uksh south west quality account 2009–2010 build on these strong foundations – continually...

UKSH SOUTH WESTQUALITY ACCOUNT

2009–2010

Emersons Green Devizes Cirencester NHS Treatment Centre NHS Treatment Centre NHS Treatment Centre

Contents

Executive summary

About UKSH South West

About this report

Part 1 Statement by the chief executive

Part 2 Quality objectives and mandatory statements

Objectives for quality improvement Reducing cancellations on the day Increasing VTE risk assessments Improving VTE prophylaxis Improving MEWs documentation Antibiotic surgical prophylaxis

Mandatory statements Review of services Audits Research CQUIN framework Statements from the Care Quality Commission Data quality Safeguarding statement from the UKSH Board

Part 3 Review of quality performance in 2009−10 Patient experience and feedback Clinical quality and outcomes Monitoring quality performance - regular clinical review Statements from NHS South Gloucestershire and South Gloucestershire Health Scrutiny Select Committee

2 UK SPECIALIST HOSPITALS

UKSH takes pride in providing the best possible service to patients throughout their care, from first appointment to our follow-up contact with them after treatment.

3QUALITY ACCOUNT 2009–2010


CQC Care Quality CommissionCQUIN Commissioning for Quality and InnovationDH Department of HealthDVT Deep-vein thrombosisMEWS Modified Early Warning ScoreIRMA Image Retrieval in Medical ApplicationsPCT Primary Care TrustPE Pulmonary embolismPROMs Patient-Reported Outcome MeasuresUKSH UK Specialist HospitalsUKSH SOUTH WEST The three centres opened in 2009: Cirencester / Devizes / Emersons GreenVTE Venous thromboembolism

Explanation of terms used in this report


UK Specialist Hospitals (UKSH) has opened three new NHS treatment centres in the South West during 2009-10. All have delivered excellent clinical outcomes and quality of care to NHS patients, building on the outstanding five-year track record of their sister site at Shepton Mallet.

These achievements mean we are able to set ambitious targets for the coming year across all our sites. Our key priority for improvement is to ensure the highest standards in patient safety, thereby paving the way for the best clinical outcomes.

Our specific targets for 2010−11 are:

Ensure the rate of cancellations on the day of surgery is no more than 4%

Carry out risk assessments for VTE (blood clots) for at least 95% of patients

Ensure that 100% of patients identified as being at risk of VTE receive the appropriate preventative measures

Carry out documented MEWS (Modified Early Warning Score - a system for detecting changes in a patient’s condition) measurements for at least 95% of patients

Ensure that 100% of patients receive appropriate antibiotic surgical prophylaxis according to protocol

During 2009-10 – in the five months since opening in November 2009 – the three UKSH South West sites have already produced results which compare favourably with established healthcare organisations.

Patient satisfaction is 98.5%, waiting times are low, lengths of stay are better than the national average and clinical outcomes are excellent.

We have had no cases of hospital-acquired MRSA bacteraemia or C. difficile. This Quality Account shows our determinationto build on these strong foundations – continually seeking to improve clinical outcomes and patient experience.

Executive summary

UKSH South West operates three treatment centres in the South West. The main facility is situated in North Bristol at Emersons Green and the other two centres are in Devizes, Wiltshire and Cirencester, Gloucestershire. UKSH South West works with its local NHS partners, including seven Primary Care Trusts, to offer high-quality, rapid access to planned treatments across a range of specialties for NHS patients. These PCTs are NHS Bristol, NHS South Gloucestershire, NHS North Somerset, NHS Swindon, NHS Wiltshire, NHS Gloucestershire and Bath, and North East Somerset NHS. All three centres opened in November 2009. The centres at Emersons Green and Devizes are new, purpose-built surgical hospitals. The centre in Cirencester is housed in a refurbished section of the existing Cirencester Hospital. UK Specialist Hospitals (UKSH), the parent company of UKSH South West, also operates the Shepton Mallet NHS Treatment Centre in Somerset. This site opened in July 2005 and has treated over 40,000 NHS patients to date. We employ over 300 skilled clinicians and support staff at our centres across the South West.

We treat a broadly similar patient population to that of a typical district NHS hospital, including elderly patients with stable chronic conditions such as diabetes.

Because of its setting and clinical mis-sion, UKSH does not undertake unplanned surgery. Also, any patients with unstable co-morbidities discovered at the time of pre-admission are referred elsewhere for management of their condition. Similarly, because there is no post-operative critical care unit, any patients expected to need this degree of support would be rerouted to an acute district general or specialist hospital.

Emersons Green NHS Treatment Centre

At Emersons Green in Bristol NHS patients can access planned procedures including joint replacements, minor orthopaedics, ophthalmology, endoscopy, general surgery, dental extractions, gynaecology, ear, nose and throat treatments, urology and diagnostic services. Emersons Green offers day case and inpatient treatment through its 33-bed facility. It has four operating theatres, an endoscopy suite, a day surgery facility, a comprehensive diagnostic department and physiotherapy services. Devizes NHS Treatment Centre

The centre at Devizes delivers a comprehensive range of day case procedures. It also offers convenient outpatient appointments for procedures such as joint replacements, for which the surgery is then undertaken at Emersons Green.

6

About UKSH South West

UK SPECIALIST HOSPITALS

7

Devizes NHS Treatment Centre offers services to NHS patients in the following areas: ophthalmology, minor orthopaedics, ear, nose and throat procedures, gynaecology, urology, dental extractions, endoscopy, general surgery and diagnostic services.

Cirencester NHS Treatment Centre The Cirencester NHS Treatment Centre specialises in day case procedures in several specialty areas: minor orthopaedics, ear, nose and throat procedures, gynaecology, urology, dental extractions, general surgery and diagnostic services. As at Devizes, patients can have their outpatient appointment at Cirencester and then the surgery at Emersons Green hospital. More information about UK Specialist Hospitals and its treatment centres in the South West is available on the website www.uk-sh.co.uk

QUALITY ACCOUNT 2009–2010

More information about UK Specialist Hospitals and its treatment centres in the south west are available on the website www.uk-sh.co.uk

UKSH is pleased to participate in the Department of Health’s new Quality Accounts reporting system.

UKSH has previously produced regular reports on performance data such as numbers of operations and the success of the outcomes for its facility in Shepton Mallet. These are published on our website (www.uk-sh.co.uk) and will be replicated for our new sites in the South West on an annual basis starting in November 2010.

Quality Accounts complement this information by placing particular focus on the quality of patient experience. They allow for comparability across providers and also give us the opportunity to identify areas for future improvement and to monitor our success in delivering on these.

The structure of our report follows the guidelines from the Department of Health and is arranged as follows:

Part 1 Statement by the chief executive

Part 2.1 Priorities for future improvements and details on how we plan to achieve them

Part 2.2 Information on areas common to all providers, following detailed guidelines set by the Department of Health

Part 3 Performance report for 2009−10 on the quality of care provided at UKSH South West NHS Treatment Centres

This Quality Account relates to our facilities in Emersons Green (Bristol), Cirencester and Devizes. A separate Quality Account is available for our sister site at Shepton Mallet.

As the UKSH South West sites only opened in November 2009 this report relates to the five months of 2009–10 during which we were operational.

8

About this report


The model of focused care which underpins the service we provide across our centres has enabled us to deliver excellence in clinical outcomes.


UK Specialist Hospitals (UKSH) welcomes the introduction of Quality Accounts into the NHS. Meaningful data provision is a cornerstone of our model of care and UKSH has always given patients and commissioners detailed information about clinical outcomes and patient experience. We believe this is crucial to enable patients to exercise proper choice and to hold NHS service providers to account.

The focus on quality of care which is at the heart of this new reporting system is important to us. UKSH takes pride in providing the best possible service to patients throughout their care, from first appointment to our follow-up contact with them after treatment.

The model of focused care which underpins the service we provide across our centres has enabled us to deliver excellence in clinical outcomes. The six principles governing our approach are: insistence on clinical best practice; extremely careful recruitment; ongoing staff training; intensive monitoring of performance; extensive reporting on patient satisfaction and clinical data; and full implementation of patient safety guidelines. These are implemented so that care is responsive to individual needs with flexible patient-focused pathways.

This approach has led to some outstanding clinical results. For example, we have a zero rate of hospital-acquired MRSA bacteraemia and low rates of re-admission and clinical complications at all our sites.

The baseline from which we start in 2010−11 is therefore high. This Quality Account now sets us the challenge to further improve our performance, and in response we have identified areas where we can take specific measures to attain the very highest standards in patient experience, patient safety and clinical effectiveness.

Our priorities for improvement in the coming year arise from patient feedback, our own insight into where we can further refine clinical success, and from wider national healthcare objectives to which we contribute. We will be seeking to exceed local, regional and national NHS targets and to respond directly to what patients tell us is important to them.

We will take initiatives to reduce the number of cancelled operations, minimise the risk of blood clots and improve recognition of early warning signs during treatment so that action can be taken to ensure patient safety and excellent clinical outcomes.

I am confident that through the commitment of our staff and the support and advice from our independent Clinical Advisory Board and UKSH Board we will deliver on these objectives and continue to provide high-quality patient care.

I confirm that to the best of my knowledge the information presented in this document is accurate.

Fiona Calnan Chief Executive

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Part 1Statement by the chief executive



In 2010−11 UKSH South West NHS Treatment Centres aim to improve quality of care in five areas:

Cancellations on the day of surgery

Risk assessments for VTE (blood clots)

Measures to prevent VTE for at-risk patients

Documentation for MEWS – the early warning system for detecting changes in a patient’s condition

Correct use of antibiotics

These priorities will ensure higher standards across all the key factors that make up successful healthcare: patient experience, patient safety and clinical effectiveness.

Our specific targets for 2010−11 are:

Ensure the rate of cancellations on the day of surgery is no more than 4%

Carry out risk assessments for VTE (blood clots) for at least 95% of patients

Ensure that 100% of patients identified as being at risk of VTE receive the appropriate preventative measures

Carry out documented MEWS measurements for at least 95% of patients

Ensure that 100% of patients receive appropriate antibiotic surgical prophylaxis according to protocol

Part 2Quality objectives

As part of our ongoing commitment to providing the best possible service to our patients, we will prioritise these objectives to ensure the quality of care at our centres is of the highest standard over the next twelve months.

In selecting these objectives we have considered each of the key aspects of healthcare as determined by the Department of Health: patient experience, patient safety and clinical effectiveness. Some of our commitments will address more than one of these areas: for example, our priorities for improving patient safety during operations will also improve the clinical outcomes of those procedures.

UKSH has an exceptionally strong record on clinical quality and outcomes.

This is in part due to our insistence on minimising unnecessary risk to patients. Building on this strong foundation we are able to focus on areas where we believe we can continue to improve our clinical effectiveness.

Progress on achieving these goals will be monitored on a monthly basis by the Board of UK Specialist Hospitals and the Clinical Advisory Board and we will report back to you on this in next year’s Quality Account. More information about our monitoring processes and monthly clinical review is given in part 3 below.

Our objectives and the initiatives we will take to achieve them can be summarised as follows:


Objective

Low rate of cancellations on the day

Increase risk assessments for VTE (blood clots)

Improve VTE prophylaxis (measures to prevent at-risk patients developing blood clots)

Improve MEWS documentation

Safe use of antibiotics

Target

Ensure on the day cancellation is no more than 4%

At least 95% of patients receive risk assessment

100% of patients receive appropriate preventative measures

MEWS documentation for at least 95% of patients

100% of patients receive appropriate antibiotic prophylaxis

Key healthcarearea

Patient experience

Patient safety & Clinical effectiveness



Patient safety

Initiatives plannedfor 2010-11

• Checkpatients’understandingof pre-operation guidance• Newstaffguidelinesonpre-operative tests• Bettertrainingforbookingstaff

• StafftraininginnewVTEe-learningtool• Allpatientstoreceiveliteratureon VTE prevention

• VTEpreventionpartofmandatory, ongoing staff training• InvolvemorestaffinreviewofVTEaudits

• Quarterlyauditstoensureincreased staff training is effective

• Quarterlyaudits• Newtrainingifnecessary


Reducing cancellations on the day– for a better patient experience

We take pride in our ability to offer dates for surgery where all parties have confidence that the procedure will go ahead on the planned date. Over 92% of procedures take place as anticipated on the day of surgery.

While this is a strong record, we want to address that remaining 8% of cases, because we know that cancellation on the day of a planned operation is not only inefficient, but also causes distress and inconvenience to the individuals affected. Patient feedback has alerted us to this concern, and we have explored the issue in focus groups.

We can identify both clinical and non-clinical ways to address cancellations on the day: Clinical:

Ensure pre-operative guidance for patients is followed

Take appropriate actions following test results

Non-clinical:

Ensure specific equipment needed is available

Communicate fully with patients to reduce cases of DNA (‘does not attend’)

UKSH has a series of systems and processes already in place to reduce these occurrences, including a dedicated team of clinical staff who contact all patients prior to surgery.

Although some cancellations are not preventable, for example those due to patient illness or adverse weather conditions making travel difficult, we believe we can be even more successful in minimising the remaining number.

Target:

Reduce cancellations on the day of surgery to no more than 4%, so that at least 96% of operations go ahead on the planned date

This will be measured as the average on-the-day cancellation rate for the last 6 months of next year, allowing the first 6 months as a period to implement the improved protocols. The measurement will include all cancellations, even those caused by events which are beyond our control.

As a first step we have examined the implementation of the internal written guideline on the management of pre-operative tests for Resident Medical Officers that we have had in place since opening. This identifies patients whose test results have either not been returned or that reveal additional actions need to be taken. It ensures timely and appropriate action is taken wherever possible to prevent cancellation.

We plan to supplement the implementation of this guideline with a series of initiatives that will help us achieve our target to reduce cancellations on the day, including:


Immediate actions

Staff in the Outpatient department to check each patient’s understanding of the pre-operative guidance before they leave the treatment centre.

All patients to receive reminder notifications prior to surgery, and UKSH to measure success rates of contacting patients.

To be implemented within three months

Implementation of procedures to ensure that social care or home equipment packages are delivered and verified prior to surgery.

Train booking staff in the completion of booking forms which highlight specific equipment requirements to ensure equipment availability.

Monitoring the time elapsed between outpatient appointments and surgery to ensure that tests such as MRSA swabs are still current.


Our second objective relates to the nationwide drive to reduce the risk to patients from blood clots (VTE) – one of the NHS’s Commissioning for Quality and Innovations (CQUIN) goals for 2010−11. This national initiative is supported by new guidelines published by the National Institute for Clinical Excellence (NICE) in January 2010: ‘CG92 Venous Thromboembolism − Reducing the Risk’.

Venous thromboembolism (VTE) is the formation of a blood clot in the veins. It most commonly occurs in the deep veins of the leg or pelvis, when it is known as deep-vein thrombosis (DVT). An embolism occurs if all or part of the clot breaks off from the site where it forms and travels through the venous system. If it lodges in the lungs, this is called pulmonary embolism (PE). Deep-vein thrombosis (DVT) and pulmonary embolism (PE) are the most common manifestations of VTE and are a significant complication of surgery, with an associated incidence of mortality.

With approximately 25,000 people dying of preventable VTE every year in the UK, it is clear that this is a crucial area for improvement nationally. At UKSH we have an excellent record on the prevention of VTE, with no VTE-related mortality, and we will continue to play our part in raising the standards across the country.

At UKSH we have already implemented much of what is set out in the new NICE guidelines: we have incorporated a VTE risk-assessment tool into the clinical care pathway for our patients, and regular internal audits are undertaken to monitor compliance with this tool. In 2010−11 we will adopt the revised VTE risk-assessment tool which has been produced by the Department of Health, and we will comply with the new reporting framework.

We currently carry out risk assessments for all our patients except those undergoing ophthalmic treatments and endoscopy, where the risk of VTE is low because the procedures are relatively non-invasive. However, in line with the new guidelines, going forward we will include all patients in the risk assessments.

In order to make a real contribution to this national initiative, our own target for increasing VTE risk assessments will be higher than the target set nationally, to reflect the high baseline we have already achieved across all our centres.

Target:

At least 95% (national target 90%) of patients admitted to our centres will be assessed for risk of VTE Because UKSH South West opened during 2009−10, a complete set of audited baseline data for last year is not available.

Increasing VTE risk assessments– to improve patient safety and clinical effectiveness

New initiatives in 2010−11 will include:

Training in use of the new VTE e-learning tool from the Department of Health for all staff. This will be incorporated as part of the induction and mandatory training programme for staff.

Provision of patient literature on VTE prevention for all patients, irrespective of their need for preventative measures (prophylaxis). Currently UKSH provides patient literature to all patients receiving prophylaxis.

The implementation of these initiatives will be led through our Clinical Governance committee and will be monitored on a monthly basis.


99.7% of our patients say they would recommend our treatment centre to a friend.


Improving VTE prophylaxis– to maximise patient safety and clinical effectiveness

In addition to implementing the new NICE guidance on risk assessments for VTE, UKSH will ensure that every patient identified as being at increased risk of VTE receives appropriate preventative measures (prophylaxis).

The 2010 national guideline on VTE published by NICE includes specific recommendations for VTE prophylaxis for different kinds of operation. We have already incorporated these recommendations into our VTE policy. The recommended preventative measures include giving patients compression stockings, special pressure boots during and after the procedure and prescribing antithromboembolytic medication (to thin the blood temporarily).

Target:

100% of patients identified as being at increased risk of VTE receive the recommended mechanical and pharmacological prophylaxis at the right time and for the appropriate duration

Because UKSH South West opened during 2009−10, a complete set of audited baseline data for last year is not available.

New initiatives in 2010−11

VTE assessment/prevention updates as part of standard mandatory training to ensure all staff are aware of the significance of this initiative on an ongoing basis.

Review of VTE audits at specialty-based clinical meetings in addition to the standard review at clinical governance meetings to ensure that clinicians and all members of the multidisciplinary team understand their responsibility for delivering the initiative.

We will carry out internal audits on a quarterly basis to ensure that all patients at risk of developing VTE are receiving the appropriate prophylactic measures.



The Modified Early Warning Score (MEWS) is a method of monitoring patients that allows changes in their condition to be recognised in time for action to be taken. This can be crucial in ensuring successful clinical outcomes.

The MEWS system is based on routine observations and is sensitive enough to detect subtle changes in a patient’s physiology. All patients have their vital signs measured and these are converted into a score. If the scores reach above a certain threshold, a doctor must be called to assess the patient. This process will identify patients who may need transfer to an acute hospital for timely and appropriate interventions.

For the MEWS system to work it is vital that the measurements are taken routinely and properly documented. This ensures that a baseline status for each patient is established and any deterioration is quickly recognised.

UKSH will therefore focus on ensuring that its staff carry out and document MEWS checks.

Target:

Carry out documented MEWS measurements for at least 95% of patients


Quarterly audits will be undertaken to assess compliance and will continue to be monitored at our Clinical Governance meetings.

Improving MEWS documentation– to maximise patient safety and clinical effectiveness


Our final objective is to ensure the safe use of antibiotics at our treatment centres, in order to fight infections effectively. While rates of both hospital-acquired MRSA bacteraemia and C. difficile are currently nil at our new facilities, we are keen to participate in nationwide initiatives to reduce all healthcare-associated infections in healthcare settings.

Antibiotics are an important tool in treating patients and preventing infections. At the same time, the inappropriate use of antibiotics can in some cases leave patients more exposed to other infections.

Nationally, while significant reductions have been achieved in recent years in the occurrence of MRSA bacteraemia and C. difficile infections, new guidelines now show that better-targeted antibiotics can prevent a wider range of infections.

Current evidence demonstrates that the use of broad-spectrum antibiotics makes patients more susceptible to harmful antibiotic-resistant bacteria such as Extended-Spectrum Beta-Lactamase (ESBL) gram negative bacteria. Broad-spectrum antibiotics should therefore be avoided unless there are clear indications for their use. We have updated our Antimicrobial Surgical Prophylaxis protocol in 2009 in line with this national guidance.

Monitoring the use of antibiotics within the healthcare setting is a key initiative in the NHS Saving Lives campaign.

To ensure that all patients are receiving appropriate prophylaxis but not receiving unnecessary antibiotic treatment, UKSH will audit quarterly the prescribing and administration of antibiotic use against the agreed protocols.

Target:

100% of patients are prescribed and receive the appropriate antibiotic surgical prophylaxis according to protocol

This means:

100% of patients receive one dose of antibiotic(s) pre-operatively on induction of anaesthesia or within 60 minutes prior to incision

The clinical indication of additional use of antibiotic is recorded in 100% of cases


New initiatives in 2010−11:

Sharing of this audit at all specialty-based meetings as well as Infection Control meetings

If we find non-compliance we will introduce update training for staff to rectify this

Antibiotic surgical prophylaxis– to improve patient safety


We are keen to participate in nationwide initiatives to reduce all healthcare-associated infections in healthcare settings.

The following section contains the mandatory statements common to all Quality Accounts as required by the regulations set out by the Department of Health.

Review of services

During 2009−10 UKSH South West NHS Treatment Centres provided the following NHS services:

• Orthopaedicssurgery (Joint replacements and Minor)

• GeneralSurgery (including colonoscopy)

• OphthalmicSurgery (including cataracts and minor eyelid procedures)

• OralSurgery

• MinorUrologyincludingcystoscopy

• Gynaecology

• EarNoseandThroatSurgery

• Imaging(X-rayandUltrasound) UKSH South West has reviewed all available data on the quality of care in these NHS services.

The income generated by the NHS services reviewed in 2009−10 represents 100% of the total income generated from the provision of NHS services by UKSH South West for 2009−10.

Audit

During 2009−10, two national clinical audits and no national confidential enquiries covered NHS services that UKSH South West provides.

During that period UKSH South West participated in 100% of the national clinical audits and 100% of the national confidential enquiries in which it was eligible to participate.

The national clinical audits and national confidential enquiries that UKSH South West participated in during 2009−10 are as follows:

• PROMs(4specialties)

• NJRHipandkneereplacements

The national clinical audits and national confidential enquiries that UKSH South West participated in, and for which data collection was completed during 2009−10, 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.

National Specialty

Mandatory statements


National Specialty Cases submitted asclinical audit percentage of cases required

PROMs Hip replacements 98.7%

PROMs Knee replacements 97.2%

PROMs Hernias 97.3%

PROMs Varicose veins 100%

NJR Hipreplacements 100%

NJR Kneereplacements 100%

The reports of 2 national clinical audits were reviewed by the provider in 2009−10 and UKSH South West intends to take the following actions to improve the quality of healthcare provided.

PROMs (Patient Reported Outcome Measures) measure how patients perceive their health has improved following treatment. From 1 April 2009, all providers of NHS-funded care have collected PROMs information. So far, the NHS Information Centre has published only pre-operative data. Post-operative information will be published during the summer of 2010 and this will allow the effect of treatment to be assessed.

Because we are waiting for the results of this ongoing audit, no action has yet been taken, except for discussions at board level about the completeness of PROMs data.

The National Joint Registry (NJR) is a monitoring database which tracks joint replacement procedures carried out throughout England and Wales. Since opening in November 2009 Emersons Green NHS Treatment Centre has submitted 100% of its hip and knee procedures to the NJR. As newly opened facilities, UKSH South West will not receive data back from the NJR until next year, when it will review the results.

Results on all procedures, including hip and knee replacements, are routinely monitored through our internal clinical governance processes. These show excellent clinical outcomes.


The reports of 8 local clinical audits were reviewed by the provider in 2009−10, and UKSH took all appropriate actions to improve the quality of healthcare provided.

The local clinical audits carried out were:

Audit

Hand hygiene

Infection prevention & control

Waste − clinical & non-clinical

Sterile Services

Information Governance

World Health Organisation (WHO) surgery checklist

Medical staff

Resuscitation

Pharmacy including Controlled Drugs audits andPrescription chart audit

Record keeping

Action

Comply with HPA requirements

Comply with HPA requirements

Comply with: HPA Health & Safety requirements

Ensure ongoing compliance with QMS 13485

Ensure ongoing compliance with: ISO 27001 IGSOC

Comply with WHO guidelines

Comply with skills, experience and competency standard as set by the External Clinical Advisory Board

Ensure best practice in resuscitation technique

Comply with National Policy & Legislation

Ensure best practice in record keeping

Monitoring results

Quarterly

All positive results audited, identifies any organism trends

Quarterly

Monthly tray list

Six-monthly external audits.Rotational internal audit plan in place

Monthly audit

Start of engagement; then at 3 months; then annual or as required

Bi-monthly audit

Monthly

Monthly Audit


Research

The number of patients receiving NHS services provided by UKSH South West in 2009−10 that were recruited during that period to participate in research approved by a research ethics committee was nil.

CQUIN(CommissioningforQualityandInnovation)Framework

UKSH South West income in 2009−10 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework because this is not included in the contractual arrangements currently in place.

Statements from the Care QualityCommission(CQC)

Each of our South West sites − Emersons Green, Devizes and Cirencester − are required to register separately with the Care Quality Commission. Their current registration status dates from November 2009.

The Care Quality Commission has not taken enforcement action against any of the three centres during 2009−10.

All three sites will be subject to periodic reviews by the Care Quality Commission; there were no reviews during the first five months of operation to the end of 2009–10.

UKSH South West has not participated in any special reviews or investigations by the CQC during the reporting period.

Data quality

All UKSH South West sites have submitted records during 2009−10 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:

100% for admitted patient care; and 100% for out patient care.

-which included the patient’s valid General Medical Practice Code was:

100% for admitted patient care; and 100% for out patient care.

UKSH’s score for 2009−10 for Information Quality and Records Management, assessed using the Information Governance Toolkit, was 68%.

As a result of a continuing improvement programme on Information Governance, UKSH has identified that for the forth-coming year 2010−11 this assessment is likely to be 80+%.

UKSH was not subject to the Payment by Results clinical coding audit during 2009−10 by the Audit Commission.


Safeguarding statement from the UKSH Board

The Board is satisfied that UKSH is compliant with the following safeguarding requirements:

UKSH meets the statutory requirement with regard to the carrying out of CRB checks on all staff.

Safeguarding policies and systems for Children and Vulnerable Adults are up to date and robust.

All eligible staff have undertaken and are up to date with safeguarding training at Level 1. This is included in Induction and mandatory training. A review of other training arrangements is ongoing, taking account of emerging messages from the national review of safeguarding training.

Named professionals are clear about their roles and have sufficient time and support to undertake them.

There is a Board level Executive Director lead for safeguarding. The Board reviews safeguarding across the organisation at least once a year.


Since our new centres opened in November 2009 we have maintained the excellent record established by Shepton Mallet NHS Treatment Centre on infection prevention, with no cases of hospital-acquired MRSA bacteraemia or C. difficile in 2009−10 at any of our facilities.

Our commitment to clinical best practice, careful recruitment and ongoing training is translating into outstanding clinical effectiveness. The new sites have achieved low rates of re-admission and returns to theatre.

Patient surveys carried out by UKSH at the new sites already demonstrate high patient satisfaction.

Patient experience & feedback

At our sister site in Shepton Mallet, UKSH has always paid careful attention to the quality of patient experience and sought feedback and opinions from patients. The understanding of patient needs gained in this way has meant the new South West sites have been able to offer an exceptional service from the outset.

Examples include:

• Good travel directions with free and ample car parking

• One-stopoutpatientvisits (iealldiagnosticstakenonthesameday)

• Timedvisitssopatientsdonotwait for outpatient visits diagnostics or surgery once they enter the facility

• On-sitekitchenpreparinghealthy cuisine with fresh ingredients

• Single-sexaccommodation

• Ensuitefacilitiestopatientrooms

• FreeWiFiaccessandphonecalls

A key factor in patient satisfaction is the overall waiting time for patients from referral to receiving surgery. UKSH strives to provide the shortest possible waiting times for patients with options to attend on a variety of dates and times.

Total waiting times for surgery at the new sites are on average below ten weeks, and we expect to reduce this futher during 2010-11.

Part 3Review of quality performance in 2009–2010


UKSH undertakes a monthly patient satisfaction survey in which all patients attending for surgery are asked their views on their experience at the UKSH South West treatment centres.

In 2009−10 we achieved a high satisfaction rate across all aspects of our service, with 99.7% of patients saying they would recommend our treatment centre to a friend.

Patients reply to 10 questions on a scale of 1 (bad) to 5 (excellent). UKSH measures satisfaction as including all responses graded 4 and 5. Responses between November 2009 and March 2010 (777) indicate the following:

Question % Satisfied

Q1 How long did you wait after you had chosen to come to the treatment centre? 87.2%

Q2 Were our booking staff helpful and efficient? 98.0%

Q3 Was it easy for you to get to and park at the treatment centre? 87.2%

Q4 How long did you have to wait before you were seen at Out Patients? 86.2%

Q5 Did the Out Patient staff meet your expectations? 96.8%

Q6 How long did you wait on the day of surgery? 84.4%

Q7 Did the surgical staff meet all your expectations? 98.2%

Q8 Did you experience any problem post discharge? 97.8%

Q9 Did the ward staff (nurses, physios) meet your expectations? 97.8%

Q10 Did the catering meet your expectations? 92.8%

Q11 Was the treatment centre welcoming and clean? 99.2%

Wouldyourecommendthetreatmentcentretoafriend?(yes) 99.7%

Any negative comments received either in surveys or by letter are followed up by a dedicated team. The patients are contacted, where a contact address is supplied, and their concerns are addressed through the Clinical Governance process chaired by the Medical Director of UKSH.

UKSH has placed further emphasis on the role of patient feedback by incorporating patient satisfaction questionnaires into the review of medical staff during their probationary period.


Clinical quality and outcomes

Achieving clinical quality and high patient satisfaction are not add-on programmes at UKSH but are fundamental to our approach to care. This is based on a model of focused care, where a high volume of specialty care is carried out in small, focused facilities.

The teams that perform these high-volume specialties have undergone intensive training to arrive at extremely high levels of clinical quality and productivity. The whole administrative structure, support staff and facility are designed around this model, with a focus on delivering the best patient experience throughout the patient pathway: from one-stop assessment and diagnostics to early, intensive physiotherapy as required, early, healthy discharge home, and follow-up care.

Supporting and building on the focused care model are the following six principal elements of UKSH’s approach:

A. Clinical best practice: Extensive identification and use of international best practice clinical guidelines embedded in clinical pathways and protocols. UKSH believes it has the most detailed and comprehensive pathways and protocols in place for the procedures it offers of any provider in the UK and insists on uniform application of proven approaches.

B. Recruitment: Extremely careful recruiting and credentialing of doctors who have long-term experience in the specialties UKSH performs. UKSH has excellent consultant staff from the UK, Scandinavia, the United States and other countries.

C. Ongoing training: A commitment to in-service clinical staff training. UKSH expects and pays for all clinical staff to engage in ten days of training every year.

D. Performance monitoring: Intensive monitoring of performance to spot and deal with anomalies with very responsive turnaround times.

E. Transparency: UKSH has published on its website one of the most extensive array of clinical and patient satisfaction data of any clinical provider in England.

F. Safety: Full implementation of patient safety guidelines, including ‘time outs’ for the surgical team just before operations.


The performance data for the three UKSH South West sites demonstrate our excellent clinical effectiveness:

A high daycase rate – where we complete a procedure within one day so that patients do not have to stay overnight

Zero rates of deep-vein thrombosis (DVT)

One incidence of pulmonary embolism (PE) within the context of 2,367procedures

A very low rate of wound infection

Low rates of unplanned returns to theatre and re-admissions

2009−2010 Clinical Effectiveness

Mortality 0.00%Lengthofstay(Joint) 4.1daysDaycaserate(excl.Jointreplacementsurgery) 94.00%DVT 0.00%PE 0.04%Unplanned returns to theatre 0.17%Emergency re-admissions 0.67%Regional/localanaestheticrate 74.00%

UKSH is committed to providing data to enable its performance across its treatment streams to be compared with other organisations, national indices and contractual performance indicators. We have commissioned independent research to compare our performance with other UK health providers but at present there is a lack of substantial data elsewhere to allow clear case-mix adjusted comparisons.

We are actively working to improve this situation, but at the moment, this means we cannot provide clear benchmark data for the figures listed above. However, from the information that we do have available, we are confident that these figures compare very favourably with other providers of similar care in the UK.

UKSH intends to play its full part in establishing quality indices that measure quality throughout the patient pathway as the health quality agenda progresses in the UK.


Monitoring performance – regular clinical review

UKSH undertakes a robust integrated clinical governance and risk management programme which monitors clinical quality and outcome performance by individual surgeons every month.

This includes a detailed review of clinical outcomes at a subspecialty level for each surgeon examining factors such as returns to theatre, DVT or PE rates. It also includes taking action in response to any trends or variances.

As part of our commitment to transparency, UKSH has published annual reports of DVT and PE rates for its hospitals which were far more detailed than those published by many other organisations before the introduction of Quality Accounts. Going forward, we will incorporate this process into the Quality Account framework. We also provide referrers with detailed scorecards of each surgeon’s personal performance.

UKSH formally meets with its commissioners of service on a quarterly basis. During this process, known as a Joint Service Review (JSR), we present a detailed report of clinical and operational performance covering all aspects of the service including re-admission rates, operational cancellation rates, untoward incidents and patient satisfaction. These are scrutinised by the commissioners on the JSR panel who can draw on formal procedures for monitoring improvement if appropriate.This process allows for greater scrutiny and risk management and enables the sharing of best practice across the local health network.


Statement from NHS South Gloucestershire

NHS South Gloucestershire, as lead commissioner for UKSH South West NHS Treatment Centres, is delighted to have had the opportunity to comment on the first annual Quality Account. This is an important requirement for all organisations providing care for NHS patients, and recognises the importance of utilising both patient experience feedback and clinical outcomes in the drive to continually improving the quality of health services.

The document has a clear structure which is compliant with the DH Quality Account toolkit, and the introduction provides comprehensive information on the context, purpose and future direction of the organisation.

The PCT fully supports the clear targets outlined in the executive summary that incorporate clinical quality, effectiveness and patient safety. UKSH has a valuable role within the wider health community and we are keen to offer patients greater choice for high quality care and patient satisfaction.

Specific targets identified for 2010−11 are measurable ensuring defined criteria to demonstrate both achievement and improvement. The inclusion of Venous Thromboembolism (VTE) prevention objectives is a national and local priority and demonstrates a strong clinical commitment to VTE management in preventing potentially avoidable deaths from Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE).

UKSH has demonstrated its commitment to high quality services that is evident within the Joint Services Review (JSR) meetings held with the PCT.

This first Quality Account provides an excellent baseline position and we look forward to continuing to work with you to meet the quality aspirations of local users, partners and staff.

Alison RobinsonDirector of Clinical DevelopmentNHS South Gloucestershire

Statement from healthcare partners

In producing this Quality Report UK Specialist Hospitals consulted with the following bodies:

NHS South Gloucestershire

South Gloucestershire Health Scrutiny Select Committee


Statement from South Gloucestershire Health Scrutiny Select Committee

The South Gloucestershire Health Scrutiny Select Committee considered the UKSH South West Quality Account 2009−10 at its meeting on 26th May 2010.

Cancellations – we are concerned about the high incidence of cancellations and have been advised that these are largely avoidable cancellations by day case surgery patients. We are pleased that cancellations for joint replacements are relatively low, which probably bears relation to the extensive pre-operative procedures that are undertaken.

Venous Thromboembolism (VTE (blood clots)) – we are encouraged that all appropriate patients receive a VTE (blood clot) assessment on admission. The Committee also noted that mortality from VTE (blood clots) is a national and international problem, and all NHS are working to the NHS’ Commissioning for Quality and Innovations (CQUIN) goals for 2010−11.

Literature – we are pleased that all literature is available in Braille and languages common to the Bristol area, and further clarification can be provided to patients as required.

Follow up phone calls – we praise the organisation on its commitment to making a follow up phone call to patients after they have been discharged.

The Committee notes that due to the Emersons Green Treatment Centre only opening in November 2009, the QA is not based on a full year’s work. However, the Committee looks forward to being able to comment on a full year’s activity in 2010−11.

To close the Committee would like to thank Edward Lotz, Executive Director at UKSH South West for attending the meeting to answer members’ questions.

Councillor Sandra GrantChair, Health Scrutiny Select CommitteeSouth Gloucestershire Council

15th June 2010

Contact: Claire Rees, Democratic Services Officer, 01454 864116, [email protected]

Providing the treatment our patients need in the surroundings they deserve.

Version 1 June 2010

uksh south west quality account 2009–2010 build on these strong foundations – continually...

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