Clinical Governance & Outcomes
In 1998 the Department of Health published "A First Class Service - Quality in the NHS". That document defines clinical governance as:
"a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards”.
At The Portland Hospital we are committed to the same fundamental approach.
We have further developed the Clinical Governance agenda at The Portland Hospital with the appointment of a paediatric consultant as Chairman of the Clinical Governance Committee. This individual has considerable experienced in clinical governance and is tasked with ensuring a unified approach throughout the hospital.
We have developed 7 pillars of clinical governance which are shown below:
- Clinical effectiveness/establishing "benchmarkable" outcomes (policies and training included)
- Clinical risk management
- CME/CPD/Personal performance
- Research and development including new technologies
- Accreditation and where possible I.T. systems as support for such activities
- Quality indicators, patient satisfaction and complaints
Key Performance Indicators
The Portland Hospital started submitting data to CHKS Signpost (the UK's leading independent provider of healthcare intelligence) in January 2008 on a monthly basis.
We also submit data to PICANet which is an international audit that collects information on all children admitted to paediatric intensive care in the UK and the Republic of Ireland.
Additionally we submit data to the Care Quality Commission (CQC) on a quarterly basis.
The CQC indicators we submit data for are:
Unplanned Readmission within 28 days for same/related condition
An unplanned re-admission is when a patient is re-admitted to the hospital within 28 days of being discharged. The reason for the second admission should be related to the first. Some patients may be at greater risk of being re-admitted than others, so this may increase the rate of re-admission at those hospitals treating very ill patients or very complex cases.
Unplanned returns to theatre
A return to theatre is when a patient has surgery and needs to return to theatre for an unplanned procedure during the same stay at the hospital.
When looking at results like this, please consider:
- Hospitals performing more complex procedures, or operating on people with other existing illnesses, are likely to have higher rates of returns to theatre.
How we keep returns to theatre low:
- Our patients undergo a rigorous assessment with our nursing and medical staff before surgery.
- Our surgeons and anaesthetists are all recognised specialists in their fields and are listed on the General Medical Council's Specialist Register.
- Our hospital has dedicated recovery areas so we can carefully monitor patients immediately after their operation.
Unplanned transfers out
This is where a patient has to be transferred out urgently for more specialised care than we may be able to offer.
We also submit data to the Care Quality Commission (since 2009) for the following indicators:
- Number of Admissions
- Number of Day Cases
- Number of Anaesthetics
- Number of trips to the operating theatre
- Number of blood culture results that were reported as positive for MRSA
- Number of blood culture results that were reported as positive for MSSA
- The number of reports of serious injury under regulation 28 of the Private and Voluntary Healthcare (England) Regulations 2001
Each quarter we also look at the following indicators within HCA Healthcare UK.
- Number of Surgical Site infections for Abdominal Hysterectomies
- Number of C.Difficile infections
- Complaints and resolution rates
- Wrong site surgery
- Retained swabs/instruments
- Radiation overdoses
- Maternity specific outcomes
Every 2 months the following outcomes are discussed at the Medical Advisory Committee:
- Unplanned Readmission within 28 days for same/related condition
- Unplanned returns to theatre
- Unplanned transfers out
- Delivery numbers
- Surgical Site Infections
- MRSA bacteraemia's & colonisations
- MSSA bacteraemia's & colonisations
- C. Difficile infections
- Medication incidents
- Clinical incidents that have been closed
- NICE guidance