St. Helens
Quality Accounts 2011/2012
Contents Page
Table of Contents
Item
Page
1. Statement from CEO
4
2. Purpose and values
6
3. Governance
7
4. Review of NHS Services
7
8
10
10
10
11
11
11
4.1 Participation in clinical audits
4.2 Research
4.3 Goals agreed with NHS commissioners (CQUIN)
4.4 External Regulation
4.5 Data Quality
4.6 Information Governance
4.7 Clinical coding error rate
5. Key Achievements 2010/2011
5.1 So how did we do?
5.2 Some other key achievements include
5.3 Capital Investment
5.4 Leadership and training
5.5 Listening and acting on patient views
SCHEDULE 1 - Inpatients Satisfaction Scores
SCHEDULE 2 - Outpatients Satisfaction Scores
5.6 Stakeholder engagement
5.7 Care Quality Commission Indicators
12
15
17
17
18
18
19
20
20
6. Priorities for Improvement for 2012/2013
6.1 Plan for 2012/2013
6.2 Capital Investment
21
22
SCHEDULE 3 - Commissioning for Quality and
Innovation (CQUIN) targets and reporting.
23
7. Summary
8. Comments external Bodies - To be populated
25
About Fairfield Independent Hospital
With over 30 years of experience Fairfield Independent Hospital provides the highest
standards of healthcare to privately insured, self-pay and NHS patients.
Fairfield Independent Hospital is a charity committed to providing accessible and
affordable healthcare to as many people as possible. Any surplus the Hospital makes
goes straight back into healthcare and not to shareholders.
Fairfield has one of the largest and busiest independent Outpatient Departments in
the North West Region, providing a range of diagnostic services for all specialities.
Part One
Chief Executive’s statement
We are delighted to present the Quality Accounts
from Fairfield Independent Hospital. The Hospital has
been delivering high quality health care to the local
community and beyond for over 30 years. We are
extremely proud of our record of service as an
independent health charity.
Quality matters to all of us working at Fairfield and
we know that it is key to the success of our
organisation. Our reputation is based on the
provision of high quality services and our core values
as a charitable organisation means we stand out from
other private providers in the area.
We monitor the views of our patients and I am
pleased to report that we have maintained the very
high levels of satisfaction that they have experienced
for yet another year. We value the feedback,
comments and suggestions that our patients make
about our services. Our services are open to all via
the insured, self-pay or NHS funding routes.
Our core business is health and optimising outcomes
for patients and we have created an integrated
governance framework for delivering excellence and
the best possible clinical results. We work in
partnership with our consultants to ensure optimum
care for our patients.
We continue to have a stable, motivated workforce
with low levels of staff turnover. Our staff team is
committed to providing excellent standards of care at
all levels across the organisation. We also value staff
development and we have strong commitment to staff
training and skill improvement.
During
2011/2012 97%
of the
patients who
visited Fairfield
as an
inpatient or
daycase patient
scored our
services and
facilities as
excellent or very
good.
During 2011/2012, we reinvested financial resources
to enhance the infrastructure of the Hospital and we
have some exciting developments planned for
2012/2013.
04
Fairfield Independent Hospital Quality Accounts 2011/2012
Chief Executive’s statement
Despite 2011/2012 being challenging economically
for us all, our financial performance was strong with
improved cash flow which we used to continue to
invest in the infrastructure of our organisation. As
always, any surplus we generate is reinvested in
health care and better services in the following
years.
Working
together as a
team to
provide the
best possible
care and a first
class
experience for
our patients.
The senior team at the Hospital and the Board have
welcomed the opportunity through these Quality
Accounts to clearly state our commitment to quality
and making sure that we continue to improve. It sets
out facts and information about the quality of our
services which I hope you will find useful and easy
to read and understand. If you have any queries or
comments on our quality account then please let us
know by emailing k.roche@fairfield.org.uk.
At Fairfield, we actively promote a culture of
openness and transparency, respecting complaints,
learning lessons and being open and honest about
any mistakes we have made and seeking to make
improvements. These opportunities have helped us
establish a positive culture and enabling the
provision of safe care.
These Quality Accounts has been compiled by
members of the senior team and Board and has
also drawn upon the feedback information we get
from our patients. We are all working together to
provide the best possible care for our patients and
we believe we have demonstrated this in our Quality
Accounts. Therefore, I am able to state to the best
of my knowledge that the information contained in
this document is accurate at the time of publication.
Cheryl Nolan, Chief Executive
Fairfield Independent Hospital Quality Accounts 2011/2012
05
The way forward
Part Two
2. Purpose and Values
Fairfield Independent Hospital’s charitable purpose is to relieve
sickness, injury and poor health and to promote and preserve good
physical and mental health.
Our vision, as the leading charitable Hospital in the area, is
delivering the highest possible standards of safe and effective care
that is accessible and affordable to all, delivered by a highly
committed workforce. This means that we are the Hospital of
choice for many patients.
At all times we act with integrity and through the professional level
of service we provide, we create an atmosphere of warmth and
friendliness. Everyone who comes into the Hospital is treated with
dignity and respect and made to feel ‘special’. We pride ourselves
on the fact that throughout the Hospital we put the patient at the
heart of everything we do. We are a fair employer and supportive
of our staff.
The aims of our organisation are focused around quality and
putting patients at the heart of everything we do. We have the
following objectives:





continuous improvement of our services.
evidencing outcomes within a robust governance framework.
providing high quality value for money services that are
accessible to all.
providing a patient-focussed service.
ensuring we are the Hospital of choice for patients and their
GPs.
We monitor the views of our patients and are delighted at the
continued high levels of patient satisfaction with our services and
our facilities.
Our staff turnover is low and we have found that this aids
continuity of care for all our patients. Our focus on continuous
improvement is reflected in our commitment to clinical governance,
audit and to partnership working. Our consultants, many of whom
are recognised leaders in their field, are crucial to how the Hospital
performs.
06
Fairfield Independent Hospital Quality Accounts 2011/2012
“I have been
treated at
Fairfield on a
number of
occasions.
Each time I have
been entirely
satisfied with all
aspects of my
treatment and
care”
May 2011
The way forward
3. Governance
“Thank you all
so much for
the care and
kindness
shown to me
during my
stay.”
March 2012
The Board of Fairfield Independent Hospital provides independent
oversight
and stewardship for the range of services we deliver.
The Board discharges its responsibilities through its regular
meetings and the other Board sub committees that make up the
Hospital’s framework for integrated governance. The Board members
give their time freely.
The organisation has developed its governance framework and
structure and realises that in order to provide effective, safe
services to patients that this is one area that needs to continually
evolve and develop. Our approach to governance enables us to
monitor our service delivery across a number of dimensions and
provide our Board, our regulators and our commissioners with the
necessary assurances. Our framework of integrated governance
spans all our services and means that we put our patients at the
heart of everything we do.
Measures of patient experience with the Hospital are again excellent
and the rate of complaints continues to be low. All of our patients
have the opportunity to give feedback and comments and all
complaints are logged, investigated and responded to.
4. Review of NHS Services
During 2011/2012 Fairfield Independent Hospital provided NHS
services for 5,726 patient episodes. This figure includes 151 extra
orthopaedic treatments that the local PCTs specially commissioned
from the Hospital in the year.
Fairfield Independent Hospital has reviewed all data available to it
on the quality of care for those services. The income generated by
the NHS services in 2011/2012 represents 100 per cent of the
total income generated for the provision of NHS services by
Fairfield Independent Hospital.
Fairfield Independent Hospital Quality Accounts 2011/2012
07
The way forward
4.1 Participation in clinical audits
During 2011/2012 5 national clinical audits and zero national
confidential enquiries covered NHS services that Fairfield
Independent Hospital provides.
During that period Fairfield Independent Hospital participated
in 9.25 % national clinical audits and 0% confidential enquiries of
the national clinical audits and national confidential enquiries, which
it was eligible to participate in.
With regard to the Cardiac Arrest National Audit, although eligible,
Fairfield Independent Hospital were unable to participate as no
patient suffered a cardiac arrest within Fairfield Independent
Hospital during the relevant dates.
The national clinical audits and national confidential enquiries that
Fairfield Independent Hospital were eligible to participate in during
2011/2012 are as follows;
National elective surgery - Patient reported outcome measures
(PROMS)
Hip and knee replacements
Hernia
Varicose veins
“Treatment
was excellent
from all
members of
staff
throughout my
visit, all were
very helpful
and
considerate at
all times - Well
done”
National Joint registry (NJR) – hip and knee replacements
The reports of 4 national clinical audits were reviewed by the
Hospital in 2011/2012 and we intend to take the following actions
to improve the quality of healthcare provided:

Venous Thromboembolism reducing the risk NICE 2010
– changes have been implemented to Fairfield Independent
Hospital’s policy and patient risk assessments.

Better Blood Transfusions, - National Bedside Blood
Transfusion audit Completed National Blood Transfusion
Committee reported Fairfield as 100% compliant.

Analysis of data from PROMS to add value to patient journey.
Ensuring that as many forms as possible are completed to
ensure high compliance levels.
08
Fairfield Independent Hospital Quality Accounts 2011/2012
April 2011
The way forward

“From my first
consultation,
operation,
after care and
physio my
treatment has
been first
Re-audits for the Quality Accounts for
categories showed the following
2010/2011 audit

Medicines Management 94% compliance in all of the data
recorded in the medicine documentation

Consent information Re-audit in January 2012 showed an
increase in compliance, which equated to 83.3% compliance
across the whole consent process. No re-audit has been
planned however; a period of random monitoring will be
undertaken throughout the year.

Privacy and Dignity, has not formed a part of any formal audit
due to the positive results obtained, 98% compliance
class.”
March 2012
National Joint Registry – The 2011/2012 compliance figure
stands at 89%, a dedicated member of staff has been
allocated time and resources to input the relevant data. Data
capture starts within in the pre-operative assessment
appointment and continues into theatre data issues are being
dealt with as and when they arise. As from the 1st April 2012
all elbow and shoulder replacements will be included in the
National Joint Register.
For 2012/2013 a comprehensive audit plan has been approved by
the Medical Advisory Committee and the Board. The audit plan will
implemented across all departments in clinical and non-clinical
areas and includes:
The clinical audits that will be undertaken are: 
Correct Surgical site marking: - will show that patients are
correctly marked for surgery which will ensure that Fairfield
patient safety remains high on the agenda, guaranteeing
Fairfield are compliant with one of the Department of Health
Never events

Record keeping within pre-operative assessment clinics: - this
will ensure that all patient information is completed with right
information in the right place at the right time as the NMC
guidelines, Fairfield protocols standards and achieve a positive
effect for CQC outcome 21

Monitoring and response to patients oxygen saturations levels:
- to ensure that the most appropriate response from all staff
is given to all patients who may deteriorate following a
general anaesthetic, this will guarantee patient safety following
surgery.
Fairfield Independent Hospital Quality Accounts 2011/2012
09
The way forward
4.2 Research
The Hospital does not participate in clinical research.
4.3 Goals agreed with commissioners
Use of Commissioning Quality and Innovation CQUIN framework
The Hospital signed the NHS Standard contract on 01 July 2011
and therefore was able to participate in CQUIN. A percentage of
the Hospital’s income was dependent on achievement of the CQUIN
targets agreed with the NHS commissioners. The CQUIN targets
were achieved.
Details of CQUIN targets
Schedule 3 Page 23.
and achievements are shown in
“All Staff & the
consultant
were extremely
friendly and
put me at
ease. To sum
up my visit professional
and friendly”
4.4 External regulation
Fairfield Independent Hospital is regulated by the Care Quality
Commission
to provide the activities detailed below in accordance
with Schedule1 of the Health and Social Care Act 2008.
Regulated Activity - Diagnostic and screening procedures.
Regulated Activity - Surgical procedures.
Regulated Activity -Treatment of disease, disorder or injury.
Regulated Activity – Accommodation for persons who require
nursing or personal care.
Additional conditions that apply - the
registered provider must only accommodate a maximum of one
service user at the Guy Pilkington Memorial Home.
The Care Quality Commission has not taken enforcement action
against Fairfield Independent Hospital as at 31 March 2012, nor
has the Hospital participated in any special reviews or investigation
by the CQC during the reporting period.
10
Fairfield Independent Hospital Quality Accounts 2011/2012
June 2011
The way forward
4.5 Data Quality
“Very friendly
atmosphere,
treated with
equality and
respect. Staff
very
professional
and
approachable.
Would
definitely
choose
Fairfield
again..”
Fairfield Independent Hospital submitted records during 2011/2012
to the Secondary Uses Service (SUS) for inclusion in 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
100% for outpatient care
4.6 Information Governance Toolkit Attainment Levels
The Hospital is continually reviewing its information governance to
ensure that all information relating to and identifying individuals is
managed, handled, used and disclosed in accordance with the law
and best practice.
Fairfield Independent Hospital’s Information Governance Assessment
report score for the period is 85%.
4.7 Clinical Coding Error rate
While we were not subject to a clinical coding audit in 2011/12 we
did implement all the findings of the audit undertaken in 2010/11
and we worked closely with our clinical coders and our consultants
to ensure the accuracy and reliability of the service we provided.
March 2012
Fairfield Independent Hospital Quality Accounts 2011/2012 11
Key Achievements
Part Three
5.1 So how did we do?
In our 2010/11 Quality Accounts we set out three key development
areas. Detailed below is what we achieved against the specific
areas identified for 2011/2012. I am delighted to report that we
met all our key targets across all areas.
Clinical Effectiveness

We reviewed our existing patient pathways and introduced a
complete collection of care pathways for all specialities.
Specific care pathways are now in use across all specialities
including patients attending for local anaesthetic procedures
and procedures under sedation.

We increased the numbers of patients being treated in other
than an inpatient setting to 82% which is a 4% increase on
the figure for last year.

We rolled out our version of ‘lean’ in three clinical areas: the
Ward, Theatre and Outpatients Department. The results and
progress have been monitored and reported to our
commissioners. Using the tools available to us and working
SMART we have been able to identify areas of waste and
duplication which were adding no value whatsoever to the
patient journey or experience and removed them from the
process.
We have improved the utilisation of our theatres by rigorous
planning, monitoring and ensuring that we are flexible to
respond to ad hoc requests for extra sessions if clinical
activity so dictates.

Patient Safety
A monthly set of key performance indicators has been
Implemented for the ward area, the findings form part of a
feedback process given to staff at staff meetings. National
achievement targets are usually set at greater than 90%. In
most cases we have exceed that target however for some
areas because of the sample size, the figures are skewed. The
indicators that need further work are clinical record keeping
(84%) and care pathways (82%) both of which form part of
the audit programme for 2012/2013 and have action plans
assigned to them in order to improve results.

12
Fairfield Independent Hospital Quality Accounts 2011/2012
“Doctors, nurses
and all staff
involved in my
care are a credit
to your Hospital.
The staff are
friendly and
courteous;
nothing is too
much trouble,
regardless of the
role”
July 2011
Key Achievements

Risk reporting and risk assessment processes have been
developed further. All incidents are reported to the Board and
for clinical incidents the Medical Advisory Committee also. We
have revised our Serious Incident Policy to take account of
the reporting arrangements via the PCT.

We continue to risk assess our services in line with national
guidance and during 2011/12 the Hospital was re accredited
via ISO 27001 (Information and Security Management
Standard) and for ISO 9001:2008 (Quality Management
Standard).

A range of policies and procedures were introduced during the
year to ensure that working practices continue to provide a
safe environment for our patients and staff.

Reduction in medication errors from 5 in 2010/2011 to 3 in
2011/2012. The reduction was a result of audits of
randomised case sheets where results are fed back to staff at
the staff meetings.

All nationally published patient safety alerts and clinical
guidance are reviewed and where relevant compliance with the
alert is documented. Fairfield Independent Hospital achieved
100% compliance with the patient safety alerts relevant to it.
“A big Thank
you to all
concerned with
my treatment.
A very positive
experience.”
January 2012
Fairfield Independent Hospital Quality Accounts 2010/2011 13
Key Achievements
Patient Experience
We continue to experience high levels of inpatient/ day-case
satisfaction with our services. We have continued in
2011/2012 to roll out outpatient questionnaires covering other
departments and services at the Hospital including
physiotherapy, x ray, and outpatients. The results are extremely
positive and are shown in Schedules 1 and 2.


Customer service training – seven newly appointed members of
the administration and housekeeping teams have received
customer services training during 11/12.

We have redesigned our physiotherapy rehabilitation suite to
provide better facilities for our patients with access to a range
of equipment and services to aid their recovery.

As part of the Productive Series the theatre lead and the
Head of Patient Safety and Quality have introduced a
questionnaire for patients regarding their emotional journey
through surgery. The questionnaire was designed to help
identify if patients felt we could improve their journey into the
theatre environment which is a very stressful and anxious time
for most patients.

As part of releasing time to care, staff across the ward,
theatre and outpatients have implemented changes that have
reduced waste. This was achieved by the staff implementing
changes within their own department to improve access to
consumables and equipment etc. This has not only saved
staff time but has seen a saving in costs due to a reduction
in stock levels. All consumables are now maintained at
appropriate levels for the clinical area.

A monthly random sample of patients is seen by the Head of
Patient Safety and Quality to ask a simple question with
regard to the patient stay “if you could change one thing what
would it be?” The results from this audit have been fed back
to staff and where appropriate have been acted upon.
14
Fairfield Independent Hospital Quality Accounts 2011/2012
“This is by far
the best Hospital
experience I
have had. From
admin to nurses
to Consultant;
everyone has
made my stay
as comfortable
as possible”
August 2011
Key Achievements
5.2 Some other key achievements include:
“Everyone, from
the moment of
admission to
discharge has
been kind &
helpful. Nothing
has been too
much trouble. It
has made what
could have been
a horrible
experience much
better. I would
also like to add
that the food
was lovely”

Provision of NHS

Our infection rates during the year were excellent with zero
levels of MRSA, MSSA, E-coli and C-difficile. Our overall
average monthly rate in 2011/12 was 0.35% which is a
reduction on the previous year’s figure of 0.43%.

The Hospital successfully passed its three year audit of ISO
27001 Information Management and Security Standard, and
also upheld its certification of ISO9001: 2008 Quality
Management Standard.

Patient outcomes: - patients who require transfer to another
unit remains at a low level with 2 patients requiring transfer to
other units in 2011/12 none of these were critical care
patients. This equates to 0.05% of patients admitted

Installation of new ultra cleaning ventilation system to ensure
that all our joint surgery is carried out in the most clinically
safe environment which further reduces the risk of infection.

The project to install new theatre lighting in both theatres was
completed.

Launch of our pre operative assessment service, which is being
rolled out across all specialities.

Completed refurbishment of inpatient bedrooms and outpatient
consulting rooms. All our rooms are now of an equally high
standard.

A new diathermy Turis machine has been purchased for
patients that require removal of the prostate gland. This new
technology has improved the patient outcome from surgery by
a reduction in blood loss, both during and after surgery, a
reduction in the need of a catheter remaining in place, which
in turn has seen a reduced length of stay for the patient.

All of our consultants now have access to their clinic list via
the iSOFT system to aid efficiency and provide the clinicians
with real time information regarding a patient’s status.
September 2011
health services
to 5726 individual patients.
Fairfield Independent Hospital Quality Accounts 2011/2012
15
Key Achievements

Pregnancy status prior to surgery is now undertaken on all
patients attending for a gynaecological procedure.

During 2011/12 94 % of our surgical patients had a VTE
assessment completed. (A VTE assessment indicates if the
patient is at risk of a blood clot).
We will continue to
monitor this measure as one of a range of clinical
performance measures during 2012/2013.

Our level of patient complaints continues to remain low. In
2011/12 we received 6 NHS complaints from the 5726
patients we treated. We continue to analyse complaints,
learn from them and disseminate that learning throughout the
organisation.

We have been awarded a five star food hygiene award by St
Helens Environmental Health Department and continue to
provide nutritious food sourced from local producers wherever
possible.

Introduction of new ways of working across our administration
function to enhance the patients’ journey from start to finish.
This has included analysis of walk through video footage
across all patient areas.

The Hospital invested resources in improving the quality of
the data it supplied to its PCT commissioners – this involved
reviews and improvements in all aspects of the Hospital’s
operations, including staff training, clerical and financial
procedures and data coding and checking. The Hospital also
enhanced its internal validation and check processes. The
consequence was that the accuracy of information being
supplied to the central SUS NHS database and the local
commissioning groups was significantly improved and the
discrepancies between the financial data and the activity
based data were minimised. The discrepancy rate fell from
8% to 1%.
16
Fairfield Independent Hospital Quality Accounts 2011/2012
“Everyone has
been wonderful,
pleasant,
courteous,
helpful and
caring. The
Hospital is in a
lovely
environment, is
clean and
comfortable.
Thank you to
everyone”
October 2011
Key Achievements
5.3 Capital Investment Strategy
“Every single
member of staff
with whom I
came into
contact with
were very
professional,
caring, kind and
nothing was too
much trouble for
them. They
were superb.
The food was
excellent and
well presented”
November 2011
We have a 5-year capital investment strategy which is refreshed
each year. During 2011/2012 the works listed below have been
completed as part of our overall strategy:

Refurbishment of the Operating Theatre One and the
installation of a new Ultra Clean Ventilation System.

Refurbishment of the X-ray department and new X-ray machine
put in place.

A programme to implement LED lighting across the Hospital
has been started. The lighting is more cost effective than the
existing systems.

Purchasing of new medical equipment and instrumentation,
which include new scopes and saws.
We continue with our planned maintenance and replacement
programme for equipment throughout the Hospital on a yearly
basis.
5.4 Leadership and Training
The Board of Trustees was strengthened by the appointment of two
new members one of whom is acting as a patient representative.
The executive team headed by the CEO continue to access CPD
and other opportunities relevant to their roles including membership
of other charitable boards and accessing short secondments in the
NHS.
Student nurses continue on placement. A further two staff members
have undertaken Mentorship training. As a result of having more
mentors, our partner Universities have asked us if we would place
two more students in our Outpatient Department for a thirteen
week placement. Placements at the Hospital are favoured by the
Universities because the student’s experience is enhanced by the
variety of specialities that the student has access to here. The
ward will continue to take two students on a thirteen-week
placement with some time spent in the theatre and recovery ward
environment. Cheshire and Merseyside Placement Officer, for the
local Universities have approached the Hospital requesting
placements to students undertaking qualifications as an Operating
Department Assistant. This will offer educational opportunities to
the students and theatre staff within Fairfield. It will further
strengthen our links with the local healthcare education system.
Fairfield Independent Hospital Quality Accounts 2011/2012 17
Key Achievements
5.5 Listening and Acting on Patient Views
As a service organisation, we are continually reviewing the service we provide to our patients.
Our managers routinely audit how patients flow through the system by shadowing patients
with their consent and ‘walking in their shoes’. We are currently working with patients
regarding their emotional journey through theatre as we realise that this is a very anxious
time for all patients. The results will be fed into our Quality Account for 2012/13 identifying
any changes we have made.
The charts, shown in the attached schedules 1 and 2, give the 2011/12 figures for patient
satisfaction. All our inpatients and day case patients are given a patient questionnaire and
all responses are reviewed by the CEO. Our outpatient figures are shown in Schedule 2
Inpatient/ Daycase Patient Satisfaction Scores. – Schedule 1 From April 2011- March
2012 3079 NHS patients where admitted to the Hospital as an inpatient or daycase.
2,586 questionnaires had been returned, from inpatients and day cases, which provided
the Hospital management team and staff with feedback, on all aspects of their care,
from pre-admission process, arrival at the Hospital, treatment, care and discharge.

During this period, an 84% response was obtained. 98% of those who responded rated
the overall standard either "very good" or "excellent".
Schedule 1
Patient Satisfaction April 2011 to March 2012
Areas Audited
100.00
90.00
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
Pre-Appontment
Out-Patient
Reception
Clinical Team
Departments
Environment
Average
Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar11
11
11 11
11 11
11 11
11
12
12 12
18
Fairfield Independent Hospital Quality Accounts 2011/2012
Key Achievements

Outpatient Satisfaction Scores. – Schedule 2
During 2011/12 we issued 3,350 questionnaires of which 2046 were returned. During this
period, a 63% response was obtained. 97% of those who responded rated the overall
standard either "very good" or "excellent". W are currently looking at ways to improve
the response rate.
The figures, as detailed in the attached schedules, evidence that we do have high levels of
patient satisfaction. Patients’ views and comments are very important to us and to the
process of continuous improvement seeing how we are doing now but also what we need to
do to get even better. For example, comments have been made about access to WiFi, car
parking pressures when spaces are limited, giving relevant patients the option of walking to
theatre – in all cases action plans have been put in place to address the issues/suggestions
and the patients who raised the issues advised of what we are doing.
“A comfortable and relaxing stay with excellent care,
cleanliness and professionalism of all your staff.
I felt
confident of procedure and after care.”
Schedule 2
Out Patients Department Satisfaction April 2011 to March
2012
Pre-Appontment
100.00
98.00
96.00
94.00
92.00
90.00
88.00
86.00
84.00
82.00
80.00
Out-Patient
Reception
Clinical Team
Departments
Environment
Apr- May- Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar11 11
11 11 11 11
11 11 11 12
12 12
Fairfield Independent Hospital Quality Accounts 2010/2011
19
Key Achievements
We continually review all of our patient information to ensure that it is accurate ,up to date
and written in plain English . The literature we provide to patients give them all the necessary
information they need in order to make informed decisions about their treatment and also an
opportunity to raise any questions they may have with the relevant staff involved in their
care.
5.6 Stakeholder engagement
We continue to develop a proactive approach to getting patients views in real time and the
senior team carry out ad hoc ‘walkabouts’ to speak with patients to ask how they feel about
Fairfield and if they feel we are getting it right. We have also embarked on a series of video
walkabouts to walk in the patients shoes through what we do and how we do it.
The Medical Advisory Committee (MAC) is a valuable tool by which we obtain the views of our
consultant body and discuss areas of good practice and concerns. The MAC has a direct line
of accountability to the Board and the Chairman of the Board of Directors attends MAC
meetings. The MAC Chair is also a Board member. The MAC provides input into how we take
specific areas of the business forward and
Total
what they feel would/could be development
numbers in
opportunities for the Hospital or implementing
Indicator
Period
%
new initiatives based on best practice.
1 Apr 10
to
5.7 Care Quality Commission Indicators
31 Mar 11
Each quarter the Hospital has to make a
regular submission to the Care Quality
Commission on a defined set of indicators.
We are very proud of our results as they
reflect the high standards of care that we give
to our patients and also provide evidence of
our low infection rates and excellent patient
outcomes.
20
Inpatient mortality
0
0
Peri-operative
mortality
0
0
Unplanned
readmission
Within 28 days
8
0.0178
%
Unplanned returns to
Theatre
2
0.044%
Unplanned transfers
To another Hospital
4
0.089%
Mortality with 7 days
Of discharge
0
0
Pulmonary Embolism
0
0
Deep Vein Thrombosis
0
0
Surgical infection rate
0
0
MRSA blood cultures
0
0
MRSA positive blood
cultures
0
0
Fairfield Independent Hospital Quality Accounts 2011/2012
Priorities for improvement
In 2012/2013
Part Four
6..1 Plan for 2012/13
“The quality of
care shown to
me during my
stay here has
been second to
none. The staff
teamwork is
totally
professional and
a pleasure to
watch a group of
people enjoying
their work”
December 2011
The theme of continuous quality improvement is reflected in our
yearly business plan and in our Strategic Plan which has been
updated for 2012-2015. Continuous quality improvement is at
the core of our business and enables us to deliver the best
possible outcomes for our patients.
Within the three areas that have been identified by the NHS our
key objectives are as follows:
Clinical effectiveness

To further develop the work on utilisation across all clinical
areas to ensure the Hospital is working as SMART as it
possibly can and getting the best out of all its resources.

Review clinical staffing across the Hospital to ensure that we
can meet needs both now and in the future.

To work with commissioners to offer services that deliver the
best possible outcomes and continuity of care for patients
including rehabilitation packages.

To reduce the amount of time that patients stay in Hospital
by utilising programmes such as enhanced recovery.

To build public health capacity in the local workforce by
providing brief intervention advice to all NHS patients who
attend for a pre-operative assessment.

Dementia training to form part of CPD for all front line staff.
Patient safety

As part of a suite of key performance indicators for the ward,
staff are concentrating their efforts on a reduction in clinical
record keeping errors. A base line audit in December showed
an achievement figure of 84%. The target for the ward is to
increase this to a minimum of 90% in 2012/13.
Fairfield Independent Hospital Quality Accounts 2011/2012
21
Priorities for improvement
In 2012/2013

100% of all surgical patients admitted to Fairfield to have a
VTE risk assessment: our most recent audit in Jan 2012
showed 95% of all patients admitted had a completed VTE
risk assessment prior to or on admission to Fairfield.

Completion of our audit/ re-audit plans in line with relevant
timescales.

We will continue to develop our governance framework by the
Introduction of further policies and procedures through the risk
management and ISO frameworks.
Patient Experience

We will review and where necessary redesign the patient
questionnaires. Making sure that we are capturing the most
relevant information from our patients on what they think and
feel about what we do, how we do it and how we can
improve.

Ensure patients receive optimum pain control following
surgery by monitoring on a quarterly basis patients
perceptions of pain.

In line with best practice and expert
procedures in an outpatient setting.
opinion provide more
6.2 Capital Investment
Resources permitting we will continue to progress with our planned
capital expenditure as approved by the Board at its meeting In
April 2012. All our staff and our consultants have had input into
how we allocate our capital during 2012/13.
The Capital Investment includes upgrading anaesthetic machines,
operating tables, medical equipment throughout the Hospital,
upgrading our Information Technology systems, upgrading plant and
equipment, redecoration of patient and staffing areas, conversion of
some existing bathrooms to wet rooms and improving the
administration environment.
22
Fairfield Independent Hospital Quality Accounts 2011/2012
“I can’t fault the
quality of care
received at this
Hospital. I would
recommend that
other Hospitals
follow the care
and procedures
at Fairfield. This
is how a Hospital should be!”
January 2012
Schedule 3
Fairfield Independent Hospital Quality Accounts 2011/2012
23
In Summary
The Quality Accounts from Fairfield Independent
Hospital is a celebration of the contribution that
everyone works here makes. We are extremely proud
of our achievements and take a great deal of pride in
what we do and how we do it . We will continue to put
quality at the forefront of the care we provide and
patients at the heart of everything we do.
Our organisation is open and transparent and
working together we ensure that we tackle any
challenges in the most appropriate way to ensure that
we deliver the highest quality care and a first class
service to all.
Comments from External Bodies
on Fairfield Independent Hospital
Quality Accounts 2011/2012
2011/12 Quality Account
St. Helens LINk Statement
General – it is possible that background photographs could bed
distracting; etc for some readers and it was felt that the contact details for
the hospital could be made more prominent.
However feedback from our visually impaired Board member is that the
language in this Quality Account document is the clearest that he had
read so far (via screen reader software).
Specific areas for improvement – none that were of a concern to
those present
The low level of patients accessing the hospital in comparison to other
Trusts enables high level of infection control to be maintained.
It is clear that clinical record keeping is a priority for the hospital ; this is
considered important to LINks also.
Plans for 2012/13 - priorities
Clinical Effectiveness - there was a number of priorities listed, the LINk
recommends that perhaps one or two should be chosen and done
thoroughly?
Dementia awareness training will be particularly relevant in St. Helens
area due to this being an emerging priority for the local authority and
health services and is a specific sub-group of the shadow Health & Wellbeing Board.
Patient Safety - various
and
Patient Effectiveness - various
The LINk agrees with these priorities and would suggest that the patient
questionnaire could be shared with LINk in order to add value when being
reviewed.
Comments from External Bodies
on Fairfield Independent Hospital
Quality Accounts 2011/2012
2011/12 Quality Account
NHS Merseyside Statement
In line with the NHS (Quality Accounts) Regulations 2011, NHS Merseyside
can confirm that we have reviewed the information contained within the
account and checked this against data sources where this is available to
us as part of existing contract/performance monitoring discussions and is
accurate in relation to the services provided. We have reviewed the content of the account and can confirm that this complies with the prescribed
information, form and content as set out by the Department of Health.
St. Helens
Fairfield Independent Hospital
Crank
St Helens
Merseyside
WA11 7RS
www.fairfield.org.uk