Claremont Hospital
Quality Account
for 2013-14
Contents
Welcome to Aspen Healthcare
3
National Awards During 2013-14
5
Statement on Quality from the Chief Executive Aspen Healthcare
6
Introduction to Claremont Hospital
Vital Stats
8
Statement on Quality
Accountability Statement
9
Quality Priorities for 2014-15
Patient Safety
Clinical Effectiveness
Patient Experience
10
tatements of Assurance S
Review of NHS Services Provided 2013-14
Participation in Clinical Audit
National Confidential Enquiry
National Clinical Audits
Local Audits
Participation in Research
Goals Agreed with Commissioners
Statements from the Care Quality Commission
Statements on Data Quality
Quality Indicators
12
Review of Quality Performance for 2013-14
Patient Safety
Clinical Effectiveness
Patient Experience
23
External Perspectives on Quality of Service
29
Welcome to Aspen Healthcare
Aspen Healthcare Hospitals and Clinics locations:
Claremont Hospital is 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.
Aspen Healthcare is the proud operator
of four acute hospitals, a cancer centre, and
three day-surgery hospitals in the UK.
Aspen Healthcare’s current facilities are:
•Cancer Centre London
Wimbledon, SW London
•The Chelmsford
Chelmsford, Essex
•The Claremont Hospital, Sheffield
•The Edinburgh Clinic, Edinburgh
•Highgate Private Hospital
Highgate, N London
•Holly House Hospital
Buckhurst Hill, NE London/Essex
•Midland Eye, Solihull
•Parkside Hospital
Wimbledon, SW London
Aspen Healthcare’s facilities cover a wide
range of specialties and treatments providing
consulting, diagnostic and surgical services,
as well as state of the art oncological
services. Within these eight facilities,
comprising over 250 beds and 17 theatres,
in 2013 alone Aspen has delivered care to:
• Almost 36,000 patients who were
admitted into our facilities
• More than 26,000 patients who required
day case surgery
• More than 10,000 patients who required
inpatient care
• More than 215,000 patients who attended
for outpatient care.
Aspen is now one of the main providers of
independent hospital services in the UK, and
through a variety of contracts provided over
11,000 NHS in-patient/day case episodes
of care and 44,000 outpatient consultations
last year. We work very closely with other
healthcare providers in each locality including
GPs, Clinical Commissioning Groups and
NHS Acute Trusts to deliver the highest
standard of services to all our patients.
Cancer Centre London
The Chelmsford
Claremont Hospital
The Edinburgh Clinic
Highgate Private Hospital
Holly House Hospital
Midland Eye
Parkside Hospital
It is our aim to serve the local community and
excel in the provision of quality acute private
healthcare serves in the UK. We are pleased
to report that in 2013 four out of five of our
patients in our hospitals that provide inpatient
services rated the overall quality of their care
as “excellent,” with 98% “extremely likely”
or “likely” to recommend the Aspen hospital
visited.
Across Aspen we strive to go ‘beyond
compliance’ in meeting required national
standards and excel in all that we endeavour
to do. Although every year we are happy
to look back and reflect on what we have
achieved, more importantly we look forward
and set our quality goals even higher to
constantly improve upon how we deliver
our care and services.
We have delivered this care always with
Aspen Healthcare’s mission statement
underpinning the delivery of all of our
care and services.
MidlandEye
Specialists in complete eye care
Our aim 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
4
National Awards During 2013-14
During 2013 Aspen Healthcare was pleased to receive
national recognition for their innovative and quality focussed
care and services.
2013 Laing & Buisson Independent Healthcare Awards
Category Winners
Category Finalists
ealthcare Outcomes – “demonstrating
H
evidence of genuine improvements in
outcomes through the provision of high
quality coordinated programmes of patient
care, education, research and advocacy”:
Nursing Practice – “recognising outstanding
nursing practice and its effect on patient
experience”:
• Holly House Hospital for the
development of their stress management
programme, “The Calm Choice”,
improving outcomes for patients
suffering neck and shoulder pains,
jaw pain, and low back pain.
Medical Practice – “recognising outstanding
examples of medical practice which has
positively impacted on patient treatment
and care”:
• The Cancer Centre, London for the
development of a new rehabilitation
pathway for neuro-oncology patients
which reflects a holistic and
multi-disciplinary approach to support
patients during their radiotherapy
treatment for brain tumours.
• The Claremont Hospital for the
development of innovative out-reach
pre-admission assessment clinics.
Experienced Sisters and Charge Nurses
from the Claremont pre-admission
assessment team take their service
to a local hospital to carry out
pre-admission assessment checks
and discuss co-morbidities saving
patients travelling long distances on
repeated occasions in preparation for
their forthcoming hospital admission.
Management Excellence – “recognising
a manager or executive and their high
expertise in their field in making the most
effective contribution towards the success
of a team, unit, or company in the last
12 months”:
• The Group Clinical Director for the
development of a bespoke model
which rigorously aligns all elements
of governance and clearly demonstrates
Aspen’s commitment to excellence
and quality.
Statement on Quality from the
Chief Executive Aspen Healthcare
We are pleased to provide this Quality
Account for Claremont Hospital. This is
our annual report to the public and other
stakeholders about the quality of services
we have provided over the last year and
also, importantly, to look forward and set
out our plan of quality improvements
for the following year.
Aspen Healthcare 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. The new quality
framework we introduced last year,
centred on nine drivers of quality and
safety, is now well embedded across our
business and helps us ensure that quality
is incorporated into every one of our
hospitals/clinics and that safety, quality
and excellence remains the focus of all
we do whilst delivering the highest
standards of patient care.
This Quality Account presents our
achievements in terms of clinical
excellence, effectiveness, safety and
patient experience and demonstrates
that our managers, clinicians and staff
at Claremont Hospital are all committed
to providing continuous, evidence based,
quality care to those people we treat.
It provides a balanced view of what
we are good at and where additional
improvements can be made.
The experience that patients have
in all our hospital/clinics is of the
utmost importance to Aspen and
we are committed to establishing an
organisational culture that puts the patient
at the centre of everything we do. We aim
to keep developing our initiatives around
quality and safety to ensure we are able
to bring further benefits to 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 2013/14 – NHS and private.
Pride of Britain Awards 2013
Lifetime Achievement Award - “recognising
an individual whose achievements have
been far-reaching, possibly on a national
or international level”:
Two doctors at the Cancer Centre, London,
Professor Trevor Powles and Professor Ray
Powles received this highly prestigious award
for their work in cancer and research. Their
work has saved thousands of lives in Britain
and around the world.
Des Shiels
Chief Executive, Aspen Healthcare
“A very restful place to have an operation and a quiet, calm
atmosphere to recover in”
Mrs B H. Sheffield
5
6
Introduction to Claremont Hospital
Claremont Hospital has been at the heart of
the South Yorkshire community providing first
class healthcare for 60 years. The hospital is
situated in large landscaped grounds to the
south west of Sheffield.
The hospital was originally founded by the
Sisters of Our Lady of Mercy, a religious
institute which relocated from Ireland to
Sheffield in 1883. The original hospital was
opened in 1921 on a different site in Sheffield
and moved to its current location in 1953.
Having seen many changes through the
years, Claremont Hospital is proud to be part
of Aspen Healthcare Group since December
2011 and already over £1.5M has been
invested. The hospital welcomes patients
whether publicly funded by the NHS or
privately funded. We continue to work hard
to protect our reputation for high quality care
and we are proud of our excellent cleanliness
and hygiene standards and our long standing
record of no known cases of hospital acquired
infection, such as MRSA.
Vital Stats
Total beds
40
X-ray
Critical care beds
4
Private GP service
Operating theatres
3
Satellite clinics
Consulting Rooms
15
Choose and Book
Endoscopy suite
Free parking
Pathology laboratory
Accept all major insurers
Physiotherapy
Consultant delivered service
Pharmacy
24/7 Resident Medical Officer
MRI
CT
Ultrasound
• £334,795 of capital in facilities and new equipment during 2013/14
• Investment planned during 2014/15 includes, installing new diagnostic equipment including
a CT scanner, relocation and development of a new endoscopy unit, continued refurbishment
of existing facilities, and, realignment of non-clinical areas to create more coherent clinical
space to enhance the user experience.
“The care, attention and
friendliness I encountered
here was nothing short of
exceptional”
Mrs B H. Sheffield
7
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Statement on Quality
Claremont Hospital is pleased to provide this, our second, Quality Account which we
trust helps to demonstrate our continued commitment to Quality and Safety.
This Quality Account allows us the
opportunity to convey an honest, open and
accurate assessment of the quality of care
our patients received during 2013/14 and
we trust the content will provide confidence
and assurance for all our future patients
on our ability to deliver safe, effective, and
personalised care for all. Our commitment
remains to provide best quality, deliver
best practice and achieve best outcomes
in everything we do. Most importantly,
our priority is to reflect our commitment
to providing the highest quality healthcare
services which deliver safe, effective and
personalised care, in the experiences of
our patients.
During the past year we have tracked and
measured our progress objectively against
the three domains of patient safety, clinical
effectiveness, and patient experience. This
has enabled us to identify areas we need
and we desire to improve. We have made
good progress in driving forward our quality
initiatives helped immensely by the level of
engagement of our staff and the ownership
of our teams. We have continued to evolve
our new quality governance framework and
actively monitored all information, outcomes
and feedback we receive as it is only by
listening and hearing what our patients tell
us that we can hope to be as responsive
as possible to any changes in values,
expectations and perceptions and ensure our
services deliver best practice all of the time.
Many of the improvements we have
made during the past year are evidenced
by our performance indicators included
throughout this report. In addition we have
also expanded our electronic incident
reporting system; continued to evolve our
Risk Register; introduced Skills for Health
e-learning for all staff; and are publishing
outcome data in compliance with the Private
Healthcare Information Network [PHIN].
None of which would be possible without
the concerted efforts of our dedicated
and valued staff.
As well as focussing on 2013/14 this
Quality Account also allows us to look
towards the forthcoming year and to set
out our plan of priority improvements
for 2014/15. There is always room for
improvement and our plans have largely
been driven and identified by listening to our
patients, our consultants and our staff. We
are committed to working in partnership with
a variety of parties, including the NHS, to
realise closer working arrangements which
bring about more general benefits to people
requiring healthcare. We will continue to work
closely with our Consultants in designing
future services ensuring that GP’s and other
commissioners can refer patients to us easily
and in the knowledge that they will receive
high quality, appropriate care.
Accountability Statement
To the best of my knowledge, as requested
by the regulations governing the publication
of this document, the information in this
report is accurate.
This report has been reviewed and
approved by:Chris Blundell, Medical Advisory Committee
Chair, Claremont Hospital
Des Shiels, Chief Executive Officer,
Aspen Healthcare
Andrew Davey, Hospital Director, Claremont
Hospital
9
Judi Ingram, Clinical Director,
Aspen Healthcare
10
Quality Priorities For 2014-15
The National Quality Account guidelines require us to identify at least three priorities
for improvement during the coming year. We have a number of quality and safety
initiatives planned for the forthcoming year and the following information focuses
on the key priorities that have been determined by our senior management team.
These have been informed by feedback from our patients and staff, audit results,
national guidance and recommendations from the various hospital/clinic teams
across Aspen Healthcare.
Our quality priorities will be reviewed at our
Quality Governance Committee which meets
quarterly to monitor, manage and improve
the processes designed to ensure safe and
effective service delivery. Regular reporting
on these priorities will also be provided to
the Group Quality Governance Committee,
to Aspen’s Executive Team and Board
of Directors, and also the commissioners
of NHS services.
Claremont Hospital is committed to delivering
services that are safe, of a high quality, and
clinically effective, and we constantly strive
to improve our clinical safety and standards.
The priorities we have identified will,
we believe, continue to drive the three
domains of quality - patient safety, clinical
effectiveness and patient experience:
•P
atient Safety
This is about improving and increasing the
safety of our care and services provided
•C
linical Effectiveness
This is about improving the outcome
of any assessment, treatment and care
our patients receive to optimise patients
health and well-being
• P
atient Experience
This is about aspiring to ensure we exceed
the expectations of all our patients.
The key quality priorities identified for 2014 -15 are as follows:
Patient Safety
ocus on further embedding a positive
F
Patient Safety Culture
A positive safety culture underpins the
improvement of patient safety. How our
staff perceive the importance of safety and
have confidence in our safety systems and
processes is vital to this. We will build upon
last year’s assessment of our safety culture
and work with our staff to actively promote
a positive safety culture and undertake a
further more detailed survey in autumn
2014 to assess our progress.
Patient Safety Leadership Training
To support our staff in consistently providing
high quality and safe care to our patients
we will further develop their understanding
in how this is integral to their everyday work
and start to roll out bespoke Patient Safety
Leadership Training. Having staff that are
empowered to lead on patent safety will
make a tangible difference to improving
patient safety at the frontline of care delivery.
Review of Nurse Staffing Levels
Having the right number of staff, with the
right skills, in the right place, at the right time,
will help ensure that appropriate numbers of
skilled nursing staff are available to care for
our patients safely. We will implement tools
that will help us to objectively assess this and
determine how many nursing staff and with
what skill mix is required. This will include
consideration of the typical dependency
of our patients and the amount of time
each individual requires.
Clinical Effectiveness
Patient Experience
Patient-led Assessments of the Care
Environment
We will register in 2014/15 to take part
in the national programme of patient-led
assessments of the care environment
(PLACE). A clean, safe and therapeutic
environment of care matters to our
patients. These assessments involve local
people coming into our hospital as part
of teams to assess how the environment
support’s patient privacy and dignity,
patient nutrition, cleanliness, and general
building maintenance. PLACE assessments
will provide motivation for improvement by
providing a clear message, directly from
patients, about how our hospital environment
or services might be enhanced.
Intentional Nurse Rounding
We will implement a model of intentional
nurse rounding which will involve our staff
carrying out regular and systematic checks
on our patients at set intervals. This will
improve our patients’ experience of care,
build their trust further, and help ensure that
care is safe and reliable. Evidence has shown
that it offers patients greater comfort, and
helps to ease any anxieties thus improving
their experience of our care. These rounds
will be in addition to our routine care delivery,
complementing our existing procedures, and
will enhance our quality assurance framework
for care.
Care Planning Documentation
High standards of patient documentation
support communication and decision
making about our patient’s care and is
vital to ensuring the continuity, safety, and
effectiveness of patient care. A review will
be undertaken of the quantity, quality and
style of patient care plan documentation
and any revisions required will be made to
enhance the quality of our clinical records.
Pre-operative Assessment
Our pre-admission assessment team helps to
ensure that our patients are fit and prepared
for surgery and, where appropriate, are
assessed in advance of their admission to
reduce the chance of their operation being
cancelled for safety or clinical reasons.
In 2014/15 work will be undertaken to
review our assessment and documentation
processes and develop a revised care
pathway that continues to meet best practice
and further supports the provision of
effective patient care.
Review of Patient Information
Our patients need to be properly informed
so that they can share in decisions about
their care and treatment. We will undertake
a review of the information we provide to
our patients and ensure that this is accurate,
impartial, evidence based and well written.
This will help to ensure our patients have
accurate expectations of any procedure, have
an improved understanding of their diagnosis
and treatment options, and support improved
after-care compliance helping to improve
patient satisfaction.
Staff Satisfaction
Our staff satisfaction results are very
important to us as satisfied, well trained and
competent staff will help to ensure patient
safety and a good experience of care. A staff
satisfaction survey is currently undertaken
every two years and is bench marked against
the other Aspen UK hospitals and clinics. We
believe that ‘satisfied staff means satisfied
patients’ and we will hold regular staff forums
to address areas for improvements identified
in the last survey.
“This was my second
operation at this hospital. On
each visit I find the staff and
conditions to be outstanding”
Mrs R H. Sheffield
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12
While targeting the above areas, we will continue to:
• Strive to further improve upon all our quality and safety measures
• Continue with our programme of development relating to other quality initiatives
• Continue to develop our workforce to ensure they have the skills to deliver high quality care
in the most appropriate and effective way
• Embed our 2014/15 Commissioning for Quality and Innovation (CQUIN) initiatives so they
become ‘business as usual’, and work to implement any locally agreed CQUIN’s with our
commissioners
• Meet and exceed the Quality Schedule of our NHS Contracts.
Statements of Assurance
Relating to the quality of NHS services provided
This section of our Quality Account provides the mandatory information for inclusion
as determined by Department of Health regulations, and reviews our performance
over the last year between April 2013 and March 2014 but reported in June as
required by the guidelines.
Review of NHS Services Provided 2013-14
Participation in Clinical Audit
Between April 2013 and March 2014, there
were no national confidential enquiries and 4
national clinical audits covered NHS services
that Claremont Hospital provides.
During that period Claremont Hospital
participated in 100% of national clinical
audits and 100% of national confidential
enquiries of the national clinical audits and
national confidential enquiries which it was
eligible to participate in.
The national clinical audits and national confidential enquiries that Claremont Hospital
was eligible to participate in during April 2013 to March 2014 are as follows:
National Clinical Audit of in-hospital cardiac arrests
National Joint Registry – hip, knee and ankle replacements
National Joint Registry – shoulder and elbow
Patient Related Outcome Measures [PROMS] –
hip replacement, knee replacement, hernia, varicose veins
NHS Blood Transfusion – audit of patient information
and consent
Between April 2013 and March 2014, Claremont Hospital provided the following
NHS services:
Anaesthetics [pain management]
Neurosurgery [spinal]
Ear Nose and Throat
Ophthalmology
General Surgery
Orthopaedics
Gynaecology
Urology
Claremont Hospital has reviewed all the data available to them on the quality of care
in all of these NHS services
The income generated by the NHS services reviewed in 2013/14 represents 100% of
the total income generated from the provision of NHS services by Claremont Hospital for
the year April 2013 to March 2014.
“All the staff I came into
contact with were excellent
ambassadors for Claremont”
Ms S W, Sheffield
13
14
Local Audits
The national clinical audits and national confidential enquiries that Claremont Hospital
participated in, and for which data collection was completed during April 2013 and March
2014, are listed below alongside the number of cases submitted to each audit or enquiry
as a percentage of the number of registered cases required in terms of that audit or enquiry.
National Clinical Audits
Name of Audit
National Clinical Audit of inhospital cardiac arrests
National Joint Registry
National PROMS programme
NHS Blood Transfusion
Participation
Yes
Yes
Yes
Yes
Number of cases submitted
(% of total NHS activity)
No submissions were made as
no cardiac arrests occurred.
721 submissions [91%]
409 [8.2%]
5 [83%]
The published reports from the national clinical audits were reviewed by the provider in April
2013 to March 2014 and Claremont Hospital intends to take the following actions to improve
the quality of healthcare provided:
•An enhanced recovery programme for patients following joint replacement orthopaedic
surgery has been introduced during the reporting period. The aim of an enhanced recovery
programme is to mobilise patients as soon as possible after surgery, wherever it is safe and
viable to do so. Such an approach has many benefits for the patient including:- improving
circulation; reducing chest infections; and, helping the patient to start gaining confidence
to move and put weight through the operated joint The enhanced recovery programme
is complimented by physiotherapy led group classes post discharge.
•To continue to increase the participation rate in the Patient Reported Outcome Measures
[PROMS] programme. Asking patients about their health and quality of life before an
operation and then asking about their health and the effectiveness of the operation
afterwards, gives us very useful information and helps us to measure and improve
the quality of care we deliver.
•To maintain the competency assessment of all staff involved in blood transfusion practices
so as to optimise the safety, quality, and effectiveness of blood transfusion and to ensure
safe standards of acknowledged best practice are maintained. Training in blood transfusion
practice now forms an integral part of annual mandatory training for the relevant disciplines
of staff.
“There is no way to improve the procedure
as I was given all the information I required
and all my questions were answered”
The following local clinical audits were reviewed by Claremont Hospital during April 2013 and
March 2014. Most of the audits were undertaken at least 2 or 3 times within the reporting
period, some more frequently:
Venous Thromboembolism (VTE)
Blood Transfusion Compliance
Record Keeping
Physiotherapy
Pathology
Diagnostics
Patient Falls
Resuscitation
Controlled Drugs (CD)
Information Governance
Patient Consent
HII Hand Hygiene
Surgical Site Safety Checklist
HII Urinary Catheter
Infection Prevention - environment
HII Peripheral intravenous device
HII Surgical Site Infection
Levels of compliance can be viewed in the table on page 25. 53 reports from the above
local clinical audits were reviewed by the provider between April 2013 and March 2014.
Claremont Hospital has taken/intends to take the following actions to improve the quality of
healthcare provided:
•We will be reviewing and enhancing our Care Pathway documentation to ensure it continues
to comprehensively evidence care delivered and supports record keeping.
•Our Venous Thromboembolism Risk Assessment form has been reviewed and revised
by a multidisciplinary team to support changes in practice which continue to be reflective
of national guidance
•The flow charts and other associated documentation pertaining to our Falls Policy has
all been revised and implemented to reflect best practice guidance
•Our Surgical Site Safety Checklist, which continues to be based on the original World Health
Organisation document, has been revised and implemented to support and enhance the
recording of safe perioperative practice
•We will aim to increase the number of patients receiving a duplicate copy of their operation
consent form at consultation so that they are in possession of all the relevant information
they need to fully consider the implications and make an informed decision prior to their
scheduled admission date.
•We have successfully extended our Infection Prevention Link Practitioner training programme
beyond the ward, theatre and outpatient departments to expand the available level of
specialist knowledge and skills within our Physiotherapy and Diagnostic departments.
Mr R B, Derbyshire
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Participation in Research
Statements on Data Quality
There were no patients receiving NHS services provided or sub-contracted by Claremont
Hospital between April 2013 and March 2014 that were recruited during that period
to participate in research approved by a research ethics committee.
Claremont Hospital takes Data Quality very
seriously and recognises that good quality
information is fundamental to the effective
delivery of patient care and is essential if
improvements in quality of care and value
for money are to be realised.
Goals Agreed with Commissioners
A proportion of Claremont Hospital income
in April 2013 to March 2014 was conditional
on achieving quality improvement and
innovation goals agreed between Claremont
Hospital 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 April 2013 to March
2014 and for the following 12 month period
are available electronically at:
http://webarchive.nationalarchives.gov.uk/*/
http://institute.nhs.uk
Statements from the Care Quality Commission
All standards were met when the service was inspected
Claremont Hospital is required to register with
the Care Quality Commission and its current
registration is “fully compliant”. Claremont
Hospital has no conditions imposed against
its registration
The Care Quality Commission has not taken
enforcement action against Claremont Hospital
during April 2013 and March2014.
Claremont Hospital has not participated in
any special reviews or investigations by the
Care Quality Commission during the reporting
period.
Our Information Governance policies continue
to inform our standards of record keeping
which support and evidence the delivery of
care and treatment. Records are regularly
monitored for accuracy, completeness,
and legibility, providing timely identification
of quality issues and any remedial steps
required.
The Information Governance Toolkit is a
performance assessment tool produced
by the Department of Health. It 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 securely.
Aspen Information Governance Toolkit
Assessment Report for 2013-14 was
67% and graded green achieving level
2 in all categories and meeting national
requirements
Claremont Hospital will be taking the
following actions to improve data quality:
• Continued investment in and development
of the Aspen Group Patient Administration
System [PAS] to improve data capture
• Ongoing review and revision of data
collection processes to support CQUIN
requirements
• Continued development of the Pharmacy
stock control and label production system
to improve audit data
17
• Development of a suite of exception
reports to enable the Administration
Manager to identify and action data gaps
in a timely manner
• Continue to embed new administrative
procedures, particularly at reception desks,
to ensure patient data is accurate at all
times
• To gain greater clarity of outcomes
between PAS and mandatory Secondary
User Service [SUS] fields by upgrading
to CDS version 6.2
• To identify proportionate dedicated
resources to improve the “referral to
treatment” [RTT] data capture for all
patients
Secondary Uses System (SUS)
Claremont Hospital submitted records
between April 2013 and March 2014
to the Secondary User Service for inclusion
in the Hospital Episode Statistics which
are included in the latest published data.
The percentage of records in the published
data which included the patient’s valid NHS
number was:
• 100% for admitted patient care
• 100% for outpatient care
and which included the patient’s valid
General Medical Practice Code was:
• 100% for admitted patient care
• 100% for outpatient care
Clinical Coding Error Rate
Claremont Hospital was not subject to the
Payment by Results clinical coding audit
between April 2013 and March 2014.
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Quality Indicators
Number of admissions risk assessed for VTE
Source: CQUIN data
As required by the national reporting requirements pertaining to Quality Accounts,
the indicators in the table below represent the core set of indicators relevant to the services
Claremont Hospital provides.
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2013-2014
Claremont Hospital considers that this data is as described for the following reasons:
• This is data recorded in the hospital’s Patient Administration System in real time
• All unplanned readmissions of patients to Claremont Hospital generate a hospital incident
report.
Actions to improve quality:
Preventing potentially avoidable readmissions is our aim. Each incident report is reviewed
by experienced clinical managers regarding the reason for readmission. Where lessons can
be learned action plans are implemented and cascaded throughout the hospital. The hospital
also works closely with partners in the wider Health and Social Care Community.
2013-2014
Claremont Hospital considers that this data is as described for the following reasons:
Many cases of VTE [venous thromboembolism] acquired within healthcare settings are
preventable through effective risk assessment and prophylaxis. During the past year we have
reviewed and revised our VTE risk assessment form, Care Pathway documentation, and
medication chart to ensure that as much support as possible is available to staff to ensure
all our patients have a VTE risk assessment completed. Continuous surveillance is undertaken
via an ongoing clinical data capture audit process. A set of notes found to be devoid of a
VTE risk assessment form is immediately investigated and action taken as appropriate. This
key indicator forms an integral part of our corporate governance reporting structures and
appropriately receives high priority.
Number of Clostridium difficile infections reported
Source: Public Health England returns
2012-2013
0
2013-2014
0
• This data is provided by Public Health England from hospital returns
Source: Family and Friends Test
98.5%
98.5%
Claremont Hospital considers that this data is as described for the following reasons:
Responsiveness to the personal needs of patients
2012-2013
2013-2014
Actions to improve quality:
Source: Care Quality Commission
3
97.6%
• This is data recorded in a timely manner in the clinical audit section of the hospital’s Patient
Administration System.
Numbers of people 15 years and over readmitted within
28 days of discharge
2012-2013
2012-2013
98.5%
Claremont Hospital considers that this data is as described for the following reasons:
• This data is collected via patient survey questionnaires and collated by an independent
company.
Actions to improve quality:
Patient experience is a key measure of the quality of care delivered. We have implemented
Worldhost® training for all of our staff. This has reinvigorated and refreshed our approach
to being more responsive to the needs of our patients all of the time. In addition to the 5
areas measured through the National Inpatient Survey we are also focussing on maintaining
high levels of responsiveness to essential areas of care – controlling pain, assistance to go
to the toilet, being treated with dignity and respect, and, providing good nutritional support.
• This data is collected in real time within the hospital through a system of continuous
infection surveillance.
Actions to improve quality:
Our Infection Prevention and Control Programme has a dedicated section relating to
Clostridium difficile infections. Our aim is to maintain our zero reporting rate.
Number of patient safety incidents which resulted in severe harm
or death
Source: Claremont Hospital Incident Reports
2012-2013
1
2013-2014
1
Claremont Hospital considers that this data is as described for the following reasons:
• All events relating to patient safety are reported via our electronic incident reporting system
“A very pleasant stay helped by everyone’s
kindness, understanding and friendliness –
a credit to you all”
Mr F S, Sheffield
19
• All incident reports are routinely reviewed by senior managers.
Actions to improve quality:
We will continue to encourage incident reporting at all levels and disciplines. During 2013
we commenced work to strengthen our Safety Culture. We will continue to build on this during
the coming year – undertaking a hospital wide Safety Culture audit, sharing the results, and
implementing an action plan to drive further improvements in this area.
20
Other Indicators
2012/13
Summary hospital-level mortality indicator
This indicator measures
whether the number of
people who die in hospital
is higher or lower than
expected. This data is
not currently collected
and analysed across the
independent sector
Number of people 15 years and over readmitted within 28
days of discharge from hospital
2013/14
3
7
98.5%
98.5%
Family and Friends Test – the percentage of Claremont
Hospital staff who would be happy to recommend this
hospital to a friend or relative due to the standard of care
provided by this hospital
No data
collected in
this reporting
period
94%
Family and Friends Test – the percentage of Claremont
Hospital patients who gave an overall rating of “excellent”
or “very good” for the quality of their care
No data
collected in
this reporting
period
Responsiveness to the personal needs of patients
98.5%
Patient Reported Outcome Measures [PROMs].
PROMs assess the general health improvement of patients from the patient’s perspective.
PROMs currently covers four clinical procedures and calculates the health gains using pre
and post-operative questionnaire surveys.
**Due to the nature of the data collection nationally, there is a time lag to publishing and
hence the reporting years of this section differ to the rest of the report.
**2011/12
**2012/13
91.3%
88.2%
[87.4% nationally]
[87.9% nationally]
83%
100%
[78.4% nationally]
[79.7% nationally]
Hip replacement surgery:
% of respondents who recorded an increase in
their EQ-5D index score following operation
Knee replacement surgery:
% of respondents who recorded an increase in
their EQ-5D index score following operation
Groin hernia surgery:
No data available
No data available
as numbers
as numbers
of procedures
of procedures
statistically too small statistically too small
No procedures
performed
No data available
as numbers
of procedures
statistically too small
Pre-operative response rate for all four
procedures
91.5%
87.4%
Post-operative response rate for all four
procedures
91.4%
67.7%
Varicose vein surgery:
Hip replacement surgery: 88.2%
of respondents recorded an
increase in their EQ-5D index score
following operation
[87.9% nationally]
Knee replacement surgery: 100%
of respondents recorded an
increase in their EQ-5D index score
following operation
[79.7% nationally]
“There is a true sense of
team work at this hospital –
thank you”
Mrs A D, Sheffiled
21
22
Review of Quality Performance
for 2013-14 (previous year)
This section reviews our progress with Aspen Healthcare’s key quality priorities
as identified in last year’s Quality Account (2013/14).
Patient Safety
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 (an
improvement tool for measuring, monitoring
and analysing patient harms and ‘harm free’
care over a period of time) will be completed
on a monthly basis for all relevant patients and
submitted centrally to the Health and Social
Care Information Centre.
Progress:
A safety culture survey was undertaken in
autumn 2013. Overall response rates across
Aspen Healthcare were 75% with staff rating
patient safety as “excellent”, “very good” or
“good” at 83%. Work to continue to promote
a positive safety culture will continue into
2014/15.
Actions taken at Claremont Hospital as a
consequence of this result include:
•To ensure feedback is cascaded to all
grades and disciplines of staff within the
hospital regarding concerns that have been
raised/reported
•To review staffing establishments and
maintain assurance of safe staffing levels
•To routinely include Patient Safety
as a standing agenda item in all staff
meetings and communiques
•To implement a framework to support the
continued focus and development of a
mature safety culture across the hospital.
Progress:
All Aspen hospitals now complete and
submit information to the NHS National
Safety Thermometer which identifies
the number of pressure ulcers, patient
falls, urinary tract infections in patients
with a catheter in situ, and new venous
thromboembolism [pulmonary embolism or
deep vein thrombosis]. These four “harms”
are monitored by the Department of Health’s
Safe Care programme because they are
common and because there is a consensus
that they are largely preventable through
appropriate patient care. The measure of
these harms at the frontline of care delivery
aims to focus attention on patient safety.
During 2013/14 all our hospitals achieved
an overall score of 99-100% relating to
these indicators. Claremont Hospitals’ overall
score was 100%.
“Nothing was too much trouble. My stay
was comfortable and I was kept informed”
Mr K H, Sheffield
23
24
Theatre Accreditation Programme
We will implement an accreditation
programme to our operating theatre
environments across the Aspen Group aiming
to excel in perioperative practice.
Clinical Effectiveness
Progress:
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.
Progress:
This audit programme was fully implemented
across Aspen Healthcare in 2013/14. This
helped us identify areas for improvement
and actions were taken in each hospital to
address these.
This programme commenced in 2013/14
and has focussed on the accreditation /
credentialing of our theatres across Aspen
Healthcare. Assessments against recognised
national standards for perioperative practice
pertaining to patient safety and outcomes
have been made and this work will continue
into 2014/15. We have pledged to
benchmark all the 17 theatres within the
Aspen Group against these standards and
ensure 100% compliance by the end
of 2014.
The outcomes of the programme to date
reveal that our staff are really engaged in
the accreditation process, have developed
solutions to further improve their practices
and patient safety, have pride in achieving
external validation, and that the profile
of the perioperative environment has been
significantly raised.
Patient Experience
Claremont Hospital results across the range of audits can be seen in the table below:
Indicator
Venous Thromboembolism (VTE)
Record Keeping
Pathology
Patient Falls
Controlled Drugs (CD)
Patient Consent
Surgical Site Safety Checklist
Infection Prevention - environment
Transfusion Compliance
Physiotherapy
Diagnostics
Resuscitation
Information Governance
Hand Hygiene
Urinary Catheter Infection
Surgical Site Infection
Peripheral intravenous device Infection
No Hospital acquired Infections
for two years
25
Average score of % compliance 2013-14
94%
89%
90%
99%
87%
85%
91%
82%
97%
96%
98%
88%
93%
94%
100%
100%
92%
Safety Thermometer
score of 100%
Worldhost® Customer Care Training
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.
Progress:
The Worldhost® Customer Care Training
programme has commenced at all Aspen
Healthcare facilities. Five of our eight facilities
have now achieved Worldhost® accreditation
status demonstrating our commitment to
providing excellence in patient experience.
Claremont Hospital has achieved Worldhost®
accreditation and Worldhost® training will
now be included within the hospitals’ annual
mandatory training programme so as to
maintain the focus on delivering high levels
of customer care.
The table below illustrates patient feedback received between April 2013 and March 2014:
Indicator
2013-14
% of responses “excellent”
or “very good”
Your welcome on arrival/admission to Claremont
Hospital
Were you treated with consideration and courtesy by
your nurses
95%
98%
Friendliness/ helpfulness of housekeeping staff
94%
Friendliness/helpfulness of catering staff
95%
26
Inpatient Survey
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.
likely a patient is to recommend one of our
hospitals to friends and family if they needed
similar care or treatment. 98% responded
that they were “extremely likely” or “likely”
to recommend the Aspen hospital they
visited.
Progress:
Claremont Hospital remains totally focussed
on maintaining and monitoring the excellent
Friends and Family Test score we achieve
responding immediately to any adverse
comments by contacting the patient where
they have provided their details, and by
reminding our patients how important their
feedback is to us. Results from our Family
and Friends Test and our inpatient survey
can be seen below:
The inpatient survey tool was revised last
year to improve the collection of information
we receive from our patients on their
experience whilst at an Aspen hospital.
Four out of five of our patients in our
hospitals rated the overall quality of their
care as “excellent”. We were one of the first
independent hospital groups to implement
the national Friends and Family Test on how
Friends and Family Test April 2013 – March 2014
Indicator
2013-14
How likely are you to recommend our
hospital to friends and family if they need
similar care or treatment?
98.5%
In-Patient Satisfaction Survey
Indicator
Overall satisfaction with nursing care
[% “excellent” or “very good”]
Overall satisfaction with consultant
[% “excellent” or “very good”]
Overall satisfaction with the quality of care
[% “excellent” or “very good”]
2012-13
2013-14
99%
96%
100%
98%
98%
97%
“First class process/
treatment/care/staff
and environment”
Mr C P. Sheffield
27
28
External Perspective
on Quality of Service
What others say about our services
NHS Sheffield 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, managed under the
conditions of the NHS Standard Contract. 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.
NHS Sheffield CCG has had the opportunity to review and comment on the information in this
quality account prior to publication. Claremont Hospital has considered our comments and
made amendments where appropriate. The CCG is confident that to the best of its knowledge
the information supplied within this account is factually accurate and a true record, reflecting
the Hospital’s performance over the period April 2013 – March 2014.
The CCG supports the Hospital’s identified three Quality Improvement Priorities for 2014/15.
Priority 1 Patient Safety. The CCG welcomes the priority around reviewing nurse staffing
levels. This provides the CCG with assurance that Claremont are working in line with the very
latest recommendations arising from NHS National reviews.
Priority 2 Clinical Effectiveness/Priority 3 Patient Experience. The CCG is encouraged that
the following two areas of work are being identified: Pre-operative assessments and review
of patient information. The results of this will directly support the work moving forward into
2014/15 to achieve a new CQUIN indicator where the patients are to be mobilised within
24 hours of surgery. This mobilisation will improve patient recovery and experience.
Submitted by Beverly Ryton on behalf of:
Kevin Clifford
Chief Nurse
and
Rachael Hague
Contracting Lead
NHS Sheffield Clinical Commissioning Group
May 28th 2014
29
30
Healthwatch Sheffield
Healthwatch Sheffield are pleased to receive the draft Quality Account from Claremont
Hospital (part of the Aspen Healthcare Group) and offer the following comments on the
report.
We are pleased to note that patients seem to have had a positive experience and report high
levels of satisfaction amongst themselves and their friends and family. Claremont Private
Hospital remains focussed on maintaining this high standard by responding immediately to
adverse comments and reminding patients how important their feedback is. It is noteworthy
that NHS patients do seem to be afforded exactly the same levels of service as the private
patients and this is reflected in the overall levels of patient satisfaction, which remain
consistently high.
The quality priorities for 2014-15 are areas with which we would agree, and are pleased
to see that patient experience features strongly alongside clinical effectiveness and patient
safety. The investment in staff training in this area is to be commended, and we support
a review of nurse staffing levels. Healthwatch have taken part in this year’s PLACE
assessments, and would be willing to aid Claremont in their aim to take part in the 2014/15
round by offering volunteers who have experience of this process. Lastly, we are pleased to
note the inclusion of intentional nurse rounding, as this is an area that we see has notable
benefits for patient experience and indeed overall health.
Healthwatch Sheffield notes that the hospital lists areas of improvement following local audits
and data quality audits. We hope to be able to check on this progress through the next QAs
to see how these improvements have been implemented.
The report seems to indicate that good progress has been made in all of the previous year’s
goals set through the quality accounts process, and Healthwatch has no concerns about
these.
We would like to commend the hospital for what appears to be a thorough report highlighting
several areas of good practice in this year, and look forward to working with them throughout
the coming year.
Pam Enderby,
Chair, Healthwatch Sheffield
Claremont Hospital requested NHS Derbyshire Clinical Commissioning Group and NHS
England South Yorkshire and Bassetlaw Area Team to supply any comments they wished to
see included in our Quality Account. Prior to publication, no comments had been received
31
32
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.claremont-hospital.co.uk
www.aspen-healthcare.co.uk
Or call us on:
0114 2630330 Claremont Hospital
020 7977 6080 Head Office, Aspen Healthcare
Write to us at:
FAO The Hospital Director
Claremont Hospital
401 Sandygate Road
Sheffield S10 5UB
Aspen Healthcare Limited
Centurion House (3rd Floor)
37 Jewry Street
London EC3N 2ER