Quality Account
for 2012-2013
Contents
Introduction to Aspen Healthcare
3
Introduction to the Quality Account for 2012-13
5
Statement on Quality from the Chief Executive
8
Accountability Statement
Quality Priorities for 2013-14
9
Patient Safety
Clinical Effectiveness
Patient Experience
Statements of Assurance 12
Review of Services
Participation in Clinical Audit
Participation in Research
Goals agreed with Commissioners
Statement on Data Quality
Quality Indicators
Review of Quality Performance for 2012-13
23
Patient Safety
Clinical Effectiveness
Patient Experience
External Perspectives on Quality of Service
29
Introduction to Aspen Healthcare
Aspen Healthcare Hospitals and Clinics locations:
Holly House and Claremont Hospitals are part of the
Aspen Healthcare Group
Aspen Healthcare Ltd was established in 1998 and is a UK-based private healthcare
provider with extensive knowledge of the healthcare market. The company’s core
business is the management and operation of private hospitals and other medical
facilities, such as day surgery clinics, many of which are in joint partnership with
our Consultants.
Cancer Centre London
Aspen Healthcare has grown considerably
over the last five years and has invested
over £60 million in capital developments
to enhance its facilities and to grow and
expand its portfolio.
Highgate Hospital
Aspen is now one of the main providers
of independent hospital services in the
UK and through a variety of local contracts
we provided over 10,000 NHS patient
episodes of care last year. We work very
closely with other healthcare providers in
each locality including GPs, PCTs (now
Clinical Commissioning Groups) and NHS
Acute Trusts to deliver the highest standard
of services to all our patients.
•The Edinburgh Clinic, Edinburgh
•The Claremont Hospital, Sheffield
•Midland Eye, Solihull
Holly House Hospital
Midland Eye
•2
2,000 day case episodes
•Parkside Hospital
Wimbledon, S
W London
•Highgate Hospital
Highgate, N London
The Edinburgh Clinic
0,000 inpatient episodes
•1
•2
05,000 outpatient episodes
•Holly House Hospital
Buckhurst Hill, NE London
Claremont Hospital
Between its eight facilities, Aspen Healthcare
has delivered in 2012/2013 alone:
Currently Aspen Healthcare offers 200
inpatient beds in eight facilities located
in London, Birmingham, Sheffield and
Edinburgh. Aspen Healthcare’s current
facilities are:
•Cancer Centre London
Wimbledon, SW London
The Chelmsford
Parkside Hospital
•T
his was supported by 62,000
attendances within our Imaging
Departments
It is our aim to serve the local community
and excel in the provision of quality acute
private healthcare services in the UK.
•The Chelmsford
Chelmsford, Essex
positive about your health
Our mission is to provide first-class independent
healthcare for the local community in a safe, comfortable
and welcoming environment; one in which we would be
happy to treat our own families.
3
MidlandEye
Specialists in complete eye care
4
Introduction to our Quality
Account for 2012-13
Aspen Healthcare is pleased to provide its first Quality Account – our annual report
to the public and other stakeholders about the quality of services we have provided
over the last year. The aim of this report is to provide an overview on what we have
achieved over the previous year and also, importantly, to look forward and set out our
plan of improvements for the next year.
Aspen is committed to excelling in the
provision of the highest quality healthcare
services and in working in partnership with
the NHS to ensure that the services delivered
result in safe, effective and personalised
care for all patients. This is evidenced by our
high quality performance over the past year
and by ensuring that we continuously make
improvements to the services we provide to
our patients. We have completely refreshed
our approach to quality governance in
2012/13. We have developed a bespoke
new quality framework, centred on nine
drivers of quality and safety, which ensures
quality is incorporated into every level of
our business and that safety, quality and
Claremont Hospital
excellence remains the focus of all we do
whilst delivering the highest standards of
patient care. We aim to keep developing
this framework to ensure we are able
to readily innovate and respond to new
initiatives that benefit our patients and
the care they receive.
The majority of information provided in
this report is for all the patients we have
cared for in 2012/13 – NHS and private.
In 2012/2013 Aspen Healthcare provided
NHS services in two of its hospitals, the
Claremont Hospital in Sheffield and Holly
House Hospital in Essex.
Holly House Hospital
Vital Stats
Total beds
41
Private GP services
Inpatient beds
34
Dedicated day case beds
7
‘Satellites’
Choose & Book
Critical care beds
4
Parking
Total theatres
3
Accept all major insurers
Consulting rooms
12
MRI
Endoscopy suite
CT
Pathology
Ultrasound
Physiotherapy
X-ray
Chatsworth Suite & 10
other NHS Based Clinics
Pharmacy
•2
4/7 Resident Medical Officer or Doctor on site
•O
ver £1m invested in facilities and new equipment
•N
ew laminar flow theatre installed for orthopaedic surgery
• Short-listed for an award for innovation in outreach pre-assesment services (closer to home)
Vital Stats
Total beds
65
Private GP services
Inpatient beds
55
Choose & Book
Day-case beds
10
Parking
Critical care beds
3*
Accept all major insurers
Total theatres
5
3T MRI
Consulting rooms
22
64 slice-CT
Chemotherapy
Ultrasound
Pathology
X-ray
Physiotherapy
Digital mammography
Pharmacy
Dexa
*Critical care beds: available from June 2013
Onsite decontamination/
sterile services department
•C
ompleted a £20million investment in technology and facilities in 2013
“Every member of the team was totally
professional in appearance, attitude and actions
were also courteous, comforting and kind.”
Mr & Mrs D. F.
Claremont Hospital patient
•S
hockwave™ Therapy
•O
nly private hospital currently with Gait Analysis (motion analysis technology to assess,
treat and prevent injuries)
•B
UPA accredited Breast Cancer Unit
•2
4/7 Resident Medical Officer or Doctor on site
•M
icroDose digital mammography offering a unique solution for combining breast screening
and osteoporosis screening in a single examination
• F irst UK private hospital to receive Worldhost® Business Status in customer service training
5
6
Statement on Quality
We are proud to present our first Quality Account and hope it helps to demonstrate our
commitment to quality and safety. We have aimed to measure our progress objectively,
identifying where we need and want to improve in 2013/14 centred on the areas of
patient safety, clinical effectiveness and patient experience.
This Quality Account is actively owned by all our teams. We have a genuine desire to
drive forward our quality initiatives over the next year, modelled on our new quality
governance framework which has been short-listed for a number of awards in 2013.
This Quality Account also helps us to openly report on what we do and what we need
to improve upon. Our Quality Governance Committee is chaired by our Group CEO, and
we will actively continue to monitor all information, outcomes and feedback that we
receive over the next year. This will help ensure that we are responsive to any changes
in values, expectations and perceptions and ensure that our services provided to our
patients are based on best practice.
Statement of Accuracy of our Quality Account
Directors of organisations providing hospital
services have an obligation under the 2009
Health Act, National Health Service (Quality
Accounts) Regulations 2010 and the National
Health Service (Quality Accounts Amendment
Regulation 2011) to prepare a Quality Account
for each financial year. This report has been
prepared based on guidance issued by the
Department of Health setting out these
legal requirements.
This report has been reviewed and
approved by:
•C
hief Executive Officer, Aspen Healthcare
•G
roup Clinical Director, Aspen Healthcare
•E
xecutive Team, Aspen Healthcare
•H
ospital Director, Holly House Hospital
•H
ospital Director, Claremont Hospital
We confirm that this report has been reviewed
by Aspen’s Executive Team and that to the
best of our knowledge, as requested by the
regulations governing the publication of this
document, the information contained in it
are accurate.
Date: 17 June 2013
Signed:
Des Shiels
CEO, Aspen Healthcare
7
Judi Ingram
Clinical Director, Aspen Healthcare
8
Quality Priorities for 2013-14
The Department of Health’s Quality Account guidelines require us to identify at
least three priorities for improvement. These have been determined by the hospitals’
senior management teams taking into account patient feedback, audit results, national
guidance and recommendations from the various hospital committees.
We will monitor our quality governance
and the identified priorities via our Group
Quality Governance Committee which meets
quarterly to monitor, manage and improve
the processes designed to ensure safe and
effective service delivery. Locally at each
hospital we will continually work hard to
improve patient experience and progress
will be monitored through regular quality
governance forums, reviewing our clinical
and quality outcomes and driving our
quality improvement priorities.
Regular reporting will also be provided
to Aspen’s Board of Directors and the
commissioners of NHS services.
We are committed to delivering services
that are safe, of a high quality, and clinically
effective and constantly strive to improve
our clinical safety and standards. The
priorities we have identified will drive
patient safety, clinical effectiveness and
improve patient experience.
The key quality priorities identified for 2013-14 are as follows:
Patient Safety
9
Clinical Effectiveness
Integrated Governance
Audit Programme
We will implement a new annual audit
programme, focusing on key areas
where we wish to assure ourselves
that we are maintaining, and excelling,
the required standards.
This was identified as a priority as audit
is a quality improvement process that
seeks to improve patient care, assessing
the effectiveness of our processes and
outcomes through systematic review of
care against explicit criteria and supports
the implementation of change. Our new
programme of audits will be very robust
and be monitored at both Group and
local quality governance committees.
Patient Experience
Safety Culture Assessment
NHS National Safety Thermometer
Each hospital and clinic will undertake a safety
culture assessment, develop an improvement
plan as appropriate, and monitor change
over time.
A Safety Thermometer survey will be
completed on a monthly basis for all relevant
patients and submitted centrally to the Health
and Social Care Information Centre. This
is a local improvement tool for measuring,
monitoring and analysing patient harms and
‘harm free’ care over a period of time.
This was identified as a priority as it has
become increasingly acknowledged that a
safety culture is vital if patient safety is to
be improved. A safety culture is determined
by both individual and organisational values,
attitudes and behaviours about the perceived
importance of safety and confidence in how
safety systems and processes are promoted
and implemented. Measuring safety culture
is important as this influences patient
safety outcomes.
Statement on Quality
This data is collected based on the presence
or absence of four harms – pressure ulcers,
falls, urinary tract infections in patients with
catheters, and venous thromboembolisms
(VTE). This was selected as a priority
because it will help us focus on the concept
of ‘harm free care’. This will let us identify
any improvements required and, as these
are largely preventable, improve our patients’
overall experience of our care.
Theatre Accreditation Programme
We will implement an accreditation programme
to our operating theatre environments
across the Aspen Group aiming to excel
in perioperative practice. The focus of the
accreditation/credentialing will be on the
validation of the theatre environment, patient
experience and linkages to patient safety.
This was chosen as a priority because as an
independent healthcare provider of acute
surgical care our operating theatres are one
of the main ‘hubs’ of our business. In having
our operating theatres externally validated,
by being assessed as meeting recognised
national standards for perioperative practice,
the programme is a vehicle in helping us
demonstrate our commitment to patient safety
and in driving quality improvement.
Worldhost® Customer Care Training
Inpatient Survey
We will implement an innovative and new
customer care training programme, for
clinical and non-clinical staff, across all our
facilities in 2013/14. We aim to become an
accredited Worldhost® recognised business
and showcase our outstanding customer
service with the focus being on teamwork
and communication.
All our hospitals will refine the inpatient survey
tool to obtain improved information on the
views and perceptions of our patients on the
care they have received and to inform the
continued development and improvement of
our services.
This is a priority for us as we wish to
exceed our patients’, their families’, and key
stakeholders’ expectations and recognise
that quality of customer service is key to
business success. Aspen Healthcare is
the first healthcare company in the UK to
seek Worldhost® recognition and status,
demonstrating our commitment to providing
excellence in patient experience.
This was identified as a priority as Aspen
Healthcare is genuinely committed to
delivering and excelling at providing excellent
care to all our patients and being responsive
to our patients’ needs. This will include
implementing the new Friends and Family Test
on how likely a patient is to recommend our
hospitals to friends and family if they needed
similar care or treatment.
10
Statements of Assurance
Relating to the quality of NHS services provided
This section of the Quality Account provides the mandatory information for inclusion in
a Quality Account, as determined by Department of Health regulations, and reviews our
performance over the last year, running from April 2012 to March 2013 but reported in
June, as required by the guidelines.
As this is our first Quality Account we had not set ourselves any published targets last
year but we have worked hard to achieve the quality objectives we had set ourselves.
Future Quality Accounts will be more comprehensive as we further improve the
measurement systems that will help us in doing this.
Review of NHS Services Provided 2012-13
During April 2012 to March 2013, Claremont and Holly House Hospitals provided the
following NHS services:
Claremont Hospital
Trauma and Orthopaedics
Urology
ENT
General Surgery
Gynaecology
Gastroenterology
Neurosurgery Spinal
Ophthalmology
Holly House Hospital
Trauma and Orthopaedics
Urology
ENT
General Surgery
Gynaecology
Anaesthetics (pain management)
Oral and Maxillo-Facial Surgery
Both Claremont and Holly House Hospitals have reviewed all the data available to them
on the quality of care in all of the above NHS services.
The income generated by the NHS services reviewed during 2012-13 represents 100%
of the total income generated from the provision of NHS services provided by Claremont
and Holly House Hospitals for the year ended 31st March 2013.
11
12
Participation in Clinical Audit
National clinical audits are a set of national
projects that provide a common format
by which to collect audit data. National
confidential enquiries aim to detect areas
of deficiencies in clinical practice and
devise recommendations to resolve them.
During 2012-13, three national clinical
audits and two national confidential enquiries
covered NHS services that Claremont and
Holly House Hospitals provided.
The national clinical audits and national confidential enquiries that Claremont and Holly
House Hospitals were eligible to participate in during 2012-13 were as follows:
N
ational Confidential Enquiry into Cardiac Arrest Procedures
N
ational Confidential Enquiry into Bariatric Surgery
National Joint Registry
National PROMS Programme
N
ational Comparative Audit of Blood Transfusion
The national clinical audits and national confidential enquiries that Claremont and Holly
House Hospitals participated in, and for which data collection was completed during
2012/13, are listed below alongside the number of cases submitted to each audit or
enquiry required by the terms of that audit or enquiry:
National Confidential Enquiry into Patient Outcome and Death (NCEPOD)
Name of Audit
Participation
Claremont
Holly House
Cardiac Arrest
Procedures
Yes
Yes
Bariatric surgery
Yes
No
Cases Submitted
Claremont
Holly House
0
0
No arrests
No arrests
took place
took place
3
N/A*
National Clinical Audit
Name of Audit
National Joint Registry
National PROMS
programme
National Comparitive Audit
of Blood Transfusion
Participation
Claremont Holly House
Yes
Yes
Cases Submitted
Claremont Holly House
628
280
Yes
Yes
157
74
Yes
No
5
N/A*
*Due to management changes, Holly House Hospital was unable to participate in two of the audits.
This has now been rectified.
The reports of the three national clinical audits were reviewed by Claremont and Holly
House Hospitals in 2012-13 and the hospitals intend to take the following actions to
improve the quality of healthcare provided:
•
Increase the participation in the PROMS programme and ensure forms are
completed correctly to ensure/maintain high compliance levels.
•
Develop an enhanced recovery programme for orthopaedic patients.
•
Ensure periodic competency assessment of all staff involved in blood
transfusion practices.
13
14
Local Audits
The reports of seven local clinical audits were reviewed by Claremont and Holly House
Hospitals in 2012-13, as shown below:
Antibiotic Usage and Prescribing
Resuscitation Management
Infection Prevention and Control Standards
Bedside Transfusion
Patient Discharge Process
Goals Agreed with Commissioners
Use of the Commissioning for Quality and Innovation (CQUIN) payment framework
A proportion of Claremont and Holly House
Hospitals’ income in 2012-13 was conditional
on achieving quality improvement and
innovation goals agreed between Claremont
and Holly House Hospitals and any person or
body they entered into a contract, agreement
or arrangement with for the provision of NHS
services, through the Commissioning for
Quality and Innovation payment framework.
Further details of the agreed goals for 201213 and for the following 12-month period are
available electronically at:
http://webarchive.nationalarchives.gov.uk/*/
http://institute.nhs.uk
Red Blood Cell Usage
Sharps Safety
The reports of all local clinical audits were reviewed by each hospital in 2012-13
and reported through various forums and the Quality Governance Committees.
Claremont and Holly House Hospitals intend to take the following actions to improve
the quality of healthcare provided:
•
Continue monitoring antibiotic prescribing to ensure usage remains within the
local Antimicrobial Policy.
• Increase the clinical emergency scenario training to ensure staff are able to
maintain their skills in the absence of actual cardiac arrest situations.
• Increase the availability and options for the delivery for infection prevention
and control (IPC) training.
• Implement a revised annual audit programme in 2013/2014.
Participation in Research
There were no NHS patients recruited during the reporting period for this Quality
Account to participate in research approved by a research ethics committee.
Statements from the Care Quality Commission
Both Claremont and Holly House Hospitals
are required to maintain registration with the
Care Quality Commission (CQC), the national
quality regulator. Both hospitals are registered
in respect of the following regulated activities:
1. Treatment of disease, disorder or injury
2. Diagnostic and screening procedures
3. Surgical procedures
The CQC has not taken enforcement action
against Claremont and Holly House Hospitals
during 2012/13 and Claremont and Holly
House Hospitals have not participated in any
special reviews or investigations by the CQC
during the period covering this report.
The Claremont Hospital was inspected by
the CQC in January 2013 and was found
to be fully compliant with the five essential
standards reviewed and as at 31st March
2013, the Claremont Hospital does not have
any conditions on its registration.
Holly House Hospital was inspected by
the CQC in February 2013 and of the six
essential standards reviewed, five were
assessed as fully compliant, and one standard
was found to have a minor concern.
15
This was in relation to Outcome 8, ‘People
should be cared for in a clean environment
and protected from the risk of infection’ where
improvements in evidencing audit of cleaning
schedules and in the labelling and storage
of clinical and non-clinical equipment were
required. Holly House Hospital has agreed,
and completed, an acceptable action plan
with the CQC to address these concerns
and as at 31st March 2013, the following
arrangements have been implemented:
•A
robust system of audit and review
ensuring adherence to the cleaning
schedule.
•A
labelling system has been introduced
to easily identify cleaned equipment.
•D
edicated areas have been created for
the separate storage of clinical and
non-clinical equipment.
•A
dedicated Infection Control Specialist
monitors these processes and reports to
the hospital’s Quality Governance
Committee.
16
Statements on Data Quality
Data Quality: Information Governance
Aspen Healthcare recognises that good
quality information underpins the effective
delivery of patient care and is essential if
improvements in quality of care and value
for money are to be made. We ensure that
our Information Governance policies guide
and inform our standards of record keeping,
supporting the delivery of care and treatment
and that accuracy, completeness and
validity of those records are monitored on
an on-going basis to continually improve
data quality.
The Information Governance Toolkit is a
performance assessment tool, produced
by the Department of Health, and is a set
of standards that organisations providing
NHS care must complete and submit
annually by 31st March each year. The
toolkit enables organisations to measure
their compliance with a range of information
handling requirements, thus ensuring that
confidentiality and security of personal
information is managed safely and effectively.
Aspen Healthcare’s Information Governance
Assessment overall score for 2012-13 was
66% and graded ‘green’ and we achieved
level 2 in all categories meeting national
requirements.
Claremont and Holly House Hospitals will be
taking the following actions to continue to
improve data quality:
•T
he appointment of a dedicated and
professionally accredited Clinical Coder as
well as an Administration Manager to meet
the requirements of the NHS contract.
•T
he development of standard operating
procedures for all key tasks pertaining to
the quality and timeliness of data capture.
• Increasing the availability of enhanced
training on data quality for all key staff.
•C
ollection of ‘Referral to Treatment’ [RTT]
data for all patients.
Secondary Uses System (SUS)
Clinical Coding Error Rate
Claremont and Holly House Hospitals
submitted records during 2012/13 to
SUS for inclusion in the Hospital Episode
Statistics. These are included in the latest
published data. The percentage of records
in the published data which included the
patients’ valid NHS number was:
Claremont and Holly House Hospitals
were not subject to the Payment by Results
clinical coding audit during 2012-13 by the
Audit Commission.
• 100% for admitted patients
• 100% for outpatient care
and which included the patients’ valid
General Medical Practice Code was:
• 100% for admitted patients
• 100% for outpatient care
• Introduction of a new role to track ‘Referral
to Treatment’ timeframes to prevent any
avoidable breaches.
•R
egular review of data reports in order
to correct omissions and/or errors in
core patient data that is submitted to the
Secondary Users Service [SUS].
“As an ex-nurse and present
NHS Manager, it is good to
see/know that this quality
of service is still available.”
Holly House Hospital patient
17
18
Quality Indicators
In January 2013, the Department of Health
advised that amendments had been made
to the National Health Service (Quality
Accounts) Regulations 2010. A core set of
quality indicators were identified for inclusion
within the Quality Account.
Not all indicator measures that are routinely
collated in the NHS are currently available
in the independent sector and work
will continue in 2013/14 on improving
the consistency and standard of quality
indicators reported across Aspen Healthcare.
This will be much improved in 2013/14
with the launch of the Private Healthcare
Information Network (PHIN) in April 2013
which will start to collect and publish
information about private and independent
healthcare, including quality indicators, to
help patients make informed choices. Aspen
Healthcare is an active member of PHIN
and is working in partnership with other
member organisations to further develop
the information available. www.phin.org.uk
A number of metrics have been chosen to
summarise our performance against key
quality indicators of effectiveness, safety
and patient experience.
Claremont and Holly House Hospitals
consider that the data is as described in this
section as it is collated on a continuous basis
and does not rely on retrospective analysis.
When anomalies arise, each one is reviewed
with a view to learning why an event or
incident occurred so that steps can be taken
to reduce the risk of it happening again.
19
Hospital-Level Mortality Indicator and
Percentage of Patient Deaths with
Palliative Care Code
This indicator measures whether the number
of people who die in hospital is higher or
lower than would be expected. This data
is not currently routinely collected in the
independent sector.
Percentage of Hospital Employed Staff
who would Recommend Hospital to
Family and Friends
This question was not asked in the most
recent or past staff surveys. A new staff
survey is being developed for 2013 which
will include this question.
Patient Reported Outcome Measures (PROMs)
Patient Reported Outcome Measures
(PROMs) assess general health
improvement from the patient perspective.
These currently cover four clinical
procedures and calculate the health gains
after surgical treatment using pre- and postoperative surveys. The data in this section is
based upon the last two available reporting
periods as complete data for 2012-13 is
not yet available (due to data time lag).
Aspen Healthcare is pleased to report that both Claremont and Holly House Hospitals
performed consistently above the national average for both hip and knee replacements.
Claremont Hospital
PROMs Indicator
Hip replacement.
(% of respondents who
recorded an increase in
their EQ-5D index score
following operation)
Knee replacement.
(% of respondents who
recorded an increase in
their EQ-5D index score
following operation)
Groin hernia:
(% of respondents who
recorded an increase in
their EQ-5D index score
following operation)
Varicose Veins
Holly House Hospital
2010/11
2011/12
2010/11
2011/12
89.4%
91.3%
94.1%
92.9%
(86.7%
nationality)
(87.4%
nationality)
(86.7%
nationality)
87.4%
nationality)
81.1%
83%
100%
88.9%
(77.9%
nationality)
(78.4%
nationality)
(77.9%
nationality)
(78.4%
nationality)
59.2%
No data
available as
numbers
too small
No data
available as
numbers
too small
No data
available as
numbers
too small
(50.5%
nationality)
No procedures No procedures No procedures No procedures
performed
performed
performed
performed
or data
or data
or data
or data
submitted
submitted
submitted
submitted
Pre-operative response
rate for all four
procedures
77.4%
91.5%
Not available
Not available
Post-operative response
rate for all four
procedures
91.3%
91.4%
78%
92%
20
Other Mandatory Quality Indicators
All performance indicators are monitored on a monthly basis at key meetings and then
reviewed quarterly at both local and corporate level Quality Governance Committees.
Any significant anomaly is carefully investigated and any changes that are required are
actioned within identified time frames. Learning is disseminated through the various
quality forums in order to prevent similar situations occurring again.
Claremont Hospital
Indicator
Source
Numbers of people
15 years and
over readmitted
within 28 days of
discharge
Holly House Hospital
2011/12
2012/13
2011/12
2012/13
Care Quality
Commission
performance
indicator quarterly
returns
2
3
8
4
Responsiveness to
personal needs of
patients
Patient satisfaction
survey data – for
overall level of care
and service
98.5%
excellent or
very good
82.6%*
93.75%
excellent or
very good
94.5%
excellent or
very good
Number of
admissions risk
assessed for VTE
CQUIN data
97.2%
97.6%
100%
100%
Number of
Clostridium difficile
infections reported
From national HPA
(now Public Health
England) returns
0
0
0
0
Number of patient
safety incidents
which resulted in
severe harm or
death
From hospital
incident reports
0
1
0
0
* A different measurement tool was used during 2012-13
“The care and service
throughout was faultless
with nothing being too
much trouble.”
Ms J. D. of Hope Valley, Derby
21
22
Review of Quality Performance
for 2012-13
This section reviews some of the key quality indicators for Claremont and Holly
House Hospitals during 2012-13.
Patient Safety
Patient safety is at the forefront of all
services that are provided. Risks to patient
safety come to light through a number of
routes such as routine audit, complaints,
the reporting of incidents and concerns or
through various national alert systems.
Patient Safety Software: Datix
Aspen Healthcare has implemented webbased patient safety software for incident,
adverse event and near miss reporting. The
Datix system allows any member of staff
to promptly make a report which is then
reviewed by a manager and actions taken
as appropriate. Learning from incidents is
readily disseminated and trend reports are
shared across the organisation with the
provision of feedback to staff on incidents
supporting our patient safety culture.
During 2012-13, all staff at Claremont and
Holly House Hospitals received training
regarding the use of the system and the
information that Datix can provide for those
working at every level.
Infection Prevention and Control
Cleanliness and Hygiene
Infection prevention and control (IPC) is a
high priority for Aspen Healthcare and is
at the heart of good management and
clinical practice.
The cleanliness of a hospital is very important
to patients, those who visit and all the staff
who work within the organisation.
During 2012-13, considerable work has
continued in further establishing Aspen’s
IPC infrastructure and policies, with excellent
work being undertaken across all its facilities.
Effective systems are in place to prevent
and control health care associated infections
(HCAI) and ensure the safety of our patients,
their relatives, our staff and visiting members
of the public.
As part of the monitoring system, the views
of patients are sought through the use of
satisfaction questionnaires.
Of those patients who completed a patient
satisfaction survey at Claremont and Holly
House Hospitals during 2012-13, the table
below identifies the percentage of patients
who considered hospital cleanliness and
hygiene as either ‘excellent’ or ‘very good’.
April 2012 – March 2013
Indicator
Cleanliness and hygiene
Claremont Hospital
% excellent or very good
97%
Holly House Hospital
% excellent or very good
96%
The reduction in HCAI has been a national
priority for several years and Claremont and
Holly House Hospitals are pleased to report
that no hospital acquired infections were
identified during the last reported year.
HCAI: April 2012 - March 2013
MRSA positive blood culture
MSSA positive blood culture
Claremont
Hospital
0
0
Holly House
Hospital
0
0
E. Coli positive blood culture
0
1
C. Difficile infection
0
0
Infection
23
Comments
Identified on admission
and was not hospital
associated/acquired
24
Clinical Effectiveness
Revalidation
Revalidation is the process by which doctors have to demonstrate to the General Medical
Council (GMC) that they are up-to-date and fit to practise. It is a new way of regulating
the medical profession, introduced in December 2012, and contributes to the on-going
improvement in the quality of medical care delivered to patients.
Revalidation is based on a local evaluation of doctors’ performance through annual appraisal.
Information from the appraisal is provided to a Responsible Officer who will make a
recommendation to the GMC, normally every five years, on whether to ‘revalidate’ a doctor
and grant a licence to practise.
During 2012-13, the Responsible Officer for Aspen Healthcare has made good progress
with supporting doctors in meeting the legislative requirements of revalidation. There is also
an excellent system in place for arranging appraisal discussions where needed, including the
administration of feedback questionnaires from patients and colleagues.
Returns to Theatre and Unplanned Transfers to other Hospitals
The majority of patients who are cared for in Aspen Healthcare facilities undergo planned
surgical procedures. As every surgical intervention carries a risk of complication, it is not
unusual to find that a small number of patients may need to return to theatre, be readmitted
or transferred to another hospital for more specialised care at a Consultant’s request.
Aspen Healthcare regularly monitors the incidence of all complications in order to identify
any trends that may emerge in relation to specific procedures or surgical teams. The results
of such monitoring are reviewed at both the local and group Quality Governance Committees
and this data is also submitted to the CQC on a quarterly basis.
Returns to Theatre and Unplanned Transfers: April 2012 – March 2013
Indicator
Returns to theatre
(number and % against number
of visits to theatre)
Unplanned transfers
(number and % against number
of inpatients who have been
discharged)
Claremont Hospital
Holly House Hospital
4
(0.07%)
5
(0.09%)
11
(0.2%)
7
(0.1%)
“My stay was so different
to my experience of other
hospitals. I felt safe, secure,
looked after and respected. I
noticed every little touch and
they made such a difference.”
Claremont Hospital patient
25
26
Patient Experience
Patient experience is very important to everyone who works at Aspen Healthcare.
All feedback is welcomed as it provides either an opportunity to build on what is
done well or to make changes when required.
The Patient Environment
Satisfaction Surveys
During 2012-13, there have been major
building and refurbishment initiatives.
Satisfaction surveys are offered to all
patients across Aspen Healthcare Hospitals.
The results are reviewed on a monthly basis
and any trends or areas for improvement are
identified and acted upon.
At Claremont Hospital, the two main
passenger lifts have been replaced, the
operating theatres have new state-of-theart equipment and all patient beds are
now electrically operated. Within each
bedroom, patients have access to a Patient
Entertainment System which includes digital
channels, a film library and an information
service providing a wide variety of choice.
In early 2013, Holly House Hospital
opened a new £20 million purpose-built
development which has doubled the size of
the hospital. The new facility provides cutting
edge treatment facilities for outpatients and
three new integrated theatres.
Of those patients who completed a patient
satisfaction survey at Claremont and Holly
House Hospitals during 2012-13, the
results from three key indicators are as
identified below:
Complaints
Overall satisfaction
with nursing care
Overall satisfaction
with consultant
Overall satisfaction
with quality of care
(% excellent or very good)
(% excellent or very good)
(% excellent or very good)
99%
100%
Claremont Hospital
Holly House Hospital patient
In January 2013, the inpatient satisfaction
questionnaire was revised and also now
includes the ‘Friends and Family’ test i.e.
those patients who would recommend the
hospital as a provider of care to their family
or friends.
Patient Satisfaction Survey: April 2012 – March 2013
93%
“This was by far my most
pleasant experience as a
day case.”
97%
98%
94.2%
Whilst Aspen Healthcare strives to provide consistently excellent care and services, there are
occasions when service users have reason to complain. Every complaint is considered a valuable
source of feedback and information on how our services can be improved. All complaints are
investigated and any opportunity for learning or service improvement acted upon.
Complaints: April 2012 – March 2013
Indicator
Number of complaints
% per 100 admissions
Claremont Hospital
56
0.02%
Holly House Hospital
52
0.07%
Holly House Hospital
27
28
External Perspective
on Quality of Service
What others say about our services
“NHS Doncaster Clinical Commissioning Group (DCCG) already had a contract in place with
Claremont Hospital and when waiting times started to increase at the local acute hospital,
they helped us to ensure that patients received their treatment as soon as possible. The
Claremont team responded very quickly and worked with the DCCG and local provider to
come up with a solution to the specific problem we were facing. Claremont colleagues were
professional, knowledgeable and solution focussed. They were also very customer focussed
and responded to the needs of the DCCG and Doncaster patients to ensure that a locally
based service was put in place to enhance the patient experience.”
Chief of Strategy and Delivery
Doncaster Clinical Commissioning Group
“For a number of years NHS Sheffield Clinical Commissioning Group (CCG) has had contact
with Claremont Hospital in relation to the provision of NHS elective care. Initially this was in
relation to the national Department of Health managed Extended Choice Network contract
and more recently for the Sheffield CCG managed Standard Acute contract. The main points
of contact have been between the Contract Lead and the Finance Director at Claremont
Hospital. This has been a very positive business relationship where we have been able to
constructively discuss any issues that have arisen and practically resolve in a timely manner.
The Director of Clinical Services has provided the clinical support to the contract and again
has worked in a very positive way to respond to clinical issues according to the contract
requirements. Over the years there have been many changes in how the contract is managed,
it has been a learning experience for us all. I have found Claremont Hospital have approached
these changes in a positive and practical way.”
Senior Contracts Manager
NHS Sheffield
“During the summer of 2011, North Staffordshire CCG commissioned a spinal service with
Claremont Hospital to assist in dealing with a backlog of patients awaiting spinal surgery and
also to provide capacity for new patients requiring an assessment for spinal surgery. This
arrangement still continues today and we have found the services to be offered by Claremont
to be of the highest standard, and the professionalism and ‘can do’ approach have made the
process simple and efficient. Feedback from patients seen at Claremont has been excellent
and they have commented in particular about the speed in which they were seen from point
of referral and the care and attention that they received during their inpatient stay.”
Commissioning Manager
North Staffordshire Clinical Commissioning Group
29
30
Thank you for taking the time
to read our Quality Account.
Your comments are always welcome
and we would be pleased to hear from
you if you have any questions or wish
to provide feedback.
Please contact us via our website:
www.aspen-healthcare.co.uk
Or call us on:
020 7977 6080
Write to us at:
Aspen Healthcare Limited
Centurion House (3rd Floor)
37 Jewry Street
London EC3N 2ER