Patient information 2015

Transcription

1 Clinical QUALITY Patient information 2015

2 Mission and values statement Above all else, we are committed to the care and improvement of human life. In recognition of this commitment we strive to deliver high quality, cost-effective healthcare in the communities we serve. In pursuit of our mission we believe the following value statements are essential and timeless: We recognise and affirm the unique and intrinsic value of each individual. We treat all those we serve with compassion and kindness. We act with honesty, integrity and fairness in the way we conduct our business and in our personal behaviour. We trust our colleagues as valuable members of our healthcare team and pledge to treat each other with loyalty respect and dignity. Created

3 Foreword by the Chief Executive Officer The Portland Hospital opened in 1983 as a dedicated women and children s hospital. Since opening, it has expanded its facilities to include three additional outpatient locations at 215, 212 and 234 Great Portland Street. In 2011 the hospital opened a dedicated Paediatric Intensive Care Unit (PICU) which has allowed it to undertake more complex paediatric treatments. Part of the HCA Healthcare UK group of hospitals, The Portland Hospital has 100 dedicated beds which includes 5 delivery rooms, 10 PICU beds, 7 neonatal cots and 11 paediatric day case beds, along with 4 operating theatres, 6 dedicated procedure rooms and 54 consulting rooms. Each service is provided in a dedicated space with specialist staff. The hospital is supported by Imaging Services including MRI/CT/Plain film/interventional lab and Ultrasound. It also has Neurophysiology, Audiology and multi-disciplinary Therapy departments. The hospital has over 500 Consultant Specialists with practising privileges, many of who are tertiary subspecialists in their field. There are approximately 450 staff and children s services have a 75% ratio of Registered Children s Nurses (RCNs). The hospital is further supported by 16 Resident Medical Officers, Resident Consultant Anaesthetists and 24/7 Consultant Neonatology, Paediatric and Intensivist cover. Our local hospital objectives feed into the wider HCA Healthcare UK strategy and values: 1) Striving to deliver the highest quality of care for our patients 2) Making our services convenient and easy to access for patients, GPs and consultants 3) Supporting our people to run operationally excellent facilities 4) Working with partners to deliver world-class care 5) The patients provider of choice The Portland Hospital is required to register with the Care Quality Commission and its current registration status is valid and compliant. We have also participated in the CHKS accreditation body since the 1990s which is an additional, voluntary accreditation. CHKS is a quality assurance tool for independent organisations which sets out a framework of standards which need to be in place to ensure a consistent high quality service. In 2015 The Portland Hospital gained both Health and Safety and Environmental Health accreditations. Janene Madden Chief Executive Officer 1

4 Incidents The incident reporting culture at The Portland Hospital is positive which indicates a strong organisational culture of patient safety. The Portland Hospital takes all incidents seriously and links reporting with learning. A quality dashboard is produced quarterly to support the delivery of harm free care and results are reviewed locally and by the senior management of HCA Healthcare UK, including the Group CEO and Vice President of Clinical Services and Patient Safety, to provide assurance of awareness and ownership within the facility. Action plans are implemented to improve the delivery of high clinical standards where required. Infection control At The Portland Hospital minimising the risk of healthcare associated infection is achieved through continuous vigilance, robust infection surveillance systems and ongoing training of staff at all levels in hospital hygiene. All infection control procedures are supervised and reinforced by an experienced and dedicated Infection Prevention and Control Nurse and Consultant Medical Advisors. The Portland Hospital s commitment to the highest quality standards has successfully kept the incidence of Methicillin Resistant Staphylococcal Aureus (MRSA) infection at very low levels. There are several measures to ensure the risk of infection is kept as low as possible: Individual rooms with private en-suite facilities for all patients before and after any treatment or operation, unless the specialist resources of critical care are necessary High nurse to patient ratios, increasing the time available for individual attention and ensuring the highest quality of care and hygiene On-site cleaning staff available to respond to any need that may arise A timely room cleaning regime between the discharge of one patient and the admission of the next. 2

5 Infection rates 2014/ MRSA RATE PER 1000 BED DAYS Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15 Q3 15 Q MSSA RATE PER 1000 BED DAYS Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15 Q3 15 Q C.Diff RATE PER 1000 BED DAYS Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15 Q3 15 Q E.Coli RATE PER 1000 BED DAYS Q1 14 Q2 14 Q3 14 Q4 14 Q1 15 Q2 15 Q3 15 Q4 15 Surgical site infections (SSI) Any surgical site infections discovered are investigated by the Infection Prevention and Control (IP&C) Nurse and then discussed with the Director of IP&C, a Microbiologist and a Pharmacist, in line with the Antibiotic Stewardship policy. Infections are also discussed at the Infection Prevention and Control Committee. 3

6 CQC key performance indicators Returns to theatre, unplanned readmissions, transfers out, serious injuries The Portland Hospital maintains extremely low numbers of patients who are returned to theatre, readmitted, transferred out to another facility or experience serious injury. As a provider of independent acute hospital services, The Portland Hospital collects, monitors and submits data to the Care Quality Commission (CQC) on a quarterly basis as part of the Private and Voluntary Hospitals Performance Indicators programme. These metrics are also a key component of internal performance monitoring. These key performance indicators are reported on a quarterly basis to the HCA Quality & Safety Review group to identify core areas for improvement and are monitored monthly at the HCA Clinical Council meeting. Relevant information is collated about every unplanned event with a root cause analysis performed as necessary to identify learning. Patient experience The Portland Hospital places high value on patient feedback which helps improve services. All patients receive a questionnaire which they are encouraged to complete and the results are analysed by an independent company. Patient feedback is discussed at the Patient Experience Group which meets monthly as well as at Quality meetings. Some actions taken as a result of patient feedback in 2015 included: Revised breastfeeding training programme for all midwives Revised patient menus Improved facilities for theatre waiting area Improved play facilities and age appropriate toys Face to face patient feedback sessions.

7 Complaints The Portland Hospital actively encourages all staff to manage and record all complaints both formal and informal. Learning from complaints is monitored by the Governance Team and the Patient Experience Group and action plans are created for significant complaints as necessary. The action plans are shared with all Heads of Department and the learning is shared with relevant teams, groups and committees. Effective initiatives around communication and patient safety which have been implemented throughout 2015 following patient complaints include: Maternity telephone triage form Introduction of discharge follow-up phone calls for all patients Implementation of Pharmacy contact cards for dispensing medication Infection control training programme for nursery nurses Introduction of new clinical policies and guidelines. Audit The Portland Hospital maintains a comprehensive audit calendar which identifies both corporate and local key clinical audits. There are 3 clinical departmental Audit Working Groups across the hospital which are responsible for the review and monitoring of actions following audit results: Women s and Neonatal Services Audit Working Group Children s Services Audit Working Group Theatre Audit Working Group. Audit results for 2015 are included in The Portland Hospital Annual Audit report. National audit Paediatrics The Paediatric Intensive Care Unit at The Portland Hospital submits data to PICANet. PICANet was established to develop and maintain a secure and confidential high quality clinical database of paediatric intensive care activity to: Identify best clinical practice Monitor supply and demand Monitor and review outcomes of treatment episodes Facilitate healthcare planning and quantify resource requirements Study the epidemiology of critical illness in children.

8 The core dataset of demographic and clinical data on all admissions, collated by PICANet, allows comparison of PICU activity at a local level with national benchmarks. This dataset provides an important evidence base on outcomes, processes and structures that permits planning for future practice, audit and interventions. Maternity The Portland Hospital Maternity Unit submits to MBRRACE-UK. This programme comprises national surveillance of late fetal losses, stillbirths and infant deaths, confidential enquiries into perinatal mortality and serious infant morbidity and the national Confidential Enquiry into Maternal Deaths. In 2015, the Portland Hospital also submitted to the following national audits; Maternity Imaging Imaging Every baby counts Nuchal Translucency Dose Monitoring 6

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