Midland Eye
Quality Account
for 2013-14
MidlandEye
Specialists in complete eye care
Contents
Welcome to Aspen Healthcare
3
National Awards During 2013-14
5
Statement on Quality from the Chief Executive Aspen Healthcare
6
Introduction to Midland Eye
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
18
External Perspectives on Quality of Service
23
Welcome to Aspen Healthcare
Aspen Healthcare Hospitals and Clinics locations:
Midland Eye 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 Midland Eye. 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
Midland Eye 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
5
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
6
Introduction to the Quality Account
for Midland Eye 2013-14
Located in Solihull, West Midlands, Midland
Eye is a private ambulatory surgery centre
providing specialist eye care and surgery.
The service was founded by four NHS teaching
hospital consultant eye surgeons who wished
to provide a broad range of high quality
general and specialised ophthalmic treatments.
In March 2012, Aspen Healthcare acquired
a majority shareholding and now works in
partnership with the consultants
and supporting team.
Midland Eye is pleased to offer to all patients
a consultant-led service with access to the
latest eye care technology.
Vital Stats
MidlandEye
Specialists in complete eye care
During 2013-14, Midland Eye provided for NHS patients:
• 7,883 Outpatient Consultations
• 1,113 Cases of Ophthalmic Surgery
Ophthalmic Consulting Rooms
with full diagnostic equipment
Ophthalmic laser room
3
State of the art Ophthalmic
operating theatre
Patient Recovery area
1
On-site free parking
Accept all major insurers
1
1
Satellites Services
- Ley Hill Surgery
- Cornwall house
- Cobridge Community Health
Centre
Choose and Book
• Latest ophthalmic equipment and technology
• Reduced waiting times for ophthalmology services across the local community
• Finalist for a national award in public private partnerships for providing community eye
services. (Health Institute Awards 2013)
7
8
Statement on Quality
Quality Priorities For 2014-15
Midland Eye is pleased to provide this first Quality Account.
National Quality Account guidelines require us to identify at least three priorities
for improvement. 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 both our patients and staff, audit results, national guidance and
recommendations from the various hospital/clinic teams across Aspen Healthcare.
We have aimed to provide an objective
indication on what has been achieved over
the last year and to identify where we want
to make improvements during 2014-15.
The delivery of a high quality service has
always been at the heart of our organisation
and Midland Eye is committed to providing
the best care for all patients. Our aim as an
organisation is to provide safe, effective and
personalised care to every patient, every day.
As part of Aspen Healthcare, we have a
well-established Integrated Governance
structure in place and a local framework
through which clinical effectiveness, clinical
incidents and clinical quality is monitored and
analysed. This allows us to identify specific
areas for us to concentrate on so that we can
make the necessary quality improvements
to our service on a timely basis. In addition,
at Group level the Quality Governance
Committee has an overview and ensures
that there is shared learning and quality
improvement across all of Aspen’s healthcare
facilities.
Through the dedication and professionalism
of all of our team, we consistently achieve
high levels of patient satisfaction. However,
the pursuit of quality is a constant journey
and so we are never satisfied or complacent
and always want to do better wherever
we can.
Midland Eye continues to have very low
levels of hospital acquired infection and has
had no MRSA, MSSA or C. difficile infections.
Accountability Statement
Midland Eye 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, drive the three domains of quality
- patient safety, clinical effectiveness and
patient experience:
• Patient Safety
This is about improving and increasing the
safety of our care and services provided
• Clinical Effectiveness
This is about improving the outcome of
any assessment, treatment and care our
patients receive to optimise patients health
and well-being
• Patient Experience
This is about aspiring to ensure we exceed
the expectations of all our patients.
Directors of organisations providing hospital
services have an obligation under the 2009
Health Act, National Health Service (Quality
Accounts) Regulations 2010 and the
National Health Service (Quality Accounts
Amendment Regulation 2011) to prepare
a Quality Account for each financial year.
This report has been reviewed and
approved by:-
The key quality priorities identified for 2014-15 are as follows:
Mr Tristan Reuser (Medical Advisory
Committee & Quality Governance Committee
Chairman, Midland Eye)
Patient Safety
This report has been prepared based on
guidance issued by the Department of
Health setting out these legal requirements.
Judi Ingram (Clinical Director, Aspen
Healthcare)
To the best of my knowledge, as requested
by the regulations governing the publication
of this document, the information in this
report is accurate.
Rachel Bradbury
Director of Clinics, Aspen Healthcare
9
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.
Des Shiels (CEO, Aspen Healthcare)
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 roles
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, 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.
10
Clinical Effectiveness
Patient Experience
Infection Prevention and Control ‘Deep
Dives’
‘Hello my name is and I am…’
While targeting the above areas, we will also continue to:
Providing compassionate care and building
therapeutic relationships often needs to
simply start with the right introduction. Every
member of staff who approaches any patient
for the first time will introduce themselves
and say ‘Hello. My name is ‘x’ and I am one
of the nurses/care assistants/managers
who will be looking after you today. How
are you feeling?’
• Strive to further improve upon all our quality and safety measures
Review of Patient Information
• Meet, and exceed, the Quality Schedule of our NHS Contracts.
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 patents 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.
Statements of Assurance
A clean and safe environment of care matters
to our patients. A comprehensive ‘deep dive’
assessment of our Infection Prevention and
Control (IPC) practices will be led by Aspen
Healthcare’s Consultant Nurse for IPC and
the Group Health and Safety Manager. The
aim of these visits is to complement our
existing audits that are in place and provide
an objective assessment of the clinical
practices of our staff and ensure compliance
with the Health and Social Care Act Infection
Prevention and Control Code of Practice.
Care Plans Documentation
High standards of patient documentation
supports communication and decision
making about our patient’s care and is
vital to ensure 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 ensure
improvements in the quality of our
clinical records.
Pre-operative Assessment
Our pre-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 meets best practice and further
supports the provision of effective
patient care.
• 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 CQUINs with
our commissioners
Relating to the quality of NHS services provided
This section of the Quality Account provides the mandatory information for inclusion
in a Quality Account, as determined by Department of Health regulations, and reviews
our performance over the last year (April 2013 to March 2014).
Review of NHS Services Provided 2013-14
Staff Satisfaction
Our levels of staff satisfaction 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.
During April 2013 to March 2014, Midland Eye provided ophthalmology NHS services and
has reviewed all the required data available to them on the quality of care.
The income generated by the NHS services reviewed in 2013-14 represents 100% per cent
of the total income generated from the provision of NHS services by Midland Eye for the
year ending 31 March 2014.
“I had anticipated this
procedure with extreme
trepidation but cannot
overstate the skill and
professionalism shown
by you all.”
Mr J L Stoke on Trent
11
12
Participation in Clinical Audit
National clinical audits are a set of national
projects that provide a common format
by which to collect audit data. National
confidential enquiries aim to detect areas
of deficiencies in clinical practice and devise
recommendations to resolve them.
Participation in Research
During 2013-14, there were no national
clinical audits or national confidential
enquiries that Midland Eye was required
to participate in for NHS ophthalmology
services.
Local Audits
During 2013, Aspen Healthcare implemented an annual clinical audit programme which
identified the topics and frequency of audit assessment.
Five clinical topics were periodically audited by Midland Eye during 2013-14, as
shown below:
Consent
Records Compliance
Medicines Management
Surgical Safety (WHO) Checklist
Infection, Prevention and Control (IPC)
The outcomes of all the local clinical audits were reviewed by Midland Eye and reported
through the local and group Quality Governance Committees. After each audit, areas
for improvement were identified thereby allowing for timely actions to be implemented.
The results of these audits in terms of compliance can be seen in the later section
‘Clinical Effectiveness’ (see page 20).
Midland Eye intends to take the following actions to improve the quality of healthcare
provided:
•Continue to periodically audit the same topics during 2014-15 aiming towards
100% compliance;
•To review the existing documentation to ensure that ophthalmic pathways are incorporated
within the records;
•To introduce an IPC Link role for Midland Eye to further improve the standards of IPC.
13
There were no NHS patients recruited during the reporting period for this Quality Account
to participate in research approved by a research ethics committee.
Goals Agreed with Commissioners
Use of the CQUIN payment
framework
Midland Eye’s income in 2013-14 was
not conditional on achieving quality
improvement and innovation goals through
the Commissioning for Quality and Innovation
payment framework because the contract
negotiated by the Clinical Commissioning
Group (CCG) did not have CQUIN goals
or payments associated with the service
provision.
Statement from the Care Quality
Commission
Midland Eye is required to register with the
Care Quality Commission (CQC) and is able to
provide the following regulated activities:
1. Treatment of disease, disorder or injury
2. Diagnostic and screening procedures
3. Surgical procedures
The CQC has not taken enforcement action
against Midland Eye during 2013-14 and
has not participated in any special reviews or
investigations by the CQC during the period
covering this report.
Midland Eye received an unannounced
inspection on 6th December 2013 and of
the five essential standards reviewed, four
were assessed as fully compliant with one
standard identifying a minor concern. This
was in relation to Outcome 14, ‘Staff should
be properly trained and supervised and have
the chance to develop and improve their skills’
where improvements in the documentation
of training and competency assessment
were required.
Midland Eye has agreed, and is completing,
an acceptable action plan with the CQC
to address the raised concerns and as at
31 March 2014, the following has been
implemented:
•Introduction of a new training and clinical
competency database;
•A competency assessment framework for
all clinical staff;
•E-learning (on-line) mandatory training,
where appropriate;
•An improved system for ensuring evidence
of training undertaken is available in all staff
files;
•1:1 supervision sessions on a periodic basis
for clinical staff;
•Regular monitoring of training and
supervision compliance.
Within the CQC report summary, the
inspectors noted:
We observed staff interacting with people
with dignity and respect. We spoke with five
people who used the service. Most were
very happy with their care and treatment, one
stated, “Superb treatment as always, was here
three years ago, standards still maintained
110% thanks to all.”
14
Statements on Data Quality
Quality Indicators
Midland Eye recognises that good quality information underpins the effective delivery
of patient care and is essential if improvements in quality of care and value for money
are to be made. We ensure that our Information Governance policies guide and inform
our standards of record keeping, supporting the delivery of care and treatment and
that accuracy, completeness and validity of those records are monitored on an ongoing basis to continually improve data quality.
The Department of Health has identified
a core set of quality indicators for inclusion
within the Quality Account.
or incident occurred so that steps can be
taken to reduce the risk of it happening
again.
Midland Eye considers that the data is as
described in this section as it is collated
on a continuous basis and does not rely
on retrospective analysis.
As Midland Eye provides outpatient and
day surgery services only, not all indicator
measures are applicable; however those
that are relevant are highlighted in the table
below:
Midland Eye will be taking the following
actions to improve data quality:
•M
idland Eye will implement Aspen
Healthcare’s patient administration system
(APAS), which will provide an improved
reporting system;
•A
ll staff will continue to receive annual
training relating to data quality and
information governance;
When anomalies arise, each one is reviewed
with a view to learning why an event
•A
n electronic reporting system has been
installed to record incidents, complaints
and accidents more accurately and to
permit analysis and review to inform further
improvements to patient care and services.
Responsiveness to the personal needs of patients
Source: Patient satisfaction telephone survey
2012-2013
Limited data
collected during
this period
98%
2013-2014
Secondary Uses System (SUS)
Clinical Coding Error Rate
Actions to improve quality:
Midland Eye commenced submission
of returns to the Secondary Uses System
(SUS) from 01 January 2014 for inclusion
in the Hospital Episode Statistics. These
are included in the latest published data.
Midland Eye was not subject to the Payment
by Results clinical coding audit during
2013-14 by the Audit Commission.
• Midland Eye will continue to monitor the patient experience through follow-up surveys.
Information Governance
To enable Midland Eye to submit to SUS we
have introduced the Aspen APAS IT system
over the last 12 months - this has allowed
connectivity to SUS and so we are now
able to run regular reports to ascertain and
check that the data submitted is that of the
required standard.
The Information Governance Toolkit is a
performance assessment tool, produced
by the Department of Health, and is a set
of standards that organisations providing
NHS care must complete and submit
annually by 31 March each year. The toolkit
enables organisations to measure their
compliance with a range of information
handling requirements, thus ensuring that
confidentiality and security of personal
information is managed safely and effectively.
Percentage of Midland Eye Staff who would recommend their service
to Family and Friends
From January – March 2014, the percentage
of records in the published data which
included the patients’ valid NHS number was:
• 100% for outpatient care
And which included the patients’ valid
General Medical Practice Code was:
• 100% for outpatient care.
15
•M
idland Eye will work closely with the local
Clinical Commissioning Groups (CCGs) to
further ensure accurate data sharing;
Aspen Healthcare’s Information Governance
Assessment overall score for 2013-14 was
67% and graded ‘Green’, achieving level
2 in all categories and meeting national
requirements.
• During 2014, a new Outpatient survey is to be introduced.
Source: Staff Survey
2012-2013
No data
collected during
this period
2013-2014
100%
Actions to improve quality:
• Midland Eye will continue to seek staff views on an informal on-going basis and on a
more formal basis every 2 years through a staff survey.
Responsiveness to the personal
needs of patients - 98 %
Percentage of Midland Eye Staff who
would recommend their service to
Family and Friends - 100%
16
Percentage of Patients who would recommend Midland Eye to Family
and Friends
Source: Patient satisfaction Survey
2012-2013
No data
collected during
this period
2013-2014
No data
collected during
this period
Actions to improve quality:
•M
idland Eye intends to collect this information during 2014-15 as part of the new
outpatient survey
Number of clostridium difficile infections reported
Source: Public Health England returns
2012-2013
0
2013-2014
0
•M
idland Eye will continue with the regular monitoring and auditing of infection prevention
& control practices
Number of patient safety Incidents which resulted in severe harm
or death
Source: Local Incident Reporting
0
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 (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:
Actions to improve quality:
2012-2013
Review of Quality Performance
for 2013-14 (previous year)
2013-2014
2
Actions to improve quality:
• A comprehensive review with root cause analysis is undertaken for all such incidents. The
investigation findings led to an improvement in the processes for lens selection and in
the management of rejected lens injectors, and enhancements have been made to the
existing systems for safety checks. The incidents were not related and did not result in poor
outcomes to either patient’s vision.
A safety culture survey was undertaken
in autumn 2013. The overall response rate
across Aspen Healthcare was 75%, with
Midland Eye 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.
Within the results of the staff survey
for Midland Eye (ME), there was 100%
agreement regarding the following
statements:
• If you had a concern that could harm
staff or patients or were concerned about
negligence or wrong doing by staff or
consultants at ME would you feel able
to report your concerns?
• My supervisor/manager seriously considers
staff suggestions for improving patient
safety
• Staff are able to freely speak up if they
see something that may negatively affect
patient care
“I wake up every day now
saying “wow”. The colours
and clarity are amazing and
I cannot thank you enough
for restoring my vision.”
• The actions of the ME management show
that patient safety is a top priority
• Customer/patient care is the top priority
for my department and facility
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, and new venous hromboembolism
(pulmonary embolism or deep venous
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 measurement 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.
Although the NHS Safety Thermometer
applies to acute care inpatient services,
Midland Eye does risk assess all patients
over 65 years of age who may be at risk
of having a fall. During 2013-14, Midland
Eye assessed 100% of all patients who fell
within this category.
• Overall, I believe that ME provides excellent
service to its patients.
Mrs P H from Stoke on Trent
17
18
Infection Prevention and Control
Infection prevention and control (IPC) continues
to be an on-going and high priority for Midland
Eye. During 2013-14, considerable work has
Infection
MRSA positive blood culture
MSSA positive blood culture
E. Coli positive blood culture
C. Difficile infection
Endophthalmitis
Clinical Effectiveness
continued in terms of staff education and
IPC audits, resulting in extremely low infection
rates, as indicated in the table below:
2012-13
0
0
0
0
0
2013-14
0
0
0
0
1
PROGRESS:
All patients attending Midland Eye for surgery/treatment are advised regarding hygiene,
post-operative care and instillation of eye drops prescribed. This is consolidated with printed
information that patients take home. Any suspected case of Endophthalmitis is investigated
and the case for 2013-14 was found to be linked to a common foot infection and probable
cross-infection by the patient.
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.
These audits helped us identify areas for
improvement and actions were taken in each
hospital and clinic to address these.
The main audits in the programme included:
• Patient falls
• Venus thromboembolism (risk assessment
and prophylaxis)
Indicator
Record Keeping
Medicines Management
Patient Consent
Surgical Site Safety Checklist
Hand Hygiene
Sharps handling and disposal
Decontamination of equipment
IPC Management, Clinical Practice & Education
Operating Theatre IPC compliance
• Patient Consent
• Patient care records/documentation
standards
• Controlled Drugs management
• Surgical Safety Checklist Completion
• Diagnostics – Standards for Reporting
MRI Scans
• Pathology
• Physiotherapy Record Keeping.
Whilst not all of the above audit topics are
applicable to Midland Eye, the relevant ones
were undertaken two to three times during
the year.
The results can be seen in the table below:
Average score of % compliance
2013-14
74%
90%
89%
88%
87%
100%
100%
94%
100%
Several actions have been taken to improve compliance with record keeping, including the
review of discharge information, printing of patient labels and the updating of staff signatory
sheets. All the audit results have provided areas to focus on for improvement and the last audit
result for the full completion of the Surgical Site Safety Checklist achieved 100% compliance.
“Thank you for the kind and
professional treatment I received
yesterday. I am very happy and amazed
by the clear vision. Well done!”
Mrs M E from Solihull
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Theatre Accreditation Programme
We will implement an accreditation
programme to our operating theatre
environments across the Aspen Group aiming
to excel in perioperative practice.
Progress:
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 is 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
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:
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.
Worldhost® training has recently
commenced at Midland Eye and the plan
is to roll out this programme by the end
of June 2014.
The Worldhost® Customer Care Training
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.
Progress:
The inpatient survey tool was revised last
year to improve the information we received
from our patients on their experience whilst
at an Aspen hospital. Four out of five of our
patients in our hospitals rated their overall
quality of their care as excellent. We were
one of the first independent hospital groups
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Complaints
Whilst Midland Eye strives to provide
consistently excellent care and services,
there are occasions when service users
have reason to complain. Every complaint is
considered a valuable source of feedback
Indicator
Number of complaints
(written and verbal)
% per 100 admissions
and information on how our services can
be improved. All complaints are investigated
and any opportunity for learning or service
improvement acted upon.
2012-13
2013-14
n/a
53
n/a
0.36%
to implement the national Friends and Family
Test on how likely a patient is to recommend
our hospitals to friends and family if they
needed similar care or treatment. 98%
responded that they were extremely likely
or likely to recommend the Aspen hospital
they visited.
Progress:
Although Midland Eye does not provide an
inpatient service, feedback is obtained by
a telephone discussion with the patient. This
method is much appreciated by the patients
and during the reporting period 98% stated
that they found the quality of care to
be excellent, very good or good.
• The introduction of clinic templates to improve the organisation of appointment bookings,
with some clinics starting later in the day and finishing earlier in the winter evenings
to ensure appointments are kept to time as much as possible
Changes have been made throughout the year in response to issues raised by complainants
and these include:
• Designated Lead Nurses have been assigned to specific specialist clinics to improve
the patient pathway and experience
• The introduction of an off-site facility which deals with NHS services and has extended
opening times to ensure there are timely responses to patients.
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External Perspective
on Quality of Service
What others say about our services
Commissioner statement for Midland Eye
This statement is from Solihull CCG as commissioners of the Midland Eye. This is the first
Quality Account from the provider as part of Aspen Healthcare Group.
Overall this report is a good reflection of the in year assurance that we as commissioners
have received in regards to the quality of services provided. We note the improvement in
systems for the reporting and analysis of incidents and would welcome the provider sharing
the specifics of learning from these incidents going forward, as has been demonstrated in
the report through the management of complaints process. We acknowledge the CQC report
from the unannounced visit and would encourage the provider to share the action plan
with commissioners as part of ongoing assurance monitoring.
Safeguarding
The commissioner undertook a visit to the provider in respect of safeguarding procedures
in particular the Mental Capacity Act and obtaining consent and provided improvement advice
for process and documentation for the handover of the safeguarding portfolio to the Aspen
safeguarding professional. The commissioner would have liked to have seen reference to
the safeguarding procedures within the provider account.
Provider priorities 2014/15
The commissioner acknowledges the provider focus on the safety culture of the organisation.
In addition we are pleased to see the focus on the patient experience and welcome the
planned implementation of the “Hello, my name is...” campaign.
The Commissioner welcomes the opportunity to comment on this report and reflect the
activity in year. We look forward to working collaboratively in 2014/15.
Midland Eye requested their key NHS Commissioners within Stoke- on-Trent and North
Staffordshire to supply them with any comments they would like adding to our Quality
Account. Prior to publication, no comments had been received.
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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.midlandeye.com
www.aspen-healthcare.co.uk
Or call us on:
0121 711 2020 Midland Eye
020 7977 6080 Head Office, Aspen Healthcare
Write to us at:
Midland Eye
50 Lode Lane,
Solihull,
West Midlands B91 2AW
Aspen Healthcare Limited
Centurion House (3rd Floor)
37 Jewry Street
London EC3N 2ER