Parkside 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 Parkside 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
13
Review of Quality Performance for 2013-14
Patient Safety
Clinical Effectiveness
Patient Experience
21
External Perspectives on Quality of Service
27
Welcome to Aspen Healthcare
Aspen Healthcare Hospitals and Clinics locations:
Parkside 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 Parkside 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
Parkside 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
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 Parkside Hospital
Parkside Hospital was established in 1983
and is an independent hospital located in
Wimbledon, London. The hospital offers
services to patients who require both
elective and emergency surgical, medical
and oncological treatments. The hospital has
85 beds (5 High Dependency beds), with
associated diagnostic and treatment facilities
to offer an holistic service.
Vital Stats
Total beds
85
Private GP Services
Inpatient beds
69
Satellites Parkside at Putney
Dedicated day case beds
11
Choose & Book
Critical care beds
5
On site Parking
Total Theatres
5
Accept all major insurers
Consulting rooms
MRI
Endoscopy Suite
CT
Pathology
Ultrasound
Physiotherapy
X-ray
Pharmacy
Nuclear medicine
Chemotherapy
Digital mammography
Radiotherapy
Extremities MRI
Sterile Services department
Dexa
Hydrotherapy pool
• Bupa accredited Breast Cancer Unit
• Aspen Healthcare a Healthcare Investor Award Finalist 2013
7
8
Statement on Quality
Quality Priorities For 2014-15
Parkside Hospital is proud to present our first Quality Account and hope it helps to
demonstrate our commitment to quality and safety. We have aimed to measure our
progress objectively, identifying where we need and want to improve in 2014/2015
centred on the areas of patient safety, clinical effectiveness and patient experience.
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 our patient and staff, audit results, national guidance and
recommendations from the various hospital/clinic teams across Aspen Healthcare.
The Quality Account is actively owned by all
the teams at Parkside Hospital. We have a
genuine desire to drive forward our quality
initiatives over the next year, modelled on
our Quality Governance Framework which
was shortlisted as a finalist in the Laing and
Buisson, Independent Healthcare Awards in
2013. This Quality Account also helps us
to openly report on what we do and what
we need to improve upon. Our local Quality
Governance Committee meets quarterly
and provides information, outcomes and
quality data on all aspects of our patient’s
journey, including feedback from our patients.
Our local Quality Governance Committee
feeds into our Group Quality Governance
Committee which is chaired by Aspens
CEO. The committee provides assurance
to the Aspen Board that we are responsive
to any changes in values, expectations and
perceptions and ensure that our services
provided to our patients are based on
best practice.
Accountability Statement
Directors of organisations providing hospital
services have an obligation under the 2009
Health and Social Act, National Health
Service (Quality Accounts) Regulations 2010
and the National Health Service (Quality
Accounts Amendment Regulation (2011) to
prepare a Quality Account for each financial
year. This report has been prepared based
on guidance issued by the Department of
health setting out these legal requirements.
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:
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.
Parkside Hospital are 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:
•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
• Patient Experience
This is about aspiring to ensure we exceed
the expectations of all our patients.
Robert Thonet, Medical Advisory Committee
Chair, Parkside Hospital
Liz Lindsey, Quality Governance Committee
Chair, Parkside Hospital
Des Shiels, Chief Executive Officer, Aspen
Healthcare
Judi Ingram, Clinical Director, Aspen
Healthcare
Date: 2nd May 2014
Signed by Hospital Director
9
10
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 roles
and start to roll out bespoke Patient Safety
Leadership Training. Having staff that are
empowered to lead on patient 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.
Clinical Effectiveness
Patient Experience
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.
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.
While targeting the above areas, we will also continue to:
• Strive to further improve upon all our quality and safety measures
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 supports a
patient’s privacy and dignity, food, cleanliness
and general building maintenance. PLACE
assessments will provide motivation for
improvement by providing a clear message,
directly from patients, about how our
environment or services might be enhanced.
Care Planning 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.
• Continue with our programme of development relating to other quality initiatives
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.
• Meet and exceed the Quality Schedule of our NHS Contracts.
• 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
“...the superb care I had whilst an inpatient for two operations
under Mr S in January and February this year. Every member
of staff was so professional in his or her capacity. I want to
make special mention of the HDU staff who made a potentially
difficult time run so smoothly both during the day and at night.”
Dr K
11
12
Statements of Assurance
Relating to the quality of NHS services provided
This section of the Quality Account provides mandatory information for inclusion
in a Quality Account, as determined by the Department of Health regulations, and
reviews our performance over the last year, running from April 2013 to March 2014
but reported in June as required by the guidelines.
As this is our first Quality Account we had
not set ourselves any published targets last
year but we have worked hard to achieve
the quality objectives we had set ourselves.
Future Quality Accounts will be more
comprehensive as we further improve the
measurement systems that will help
us in doing this.
Participation in Clinical Audit
National clinical audits are a set of national projects that provide a common format
by which to collect audit data. National confidential enquiries aim to detect areas
of deficiencies in clinical practice and devise recommendations to resolve them.
During April 2013 to March 2014, two
national clinical audits and no national
confidential enquiries covered NHS services
that Parkside Hospital provides.
The national clinical audits and national
confidential enquiries that Parkside Hospital
participated in during April 2013 to March
2014 are as follows:
During this period Parkside Hospital
participated in 50% of national clinical audits
it was eligible to participate in.
Review of NHS Services Provided 2013-14
National Joint Registry
Only a small proportion of Parkside Hospital’s activity is NHS and during April 2013 to March
2014, Parkside Hospital provided 483 NHS episodes of care within the services as follows:
ENT
Urology
Neurosurgical Spinal
Gynaecology
Orthopaedic
Oral and Maxillo-Facial Surgery
Plastic Surgery
Pain
General Surgery
Parkside 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 represents 100% of the
total income generated from the provision of
NHS services by Parkside Hospital for April
2013 to March 2014.
National PROMS Programme
The national clinical audits and national confidential enquiries that Parkside hospital
participated in, and for which data collection was completed during April 2013 to 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 by the terms of that audit
or enquiry.
Name of Audit
National Joint Registry
National PROMS
Participation
Number of cases submitted
Yes
No
277
n/a
Parkside hospital had only a very small volume of NHS patients eligible for PROMs in
2013/2014 and therefore the number reported were below the national required reporting
threshold.
The report of one national clinical audit was reviewed in April 2013 to March 2014 and
Parkside hospital intends to take the following actions to improve the quality of healthcare
provided:
• Review PROMS programme data and assess if this is relevant for Parkside Hospital to
include in 2014-2015
13
14
Participation in Research
Local Audits
The reports of 14 local clinical audits were reviewed in April 2013 to March 2014:
Medical, nursing and
physiotherapy records completion
audits
Falls risk assessment compliance
Infection, Prevention and
Control (IPC), hand hygiene,
peripheral access devices and
Environmental Audits
Safeguarding Adults and Children
Resuscitation Management
Surgical safety (WHO) checklist
completion
VTE management
There were no patients receiving NHS services provided or sub-contracted by Parkside
Hospital in April 2013 to March 2014 that were recruited during that period to participate
in research approved by a research ethics committee.
Goals Agreed with Commissioners
Consent form completion
Controlled Drugs management
Standards for reporting MRI
scans
Pathology specimen pathways
Transfusion compliance
Sharps safety
Harm Free Care (Safety
Thermometer)
Parkside Hospital income in April 2013 to
March 2014 was not conditional on achieving
quality improvement and innovation goals
through the Commissioning for Quality and
Statements from the Care Quality Commission
All standards were met when the service was inspected
Parkside Hospital is required to register with
the Care Quality Commission (CQC) and its
current registration status is to provide the
following regulated activities:
Parkside Hospital has taken the following actions to improve the quality of healthcare
provided as a result of the above audits (see page 23 for audit outcomes):
•Diagnostic and/or screening services
•Developed a discharge information sheet for patients, which sets out the common
expectations following discharge, along with a contact number they can assess 24 hours
a day for advice
•Surgical procedures
•Set up a Resuscitation Committee that meets quarterly to ensure the resuscitation
management pathway is evaluated and feedback to staff
•Moved to ELearning mandatory training for all staff to ensure IPC training is available
for all staff
Innovation (CQUIN) payment framework
because this was not applicable to the
commissioning contracts with the NHS
in 2013/14 at Parkside Hospital.
•Services for everyone
•Treatment of disease, disorder or injury
•Caring for children (0 - 18yrs)
to March 2014.
Parkside Hospital has not participated in any
special reviews or investigations by the CQC
during the reporting period.
Parkside Hospital was inspected by the
CQC in November 2013 and was found
to be fully compliant with the five essential
standards reviewed and as at 31st March
2014 Parkside Hospital does not have any
conditions of registration.
The CQC has not taken enforcement action
against Parkside Hospital during April 2013
•Commenced monthly national reporting on the NHS Safety Thermometer for all Parkside
Hospital patients which assesses patients for degree of harm
•Reviewed, updated and disseminated a safeguarding adults and children flowchart to
all departments setting out the steps staff should take if they were concerned about a
safeguarding issue
•Carried out waste disposal training which includes sharps disposal management following
the implementation of new waste disposal systems.
“We want to thank you very
much for all your have done
to help and support S and
our family in this very difficult
time. You were always so
caring and understanding.”
The H Family
15
16
Statements on Data Quality
Parkside Hospital 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. Information
Governance is high on the agenda and
robust policies and procedures are in place
which support the information governance
process. This includes standards for record
keeping and storage, continuous audit of
records to ensure accuracy, completeness
and validity.
The Information Governance Toolkit is a
performance assessment tool, produced
by the Department of health, and is a set
of standards the organisations providing
NHS care must complete and submit
annually by 31st March each year. The
toolkit enables organisations to measure
their compliance with a range of information
handling requirements, thus ensuring that
confidentiality and security of personal
information is managed safely and effectively.
Quality Indicators
Secondary Uses System (SUS)
Parkside Hospital submitted records during
April 2013 to March 2014 to the Secondary
Uses 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:
• 14% for admitted patient care;
• 86% for outpatient care.
And which included the patient’s valid
General Medical Practice Code was:
• 12% for admitted patient care;
• 88% for outpatient care.
Clinical Coding Error Rate
Parkside Hospital was not subject to the
Payment by Results clinical coding audit
during April 2013 to March 2014 by the
Audit Commission.
In January 2013, the Department of Health advised amendments had been made
to the National Health Service (Quality Accounts) Regulations 2010. A core set
of quality indicators were identified for inclusion in the quality account.
Not all indicator measures that are routinely
collated in the NHS are currently available
in the independent sector and work will
continue during 2014/15 on improving
the consistency and standard of quality
indicators reported across Aspen Healthcare.
A number of metrics have been chosen to
summarise our performance against key
quality indicators of effectiveness, safety
and patient experience.
Parkside Hospital considers that this data
is as described in this section as it is collated
on a continuous basis and does not rely on
retrospective analysis.
Parkside Hospital has taken the following
This indicator measures whether the number
of people who die in hospital is higher or
lower than would be expected. This data
Parkside Hospital will be taking the following
actions to improve data quality
Patient Reported Outcome Measures
(PROMs) assess general health improvement
from the patient perspective. These currently
cover four clinical procedures and calculate
the health gains after surgical treatment using
pre and post operative surveys. Parkside
Hospital does not currently collect this data
• Review of storage facilities for medical
records. This will involve refurbishment of
the storage area which will allow staff to be
able to track, retrieve and mange records
more effectively
When anomalies arise, each one of the
indicators is reviewed with a view to learning
why an event or incident occurred so that
steps can be taken to reduce the risk of
it happening again.
Hospital Level Mortality Indicator and Percentage of Patient Deaths with Palliative
Care Code
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.
• Monthly ongoing audit of patients medical
records
actions to improve our data collection
submissions, and the quality of its services,
by working with the Private Healthcare
Information Network (PHIN) which was
launched in April 2013. Data is collected
and published about private and independent
healthcare, which includes quality indicators.
Aspen Healthcare is an active member of
PHIN and is working with other member
organisations to further develop the
information available. www.phin.org.uk.
is not currently routinely collected in the
independent sector.
Patient Reported Outcome Measures (PROMs)
as the hospital does not have sufficient
numbers of NHS patients admitted in the
four surgical categories. When numbers
of these patients increase then Parkside
Hospital will ensure that PROMs data
is captured and reported.
• Ensure 100% of staff complete the
ELearning modules related to record
keeping and Information Governance
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18
Percentage of Hospital Employed Staff who would recommend the Hospital to
family and Friends
Aspen Healthcare carried out a staff survey in November 2013. The results of this survey
showed that 76% of staff would recommend Parkside Hospital to family and friends.
The management of Parkside Hospital will continue to hold open staff forums to feedback to
staff the results of the staff survey. Parkside Hospital has also set up a staff representative
committee which has staff membership from all staff groups. The purpose of this committee
will be to discuss and find solutions to issues or concerns raised by staff and to give staff a
broader understanding of the patient pathway. Another staff survey is planned to
be undertaken in 2015 and is hoped that impovements will be made.
Other Mandatory Indicators
All performance indicators are monitored on
a monthly basis at key meetings and then
reviewed quarterly at both local and group
level Quality Governance Committees. Any
significant anomaly is carefully investigated
Indicator
Source
Number of people
aged 15 years and over
readmitted within 28
days of discharge
CQC
performance
indicator
Clinical audit
report
Number of admissions
risk assessed for VTE
CQUIN data
Number of Clostridium
difficile infections
reported
and any changes that are required are
actioned within identified time frames.
Learning is disseminated through various
quality forums in order
to prevent similar situations occurring again.
2012-13
2013-14 Actions to improve quality
6
7
Not
collected
97.5%
Continue to audit all records.
Disseminate audit results and
implement any action plans
as required.
From national
Public Health
England
returns
0
0
Continue to monitor reports.
Number of patient
From hospital
safety incidents which
incident
resulted in severe harm reports (Datix)
or death
0
0
Continue to monitor data.
94.9%
97.1%
Continue to monitor data.
Refurbishment of inpatient
bedrooms. World Host customer
care training programme.
Not
collected
100%
Continue to monitor data.
Responsiveness to
personal needs of
patients
Patient
satisfaction
survey data –
for overall level
of care and
service
Friends and Family test
- patients
Patient
satisfaction
survey –
extremely
likely/likely
Continue to monitor data.
Review all readmissions at
Quality Governance and
Medical Advisory Committees.
Investigate each one and
provide learning and actions
plans where appropriate.
“Staff could not be nicer
– they go the extra mile –
Sister in particular”
Suggestions box OPD
19
20
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
Infection Prevention and Control
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.
Infection prevention and control (IPC) is
a high priority for Aspen Healthcare and is at
the heart of good management and clinical
practice.
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.
Notably 90% of Parkside Hospital staff said
that if they had a concern that could harm
patients or staff or were concerned about
negligence or wrong doing by staff
or consultants they would feel able to report
those concerns. 89% of staff reported that
they knew how to raise a concern. Parkside
hospital plans to further promote a positive
safety culture in 2014/2015 by:
•Holding open staff forums
•Developing a staff representative committee
•Giving all staff feedback on the actions
taken on all safety concerns.
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 thromboembolism
(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 Aspen hospitals achieved
an overall score of 99-100% relating to
these indicators.
During 2013-2014 considerable work has
continued in further establishing Aspen’s IPC
infrastructure and polices, with excellent work
being undertaken across all facilities. Effective
systems are in place to prevent and control
health care associated infections (HCAI)
and ensure the safety of our patients, their
relatives, and staff and visiting members
of the public.
Parkside Hospital carried out a pilot of IPC
Environmental Audits during 2013-2014
in all patient centred clinical areas. This audit
is now being used across all Aspen sites.
Hand hygiene and insertion of peripheral
canulla audits continue with an average result
of 98% compliance across all areas audited.
Parkside Hospital held all regular IPC
committee meetings during 2013-2014
and aims to do the same in 2014-2015. The
minutes of these meetings are circulated to
all staff and feed into the governance and
quality agenda. IPC is a standing item on the
Medical Advisory Committee agenda and
all issues related to IPC are discussed.
Healthcare Associated Infections
Infection
MRSA positive blood culture
MSSA positive blood culture*
E. Coli positive blood culture
C. Difficile infection
2012-13
0
1
0
0
2013-14
0
1
1
0
* Not Hospital Acquired
Cleanliness
The cleanliness of a hospital is very
important to patients, those who visit and all
the staff who work within the organisation.
As part of the monitoring system, the views
of patients are sought through the use of
satisfaction questionnaires. The table below
identifies the percentages of patients who
considered hospital cleanliness and hygiene
as either ‘excellent’ or ‘very good’.
The results in 2013-2014 have improved
due to refurbishment of inpatient rooms and
implementation of a spot-check audit system
by supervisory staff.
Patient Views of Cleanliness
Indicator
Cleanliness
21
2012-13
% excellent or very good
88%
2013-14
% excellent or very good
92%
22
Clinical Effectiveness
Theatre Accreditation Programme
Integrated Governance Audit Programme
We will implement an accreditation
programme to our operating theatre
environments across the Aspen Group aiming
to excel in perioperative practice.
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
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:
•Venus thromboembolism (VTE) (risk
assessment and prophylaxis)
•Patient Consent
•Patient care records/documentation
standards
•Controlled Drugs management
•Surgical Safety Checklist Completion
•Diagnostics – Standards for Reporting
MRI Scans
•Pathology
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.
Parkside Hospital has undertaken its first
audit as part of the accreditation programme
and project work has commenced on the
ensuring that the standards required can
be demonstrated.
•Physiotherapy Record Keeping
•Patient falls
Patient Experience
Parkside Hospital Audit of Quality Indicators April 2013 – March 2014
Indicator
Falls
VTE
Consent
Records
Controlled Drugs
Surgical Safety (WHO) Checklist
Average score of % compliance 2013-14
% compliance: average score 2013-14
100%
93%
98%
90%
96%
95%
Parkside Hospital plans to do the following to improve the results of the above audits:
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.
Parkside Hospital has implemented a
programme of training for staff in World
Host. From April 2013 to March 2014 135
staff have undergone training. It is anticipated
that in 2014/2015 95% of staff will have
undertaken the course.
•Monthly (instead of quarterly) records audit with feedback to relevant staff and consultants
•Implementation of a Theatre accreditation programme
•Champion the WHO five steps to patient safety checklist
Patient Feedback April 2013 – March 2014
Indicator
•Six monthly controlled drug audit.
23
2013-14
% excellent or very good
Your welcome on arrival (admission)
90.5%
Were you treated with consideration and courtesy by
your nurses?
97.5%
Friendliness/helpfulness of housekeeping staff
92%
The friendliness/helpfulness of catering staff
89%
24
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 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. 100% responded that they were
extremely likely or likely to recommend the
Aspen hospital they visited.
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? (% extremely
likely and likely)
100%
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
86%
95.7%
98%
96.8%
Complaints
95%
97.2%
Whilst Parkside Hospital 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
How likely are you to recommend our hospital to friends and family if they need similar
care or treatment? (% extremely likely and likely) - 100%
Indicator
Number of complaints
% 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
120
0.15%
136
0.15%
“...your staff are amazing and must be acknowledged for all that
they do. I would not hesitate in having any procedure done at
Parkside Hospital and will highly recommend it.”
Mr E
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External Perspective
on Quality of Service
What others say about our services
Parkside Hospital requested their NHS Commissioners, NHS London , London Health and
Wellbeing Board and Healthwatch 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.parkside-hospital.co.uk
www.aspen-healthcare.co.uk
Or call us on:
020 8971 8000 Parkside Hospital
020 7977 6080 Head Office, Aspen Healthcare
Write to us at:
Parkside Hospital
53 Parkside
Wimbledon
London SW19 5NX
Aspen Healthcare Limited
Centurion House (3rd Floor)
37 Jewry Street
London EC3N 2ER