Optegra Yorkshire Eye Hospital

Transcription

1 Optegra Yorkshire Eye Hospital Quality Accounts

2 CONTENT Part 1: Statement of Commitment Gareth Steer, Optegra UK Managing Director Part 2: Our Priorities for Improvement 2012 / 2013 Statement of Quality, Sue Boyes Hospital Manager Priorities for improvement Statement of Assurance Part 3: Review of our Quality Performance 2011/ 2012 A Look Back 2

3 Part 1: Statement of Commitment Optegra UK ltd is totally committed to fostering an organisational culture that puts the patient at the centre of everything the Optegra Yorkshire Eye Hospitals does. The Optegra Yorkshire Eye Hospital was established by its founding surgeons specifically to demonstrate the highest levels of patient safety, clinical outcomes and customer satisfaction. It is that vision that remains at the heart of our dedication to the highest levels of quality and reflected in the Optegra mission statement - To be the worlds most trusted choice for eye care" The hospital was acquired in February 2010 by Optegra UK, who specialise in Ophthalmology services across the country and is one of five hospitals based in the UK, with the others being situated in Surrey, Solent, Manchester and Birmingham. As Managing Director of Optegra UK, I am passionate about ensuring that high quality patient care is at the centre of all we do and how we operate in all our facilities. This relies not only on excellent medical and clinical leadership in our hospitals but also upon our overall continuing commitment to drive year on year improvement in clinical outcomes. Following the appointment of our new Head of Eye Sciences role in 2011, we have expanded the use of Medisoft, the UK's only Ophthalmology specific patient pathway system that records patient clinical data from onset to discharge. It has a comprehensive audit element that records both pre and post-surgical outcomes and also surgical and anaesthetic complications. For the first time Optegra UK will be able to produce consistent and high quality surgical outcome data for all of its hospitals. Our Head of Eye Sciences, in conjunction with our consultant Ophthalmologist Medical Director, will be instrumental in approving any new procedures and technologies into Optegra hospitals and will also enable us to participate in a wide range of research projects. As a provider of ophthalmic healthcare, we have worked hard in 2011 to synergise a structured clinical governance framework and risk management systems across all our hospitals and we will continually review our performance so we can drive improvements to the benefit of all our patients. I believe that delivering clinical excellence depends upon everyone in the organisation; everyone is responsible for ensuring that are delivering high levels performance and constantly seeking to improve. The requirement to ensure clinical excellence is the role of everyone in the organisation and is not about reliance upon one or two people. Across Optegra we nurture teamwork and professionalism, we value our people and set our targets high, and we work hard in every aspect of our services to provide facilities of a high order. We believe in investing substantially in our people, our hospitals and our equipment to ensure care is delivered in a consistent and safe manner at all times. 3

4 Patient feedback is extremely important to us and we will undertake our second patient satisfaction survey in May 2012 with the expectation we will maintain or improve upon our 2011 results of a patient certain to recommend Optegra rating of > 62%. The Optegra Yorkshire Eye Hospital is accustomed to the disciplines of regulatory and contractual requirements to assure health commissioners of our clinical performance and to report complaints and serious incidents accordingly. The hospital maintains a Risk Register and reviews specific actions to achieve risk reduction. To the best or my knowledge as requested by the regulations governing the publication of this document, the information in this report is accurate. Gareth Steer, Optegra UK Managing Director 4

5 Optegra Yorkshire Eye Hospital Optegra Yorkshire Eye Hospital is a private hospital situated between Leeds and Bradford. The hospital offers care to NHS patients, patients with private medical insurance and patients who wish to fund their own treatments. The hospital provides a full range of Ophthalmic services, including outpatient consultations, diagnostics and surgery, through to follow-up care. During the period January 2011 December 2011 the hospital has seen 15,887 patients through its doors, and 65% were treated under the care of the NHS. Currently 25 specialist ophthalmic consultants work from the hospital and are supported by 18 clinical staff, a skill mix of Nurse s, Healthcare Technicians and Optometrists and 15 Administration staff, along with dedicated Facilities and Housekeeping support. The hospital has built an excellent relationship with Leeds Teaching Hospital Trust, Bradford Teaching Hospitals and Airedale Foundation Trust to deliver a collaborative approach to patient care. Our field-based Professional Partnership Managers provide vital links to the Optometry community and GP s to ensure their needs and expectation are managed through a partnership referral process and streamlined patient choice referrals. 5

6 Part 2: Statement of Quality: Hospital Manager Sue Boyes Optegra Yorkshire Eye Hospitals provides a full service directory of Ophthalmic procedures, including cataract, retinal and ocular plastics, it also provides a consultation only service to children from birth. We strongly believe in ensuring patients are fully informed about each step of their care. Our medical and clinical teams spend dedicated time on patient preparation for surgery; this not only reduces risk but alleviates patient anxiety. Patient feedback and involvement in their care and treatment is paramount as it helps us to ensure that we are delivering the right care and treatments that are evidence based and effective. We ensure our services are delivered by the most appropriate qualified clinicians and nurses with the relevant skills required. This is managed by a robust recruitment and training process. It is important to have the right role at the right time in order to deliver safe and excellent care. Through our integrated governance process we foster a "no blame culture" to ensure openness in reporting serious incidents, complaints, near misses and equipment failures. We have over 50 clinical and quality policies that are reviewed annually against national guidance. Specific work in collaboration with our commissioners has been undertaken in 2011 to align our polices on Safeguarding to Department of Health guidance. Robust processes have been put in place to allow staff to openly report abuse and notify the relevant body. Optegra UK and Optegra Yorkshire Eye Hospital are keen to learn throughout its organisation and implement and support changes in clinical practice to ensure patient safety at all times. 6

7 Part 2 Priorities for Improvement 2012/2013 The priorities for improvement have been determined by evaluating and acting upon our governance processes and learning from our patients and staff. The priorities are supported by the Medical Advisory Committee. We have a clear commitment to our patients and we work in partnership with the NHS to ensure our services are safe and of high quality. We constantly strive to improve clinical safety and standards by a process of governance, including audit and feedback from all those experiencing our services. Patient Safety 1, Never Events are serious and largely preventable patient safety incidents that should not occur if preventable measures have been put in place. There are 25 nationally recognised never events of which 4 are core to the hospital and will form part of our measurement of patient safety during 2012/13. Wrong site surgery the Optegra Yorkshire Eye Hospital implemented the World Health Organisation (WHO) recommendation for safer cataract surgery checklist. The checklist is a tool used throughout cataract surgery to improve the safety of surgery by improving good communication and setting out safety checks throughout cataract surgery; the hospital had a 98% compliance rate for completion of the checklist and will continue to audit and evaluate its use throughout 2012/13. Wrong Implant / prosthesis Wrong intraocular lens implant; learning from reported patient safety incidents (SP Kelly Feb 2011) showed that a large percentage of incidents of wrong implantation of IOL were due to wrong IOL selection. The Optegra Yorkshire Eye Hospital experienced one Never Event of this category in 2011 and has since put in place in (February 2012) a robust Optegra Wide Lens Check Protocol; this will be under a strict audit review and reported to the Integrated Governance Committee Steering Group (IGCS) on a quarterly basis. 7

8 Retained Foreign Object Post Operation - this rarely occurs due to the nature of our surgery but extra vigilance will be undertaken due to the tiny microscopic sutures used sometimes, this will be audited via the WHO check sheet Overdose of Midazolam during conscious sedation minimal procedures require the need for sedation at the Optegra Yorkshire Eye Hospital but the use will be monitored and reported under policy guidance. 2, VTE Risk Assessments due to the nature of our services; surgery that is less than 90 minutes in duration, the need to assess for VTE risk is minimal. A series of elimination questions are used by the pre assessment staff to determine any likely risk and an audit is place and will monitored during 2012/13. 3, IT Solution for Enhanced Patient Safety - from April 2012 the Optegra Yorkshire Eye Hospital has entered into a contract with NHS Airedale Bradford and Leeds for the provision of NHS services, through the Commissioning of Quality & Innovation Payment Framework (CQUINS). Payment will be conditional on achieving quality improvement in the following area. Clear and effective E-communication with GPs following day case/inpatient discharge and outpatient attendance 4, Infection Prevention and Cure a comprehensive programme has been in place during 2011 with an increase in promoting staff and patient awareness. Audits that were undertaken and will remain priority in 2012/13 are: Sharps disposal Surgical Scrub technique Hand Hygiene 5, Cleanliness - environmental audits were completed as per the High Impact Intervention VIII (DOH Saving Lives: Reducing Infection, Delivering Clean and Safe Care 2007). This evidenced the need for a new cleaning matrix. The introduction of the green label system is used to evidence cleanliness to patients and staff. Cleanliness is a prime focus of first impressions by our patients and will remain a priority for 8

9 2012/13 A compliance rate increase of 20% has been seen in the 12 months to March 2012 Patient Experience Patient feedback in 2011 has shown that some patients are experiencing a wait within the clinic areas for their appointments and also that the patient discharge information needs to be clearer. Optegra Yorkshire Eye Hospital has recognised an opportunity to improve within this area. o A continued audit will be carried out through 2012/13 of patient waiting times in clinic and work has been undertaken throughout Optegra to standardise our patient literature. Each patient leaving the hospital will be given a take home pack specific to the treatment they have undertaken. o Optegra Yorkshire Eye Hospital will endeavor to create a Patient Focus Group, with quarterly meeting to enable us to gain face to face feedback on our services. Clinical Effectiveness Optegra Yorkshire Eye Hospital, in collaboration with its sister hospitals within Optegra, has in 2011 implemented a universal system to report and escalate clinical incidents. The formulation of an integrated governance reporting document and an all hospitals alert process helps us effectively action incidents in a timely manner and through quarterly reporting to the Integrated Governance steering committee (IGSC) we can share lessons learnt and disseminate best practice to the hospital clinical teams. From May 2012, a monthly Clinical Incidents / Near Miss conference call will be held to share any incidents from each of the hospitals within that month, this will help re-inforce our open and honest culture of patients safety incident reporting and will aid in disseminating lessons learnt and aligning best practice at all times. Quality Data & Audit Optegra Yorkshire Eye Hospital installed its NHS N3 connectivity during 2011; this enabled our NHS team to communicate securely and safely via the NHS.net account. This also allows our activity and financial data to be received via the Service Users System (SUS). Staff will undergo training on the NHS Choose and Book system during 2012, which will 9

10 enable patients to access our services with ease and help our clinical team triage the patient referral for the best possible care. During 2012/13 reporting via this system will be monitored with our commissioners to ensure accuracy and financial payments are made in line with the Payment by Results Framework 2012/13. Optegra Yorkshire Eye Hospital will improve on its Quality data reporting and submit the agreed quality and performance reports to the commissioners on a monthly basis during 2012/13. 10

11 Statements of Assurance on Quality In accordance with The National Health Service (Quality Accounts) Regulations 2010 Optegra Yorkshire Eye Hospital makes the following statements of assurance: 1. During 2011/12 the Optegra Yorkshire Eye Hospital provided Ophthalmology services to the NHS through the NHS Standard Acute Contract. It did not subcontract out any of those services The Optegra Yorkshire Eye Hospital has reviewed all the data available to them on the quality of care in all of these NHS services 1.2. The income generated by the NHS services reviewed in 2011/12 represents 100 per cent of the total income generated from the provision of NHS services by the Optegra Yorkshire Eye Hospital for 2011/ During 2011/12 no national clinical audits and one national confidential enquiry covered NHS services that the Optegra Yorkshire Eye Hospital provides During that period the Optegra Yorkshire Eye Hospital participated in all national clinical audits and all national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. (Note: there were none specifically relevant) The Optegra Yorkshire Eye Hospital is committed to acting on guidance resulting out of national and local audits. The National Confidential Enquiry into Patient Outcomes and Death (NCEPOD): An age old problem 2010, looked into the death of elderly patient 30 days post emergency and elective surgery, any lessons learnt and areas for improvement were noted and have been adopted where relevant to our services 11

12 Although there were no national clinical audits specifically relevant during the reporting period, the Optegra Yorkshire Eye Hospital held the following local clinical audits as follows: Hospital Audit % Compliance Optegra Medicines Audit 100% Yorkshire Eye WHO surgical check list Patients Notes Audit 98% 98% Hand Hygiene 99% Surgical Scrub Audit 92% 2.2. The reports of the local clinical audits were reviewed by the provider in 2011/12 the Optegra Yorkshire Eye Hospital intends to take the following actions to improve the quality of healthcare provided. Adhere to best practice for Medicine Prescribing Adhere to the WHO recommendations on Safer Cataract Surgery Adhere to Afpp guidance on length of first surgical scrub 12

13 3. The number of patients receiving NHS services provided by the Optegra Yorkshire Eye Hospital in 2011/12 that were recruited during that period to participate in research approved by a research ethics committee was nil. The Optegra Yorkshire Eye Hospital had a no research policy during the reporting period. 4. The Optegra Yorkshire Eye Hospital income in 2011/12 was not conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation (CQUIN) payment framework because being offered income conditional on the framework was not mandatory under the NHS acute service contract for PCTs during the reporting period. 5. The Optegra Yorkshire Eye Hospital is required to register with the Care Quality Commission and its current registration status is registered. The Optegra Yorkshire Eye Hospital has the following conditions on registration: none. The Care Quality Commission has not taken enforcement action against Yorkshire Eye Hospital during 2011/12. The Optegra Yorkshire Eye Hospital was registered during this period under the Health and Social Care Act The Optegra Yorkshire Eye Hospital is subject to periodic reviews by the Care Quality Commission and the last review was in November The CQC s assessment of the Optegra Yorkshire Eye Hospital following that review was fully compliant and no inspection required. The Optegra Yorkshire Eye Hospital intends to take the following action to address the points made in the CQC s assessment (No actions to review in this period]. 13

14 Statement of Quality Delivery The Optegra Yorkshire Eye Hospital operates a quality framework to ensure it is accountable for improving the quality of its services and safeguarding the highest standards in creating an environment where clinical care will excel. Infection Control The Optegra Yorkshire Eye Hospital has a very low rate of hospital acquired infections. Infection Prevention and Control Management is very active. An annual plan is developed, IPC committee meetings are held on a quarterly basis, supported by NHS Airedale Bradford & Leeds and a consultant microbiologist as chairman. In 1998 a study reported that there are 1 in 350 cases of Endophthalmitis (a serious infection in the eye following surgery) within the NHS; there has been 1 case in the last 10 years at the Optegra Yorkshire Eye Hospital. We comply with mandatory reporting of all alert organisms including MRSA and Clostridium Difficile.There has never been a case of MRSA or Clostridium Difficile at the Optegra Yorkshire Eye Hospital Education of staff is paramount; the Optegra Yorkshire Eye Hospital undertakes mandatory training and a training booklet has been developed for staff to complete as an ongoing assessment of knowing their working environment. The Optegra Yorkshire Eye Hospital signed up to the National Patient Safety Agency NPSA Clean Hands Campaign, posters were displayed, and staff, patients and visitors were actively encouraged to promote good hand hygiene. Hand hygiene and Surgical Scrub Technique are continually audited by observation and will continue to be a priority during 2012/13. Audit for the period February 2012 presented below. 14

15 Time in minutes Surgical Scrub Audit Results February Consultants time taken for 1st scrub Feb Consultant

16 Time in minutes Nurses time taken for 1st scrub Feb Nurse Return to Theatre The Optegra Yorkshire Eye Hospital treats approximately 300 patients for surgery each month. This is planned surgery, and monitoring the numbers of patients who return to theatre is very important. The value is to identify any trends in either the surgical procedure or a specific surgical team. The Optegra Yorkshire Eye rate of return is very low, in 10 years the Optegra Yorkshire Eye Hospital has undertaken over 20,000 surgical procedures with 4 return to theatre =.234%. Staffing in the Work place The Optegra Yorkshire Eye Hospital has a dedicated team of clinical staff with a collective experience in Ophthalmology of well over 100 years. o Sickness, absence rates and staff turnover rates for 2011 are 14% turnover and 2% absence, which is below the national average of 2.5% absence rate (

17 o Staff appraisals are undertaken annually, and reviewed at 6 months, these directly link to Optegra UK's performance and training systems. The following work has been undertaken in 2011 as a direct result of our Staff survey; to improve on training and development, communication and reward and recognition. Learning and Development Programme Role Coach Talent Management Communication Who s Who s on the intranet Quarterly newsletter Quarterly Town Hall meetings at each hospital Reward & Recognition Give as you Earn Long Service Awards Shared Values Recognition Raffle ticket awards for exceptional work o Staff satisfaction scores for 2011 showed 51% of Optegra Yorkshire Eye hospital staff hospital would recommend Optegra to a friend. Having acted on feedback during the 2011 survey and implementing the improvements above our expectation is to see an increase in staff satisfaction levels from our 2012 survey o The number of significant staff injuries was none for the period 2011 /

18 Part 3 Review of our Quality Performance 2011 / 2012 A Look Back The following are the areas for improvement that were highlighted in the Optegra Yorkshire Eye Hospital Quality Accounts for the period 2011 / 2012 Implement and evaluate the WHO surgical cataract check list Improvements made in 2011: The Optegra Yorkshire Eye hospital effectively implemented the WHO cataract surgical check list and is currently seeing a 98% compliance rate. Improving outpatient waiting times for patients within clinic o In response to: Patient satisfaction survey April 2011 Improvements made in 2011: The Optegra Yorkshire Eye Hospital through its patient survey identified the need to look at wait times in clinic; an audit was undertaken with an action plan put in place. o A new streamlined patient check in process was put in place o Meet and greet only was put in place on reception, telephone calls were moved off site, creating a much calmer and stress free welcome. o Consultant timekeeping issues were addressed 18

19 Implement a universal Integrated Governance process across its hospitals o In response to moving from 1 hospital into 5 hospitals within one organisation can potentially impact patient risk and safety Improvements made in 2011: The Optegra Yorkshire has implemented the new integrated governance document for all its governance meetings. This document: o Reports in a standardised way o Reports quarterly to the Integrated Governance Steering Committee o Attends the monthly clinical incident / near miss national conference call Eliminating Mixed Sex Accommodation (EMSA) The Optegra Yorkshire Eye Hospital has an EMSA plan in place and submitted its monthly report to the commissioner during 2011/12; there were no breaches during this period. The Optegra Yorkshire Eye Hospital displayed on its website a declaration of compliance to EMSA as set out by the DOH. This will be undated for the period 2012/13. Complaints The Optegra Yorkshire Eye Hospital has received 1 written and 2 verbal complaints during the 2011/12 all were resolved at hospital level. None were referred to the ombudsman. Quality Accounts: Reporting Requirements for 2011/2012 and planned changes for 2012/13 Optegra Yorkshire Eye Hospital acknowledges the communication dated 16 th February 2012 outlining requirements for 2011/ 12 Quality accounts submission and the changes for 2012/13. Having looked at the new set of core quality indicators Optegra Yorkshire Eye Hospital feels not all the indicators are relevant to the services it provides, but will work with the commissioners to ensure we are measuring against those that are, mainly: o Domain 4: Ensuring that people have a positive experience 19

20 o Domain 5: Treating and caring for people in a safe environment and protecting them from harm. We believe the areas of improvement demonstrated throughout 2011/12 have been fundamental in providing the highest quality Ophthalmic care, which we know is high on our patients and commissioners agenda. 20

21 Stakeholders views on the Quality Account. Yorkshire Eye Hospital Quality Accounts Statement by Bradford District LINk Care Quality Working Group (CQWG) We welcome this opportunity to submit a statement on the Yorkshire Eye Hospital (YEH) Quality Accounts (QA). The report is clear and suggests to us that the YEH is a well-managed hospital. The Trust s approach to open reporting of serious incidents, near misses, equipment failure and patient complaints thanks to a no blame culture is highly commendable. However, we would welcome more detail describing what has been leant from audits, policy reviews and patient feedback and what were the changes to procedures that were implemented for example: What in practice were the changes implemented to align with Department of Health guidance on safeguarding to allow reporting of abuse mentioned in part 2? What in detail were the changes implemented following the wrong implant episode in 2011? What precisely did patients say about waits in clinical areas and lack of inadequate discharge information? What changes to cleaning regimes were introduced and what was the before and after compliance rate that increased by 20% 21

22 A simple description of the manner in which audits of cleaning scrubs were carried out would be welcome and would greatly help comprehension of the two tables published An analysis of the subjects covered by the small number of complaints received and the manner in which they were resolved would be useful We would be interested to learn in more detail the way in which field-based Professional Partnership Managers provide vital links to the Optometry community and GP s to ensure their needs We are pleased to see that lessons appear to have been learnt and that continual improvement in practice has resulted but we believe that it would reflect well on YEH to tell a fuller story. We very much welcome the YEH s commitment to establishing a Patient Focus Group. 22

23 NHS Bradford and Airedale statement on Optegra Yorkshire Eye Hospital (OYEH) Quality Account 2011/12 NHS Bradford and Airedale (part of the NHS Airedale, Bradford and Leeds cluster PCT) welcomes the opportunity to comment on Optegra Yorkshire Eye Hospital s Quality Account for 2011/12, the third quality account since the national introduction of Quality Accounts. As a commissioner of care services on behalf of the local population, we believe this Quality Account demonstrates a commitment to quality improvement and high quality services. The Operating Framework for the NHS in England describes quality as spanning three areas: safety, effectiveness and patient experience. This Quality Account provides an overview of these areas and overall is a fair reflection of the provider s achievement of quality of service delivery against the backdrop of a changing NHS. Delivering care and treatment in an organisation with specialist ophthalmic services requires strong commitment to continuously monitoring and delivering high quality patient care. NHS Bradford and Airedale (NHSBA) are pleased to note early engagement with the commissioner in the development of this Quality Account. Optegra Yorkshire Eye Hospital (OYEH) has continued to make significant progress over the past 12 months to improve the quality of patient care and services. The need for improvements in the last year has been addressed positively despite competing priorities. In light of these challenges, we are especially pleased to note the following achievements: Optegra Yorkshire Eye Hospital is registered with the Care Quality Commission and their registration status is fully compliant and no enforcement action has been taken by the CQC. Optegra Yorkshire Eye Hospital is compliant in eliminating mixed sex accommodation to deliver increased privacy and dignity for patients. It is pleasing to note that patient feedback in response to the April 2011 patient survey has resulted in improvements to the patient experience Where incidents occur, Optegra Yorkshire Eye Hospital is open and transparent in reporting these to the commissioner and works well with the commissioner to learn and implement lessons from incidents. Optegra Yorkshire Eye Hospital is part of the wider Optegra group Red ball project which is driving governance standards throughout the organisation. The reporting of incidents is considered as positive by NHSBA in that it is an indication of an organisation's safety culture and this is actively encouraged. NHSBA welcome the Hospital s on-going collaboration with the commissioner and proactive management of infection prevention and control and health care associated infection assurance. The Hospital did not participate in a Commissioning for Quality and Innovation (CQUIN) scheme in 2011/12, however, they are doing so in 2012/13. It is hoped Optegra Yorkshire Eye Hospital s participation in the CQUIN scheme will drive forward improvement in patient and clinician communication. In reviewing this Quality Account, NHSBA would recommend that further opportunities to enhance the quality of patient care and services should be considered within the Hospital priorities: 23

24 Optegra Yorkshire Eye Hospital acknowledges national patient and staff survey data however, not all data was available to the Hospital at the time of developing the Quality Account. Acting on the findings of survey results to improve patient and staff experience is essential for continued delivery of quality. NHSBA would welcome inclusion of such in the 2012/13 Quality Account. Plans, actions and outcomes in relation to training, capability, deployment and skill mix of the workforce to deliver against the priorities outlined within the Quality Account could be incorporated and strengthened in future accounts and NHSBA anticipate such reporting to be realised throughout 2012/13 through the contract mechanisms. This Quality Account covers a broad number of areas and would be enhanced with the inclusion of further information relating to complaints; in particular, reference to examples of learning within the body of the Quality Account would be valued. NHSBA acknowledges the continued prioritisation of investment that the Hospital has made in its services over the last year and its continued intentions for quality improvements in 2012/13. It is clear that the Hospital has many committed and enthusiastic staff members who contribute to a positive experience for patients. NHS Bradford and Airedale commends Optegra Yorkshire Eye Hospital for its proactive approach towards providing high quality services for its patients. Dr. Damian Riley Medical Director, NHS Airedale, Bradford and Leeds On behalf of NHS Airedale and Bradford 24