2010–2011

Page 3
Page 5
Page 7
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Part 2.1
Page 11
Objective 1: Treat all patients in single-sex areas
Objective 2: Deliver comprehensive pre-operative service within 2.5 hours
Objective 3: Minimise patient falls
Objective 4: Establish laparoscopic cholecystectomy as a day case procedure
Objective 5: Improve returns of Patient Reported Outcome Measures
Part 2.2
Page 26
Part 3
Page 35

2010–11 was the first full year of operation for the three facilities opened by UKSH South West in November 2009:
Emersons Green, Devizes and Cirencester
NHS Treatment Centres.
UKSH South West has applied the successful UKSH model of focused care at these sites, delivering excellent clinical outcomes and patient experience. In
2010–11 we 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%, this was significantly
better than our target of 4%.
Improvements to clinical effectiveness
• We carried out VTE (blood clot) risk
assessments for 93.7% 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 that
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 87.5% 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 3 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 UKSH South West treatment
centres.

• Establish laparoscopic cholecystectomy
(gall bladder removal) as a day case
procedure as recent research that 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 Quality Account, we regularly monitor our performance in all areas, and outcomes are reported in detail in Part 3 of this Quality Account. These include:
• Exceptional patient services: winners
of the ‘Hotel Services’ category in the
2010 Independent Healthcare Awards,
we provide free parking, ensuite facilities
and free WiFi and phone calls as
standard to all our patients.
• Average waiting time from referral to
treatment of 10.8 weeks.
• Zero rate of hospital-acquired MRSA
bacteraemia and C. difficile.
• 99% of procedures planned as day
case are carried out as day case
procedures.
• 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.

UKSH South West operates three treatment centres. 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 specialities for NHS patients.
These PCTs are NHS Bristol, NHS South
Gloucestershire, NHS North Somerset,
NHS Swindon, NHS Wiltshire, NHS
Gloucestershire and NHS Bath and North
East Somerset.
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 and, since August 2010, the Peninsula NHS
Treatment Centre in Plymouth.
UKSH employs over 450 skilled clinicians and support staff at our centres across the
South West, and to date we have carried out nearly 70,000 procedures across all sites.
Emersons Green NHS Treatment Centre
At Emersons Green in Bristol, NHS patients can access planned procedures including dental extractions, diagnostic services, ear, nose and throat treatments, endoscopy, general surgery, gynaecology, joint replacements, minor orthopaedics, ophthalmology and urology.
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.
Devizes NHS Treatment Centre offers services to NHS patients in the following areas: dental extractions, diagnostic services, ear, nose and throat procedures, endoscopy, general surgery, gynaecology, minor orthopaedics, ophthalmology and urology.
Cirencester NHS Treatment Centre
The Cirencester NHS Treatment Centre specialises in day case procedures in several speciality areas: dental extractions, diagnostic services, ear, nose and throat procedures, general surgery, gynaecology, minor orthopaedics and urology.
To improve convenience and ease of access, patients can have their outpatient appointment at Cirencester or Devizes followed by surgery at Emersons Green
Treatment Centre for certain procedures.
More information about UKSH and our treatment centres in the South West is available on our website: www.uk-sh.co.uk

UKSH is pleased to participate for the second year in the Department of Health’s
Quality Account 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, including from our patient forums, 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.
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 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 each of our sister sites at
Shepton Mallet and Plymouth.
More information about our performance can be found on our website, www.uk-sh.co.uk

Part 1

2010–11 was a significant year for UK
Specialist Hospitals.
It was our first full year of providing services to patients in Emersons Green,
Devizes and Cirencester. This Quality
Account demonstrates the progress we made delivering high-quality care while always aiming for the best possible experience for patients.
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, and we were contracted to provide services to patients at Shepton Mallet NHS Treatment
Centre for a further three years. Both 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 year’s Quality Account shows how we have embedded leading-edge 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.
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.

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

Part 2.1
Patient comment:
“How often have you heard people say well it’s alright for them, they can afford private hospital treatment, they are seen quickly by a consultant and admitted soon after for treatment in luxurious surroundings?
Well now you can have this sort of treatment for free on the NHS and I can prove it. Last November I was referred to Emersons Green by my doctor. I was seen within two weeks by a consultant who recommended me for a knee replacement and was then admitted within eight days for my operation.
This hospital is luxurious and spotlessly clean. Food was excellent and cooked onsite by the resident chef. The wards are small and manned 24 hours a day by the most professional, cheerful and helpful staff I have ever come across. My operation was such a success that I have just returned and had the other knee replaced.
I have also recommended the centre to quite a few friends and my wife will be having a cataract operation there in a few weeks. Oh yes, I almost forgot – they provide you with free telephone and television, and there is also ample free parking. What more could anyone ask for?”
Roland from Bristol
Member of patient forum

Patient experience
Clinical effectiveness and patient safety
Patient safety
UKSH quality objective for
2010-11
Target for 2010-11 Overall
performance at AGW in 2010-11
2.0%
Status
Reduce rate of cancellations on the day
On the day cancellations no more than 4%
Increase risk assessments for
VTE
At least 95% of patients receive risk assessment
Improve VTE
prophylaxis
Improve MEWS documentation
Safe use of antibiotics
93.7%
Target exceeded
Close to target and exceeded national target
100% of patients receive appropriate preventative measures
100% Target met
MEWS documentation for at least 95% of patients
100% of patients receive appropriate antibiotic prophylaxis
100% Target exceeded
87.5%
(last two quarters 100%)
Target rate achieved by end of year
UKSH South West has made significant progress against all its quality improvement targets for 2010–11. We met or exceeded our targets for reducing cancellations, improving
VTE prophylaxis and increasing MEWS documentation. We reached our target of 100% of patients receiving a full suite of antibiotics by the second half of the year and consistently exceeded the national target for VTE risk assessments.

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. Some reasons for cancellations are inevitably outside our control, such as patient illness or disruptions to travel and during the particularly harsh winter earlier this year many patients chose to delay their treatment. Our focus is on reducing cancellations caused by clinical and operational factors.
Building on our already strong record, UKSH South West succeeded in reducing the rate of on the day cancellations last year, exceeding our target of 4% to achieve a rate of just 2%.
This means that 98% of our patients had their procedure on the planned date, compared to 92% in the previous year.
One of the factors which contributed to the overall achievement of 2% was our focus on reducing avoidable clinical cancellations. The graph below shows how this subset of overall cancellations decreased to around 0.5% by the end of the year.
2.50
2.00
1.50
1.00
0.50
0.00
1 2 3 4 5 6 7 8 9 10 11 12

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.
• 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.

100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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NATIONAL
TARGET
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%.
UKSH South West achieved 94% 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 month of implementing the metric, where we recorded an 86% compliance rate. This metric commenced in June in line with the national programme and within one month performance had climbed above the national target. Once the processes were bedded in by the middle of the year performance was steady around 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. The
electronic patient record was a useful
tool for analysing when assessment was
not performed so that specific
individuals or teams could be mentored
or coached to better understand the
importance of the assessments.
• Rolled out e-learning programme for
all staff.
• 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.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
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100%
80%
60%
40%
20%
0
100% 100% 100% 99%
Q1 Q2 Q3 Q4
100%
80%
40%
20%
0
Q1 Q2 Q3 Q4

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
(prophylaxis). In addition, every patient is assessed for the risk of bleeding. UKSH
South West 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.
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%.
UKSH South West 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 etc.
These audits were routinely reviewed at clinical governance meetings and discussed at ward meetings. We found that we scored highly, 90% or over throughout the year, against these additional internal quality checks.
This review process has enabled us to identify areas where best practice can be more consistently applied and 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. 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.

100%
90%
80%
70%
60%
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100%
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60%
40%
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100% 100% 100% 99%
Q1 Q2 Q3 Q4
100%
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60%
40%
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0
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.
We addressed this by ensuring staff engaged in appropriate discussion and education and it can be seen how for the remainder of the year an absolute level of
100% compliance was achieved. We are continuing to perform at that level.
We reached our target during the second half of the year, having learned lessons from our audits carried out in the earlier part of the year.
UKSH set an absolute target to apply this metric to every single patient. Initial audits, based on a random sample of medical records during each quarter, showed a promising start though not yet at the target level. Unfortunately, compliance dropped to
90%
66% in the second quarter. We addressed the reasons for non-compliance, which related in part to cautious use of some antibiotics because of patient comorbidity factors, through clinical governance meetings. We found that non-compliance related to the use of only one drug in circumstances where two were appropriate, but we would stress that these patients were still receiving antibiotic prophylaxis. FE
B
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.
Measures we have taken to ensure the safe use of antibiotics include:
• Daily ward rounds by pharmacy team
to check all patients have received
appropriate antibiotics where applicable,
including routine checks to identify any
discrepancies in prescribing and to
address issues in real time.
• Increased mentoring and support for
prescribers principally performed by the
UKSH South West infection control lead,
with further support from the UKSH-
• Introduced safe use of antibiotics as
standing item at infection control and
clinical governance meetings, so that
our performance is regularly monitored
and appropriate actions taken.
We will continue to implement and monitor these measures to maintain our performance at the high level we achieved in 2010–11.
Q1 Q2 Q3 Q4

Patient experience
Patient safety
Clinical effectiveness
Objective Target
Treat all patients in single-sex areas
Deliver comprehensive pre-operative service within 3 hours
Minimise patient falls
Establish laparoscopic cholecystectomy as a day case procedure
Improve response rates for
Patient Reported Outcome
Measures (PROMs)
No breaches
70% of pre-operative appointments completed within 3 hours
10% reduction in patient falls
Increase the proportion of laparoscopic cholecystectomy procedures carried out as day cases
85% return rate for PROMs questionnaires
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.
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.

UKSH has never breached its aim of
100% of inpatients accommodated in single-sex wards.
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.
The national element of this initiative will enable our performance to be judged against all other providers of care to NHS patients.
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
Current performance
Measures to achieve objective
Monitoring/reporting process
100% of patients always accommodated and treated in single-sex areas
100% of patients always accommodated in single-sex rooms
• 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.
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.

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.
Delivering a comprehensive one-stop pre-operative assessment and outpatient appointment involves many different stages.
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.
The objective is that by the end of this appointment each patient will leave with an agreed date for surgery.
Fitting all this in can be logistically challenging, yet patients have quite reasonably told us that three hours is long enough. We therefore aim to ensure that during 2011–12 we will complete 70% of pre-operative assessments within three hours at UKSH South West.
Target
Current performance
Measures to achieve objective
Monitoring/reporting process
70% of pre-operative assessments completed within 3 hours
Average waiting time is 2h 17m*
• 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.).
The 3-hour statistic will be reported monthly through the UKSH performance reporting mechanism. It will be measured as the volume of first attendances <3 hours divided by the total volume of first attendances in the month.
* This figure is based on sample audits and excludes patients who do not require surgery.

UKSH is proud of its record in patient safety, and although there were only 16 falls at UKSH South West last year (2.5 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 UKSH South West is 62% 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.
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.

Target
Current performance
Measures to achieve objective
Monitoring/reporting process
Reduce number of falls by 10%
16 falls equivalent to 2.5 falls per 1000 bed days
• 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 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.
• Patient directory at each bed space giving information on falls
prevention.
• UKSH-wide falls prevention working group with representatives
from each centre, to share best practice and awareness and to lead
measures for improvement.
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.

Laparoscopic cholecystectomy (gall bladder removal) is a common surgical procedure provided by UKSH South
West. During the past year we carried out
306 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
Current performance
Measures to achieve objective
Monitoring/reporting process
Establish laparoscopic cholecystectomy as a day case procedure and identify effective improvement measures
6% of laparoscopic cholecystectomies were carried out as day case procedures.
• 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.
• Ensure each patient receives post-operative information prior to
discharge enabling them to recognise signs and symptoms of
possible complications, in line with guidance from the NHS
National Patient Safety Agency.
UKSH Quality Report produced monthly

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 and varicose vein treatments are invited to complete a short questionnaire before and after their treatment, to capture information on their health and healthrelated quality of life. The purpose is to allow patient’s own assessment of the health benefits of their treatment 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.
Although our rate of PROMs returns is higher than many other healthcare providers, our rates of pre-operative
PROMs returns at UKSH South West in the current reporting period have not matched our own expectations and the standards of compliance we achieve in other areas.
We will implement a range of measures to improve our pre-operative PROMs return rate to achieve our 85% target.
This will include:
• A thorough review analysing each
stage of the PROMS collection process
to understand any operational
challenges that are impeding the
collection and submission of returns.
• The development of new processes
based on the learning from this analysis.
• Additional training to ensure the
new processes are followed ensuring
we encourage patients to complete
pre-operative PROMs questionnaires
while always making it clear that
participation is voluntary.
We will also ensure that these are routinely submitted at the point of treatment.
Because UKSH South West believes these are an important measure of clinical outcomes, we will prioritise improving our returns performance for pre-operative
PROMs questionnaires as one of our quality objectives for 2011–12.
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 and varicose veins relate to a small group of patients 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, UKSH South West patients reported an improvement in their Overall Wellbeing
Index which was above the national average for England.

Target
Current performance
Measures to achieve objective
Monitoring/reporting process
To progress to submitting 85% of patient returns for all procedures by the fourth reporting quarter of 2011–12.
Hip: 50.4%; knee: 55.1%; hernia: 37.9%; varicose veins: 70.0%
• 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.
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.

Part 2.2
Staff comment:
“I joined UKSH earlier this year together with a number of other new recruits, and all of us shared a common aim – to provide really high quality care for patients.
Joining UKSH has been amazing. The facilities, cleanliness and attention to patient service are absolutely great. Things are so much more organised than I’ve ever experienced before. Everything from little details that send out a big message
– like providing bottled mineral water for patients – through to making sure the patient journey is planned in meticulous detail. This means that effective clinical procedures are always followed and so patients know what to expect, for example that they will be going home on a specific day. They really appreciate this clarity.
The staff here are incredibly happy because we know we can rely on the systems in place. That reduces stress and allows us to concentrate on patients. In turn, patients frequently comment on how content the staff seem to be. And it’s certainly true that I have never been happier professionally.”
Jayne Croucher
Senior Ward Nurse

The following section contains the mandatory statements common to all Quality Accounts as required by the regulations set out by the Department of Health.
During 2010–11, UKSH provided nine
NHS services at UKSH South West NHS
Treatment Centres. These were:
• Dental procedures
• Ear, nose and throat surgery
• Endoscopy diagnostics
(gastroscopy and colonoscopy)
• General surgery
• Gynaecology
• Imaging (x-ray and ultrasound)
• Minor urology
• Ophthalmic surgery (including cataracts
and minor eyelid procedures)
• Orthopaedics surgery
(joint replacements and minor)
UKSH has reviewed all the data available to them on the quality of care in nine (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
UKSH South West for 2010–11.
During 2010–11, two national clinical audits and one national confidential enquiry covered NHS services that UKSH provides at UKSH South West.
During that period UKSH South West 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.
The national clinical audits and national confidential enquiry that UKSH South
West was eligible to participate in during
2010–11 are as follows:
Hip and knee replacements
(National Joint Registry)
Elective surgery (National PROMs Programme)
National Confidential Enquiry into Patient
Outcome and Death (NCEPOD) Cardiac Arrest
Procedures study

The national clinical audits and national confidential enquiry that UKSH South West 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
Hip and knee replacements (National Joint Registry): Knee
Elective surgery (National PROMs Programme): Hip
Elective surgery (National PROMs Programme): Knee
Elective surgery (National PROMs Programme): Hernia
Elective surgery (National PROMs Programme): Varicose veins
Yes
Yes
Yes
Yes
Yes
Yes
97.1%
97.4%
50.4%
55.1%
37.9%
70.0%
National Confidential Enquiry into Patient Outcome and Death
(NCEPOD) Cardiac Arrest Procedures
* see below
The reports of two national clinical audits were reviewed in 2010–11 and
UKSH South West intends to take the following actions to improve the quality of healthcare provided.
Yes n/a*
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 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 97% of its hip and knee procedures to the NJR.
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 we can report the following results at UKSH South West:
• Patients reported an improvement of
the Overall Wellbeing Index for both
hips and knees which was above the
national average for England.
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 collected by the NHS Information
Centre.
• Patients reported an improvement of
joint mobility for both hips and knees
which was above the national average
for England.

Because this process is still at an early stage, the results available for hernias and varicose veins relate to small groups of patients and therefore UKSH is waiting for more data to be available before drawing conclusions.
While the level of returns of pre-operative
PROMs questionnaires was in line with many other NHS providers, the rate at UKSH South West fell short of our expectations. This is why we have identified PROMs submissions as one of our improvement objectives for 2011–12.
In 2010–11, UKSH registered with
NCEPOD. The only relevant survey to
UKSH South West was the Cardiac Arrest
Procedures survey. During the reporting period of 1 November to 14 November
2010 there were no Cardiac Arrests at
UKSH South West, so submissions were not required.
UKSH South West will complete the organisational questionnaire related to the
Cardiac Arrest survey which we expect to be issued shortly by NCEPOD.
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.
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 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:
Consent
Endoscopy
Hand hygiene
Infection prevention and control
Information governance
MEWS
Patient management
Patient records
Comply with consent policy
Comply with JAG standards
Comply with HPA requirements
Comply with HPA requirements
Ensure ongoing compliance with: ISO 27001, IGSOC
Comply with early warning system identifying deterioration in patient condition
Ensure effectiveness of current pain protocols
Ensure best practice in patient medical record
Comply with national policy and legislation
Quarterly
Quarterly
Quarterly
All positive results audited, identifys any organism trends
Six-monthly external audits
Rotational internal audit plan in place
Monthly
Quarterly
Quarterly
Monthly Pharmacy including controlled drugs audits
Prescription chart audit
Radiology
Resuscitation
Sterile services
Surgical technique
VTE prophylaxis
Comply with Ionising Radiation
(Medical Exposure) Regulations
(IRMER) requirements
Ensure best practice in resuscitation technique
Ensure ongoing compliance with
QMS 13485
Shared learning on difficult cases at speciality meetings and ensure compliance with best practice
Comply with updated NICE
Guideline (Jan 10)
Ensure best practice in patient care Ward
1. Fluid balance chart
2. Blood fridge
3. Falls risk assessment
4. Condition of mattresses
5. VTE
Waste
Clinical and non-clinical
World Health Organisation
(WHO) surgery safety checklist
Comply with:
Health and safety requirements
Comply with WHO guidelines
Annual IRMER programme in place
Monthly local audits to support
Monthly
Monthly tray list
Quarterly
Quarterly
Annual audit programme in place with monthly reporting to clinical governance committee
Quarterly
Monthly

The number of patients receiving NHS services provided or sub-contracted by
UKSH at UKSH South West NHS Treatment
Centres 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.
UKSH South West income in 2010–11 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and
Innovation payment framework because
UKSH did not use any of the NHS National
Standard Contracts, and was therefore not eligible to negotiate a CQUIN Scheme.

Each of our South West sites, Emersons Green, Devizes and Cirencester are required to register separately with the Care Quality Commission (CQC).
Their current registration status is: active
UKSH South West NHS Treatment Centres, which include Emersons Green NHS Treatment
Centre, Devizes NHS Treatment Centre and Cirencester NHS Treatment Centre, are registered for the following:
• Surgical procedures
• Diagnostic and screening procedures
• Treatment of disease, disorder or injury
UKSH South West 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 Cirencester NHS Treatment Centre, Devizes NHS Treatment Centre and Emersons Green NHS Treatment Centre.
Met
The regulated activity may only be carried on at or from the following location:
Cirencester NHS Treatment Centre
Tetbury Road
Cirencester
GL7 1UY
Devizes NHS Treatment Centre
Marshall Road
Devizes
SN10 3UF
Emersons Green NHS Treatment Centre
The Brooms
Bristol
BS16 7FH
Met
The CQC has not taken enforcement action against UKSH South West during 2010–11.
UKSH South West has not participated in any special reviews or investigations by the CQC during the reporting period.
UKSH South West is subject to periodic unannounced inspections by the CQC and the last inspection was on 29 April 2010. The subsequent report recommended a number of improvements which we have implemented as follows:
Area for improvement Action Progress
CD record keeping
Clinical waste
• Clinical staff made aware of required standard.
• Weekly audits implemented with effect from
29 April 2010, to be reviewed by the Registered
Manager and pharmacist to ensure standards are
fully met and continue to be fully met.
• All staff made aware of required standard in
relation to closing and labelling waste bags.
Complete
Complete
Complete
• Monthly audits implemented with effect from
May 2010. Audits reviewed by head of nursing
and clinical services to ensure standards are fully
met and staff comply with the policy.
Complete
• Re-training on waste management for relevant staff. Complete

UKSH South West 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.
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.
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.
Information Governance Toolkit attainment levels
UKSH’s Information Governance
Assessment Report overall score for
2010–11 was 100% and was graded green.
UKSH takes information governance and the security of patient details very seriously and treats it with paramount importance. Last year UKSH already scored highly in this area (87% and green). Through our focused efforts we are pleased to report that we have now achieved 100% in the Information
Governance Tool-kit.
Clinical coding error rate
UKSH South West was not subject to the Payment by Results clinical coding audit during 2010–11 by the Audit
Commission.

• 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 board reviews safeguarding across the organisation at least once a year.

Part 3
Staff comment:
“I am a registered nurse who has been working for UKSH at Emerson Green
Treatment Centre since November 2009.
The care that we give to the patients on the ward is of the highest quality and we view the Care Quality Commission outcomes as the minimum standards. At UKSH we value every person as an individual and as such provide individualised care to all our patients.
We encourage patient feedback and deal effectively with customer concerns which we try to resolve as soon as they are raised. We always go that extra mile to deliver care to the patients and their relatives. As employees, we find satisfaction in the positive feedback from patients about the experience we offer, from the very first contact on admission until they leave the hospital and during their after care. We do this through the highest level of personal responsibility and through roles that interact closely with our patients and other members of the multi-disciplinary team during their treatment at the centre.
We welcome patients and their relatives with courtesy and respect and make them feel at ease once they arrive on the ward ensuring that they settle in properly. A dedicated nurse is allocated to each patient who is responsible for the patient during every shift.
As the Infection Control Nurse, I also ensure that we comply with all the policies and procedures and national guidelines. In 2010 a position for Senior Nurse became available in the ward and I was promoted to senior staff nurse. I enjoy the opportunity that the organisation has given me to be involved with the training of
NVQ students as an Assessor.”
Roberta Isnard
Registered nurse

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.
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.
In 2010–11 we have continued to provide patients with exceptional levels of convenience and comfort including:
• 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.
Waiting times
In 2010–11 the average waiting time for patients from referral to treatment was
10.8 weeks.
Patient information
UKSH recognises the importance of good information in promoting patient choice, enhancing patient experience and optimising outcomes.
As part of our communications with local practices, UKSH South West has appointed three GPs whose role is to liaise closely with local GPs to ensure the best possible patient experience.
UKSH has created and developed patient information leaflets containing details of services available at UKSH South West, an outline of what the different treatments involve and a summary of the support services available to patients.
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.
Patient feedback
UKSH South West consults regularly with patients through patient forums, regular patient surveys and by providing an effective and accessible complaints procedure. All patient experience results are reported through the Integrated
Governance Framework, the UKSH
South West board and the main UKSH board. 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.
UKSH South West 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.
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.
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:
Area of patient experience % satisfaction
(respondents choosing good or excellent)
Emersons Green Devizes Cirencester
How clean was your room?
Do you feel you were treated with respect and dignity?
How would you rate the care you received?
Would you recommend this hospital?
97%
94%
95%
98%
100%
97%
95%
97%
94%
97%
98%
98%

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 UKSH South West treatment centres.
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:
Area of patient experience
Were our staff helpful and efficient?
Did the outpatients staff meet your expectations?
Did the surgical staff meet all your expectations?
Did the ward staff (nurses, physiotherapists) meet your expectations?
Did the catering staff meet your expectations?
Were there any problems once you have been discharged?
Was the Treatment Centre welcoming and clean?
Would you recommend the treatment centre to a friend
(% saying yes probably and yes definitely)
% satisfaction
(respondents choosing
‘good’ or ‘excellent’)
97%
97%
99%
95%
91%
99%
99%
99%

UKSH South West has continued to deliver outstanding results in patient safety, with an unbroken record of zero cases of hospital-acquired MRSA bacteraemia and
C. difficile at Emersons Green, Devizes and Cirencester since opening.
This is a reflection of our multidisciplinary 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
Hospital-acquired MRSA bacteraemia
Hospital-acquired C. difficile
Surgical site infection: hip
Surgical site infection: knee**
* UKSH South West opened in November 2009
** deep wound infections
2009−10*
0
0
0
0
2010−11
0
0
0
1 case
(0.01%)
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.

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.
Our results for 2010–11, our first full year of operation in the three treatment centres that make up UKSH South West, demonstrate improvements in many areas on the excellent baseline we established in the initial reporting period (November
2009 - April 2010).
At UKSH South West 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).
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 and varicose veins relate to a small group of patients 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, UKSH South West patients reported an improvement in their Overall Wellbeing
Index which was above the national average for England.
Our average length of stay for joint replacements (hip and knee) was
3.8 days. While we do not 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 2009-
10 were 6.4 days for hip replacements and 5.7 days for knee replacements.

Clinical outcomes
Mortality within 7 days
Average length of stay (joint)
National average length of stay
(for benchmarking purposes)
Day case rate (excl. joint replacement surgery) (percentage of day case procedures as percentage of procedures anticipated to be day case procedures)
Deep-vein thrombosis
Pulmonary embolism
Unplanned returns to theatre
Emergency re-admissions within 29 days
Regional/local anaesthetic rate
2009−10
0.00%
4.1 days
6.4 days (hips)
5.7 days (knees)
93.6%
0.00%
0.04%
0.17%
0.67%
73.8%
2010−11
0.00%
3.8 days
Not yet available
98.9%
0.04%
0.04%
0.04%
0.60%
66.5%
* Note, there were also four mortalities within 30 days, three of which were due to causes
unrelated to their procedures. One patient died following a pulmonary embolism.

The following tables 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.
• Primary hip replacements (cemented)
• Primary hip replacements (un-cemented)
• Primary knee replacements
Measure Total %
Unplanned return to theatre
Transfer of patient to another provider for IP care (excludes rehab)
Unplanned re-admission within 29 days of discharge (*)
Surgical repair within 14 months/revision
Mortality (within 7 days)
Acute myocardial infarction
Pulmonary embolism
Deep vein thrombosis
Cerebral vascular event
Hospital acquired infections (MRSA & C.difficile)
Deep wound infection needing treatment at UKSH
Dislocation % by hips only
Average length of stay
3
14
29
2
0
2
3
4
1
2
0
0
3.8 days
0.00%
0.00%
0.10%
0.37%
0.30%
1.40%
2.90%
0.20%
0.00%
0.20%
0.30%
0.40%

• Arthroscopies
• Foot procedures
• Hand procedures
• Other soft tissue procedures
Measure
Unplanned return to theatre
Conversion from day case to overnight stay
Transfer of patient to another provider for IP care (excludes rehab)
Unplanned re-admission within 29 days of discharge (*)
Surgical repair within 14 months
Mortality (within 7 days)
Acute myocardial infarction
Pulmonary embolism
Deep vein thrombosis
Cerebral vascular event
Hospital acquired infections (MRSA & C.difficile)
Deep wound infection needing treatment
Haematoma requiring evacuation
Total
0
2
2
0
0
30
1
7
0
0
2
0
0
%
0.00%
1.07%
0.04%
0.25%
0.07%
0.00%
0.00%
0.07%
0.07%
0.00%
0.00%
0.00%
0.00%
(*) Re-admission reporting includes those to other providers where UKSH advised of re-admission

• Hernia repair
• Peri-anal
• Cholecystectomies
• Minor GS (skin excisions)
Measure Total %
Unplanned return to theatre
Conversion from day case to overnight stay
Transfer of patient to another provider for IP care (excludes rehab)
Unplanned re-admission within 29 days of discharge (*)
Surgical repair within 14 months
Mortality (within 7 days)
Acute myocardial infarction
Pulmonary embolism
Deep vein thrombosis
Cerebral vascular event
Hospital acquired infections (MRSA & C.difficile)
Deep wound infection needing treatment at UKSH
Haematoma requiring evacuation
Cholecystectomy
Duct Injury
Bile leak
Conversion planned laparoscopic to open
Retained common bile duct stones
Bowel injury
Endoscopy
Caecal intubation
Significant bleeds from endoscopy
Perforation
2
70
2
20
2
0
0
1
1
0
0
0
4
0
1
9
1
0
638
0
0
0.00%
0.33%
2.94%
0.33%
0.00%
94.80%
0.00%
0.00%
(*) Re-admission reporting includes those to other providers where UKSH advised of re-admission
0.06%
2.12%
0.06%
0.61%
0.06%
0.00%
0.00%
0.03%
0.03%
0.00%
0.00%
0.00%
0.12%

• Minor ear
• Myringotomy
• FESS
• Septoplasty
• Tonsillectomy
• Dental extractions
Measure Total %
Unplanned return to theatre
Conversion from day case to overnight stay
Transfer of patient to another provider for IP care (excludes rehab)
Unplanned re-admission within 29 days of discharge (*)
Mortality (within 7 days)
Acute myocardial infarction
Pulmonary embolism
Deep vein thrombosis
Cerebral vascular event
Hospital acquired infection (MRSA & C.difficile)
Deep wound infection needing treatment
Haematoma requiring evacuation
Primary haemorrhage
Secondary haemorrhage
1
7
4
19
0
0
0
0
0
0
1
0
1
6
(*) Re-admission reporting includes those to other providers where UKSH advised of re-admission
0.00%
0.00%
0.02%
0.00%
0.02%
0.14%
0.02%
0.17%
0.15%
0.45%
0.00%
0.00%
0.00%
0.00%

• Hysterosocpy
• Colporrhaphy
• Hysterectomy
• Laparoscopy
• TVTO
Measure
Unplanned return to theatre
Conversion from day case to overnight stay
Transfer of patient to another provider for IP care (excludes rehab)
Unplanned re-admission within 29 days of discharge (*)
Surgical repair within 14 months/revision
Mortality (within 7 days)
Acute myocardial infarction
Pulmonary embolism
Deep vein thrombosis
Cerebral vascular event
Hospital acquired infection (MRSA & C.difficile)
Deep wound infection needing treatment at UKSH
Primary haemorrhage
Secondary haemorrhage
Bladder injury
Bowel injury
Ureteric injury
%
0.00%
0.00%
0.00%
0.00%
0.00%
0.37%
0.19%
0.09%
0.00%
0.00%
2.06%
0.19%
1.03%
0.00%
0.00%
0.00%
0.00%
Total
2
1
0
4
0
0
0
0
0
0
0
0
0
0
22
2
11
(*) Re-admission reporting includes those to other providers where UKSH advised of re-admission

• Cataracts
• Minor opthalmics
Measure
Choroidal expulsive haemorrhage
Corneal oedema
Hyphaema
Iris damage from phaco
PC rupture with vitreous loss
Cystoid macular oedema
Endophthalmitis
Raised IOP
Uveitis
Wound leak / rupture
TASS * (Toxic Anterior Segment Syndrome)
Total
16
0
0
11
0
16
1
4
4
0
0
%
0.00%
0.46%
0.03%
0.11%
0.46%
0.00%
0.00%
0.31%
0.11%
0.00%
0.00%

• Circumcision
• Flexible cystoscopy
• Minor penile/scrotal procedures
Measure
Unplanned return to theatre
Conversion from day case to overnight stay
Transfer of patient to another provider for IP care (excludes rehab)
Unplanned re-admission within 29 days of discharge
Surgical repair within 14 months/revision
Mortality (within 7 days)
Acute myocardial infarction
Pulmonary embolism
Deep vein thrombosis
Cerebral vascular event
Hospital acquired infection (MRSA & C.difficile)
Deep wound infection needing treatment at UKSH
Primary haemorrhage
Secondary haemorrhage
Bladder injury
Bowel injury
Ureteric injury
Total
1
0
0
0
0
0
0
0
0
0
0
0
0
1
1
0
0
%
0.00%
0.00%
0.00%
0.00%
0.00%
0.00%
0.20%
0.00%
0.00%
0.00%
0.00%
0.20%
0.20%
0.00%
0.00%
0.00%
0.00%

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 top-down 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.
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.

UKSH South West has established a patient forum which includes patients who have been treated since the opening of the facilities in 2009.
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.
The guidance issued to OSCs on 16/3/11 suggested that OSCs comment on the four areas below.
Do the provider’s priorities match those of the public?
Eduard Lotz, Executive Director, and Robin Smith, Chairman, gave a presentation on the key themes of UK
Specialist Hospitals, Draft Quality Account for 2010–11 to the Select Committee on
20th April 2011. The presentation was particularly focused on UKSH South West and the performance of the Emersons
Green NHS Treatment Centre, which is located in South Gloucestershire.
Do you believe that there are significant omissions of issues of concern that had previously been discussed with providers in relation to Quality Account?
No.
Has the provider demonstrated they have involved patients and the public in the production of the Quality Account?
Not applicable as due to the timing of the meeting it was not possible to see the actual QA document.
Any comment on issues the OSC is involved in locally?
No.
Any other Comments?
The Committee received details of the
UKSH Safeguarding Statement and is pleased that this will be included in the
QA. The Committee welcomes UKSH’s commitment to reducing the time patients spend in Outpatients to around two hours rather than more than three hours, which some patients spend there currently.
The Committee notes that UKSH just missed out on achieving its target of at least 95% of patients receiving a risk assessment for Venous Thromboembolism
(VTE) in 2010-11 (it recorded 94.6%).
The Committee supports this target going forward in 2011-12. The Committee was also advised that UKSH, along with other healthcare providers across Bristol, North
Somerset and South Gloucestershire are part of a VTE Strategy Group to share knowledge and working practices, which the Committee welcomes.

Formal Response to UKSH’s 2010 - 2011
Quality Account
NHS South Gloucestershire, as lead commissioner for UK Specialist Hospitals
(UKSH), is pleased to assure their second annual Quality Account. The document is clearly presented in the format required by the Department of Health Toolkit and the information it contains accurately represents the quality profile of their
Treatment Centres.
During 2010-2011, UKSH made positive progress in a number of areas including:
• Reducing the rate of procedures
cancelled on the day
• Reducing the risk of deep vein
thrombosis and pulmonary embolism
• Increasing the safe use of antibiotics
• Improving the recording of patient early
warning information
Demonstrating service user involvement in the development of Quality Accounts is an opportunity for healthcare providers to evidence their commitment to listening to their service users and carers. We would therefore like to have seen the inclusion of service user and staff comments, stories, pictures and Local Involvement Network engagement within the document.
Furthermore, within the review of patient experience, we would like UKSH to have including information about the complaints they received and subsequent improvements they have made.
UKSH’s priorities for 2011-2012 are aligned with those identified by service users and commissioners and we therefore support their aspirations in these areas.
In particular, we endorse the pledge to increase the use of Patient Reported
Outcome Measures at Emerson’s Green.
We welcome the inclusion of quantifiable success measures within the Quality
Account, providing a gauge upon which patients, families and commissioners can appraise UKSH’s achievements in the coming year.
NHS South Gloucestershire looks forward to working with UKSH as they fulfill their commitment to continuously improve the quality of care for our local patients and their families.

Health Services Working Task Group
South Gloucestershire Local Involvement
Network (LINk) welcomes the opportunity to comment on UK Specialists Hospitals
(UKSH) Quality Account 2010/2011.
However, the LINk was very disappointed to be given only 4 days to respond to the account and felt that this deadline was unacceptable. As a consequence the
LINk’s response is very brief as there has been inadequate time for it to put together a more complete response to the QA.
The LINk is pleased and encouraged to see some progress on
Venousthromboembolism risk (VTE) assessments. The LINk notes that despite this they report 7 cases of VTE in
2010/11. UKSH is to be congratulated on their zero MRSA bacteraemia rates.
They are also to be congratulated on the response they have received to service user questionnaires.
The LINk would like to commend the
‘open culture of reporting’ which suggests that staff are encouraged to report near misses without being blamed. However, it would have been interesting and useful to see some staff views included in the QA.
It is encouraging to see the QA reports good results on orthopaedic procedures; it would have been relevant to some information about how they measure clinical outcomes in relation to this.
The LINk noted that some sections of the Quality Account were incomplete; for example an Executive summary is not included.