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Clinical Governance & Outcomes

Clinical Governance

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 and 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.

Further development of the Clinical Governance agenda at The Portland Hospital is proven with the appointment of a retained gynaecology consultant as the Director of Clinical Governance. This individual has considerable experienced in clinical governance and is tasked with ensuring a unified approach throughout the hospital.

We have developed with 7 pillars of clinical governance which are shown below:

  • Audit
  • Clinical effectiveness/ establishing "benchmarkable" outcomes (polices 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

Independent Healthcare Awards 2011 Finalist

Clinical Outcomes

Since Jan 2008 we have been submitting data to CHKS Signpost.

Clinical Performance Indicators

The Portland Hospital became involved with submitting data to CHKS Signpost (UK's leading independent provider of healthcare intelligence, the UK healthcare intelligence market with hospital benchmarking in 1989) in Jan 2008 on a monthly basis.

The 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. Our rate in 2010 was 0.47%, compared to 1.63% in NHS. This is a percentage of all discharges.

Mortalities

These are any deaths within the hospital stay. Our rate in 2010 was 0.01%, compared to 1.39% in NHS. This is a percentage of all discharges.

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. Our rate in 2010 was 0.08%, compared to 5% in NHS. This is a percentage of all theatre cases.

When looking at results like this, please consider:

  • Hospitals treating small numbers of patients can show a high rate of returns to theatre because of a low number of cases.
  • The same hospital may then go on to have no more cases for a long time.
  • 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 anesthetists 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.

Our rate in 2010 was 0.14%, compared to 1.55% in NHS. This is a percentage of all discharges.

Our rate is higher than some other HCA hospitals due to the nature of our work with children from overseas that have multiple problems and need further specialist care.

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Outcomes broken down by speciality.

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Each Quarter we also submit data to the Healthcare Commission (Care Quality Commission from April 2009) for the following indicators:

  • Mortalities
  • Number of Admissions
  • Number of Day Cases
  • Number of Anaesthetics
  • Number of trips to the operating theatre
  • Unplanned returns to the operating theatre
  • Unplanned Readmission within 28 days for same / related condition
  • 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 indictors within HCA.

  • Number of Surgical Site infections for Abdominal Hysterectomies
  • Number of C.Difficile infections
  • Complaints & resolution rates
  • Wrong site surgery
  • Retained swabs/instruments
  • Radiation overdoses
  • Maternity specific outcomes

Each month the following outcomes are discussed at the Head’s of Department meetings:

  • Unplanned Readmission within 28 days for same / related condition
  • Mortalities
  • Unplanned returns to theatre
  • Unplanned transfers out
  • Patient Feedback scores

Every 2 months the following outcomes are discussed at the Medical Advisory Committee:

  • Unplanned Readmission within 28 days for same / related condition
  • Mortalities
  • Stillbirths
  • 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