Quality and standards
Internationally renowned for clinical excellence
We are dedicated to embracing continuous improvement, following feedback from our patients and staff. Working within the seven key areas of clinical governance, we aim to provide the highest standard of care for our patients.
Care Quality Commission
The hospital is regularly inspected by the Care Quality Commission to ensure compliance with the Private and Voluntary Healthcare (England) Regulations.
How do we ensure that our services are safe?
Our top focus is providing outstanding quality of care for our patients. We have SafeCare rostering to ensure we have staff with the right skills and knowledge on duty to provide care safely. We closely monitor the use of bank and agency staff.
- SafeCare is a staff rostering system that allows us to match staffing levels and skill mix to the actual patient demand. SafeCare has been awarded an endorsement statement by The National Institute for Health and Care Excellence (NICE) in relation to its guidelines for Safe Staffing.
- Q-Pulse helps healthcare organisations to comply with standards and regulations, control safety and risk and achieve unprecedented levels of quality and efficiency. There are safeguarding policies and processes in place, accompanied by training appropriate to the staff level.
- International Safety Award Merit - we have been awarded the International Safety Award Merit by the British Safety Council in both 2018 and 2019. This recognises commitment to good health, safety and wellbeing management.
How do we demonstrate quality of care?
We are constantly looking at ways to improve clinical care in order to give patients safe care and excellent outcomes.
- 1.2 inpatient falls per 1,000 bed days, compared to the 2015/16 average of 6.1/1000 bed days in an acute setting (NHS Improvement, 2017).
- 23 new hearing loops throughout the hospital, available at reception desks, ‘map for all’ (to aid visually impaired) being developed.
- Kidney transplants - at one year follow up, there was a 100% survival rate (for both mortality and the transplanted grafts).
- Bariatrics - 73% had lost 30% of body weight at 3 months.
- Prostate - 75% positive diagnosis, of which 85% were clinically significant.
- 11 Multi-disciplinary teams, in 2017 1,085 cases were discussed. We bring together a range of medical experts to review your diagnosis and make the best individualised plan for your treatment.
- Schwartz Rounds give space for staff to reflect on and share their experiences of the emotional impact of working in healthcare. This ensures staff get access to great support, enabling them to provide better care for our patients.
We were the first Private Hospital to submit data to Private Hospitals Information Network (PHIN) at the beginning of 2016 and are now ranked second in the country for data maturity.
PHIN is an independent, government mandated organisation which aims to empower patients to make better informed decisions about their choice of care provider.
Patient-Led Assessments of the Care Environment (PLACE) programme
These self-assessments are undertaken by teams of NHS and private/independent healthcare providers, and include at least 50% members of the public (known as patient assessors).
They focus on the environment in which care is provided, as well as supporting non-clinical services, such as cleanliness, food, hydration, and the extent to which the provision of care with privacy and dignity is supported, as well as aspects of the environment in relation to the provision of care to those with dementia.
Cromwell Hospital achieved 100% in four broad categories of:
- Condition, appearance and maintenance
- Food and hydration
- Privacy, dignity and wellbeing
We are committed to publishing our performance and bench marking ourselves against our peers nationally to ensure that you feel confident that you are getting the right care for you. Our three year Patient Outcomes Strategy is helping us to participate in a larger range of National Audits and Registries.
We are working with the Healthcare Quality Improvement Partnership (HQIP) to pilot increased independent healthcare sector participation and have joined the Get It Right First Time (GIRFT) steering committee for the independent sector. We submit our outcomes to the Private Healthcare Information Network (PHIN) and are engaging with them on improving the transparency and reliability of data and increasing our Patient Reported Outcome Measures (PROMs) and QPROMs (for cosmetic surgery) submission.
We contribute to the following national registries:
- Adult Cardiac Surgery – National Institute for Cardiovascular Outcomes Research (NICOR)
- Breast and Cosmetic Implant Registry
- Cardiac Rhythm Management (NICOR)
- Intensive Care National Audit and Research Centre (ICNARC)
- National Audit of Percutaneous Coronary Interventions (PCI) (NICOR)
- National Bariatric Surgery Registry
- National Cardiac Arrest Audit (NCAA)
- National Joint Registry (NJR) – we are better than the national average for knee joint revision rate (NJR 2016/17 data), so you are less likely to need revision surgery following a knee joint operation
- National Patient Results and Management (PROMs) Programme
- NHS Blood Stock Management System (VANESA)
- NHS Blood & Transplant Registry
- Serious Hazards of Transfusion (SHOT)
- UK National Flap Registry
We also collect data in line with the National End of Life Care Audit which currently restricts private providers from submitting data.
Clinical Audit is the systematic process of setting standards for good practice, comparing a sample of current practice with these standards, identifying areas which might be improved and, most importantly, implementing appropriate change, and re-auditing to complete the process.
Clinical Audit is a valuable tool for measuring and improving quality of care and is one of the drivers for Clinical Governance. The hospital has a well-established infrastructure for supporting and monitoring Clinical Audit.
We have a comprehensive annual audit programme which is coordinated by our Clinical Audit Lead. The schedule focuses on key safety initiatives including Early Warning Scores to identify patients whose condition is deteriorating, Early identification and management of Acute Kidney Injury (AKI) and prevention of hospital acquired deep vein thrombosis (DVT). We also audit based on NICE guidance, and in particular the NICE Quality Standards which are of most relevance to our patients.
Providing high quality clinical care requires our clinicians to be responsive to our patient’s complex and fluctuating conditions. It requires them to anticipate and respond to changes and adjust treatment accordingly.
We apply the same process to thinking about safety and quality in the hospital. Our clinical teams and our managers need to have regular information which helps them to diagnose problems with safety or quality in the organisation quickly so that they can act swiftly to treat the cause and ensure our patient’s have the best experience of care.
Each month we produce a comprehensive integrated quality report (IQR) which includes a range of metrics about our safety and quality performance. This includes feedback from our patients, our staff and our consultants.
We track and monitor our performance closely, making adjustments month on month to ensure that we are always improving. When we identify actions from internal or external sources we add them to our Quality Improvement Plans.
Integrated Quality Report (IQR)
We use IQR to track safety trends and areas for improvement. Latest results (March 2018) show:
- Hand Hygiene compliance was 98%
- WHO Surgical Checklist compliance was 100%
- Surgical Site Infections, none reported
- No Never Events.
Human Tissue Authority
We are regulated by the Human Tissue Authority to ensure that human tissue and organs are used safely and ethically, and with proper consent.
We were licenced by the HTA in 2018 where we met all assessment criteria in addition to those noted: ‘Areas of good practice were observed during the audit, which includes checklists to ensure that relevant departments have been informed and contacted, and a ward discharge checklist to confirm that the donor has been provided with information about what to expect following the transplant.’
The hospital has developed a patient education pack so patients understand what to expect post transplantation such as post-operative medication regime and recognised post-operative complications.
The Radiotherapy and Medical Physics Department is committed to continual improvement and offering a quality service. The departments operate a quality management system to the standards BS EN ISO9001:2008, verified by a recognised Certification body. Certificate renewal was achieved in September 2009, extending the scope to include Gamma Knife.
Accreditation was initially 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 9001:2008 and documented patient practices.
Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accreditation
The current JAG accreditation scheme was established in 2005 and, along with the Global Rating Scale (GRS), has supported endoscopy services across the UK to focus on standards and identify areas for development. The scheme is regarded as one of the most innovative and effective in the healthcare sector, and has been used as a model and source of inspiration for similar schemes both here and overseas.
We were re-accredited in 2018.
Accreditation enables endoscopy services to assess their current performance, and it supports them in planning and developing their services. It helps with:
- people – it helps to improve their focus on meeting users’ needs
- workforce – it helps to improve their focus on meeting the team’s needs
- profile – it raises awareness and understanding of endoscopy, so building confidence and credibility both within the organisation and among the public
- improving performance – the standard serves as an authoritative benchmark for assessing performance, rewarding achievements in the service and driving quality improvement.
We are currently working towards specialised JAG accreditation for our paediatrics services.
British Safety Council
International Safety Awards Winner 2018
Through their awards they set health and safety standards and set best practice.
We have met the following Bupa enhanced quality standards that demonstrate specialist care for the services:
Breast care centre
This Bupa accredited breast care centre offers specialist care in the following areas:
- Breast diagnosis centre
- Breast reconstruction centre
- Breast surgery centre
Bowel cancer centre
This Bupa accredited bowel care centre offers specialist care in the following areas:
- Bowel endoscopy centre
- Bowel surgery centre
Cancer survivorship programme
Cromwell Hospital offers a cancer survivorship programme to support people living with and beyond cancer.
- Cancer survivorship programme
Specialist services for Bupa insured customers
This hospital is able to provide outpatient services for children 16 and under and inpatient services for the age ranges indicated below.
- Newborn / neo-natal
- 1 month to 3 years
- 4 to 12 years
- 13 to 16 years
We recognise that in the delivery of complex health care things can and do go wrong. We are committed to being open with ourselves and with you about things that do go wrong, so that we have an opportunity to learn from them and improve the quality of care we offer to our patients.
A safety 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. 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 skillful 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.
Our near miss reporting has improved from 5% in Sept 2017 in 22% of all incidents reported in the hospital in June 2018
Cromwell Hospital has implemented DATIXWeb which is an integrated system for reporting incidents, complaints and compliments and managing risk. The system went live in October 2011.
We promote an open culture and encourage all of our staff to report incidents, complaints and compliments directly onto the system. Our Executive team and senior leadership team get email notifications instantly and can work quickly to help teams address any issues which may impact safety or quality.
Keeping our hospital infection free
All our in-patients have their own rooms with en-suite facilities reducing the potential for transmitting infections.
All staff are taught the value of maintaining high standards of cleanliness including:
- cleaning their hands at the right times
- wearing disposable gloves and aprons
- keeping the hospital environment and medical equipment clean. Our lead nurses, sisters and managers have a particular responsibility to ensure high standards of hygiene
- using special procedures to take care of drips, drains and catheters
- taking great care of wounds.
Patients and visitors can help in a number of ways:
- hand hygiene is one of the best ways of preventing infection – the hospital has hand sanitizing gel containers available
- avoid touching wounds or any drips, drains or catheters
- If family members or visitors are feeling unwell with colds, flu or stomach upsets, they should delay visiting the hospital until they are feeling better.
Download a leaflet which will explain our MRSA Screening Programme.
MRSA Screening Programme
To help protect patients, visitors and staff from risk of infection, we screen certain high risk patients admitted to the hospital to ensure they are free of the MRSA bacteria.
Our policy is to screen inpatients at least 1 week in advance of their admission date. The test is simple and involves swabbing both nostrils. The specimens are then sent to our on-site laboratory for testing. The results are available within a day and those whose test shows they have MRSA bacteria the skin will be contacted and given an ointment for the nose and a body and hair wash to use for five days.
The MRSA swab result is valid for six weeks. In cases where patients are admitted to another hospital whilst waiting for surgery, the MRSA swab will have to be repeated prior to surgery.
The cost of the MRSA test performed at Cromwell Hospital will be covered by the hospital, even if you see your consultant elsewhere.
If you choose to have the MRSA screening done elsewhere or though your consultant, you will be responsible for any costs. You must provide a printed laboratory report of your MRSA status to the pre-admission team at the hospital before your admission can be confirmed.
Download a leaflet for more information about our MRSA screening information