The Edinburgh Clinic Quality Account

Transcription

1 The Edinburgh Clinic Quality Account EC A4 Quality Accounts AW.indd 1 25/08/ :15

2 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. Christine Allan Clinic General Manager 1323 EC A4 Quality Accounts AW.indd 2 25/08/ :15

3 Contents Introduction 05 Statement on Quality 06 Accountability Statement 07 Statements on Assurance Relating 08 to the Quality of NHS Services Provided Statement on Data Quality 10 Review of Aspen s Quality Performance /2015 Complaints Indicator 2014 / Aspen Healthcare 20 Statement on Quality from the 23 Chief Executive Aspen Healthcare Quality Priorities for / EC A4 Quality Accounts AW.indd 3 25/08/ :15

4 The Edinburgh Clinic is committed to excelling in the provision of the highest quality healthcare services and are proud to have been formally awarded AfPP accreditation. Christine Allan Clinic General Manager Aspen Healthcare is the first healthcare provider to achieve national quality standards for perioperative practice and accreditation across all of its theatres from the Association for Perioperative Practice (AfPP) EC A4 Quality Accounts AW.indd 4 25/08/ :15

5 Introduction Located in Edinburgh, Scotland, The Edinburgh Clinic day case hospital is a private diagnostic and day surgery centre founded in 2008 and in 2011 became part of Aspen Healthcare. The facility comprises of a theatre suite, outpatient clinics with specialist consultants, supported by onsite physiotherapy, MRI, CT, Ultrasound, X-ray and surgical facilities. During ,740 outpatients attended for outpatient care and 3,296 day case surgery Our facilities Operating Theatre 1 On-site Eye Clinic Consulting Rooms 7 Patient Reception Areas 1 Discharge Lounge The Haven 1 Diagnostics suite comprising: Diagnostics MRI 1 Diagnostics CT 1 Free Parking Private GP Services Physiotherapy Diagnostics Ultrasound 1 Diagnostics X-ray 1 Diagnostics DXA 1 04/ EC A4 Quality Accounts AW.indd 5 25/08/ :15

6 Statement on Quality We are proud to present our first Quality Account. Our commitment to quality is evidenced by our high quality performance and aspiration to continually improve the outcomes and experience for our patients. We have aimed to provide an objective indication on what has been achieved over the last year and to identify where we want to make improvements during The delivery of a high quality service has always been at the heart of our organisation and we want everyone to have complete confidence that The Edinburgh Clinic will provide the best care for all patients. Our aim as an organisation is to provide safe, effective and personalised care to every patient, every day. As part of Aspen Healthcare there is a well-established Integrated Governance structure, ensuring all the necessary controls are in place to confirm clinical excellence and that The Edinburgh Clinic is properly managed and directed at all times. We have a comprehensive audit programme in place that demonstrates all our clinical professionals deliver high quality, good clinical outcomes, which meet or exceed the expectations of our patients. Through the dedication of all of our team, we continuously have very high levels of patient satisfaction and extremely low rates of dissatisfaction. The Edinburgh Clinic continues to have no hospital acquired infections and has a zero tolerance to MRSA, MSSA or C. difficile infections EC A4 Quality Accounts AW.indd 6 25/08/ :15

7 Accountability Statement This Quality Account covers the reported year 1st April 2014 to 31st March All NHS/ Healthcare providers in England have been required to produce an annual Quality Account since This is not a requirement for Healthcare providers in Scotland however, The Edinburgh Clinic is keen to share this information with key service users, patients and their families giving valid information about the current quality of our services and our plans to improve even further. The Scottish Patient Safety Programme (SPSP) aims to improve the safety reliability of healthcare and reduce harm whenever care is delivered. Five principles of this programme have been utilised by the Clinic to improve the quality of care provided. These include; + + Hand Hygiene: Our link Infection control link practitioner nurse routinely audits all the medical/clinical staff and our results are constantly %. + + Training: All staff receive mandatory training regarding the importance of hand hygiene in relation to quality of patient care. + + Early Warning Scores: All patients having a general anaesthetic are monitored frequently using the Early Warning Score observation chart. This helps to monitor the patient s condition giving clear guidelines on the specific care and treatment to be delivered. + + Safety Briefs: We conduct Daily Safety Briefs within the clinic paying particular attention to any safety issues regarding patient care. + + Leadership walkabouts: Our Clinic Manager meets with all departmental staff on a daily basis. We regularly audit care delivery at The Edinburgh Clinic and this gives us the opportunity to share good practice and enhance our patient safety culture. To the best of my knowledge, the information in this report is accurate. Christine Allan Clinic General Manager 1st May 2015 This report has been reviewed and approved by: Mr Laurence Stewart (Medical Advisory Committee Chairperson, The Edinburgh Clinic) Des Shiels (CEO, Aspen Healthcare) Judi Ingram (Clinical Director, Aspen Healthcare) Christine Allan (Clinic General Manager, The Edinburgh Clinic). 07/07 06/ EC A4 Quality Accounts AW.indd 7 25/08/ :15

8 Statements on Assurance Relating to the Quality of NHS Services provided Review of Services During April 2014 to March 2015 The Edinburgh Clinic provided spot NHS services only in collaboration with our local NHS Trust. This included services for ophthalmology, rheumatology, hand surgery and MRI. Up to patients have also been seen per week in our X-ray department. Patient satisfaction and feedback therefore has been incorporated with the private services. Participation in Clinical Audits Aspen Healthcare has an annual clinical audit programme which identifies the key topics and frequency of audit assessment. Six clinical topics were periodically audited by The Edinburgh Clinic during , as shown below (for outcomes please see page 12-16): + + Consent + + Records compliance + + Controlled Drugs + + Surgical Safety World Health Organisation (WHO) Checklist + + Pre-operative Venous Thromboembolism (VTE) risk assessment + + Infection, Prevention and Control (IPC). The reports of these local clinical audits were all reviewed and The Edinburgh Clinic intends to take the following actions to improve the quality of healthcare provided: + + Continue to periodically audit the same topics during with a view to identifying specific areas for improvement, thereby working towards 100% compliance + + To introduce wall mounted soap dispensers and detergent wipes to assist with hand hygiene and cleaning + + To review patient pathway documentation to ensure compliance with best practice standards and audit + + Increase the clinical emergency scenario training to ensure staff are able to maintain their skills in emergency situations. Establish a Resuscitation Committee which will consist of our Advanced Life Support (ALS) providers and Consultant Anesthetist EC A4 Quality Accounts AW.indd 8 25/08/ :15

9 ...identifying specific areas for improvement, thereby working towards 100% compliance. Participation in Research There were no NHS patients recruited during the reporting period for this Quality Account to participate in research approved by a research ethics committee. Statement from Health Improvement Scotland (HIS) HIS last assessed the Clinic in 2013 against four quality themes related to the National Care Standards and inspected the following areas: + + the reception waiting area + + operating theatre + + consultant rooms + + the recovery area, and + + the discharge lounge. Overall, HIS found evidence that The Edinburgh Clinic: + + staff have been recruited in a safe and robust manner + + there is a good system for checking clinical and non-clinical equipment, and + + there are clear clinical governance structures in place. 08/ EC A4 Quality Accounts AW.indd 9 25/08/ :15

10 Statement on Data Quality The Edinburgh Clinic recognises that good quality information underpins the effective delivery of patient care and is essential if improvements in quality of care and value for money are to be made. We ensure that our Information Governance policies guide and inform our standards of record keeping, supporting the delivery of care and treatment and that accuracy, completeness and validity of those records are monitored on an on-going basis to continually improve data quality. The Edinburgh Clinic will be taking the following actions to further improve data quality: + + The Edinburgh Clinic will implement Aspen s patient administration system (APAS), which will provide an improved reporting system; + + All staff will continue to receive annual training relating to data quality and information governance; Information Governance. The Information Governance Toolkit is a performance assessment tool, produced by the Department of Health, and is a set of standards that organisations providing NHS care in England must complete and submit annually by 31 March each year. The toolkit enables organisations to measure their compliance with a range of information handling requirements, thus ensuring that confidentiality and security of personal information is managed safely and effectively, and The Edinburgh Clinic has adopted this approach. Aspen Healthcare s Information Governance Assessment overall score for was 70% and graded green, and we achieved level 2 in all categories meeting national requirements. 100% of The Edinburgh Clinic staff would recommend their services to Family and Friends EC A4 Quality Accounts AW.indd 10 25/08/ :15

11 100% of patients would recommend The Edinburgh Clinic to Family and Friends figures Quality Indicators The Department of Health (England) has identified a core set of quality indicators for inclusion within Quality Accounts. The Edinburgh Clinic considers that the data is as described in this section as it is collated on a continuous basis and does not rely on retrospective analysis. When anomalies arise, each one 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. As The Edinburgh Clinic provides outpatient and day surgery services, not all indicator measures are applicable; however those that are relevant are highlighted in the table below: Indicator Source Actions to improve quality Responsiveness to the personal needs of patients Patient Satisfaction Survey N/A The Edinburgh Clinic will continue to monitor patient experience through telephone follow-up surveys and will introduce a new outpatient survey in Percentage of The Edinburgh Clinic Staff who would recommend their service to Family and Friends Staff Survey 100% Percentage of Patients who would recommend The Edinburgh Clinic to Family and Friends Patient Satisfaction Survey N/A Continue to monitor regularly. To maintain 100% compliance. Introduce a new feedback survey in Number of clostridium difficile infections reported 0 The Edinburgh Clinic will continue to monitor infection status of all patients; ensuring staff receive ongoing training in infection prevention and control and adhere to policies and procedures. Number of patient safety incidents which resulted in severe harm or death Local Incident Reporting 0 The Edinburgh Clinic will continue monitoring safety processes and encourage reporting. Number of NHS Scotland Never Events 0 The Edinburgh Clinic will continue monitoring safety processes and encourage reporting. 10/ EC A4 Quality Accounts AW.indd 11 25/08/ :15

12 Review of Aspen s Quality Performance 2014 / 2015 This section reviews our progress with Aspen Healthcare s key quality priorities EC A4 Quality Accounts AW.indd 12 25/08/ :15

13 Patient Safety Focus on further embedding a positive Patient Safety Culture A positive safety culture underpins the improvement of patient safety and we undertook a detailed staff patient safety culture survey in autumn 2014 to assess our progress. Results + + Patient safety rated as excellent, very good, or good at 91%. + + Staff stated that they are confident that any concerns would be dealt with and acted upon by the hospital management (97%) + + The actions of hospital management show that patient safety is top priority (97%) % of staff would feel confident bringing a friend or family member for similar care or treatment here. Following the results of our survey the following action will be taken; + + Action improvement plan completed by Clinical Services Lead + + Staff listening forum to be introduced from May All patient safety issues to be discussed at appropriate meetings + + The Clinic to continue to maintain good practice with patient safety. Overall Grade on Patient Safety 64% Excellent 3% Failing 3% Poor 3% Acceptable 27% Very Good 12/ EC A4 Quality Accounts AW.indd 13 25/08/ :15

14 Patient Safety Leadership Training Having staff that are empowered to lead on patent safety will make a tangible difference to improving patient safety at the frontline of care delivery. In 2014 we commenced the roll out of bespoke Patient Safety Leadership staff training. Progress This was included in our staff training and development programme Investing in You which was well evaluated by our staff and has been further expanded in our 2015/16 programme for both frontline staff and middle managers. 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. 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 implemented tools to help us to objectively assess this and determine how many nursing staff and with what skill mix is required. Progress The Aspen Manpower tool has been utilised for assessing and increasing staffing numbers for expansion later this year and was presented at our Head of Department meeting. All staffing levels are assessed according to the clinic actively and the skill mix required. Clinical Effectiveness + + Infection Prevention and Control Deep Dives A clean and safe environment of care matters to our patients. A comprehensive deep dive assessment of our Infection Prevention and Control (IPC) practices led by Aspen Healthcare s Consultant Nurse for IPC and the Group Health and Safety (H&S) Manager were undertaken. Progress A deep dive at The Edinburgh Clinic took place in June Following on from this an action plan was completed. All appropriate actions were completed within the allocated timeframe and this was fed back at our quarterly IPC and H&S meetings. + + Care Plan 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 was undertaken of the quantity, quality and style of patient care plan documentation. Progress A review was undertaken of the surgical, day case and ophthalmology care plan pathways. Associated policies were revised and new risk assessments developed and implemented in line with national guidance and best practice, which have been incorporated into the updated pathways. To ensure that these are completed to a high standard audits are also in place reflecting the revised policies and documentation. + + 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. Progress In 2014/15 we completed a review of our assessment and documentation processes and developed a revised Pre-assessment Policy and Pre-operative Assessment Questionnaire that meets best practice and further supports the provision of effective patient care EC A4 Quality Accounts AW.indd 14 25/08/ :15

15 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. Patient Experience + + Hello my name is and I am Providing compassionate care and building therapeutic relationships often needs to simply start with the right introduction. We endeavoured to ensure that every member of staff approaching any patient for the first time introduced themselves and said Hello. My name is x and I am one of the nurses/care assistants/ managers who will be looking after you today. How are you feeling? Progress The Edinburgh Clinic has incorporated this within their World Host customer care training, which all staff undertake. + + Review of Patient Information Our patients need to be properly informed so that they can share in decisions about their care and treatment. We undertook a review of the information we provide to our patients and ensured that this was accurate, impartial, evidence based and well written. Progress To support our patients in being properly informed so that they can share in the decision-making process we adopted a nationally endorsed library of treatment specific Patient Information Leaflets. This is supported by a policy outlining the standards expected in the provision of written information to our patients. This enables us to work in partnership with our patients to ensure that they receive a high standard of relevant and comprehensive information which meets their needs. + + 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. After the last staff satisfaction survey we commenced holding regular staff forums to address areas for improvements identified in the survey Progress Staff forums introduced in early 2015 with turnout from all departments. Scheduled quarterly, to maximise staff engagement and motivation....considerable work has continued in terms of staff education and IPC audits, resulting in no incidences of infection Infection Prevention and Control Infection prevention and control (IPC) continues to be an on-going high priority for The Edinburgh Clinic. During , considerable work has continued in terms of staff education and IPC audits, resulting in no infection rates, as indicated in the table below: Infection MRSA positive blood culture 0 MSSA positive blood culture 0 E. Coli positive blood culture 0 C. Difficile infection 0 Endophthalmitis / Surgical Site Infection / Hand Hygiene / Peripheral Vascular Cannula Insertion 0 14/ EC A4 Quality Accounts AW.indd 15 25/08/ :15

16 Integrated Governance Audit Programme In we implemented 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 and 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: + + Patient falls + + Venus thromboembolism (risk assessment and prophylaxis) + + Patient Consent + + Patient care records/documentation standards + + Controlled Drugs Management + + Surgical Safety Checklist Completion + + Resuscitation + + Traceability + + Safeguarding + + IG Governance No healthcare associated infections reported for the last 2 years. Whilst not all of the above audit topics are applicable to The Edinburgh Clinic, the relevant ones were undertaken at least two or three times during the year. The results can be seen in the table below: Indicator Average score of % compliance Patient falls Venous thromboembolism (VTE) 100% Patient consent 100% Record keeping 96% Controlled drugs 98% Surgical Safety Checklist 98% No falls reported Several actions have been taken to improve compliance with record keeping, and this continues to be closely monitored EC A4 Quality Accounts AW.indd 16 25/08/ :15

17 Assessments against recognised national standards for perioperative practice pertaining to patient safety and outcomes have been made. Theatre Accreditation Programme We have implemented an accreditation programme to our operating theatre environments across the Aspen Group aiming to excel in perioperative practice. Progress The Edinburgh Clinic is committed to excelling in the provision of the highest quality healthcare services and are proud to have been formally awarded AfPP accreditation. Aspen Healthcare is the first healthcare provider to achieve national quality standards for perioperative practice and accreditation across all of its theatres from the Association for Perioperative Practice. Patient Experience + + World Host Customer Care Training We implemented 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 World Host recognised business and showcase our outstanding customer service with the focus being on teamwork and communication. Progress All members of the team (100%) at The Edinburgh Clinic have received World Host training and we achieved World Host accreditation status in October 2014 demonstrating our commitment to providing excellence in patient experience. Patient Survey All Aspen Clinic s developed a new patient 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 Outpatient questionnaire & feedback form that was introduced in Q1 2015, during the reporting period 100% stated that they found the quality of care to be excellent, very good or good. 16/ EC A4 Quality Accounts AW.indd 17 25/08/ :15

18 Complaints Indicator 2014 / 2015 Whilst The Edinburgh Clinic 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 and information on how our services can be improved. All complaints are investigated and any opportunity for learning or service improvement acted upon. 8 The total number = vs of written and verbal complaints. This works out at just 0.04% of our patient contacts! 1323 EC A4 Quality Accounts AW.indd 18 25/08/ :15

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20 Aspen Healthcare The Edinburgh Clinic Hospital / Clinic is part of the Aspen Healthcare Group. Cancer Centre London Wimbledon, SW London Aspen Healthcare was established in 1998 and is a UK-based private healthcare provider with extensive knowledge of the healthcare market. The Group 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, two cancer centres, and three day-surgery hospitals in the UK. Aspen Healthcare s current facilities are: The Chelmsford Private Day Surgery Hospital Chelmsford, Essex The Claremont Private Hospital Sheffield The Edinburgh Clinic Edinburgh Highgate Private Hospital Highgate, N London Holly House Private Hospital Buckhurst Hill, NE London Midland Eye Solihull Nova Healthcare Leeds Parkside Hospital Wimbledon, SW London EC A4 Quality Accounts AW.indd 20 25/08/ :15

21 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 nine facilities, comprising over 250 beds and 17 theatres, in 2014 alone Aspen has delivered care to: Almost 42,000 patients who were admitted into our facilities Nearly 32,000 patients who required day case surgery + + More than 10,000 patients who required inpatient care + + More than 311,000 patients who attended our outpatient and diagnostic departments We have delivered this care always with Aspen Healthcare s mission statement underpinning the delivery of all our care and services: Our aim is to provide first class private healthcare in a safe, comfortable and welcoming environment in which we d be happy for our own families to be treated. Aspen is now one of the main providers of independent hospital services in the UK and through a variety of local contracts we provided nearly 17,000 NHS patient episodes of care 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. It is our aim to serve the local community and excel in the provision of quality acute private healthcare services in the UK and we are pleased to report that in 2014 we have further improved our patient satisfaction ratings with 99% of our inpatients rating their overall quality of their care as excellent, very good or good, and 98% responding that they were 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. 20/ EC A4 Quality Accounts AW.indd 21 25/08/ :15

22 We have built our reputation on establishing strong partnerships and believe that through our shared expertise we can continue to grow within the competitive private healthcare market EC A4 Quality Accounts AW.indd 22 25/08/ :15

23 Statement on Quality from the Chief Executive Aspen Healthcare On behalf of Aspen Healthcare I am pleased to provide this Quality Account for The Edinburgh Clinic - this is our annual report to the public and other stakeholders and focuses on the quality of services we have provided over the last year (April 2014 to March 2015). It also importantly looks forward and sets 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. Our quality framework centres on nine drivers of quality and safety, helping 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 The Edinburgh Clinic 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 continue developing our initiatives around quality and safety to ensure we are able to bring further benefits to our patients and the care they receive. Our new Quality Strategy underpins this, centering on the three dimensions of quality: patient safety, clinical effectiveness and patient experience, as described in this Quality Account. The majority of information provided in this report is for all the patients we have cared for in 2014/15 NHS and private. Des Shiels Chief Executive Officer Aspen Healthcare 22/ EC A4 Quality Accounts AW.indd 23 25/08/ :15

24 Quality Priorities for National Quality Account guidelines require us to identify at least three priorities for improvement. Aspen s quality strategy outlines how we will progress a number of quality and safety initiatives for the forthcoming years and the following information provided focuses on the key priorities to include in this year s Quality Account. These have been determined by our senior management team and are informed by feedback from our patients and staff, audit results, national guidance and recommendations from the various hospital/clinic teams across Aspen Healthcare. Our quality priorities are 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. The Edinburgh Clinic is committed to delivering services that are safe, of a high quality, and clinically effective and we constantly strive to improve our clinical safety and standards. The priorities we have identified will, we believe, drive the three domains of quality - patient safety, clinical effectiveness and patient experience: 1. Patient Safety This is about improving and increasing the safety of our care and services provided 2. Clinical Effectiveness This is about improving the outcome of any assessment, treatment and care our patients receive to optimise patients health and well-being 3. Patient Experience This is about aspiring to ensure we exceed the expectations of all our patients EC A4 Quality Accounts AW.indd 24 25/08/ :15

25 Patient Safety + + Safety Leadership Walkabouts Strong effective leadership is essential to building a safety-oriented organisational culture and we will implement safety leadership walkabouts over the next year to further help embed our safety culture. Leadership walkabouts have been demonstrated to have a significant impact on safety culture and are a way of ensuring that senior management teams are informed first hand of any safety concerns by their own frontline staff. They are also a way of demonstrating visible commitment by listening to and supporting staff when issues of safety are raised. These will help our senior leaders to not only talk the talk but to walk the walk. + + Patient Safety Newsletter To help ensure we share our learning and initiatives around further improving our clinical safety we will launch a new staff patient safety newsletter. This will provide a vehicle to share best practice and learning across our clinic, promoting a culture of safety and continuous learning. This will help us to focus on continually improving our systems and processes to provide the best and safest possible care to our patients. The key quality priorities identified for are as follows: + + Datix Risk Register Rollout Risk management involves identifying and understanding the things that could have an adverse impact upon the delivery of our services to our patients. As part of our risk management framework and to support the identification of risks, their prioritisation and actions required to reduce the likelihood of recurrence, we will implement the Datix system, risk register module. This will enable us to robustly record and track the risks across our clinic and the principal objectives they threaten. + + Implement a VTE Root Cause Analysis Toolkit Venous thromboembolism (VTE), deep vein thrombosis or pulmonary embolism, is a well-known cause of death of patients who are admitted into hospital. We will introduce a more formalised approach to undertaking root cause analysis (RCA) on all confirmed cases of VTE and develop a toolkit to help ensure a systematic and evidence based approach is taken to understanding the factors that lead to any pulmonary embolism/deep vein thrombosis and ensure that all actions are taken to reduce them occurring again. Clinical Effectiveness + + Departmental Datix Dashboards rollout Ensuring our staff receive meaningful and relevant information on reported clinical indicators will help inform their daily decisions on the quality of patient care. We will develop department based Datix dashboards of measures to provide near time information on the effectiveness of care so that this improves our staff understanding of outcomes and actions taken and supports local quality improvement initiatives. + + Core Clinical Training Programme Our staff need to be supported in maintaining their skills to provide the best possible care to our patients and we will support our frontline clinical staff in developing and building upon their clinical skills and knowledge by implementing a new training programme. This will include a competency based foundation programme in critical care, clinical skills updates and training in the context of care delivery. + + PROMs to Private Patients Patient Reported Outcome Measures (PROMS) collect information on the effectiveness of care delivered to patients as perceived by the patients themselves, based on responses to questionnaires before and after surgery. The NHS England PROMs programme covers four common elective surgical procedures: groin hernia operations, hip replacements, knee replacements and varicose vein operations. In we will roll out PROMS to our private patients. This will commence with a cataract PROMS, and we will add other procedures as our casemix activity changes. 24/ EC A4 Quality Accounts AW.indd 25 25/08/ :15

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27 Patient Experience + + Embedding our Values Improving our Patients Experience After developing our values with our staff, we formally launched the Aspen Values of Beyond Compliance; Personalised Attention; Investing in Excellence, Partnership and Teamwork; Always with Integrity in 2014 to all our staff. In 2015, we will now seek to further embed these into our clinic culture in order to distinguish ourselves from other healthcare organisations; we aim to ensure that these values inform our staff how they should go about their work demonstrating positive behaviours and attitudes. We will train values partners to take this exciting work forward and deliver bespoke training to our staff with the primary aim of continuously improving the experience and satisfaction of our patients and our staff; putting quality at the heart of everything that we do. + + Implement Practice Observational Tools We wish to assure ourselves that our patients have an excellent experience of care in our clinic and understand what good quality care looks and feels like from a patient s perspective. By observing clinical practice we will be able to capture those elements of care that make such a difference to our patients. We will celebrate excellent examples of care delivery and make recommendations on where to improve certain aspects of care based on our findings. Staff will be trained to use observational tools to help see care from the patients perspective providing them with important insights into the difference their interactions can make to patient care, dignity and respect. Tools to be used will include the Sit and See Tool TM and the Fifteen Steps Challenge. These tools will help us to highlight what is working well and what might be done to increase patient confidence. + + Increase Friends and Family Test Response Rates The national Friends and Family Test (FFT) is a broad measure of patient experience that can be used alongside other data to continuously improve the services we offer, reinforce exemplary standards of care, and improve care where improvement is needed. The FFT is a feedback tool that supports the fundamental principle that people who use our services should have the opportunity to provide feedback on their experience and asks if people would recommend the services they have used to friends and family if they needed similar care or treatment. To ensure this information is representative we wish to increase our response rates ensuring that at least 15% of our eligible patients respond. While targeting the above areas, we will continue to: + Strive to further improve upon all our quality and safety measures + Continue with our programme of development relating to other quality initiatives + Continue to develop our workforce to ensure they have the skills to deliver high quality care in the most appropriate and effective way + Meet and exceed the Quality Schedule of our NHS Contracts. 26/ EC A4 Quality Accounts AW.indd 27 25/08/ :15

28 Continually exceeding expectations... For further information Telephone The Edinburgh Clinic Head Office, Aspen Healthcare The Edinburgh Clinic 40 Colinton Road, Edinburgh EH10 5BT or visit This brochure is available in large print on request EC A4 Quality Accounts AW.indd 28 25/08/ :15