Select Committee on Health Written Evidence

Memorandum by Independent Healthcare Advisory Services (IHAS) (PS 61)



  The IHAS brings together members and specialists across the health care industry in all four countries, to share a unique level of knowledge, experience and understanding in order to:

    —  facilitate effective communication between all its subscribers, the government and external organisations

    —  strive to develop and drive policy advancement through shared subscriber input and consultation

    —  deliver focused, practical information and guidance in all areas of regulation and policy, sharing and distributing knowledge

  The IHAS's primary focus is in the area of operational policy and the regulation of the sector. As such it seeks to:

    —  Facilitate the development of operational policy, through consultation with its member organisations

    —  Provide its members with accurate and timely information regarding regulatory and policy matters

    —  Administer an independent complaints process

    —  Develop a range of quality initiatives to raise awareness of good practice within independent providers

    —  Represent independent health care providers on matters of quality and regulation to government, external organisations, and the public, providing a channel for effective communication and dialogue

  The IHAS welcomes the opportunity to submit evidence to the Patient Safety Inquiry. The IHAS has a number of working groups that address patient safety issues such as the IHAS Quality group chaired by Jane Cameron Ramsay Healthcare UK, the Perioperative Care Working chaired by Miranda Eyles HCA International, Decontamination chaired by Chris Ayton BMI Healthcare, the Infection Control Group chaired by Sue Manning BMI Healthcare and Critical Care Group chaired by Sally Taber IHAS. Our response is set out in respect to the terms of reference with submissions from our member organisations. The details of the person/s submitting are included in the relevant sections.

  The chairman of IHAS Board is Stephen Collier BMI Healthcare. He has the independent sector place on the Patient Safety Forum chaired by Sir Liam Donaldson and David Nicholson and ensures that the National Patient Safety Forum agenda is communicated to the IHAS Board at the quarterly meetings

  The IHAS would be very prepared to give oral evidence to the committee.


Critical care Transfer

  Independent Healthcare providers completing the IHAS 2007 Hospital Profile carried out 631, 000 procedures each year—of these a tiny proportion have unexpected complications that require specialised care including within NHS critical care facilities. The number of cases that need to be transferred to the NHS is less than 0.5% of the total cases. The transfer document has been put together to ensure that the safety of patients is a high priority and is enabling in order to:

    (a)  To facilitate escalation of care when appropriate for all patients in a timely fashion

    (b)  To ensure that all independent hospitals/clinics fulfill that there is a requirement for independent hospitals and treatment centres to have in place written policies and procedures for the transfer of patients to another hospital where required.

  The critical transfer paper has been prepared in conjunction with the Intensive Care Society, the Critical Care Network Managers, the Department of Health (England) and the National Critical Care Stakeholders Forum.

Perioperative Care Collaborative

  The IHAS is currently chairing the Perioperative Care Collaborative which is made up of the Association of Perioperative Practice (AfPP), British Anaesthetic and Recovery Nurses Association, British Association of Day Surgery, College of Operating Department Practitioners, PROPRIUS—Forum for Perioperative Education, Royal College of Nursing and The Royal College of Surgeons (England). The work around patient safety issues has included addressing how surgical procedures are performed in primary care. With the continued drive to move services from secondary care to primary care the Perioperative Collaborative members have been concerned that there is a lack of assurance with regards standards, governance and a clear framework to ensure safe delivery of services which protect patients. The AfPP have produced Standards and Recommendations for Surgery in Primary Care and the Collaborative members are ensuring that these are widely circulated.

  IHAS Members have been addressing Correct Site Surgery following the issue of the NPSA Correct Site Surgery alert in March 2005 with a 12 month implementation date. Evaluation of the implementation of the Alert has caused concern. It has been agreed that this should now be taken up by the Perioperative Care Collaborative. The Collaborative will be following the agenda of the World Health Organisation (WHO) who are promoting correct site surgery through the development of standing operating procedures and the Safer Surgery check list as well as obviously the NPSA.

  Self regulation agenda for Cosmetic Injectables—The IHAS have been taking forward this agenda and signed up to NPSA/Healthcare Commission Patient Safety Charter in order to address the issues of Patient Safety for patients wishing to receive cosmetic injectables. Issues such as remote prescribing and the cosmetic injectables being given by an appropriately trained practitioner have been taken forward. The IHAS has been delighted that the Nursing and Midwifery Council, the General Medical Council and the General Dental Council have all responded in ensuring that appropriate guidance is available to address poorly performing practitioners to ensure patient safety.


What the current effectiveness is of systems for incident reporting, risk management and safety improvement in ensuring patient safety

Jane Cameron, Director of Clinical Services, Ramsay Healthcare UK

Patient identification

  Ramsay Healthcare UK, following a successful trial, is adopting Laserband to replace patient identification wristbands. This product rules out human error related to handwriting on bands. Laserband technology is linked to the Patient Administration System (PAS): the patients' data is printed direct from the Pas onto the Laserband in the clinical ward area.

Fit for surgery and Pre-operative assessment

  Ramsay Healthcare UK has redesigned existing patient assessments to meet evidence based practice. The revised patient questionnaire pinpoints significant medical history and risk factors to identify a specific group of patients who require further investigation and work-up before surgery. Following a pilot study the new process has been rolled out across the organisation. The pilot demonstrated that over 50% of patients only require a telephone assessment, permitting clinical resource to be focussed on face to face assessment of at risk patients. Outcomes in terms of perioperative complication rates are being tracked to measure efficacy.

Anaesthetic safety

  Anaesthetists practising in Ramsay Independent Sector Treatment Centres have adopted an electronic assessment tool which permits the clinician to evaluate multiple patient medications (including herbal remedies) as part of the anaesthetic patient assessment. The assessment pinpoints any potential contraindication and hyperlinks to guidance sheets.

Dr Andrew Jones, Medical Director, Nuffield Health

  As part of the overall commitment to improving Integrated Governance processes, in 2007 Nuffield Health implemented the Datix Risk Management System for reporting and management of incidents, risks, complaints handling and claims and for governance reporting. The Datix system has transformed the incident reporting and management processes at Nuffield Health, resulting in a 100% increase in the number of incidents reported. In 2007 Nuffield Health published the first Integrated Governance Report which outlined the main activities to develop and promote integrated governance reporting.

  Nuffield Health has recently introduced a Quality Performance Indicator (QPI) reporting framework, reflecting activity across all Nuffield Health Divisions and includes:

    —  Statutory/regulatory reporting requirements such as the NHS Litigation Authority.

    —  the management of risks and patient safety

    —  Department of Health policy

    —  Best Practice.

  Nuffield Health's approach to Integrated Governance is to realise opportunity, support the demands of compliance, and help to provide treatments and services that are safe, quality assured and cost effective. The Datix system is then used to collate significant events and "near misses" by categories. Between January and August 2008 Nuffield Health identified 187 potential errors in the blood transfusion policy. This led to work streams to remedy the main factors with a substantial reduction in errors.

  Evidence source: Integrated Governance Report 2007, Nuffield Health

A systematic approach to health and safety has reduced incidents by one third.

  Nuffield has set up a series of 6 sterilisation hubs with a fall from the industry standard defect rate from 0.5% to current rate of 0.2%. The first three units have all been accredited to the new MHRA standards for operating equipment.

Rosemary Hittinger, Director of Clinical Governance HCA International

  HCA employs the Datix system which is common to all our sites. The system is centrally managed to allow for commonality of thresholds to cover adverse incidents, adverse incidents no harm, near misses, peri-operative/procedure complications, complaints and claims. This allows a fully integrated register to identify common trends and analysis. This is a particularly useful coordination for consultants who have practising privileges at more than one of our facilities. HCA hospitals are independently accredited which requires identification of incidents that change practice and forms part of each hospital's annual report. We are introducing bar coding for patients and medications and have a Positive Patient Identification Project ongoing. HCA also has a traffic lighted balanced scorecard which is reviewed quarterly with the Chief Executive Officers (CEOs). This covers a number of clinical and non clinical performance issues including infection rates and is designed to take accountability to the highest level embedding quality indicators with business practice. E.g. if there are any infections the relevant CEO is required to explain the findings of the root cause analysis and provide a remedial plan. Amongst other measures we have

    —  implemented the SSI care bundle and ventilator bundle in ITU.

    —  introduced a blood transfusion tracking system


Dr Andrew Jones, Medical Director, Nuffield Health

  Nuffield Health has Infection Prevention Control Link Practitioners (Alps) in place within 30 Hospitals and their role is to support the Hospital Matron in the detection of risks and implementation of Best Practice. 87.5% of Nuffield Health Hospitals have a trained ICLP who have completed the Royal College Nursing (RCN "Principles of Infection Prevention") Accredited course. 57.5% of Hospitals have an ICLP in every clinical area. ICLP programme has produced dramatic results with average scores exceeding 90% in the 10 key areas of infection prevention. Nuffield Health completed 89,000 orthopaedic cases in 2008 with only one case of MRSA.

Rosemary Hittinger, Director of Clinical Governance HCA International

  HCA has an assigned Infection Control Nurse for every facility as well as site link nurses. They have a strong educational function as well as a monitoring and advisory one. Feedback on incidents and adverse events is disseminated at each site to the department heads via the Clinical Governance Team in order that events are learnt from. There is also a corporate forum to share learning. Each site is required to cascade any Alerts and guidance relevant to their practice to those that are actually delivering the care and at the Corporate Clinical Governance Steering Committee there is a standing agenda item on "Horizon Scanning" when new guidances etc. are considered as relevant. This committee had representation from every site and meets monthly.


Dr Andrew Jones, Medical Director, Nuffield Health

  Nuffield Health's collaborative approach to claims, complaints and incidents resulted in a 20% reduction in litigation and insurance premiums in 2007. What the current effectiveness is of national policy in ensuring patient safety?

Dr Jean-Jacques de Gorter, Director of Clinical Services Spire Healthcare

  Spire Healthcare is committed to infection control excellence, evidenced by its infection control strategy, implemented by Infection Control Leads at each of its 36 hospitals and coordinated by a national Head of Infection Control with experience of working for the Health Protection Agency. Over the past 3 years, Spire has reduced surgical site infections by up to 75%, and has an enviably low rate of MRSA bacteraemia and C. difficile.

  The national guidance for MRSA screening (Department of Health Operational Guidance for MRSA Screening 31 July 2008) raises some concerns regarding evidence to support this approach. Whilst Spire Healthcare has a screening programme in place for high risk patients, it believes in maintaining a focus on the fundamentals of a robust infection control programme and on targeting resources into improving clinical practice. It believes this is a view shared and supported by many experts in the field.

  Adverse events related to blood transfusion account for a significant proportion of total clinical adverse events. Clear standards were set out in the Serious Hazards of Transfusion (SHOT) guidelines in 2005. Spire hospitals adopted these standards soon after their release and following focussed attention, succeeded over a period of 3 years in reducing blood cross-matches by 47%, and blood transfusion by a fifth as a result of embedding these into care pathways resulting in safer patient care and more appropriate use of blood products.

  Finally, Spire Healthcare has since 1998 run a Patient Reported Outcome Measures (PROMS) programme—the most mature active programme of its kind in the UK, with data on approximately 200,000 patient episodes. This provides information on the degree of health improvement experienced by patients following treatment, and is incorporated into Spire's overall clinical governance framework. As a vocal champion of PROMS for many years, Spire is pleased that the NHS intends to roll out this approach starting in April 2009.

September 2008

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Prepared 30 October 2008