personal performance.
30
UK SPECIALIST HOSPITALS
UKSH formally meets with its commissioners
of service on a quarterly basis. During this
process, known as a Joint Service Review
(JSR), we present a detailed report of
clinical and operational performance
covering all aspects of the service
including re-admission rates, operational
cancellation rates, untoward incidents and
patient satisfaction. These are scrutinised
by the commissioners on the JSR panel
who can draw on formal procedures for
monitoring improvement if appropriate.
This process allows for greater scrutiny
and risk management and enables the
sharing of best practice across the local
health network.
Statement from healthcare partners
In producing this Quality Report UK Specialist Hospitals consulted with the following
bodies:
NHS South Gloucestershire
South Gloucestershire Health Scrutiny Select Committee
Statement from NHS South
Gloucestershire
NHS South Gloucestershire, as lead
commissioner for UKSH South West NHS
Treatment Centres, is delighted to have
had the opportunity to comment on the
first annual Quality Account. This is an
important requirement for all organisations
providing care for NHS patients, and
recognises the importance of utilising both
patient experience feedback and clinical
outcomes in the drive to continually
improving the quality of health services.
The document has a clear structure which
is compliant with the DH Quality Account
toolkit, and the introduction provides
comprehensive information on the context,
purpose and future direction of the
organisation.
The PCT fully supports the clear targets
outlined in the executive summary that
incorporate clinical quality, effectiveness
and patient safety. UKSH has a valuable
role within the wider health community
and we are keen to offer patients greater
choice for high quality care and patient
satisfaction.
Specific targets identified for 2010−11
are measurable ensuring defined criteria
to demonstrate both achievement and
improvement. The inclusion of Venous
Thromboembolism (VTE) prevention
objectives is a national and local priority
and demonstrates a strong clinical
commitment to VTE management in
preventing potentially avoidable deaths
from Deep Vein Thrombosis (DVT) and
Pulmonary Embolism (PE).
UKSH has demonstrated its commitment
to high quality services that is evident
within the Joint Services Review (JSR)
meetings held with the PCT.
This first Quality Account provides an
excellent baseline position and we look
forward to continuing to work with you to
meet the quality aspirations of local users,
partners and staff.
Alison Robinson
Director of Clinical Development
NHS South Gloucestershire
QUALITY ACCOUNT 2009–2010
31
Statement from South
Gloucestershire Health
Scrutiny Select Committee
The South Gloucestershire Health Scrutiny
Select Committee considered the UKSH
South West Quality Account 2009−10 at
its meeting on 26th May 2010.
Cancellations – we are concerned
about the high incidence of
cancellations and have been advised
that these are largely avoidable
cancellations by day case surgery
patients. We are pleased that
cancellations for joint replacements are
relatively low, which probably bears
relation to the extensive pre-operative
procedures that are undertaken.
Venous Thromboembolism (VTE (blood
clots)) – we are encouraged that all
appropriate patients receive a VTE
(blood clot) assessment on admission.
The Committee also noted that mortality
from VTE (blood clots) is a national
and international problem, and all
NHS are working to the NHS’
Commissioning for Quality and
Innovations (CQUIN) goals for 2010−11.
32
UK SPECIALIST HOSPITALS
Literature – we are pleased that all
literature is available in Braille and
languages common to the Bristol area,
and further clarification can be
provided to patients as required.
Follow up phone calls – we praise the
organisation on its commitment to
making a follow up phone call to
patients after they have been
discharged.
The Committee notes that due to the
Emersons Green Treatment Centre only
opening in November 2009, the QA is not
based on a full year’s work. However, the
Committee looks forward to being able to
comment on a full year’s activity in
2010−11.
To close the Committee would like to
thank Edward Lotz, Executive Director at
UKSH South West for attending the
meeting to answer members’ questions.
Councillor Sandra Grant
Chair, Health Scrutiny Select Committee
South Gloucestershire Council
15th June 2010
Contact:
Claire Rees,
Democratic Services Officer,
01454 864116,
claire.rees@southglos.gov.uk
Providing the treatment our patients need
in the surroundings they deserve.
Version 1 June 2010