Quality & Standards

Cromwell Hospital aims to provide the highest standard of patient care and takes Clinical Governance extremely seriously. The Hospital is also inspected by the Healthcare Commission to ensure compliance to the National Minimum Standards (PDF) and the Private and Voluntary Healthcare (England) Regulations.

To this end a number of quality improvement processes are in place to ensure that patient care and treatment is continuously updated, improved and reflective of the latest evidence available. Our quality programme includes:

Adverse incident reporting

An adverse incident is any event that causes a patient, visitor, member of staff, consultant, or the Hospital unintended or unexpected harm and includes clinical and/or non-clinical incidents.

All incidents that occur within the Hospital are reported and logged so that further investigations can take place if necessary. This enables us to learn lessons from incidents so that safety can be enhanced and future risk prevented. The Hospital also encourages reporting of "near misses". Near misses can be defined as: an occurrence which but for luck or skilful management would in all probability have become an incident.

The information from near misses identifies potential problem areas and opportunities to learn and improve practice. It also provides useful information on preventing future adverse incidents.

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BS EN ISO9001:2000

The Radiotherapy Department is committed to continual improvement and offering a quality service. The Department operates a quality management system to the standards BS EN ISO9001:2000, verified by a recognised Certification body.

Accreditation was achieved in 2003 and regular audits of all aspects of the service ensure that the Department continues to meet the aims of their Quality Policy. This policy is fulfilled through the adoption and implementation at all times of the Quality Management Systems and Procedures required by BS EN ISO 9001: 2000 and documented patient practices.

The Department has just undergone its 3 yearly audit and has been granted the ISO9001:2000 for a further 3 years, until 2009.

Care pathways programme

In order to continuously improve the quality of patient care and improve our service, a team of people are working on redesigning the patient journey to enhance it for both patients and carers. This programme also makes sure that we are practicing to the latest guidelines and evidence, and improves communication within the Departments.

A Care Pathway is a multidisciplinary outline of anticipated care, placed in an appropriate timeframe to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. Variations from the pathway may occur as clinical freedom is exercised to meet the needs of the individual patient.

Examples of care pathways in use include cardiac procedures, diabetes referral and management and some short stay surgery procedures for adults and children.

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Hospitality Assured

Hospitality Assured is The Standard for Service and Business Excellence in hospitality, championed by the Institute Of Hospitality and supported by the British Hospitality Association (BHA).

The process is fully endorsed by the British Quality Foundation and the Quality Scotland Foundation as meeting the criteria in the EFQM Excellence Model, which is owned by the European Foundation of Quality Management (EFQM). It is the only standard within hospitality that focuses on the customer experience.

The process of achieving Hospitality Assured recognition is rigorous and takes into account customer opinion and considers all aspects of service from the customers' point of view. The Hospital was awarded the mark in 2005 and we are tested annually. For further information please go to the Hospitality Assured website.

Infection control

The Hospital considers the prevention of hospital-acquired infection of paramount importance for all patients, visitors and staff. We have an Infection Control Team consisting of specialist nurses and a microbiologist who take a special interest in infections diagnosed in hospital. We offer advice in accordance with Department of Health and Healthcare Commission recommendations and nationally agreed protocols.

A pro-active approach ensures that hospital-acquired infections are kept to a minimum and there are guidelines and policies in place to minimise the possibility of the spread of any infection including MRSA (see below).

The Hospital considers that a clean environment provides the right setting for good patient care practices and good infection control. For example; Infection Control training is included in the induction and yearly update courses for all Cromwell staff; all staff clean their hands with alcohol hand rub or soap and water before and after examining patients or performing any invasive procedure; all patients are nursed in single en-suite rooms with the exception of certain specialist areas (e.g. Intensive Care).

In addition, a revolutionary cleaning system has recently been introduced; the Microfibre Cleaning System® which maintains and increases cleaning effectiveness and is also economical and ecologically sound.

The Cromwell monitors its infection rates as part of the national surveillance scheme.

MRSA

The Cromwell has an established MRSA screening policy for all patients admitted to the Hospital for certain surgical procedures and all patients admitted from other hospitals or healthcare environments. A nose and wound (if present) swab are taken to screen for MRSA.

Transmission of the organism within the Hospital is rare. In 2005, there was 1 case of MRSA blood stream infection detected in the hospital.

Approximately 0.16 % of in-patients were found to have MRSA in 2005 and these positive results were generally from admission screening swabs.

For more information please download our MRSA Information for Patients leaflet.

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Patient feedback

We aim to provide the highest standards of care and service to our patients, and regard your opinions and comments as extremely valuable as they help us to identify areas of success and opportunities for improvement.

Our Share Your Views leaflet is a guide to giving us your views about your Hospital experience.

In addition, to help us measure our level of achievement we ask patients to complete a questionnaire which is made available either during their stay or sent to them when they have gone home. The results of this questionnaire from 917 patients for the period 12 months until May 2006 are available below. Results are displayed as a percentage (%) of 100.

• Quality of care
  
• Consultant care
  
• Nursing care
  
• Physiotherapy
  
• Imaging (x-ray)
  
• Accommodation
  
• Catering
  
• Discharge process
  

Quality Indicator Project^® (UK QIP)

The Quality Indicator Project^® began in the United States in 1985 to assist hospitals in identifying opportunities for improvement in patient care. Around 1,000 hospitals now participate in the Project across the USA, Europe and Asia. UK participation began in 1991 and over 80 hospitals currently participate in the Project in UK and Ireland.

Participation in the UK QIP project enables Cromwell Hospital to continuously improve the quality of care provided to patients. This is achieved by assessing and evaluating data that can be compared anonymously with other private healthcare providers in the UK, ensuring that the Hospital continuously strives towards an equal or higher level.

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