St. Helens
Quality Accounts
2012/2013
Contents Page
Table of Contents
Item
Page
1.
Statement from CEO
3
2.
Purpose and values
5
3.
Governance
6
4.
Review of NHS Services
6
4.1
4.2
4.3
4.4
4.5
4.6
4.7
Participation in Clinical Audits
Research
Goals agreed with NHS Commissioners (CQUIN)
Regulation
Data Quality
Information Governance
Clinical Coding Error rate
7
8
8
8
9
9
10
5.
Key Achievements 2012/2013
11
6.
Key Priorities for 2013/2014
21
21
22
23
23
25
26
27
28
7.
6.1
6.2
Clinical Effectiveness
Patient Safety
6.3
6.4
6.5
6.6
6.7
6.8
Patient Experience
Further Development Areas 2013/2014
Financial Security
Partnerships
Marketing and Communication
Fundraising and alternatives
Conclusion
29
Schedule 1 CQUIN
30
Comments External Bodies
31
Part One
Chief Executive’s statement
2012/2013 has been an exciting and challenging year for Fairfield
Independent Hospital. With difficult economic conditions that have
characterised the business environment, the charity has nevertheless continued to provide high quality health care, invest in its
services, infrastructure and staff in pursuit of its overall strategic
objectives.
The difficult financial situation has served to emphasise the
importance of values and integrity. Our not-for-profit model is
unique, enabling us to remain independent, offering choice and
putting the patient at the heart of everything we do.
The Hospital has been delivering high quality health care to the
local community for 40 years. We are extremely proud of our
record of service as an independent health charity.
The Quality Report is designed to provide a transparent look at
our organisation to give confidence to our patients, partners and
commissioners. As an organisation we depend on our staff for
their skills and expertise. They can only do their jobs effectively
if we listen to them and learn from their experience and ideas.
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.
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, personalised care 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.
03
Fairfield Independent Hospital Quality Accounts 2012/2013
“I was overwhelmed by the
professionalism
of all staff and
the care and
attention that I
was given at all
times. I feel
indebted to their
kindness.”
June 2012
Chief Executive’s statement
“I was so
pleased and
grateful for the
opportunity to
come to
Fairfield Hospital
and I actually
felt special;
something that
I haven’t
experienced in a
hospital before.
“Thank you.”
May 2012
During 2012/2013, we reinvested financial resources to enhance
the infrastructure of the hospital and we have some exciting
developments planned for 2013/2014.
Despite 2012/2013 being challenging economically for us all, our
finances remained on a path of improvement 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.
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 have been compiled by members of the
senior team and Board and have 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 2012/2013
04
Patients First
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-focused 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.
05
Fairfield Independent Hospital Quality Accounts 2012/2013
“I was much
impressed with
the Consultant,
all Reception
and Nursing
staff. Clinical
areas were
spotless; the
room was
comfortable
and clean. The
Consultant
explained the
procedure in
detail allowing
the right
choice to be
made. Keep up
the good
work.”
March 2013
Patients first
3. GOVERNANCE
“Your staff are
an excellent
example to the
medical field.
Everyone was
so lovely and
attentive. I’ve
never had
better care.”
May 2012
The Board sets the strategic direction of the organisation and
oversees the delivery of planned results by monitoring performance against objectives. Its role is also to ensure effective
stewardship and to ensure high standards of corporate
governance and personal behaviour. The Board is led by the
Chairman of the Trustees. It is important that the Hospital has
a highly effective and efficient Board that has the skills,
competence and business acumen to drive the strategic agenda.
As a registered charity and a company limited by guarantee
without share capital we have to balance the requirements of
running a not-for-profit business with the need to achieve our
charitable aims and objectives, to demonstrate public benefit;
adhere to the values of our charity; adopt best practices and
act with integrity at all times.
The Chief Executive is responsible for ensuring that effective
processes are in place so that the Hospital can discharge its
legal duty for all aspects of governance and quality, and for the
health and safety of patients, staff visitors and contractors. The
Chief Nurse has executive responsibility for the effective and safe
delivery of clinical services. The Head of Patient Quality and
Safety supports the Chief Nurse in her role and in implementation of the clinical governance agenda. They work with staff to
ensure that systems and processes are in place to enable
improvements in the delivery of safe effective patient care.
4.
REVIEW OF NHS SERVICES
During 2012/2013 Fairfield Independent Hospital provided 7321
NHS patient episodes.
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 2012/2013 represents 100%
of the total income generated for the provision of NHS services
by Fairfield Independent Hospital.
Fairfield Independent Hospital Quality Accounts 2012/2013
06
Patients first
4.1 Participation in Clinical Audits
During 2012/2013 3 national clinical audits 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.
Fairfield Independent Hospital was eligible to participate in only one
National Comparative Enquiry into Patient Outcome and Death
(NCEPOD) audit. This was The Cardiac Arrest Audit.
However,
during the period of the study there were no cardiac arrests thus
making the audit void.
The national clinical audits that Fairfield Independent Hospital were
eligible to participate in during 2012/2013 were as follows;
National elective surgery - Patient reported outcome measures
(PROMS)
- Hip and knee replacements
- Hernia
- Varicose veins
National Joint registry (NJR) – hip and knee replacements
National Comparative Audit of Blood Transfusion – Labelling of blood
samples for transfusion
The reports of 3 national clinical audits were reviewed by the Hospital in
2012/2013 and we intend to take the following actions to improve the
quality of healthcare provided:
Patient Reported Outcome Measures - activity within two of the four
identified areas is relatively low due to patient numbers. Work to
increase uptake is ongoing across all 4 areas.
National joint registry for hip and knee replacements – we have
achieved 100% compliance for 2012/13
The Blood transfusion audit did not identify any problems with
regard to the process. One transcription error was made and the
nurse involved was advised of the error.
07
“I would just like
to say a big
thank you to all
staff for their
time and
patience, for the
care they took
to ensure that
my treatment
and stay was as
comfortable as
possible. Each
member of staff
carried it out in
a calm and
friendly manner.
Should I require
further treatment in the
future, I would
endeavour to
attend Fairfield
and will
recommend.”
April 2012
Fairfield Independent Hospital Quality Accounts 2012/2013
Patients first
“The treatment
I received was
first class. I
could not have
asked for anything better.
All the staff
conducted
themselves very
professionally
and were
courteous at all
times. It was
very nice to be
looked after by
such a
dedicated
team. The staff
are a credit to
Fairfield
Hospital.”
Re-audits for the Quality Accounts for 2012/2013 audit
categories showed the following:
Correct Surgical site marking.
Record keeping within preoperative assessment clinics.
Audit tool introduced February 2013.
Re audit July 2013
Final audit Jan – March 2013
showed 100% compliance
Monitoring and response to
patients’ oxygen saturations
levels.
Audit showed 100% compliance with
procedures for monitoring oxygen
saturation levels to ensure safe care.
4.2 Research
The Hospital does not participate in clinical research.
4.3 Goals agreed with NHS Commissioners (CQUIN)
Use of Commissioning Quality and Innovation (CQUIN) framework
The Hospital again in 2012/13 entered into an agreement with
the NHS to provide services. 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 and achievements are shown in
Schedule 1.
4.4 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
August 2012
Regulated Activity - Treatment of disease, disorder or injury
Regulated Activity – Accommodation for persons who require
nursing or personal care. Additional conditions that apply - the
Fairfield Independent Hospital Quality Accounts 2012/2013
08
Patients first
registered provider must only accommodate a maximum of one
service user at the Guy Pilkington Memorial Home.
During the year we have had a number of formal inspections and
audits which showed no problems or issues with the services that
we provide. I am delighted to confirm that we have achieved, in
some case exceeded, our targets and goals.

We had an unannounced visit from the Care Quality
Commission in October 2012. All the essential standards of
care that were assessed during the visit were met. A copy
of the full report can be found on our website
www.fairfield.org.uk

In 2012 the Hospital successfully passed its three year
recertification audit of ISO 9001:2008, Quality Management
Standard and upheld its certification of the ISO 27001:2005
Information and Security Management Standard.

We were successful in our three year accreditation for
Investors in People
4.5 Data Quality
Fairfield Independent Hospital submitted records during 2012/2013
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
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 rose from 85% to 88%.
09
Fairfield Independent Hospital Quality Accounts 2012/2013
“The staff at
Fairfield have a
very warm and
friendly
approach; they
are willing to
help at all
times, day or
night. All staff
members
carried out
their duties to
a very high
standard.”
November 2012
Patients first
4.7 Clinical Coding Error Rate
“There was a
very relaxed
and friendly
atmosphere. I
was treated
with dignity
and respect.
The staff were
professional,
approachable
and I would
choose
Fairfield
Hospital
again.”
Admitted patient care data in a targeted sample for the period July
to September 2012 was audited at Fairfield Independent Hospital by
auditors commissioned by the Audit Commission. The audit
focused on Orthopaedics and General Surgery activity of the
Hospital. The audit covered the hospital’s clinical coding using
the Connecting for Health (CFH) Audit Methodology v6, as well as
the accuracy of other data items that affect the price
commissioners pay for a spell under Payment by Results: age on
admission, admission method, sex, and length of stay. For each of
these data items the information in Secondary User Service was
verified against information in source documentation.
In the sample audited, the hospital had 2.5 per cent of spells (one
spell) with an error that affected the price.
The performance of the Hospital, measured against the number of
spells with an incorrect payment would place the hospital in the
best performing 25 per cent of trusts compared to last year’s
national performance. This is an improvement on the 2010/11
audit, when the Health Related Group error rate was 9.0 per cent.
All the recommendations from the audit were agreed and an action
plan has been put in place to further improve clinical coding at the
Hospital.
April 2012
Fairfield Independent Hospital Quality Accounts 2012/2013
10
Part Three
Key Achievements
5 KEY ACHIEVEMENTS 2012/2013
In our 2011/12 Quality Accounts we set out three key development areas.
Detailed below is what we achieved against the specific areas identified. I
am delighted to report that we met all our key targets across all areas.
“Excellent
caring staff.
If only all
hospitals were
like this one.
Thank you
all.”
Clinical Effectiveness
Development Area
identified
Outcome
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.
The hospital is now collecting data on a regular
basis of how it utilises is resources. The data is
collected hospital wide so includes all patients.
Utilisation across theatre for the 2012/13 period
stands at 89%.
Communication boards have been introduced to
ensure effective communication within teams and
across departments. This has worked particularly
well in the theatre environment and has led to less
delays and more effective planning with regards to
theatre equipment.
Review clinical staffing
across the hospital to
ensure that we can meet
needs both now and in
the future.
Clinical staffing is reviewed on a weekly basis. The
current levels of qualified to non qualified staffing
ratios are higher than those in many organisations
and reflect the high level of nursing input to the
patient’s journey.
To reduce the amount of
time that patients stay in
hospital by utilising
programmes such as
enhanced recovery.
This links with effective discharge planning work
across outpatients, ward and theatre. Work that
has been undertaken has shown a reduction in
patient stay for hip and knee replacements.
Discharge planning has been introduced at preoperative assessment stage as part of the multi
disciplinary team approach. For example joint
replacement length of stay has been reduced from
7 to 12 days to between 4 to 7 days post
operation.
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.
At pre-operative assessment all patients are asked
about their lifestyle. 100% of patients who attended
pre-operative assessment have been asked their
smoking status which is then recorded. Identified
smokers are offered further advice if they wish to
give up smoking. Of these patients, 98% have
asked for and been given further advice.
Dementia training to form
part of CPD for all front
line staff.
E-Learning for dementia has been completed for all
clinical staff and will be rolled out to non clinical
front line staff. Dementia leads have been
identified in the three clinical areas for further
in-depth training to be commenced 2013/14.
11
May 2012
Fairfield Independent Hospital Quality Accounts 2012/2013
Key Achievments
Patient Safety
“All the Doctors
and Nurses
were polite and
kind. They
explained
everything
clearly and did
all they could
for me. It’s a
brilliant hospital
with great
staff.”
December 2012
Development Area Identified
Outcome
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 Dec.
2011 showed an achievement figure
of 84%. The target for the ward is to
increase this to a minimum of 95%
in 2012/13.
Clinical record keeping errors have been
identified in specific areas as part of this
audit process and plans put in place to
address. However, the total results for
the year show that the 95% target has
been achieved.
100% of all eligible surgical patients 100% of all eligible patients had a VTE
admitted to Fairfield to have a VTE
risk assessment prior to or on admission.
risk assessment:
We will continue to develop our
governance framework by the
introduction of further policies and
procedures through the risk
management and ISO frameworks
ISO procedures have been reviewed and
necessary changes implemented. A further
accreditation for ISO was awarded in
2012/13.
Further policies have been reviewed and
introduced for example, Risk Management,
Clinical Audit, Making Reasonable Adjustments for Employees with Disabilities.
Patient Experience
Development Area Identified
Outcome
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.
Patient questionnaires were redesigned
during the period. We also introduced
the ‘change one thing’ initiative. An
example of a change we have implemented from this initiative is that a
patient commented that the pedal bins
in the bathrooms were awkward when
you were on crutches. Open bins have
now been purchased for the rooms that
are used for joint replacements.
Random sampling also took place by
facilities team regarding how patients
felt about their experience and the
facilities that we offered.
In all cases the results were very
positive and some of the suggestions
have been taken forward, for example
WiFi access in bedrooms.
Fairfield Independent Hospital Quality Accounts 2012/2013
12
Key Achievements
Patient Experience (cont…)
Development Area Identified
Outcome
Ensure patients receive optimum pain
control following surgery by
monitoring on a quarterly basis
patients’ perceptions of pain.
All Fairfield patients are monitored via
the Modified Early Warning System
(MEWS). Patients’ perception of their
pain levels are part of this process
which is one of the key performance
indicators for the Ward. This key
performance indicator is audited on a
monthly basis showing an average of
98.7% compliance for the period Sept.
2012 to March 2013.
In line with best practice and expert
opinion provide more procedures in an
outpatient setting.
Outpatients procedures within the outpatient environment are restricted by
the physical layout of the building
However, listening to our patients and
taking on board what they have said
we have developed a specific rapid
access urology clinic for flexicystoscopy and vasectomy. We will
look to develop more services of this
nature in the future.
Patient feedback on the service to
date has been positive as the service
is offered on Saturdays which suits
certain patients.
5.2 What else did we achieve during the year ?
5.2.1 Governance
Our programme of review and updating of our policies continues.
A number of policies have been introduced through the year to
strengthen our governance structure and to also develop our
arrangements for risk management. The risk register continues to
be populated and reported to the Board identifying the top risks
and the actions that have been put in place to mitigate those
risks.
“Top class
service, I was
made to feel
like a person
not just another patient.
It’s a shining
example of
how the NHS
should and
could be run.
Any nerves I
had were
quickly eased
from the
moment I
booked in at
Reception.”
July 2012
Our audit programme for 2012/13 was agreed by the Board and
the Medical Advisory Committee. The programme included clinical
and non clinical audits and was be linked into any incidents/
adverse events that may have occurred and we also demonstrated
the learning that took place as a result.
13
Fairfield Independent Hospital Quality Accounts 2012/2013
Key Achievements
“The most
pleasant
hospital stay
that I have
ever
experienced. “
October 2012
5.2.2 Leadership and training
The executive team headed by the CEO continue to access
Continuing Professional Development and other opportunities
relevant to their roles including membership of other charitable
boards and accessing short secondments in the NHS.
The Board of trustees attend various external courses and also
attend in-house training with regards to topics such as Risk
Management and Productive Series. The Heads of Department
attend Board meetings as part of their continued professional
development.
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. The links with the Universities
and the education system remains strong, the hospital has
recently allocated a placement for a student undertaking an
Operating Department Practitioner qualification.
5.2.3 Listening and acting on patients views/patient satisfaction
No organisation can stand still and we are continually reviewing
how we provide our services.
Our managers routinely audit how
patients flow through the system by shadowing patients, with their
consent, and ‘walking in their shoes’. We have done some work
with patients regarding their emotional journey through theatre as
we realise that this is a very anxious time for all patients. The
results indicated that most patients were Happy, Reassured,
Comfortable and Informed at all stages. Some patients felt
Anxious, Nervous or Afraid from the point of admission to actually
going to theatre. Seven patients commented that they had pain,
and two patients felt confused in recovery.
Fairfield Independent Hospital Quality Accounts 2012/2013
14
Key Achievements
We have introduced hourly care rounds. This ensures that
patients are seen on a regular basis and their needs assessed
and any questions answered.
All patients in the recovery ward have their pain score documented and analgesia is given if indicated via the scoring system.
All of our patient questionnaire responses are reviewed by the
CEO on a daily basis which means our results are in real time
and any actions that are needed can be taken quickly. We are
delighted that patients rate our services highly. The results for
2012/13 are as shown below:



99% of the patients rated the cleanliness of the Hospital as
very good or excellent.
99% of patients rated the overall standard as very good or
excellent.
100% of patients would recommend the Hospital to a friend
or family member.
5.2.4 Stakeholder Engagement
It is very important that we seek out patients’ views in ‘real time’.
As well as our own internal questionnaire we also do ad hoc
audits where members of the team speak with patients, ask
questions about how their experience has been, if we are getting
it right and if there could be any improvements.
We obtain the views of our consultants and discuss areas of
good practice and concerns via the Medical Advisory Group
(MAC). 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 they also advise on development opportunities for
the Hospital and implementing new initiatives based on best
practice. We have been fortunate that the numbers of MAC
members has increased during 2012/13 and for each speciality
we have a lead consultant.
5.2.5 Quality
Our core values compliment the increased emphasis from all of
our commissioners on the need to evidence and demonstrate our
15
Fairfield Independent Hospital Quality Accounts2012/2013
“As always, I
it’s such a
pleasure to
know that you
are always in
safe hands at
this wonderful
hospital. The
staff are very
professional
and friendly,
putting you at
ease from
entering to
leaving the
Hospital.
Thank you so
much.”
September 2012
Key Achievments
“I have 20
years
experience
working in
hospitals. This
is the best
treatment that
I have ever
had and the
best hospital
that I have
been in.”
commitment to the provision of quality services. We strongly
believe that the quality of the clinical and non clinical services
that we provide allows us to demonstrate this. Our patients tell
us about how they feel we have treated and cared for them and
the results of this ‘real time‘ feedback is excellent.
5.2.6 Infection Control
Our infection control performance continues to be excellent and
something we are all very proud of. During 2012/3 we have
continued to maintain our average monthly infection rate at
below one percent. We continue to maintain our zero rates for
MRSA, MSSA, C Difficile infection organisms. Our hand washing
compliance audits show 100% compliance across the Hospital.
5.2.7 Refurbishments/Capital Programme 2012/13
Work to meet the capital programme during the year has been
continuing. The following major works have been completed:



February 2013



In December 2011/January 2012 the Hospital replaced its
Ultra Clean Ventilation System in Theatre One. The cost
was £135,000.
Two new operating tables were purchased for the operating
theatres. The cost was £55,000.
Two new anaesthetic machines were purchased for the
operating theatres. The cost was £62,000.
New medical equipment has been purchased throughout the
Hospital and includes general items such as instrument
upgrades, medical trolleys, medical mobile lighting, blood
pressure monitors, operating saw for lower limb surgery and
patient trolleys have also been purchased. The total spend
in 2012 is approximately £50,000.
A programme of converting existing en-suite bathrooms into
wet rooms has commenced.
A replacement for the cold air chilling unit for the operating
theatres was installed. Project cost was £63,000.
5.2.8 Staff Survey
In 2012/13 we carried out a formal staff survey. The overall
response rate for the survey was 42%. A number of reasons
where given for not responding including not enough time to
complete, couldn’t be bothered, nothing would happen with the
results.
Fairfield Independent Hospital Quality Accounts 2012/2013
16
Key Achievements
The senior team will devise actions within their individual
departments to try and encourage a better response during
2013/14.
When staff were asked if they would recommend the hospital to
a family member or a friend, 97% of those who responded said
they would.
5.2.9 Productivity and Efficiency
During 2012/13 we have continued with the work on reducing our
cost base and making sure that we utilise our resources to their
maximum effect. We have further enhanced what we identified as
priority areas in 2012/13 with other elements which became a
condition under our NHS contract terms.
We have continued to use the tools from the ‘productive
environment’ to eliminate waste from what we do and how we do
it. This has led to a more efficient use of all hospital resources.
Some examples are as follows:






Inventory of all surgical instruments
Surgical site marking in line with WHO requirements
Organisation of stock and better systems for stock control
including ordering
More effective rostering of staff so that shifts are more
aligned to clinical activity and that time can be allocated
more effectively for continuous professional development and
other training
Use of available technology to ensure that patient discharge
summaries are with their respective GPs within 24 hours of
discharge
Better use of our patient administration system in order to
provide monitoring and reporting to our Board and
commissioners.
Where there are reductions in the prices paid to us from any of
our commissioners in 2012, we in turn have had to reduce what
we pay out. Working with an evidence based approach, we are
now in a far better position to determine what is profitable and
what is not. We will continue with this approach as we do need
to ensure that we remain profitable and that all new services that
are proposed for introduction are assessed in terms of what they
can bring to the organisation.
17
Fairfield Independent Hospital Quality Accounts 2012/2013
“I have to say
that I have only
praise for all
the staff who
have been
involved with
my treatment
and recovery.
I have felt safe
and very well
cared for. It’s a
truly calming
atmosphere, a
lot of compassion and a love
for the job that
they do. Also
the meals were
excellent.
Thank you so
much.”
January 2013
Key Achievements
“Very professional in all
aspects of
the nursing
process.
Theatre staff
and Doctors
are a credit
to the
Hospital.
Overall
excellence
achieved.”
June 2012
In 2012/13 based on our Business Plan for the year, we widened
our medical services to include granting practising privileges to
consultants from other hospitals not traditionally associated with
Fairfield.
During 2012/13 we have rolled out our pre operative assessment
clinic. The role of pre op cannot be underestimated as it is
crucial in preparing patients for their surgery, ensuring that they
are fit for surgery and that if there are any problems, they can
be dealt with in a timely fashion. During the pre operative
assessment phase we have been providing public health advice
and support for those patients who for example perhaps wish to
give up smoking and signposting patients to the most appropriate
services.
Contracts with suppliers have been renegotiated and savings of
over £30,000 have been achieved.
Out theatre utilisation throughout the year was on average 89%.
This has given us a good baseline on which to set targets for
2013 and beyond.
During the year we have introduced a scheme whereby we ring
patients directly to agree a date and time of their inpatient procedure. This cuts down on missed appointments, unnecessary
paperwork being produced and patients being able to make the
necessary arrangements to cover child care, work absences, etc.
well in advance of their procedure date.
We have introduced speciality specific Saturday minor procedure
clinics, which have proved very popular with patients. These
clinics will continue in 2013/14.
We increased the number of patients that we treated either in
a day case or out patient setting from 91% to 92% as a
proportion of all procedures.
Fairfield Independent Hospital Quality Accounts 2012/2013
18
Key Achievements
5.2.10
Regularly Reported Indicators
Total numbers
in period
1 Apr 2012 to
31 Mar 2013
%
Inpatient mortality
0
0
Peri-operative mortality
0
0
Unplanned readmissions within 28 days
8
0.2
Unplanned returns to theatre
2
0.05
Unplanned transfers to another hospital
2
0.05
Mortality within 7 days of discharge
0
0
Pulmonary Embollism
0
0
Deep Vein Thrombosis
1
0.025
Surgical Infection Rate
0
0
MRSA blood cultures
0
0
MRSA positive blood cultures
0
0
Indicator
5.2.11 Prescribed Information
The indicators detailed below have been included by the Department of Health as part of the suite of information that should be
included in the 12/13 Quality Accounts. Some of the information
is not yet routinely available for the independent sector, the
source of the data has therefore been identified in the results
column.
NHS Outcomes Framework
Domain
Indicator
Results
1. Preventing people from
dying prematurely
a) Summary hospitallevel mortality indicator
0% (in house data)
b) The percentage of
0% (in house data)
patient deaths with palliative care coded
19
Fairfield Independent Hospital Quality Accounts 2012/2013
“I was treated
very well in
the short time
that I was
there and
have found no
faults
whatsoever.”
June 2012
Key Achievements
“I have been
very well
looked after;
everyone has
been very
kind and
friendly and
very helpful”.
April 2012
NHS Outcomes
Framework Domain
Indicator
Results
*Helping People to
recover from episodes of ill health or
following injury.
1. Patient reported outcome
measures (PROMS)
a) groin hernia
surgery
b) varicose vein
surgery
c) hip replacement
surgery
d) knee replacement
surgery
Participation rate
12.1%
No data in period
101.3%
96.9%
*It should be noted that 2. The percentage of patients
the only full year data
aged 15 and over readmitted
available is for the
to the hospital within 28 days
period 01.04.11-31.03.12
98.1% of hip replacement patients reported
joint related improvements following their
operation. The figure
for knee replacement
was 93.3% of patients.
Ensuring that people
have a positive
experience of care
1. Personal needs data from
Health and Social Care
Information Centre.
National data not
available. In-house
questionnaire results
detailed on Page 13
2. The percentage of staff
employed in the reporting
period who recommend the
hospital as a provider of care
to their friends and family.
97% (in-house data)
1. Percentage of patients who
were admitted to hospital and
who were risk assessed for a
venous thromboembolism.
100%
2. Case of C-difficile reported.
0%
3. Rates of patient safety
incidents and the number of
such incidents that resulted in
severe harm or death.
0%
of being discharged.
Treating and caring
for people in a safe
environment and
protecting them from
avoidable harm
Fairfield Independent Hospital Quality Accounts 2012/2013
20
Priorities for 2013/2014
6. KEY PRIORITIES 2013/14
During 2013/14 we have identified the following:
6.1 Clinical Effectiveness
Information
We will provide as much information to outside organisations/
individuals including GP practices and patients via a secure
service. This will mean that GPs will have discharge summaries
and letters promptly and that patients can be given information
electronically, if they so wish, and can be reminded of their
appointment times.
We will use the information that we have available to us in a more
structured way in order to make better informed decisions about
what we do and how we do it.
We will ensure that our information governance is robust and that
we continue to meet all the required standards with regard to
information management and security.
Clinic utilisation
We will set a base line target for usage of out outpatient clinic
environment. and monitor performance against that target to reduce
any areas of inefficiency. Occasionally there are clinic pressures
on certain days and these need to be managed more effectively.
Not only should there be an improvement in clinic utilisation but
the patient experience should also be enhanced.
Increase uptake of Patient Reported Outcome Measures (PROMS)
Working with our consultants and patients we will increase our
PROMs uptake in groin hernia and varicose veins to a participation
rate of at least 80%. It is vitally important that outcomes are
monitored for the cohort of patients currently identified as part of
the PROMs programme. This will include staff training so that our
staff understand the need for the feedback which in turn can be
passed on to patients who enquire about the questionnaire when
they are asked to complete it pre operatively.
21
Fairfield Independent Hospital Quality Accounts 2012/2013
“A brilliant
service from
top to bottom.
I would highly
recommend
this hospital
and would use
it again if
required.”
October 2012
Priorities for 2013/2014
“An excellent,
efficient
hospital. I
was treated
with dignity
and respect
at all times.
The staff was
helpful and
professional.”
October 2012
Development of enhanced radiology and scanning facilities
To implement a radiology information system across the
organisation that allows images to be exchanged via a secure
portal, allows GPs to book directly and have results transmitted
via a secure portal. To provide statistics for onward transmission
to commissioners.
6.2 Patient Safety
Implement recommendations of Francis report
Working with our NHS Commissioners, ensure that the relevant
recommendations of the Francis report are embedded into the
culture of the organisation. Ensuring that the Board of trustees
are aware of their role and that there are measures in place to
treat patients in an open and transparent environment.
Medicines Management
To further reduce the risks of medication errors across the
Hospital by promoting the safe use of injectable medicines. This
will include specific risk assessment for each department and
detailed information on the correct preparation of individual
drugs.
To review procedures and process in place to ensure the safe
and effective ordering and use of medicines.
Decontamination
To replace the existing facility for processing and cleaning all
scopes within the Hospital. The current facility, whilst fit for
purpose, will not accommodate increased provision/capacity.
Therefore, a more efficient, cost effective facility will be
commissioned and installed on site.
Workforce
We will strengthen our leadership across the organisation that it
is not just fit for today but also for tomorrow. We will, via our
recruitment process, ensure that our workforce are competent,
motivated and effective and that they are patient focused.
Fairfield Independent Hospital Quality Accounts 2012/2013
22
Priorities for 2013/2014
We will ensure that all staff within the Hospital have training and
development plans that are specific to their job role. This will
include a mixture of external and internal training, accredited
training and qualifications and continued professional development
over and above mandatory and statutory training.
6.3 Patient Experience
Friends and Family test
A large element of the Hospital’s CQUIN for 13/14 focuses on the
Friends and Family test. Via the test, regular real time feedback
from patients will be consistent, monitored and reported in a far
more structured way than previous.
We will act on the results of the test if there are areas identified
that need improvement or further action.
Workforce
We will ensure and monitor that our staff are competent for the
role they have been employed to do and that they act with
kindness, thoughtfulness and compassion.
More flexibility built into services
To ensure that we offer a range of appointment times to suit
patients and that wherever possible we offer multiple appointments
on the same day such as pre operative assessment, scanning, etc.
Facilities
We will continue to improve and update our facilities through our
renovation/improvement programme. We will improve our access
to diagnostics.
6.4 Further Development Areas 2013/14
Governance

23
We will improve our methods of monitoring our performance
against Care Quality standards. We will continually update
and demonstrate evidence in our Care Quality Commission
compliance assessment files to ensure that we are compliant
Fairfield Independent Hospital Quality Accounts 2012/2013
“Excellent
caring staff.
If only all
hospitals
were like this
one. Thank
you all.”
May 2012
Priorities for 2013/2014
with the standards. If we identify areas where we are not
compliant, we will ensure that there are clear action plans in
place that enable us to move to compliance quickly.
“It was an
extremely
professional
and trusting
experience.
I was treated
with utmost
respect and
dignity. It
was a faultless

We will continue to develop our governance framework by the
introduction of further policies and procedures through the ISO
framework.

We will ensure that all current polices are reviewed and
amended in line with changes in requirements or in accordance with our policy review timetable.

Complete our audit programme for 2013/14 as agreed by the
Board and the MAC. The programme will include clinical and
non clinical audits and will be linked into any incidents/
adverse events that may have occurred and also demonstrate
the learning that we would expect to see as a result. The
Chief Nurse and Director of Hospital Services will continue to
complete six monthly clinical and non clinical audits across
the Hospital.

We will undertake Root Cause Analysis scenarios with senior
staff at least twice yearly.

We will continue to build up our Risk Register. Updating the
Board bi annually and reporting incidents bi monthly.
experience.”
May 2012
Refurbishments/Capital Programme
The following items form the programme for 2013/14:
A full review of the type of sterilisation equipment required to
clean the Hospital scopes is required as well as finding a
facility with clear dirty and clean segregation is required.
Budget allocation of £150,000.
 Creation of a flexible orthopaedic/general suite on the ground
floor will be considered, working in partnership with the
Hospitals consultants. Capital requirement will depend on
equipment, location, etc.

The programme to replace and upgrade the Hospital’s IT
equipment will be undertaken. Budget allocation of £35,000.

Fairfield Independent Hospital Quality Accounts 2012/2013
24
Priorities for 2013/2014







The ultrasound machine in X-ray will need to be replaced.
Budget allocation of £75,000.
Change the main entrance to the Hospital and extend doors.
Budget allocation of £25,000
Upgrade theatre doors within the operating theatre.
Budget allocation of £25,000.
Upgrade boilers in the old theatre plant room.
Budget allocation of £60,000.
General upgrade of theatre equipment throughout the
Hospital. Budget allocation of £50,000.
Replacement of windows in Elizabeth House.
Budget allocation of £40,000.
Renewable energy sources will continue to be monitored for
feasibility. If a project is found to add significant value to
the business and contribute to realistic savings then a business case will be developed in order to raise capital to do it.
Efficiency
We will continue to renegotiate contracts with our suppliers in
order to get best value and the best deal for the Hospital.
Utilisation across the Ward and Theatre areas will be reported to
the Board and we will set targets, once a baseline has been
established, to improve our utilisation or to redesign specific areas
and services in order to increase throughput and utilisation.
We will consider the best way to utilise our pharmacy provision
and look to explore other options for provision of pharmaceutical
services to Fairfield.
6.5 Financial Security
The Charity must consider how services are to be provided in the
future to reduce the overall cost of provision and obtain sustainable long term financial stability. This will be done in a staged
way and will include a number of initiatives that will act as
enablers for cost reduction.
We will look to target specific groups of the population in order
to promote the Hospital and make people aware of the services
that we provide.
25
Fairfield Independent Hospital Quality Accounts 2012/2013
“My hospital
experience at
Fairfield
Hospital was
wonderful. I
would like to
praise and
thank everyone involved
in taking care
and making
my time here
pleasant.”
March 2012
Priorities for 2013/2014
“It is a very
friendly and
professional
environment
to have a
hospital stay.
It is difficult to
suggest
improvements
as everything
was excellent.
Thank you.”
March 2013
The demand for our services from the NHS and our other market
may well go up and down in the coming year. However, it is
vital that we are flexible enough to respond to these changes.
Where the NHS is actually restricting access to certain services,
we will look to capitalise on these restrictions by working with our
consultants and offering competitively priced packages of
affordable care.
We will consider, by broadening the range of the services we can
offer, how we can make a further contribution to improving health
in the area and consolidate our financial position in the local
health economy.
6.6 Partnerships
We will look to building and strengthening our existing partnerships. We will also develop new ones. We have seen the
emergence of CCGs in 12/13 and we will explore with the CCGs
new ways of doing things. Whilst 2013/14 is highly unlikely to
see radical changes, it is becoming clearer what the new commissioners want and how they want it providing. The Executive Team
will need to ensure that they are ‘connected’ to what is happening
in and around the catchment area.
This will involve many different forms of communication both to
and from the practices. We will continue to support the NHS
when it requests us to carry out work on a sub contractual basis.
In 2012/13 we established some good relationships with
neighbouring NHS Trusts and the work that we have done for
them has been beneficial to us and has provided positive
outcomes for patients. In 2013/14 we will respond to ad hoc
requests to carry out extra work when we can but it will be:



at a cost that offers us a realistic margin
takes up any spare capacity we may have
is not detrimental to the efficiency and high standards of the
Hospital.
Fairfield Independent Hospital Quality Accounts 2012/2013
26
Priorities for 2013/2014
We will establish a new partnership with an MRI provider and
hopefully this will be the start of a meaningful business relationship that will benefit our patients in the future. The face of
imaging services is changing and we need to take a proactive
approach. With new techniques coming on stream we will need to
ensure that we have the right provisions in place to enable us to
deliver the service ourselves or to commission the service from an
accredited provider.
6.7 Marketing and Communication
Our new website was launched in October 2012. As part of the
work that was undertaken we ensured that the new site would be
mobile device ‘friendly’.
In 2013/14 we will develop our marketing activities. Using the
following target groups, we will put in place actions against each
area and monitor our success. The four strands are:




The public who are or may become patients – the message
for this group is that we are here as an independent
hospital and so our main target is to raise familiarity with
them and emphasise our cleanliness, location and
accessibility.
The GPs who need to know about the clinical services we
can provide, how to access them and the follow-up service
we provide for their patients and the way we manage the
information flow.
The commissioners from the public and private sector – who
need to know what we do, how much we charge and how
we can meet their service requirements.
The medical profession more generally – who will provide our
next generation of consultants and the partnerships which
will use our services or refer patients to us as part of their
own treatment plans.
Whilst some elements of our service, for example our low infection
rates and our standards of cleanliness, will be core elements of
our promotion to all these strands, each of the four will require a
different focus, plan and action.
27
Fairfield Independent Hospital Quality Accounts 2012/2013
“I have used
this hospital
as a private
patient since
1981. Today
I was an NHS
patient and
the treatment I
have received
has been of
an equal
standard.
Thank you.”
November 2012
Priorities for 2013/2014
“It’s almost a
pleasure to
have an
operation here!
There was
excellent
service and
medical
treatment.”
April 2012
Our communications activity is key to our plans and is a building
block on which we realise we must do more work. To this end
we will ensure that we:







6.8
produce a quarterly staff newsletter
produce a quarterly GP/primary care newsletter
keep the website regularly updated and refreshed and analyse
the monitoring data that is available on number of people
accessing the site
continue to monitor and respond to patient comments and
suggestions as appropriate, including more feedback to
patients along the lines of “you said,” “we did”
have a least two joint meetings during 2013 between the staff
and the CEO
ensure we meet at least once a year with all the major
private commissioners
develop links with patient groups so we can identify where we
can develop our role as a significant healthcare provider in
the area.
Fundraising and Alternatives
During 2013/14 we will capitalise on the work that commenced in
2012 to raise our profile and raise much needed funds for
specific investment for the hospital. With the 40th anniversary of
the Charity taking place in 2013 there is an opportunity to
capitalise on our celebrations and make them memorable.
We have established a steering group to oversee the activities the
objectives being:



to celebrate 40 years of quality healthcare in this community
widen the awareness and raise the profile of Fairfield
raise funds to improve our diagnostic facilities and capacity
Fairfield Independent Hospital Quality Accounts 2012/2013
28
Priorities for 2013/2014
7.
CONCLUSI0N
We do believe that delivering high quality care is not a choice we
choose to make, it’s part of everything we do here at Fairfield.
As part of our programme of continuous improvement we aim to
provide information and transparency in how our organisation is
performing.
The NHS landscape continues to change and that presents us with
both challenges and opportunities, differentiating ourselves as a
not-for-profit organisation offering the best outcomes for those
patients who choose to come here - something we never forget.
We have a role to play in prevention and have taken measures to
include health and lifestyle interventions and support as part of
our patient pathways.
We recognise we still have a long way to go - with increases in
technology, different ways of providing services and pressure from
consumers and commissioners alike, it is certainly not going to
be easy. We do feel we are on the right track and that the
culture and ethos of the organisation that is already in place
provide sound building blocks on which we can move the
organisation forward.
29
Fairfield Independent Hospital Quality Accounts 2012/2013
“I don’t think
anything needs
improving. I
had excellent
treatment and
care. Thank
you.”
March 2013
Schedule 1 CQUIN - Targets and
Achievements 2012/2013
Target
Outcome
Venous thromboembolism
All eligible patients
(VTE)
to receive a VTE risk assessment
Achieved
VTE prophylaxis in accordance with NICE guidance
Achieved
Patients given care and advice on VTE
Achieved
Completion of Root Cause Analysis for patients who
have DVT or Pulmonary Embolism
One patient suffered a DVT and the RCA
was completed
Participation in national safety thermometer monitoring Achieved
Equality and Diversity
Improve accessibility and deliver the right services
Achieved - adjustments in how we provide
our services are made if required
Ensure workforce is representative of patients it
services
Achieved
Ensure workforce is skilled in delivering equality
agenda
Various policies and procedure in place.
All staff receive induction training and
further training on E&D
Public Health
Smoking Status of all patients at Pre-Operative Assessment
Achieved
Brief Intervention to all appropriate patients at PreOperative Assessment
Achieved
Additional Support discussed with patients
Patients who request further support are
offered advice and contact details
Discharge Planning
Timeliness of completion of the discharge
summary: 90% discharge summaries to be sent back to
the GP within 24 hours
Achieved
98% of Discharge Letters to be received by patients’ Achieved
GP within 2 weeks of discharge and to contain the
Minimum Dataset for OPD letters.
Discharge Planning - 95% of patients to receive a
copy of their discharge summary on day of discharge
Achieved
Please note awaiting formal confirmation
achievement by CCG
of
Fairfield Independent Hospital Quality Accounts 2012/2013
30
Statements from external
sources
1.
LOCAL OVERVIEW & SCRUTINY PANEL
Cheryl Nolan
Chief Executive
Fairfield Independent Hospital
Crank
St Helens
Merseyside
Health and Adult Social Care Scrutiny Panel
Town Hall
Victoria Square
St Helens
Merseyside
WA10 1HP
15th June 2013
Dear Cheryl
Re: St Helens Health and Adult Social Care Overview and Scrutiny Panel
Quality Account Commentary 2012/13 – Fairfield Independent Hospital
Thank you for submitting your Quality Accounts for 2012/13 and for your
attendance at the Health and Adult Social Care Overview and Scrutiny
Panel on 10th June 2013. Our comments are as follows:
On behalf of the Scrutiny Panel and Healthwatch St Helens, I would like to
confirm that the Quality Accounts have been thoroughly explained and it
is my belief that they present an accurate overview of the organisation’s
performance during the year, particularly around Patient Safety, Patient Experience and Clinical Effectiveness. The report was extremely easy to
read and this was welcomed by all members of the Panel.
We note that there are very few complaints made about services and that
a score of 100% in the Friends & Families test is indicative of patients
and the public experiences of treatment at the Trust.
There have been no SUIs, cases of C.Difficle or MRSA, which shows infection control
procedures e.g. hand washing are fully adhered to; however at last year’s presentation,
this was explained as also due to the slower nature of the Trust’s work compared to an
acute hospital with multiple wards and visitor footfalls plus. Fairfield Trust is also able to
swab all patients before their elective surgery and postpone treatment where any infection is detected, so that infections do not enter the hospital.
31
Fairfield Independent Hospital Quality Accounts 2012/2013
Statements from external
sources
A reduction of the average length of stay will maintain low levels of hospital acquired
infections and enhance the patient experience further. Work on the emotional journey of
patient having surgery is also to be commended; tackling anxiety of patients could improve
their recovery.
A slight concern noted by the Panel was the staff comments regarding their noncompletion of the in-house survey and that ‘things wouldn’t change’. We support attempts
by the management to improve staff survey return rates by allowing time to complete the
survey within working time and incentives for the best participating department, which still
enables the people replying to be anonymous.
We note the ratio of NHS funded to private or mutual society work has remained the
same as last year (60% : 40%) and were assured that there was never a clash of
priorities. We note the Trust is seeking to develop its charitable status particularly with
community fundraising and now employs a part time fundraiser to assist with this.
Clinical record keeping errors have improved significantly from 84% 2011-12 to 95%
2012-13 – Fairfield might wish to describe what good practice was used to achieve this in
the document and then this be shared with other Trusts via personnel at NHS England
Local Area Team.
Healthwatch also acknowledges changes to the design of patient questionnaires and
asking about ‘changing one thing’ which have led to improvements in facilities for patients
e.g. appropriate bins and wifi access. Also the provision of outpatient services on
Saturdays will enhance access of the service.
In summary the Panel was pleased to receive the Quality Accounts for 2012/13 and looks
forward to maintaining positive partnership working with Fairfield Independent Hospital.
Yours sincerely
Councillor Anthony Burns
Chairman of Adult Social Care and Health Overview and Scrutiny Panel
Fairfield Independent Hospital Quality Accounts 2012/2013
32
Statements from external
sources
2.
33
CLINICAL COMMISSIONG GROUP COMMENTS
Fairfield Independent Hospital Quality Accounts 2012/2013
St. Helens
Fairfield Independent Hospital
Crank
St Helens
Merseyside
WA11 7RS
www.fairfield.org.uk