Shepton Mallet
NHS Treatment Centre
Quality Account
2010 – 2011
Contents
Executive summary
Page 3
About Shepton Mallet NHS Treatment Centre
Page 5
About this report
Page 6
Part 1 Statement by the Chief Executive
Page 7
Part 2.1 Objectives for quality improvement
Page 10
Achievement of 2010–11 objectives
Objectives for 2011–12
Objective
Objective
Objective
Objective
Objective
1:
2:
3:
4:
5:
Treat all patients in single-sex areas
Deliver comprehensive pre-operative service within 2.5 hours
Minimise patient falls
Establish laparoscopic cholecystectomy as a day case procedure
Improve returns of Patient Reported Outcome Measures
Part 2.2 Mandatory statements
Page 25
Part 3 Review of quality performance in 2010–11
Page 35
Quality Account 2010–2011
2
Executive summary
During 2010–11 UK Specialist Hospitals
(UKSH) won the contract to continue
delivering services for NHS patients at
Shepton Mallet NHS Treatment Centre
(SMTC).
We are delighted to have the opportunity
to continue delivering excellent clinical
outcomes and patient experience
based on our model of focused care. In
2010–11 we have worked towards the
quality objectives we set ourselves in last
year’s Quality Account to further improve
our service to patients. We have made
significant progress in all five quality
improvement areas, as follows:
Improvements to patient experience
• We reduced our on the day cancellation
rate to 2.2%, this was significantly
better than our target of 3%.
Improvements to clinical effectiveness
•
We carried out VTE (blood clot) risk
assessments for 93% of patients,
exceeding the national target of 90%
and thereby contributing to the
nationwide drive to increase VTE risk
assessments.
•
We achieved our target of ensuring
100% of patients identified as being at
increased risk of VTE received
appropriate preventative measures.
•
We achieved our target of ensuring
that Modified Early Warning Scores
(MEWS) were recorded for 100% of
patients, and we took measures to
assess and improve the quality of our
MEWS observations.
Improvements to patient safety
•
We ensured the safe use of antibiotics
and achieved 99% compliance with
our target to ensure all patients
received appropriate antibiotic
prophylaxis.
The measures we took to achieve these
targets have become embedded in our
organisational processes and we will
continue to monitor our performance
to ensure the improvements remain
permanent.
Quality objectives for 2011–12
In this Quality Account we are setting five
new objectives for 2011–12 as follows:
• Ensure all patients are treated in single sex areas in addition to the single-sex
accommodation we already provide.
•
Deliver a comprehensive pre-operative
service within 2.5 hours. Patients
value our one-stop pre-operative service
and we are undertaking to improve this
further by reducing the overall time of
the single appointment we already offer.
• Minimise patient falls. We will take
measures to reduce the already low
number at SMTC.
Shepton Mallet NHS Treatment Centre
3
•
Establish laparoscopic cholecystectomy
(gall bladder removal) as a day case
procedure, as recent research has shown most patients can safely recover and
return home on the day of the procedure.
• Improve response rates for Patient Reported Outcome Measures (PROMs).
Summary of performance in 2010-11
In addition to the specific targets we set
in last year’s UKSH Quality Accounts, we
regularly monitor our performance in all
areas, and outcomes are reported in detail
in Part 3 of this Quality Account. These
include:
• 99% of procedures planned as day
case are carried out as day case
procedures.
•
Increased proportion (81%) of
patients receiving local/regional rather
than general anaesthetic, contributing to
shorter recovery times.
• In general clinical outcomes are
excellent as evidenced by the low
complication rates.
• 99% of patients said they would
recommend our treatment centre to a
friend.
• Average waiting time from referral to
treatment of 7.1 weeks.
• Zero rate of hospital-acquired MRSA
bacteraemia.
•
There was one incident of healthcareacquired C. difficile in April 2010 (i.e. most likely brought into the facility by
the patient as opposed to being
contracted in the facility) and no
recorded cases of hospital-acquired
C. difficile.
Quality Account 2010–2011
4
About Shepton Mallet
NHS Treatment Centre
Shepton Mallet NHS Treatment Centre
(SMTC) was opened in 2005 by UK
Specialist Hospitals (UKSH), a leading
independent provider of healthcare in the
South West. During 2010–11, UKSH was
awarded the contract to continue providing
services at SMTC for a further three years.
At Shepton Mallet, UKSH has developed
a patient-centred model of focused care
delivering excellent clinical outcomes.
UKSH has since applied this model
to other treatment centres, and SMTC
has continued to play a leading role in
developing best practice which has been
rolled out across all our sites. These include
centres in Bristol (Emersons Green),
Wiltshire (Devizes) and Gloucestershire
(Cirencester), all of which were opened
by UKSH South West in November 2009,
and Peninsula NHS Treatment Centre
in Plymouth, where we began providing
services in August 2010.
UKSH employs over 450 skilled clinicians
and support staff at our centres across the
South West, to date we have carried out
nearly 70,000 procedures across all sites.
SMTC treats NHS patients on behalf of
NHS Somerset. In 2010–11 we offered
a range of planned procedures to NHS
patients, including:
• Diagnostic imaging
(x-ray and ultrasound)
• Endoscopy diagnostics
(gastroscopy and colonoscopy)
• General surgery
• Ophthalmic surgery
(cataracts and minor eyelid procedures)
• Orthopaedics surgery
(joint replacements and minor)
• Pain management
In 2011–12 this range will be extended
further to include dental, ear nose and
throat, gynaecology, shoulder surgery and
urology services.
Shepton Mallet offers day case and
inpatient treatment through its 34-bed
facility. It has four operating theatres, an
endoscopy suite, a day surgery facility, a
comprehensive diagnostic department and
physiotherapy services.
More information about UKSH and the
services we provide can be found on our
website, www.uk-sh.co.uk
Shepton Mallet NHS Treatment Centre
5
About this report
UKSH is pleased to participate for the
second year in the Department of Health’s
Quality Accounts reporting system.
UKSH welcomes the emphasis placed
by Quality Accounts on the quality of
care. 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 quality objectives we identified in last
year’s Quality Account have led to real
improvements in patient care and this
year we report on our performance against
the targets we set ourselves, as well as
highlighting new areas for improvement.
UKSH was pleased to receive positive
feedback on the Quality Account we
published last year and we will again take
care to produce a Quality Account that
is helpful to the public in understanding
the quality of services we offer and our
commitment to continual improvement.
The structure of our report follows the
updated guidelines from the Department of
Health and is arranged as follows:
Quality Account 2010–2011
Part 1
Statement by the Chief Executive
Part 2.1
Report on achievement of last year’s
targets
Priorities for future improvements and
details on how we plan to achieve them
Part 2.2
Information on areas common to all
providers, following detailed guidelines set
by the Department of Health
Part 3
Performance report for 2010–11 on the
quality of care provided at Shepton Mallet
NHS Treatment Centre
This Quality Account relates to our facility in
Shepton Mallet. A separate Quality Account
is available for our sister sites at Emersons
Green, Cirencester and Devizes (UKSH
South West) and Plymouth (Peninsula NHS
Treatment Centre).
More information about our performance can
be found on our website, www.uk-sh.co.uk
6
Part 1
Statement by the
Chief Executive
Statement by the
Chief Executive
2010–11 was a significant year for UK
Specialist Hospitals.
Following a competitive tender process,
local commissioners decided that UKSH
offered the best approach to delivering
services at Shepton Mallet and so awarded
us a contract to continue providing care
to patients at the treatment centre for a
further three years.
More widely for UKSH, commissioners in
Devon and Cornwall recognised the value
of our approach by asking UKSH to run
the Peninsula NHS Treatment Centre in
Plymouth, we completed our first full year
of providing services to patients in our new
centres at Emersons Green, Devizes and
Cirencester. All these achievements further
strengthen UKSH to ensure that we make
the most of our expertise at all five of our
treatment centres working cooperatively
with our NHS colleagues.
This Quality Account demonstrates the
progress we have made delivering highquality care while always aiming for the
best possible experience for patients in
every one of the 70,000 procedures we
have performed across these centres. It
shows how we have embedded leadingedge practice in our care. By measuring
and reporting on last year’s objectives, a
clear picture emerges of increasing quality
and new improvement areas for next year
following close consultation with staff and
patients.
Quality Account 2010–2011
Last year we set tough targets 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 could be
taken. With targets in excess of national
benchmarks, these were stretching and
ambitious.
We made significant improvements on the
previous year’s performance in all areas,
achieving four out of five of our targets by
the end of the year, and we significantly
exceeded the national target in the fifth.
With good practice ingrained in all these
areas, we will monitor progress in the
future to ensure we continue to deliver the
same high standards.
We also continued to deliver excellent care
beyond last year’s improvement objectives
as measured through other key indicators,
including maintaining our record of
zero cases of hospital-acquired MRSA
bacteraemia across all our sites.
Our aim for 2011–12 is to ensure we
maintain and where possible improve our
performance in last year’s priority areas
while also focusing on new areas identified
by patients as particularly important for
them.
8
Our aim for 2011–12 is to ensure we
maintain and where possible improve our
performance in last year’s priority areas
while also focusing on new areas identified
by patients as particularly important for
them. Our new improvement objectives set
demanding targets: to shorten preoperative
appointments; ensure all patients are
treated in single-sex areas in addition to
the 100% single-sex accommodation we
already provide; reduce the number of
patient falls from an already low number;
establish laparoscopic cholecystectomy as
a day case procedure; and to improve our
return rates for PROMs (Patient-Reported
Outcome Measures).
As ever, the commitment and
professionalism of our staff will be
essential to achieve these demanding
goals. Through their dedication, supported
by the world-leading expertise available to
us from our independent Clinical Advisory
Board and the UKSH board, we are
confident that we will be able to achieve
these objectives and continue to provide
ever higher quality of care for all our
patients.
I confirm that to the best of my knowledge
the information presented in this document
is accurate.
Fiona Calnan Chief Executive
Shepton Mallet NHS Treatment Centre
9
Part 2.1
Objectives for
quality improvement
Patient comment:
“We are extremely lucky to have this wonderful modern facility in our area,
stuck as we are in the ‘Bermuda triangle’ over 20 miles from surgical
facilities in Bath, Bristol or Taunton. There are risks attached to any kind of
surgery wherever you have it, but Shepton Mallet NHS Treatment Centre is
achieving the very highest standards. The centre is spotlessly clean, and the
staff from the cleaners and catering ladies up to the consultant surgeons
treat the patients with skill, respect, kindness and professionalism. I would
have no hesitation in returning for further surgery.”
Retired Registered Nurse and recent patient
Hazel from Wells
Achievement of
2010–11 Objectives
UKSH quality
objective for
2010-11
Target for 2010-11
Patient
experience
Reduce rate of
cancellations on
the day
On the day
cancellations
no more than 3%
Clinical
effectiveness
Increase risk
assessments for
VTE
At least 95% of
patients receive
risk assessment
92.8%
Target exceeded
in last two
quarters
Improve VTE
prophylaxis
100% of patients
receive appropriate
preventative measures
100%
Target met
Improve MEWS
documentation
MEWS documentation for
at least 95% of patients
100%
Target
exceeded
Safe use of
antibiotics
100% of patients receive
appropriate antibiotic
prophylaxis
99.8%
Target rate
achieved in
three of four
quarters
Patient safety
Overall
performance
at SMTC
in 2010-11
2.2%
Status
Target
exceeded
Shepton Mallet NHS Treatment Centre has met or exceeded three quality improvement
targets for 2010–11 and made significant improvements in respect of the remaining two
priority areas, exceeding the national target in one of these and achieving our internal
target in three out of four quarters of the year in the other.
Shepton Mallet NHS Treatment Centre
11
Patient experience
Reducing on the day cancellations
We know from patient feedback and
focus groups that cancellations on the
day of surgery are inconvenient and can
cause distress to patients, as well as
being inefficient for the organisation.
While some reasons for cancellations are
inevitably outside our control, such as
patient illness or disruptions to travel, we
focused on reducing cancellations caused
by clinical and operational factors.
Building on an already strong record,
Shepton Mallet NHS Treatment Centre
succeeded in reducing the rate of on the
day cancellations last year, exceeding
our target of 3% to achieve a rate of
just 2.2%. Cancellations for clinical
reasons fell from 1.15% in Q1 to 0.84%
in Q4 with avoidable cancellations kept
consistently below 0.5%.
This means that 97.8% of our patients
had their procedure on the planned date,
compared to 96.6% in the previous year.
The measures we took to deliver this
quality improvement included:
•
Refining the pre-operative call to
patients. This was key to achieving the
target. Our dedicated patient
experience team carefully designed an
effective script that would ensure
patients were aware of all necessary
preparations and arrangements.
This included checking whether there
were any medical developments since
the outpatient visit and verifying
that any medication was being
managed appropriately.
Quality Account 2010–2011
•
The patient experience team also
managed the patient pathway from the
pre-operative assessment to admission,
ensuring that results were checked and
actioned at every stage.
• Implementing new guidance for pre operative testing in line with NICE best
practice.
•
Sharing this guidance through our
clinical governance forum, speciality
meetings and heads of departments
meetings.
•
Assigning the theatre manager as lead
to be responsible for ensuring
appropriate or specific equipment was
in place for each procedure.
Our aim going forward is to maintain this
level of high performance. We will achieve
this by continuing to:
•
Monitor our performance. The rate of
on the day cancellations is a standing
item on the monthly clinical
governance report.
• Apply the measures that we have shown
to be effective in keeping on the day
cancellations to a minimum.
12
Patient safety & clinical effectiveness
Increasing risk assessments for VTE
In 2010–11 we set ourselves an ambitious
target to further improve our excellent
record on venous thromboembolism (VTE)
risk assessments and to promote best
practice in this area. This was in response
to a national drive to reduce the risk to
patients from VTE or blood clots. Our target
was to carry out risk assessments for 95%
of all patients, compared with a national
target of 90%.
SMTC achieved 92.8% compliance, falling
just short of our internal target but still
higher than the national target. The graph
below shows how the majority of this small
shortfall occurred during the first two
months of implementing the metric where
we recorded compliance rates averaging
82%. This metric commenced in June in
line with the national programme, and by
August, performance had climbed above
the national target.
Once the processes were bedded in by the
middle of the year following appropriate
training, performance was consistently
above our target of 95%.
The measures we took led to improvements
and contributed to the national initiative.
They included:
• Continual monitoring and review at clinical governance meetings.
• Established thrombosis committee to
promote best practice across all our sites.
• Participation by senior management in
external VTE strategy group to share best
practice among local providers.
• Distribution of targeted patient literature
on VTE risk for all patients.
There will be a continued focus on
increasing VTE risk assessments through
training, monitoring and auditing of VTE
risk assessment processes and outcomes.
VTE Risk Assessment
60%
100%
90%
80%
70%
60%
50%
40%
30%
50%
40%
30%
20%
10%
0%
20%
10%
100%
90%
80%
70%
NATIONAL
TARGET
100%
100%
100%
100%
99%
100%
80%
80%
60%
60%
40%
40%
Shepton Mallet NHS Treatment Centre
JU
LY
JU
NE
M
AR
FE
B
JA
N
DE
C
NO
V
OC
T
JU
LY
AU
G
SE
PT
JU
NE
0%
13
Patient safety & clinical effectiveness
Improving VTE prophylaxis
As a further contribution to the national
drive for reducing the risk to patients from
VTE, UKSH adopted the improved use of
VTE prophylaxis as a quality objective for
2010–11.
UKSH set out to ensure that every patient
identified as being at increased risk of VTE
receives appropriate preventative measures
or prophylaxis. In addition, every patient is
assessed for the risk of bleeding. Shepton
Mallet NHS Treatment Centre achieved this
target with 100% compliance. We took the
following measures to achieve this:
• Updated UKSH policy on VTE prevention
and management.
•
Introduced specific root cause analysis
tool for VTE events to ensure the
cause was identified if possible and
the appropriate learning shared within
the organisation.
•
VTE risk assessment score is part of the
surgical safety checklist and thus
highlights the need for prophylaxis if
necessary.
We have carried out random audits of
prophylaxis every quarter and plan to
continue these for the next year, increasing
the frequency to monthly.
Quality Account 2010–2011
Improving MEWS documentation
The Modified Early Warning Score (MEWS)
is a method of monitoring patients to detect
changes in their condition and prompt
appropriate timely action. UKSH focused
on ensuring that all patients attending the
treatment centres for surgery had MEWS
observations. MEWS charts were therefore
incorporated into every medical record as a
monitoring tool for every patient. Quarterly
audits were undertaken and confirmed
that MEWS were recorded on all patients,
achieving the target of 100%.
SMTC went further than the target. As well
as ensuring 100% of patients had MEWS
documentation, we also assessed the
quality of the MEWS observations being
undertaken. We applied an audit tool to
assess a number of parameters in relation
to the documentation of the required
observations. This assessed the frequency
of the recordings, scoring accuracy and
completion of timings.
These audits were routinely reviewed at
clinical governance meetings and discussed
at ward meetings. Generally we scored
highly against these additional internal
quality measures, achieving 90% or over
for three of the four quarters of the year.
14
Patient safety & clinical effectiveness
In the last quarter of the year, our
monitoring and audit measures identified
a need to improve performance among
a small number of staff. We took timely
action and are confident the quality of
data recorded in MEWS documentation
will return to its previously high standard.
We would emphasise that even among
those records affected, we maintained
our target of 100% of patients receiving
MEWS observations.
As this audit process was relatively new we
have also considered how to improve this
analysis and will implement an improved
version from the beginning of 2011–12 for
the new accounting year.
Our training programme is ongoing.
UKSH will continue to audit MEWS
measurements on a monthly basis with the
aim of further refining the documentation
and accuracy.
This review process has enabled us to
identify areas where best practice can be
more consistently applied, as a result we
have provided further training on MEWS
measurements to staff throughout the
year, both on a classroom basis and as
direct mentoring in the live environment in
clinical areas.
Shepton Mallet NHS Treatment Centre
15
Patient safety
Antibiotic prophylaxis
100%
100%
100%
100%
99%
100% taken to ensure the safe
Measures
NATIONAL we have
90%include:
TARGET
use of antibiotics
60%
40%
80%
70%
rounds
60%
•
Daily ward
by pharmacy team
to check all 50%
patients have received
appropriate 40%
antibiotics where applicable,
including routine
30% checks to identify any
20%
discrepancies
in prescribing and to
10%in real time.
address issues
•
Increased mentoring and support for
prescribers principally performed by the
SMTC infection control lead, with
further support from the UKSH-wide
infection control lead.
M
AR
FE
B
JA
N
DE
C
NO
V
OC
T
JU
LY
AU
G
SE
PT
JU
NE
0%
100%
•
80%
Introduced safe use of antibiotics as
80%
standing item at infection control and
clinical governance
60% meetings, so that
our performance is regularly monitored
40%
and appropriate
actions taken.
20%
20%
0
M
AR
FE
B
JA
N
DE
C
During 2010–11, SMTC achieved 100%
compliance in the first three quarters and
99% in the last quarter.
JU
NE
20%
10%
0%
NO
V
50%
40%
30%
Our final quality objective for 2010–11
was to ensure the safe use of antibiotics
in order to fight infections effectively,
and to achieve this we implemented new
national guidelines for the appropriate use
of antibiotics.
OC
T
80%
70%
60%
Safe use of antibiotics
JU
LY
AU
G
SE
PT
100%
90%
Q1
Q2
Q3
Q4
During 2010–11 we created a dedicated
infection control lead position to work
across all our sites overseeing infection
control leads already in place at each site
and to ensure we are at the forefront of
best practice in this area nationally.
Quality Account 2010–2011
We will continue to implement and
monitor these measures
to maintain our
0
Q2
Q3
performance at the high levelQ1we achieved
in 2010–11.
Q4
16
Objectives for 2011–12
Objective
Target
Treat all patients in
single-sex areas
No breaches
Deliver comprehensive
pre-operative service
within 2.5 hours
70% of pre-operative appointments
completed within 2.5 hours
Patient safety
Minimise patient falls
10% reduction in patient falls
Clinical
effectiveness
Establish laparoscopic
cholecystectomy as a day case
procedure
Increase the proportion of laparoscopic
cholecystectomy procedures carried out
as day cases
Improve response rates for
Patient Reported Outcome
Measures (PROMs)
85% return rate for PROMs
questionnaires
Patient experience
During 2010–11 our objectives for quality
improvement have been a standing
agenda item at UKSH board meetings. We
have examined our performance against
last year’s targets and the evidence and
rationale for new objectives. In 2010–11
we successfully implemented measures
to achieve significant improvements
relating to last year’s quality objectives.
We are therefore able to incorporate these
measures into our ongoing practice and
will continue to monitor our performance
in those areas.
Shepton Mallet NHS Treatment Centre
This puts us in a position to set new
quality objectives for the coming year. We
have arrived at these objectives through
careful and balanced consideration of the
following factors: feedback from patients
and consultation with patient groups
including our patient forum, expertise
and experience of our staff, advice from
external clinical consultants, and national
programmes for improvement. The final
shortlist was presented to the strategic
governance committee who ratified the
chosen indicators.
17
Patient experience
Treat all patients in single-sex areas
UKSH has never breached its aim of
100% of inpatients accommodated in
single-sex wards.
The national element of this initiative
will enable our performance to be judged
against all other providers of care to NHS
patients.
We know from our patient forums how
much patients value UKSH’s approach to
single-sex accommodation. Because it is
such a critical factor in overall experience
of care, UKSH has embraced the national
initiative to extend this approach so that
it also covers pre-operative waiting areas,
the post anaesthesia care unit (PACU) and
recovery units.
Our target is to ensure there are no
breaches of the new standard for
patients to be treated in single-sex
areas. To achieve this we have already
taken measures which we believe will
lead to continued compliance with the
Department of Health’s new requirements
to eliminate mixed sex accommodation in
the coming year, as detailed below.
Target
100% of patients always accommodated and treated in
single-sex areas
Current performance
100% of patients always accommodated in single-sex rooms
Measures to achieve
objective
•
•
•
Monitoring/reporting
process
Declaration of compliance is audited locally. This can be viewed at www.
uk-sh.co.uk/same-sex-accommodation. Figures are reported via Unify2,
the Department of Health’s data collection system, on a monthly basis.
Quality Account 2010–2011
Changes to the processes for managing patients through their care pathway when undergoing treatment.
The installation of dividers in the PACU where patients recover
following surgery.
Eliminated need for patients to cross paths on route to toilet facilities.
18
Patient experience
Deliver comprehensive pre-operative
service within 2.5 hours
We know from talking to patient groups
that they greatly value the one-stop
pre-operative service offered by UKSH.
It means significantly fewer hospital visits
for the patient and far less disruption to
their day-to-day routine.
Fitting all this in can be logistically
challenging, yet patients have quite
reasonably told us that they want to finish
their appointment as quickly as possible.
Already, 96% of patients at SMTC have
completed their appointments within three
hours, and over 43% are seen before their
booked time.
Delivering a comprehensive one-stop
pre-operative assessment and outpatient
appointment involves many different stages.
There are, however, a number of patients
who spent longer than two and a half
hours.
For example, a typical pre-operative
assessment for a hip replacement would
include an x-ray as well as separate
consultations with a nurse, physiotherapist,
and consultant surgeon.
We will expand the range of procedures
performed at SMTC in 2011-12, so our
current performance is not a like-for-like
benchmark. Our aim for 2011-12 will
be to ensure we complete 70% of preoperative assessments within two and a
half hours at SMTC.
The objective is that by the end of this
appointment each patient will leave with
an agreed date for surgery.
Target
70% of pre-operative assessments completed within 2.5 hours
Current performance
Because SMTC is introducing new procedures during 2011–12,
there is no comparable data from 2010–11.
Measures to achieve
objective
•
•
•
Monitoring/reporting
process
The 2.5-hour statistic will be reported monthly through the UKSH
performance reporting mechanism. It will be measured as the volume
of first attendances <2.5 hours divided by the total volume of first
attendances in the month.
An electronic patient pathway for each type of procedure that defines the precise process for each patient. It ensures every
patient efficiently follows the same, clinically-appropriate pathway.
Electronic monitoring of patients’ progress along the pathway
with a traffic light system to alert staff to urgent actions.
Clinical coordinator has overview of clinic and can see where
patients are (waiting, x-ray, etc.).
Shepton Mallet NHS Treatment Centre
19
Patient safety
Minimise patient falls
UKSH is proud of its record in patient
safety, and although there were only 15
falls at SMTC last year (4.4 inpatient falls
per 1,000 bed days) we recognise that
every fall is important because it poses a
potentially serious risk to health.
To put our rate of falls into context, the
NHS National Patient Safety Agency
(NPSA) sets a benchmark of 6.5 falls per
1,000 bed days. This means the rate at
SMTC is 32% lower than the national
benchmark, though we would recognise
that this covers a broader casemix.
We welcome the national initiative led by
the NPSA to reduce falls, and in response
we have conducted an assessment of
measures we can take to reduce risk to
patients from the already low level of falls
at UKSH.
We have consulted the NPSA’s national
guidelines on how best to monitor and
report on this area. As it is difficult to
report accurately on the level of harm
from falls, we will instead report on the
numbers of all falls.
Quality Account 2010–2011
We are also taking care to ensure that the
target we set and the measures we take to
achieve it take account of all the factors
relating to patient experience as well as
safety. This includes ensuring that patient
dignity and privacy are preserved, based
on an understanding that patients have a
right to make their own decisions about
independent movement. Beginning to walk
again independently after a procedure is
part of the patient’s rehabilitation and we
will support patients to do this while being
aware of ways we can help minimise falls
appropriate to each individual patient.
As part of our continuous quality
improvement, our motivation is to build on
our culture of reporting incidents across
all UKSH sites. We recognise that this
may mean that initially more falls are
recorded as staff recognise incidents that
previously might not have been perceived
as sufficiently serious to require reporting.
We are also aware of research that shows
the introduction of targets which are based
on self-reporting of incidents risks fewer
incidents being reported because staff
become reluctant to admit to failings. We
will counter this risk by reinforcing and
further embedding our open culture of
reporting across all our sites.
20
Patient safety
Minimise patient falls
Target
Reduce number of falls by 10%
Current performance
15 falls in total, equivalent to 4.4 inpatient falls per 1,000 bed days
Measures to achieve
objective
•
We have introduced a risk assessment tool, MORSE, as part of the electronic integrated care pathway. This is implemented at
the pre-assessment stage and then daily for each patient on site.
It is updated whenever there is a change in the patient’s condition
or medication regime.
•
The electronic patient record (EPR) contains an obligatory field
into which staff must enter the outcome of the MORSE risk
assessment. This ensures that staff are fully aware of risks
associated with each patient and prompts appropriate actions.
• UKSH-wide falls prevention working group with representatives from each centre, to share best practice and awareness and to lead
measures for improvement.
Monitoring/reporting
process
We will report the actual number of patient falls, including both
inpatient and outpatient falls.
We will also report the number of falls as a percentage of inpatient
bed days. This will allow comparison with all other providers of care
to NHS patients as part of the national NPSA initiative.
Shepton Mallet NHS Treatment Centre
21
Clinical effectiveness
Establish laparoscopic cholecystectomy
as a day case procedure
Laparoscopic cholecystectomy (gall
bladder removal) is a common surgical
procedure provided by Shepton Mallet
NHS Treatment Centre. During the past
year we carried out 65 procedures, and
our outcomes were generally excellent.
Patients for this procedure at UKSH
Treatment Centres typically stay overnight.
This reflects a cautious approach to ensure
full recovery before discharge. However,
following improvements in care over recent
years supported by a clear evidence base,
the procedure is now seen as appropriate
to be carried out as a day case by both
the Audit Commission and the British
Association of Day Case Surgery (BADS).
While the overall current national day case
rate for this procedure is only 16%, the
Association’s research has shown that this
could be increased significantly without
risk to patients.
Because most patients can safely recover
and return home on the same day and
the measures taken to achieve the target
would promote faster recovery for patients,
UKSH is committed to establishing
laparoscopic cholecystectomy as a day
case procedure.
Our aim is to establish laparoscopic
cholecystectomy as a day case procedure
over the next year and then identify what
further measures need to be put in place
to achieve the BADS target (60%) going
forward.
Target
Establish laparoscopic cholecystectomy as a day case procedure and
identify effective improvement measures
Current performance
0% – we do not currently provide laparoscopic cholecystectomy as a day
case procedure
Measures to achieve
objective
• We will modify the integrated care pathway to reflect a shorter
stay. This includes identifying patients who would most benefit from
day case procedures.
• Review, modify and standardise anaesthetic techniques so that
patients can make a faster recovery.
• Further enhance multi-modal analgesia to manage post-operative pain
while reducing nausea and vomiting.
• Educating patients so that they are prepared for the procedure as
a day case.
Monitoring/reporting
process
UKSH Quality Report produced monthly
Quality Account 2010–2011
22
Clinical effectiveness
Improve PROMs reporting
Patient Reported Outcome Measures
(PROMs) measure how patients perceive
their health has changed following
treatment. Patients undergoing hip and
knee replacements as well as hernia
repair are invited to complete a short
questionnaire before and after their
treatment, to capture information on their
health and health-related quality of life.
The purpose is to allow patient’s own
assessment of the health benefits of their
assessment to be included in measures of
clinical outcomes.
While active participation by patients
is an essential prerequisite for PROMs,
UKSH recognises we have an important
role to play in encouraging patients to
complete their forms and ensuring the
documentation is submitted.
PROMs data have begun to be published
on the Health Episode Statistics (HES)
website (www.hesonline.nhs.uk). Because
this process is still at an early stage, the
results available through HES for hernias
relate to a small group of patients, less
than 50 for SMTC, and therefore UKSH
is waiting for more data to be available
before drawing conclusions. A greater
volume of information is available for hip
and knee replacements.
During the period April 2009 to November
2010, SMTC patients reported an
improvement in their Overall Wellbeing
Index which was above the national
average for England. SMTC patients also
reported an improvement of joint mobility
which was above the national average for
England, in both procedures.
Shepton Mallet NHS Treatment Centre
Although our rate of PROMs returns
is higher than many other healthcare
providers, our rates of pre-operative
PROMs returns for hernia operations at
SMTC in the current reporting period have
not matched our own expectations and the
standards of compliance we achieve in
other areas.
We have conducted a review to establish
why our pre-operative PROMs return rate
for hernia procedures was low at SMTC.
The process whereby patients were offered
the questionnaires was not robust in all
cases, particularly in the early part of the
year. A protocol for the provision of the
questionnaires was put in place and in
the latter quarter of the year the PROMS
return rates increased from 60% in
February to 86% in March.
We expect to continue this upward
trajectory into 2011–12. Staff received
additional training to ensure the process
was followed. We will continue with these
measures to encourage the completion
of pre-operative PROMs questionnaires,
always making it clear to patients that
participation is voluntary. We will also
ensure that these are routinely submitted
at the point of treatment.
Because UKSH believes PROMs are an
important measure of clinical outcomes,
we will therefore prioritise improving our
returns performance for pre-operative
PROMs questionnaires as one of our
quality objectives for 2011–12.
23
Clinical effectiveness
PROMS reporting
Target
To progress to submitting 85% of patient returns for all procedures by
the fourth reporting quarter of 2011–12.
Current performance
Hip: 87.5%; Knee: 76.2%; Hernia: 50.6%
Measures to achieve
objective
• Staff training to ensure all patients are proactively encouraged to complete pre- and post-operative questionnaires.
• Staff training to ensure patients are made aware of the process and benefits of completing the questionnaires.
• New administration processes to ensure all questionnaires are
collected, collated and submitted.
• Ongoing monitoring of PROMs rates across all UKSH facilities so
that staff have continuous visibility of current performance across
each centre.
• Closer monitoring of patients who actively decide not to submit
PROMs so that their decisions can be respected and to ensure
their choice is reflected appropriately in the metrics.
Monitoring/reporting
process
Internal monitoring as part of monthly UKSH Quality Report.
Reported figure will be pre-operative questionnaires submitted as
percentage of number of patients undergoing each procedure.
Quality Account 2010–2011
24
Part 2.2
Mandatory
statements
Patient comment:
“The standards of cleanliness, nursing care, catering and reception keep the
hospital going like clockwork. All the patients are extremely well screened and
the staff are really on the ball.
I was in for four days and the aftercare was also excellent. I like the way all
the staff gel as a team, very thorough, very disciplined in whatever task they
are doing, very patient orientated, producing good results for very satisfied
patients. And the food is excellent too. It’s of a hotel standard and caters for
all ages and tastes.
Since my operation, I’ve also been involved in the patient forum. We’ve been
able to provide feedback on how to make improvements and also what we like
about the service they offer. It’s somewhere I would have loved to work.
I shall carry on recommending the centre to people I see.”
Recent patient and member of SMTC patient forum
Dianne from Wells
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 2010–11, UKSH provided six NHS
services at Shepton Mallet NHS Treatment
Centre.
These were:
•
•
•
•
•
•
Endoscopy diagnostics
(gastroscopy and colonoscopy)
General surgery
Imaging (x-ray and ultrasound)
Ophthalmic surgery (including cataracts
and minor eyelid procedures)
Orthopaedics surgery
(joint replacements and minor)
Pain management
UKSH has reviewed all the data available
to them on the quality of care in six (all) of
these NHS services.
The income generated by the NHS
services reviewed in 2010–11 represents
100% of the total income generated from
the provision of NHS services by UKSH at
Shepton Mallet NHS Treatment Centre for
2010–11.
Participation in clinical audits
During 2010–11, two national clinical
audits and one national confidential
enquiry covered NHS services that UKSH
provides at Shepton Mallet NHS Treatment
Centre.
The national clinical audits and national
confidential enquiry that Shepton Mallet
NHS Treatment Centre was eligible to
participate in during 2010–11 are as
follows:
During that period Shepton Mallet NHS
Treatment Centre participated in 100%
national clinical audits and 100% national
confidential enquiries of national clinical
audits and national confidential enquiries
in which it was eligible to participate.
Hip and knee replacements
(National Joint Registry)
Quality Account 2010–2011
Elective surgery (National PROMs Programme)
National Confidential Enquiry into Patient
Outcome and Death (NCEPOD) Cardiac Arrest
Procedures study
26
Participation in clinical audits
The national clinical audits and national confidential enquiry that Shepton Mallet NHS
Treatment Centre participated in and for which data collection was completed during
2010–11, 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.
National audits & national confidential enquiries
Participation
Yes/No
% of cases
submitted
Hip and knee replacements (National Joint Registry): Hip
Yes
83.7%
Hip and knee replacements (National Joint Registry): Knee
Yes
88.1%
Elective surgery (National PROMs Programme): Hip
Yes
87.5%
Elective surgery (National PROMs Programme): Knee
Yes
76.2%
Elective surgery (National PROMs Programme): Hernia
Yes
50.6%
National Confidential Enquiry into Patient Outcome and Death
(NCEPOD)
Yes
n/a*
* see below
The reports of two national clinical audits
were reviewed by UKSH in 2010–11
and UKSH intends to take the following
actions to improve the quality of
healthcare provided.
The National Joint Registry (NJR) is a
monitoring database which tracks joint
replacement procedures carried out
throughout England and Wales. The board
of Shepton Mallet NHS Treatment Centre
has reviewed the results from the NJR
audit for one-, two- and three-year revision
rates for hip replacements carried out at
SMTC since 2005. The average revision
rates were found to be low, in most years
under 1%.
PROMs (Patient Reported Outcome
Measures) measure how patients perceive
their health has improved following
treatment. PROMs collection began in
April 2009 when all providers of NHSfunded care were required to collect
PROMs information. Last year saw the first
tranche of pre- and post-operative PROMs
data by the NHS Information Centre.
Shepton Mallet NHS Treatment Centre
UKSH has analysed its PROMS outcomes
for hips and knees for the period April
2009 to November 2010, which have
been published on the HES (Hospital
Episode Statistics) website,
www.hesonline.nhs.uk
The published results look at both an
overall health or welfare score and a score
relating to movement of the joint itself.
For both specialities UKSH can report the
following results at SMTC:
•
Patients reported an improvement of
the Overall Wellbeing Index for both
hips and knees which was above the
national average for England.
•
Patients reported an improvement of
joint mobility for both hips and knees
which was above the national average
for England.
27
Participation in clinical audits
Because this process is still at an early
stage, the results available for hernias
relate to small groups of patients and
therefore UKSH is waiting for more data to
be available before drawing conclusions.
Shepton Mallet NHS Treatment Centre will
complete the organisational questionnaire
related to the Cardiac Arrest survey
which we expect to be issued shortly by
NCEPOD.
While the level of returns of pre-operative
PROMs questionnaires was in line with
many other NHS providers, the rate for
hernia PROMs at SMTC fell short of
our expectations. This is why we have
identified PROMs submissions as one of
our improvement objectives for 2011–12.
We have in place systems and a staff
reporting line to ensure 100% compliance
in the future for any relevant surveys.
The clinical director for anaesthetics is
the nominated local director for NCEPOD
and coordinates participation in the
appropriate surveys.
In 2010–11, UKSH registered with
NCEPOD. The only relevant survey to
Shepton Mallet NHS Treatment Centre
was the Cardiac Arrest Procedures survey.
During the reporting period of 1 November
to 14 November 2010 there were no
cardiac arrests at Shepton Mallet NHS
Treatment Centre, so submissions were not
required.
Results on all procedures, including hip
and knee replacements, are routinely
monitored through our internal clinical
governance processes. These show
excellent clinical outcomes.
Quality Account 2010–2011
28
The reports of 17 local clinical audits were reviewed by the provider in 2010–11 and
UKSH intends to take the following actions to improve the quality of healthcare provided:
Audit
Action
Monitoring results
Consent
Comply with consent policy
Quarterly
Endoscopy
Comply with JAG standards
Quarterly
Hand hygiene
Comply with HPA requirements
Quarterly
Infection prevention
and control
Comply with HPA requirements
All positive results audited,
identify any organism trends
Information Governance
Ensure ongoing compliance
with: ISO 27001, IGSOC
Six-monthly external audits
Rotational internal audit plan
in place
MEWS
Comply with early warning system
identifying deterioration in patient
condition
Monthly
Patient management
Ensure effectiveness of current pain
protocols
Quarterly
Patient records
Ensure best practice in Patient
Medical Record
Quarterly
Pharmacy including
controlled drugs audits
Prescription chart audit
Comply with national policy and
legislation
Monthly
Radiology
Comply with Ionising Radiation
(Medical Exposure) Regulations
(IRMER) requirements
Annual IRMER programme in
place
Monthly local audits to support
Resuscitation
Ensure best practice in
resuscitation technique
Monthly
Sterile services
Ensure ongoing compliance with
QMS 13485
Monthly tray list
Surgical technique
Shared learning on difficult cases
at speciality meetings and ensure
compliance with best practice
Quarterly
VTE prophylaxis
Comply with updated NICE
Guideline (Jan 10)
Quarterly
Ward
1. Fluid balance chart
2. Blood fridge
3. Falls risk assessment
4. Condition of mattresses
5. VTE
Ensure best practice in patient care
Annual audit programme in
place with monthly reporting
to clinical governance
committee
Waste
Clinical and non-clinical
Comply with:
Health and safety requirements
Quarterly
World Health Organisation
(WHO) surgery safety checklist
Comply with WHO guidelines
Monthly
Shepton Mallet NHS Treatment Centre
29
Participation in clinical research
The number of patients receiving NHS
services provided or sub-contracted by
UKSH at Shepton Mallet NHS Treatment
Centre in 2010–11 that were recruited
during that period to participate in research
approved by a research ethics committee
was nil.
Our treatment centres deliver high-quality,
high-volume specialist treatments based
on a model of focused care. Because of
our specialist focus, our contracts do not
include provision for clinical research.
Use of the CQUIN payment framework
Shepton Mallet NHS Treatment Centre
income in 2010–11 was not conditional
on achieving quality improvement and
innovation goals through the Commissioning
for Quality and Innovation payment
framework because SMTC did not use any
of the NHS National Standard Contracts
during 2010–11, and was therefore not
eligible to negotiate a CQUIN Scheme.
Quality Account 2010–2011
30
Statements from the Care Quality Commission
Shepton Mallet NHS Treatment Centre is required to register with the Care Quality
Commission (CQC) and its current registration status is: active (registration dated from
1 October 2010). Shepton Mallet NHS Treatment Centre is registered in respect of the
following regulated activities:
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury
Shepton Mallet NHS Treatment Centre has the following conditions on registration:
Condition of Registration
Status
The Registered Provider must ensure that the regulated activity is managed by
an individual who is registered as manager in respect of the activity, as carried
out at or from Shepton Mallet NHS Treatment Centre.
Met
The regulated activity may only be carried on at or from the following location:
Met
Shepton Mallet NHS Treatment Centre
Old Wells Road
Shepton Mallet
Somerset BA4 4LP
The CQC has not taken enforcement action against Shepton Mallet NHS Treatment Centre
during 2010–11.
Shepton Mallet NHS Treatment Centre has not participated in any special reviews or
investigations by the CQC during the reporting period.
Shepton Mallet NHS Treatment Centre
31
Data quality
Shepton Mallet NHS Treatment Centre will
be taking the following actions to improve
data quality:
We will continue to treat data quality
as an integral part of the governance
programme, subject to continual
monitoring and improvement. We employ
a dedicated team of informatics personnel
whose role is to collate and ensure the
accuracy of data, and this is reflected
in the existing high quality of data
submissions, for example 100% score
in the Information Governance Toolkit
assessment report.
As part of our ongoing improvement to our
information technology programme, UKSH
is implementing an electronic patient
record system across all sites. The system
requires the user to input all required
information, clinical and non-clinical, and
will not allow the user to proceed without
doing so. The critical difference compared
with other systems is that this includes
clinical data and outcomes. Audit reports
are also run by the informatics team and
this ensures compliance with the same
system.
Continuing management actions that
we implement under the ISO27001
framework certification also add to
the quality of data as it is tracked and
managed efficiently.
We have also identified PROMs completion
as an improvement objective for 2011–12.
Please see section 2.1 for more information.
NHS Number and General Medical
Practice Code Validity
UKSH submitted records during 2010–
11 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 GP’s valid General
Medical Practice Code was:
100% for admitted patient care; and
100% for out patient care.
Clinical data is also reviewed and audited
as part of the governance framework on
an episode basis, ensuring that a patient’s
care record is complete from referral to
discharge.
Quality Account 2010–2011
32
Data quality
Information Governance Toolkit attainment
levels
UKSH’s Information Governance
Assessment Report overall score for
2010–11 was 100% and was graded green.
Clinical coding error rate
Shepton Mallet NHS Treatment Centre was
subject to the Payment by Results clinical
coding audit during the reporting period by
the Audit Commission and the error rates
reported in the latest published audit for
that period for diagnoses and treatment
coding (clinical coding) were:
primary diagnoses incorrect 15.0%;
secondary diagnoses incorrect 45.3%;
primary procedures incorrect 19.0%;
secondary procedures incorrect 3.9%.
These figures relate to how UKSH coded
procedures for billing purposes. It is
important to note:
This typically resulted in UKSH seeking
payment below the standard rate for the
procedure.
The Audit Commission commended SMTC
in several areas:
•
all patient episodes reviewed were
deemed safe to audit – i.e. there was
always sufficient information on each
patient’s medical record;
• the case notes were in excellent order;
• most operation sheets were typed
and found to be comprehensive and
well structured;
•
UKSH adheres to a very rigid pathway
for the structure and development of
case notes which ensures accuracy in
clinical record keeping.
• diagnostic information was
systematically and correctly recorded as
part of each patient’s medical record;
The Audit Commission also made several
recommendations, which UKSH is pleased
to confirm we will adopt, so that we can
further improve our performance. In
2011–12, we will:
• UKSH achieved better clinical coding
accuracy than the average of NHS
Trusts;
• introduce regular internal audits to
identify training requirements for
clinical coding;
• UKSH undercharged the NHS for the
procedures we carried out.
• provide feedback on clinical coding to
clinicians and clinical coders;
The Audit Commission carried out its
routine audit of UKSH’s clinical coding
during September 2010. This covered
a random sample of 100 episodes of
care from general surgery. It found that
discrepancies between patient records
used by clinicians and the billing process
arose most commonly where patients
had conditions that were unrelated to the
reason why they were being treated at
UKSH (secondary diagnoses).
Shepton Mallet NHS Treatment Centre
•
provide additional training to clinical
coders, particularly in relation to
co-morbidities (where patients have
more than one condition);
• ensure coding is updated promptly
following histology results (diagnostic
tests on patients’ tissue samples).
In summary, the Audit Commission found
that UKSH’s overall clinical coding error
rate which led to significant undercharging
is 7%. This is significantly better than the
average performance of NHS trusts for the
same period.
33
Safeguarding statement
• UKSH meets the statutory requirement with regard to the carrying out of
Criminal Records Bureau 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 UKSH board reviews safeguarding across the organisation at least once a year.
Quality Account 2010–2011
34
Part 3
Review of quality
performance in 2010–11
Patient comment:
“I joined SMTC in 2009 to set up the Patient Experience Team. It has
been very fulfilling to have a role focused entirely on understanding
patient needs and then taking actions to meet those needs – it has meant
I’ve been able to make a real difference to the quality of experience
patients have at our treatment centre.
“The main challenge was to make sure that the whole organisation was
supportive and involved with this initiative, because improving patient
experience is so dependent on a seamless patient pathway through all the
aspects of their care.
“So I made sure our team had effective channels of communication
with all disciplines internally, as well as with the Primary Care Trust. It
was this communication that allowed us to develop our seamless patient
pathways all the way from the initial discussion with the GP to the
follow-up after the patient’s discharge. The way my team and the clinical
teams worked so closely together on this has been the key to making the
pathways so effective, because it means clinical outcomes, safety and
patient experience have always gone hand in hand.”
Catherine Farr
Clinical Governance and Effectiveness Manager
Review of quality
performance in 2010-11
UKSH welcomes the Department of Health’s Outcomes Framework which highlights the
importance of focusing on patient experience, safety and clinical effectiveness. We place
equal importance on each of these areas because we believe they reinforce each other
and all three are paramount to delivering the high quality of care our patients deserve.
We therefore include a section on our performance in each of these areas, as well as an
account of our process for continually monitoring and improving our performance.
In 2010–11 we delivered outstanding results in all of these areas which gives us a strong
platform on which to build when the Framework comes into force.
Patient experience
At UKSH our philosophy is that by putting
patients at the centre of everything we do,
we can and will continue to improve care.
This means we design everything from the
patient perspective, so that services are
convenient, of the highest clinical quality
and sensitive to individual needs. Two
factors are crucial in succeeding in this
aim: giving patients the information they
need to exercise choice, and consulting
regularly with patients to make sure the
priorities we set are in line with their needs
and views. We have a dedicated patient
experience coordinator to oversee the
implementation of our patient experience
objectives. Our high levels of patient
satisfaction are testament to this approach.
Our service to patients
As winners of the ‘Hotel Services’ category
in the 2010 Independent Healthcare
Awards, UKSH is particularly aware of the
importance of relevant and convenient
services to the overall patient experience.
Waiting times
For several years, the NHS has set a
target that all elective patients should
receive treatment within 18 weeks of
being referred by their GP. Although the
Department of Health has made some
changes to waiting time targets during the
past 18 months, we continue to collect
this indicator.
UKSH is pleased to report that waiting
times for treatment at SMTC are
significantly better than the average NHS
performance. Over the past year, the
average NHS waiting time was 8.4 weeks,
but at SMTC it was just 7.1 weeks.
This is more significant when put in the
context of specialty waiting times, for
example the overall NHS waiting time for
orthopaedic surgery was 12.5 weeks in
March 2011 compared to 7.3 weeks for
SMTC.
For patients we provide the following:
•
•
•
•
One-stop patient visits with all
diagnostics taken in a single day.
Free car parking.
Single-sex accommodation in
100% of cases.
Ensuite facilities in patient rooms.
• Free TV and WiFi access.
Quality Account 2010–2011
36
Patient experience
Patient information
UKSH recognises the importance of
good information in promoting patient
choice, enhancing patient experience and
optimising outcomes.
Patient feedback
SMTC consults regularly with patients
through patient forums, regular patient
surveys and by providing an effective and
accessible complaints procedure.
UKSH has created and developed patient
information leaflets containing details of
services available at SMTC, an outline
of what the different treatments involve
and a summary of the support services
available to patients.
All patient experience results are reported
through the Integrated Governance
Framework, the SMTC board and the main
UKSH board.
We are also developing a highly innovative
app for the iPhone and the iPad which
joint replacement patients can use to
help them through post-operative recovery
exercises and at home following discharge.
This is currently in beta testing and we
plan to make it available to all patients as
soon as possible.
All patients receive a pre-operative
telephone call from our patient experience
team seven days before treatment. This
call is an effective way to make sure
patients have understood vital information
in preparation for their operation, such
as ensuring certain kinds of medication
are ceased in time. The patients are
also encouraged to discuss any issues of
concern at this time, and any perceived
problems can be resolved. Staff are
trained to communicate with the patient
in a respectful way and the calls have
been very well received. The team are
experienced practitioners who are aware of
services which patients may require to aid
their recovery.
Shepton Mallet NHS Treatment Centre
The reports include summaries of
outcomes and issues, actions taken and
trends to inform progress.
The patient forums are an important
means of two-way communication with
patients and we have used them to
consult with patients on our priorities for
improvement. The forums have reviewed
and actively support our quality objectives
for 2011–12.
SMTC partakes in the annual national
NHS patient experience survey which is
comparable across NHS facilities and
is independently monitored. In addition
UKSH undertakes routinely an internal
patient satisfaction survey.
We have had similarly high satisfaction
rates to last year, with 99% of patients
saying they would recommend our
treatment centre to a friend.
While we are proud of our performance on
patient satisfaction we are not complacent
and continue to scrutinise the results,
paying close attention to opportunities to
improve our performance.
37
Patient experience
Each year, the Department of Health commissions a national survey of NHS patient
experience. The most recent questionnaire included 54 questions and we have highlighted
our performance on some of the principal indicators below:
NHS national patient experience survey results
Area of patient experience
% satisfaction
(respondents choosing
good or excellent)
How clean was your room?
100%
Do you feel you were treated with respect and dignity?
96%
How would you rate the care you received?
97%
Would you recommend this hospital?
99%
Quality Account 2010–2011
38
Patient experience
In addition to participating in this national survey, we also undertake an ongoing patient
satisfaction survey in which all patients attending for surgery are asked their views on their
experience at SMTC.
Patient are asked about different aspects of their experience at the treatment centre and
are invited to score each aspect on a scale of 1 (bad) to 5 (excellent). UKSH measures
satisfaction as including all responses graded 4 and 5 – good or excellent. Responses
between April 2010 and March 2011 indicate the following:
UKSH Patient satisfaction survey results
Area of patient experience
% satisfaction
(respondents choosing
good or excellent)
Were our staff helpful and efficient?
98%
Did the outpatients staff meet your expectations?
98%
Did the surgical staff meet all your expectations?
99%
Did the ward staff (nurses, physiotherapists) meet your expectations?
97%
Did the catering staff meet your expectations? 84%
Were there any problems once you have been discharged?
99%
Was the Treatment Centre welcoming and clean?
99%
Would you recommend the treatment centre to a friend (% saying yes probably and yes definitely)
99%
Shepton Mallet NHS Treatment Centre
39
Patient safety
SMTC has continued to deliver outstanding results in patient safety.
This is a reflection of our multi-disciplinary approach to infection prevention and our
commitment to putting cleanliness and good clinical practice at the centre of everything
we do.
The following measures have contributed to our excellent record on patient safety:
• A dedicated infection control lead working across all UKSH sites.
• Targeted training programmes for clinical staff and housekeepers.
• Any infection concerns lead to a vigorous root cause analysis, and lessons learned are presented at our clinical governance meetings.
Measures of patient safety
2009−10
2010−11
Hospital-acquired MRSA bacteraemia
0
0
Hospital-acquired C. difficile**
0
0
Surgical site infection: hip*
0.97%
0.01% (1 case)
Surgical site infection: knee*
0.75%
0.03% (2 cases)
* deep wound infections
** There was one incident in April 2010 of healthcare-acquired C. difficile (i.e. most likely
brought into the facility by the patient as opposed to being contracted in the facility
UKSH recognises that reporting of superficial infections is variable as many are managed
locally in primary care and therefore accurate reporting is difficult to achieve.
Quality Account 2010–2011
40
Clinical outcomes
UKSH strives relentlessly for the best
possible clinical outcomes and we are
proud of our achievements. A combination
of robust clinical governance and highly
trained and motivated clinical staff ensure
we have an outstanding record on clinical
effectiveness.
Our clinical advisory board brings together
senior clinicians from the UK and abroad
to ensure we adhere to the latest and
best clinical practice supported by a
clear evidence base. This feeds into
our innovative care pathways, which
we believe are the most detailed and
comprehensive of any provider in the UK.
We insist on the consistent application
of proven approaches, and this ensures
we optimise patient safety and clinical
quality. At the same time, the pathways
are designed to be flexible in determining
the most effective treatment plan for each
individual patient.
Our staff perform a high volume of
specialist procedures in small, focused
facilities, so our teams gain substantial
relevant experience and expertise
supported by intensive training.
At Shepton Mallet NHS Treatment Centre
the rates of complications continue to be
extremely low in 2010–11, as can be seen
from the results for unplanned returns to
theatre, emergency re-admissions, DVT,
PE and surgical site infections (for which
see table in patient safety section above).
A greater volume of information is
available for hip and knee replacements.
During the period April 2009 to November
2010, SMTC patients reported an
improvement in their Overall Wellbeing
Index which was above the national
average for England. SMTC patients also
reported an improvement of joint mobility
which was above the national average for
England, in both procedures.
We have this year achieved a very high day
case rate, with over 99% of procedures
expected to be carried out within a day
indeed being completed on the day of
admission, so that patients did not have
to stay overnight. One of our objectives for
2011–12 is to increase the proportion of
laparoscopic cholecystectomies that can
be carried out as day case procedures,
building on our success in delivering
high day case rates to achieve this. Our
high non-general anaesthetic rates which
compare favourably with other providers is
one of the contributory factors to achieving
our high day case rate.
Our average length of stay for joint
replacements (hip and knee) was 3.9
days. While we don’t yet have comparative
national data for the same reporting
period, the outcomes published by
HES (Health Episode Statistics) for the
previous year give an indication that we
are achieving comparatively short stays for
patients. The national averages for 200910 were 6.4 days for hip replacements
and 5.7 days for knee replacements.
PROMs data have begun to be published
on the Health Episode Statistics (HES)
website (www.hesonline.nhs.uk). Because
this process is still at an early stage, the
results available through HES for hernias
relate to a small group of patients, less
than 50 for SMTC, and therefore UKSH
is waiting for more data to be available
before drawing conclusions.
Shepton Mallet NHS Treatment Centre
41
Clinical outcomes
Total volume of procedures: 7300
Clinical outcomes
2008−9
2009−10
2010−11
Mortality within 7 days
0.00%
0.03%
0.00%
Average length of stay (joint)
4 days
4 days
3.9 days
6.7 days (hips)
6.1 days (knees)
6.4 days (hips)
5.7 days (knees)
Not yet
available
Day case rate (excl. joint replacement surgery) (percentage of day case
procedures as percentage of
procedures anticipated to be
day case procedures)
95.4%
96.3%
99.6%
Deep-vein thrombosis
0.14%
0.12%
0.03%
Pulmonary embolism
0.05%
0.01%
0.03%
Unplanned returns to theatre
0.13%
0.12%
0.07%
Emergency re-admissions within 29 days
0.56%
0.61%
0.37%
Regional/local anaesthetic rate
72.4%
68.4%
81.3%
National average length of stay (for benchmarking purposes)
Quality Account 2010–2011
42
The tables below set out the most complete data available to UKSH and include information
that we have generated as well as follow-up data provided by other local healthcare providers
about UKSH patients following discharge. While we take full responsibility for the accuracy
of data collected by UKSH, we are limited in the extent to which we can guarantee the
completeness of data provided to us from other organisations.
Speciality data - Joint replacements
• Primary hip replacements (cemented)
• Primary hip replacements (un-cemented)
• Primary knee replacements
Joint replacements: 900
Measure
Total
%
5
0.56%
Transfer of patient to another provider for IP care (excludes rehab)
14
1.56%
Unplanned re-admission within 29 days of discharge (*)
17
1.89%
Surgical repair within 14 months/revision
2
0.22%
Mortality (within 7 days)
0
0.00%
Acute myocardial infarction
0
0.00%
Pulmonary embolism
2
0.22%
Deep vein thrombosis
1
0.11%
Cerebral vascular event
0
0.00%
Hospital acquired infections (MRSA & C.difficile)
0
0.00%
Deep wound infection needing treatment at UKSH
3
0.33%
Dislocation % by hips only
3
0.66%
Unplanned return to theatre
Average length of stay
3.9 days
(*) Re-admission reporting includes those to other providers where UKSH advised of re-admission
Shepton Mallet NHS Treatment Centre
43
Speciality data - General orthopaedic
• Shoulder procedures
• Arthroscopies
• Foot procedures
• Hand procedures
• Other soft tissue procedures
General orthopaedics: 1600
Measure
Total
%
Unplanned return to theatre
0
0.00%
Conversion from day case to overnight stay
4
0.25%
Transfer of patient to another provider for IP care (excludes rehab)
0
0.00%
Unplanned re-admission within 29 days of discharge (*)
3
0.19%
Surgical repair within 14 months
2
0.13%
Mortality (within 7 days)
0
0.00%
Acute myocardial infarction
0
0.00%
Pulmonary embolism
0
0.00%
Deep vein thrombosis
1
0.06%
Cerebral vascular event
0
0.00%
Hospital acquired infections (MRSA & C.difficile)
0
0.00%
Deep wound infection needing treatment at UKSH
0
0.00%
Haematoma requiring evacuation
0
0.00%
(*) Re-admission reporting includes those to other providers where UKSH advised of re-admission
Quality Account 2010–2011
44
Speciality data - General surgery
• Hernia repair
• Peri-anal
• Cholecystectomies
• Minor GS (skin excisions)
General surgery: 2500
Measure
Total
%
0
0.00%
21
0.84%
Transfer of patient to another provider for IP care (excludes rehab)
4
0.16%
Unplanned re-admission within 29 days of discharge (*)
4
0.16%
Surgical repair within 14 months
0
0.00%
Mortality (within 7 days)
0
0.00%
Acute myocardial infarction
0
0.00%
Pulmonary embolism
0
0.00%
Deep vein thrombosis
0
0.00%
Cerebral vascular event
0
0.00%
Hospital acquired infections (MRSA & C.difficile)
0
0.00%
Deep wound infection needing treatment at UKSH
0
0.00%
Haematoma requiring evacuation
0
0.00%
Duct Injury
1
1.54%
Bile leak
0
0.00%
Conversion planned laparoscopic to open
2
3.08%
Retained common bile duct stones
0
0.00%
Bowel injury
0
0.00%
431
94.10%
Significant bleeds from endoscopy
0
0.00%
Perforation
0
0.00%
Unplanned return to theatre
Conversion from day case to overnight stay
Cholecystectomy
Endoscopy
Caecal intubation
(*) Re-admission reporting includes those to other providers where UKSH advised of re-admission
Shepton Mallet NHS Treatment Centre
45
Speciality data - Opthalmology
• Cataracts
• Minor opthalmics
Ophthalmology: 2300
Measure
Cataract
Total
%
Choroidal expulsive haemorrhage
0
0.00%
Corneal oedema
4
0.17%
Hyphaema
0
0.00%
Iris damage from phaco 0
0.00%
PC rupture with vitreous loss
4
0.17%
Cystoid macular oedema
1
0.04%
Endophthalmitis
0
0.00%
Raised IOP
0
0.00%
Uveitis
0
0.00%
Wound leak / rupture
0
0.00%
TASS * (Toxic Anterior Segment Syndrome)
0
0.00%
Quality Account 2010–2011
46
Monitoring and improving performance
UKSH has a clear focus on quality and
patient safety and this is supported by
effective management and monitoring
of services. The reporting structure
encompasses all members of UKSH
staff who are involved in delivering care
or services to patients and allows for
communication between the boards,
committees and groups through a topdown and bottom-up approach.
UKSH has created a working environment
which facilitates learning through
experience, based on fair and consistent
principles that encourage openness
and a willingness to admit mistakes.
Employees are encouraged to report any
situation where improvements could be
made or lessons learned for the benefit
of patients. There are robust processes in
place to ensure that any issues arising are
addressed and actions followed through.
This culture of openness and shared
commitment to improvement is supported
by our Clinical Advisory Board using
audit, clinical incident and regular review
of outcomes, to ensure that our clinical
teams are evaluated and supported in
developing their clinical services.
Our monthly clinical governance meetings
monitor all aspects of care based on
quality reports from each department
as well as ongoing patient satisfaction
surveys. Any complaints received are
reviewed at these meetings and actions for
improvement are identified. In addition,
our bi-monthly morbidity and mortality
meetings review any significant clinical
care or ‘near miss’ incidents to ensure
that lessons are learned, and bi-monthly
speciality meetings review any complaints
or incidents pertaining to each discipline.
Shepton Mallet NHS Treatment Centre
We also have quarterly infection control
meetings focusing specifically on this
important area of patient safety.
The results from all these monitoring
processes feed into the monthly board
meetings at each UKSH site as well
as the quarterly strategic governance
meetings. The key findings are reported
to the UKSH-wide board meetings and
to our Clinical Advisory Board. This is
made up of external clinical advisors who
review all the clinical governance reports
each quarter and recommend changes to
practice where appropriate.
Findings and actions are then cascaded
back through the organisation. The
medical director feeds back to individual
consultants on quarterly audits and
provides support and mentoring where
necessary. Our clinical advisors come on
site to discuss outcomes and best practice
with consultants. The head of nursing
and clinical services works with heads
of departments to implement changes in
clinical practice as discussed at clinical
governance meetings. The clinical
effectiveness and clinical governance
manager oversees the implementation of
new guidance and coordinates audits to
ensure that improvement is achieved, as
well as supporting heads of departments
with mentoring and coaching as needed.
These monitoring processes allow us to
constantly review evidence-based best
practice and to create a culture of shared
commitment to achieving the best possible
clinical outcomes and patient experience.
47
Staff comment:
“An example of the things we do to make sure patients have the
best possible treatment is to call them seven days before their
surgery to make sure they are ready and to answer any questions
they might have. We use a script to make sure the phone call
covers everything, because it’s very important we intercept any
problems a patient may have in the week up to surgery, for example
if they have any infections or changes in their condition. People
wouldn’t necessarily know that if they have had, say, a dental
problem, this could impact on their hip replacement operation.
We can explain all these things and advise them about diet,
changes to medication and all the arrangements for the day of their
appointment.
Calling them at home means they are in a familiar environment and
feel relaxed enough to ask any questions they might have about the
procedure.
We also check pre-op results and intercept any problems. For
example, if our clinicians identify anything unusual, we would
contact the patient to make sure they are seen here again or advise
them to go to their GP if that is more appropriate.”
Jennie Miller
SMTC patient experience team member
Quality Account 2010–2011
48
Patient forum
UKSH has established a patient forum through which we consult with our patients at
Shepton Mallet NHS Treatment Centre.
The patient forum reviewed our performance against last year’s quality objectives and were
pleased to see the progress that UKSH had achieved. The group discussed the proposed
quality improvement targets for the forthcoming year and in particular supported the
proposed work regarding minimising waiting times.
Statement from NHS Somerset
I am writing in reply to your email dated 2
June 2011, and the enclosed copy of the
Quality Account 20010/11 for Shepton
Mallet Treatment Centre.
During 2010 -11 NHS Somerset has
monitored the quality and patient
experience for health services that
we commission from Shepton Mallet
Treatment Centre. This provides the basis
for NHS Somerset to comment on the
quality account, performance against
quality improvement priorities, and the
quality of the data included.
We have reviewed the achievements
against the identified Quality Improvement
priorities for inclusion in the Quality
Account for 2010 / 11 and would
comment as follows:
•
Safe use of antibiotics: achievement of
99.8% of patients receiving appropriate
antibiotic prophylaxis against a target
of 100%
Antibiotic prophylaxis is important for
preventing post operative infection
for patients and using the appropriate
antibiotics reduces the risk of patients
developing C difficile infection.
Shepton Mallet NHS Treatment Centre
Ensuring that there is appropriate clinical
leadership for infection control and
pharmacy review of antibiotic prescribing
is key to achieving this patient safety
indicator.
• Reduce rate of cancellations on the day
Reducing cancellations of surgery on the
day is an important indicator of patient
experience. Patients often need to make
a number of practical arrangements in
order to attend hospital for treatment. The
Treatment Centre is commended for the
progress on last year’s position.
We have discussed the timing of pre
operative phone calls to patients to reduce
the rate of cancellations with the Centre
during the year, and can confirm that the
Treatment Centre has exceeded the target
of no more than 3% of day cancellations.
• Improve MEWS documentation:
100% of all MEWS documentation
being completed
MEWS documentation provides the record
of patient physiological observations
using a tool to provide early warning of
when a patient’s physiological condition
is deteriorating and requires medical
attention.
49
Statement from NHS Somerset
Use of MEWS scoring and documentation
improves the safety of patients. It is
positive to see the actions the Treatment
Centre has taken to audit the quality
of the MEWS recording and to provide
additional training for staff in this area of
patient safety.
Clinical Effectiveness
Participation in national audit programmes
and national confidential enquiries, as well
as undertaking a local audit programme,
provides assurance of the quality of
treatment and care and the outcomes of
care for patients.
• Increase risk assessments for VTE
(blood clots)
Patient Safety
We confirm that the Treatment Centre has
had no incidence of healthcare acquired
MRSA bacteraemia and one case of C.
difficile during 2010 -11.
• Improve VTE prophylaxis
These targets require the Treatment Centre
to demonstrate that all patients admitted
to hospital have had a VTE assessment.
VTE assessment ensures that patients
will receive the appropriate preventative
treatment to prevent a clot developing
in their leg, and is key component of
preventative care that improves the safety
of all patients in hospital. We can confirm
achievement of 92.5 % of patients
receiving an assessment for venous
thrombo – embolism (VTE) and 100% for
VTE prophylaxis.
Data Quality
NHS Somerset reviews performance data
on procedures completed, and associated
indicators for quality of care.
In 2011 -12 we will be initiating quality
contract monitoring meetings with the
Treatment Centre to review, in detail,
performance against a range of quality and
patient safety indicators. With increasing
patient choice the provision of high quality
data on the effectiveness and safety of the
care provided to patients will be important
for patients to make a choice about where
to have their treatment.
Quality Account 2010–2011
The Treatment Centre has reported
one Never Event as a serious untoward
incident during 2010 -11. This was in
relation to wrong site surgery where a
patient received a joint injection on the
wrong side. The patient suffered no ill
effect and was rebooked for the correct
procedure which was completed. The
investigation identified the importance
of ensuring that the World Health
Organisation Surgical Safety checklist is
fully completed prior to all procedures and
that this is audited on a monthly basis in
all operating procedures.
Patient Experience
The Treatment Centre has undertaken a
number of initiatives during the year, in
discussion with commissioners, to improve
the patient experience.
The extended hours of opening, free
bus service for patients for identified
areas, and provision of services in some
community hospitals for ease of access for
patients, has been welcomed.
50
Statement from NHS Somerset
The Treatment Centre completed
additional works to the pre and post
operative clinical areas in order to achieve
full compliance with the standards for
eliminating mixed sex accommodation by
1 April 2011.
The referral to treatment waiting time of
7.1 weeks is valued by patients using the
centre.
Quality Improvement Priorities for 2011 -12
• No breaches in Single-sex treatment
areas
• Deliver comprehensive pre-operative
service within three hours – to achieve
a target of 70%
• Achieve a 10% reduction in patient
falls
• Improve response rates to 85% for
Patient Reported Outcome Measures
(PROMs) questionnaires
•
Establish laparoscopic cholecystectomy
as a daycase procedure, and
increase the proportion of laparoscopic
cholecystectomy procedures carried out
NHS Somerset supports the quality
improvement priorities identified by
Shepton Mallet Treatment Centre for 2011
– 12.
NHS Somerset is establishing quarterly
quality monitoring meetings with the
Treatment Centre for 2011 - 12 which will
provide increased assurance of the quality
and safety of the services commissioned.
We welcome the engagement of the
Treatment Centre in this We look forward
to continuing to work with Shepton Mallet
Treatment Centre during 2011 – 12 to
improve the safety, clinical effectiveness
and patient experience of the services
provided by the Trust, and in the
development of the Quality Account for
2011/12.
Please contact me at the above address
if you wish to discuss any of the above
comments further.
Yours sincerely
Lucy Watson
Acting Director of Nursing and Patient
Safety
These include improvement priorities in
the three domains of patient experience,
patient safety and clinical effectiveness.
It is positive to note that these quality
improvement priorities have been
developed with consideration of the
feedback provided by patients.
Shepton Mallet NHS Treatment Centre
51
Somerset Local Involvement Network
The Department of Health specifies that each Quality Account should be reviewed by the
provider’s relevant Local Involvement Network (LINk), though the LINk may choose not to
respond or issue a formal statement.
UKSH has engaged Somerset LINk with a draft copy of this Quality Account prior to
publication. The LINk has been unable to respond because of the short timescales
involved, but has committed to disseminating this Quality Account and will feedback any
responses to SMTC.
UKSH looks forward to receiving comments from the members of Somerset LINk and we
will continue to engage all stakeholders during 2011–12
Quality Account 2010–2011
52