Quality of Care for All
Quality Account 2014
Quality Account 2014-2015
Page 1 of 23
CONTENTS
Glossary
Introduction from Diane Thomas, Chief Executive
Highlights from 2013 - 2014
External Regulation under the Health and Social Care Act 2012
Review of Services
Quality Overview
Quality Priorities for 2014-2015
Clinical Governance
•
CQC Indicators
Patient safety and Incident reporting
Internal Audit
•
Local Audit programme
•
Stakeholder Engagement
External Audit
•
Participation in Clinical Audits
•
PROMS
•
NJR
•
Clinical Coding
•
PLACE
Information Technology
•
Data Quality
•
NHS Number and General Medical Practice Code Validity
•
PHIN
•
Information Centre
Information Governance
Capital Investment
Statement from the Chairman of the Board of Directors
Statement from lead Clinical Commissioning Group
Quality Account 2014-2015
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Glossary of Terms Used in This Document
CDI
Clostridium Difficile
CQC
Care Quality Commission
CQUIN
Commissioning for Quality and Innovation
ERP
Enhanced Recovery Programme
GMC
General Medical Council
IG
Information Governance
IOFM
Intra-Operative Fluid Management
MAC
Medical Advisory Committee
MRSA
Methicillin-Resistant Staphylococcus Aureus
MSK
Musculoskeletal
MSSA
Methicillin-Sensitive Staphylococcus Aureus
NCEPOD
National Confidential Enquiry into Patient Outcome and Death
NICE
National Institute for Health and Care Excellence
NTAC
National Technology Assessment Centre
NJR
National Joint Registry
PBR
Payment by Results
PHIN
Private Healthcare Information Network
QIPP
Quality, Innovation, Productivity and Prevention
RCA
Root cause Analysis
SOA
Specialist Orthopaedic Alliance
SSI
Surgical site infection
SUI
Serious Untoward Incident
THC
The Horder Centre
THR
Total hip replacement
TKR
Total knee replacement
VTE
Venous Thromboembolic Embolism
Quality Account 2014-2015
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INTRODUCTION FROM THE CHIEF EXECUTIVE
I am very proud to present to you our Quality Account and take this opportunity to introduce
you to Horder Healthcare (HH).
Horder Healthcare has been a charity for sixty years, whose purpose is to advance health:
being a charity means that HH does not have to pay shareholders and private investors.
Any surpluses that are generated by performing healthcare activities are reinvested into
advancing health; predominantly to the communities it serves. This is achieved in a number
of ways, including the creation of therapeutic environments for healthcare, such as our
Centre of Excellence, The Horder Centre, situated in the heart of the Ashdown Forest, which
specialises in Musculoskeletal and Elective orthopaedics. The Horder Centre is the largest
single site ‘independent hospital’ provider of these services in the country and has some of
the very best clinical outcomes.
The broader spectrum of work we currently undertake is to advance health and includes
education and training sessions for healthcare professionals, including GPs and community
seminars for the broader public. We launched our interactive website, which has our very
popular exercise programs, including wellness videos as well as being focused on specific
orthopaedic conditions. This new website enable us to empower people by providing them
with healthcare information, which helps them make decisions, select choices and take
ownership about their general health and lifestyle.
The Horder Way:
We have invested in designing an approach to care delivery which is described as The
Horder Way. This approach is based on the concepts of operational excellence; using tried
and tested approaches we are hard wiring continuous improvement concepts into the
following domains:
•
•
•
•
•
•
Leadership
Strategy
Stakeholder Engagement
Engaging staff and rewarding success
Creating a culture of high performance
Effective Communication
What we are: Our Mission:
We are a leading provider of high quality healthcare services, demonstrably improving
patients’ health and striving to make a positive difference to people’s lives.
Our primary objective: Vision
Our vision is to be the very best provider of healthcare services, within a therapeutic
atmosphere - a great place to work, practise medicine and receive care. It is our ambition to
meet and exceed customer expectations and delight patients; bring our services to more
people, enhancing the quality of their lives; to deliver high quality, effective and safe care,
which is perceived as having a high value.
Quality Account 2014-2015
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Our Values:
Caring – We believe that all
with whom we interact will be
treated with utmost respect
and empathy
Pride - Our team are proud of
what they do, taking pleasure in
delivering a unique service.
Integrity – We are always
reliable, honest, consistent and
transparent in our approach.
Friendly – We foster a culture
that is warm, welcoming and
responsive.
Quality – We deliver the best
service we can whilst striving to
continuously improve.
Our values give us a very principled and ethical way of doing things, which together with our
focus on quality truly sets us apart from other healthcare organisations. Our commitment to
quality is evidenced by our high quality performance and aspiration to continually improve
the outcomes and experience for our patients through the dedication of all of our team.
The creation of this Quality Account has involved a great deal of collaboration, utilising
inputs and feedback from key stakeholders, including our Board of Directors, patients,
visitors, consultants and staff and I am delighted to commend this report to you.
Di Thomas
Chief Executive
_________________________________________________________________________
“The care, dedication and compassion, and especially the laughter made my stay so very, very
special. Everyone was there for us, which made us feel as if we were the only people on this lovely
planet of ours. You have the very best staff I have ever met; I can't speak highly enough of them all.”
(Mrs V)
Quality Account 2014-2015
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HIGHLIGHTS OF 2013 - 2014
•
•
At The Horder Centre:
o
Successful unannounced inspection by Care Quality Commission (CQC) with
full compliance to all essential standards
o
THC was rated as a 5 star healthcare organisation on NHS Choices
o
Patient Related Outcome Measures (PROMS) – 99.8% positive outlier for hip
replacements for the 3rd consecutive year
o
99% general satisfaction rate from patients at good, very good or excellent
o
Friends and family – consistently achieving as one of the top 5 scoring
organisations
o
Sussex Heritage award for our therapeutic environment
o
Finalist for HSJ/Nursing Times Patient Safety and Care award
o
Finalist for HSJ Environmental Efficiency award
o
Healthy Workplace award
o
Zero cases of MRSA and MSSA blood stream infections
o
98%of patients rated the cleanliness as good, very good or excellent
o
100% of patients said that they were treated with dignity and respect
Horder Healthcare
o
Therapy patient outcome tool developed with excellent results
o
Completed phase 2 of the Information Centre
o
Achieved exceptional levels of staff engagement and satisfaction
o
Purchased Horder Healthcare Seaford as outreach centre
______________________________________________________________________
“From the moment of referral, colleagues had told me of this centre of excellence. They underestimated it by some considerable way. The Horder Centre is quite simply perfection. It functions like
a well-oiled machine, and communication between the staff is outstanding.
There is, for me, no possible compromise. I am likely to need my other hip replaced in the next couple
of years. There is no question of going anywhere else. The Horder is the place to go. Quite simply, it is
excellent in all respects.” (Anon – NHS Choices)
Quality Account 2014-2015
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External Regulation under the Health and Social Care Act 2012
Horder Healthcare is required to register with the CQC and its current registration is full
registration under the Health and Social Care Act 2012. Horder Healthcare is registered in
respect of the following regulated activities:
1. Treatment of disease, disorder or injury
2. Diagnostic and screening procedures
3. Surgical procedures
Horder Healthcare was inspected by the CQC in February 2014 and demonstrated that it
meets all the National Minimum Standards inspected and had no areas of non-compliance.
Horder Healthcare has not participated in any special reviews or investigations by the CQC
during the reporting period.
The CQC has not taken enforcement action against Horder Healthcare during 2013/2014.
_______________________________________________________________________
“At the relatively young age of 54 I found myself needing a hip replacement, on the recommendation
of my friend who had a similar op there, I chose the Horder Centre for my op. The Consultant carried
out the op and the nursing and physio team supported me so well I was able to take my first steps
just 5 hours after the operation. The food was tasty and nutritious with a good level of choice. Six
weeks after my op I am driving again and have even been able to take short rides on my bike. My
walking gets better all of the time and I am amazed at my own progress. I would recommend this
hospital to anyone needing hip or knee surgery. Thank you so much.” (Mr H)
Quality Account 2014-2015
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Review of Services
During 2013/2014 The Horder Centre provided three NHS services for orthopaedics,
rheumatology and pain.
In 2013/14 Horder Healthcare had a
strategic aim to provide orthopaedic and
musculoskeletal services to more patients
in the South East Coastal area. A total of
11,636 patients benefited from treatment,
care and services. 8,494 of these were
NHS patients and 3,723 were private
patients.
Horder Healthcare had a total of 5,104
admissions during the year consisting of
2,374 inpatients and 2,730 day case
patients
Patients benefitting from
Treatment
10,000
8,000
6,000
NHS
4,000
PP
2,000
0
2012/2013 2013/2014
A total of 2,971 patients were treated by
outpatient physiotherapy and attended a
total of 14,187 treatment sessions.
Total Admissions
2012/2013
45%
55%
Total Admissions
2013/2014
In Patients
2,350
Day cases
2,889
47%
53%
In Patients
2,374
Day cases
2,730
_________________________________________________________________________
“This is my personal Thank You to all the staff and the consultant for the wonderful treatment I
received today. From the initial assessment to my Knee surgery I cannot fault everyone’s professional
attitude and friendly demeanour. The facilities are second to none!! Modern, comfortable and
spotlessly clean. The consultant made it clear and easy to understand the procedure which gave me
full confidence in him. We feel fortunate to live in an area with access to a Hospital of such high
standards and can recommend The Horder Centre to anyone contemplating Orthopaedic surgery.”
(Mr R)
Quality Account 2014-2015
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QUALITY OVERVIEW 2013 – 2014
The key areas that were chosen for development during 2013-2014 were:
Clinical Effectiveness –
1. Use of outcomes to enhance practice. This has been demonstrated by reviewing
PROMS and ERP results for any areas of improvement and ensuring action plans
are put in place. This year has also seen the development of MSK outcome
measures put in place with significant improvements in results.
2. Work as part of the Specialist Orthopaedic Alliance (SOA) on specialist orthopaedic
commissioning. HH has attended all SOA meetings and conferences to ensure HH
has a voice at national debates on orthopaedic care. We have also participated in
benchmarking activities with the SOA and audit activities.
3. Work with Private Healthcare Information Network (PHIN) on benchmarking. The IT
and audit departments have been involved in the set up and development of the
PHIN programme and reviewing data comparisons.
4. Compliance with NHS Safety Thermometer audit. This is a monthly audit by frontline
teams to measure how safe their services are and to deliver improvement locally.
This has involved monthly audit on
a) Falls
b) Catheter associated urinary tract infections
c) Pressure ulcers
d) VTE (PE & DVT)
Between April 2013 and March 2014 98.1% patients surveyed were harm free.
5. Further develop our enhanced recovery programme for hip and knee replacement
patients to ensure patients are nutritionally prepared for their operation by ensuring
an adequate intake of carbohydrates. Carbohydrate drinks are now issued to patients
prior to surgery to ensure adequate nutrition to aid their recovery and wound healing.
6. Develop our Information Centre. Phase 2 has been completed with over 60 health
related articles and 12 new videos added to the site to prevent ill health or assist
people to maintain their optimum health.
_________________________________________________________________________
“I have had both hips replaced at the Centre this year. It is quite honestly the perfect hospital for this
type of surgery. I cannot fault the care, professionalism, compassion, skills, and friendliness of the
entire staff. The facilities are excellent in every respect. The Centre is a shining example of really good
medical care. Anyone contemplating surgery here should be confident that they will receive the best
possible treatment and care available. I was very lucky my GP recommended it.” (Mrs. T)
Quality Account 2014-2015
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Patient Safety –
7. Achieve Venous Thromboembolism (VTE) exemplar status - The aim is to reduce the
number of VTE episodes occurring, therefore evidence is required that all adult
inpatients have had a VTE risk assessment on admission to hospital, using national
clinical criteria. A root cause analysis (RCA) will also need to be carried out on
confirmed cases of pulmonary embolism or deep vein thrombosis. We currently risk
assess all patients and are also applying for VTE exemplar status. All patients are
risk assessed for VTE prior to admission, on admission and reviewed after 24 hours
and daily if their condition changes. Our target of 95% has been consistently
achieved with an average of 99.83% over the year. This is reflected in our relatively
low incidence of VTE.
8. Intra-operative fluid management (IOFM) - This is to ensure all patients are
adequately hydrated prior to and during surgery. We will need to demonstrate that we
meet the guidance provided by the National Technology Assessment Centre (NTAC)
by identifying which procedures qualify, establish a baseline audit and then agree a
target of 80% for compliance. This was reviewed via our clinical governance
committee who were satisfied that we were complying with the guidance.
9. Achieve a full controls assurance model. Controls assurance model in place to
integrate clinical and commercial aspects.
Patient Experience –
10. Comply with Friends and Family test - All patients will be asked on discharge whether
they would recommend the hospital to their friends and family. The questionnaire
must be in place, a baseline response rate must be achieved and results compare
favorably with the top 25% of NHS hospitals to achieve the full CQUIN payment.
Consistently placed in top five scoring hospitals. Current score for March 2014 is
99%.
11. Expand Horder Healthcare to a wider population via further community based
services or acquisitions. Purchased Seaford Day Hospital (see under Capital
Investment)
12. Complete the next phase of the building plans for The Horder Centre. As above.
_________________________________________________________________________
“I have been referred to the physiotherapy department at the Horder Centre in Crowborough three
times now. The physiotherapists I have seen have been extremely professional in their approach but
also friendly and kind. I wouldn't hesitate to recommend their services to anyone.” (Anon – NHS
Choices)
Quality Account 2014-2015
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QUALITY PRIORITIES 2014 – 2015
Clinical Effectiveness –
•
To participate in the new model of MSK service provision across Sussex actively
demonstrating improvements in patient outcomes from both community based care as
well as hospital based care.
•
To continuously review and implement any identified best practice from the new
pathways of care.
•
To be able to demonstrate that THC has moved from a ‘good’ to ‘great’ orthopaedic
centre with benchmarking activities with the SOA.
•
Ensure a programme of ‘shared decision making’ is developed across all clinical
services.
•
Develop an enhanced learning culture across the clinical services including increased
up-skilling of non-registered staff i.e. theatre assistants.
Patient Safety –
•
To review our patient falls rate and identify any areas for improvement after
benchmarking nationally and against other orthopaedic providers
•
To continuously seek to reduce any harm to patients by training more staff in root cause
analysis and learning from clinical incidents.
Patient Experience –
•
Complete phase 3 of the Information Centre including the introduction of health and well
being apps for iPhones, tablets and computers; the introduction of on-line booking for
classes.
•
Enhance the differentiation between the NHS and Premium Plus product and promote to
the market.
•
To improve discharge processes with increased compliance to discharge targets as
planned.
_________________________________________________________________________
“I was amazed at the efficiency and friendliness of ALL the staff, from the receptionists on my first
visit, through to the operation and aftercare. I was kept fully informed at all stages and all my
questions were fully answered, jargon free but not in a condescending manner.
This hospital is a shining example and proof that adequate high quality staff in high quality facilities
provide a high quality service of which the can justifiably be very proud. Sincere thanks to all
concerned with my treatment.” (Anon – NHS Choices)
Quality Account 2014-2015
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Clinical Governance
Care Quality Commission Indicators
The Horder Centre submits regular reports and KPIs to the Care Quality Commission and
local commissioners. The Horder Centre Clinical Governance Committee meets quarterly
throughout the year and monitors quality and effectiveness of care.
Indicator
Total Number
April 13 – March 14
(on discharge date)
0
Inpatient mortality
%
0
Peri-operative mortality (i.e. within 48 hours of surgery)
0
0
Unplanned readmissions within 29 days of discharge
20
0.39
Unplanned returns to the operating theatre
8
0.16
Unplanned transfers of inpatients to another hospital
20
0.39
Mortality within 7 days of discharge
0
0
Pulmonary Embolus (PE) at The Horder Centre
8
0.16
Deep Vein Thrombosis (DVT) at The Horder Centre
1
0.02
Inpatient dislocation at The Horder Centre
1
0.11
Unplanned overnight admission after day case surgery
55
2.02
Hip replacements (arthroplasty) infection rate
1
0.11
Knee replacements (arthroplasty) infection rate
2
0.21
Serious Untoward Incidents (SUIs)
1
0.1
Clinical Indicators
0.80
0.70
0.60
0.50
0.40
0.30
0.20
0.10
0.00
Apr 11 - Mar 12
Apr 12 - Mar 13
Apr 13 - Mar 14
Quality Account 2014-2015
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Mortality rate
There were no deaths in the hospital during the year.
Unplanned Readmissions within 29 days of discharge
All unplanned readmissions are monitored as unnecessary readmissions to hospital could
indicate a patient has been discharged too soon. These are unplanned admissions that
follow a patient spell and were not scheduled at the time of discharge. There were 20
unplanned admissions during the year; this is 0.39% of all discharges.
Unplanned Returns to Theatre
There were eight unplanned returns to theatre during the year; this is 0.16% of all
anaesthetic episodes.
Unplanned transfers of inpatients to another hospital
There were 20 unplanned transfers to another hospital; this is 0.39% of all discharges.
Unplanned overnight admission after day case surgery
There were 55 day case patients who were admitted as an inpatient following their day case
surgery; this is 2.02% of all day cases.
_________________________________________________________________________
“I have recently experienced my second replacement knee operation at The Horder Centre,
Crowborough and I can only say what an excellent experience it was yet again. The wonderful skill
and professionalism of the surgeon and the anaesthetists, coupled with the natural care and
dedication of the after-op staff, made my operation as pleasant as it was possible to be. The speed at
which my recovery appears to be progressing bears testimony to the fantastic treatment I received. I
would recommend unreservedly that anyone requiring knee or hip treatment should contact The
Horder Centre.” (Mr C)
Quality Account 2014-2015
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Patient Safety and Incident Reporting
Patient safety is our highest priority and our aim is to remove or minimise risk wherever
possible. We encourage the reporting of all actual and potential incidents and support a
culture of learning from mistakes in an open way. We fully involve any patient and/or their
relative in investigation reports and share outcomes with them in a transparent way. When
mistakes are made, the hospital ensures patients, relatives or carers receive a full apology
and a clear explanation of cause and preventative steps that have been taken to ensure the
mistake cannot happen again.
During 2013 – 2014 there were 409 incidents reported via our Datix risk management
system:
Incidents Reported 2013 - 2014
2%
10%
Patient
Staff
Visitor
88%
Of these 409 incidents recorded only 30 resulted in harm:
Incidents that resulted in harm
20
13
15
17
10
5
0
0
Patient
Staff
Visitor
Quality Account 2014-2015
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During 2013/14 The Horder Centre reported one Serious Incident. There were zero ‘never
events’ at the hospital during the year.
Patient falls was a priority and a falls prevention group was set up to review methods to
reduce the number of patient falls. It should be noted that this also includes ‘assisted
lowering’ when a patient is helped to the floor. Our current falls rate is below that of the
national average across the United Kingdom.
Patient Falls
As % of In Patients
6
5
4
3
2
1
0
Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1
2011 2011 2011 2012 2012 2012 2012 2013 2013 2013 2013 2014
_________________________________________________________________________
“The treatment, care and level of respect both pre and post op is second to none at this specialist
unit. I had my knee replacement surgery on Tuesday 7th January 2014 and was discharged home on
10th January. My care and the level of information and support given at all times from all levels of
staff from reception to surgeon, anaesthetist, nursing and physio staff, and general hospital support
staff could not have been better. Nothing was too much trouble and their kindness outstanding. I
have to return to have my other knee replaced as soon as fully recovered from this operation but
have no hesitation in doing so, knowing that I could not have had better care or treatment anywhere
else. A big thank you to all at The Horder Centre.” (Anon - NHS Choices)
Quality Account 2014-2015
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Internal Audits
Local Audit Programme:
The following internal clinical audits took place during 2013/14 which were reviewed by our
Clinical Governance Committee:
•
Compliance to radiology standards that showed an improvement from the previous year.
•
The number of hip and knee replacement patients mobilised on day of surgery. Over the
last six months we have been auditing numbers of patients who mobilise on Day 0 in line
with the supporting of ERP at THC. The figures have been fairly consistent, with
approximately 50% of all hip patients and just under 30% of knee patients being
mobilised out of bed on the day of surgery.
•
Continuous review of anti-thromboemboletic medication to reduce the risk of deep vein
thrombosis. The pre-admission and theatre care pathway both include VTE risk
assessment and a section included for the consultant to complete before the patient
leaves the operating theatre.
•
Infection Prevention. A comprehensive audit programme has taken place throughout the
year ensuring compliance to CQC regulations and standards set by NICE. This includes
hand hygiene audits and an environmental audit.
•
Blood Transfusion. The Horder Centre undertakes a quarterly review of blood transfusion
usage through a review of data ensuring blood usage is in accordance with the
Maximum Surgical Blood Ordering Schedule (MSBOS).
•
Medical Record Audit – a monthly audit assesses that the content of medical records
meets legislative requirements and best practice.
•
Patient falls – Our aim in 2013 was to review the number of inpatients falling following
surgery. Preventing patients from falling can present a challenge and our patients are
encouraged to mobilise following surgery as part of their rehabilitation. However, there
are measures to reduce the risk of falling and all patients who are admitted to THC have
undergone a falls risk assessment at their pre-admission clinic appointment including a
check of what footwear they will be bringing in and this is reviewed on admission and
repeated during their stay if their medical condition changes. Patients at risk are located
in a more observable room and encouraged to call for assistance when mobilising; to
encourage this there are notices ‘call before you fall’ on the inside of each bedroom
door.
•
THC took part in a multi-site consent audit with three other hospitals; Royal National
Orthopaedic Hospital, Robert Jones & Agnes Hunt Orthopaedic Hospital and
Wrightington Wigan & Leigh NHS Foundation Trust, in 2013. There was clear evidence
that all four hospitals are complying with the majority of standards of gaining consent
and patients were satisfied with the consent process.
Quality Account 2014-2015
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Areas for improvement across all sites were identified:
o
The doctor’s signature needs to be identifiable and their name printed on the consent
form.
o
Documentation that a) the risk of non-treatment and b) alternative treatment options
have been discussed with the patient within the medical notes.
o
A record that the patient had been offered and taken a copy of the consent form.
Stakeholder Engagement
We continually review the service given to our users through feedback with the aim of
continuous improvement. All inpatients and day case patients are sent a Patient Satisfaction
Questionnaire after discharge from hospital to ascertain any areas for improvement.
Currently 99% of our patients rate the care received at The Horder Centre as good, very
good or excellent.
The highlights from the responses to these questionnaires include excellent results for:
•
•
•
•
•
•
the information given to patients prior to admission
patients being given written instructions and information before they left hospital
the confidence and trust patients have in the doctors and nurses treating them
the maintenance of patient privacy and dignity
overall cleanliness
members of staff providing patients with information on their medicines in a way that
they can understand.
We also discuss our provision of care with patients and their family and friends through
regular patient forums.
________________________________________________________________________
“I was recommended to the Horder Centre when I needed my 2nd knee replacement. From the first
appointment I was convinced that I was in good hands and this was confirmed. The experience was
great, clean well appointed rooms - professional and caring staff and best of all a great result - a
knee that is as good as new. Daily visits to the gym, although painful were fun (yes fun!) comparing
notes with other patients. The physios are firm but fair and work you hard (essential for a good
recovery) but with kindness and understanding. The nursing and aid staff were without exception,
fabulous. They are all well trained, professional, caring and above all knowledgeable. They really
understand what you are going through and will do anything to make you more comfortable. I had a
first rate job done on my knee and cannot recommend the Horder Centre and its staff enough.”
(Anon - NHS Choices)
Quality Account 2014-2015
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External Audits
Participation in Clinical Audits
During 2013-14, five national clinical audits and one national confidential enquiry covered
NHS services that The Horder Centre provides.
During that period The Horder Centre participated in 100% national clinical audits and 100%
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 The Horder Centre
participated in during 2013-14 are as follows:
•
•
•
•
•
•
•
National Elective Surgery - Patient Reported Outcome Measures (PROMs)
NJR: hip and knee replacements
National Cardiac Arrest Audit (0 cases reported)
NCEPOD: Peri-operative care study
ERP audit for primary hip and knee replacements
NHS Safety Thermometer – The NHS Safety Thermometer is the measurement
tool to support patient safety improvement. It is used to record patient harms at
the frontline, and to provide immediate information and analysis for frontline
teams to monitor their performance in delivering harm free care. The NHS Safety
Thermometer records the presence or absence of four harms; pressure ulcers,
falls, urinary tract infections (UTIs) in patients with a catheter and new venous
thromboembolisms (VTEs). For the 2013/14 period 98.4% of patients were harm
free.
Human Tissue authority audit supporting compliance with live bone donation
Other studies conducted at The Horder Centre have included the evaluation of specific
prosthesis over time, including a 15 year multi-centre study of the Exeter hip stem. Results
to date show excellent outcomes as reported by our patients.
Patient Reported Outcome Measures (PROMS)
The PROMS scores measure general health improvement (EQ-5D) as well as site specific
Oxford joint scores for total hip and total knee joint replacements. This information is
obtained from a pre-operative and a six month post-operative questionnaire and is case mix
adjusted.
The Oxford hip and knee scores assess how a patient’s hip or knee affects their life in
measures such as pain, stiffness, mobility and usual activity such as dressing and shopping
compared to their pre-operative score.
_______________________________________________________________________
“I’ve never been so well cared for, or looked after anywhere like to the standard in the Horder Centre.
I am back doing all of my favourite activities, and have not had pain since.” (Anon – NHS Choices)
Quality Account 2014-2015
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The published (provisional) data on 8 May 2014 for the period April 2012 to March 2013
show that The Horder Centre scored significantly higher than the national average for
PROMS Oxford Scores in the number of patients who had an improvement.
•
•
•
•
For primary knee procedures we scored 94.4% (the national average was 93.2%)
For knee revision procedures we scored 81.8% (the national average was 82.1%)
For primary hip procedures we scored 98.3% (the national average was 97.1%)
For hip revision procedures we scored 89.3% (the national average was 84.6%)
NJR
Between 1st April 2013 and 31st March 2014, based on operation date:
Total forms completed
% compliance
955 hip
972 knee
1 ankle
1 elbow
16 shoulders = 1945 total
Average consent rate for all 1945 procedures =
99.58%
Clinical Coding
The coding department did not receive an external audit this year but carry out a monthly
internal audit. The results showed that any inaccuracies did not affect the HRG code and
tariff. Horder Healthcare’s Clinical Coder is currently being extensively trained and working
towards the NHS Accredited Clinical Coding exam, which is due to be taken in the summer
of 2014. Horder Healthcare submits data for PbR (Payment by Results).
Patient Led Assessment of the Care Environment (PLACE)
Horder Healthcare strives to maintain and improve upon these results by participating in the
PLACE audit which was previously called Patient Environmental Audit Tool (PEAT).
Cleanliness
Food
97.33%
88.89%
Excellent
Privacy, dignity &
wellbeing
94.74%
Condition, appearance
and maintenance 95.98%
_______________________________________________________________________
“Incredible personal attention from consultants through to nurses and all staff who attend you in any
way. A very strong team approach, a true centre of excellence.” (Mr F)
Quality Account 2014-2015
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Information Technology
In the last year Horder Healthcare has introduced a new electronic referral management
system (Docman), linking THC to the 120 top GP referring surgeries across the region. This
enhances referral capability and turnaround of information for GPs, who were identified as
one of the most powerful stakeholder groups, being one of the key gatekeepers to
secondary care.
THC has also introduced SMS text notification for outpatient, pre-admission and health and
fitness appointments for patients and clients.
The data warehouse project has expanded to include our risk management system which
will see new available reports for operational managers. Later during 2014 we will bring a
new Human Resources (HR) system with a time management module into the data
warehouse.
Data Quality
Horder Healthcare believes that accurate information is central to high quality patient care. It
continues to strive for the highest level of data quality in its computerised Patient
Administration System (iPM) by working across technical and clinical teams to identify and
resolve issues in the accuracy of data.
NHS Number and General Medical Practice Code Validity
Horder Healthcare submitted records during 2013/14 to the Secondary Uses Service for
inclusion in the Hospital Episodes Statistics which are included in the latest published data.
With the use of the Demographics Batch Service (DBS) Horder Healthcare is able to trace
and verify NHS numbers. Throughout the period of 2013/14 the percentage of records in the
published data which included the patient’s valid NHS number was 100% as was the
percentage of records which included the patient’s valid General Medical Practice Code.
_________________________________________________________________________
“From entering the hospital for my out patients appointment I was very impressed with the staff.
They make you feel very welcome in a very friendly and relaxed atmosphere. The Consultant was very
good and understanding. The whole process from this first appointment to the date of my surgery
was a very good experience. The Nursing and Reception staff in the Pre-assessment unit were
excellent and nothing was too much trouble for any of them. They fully answered my questions and
they give you lots of information booklets to take home with you. The main concern of ALL the staff
was that the patients were comfortable and that they had everything they needed. I could not find a
single minor fault to comment on. As far as I am concerned the Horder Centre is a place of Excellence.
I will be delighted to go back again to have my other hip replacement done.” (Mrs. G)
Quality Account 2014-2015
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Private Healthcare Information Network (PHIN)
Horder Healthcare has and will continue to be part of the ongoing “Development Group” with
PHIN. Over the past year PHIN has introduced many new indicators onto the website. These
indicators consist of “Number of Beds”, “Number of Wards”, “Friends and Family Score” and
“Regulatory Information”.
Horder Healthcare is also a member of subgroups for specific topics “PROMS for Private
Patients” and “Clinical Coding”. These sub groups are to enhance PHIN even more with
changing the Independent Sector to match, if relevant, the NHS guidance of reporting and
clinical coding.
Information Centre
We embarked on the second phase of our information project, to advance health - giving
people health information, to enable them to prevent ill health or maintain their optimum
health. Our new web platform is in place: there are over 60 healthcare related articles and
12 new videos including Pilates, simple desk exercises, preparing for surgery and top tips for
warming up prior to exercise and for easing lower back pain. These videos are also
available as podcasts. A patient journey video has been created, showing off the unique
therapeutic environment of THC. There are currently eight consultant educational videos,
with more being formulated.
Information Governance
Horder Healthcare successfully submitted the Information Governance Toolkit for 2013/14 in
April 2014. This web-based self-assessment system is an effective way of demonstrating IG
compliance so as to be able to deliver NHS services. As an independent provider of NHS
services, there are 29 criteria for which there have to be correct processes in place and
evidence that they are being adhered to, ensuring that patients’ information is being used
correctly. Each of these criteria is graded on a 0-3 basis with 0 being failure and 3 being the
highest rating an organisation can achieve. As an independent provider of NHS services,
Horder Healthcare is required to achieve at least a Level 2 for each criterion. The final result
was, scoring 27 at Level 2 and with two criteria not being relevant to the organisation.
Overall this gives a score of 68%.
In addition to this, Horder Healthcare demonstrates its commitment to maintaining robust
processes in the management of patient information by its certification to the International
Standard on Information Security, ISO 27001. The appropriateness of processes was
confirmed at an Annual Assessment Visit in May 2014, where no non-compliances to the
Standard’s guidelines were identified. Horder Healthcare has also been awarded two gold
standards in the areas of “Business continuity” and “Risk management”. Re-certification is
due in May 2015.
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“Having referred a number of patients to The Horder over the years I had had good feedback, but
now I was using it as an NHS patient myself for the first time. The hospital has clearly got its priorities
right, because the staff SMILE when they welcome you, and from that point onward there is a sense
of order, knowledge, concern for your well-being and attention to detail like hygiene, cleanliness and
safety. The Horder staff clearly take a pride in the service they offer, and it shows!” (Dr MB)
Quality Account 2014-2015
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Capital Investment Programme
Our new build project has continued on schedule with the following areas having been
completed:
•
New accommodation for resident medical officers.
•
Landscaping of therapy courtyard enabling patients to be mobilised and exercise out
doors (weather permitting) giving access to practice walking on a variety of floor
surfaces, slopes, steps etc to fully prepare them for when they arrive home.
•
Ward and new kitchen plant room.
•
Diagnostic redevelopment to fully integrate with the outpatient department, provide
new changing facilities, waiting and office space.
•
Provision of an area of hard standing for a potential fixed MRI scanner as part of the
diagnostic redevelopment.
•
Refurbishment of ward inpatient rooms.
•
New ward sluice and treatment room.
We have also commenced the building of a new kitchen and dining room facility to be used
by staff and patients to be opened in July 2014. This will allow patients to access the dining
room from the ward for meal times to encourage social interaction and their return to daily
activities post surgery. We are also redeveloping the main entrance of the hospital to
improve the road surface, signage and therapeutic look of the Centre.
The other significant capital investment this year was the purchase of Seaford Day Hospital
which will be known as Horder Healthcare Seaford. The building is currently being
refurbished and is due to open in August 2014. The aim will be to provide outpatient
consultations, physiotherapy (to include group classes) and minor surgical procedures from
Seaford making services more accessible to the local population.
_________________________________________________________________________
“I want to give a testimonial for Debra and the Modified Intermediate Pilates class.
I have been coming for over a year now at this level and previously to your beginners’ class.
I really can see the difference in my general mobility and strengthening of my core. I find it very reassuring that Debra takes such care that we are doing everything correctly but at our level of ability,
whilst encouraging us positively to stretch ourselves!
I can highly recommend these classes - they are enjoyable whilst doing us good.” (Mrs. W)
Quality Account 2014-2015
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Statement from the Chairman of the Board
The Quality Account demonstrates the excellent level of healthcare that Horder Healthcare
provides to its patients. The data reflect the organisation’s continuing push to improve the
patient experience, outcome and subsequent quality of life. The Board places the highest
priority on maintaining these standards and will continue to assiduously monitor any and all
issues as they arise.
Dr Sue Grieve, Chairman, June 2014
_________________________________________________________________________
Statement from Co-ordinating Commissioner
“High Weald Lewes Havens Clinical Commissioning Group (HWLH CCG) has
reviewed the Horder Healthcare Quality Account 2013 – 2014 against the
requirements set out by the Department of Health.
The account evidences a strong focus on providing quality services that ensure high
levels of patient satisfaction and clinical outcomes. The Care Quality Commission
inspection report published in March 2014 was favourable of the organisation and
found them to be compliant with all assessed standards.
We hold meetings with Horder Healthcare to monitor and gain assurances on the
quality of services provided for our patients and to identify any early warnings of
concerns to be addressed. During the coming year we will be working with Horder
Healthcare to further develop the quality dashboard submitted on a monthly basis
and use to recognise areas of success or potential weaknesses. Quarterly site visits
will be completed to gain further assurance of quality alongside monitoring the locally
agreed Commissioning for Quality and Innovation (CQUIN) measures.
HWLH CCG can support that overall the document is an honest and accurate report
on the quality of services provided in 2013/14 providing the organisation with an
excellent platform from which to continue to improve quality in 2014/15.”
Wendy Carberry
Chief Officer
30 June 2014
Quality Account 2014-2015
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