Quality Account 2022-23 PART ONE - PowerPoint Presentation

1. Quality Account2022-23

2. PART ONEAbout Sulis Hospital BathAbout the Quality AccountStatement from the Hospital DirectorPART TWOAchievement against quality improvement priorities for 2022-23Quality improvement priorities for 2023-24Mandatory statementsPART THREEReview of quality performance during 2022-23Jargon-buster

3. PART ONE

4. ABOUT SULIS HOSPITALSulis Hospital Bath is an award-winning hospital designed to feel modern and relaxed so patients can enjoy their stay in comfort.It was purpose-designed through a collaboration between world-renowned architects Foster & Partners and doctors, who combined their experience in the NHS and private practice to create a healing experience for our patients.As a site, Sulis Hospital benefits from:28 bedrooms, each with en-suite facilities22 day-case bedsFlexible visiting hoursFive ambulatory chairs11 consulting roomsFour state-of-the-art operating theatresEndoscopy suite with JAG accreditationDedicated cardiology suiteIntervention treatment roomsDigital diagnostic unitResident medical officer (RMO) on site 24 hours a dayFree car parking directly outside the hospitalDelicious food, available all daySulis Hospital’s unique private patient care model benefits all by allowing any additional income, earned through private care, to be reinvested in high-quality services for all patients at the two hospitals Sulis Hospital and the Royal United Hospital.Sulis Hospital is the first private hospital in the UK where 100% of the shares are owned by an NHS Trust. The acquisition by the RUH has grown the hospital’s services, increasing capacity for both NHS and private patients. This is particularly important at a time of recovery for NHS waiting lists nationally.All care at Sulis Hospital Bath is consultant-led with over 150 consultants practising on site in over 40 specialities.

5. ABOUT THE QUALITY ACCOUNTA Quality Account must include:A signed statement from the most senior manager of the organisation describing the quality of healthcare provided. Within this statement, senior managers should declare they have seen the Quality Account and they are happy with the accuracy of the data reported, are aware of the quality of the NHS services they provide, and highlight where the organisation needs to improve the services it delivers. The statement is also an acknowledgement of any issues in the quality of services currently provided.Answers to a series of questions all healthcare organisations are required to provide. This includes information on how the healthcare provider measures how well it is doing, continuously improves the services it provides, and how it responds to checks made by regulators like the Care Quality Commission (CQC).A statement from the organisation detailing the quality of the services it provides. Clinical teams, managers, patients and patient groups may all have a role in choosing what to write about in this section, depending on what is important to the organisation and the local community. You will find a statement from the provider's main commissioner (buyer of their NHS services) at the end of this Quality Account.The Health Act 2009 requires all providers of healthcare services to NHS patients to publish an annual report about the quality of their services; this report is called a Quality Account. Amendments were made in 2012, such as the inclusion of quality indicators according to the Health and Social Care Act 2012.Quality Accounts are an important way for local providers of NHS services to report on quality and show improvements in the services they deliver to local communities and stakeholders.The quality of the services is measured by looking at patient safety, the effectiveness of treatments patients receive, and patient feedback about the care provided.

6. STATEMENT FROM THE HOSPITAL DIRECTORIt is with great pleasure that we welcome you to the 2022-23 Quality Account produced by Sulis Hospital, Bath. We are pleased to report on the quality of our services, patient experience and assurance procedures. This report outlines our approach to quality improvement, progress made in 2022-23 and our plans for the coming year.The aim of our Quality Account is to provide information to our patients and commissioners to assure them we are committed to making progressive achievements. For example, we participate in the UK Health Security Agency’s Surgical Site Surveillance Service, National Joint Register and Patient Reported Outcome Measures.Since the acquisition of the site from Circle by Royal United Hospitals Bath NHS Foundation Trust in June 2021, Sulis has maintained and demonstrated its ongoing commitment to the highest standards of care and quality, having been closely interrogated at a number of levels by the RUH, ICBs and third parties.We have a robust quality and assurance framework in place that ensures safety and accountability are at the heart of everything we do. Our governance team are embedded in the processes and running of every department so we can evidence our safe practice to our patients and stakeholders.The launch of our Mission and Values has been staff-driven to ensure that the voices of our staff are heard. The Senior Management Team is dedicated to ensuring we facilitate best practice at all levels and through all departments, clinical and support services.Our programme of equipment replacement is well underway, with the installation of an MRI scanner which commenced in March 2023, dedicated to BSW’s Community Diagnostic Centre (CDC). As such, Sulis is proud to be a CDC hub, working with NHS partners to enable closer access to much-needed diagnostics.Investment in Learning and Development for our staff is paramount to ensure not only the safety of our patients, but enhancing the career opportunities for our staff. The appointment of a L&D Lead demonstrates our commitment to this investment.The outcome of our recent Staff Satisfaction Survey demonstrated compassionate leadership and an improving relationship with staff. Patient, ICB and consultant testimonials reflect the positive outcomes of our dedicated staff, something which we remain very proud of.Our commitment to the highest level of patient care, clinical standards and service quality remains foremost in all that Sulis does. During difficult and challenging times, Sulis and our staff have consistently risen above and delivered exceptional care and we remain committed to this goal.We trust that this Quality Report demonstrates our capability and commitment at Sulis.Simon MilnerHospital Director

7. PART TWO

8. ACHIEVEMENT AGAINST QUALITY PRIORITIES 2022-23DomainPriorityMeasure2022-23 ProgressStatusEFFECTIVEReduce the amount of time patients spend in hospital following elective orthopaedic proceduresAverage length of stay (LOS) for Hip and Knee proceduresAVLOS for all activity reduced from 2.1 days in April 22 to just 1.5 days in March 23.CompletedEFFECTIVEIncrease theatre capacity on site with 5th operating theatreNew theatre established and operationalOpened in April (add in numbers seen since opening)CompletedEFFECTIVEIncrease diagnostic capabilities on siteNew MRI scanner installed and operationalThe second MRI scanner at Sulis was commissioned during March 2023, with the first patients being scanned on 20/03/23CompletedWELL-LEDIncrease workforce resilienceReduce staff turnoverReduce number of open vacanciesNumber of Freedom to speak up guardian and HR support session contacts offered on siteAnnual turnover reduced from 25.3% in Q1 to 22.9% in Q4 2022-23.Up to establishment on IPU. Increased establishment in radiology to staff new scannersSulis now have 3 trained FTSU guardians on site.CompletedCompletedCompletedSAFEIncrease workforce resilienceAchieve >90% Covid vaccine uptakeAchieve >90% Influenza vaccine uptakeIn line with regional trends, staff uptake of the Covid and Influence vaccines at Sulis fell below the 90% target during 2022-23Not achievedNot achieved

9. ACHIEVEMENT AGAINST QUALITY PRIORITIES 2022-23DomainPriorityMeasure2022-23 ProgressStatusCARINGContinue to deliver excellent patient experienceMaintain >95% patients reporting their experience is Good, or Very GoodContinue to deliver patient connect programme on site97.8% rated their experience as Good or Very GoodSMT now involved in patient connect visits to inpatientsCompletedCompleted, ongoingRESPONSIVEProvide staff the opportunity to discuss concerns outside of usual management structuresHost regular listening events on siteListening events hosted, along with staff survey and ‘Simon on the stump’ (departmental visits by Hospital Director).Completed, ongoingRESPONSIVEEstablish new Private GP serviceNumber of patients accessing private GP serviceService established and over 500 appointments offeredCompletedRESPONSIVEContinue to reduce the length of time patients have to wait for treatment at SulisContinue to treat the backlog of elective recovery patients in the region due to the pandemicReduce number of patients with >52 week wait from referral to treatment (RTT)Number of patients treated for the RUH and across the BSW region by Sulis to aid the elective recovery programme. Reduced from 361 in April 2022 to just 31 in March 2023Treated and removed over 1400 patients from regional trusts wait lists while maintaining our RTT position for new referrals and existing care pathwaysCompleted, ongoingCompleted, ongoingSAFEAchieve formal accreditation of anaesthetic servicesACSA: (Anaesthetic Clinical Services Accreditation) achievedResus lead continuing to work with RUH anaesthetists and surgeons to completeOngoingSAFEDeliver Safeguarding refresher training (MCA & DoLS)and assess staff’s understanding of Safeguarding topics including escalations processes.Training delivered to department leads and relevant staffSafeguarding knowledge audits completed by HoN & AHPsSafeguarding training delivered to leads to cascade. Level 3 adult and children safeguarding training rolled outAudits completed, and more planned for 23-24.CompletedOngoing

10. QUALITY PRIORITIES for 2023-24Quality improvement priorities for 2023-24 look to build upon the positive steps taken during 2022-23 and further increase capacity and resilience within the organisation in order that we can continue to deliver NHS patients excellent, safe and sustainable care.CQC DomainPriorityMeasureRationale for inclusionEffectiveProgress SERP project and pathway for reducing AVLOSReduced LOS for patients seen in modular theatreAll NHS patients included on SERP pathway that are treated at Sulis. Increase numbers of patients who can be treated at Sulis to aid elective recovery programmeEffectiveIncrease diagnostic testing provision at SulisIncreased opening hours for CT and MRI scansMobilise physiological measurements for patients attending through CDC by January 2024Improved diagnostic IT capabilityContinue to support the BSW region in reducing the backlog of patients awaiting diagnosticsFurther increase Sulis’ capacity for providing diagnostic services in line with NHS’s priorities and operational planning guidance 23-24Improve the efficiency with which Sulis can process diagnostic referrals and therefore maximise utilisation of diagnostic services on siteEffectiveEstablish Digital Mutual Aid System (DMAS) at SulisDMAS contract signedIn line with national priorities and operational planning, Sulis can become a treatment location option for patients people have been waiting a long time for their procedureWell LedImproved nursing and allied health professional (AHP) efficiency and reduction of agency usageNumber of agency shifts usedDuring 202-23 Sulis reduced their spend on agency by 57% through a successful programme of efficiencies and additional staff recruitmentSAFEAchieve formal accreditation of anaesthetic servicesACSA: (Anaesthetic Clinical Services Accreditation) achievedParticipation in the scheme provides valuable assurance about anaesthetic services and the CQC regard it as important evidence about the safety, effectiveness and responsiveness of services

11. QUALITY PRIORITIES for 2023-24CQC DomainPriorityMeasureRationale for inclusionResponsiveBroaden complex work delivered at SulisIncrease in complex patients treated at SulisHelp reduce inequity in access to services at Sulis by supporting the treatment of more complex patients as part of the elective backlogEffectiveProvide more training opportunities at Sulis for medical traineesNumber of procedures completed by trainee surgical staff compared with 2022-23Support the NHS’s future workforce development.SafeComplete One Together AFPP Assessment ToolkitSelf assessment completed and recommendations developed as requiredSurgical site infections (SSIs) account for 16% of healthcare associated infections and are associated with considerable morbidity, mortality and increased costs of careResponsiveProgress transfer to Patient Initiated Follow-UpReduction in proportion of patients returning for outpatient review following surgeryBetter utilise consultant capacity to tackle backlog of patients awaiting elective procedures at Sulis. Aligned to objective from NHS’s priorities and operational planning guidance 23-24 to deliver a reduction in outpatient follow up. SAFEDeliver Safeguarding refresher training (MCA & DoLS)and assess staff’s understanding of Safeguarding topics including escalations processes.Safeguarding L3 Adult and children training compliance >90%Safeguarding knowledge audits completed by HoN & AHPsThe safety of patients is a priority for Sulis. Thorough safeguarding training enables staff to better identify where action may need to be taken to keep patients safe from harm.Audits of staff knowledge help show where additional training may be required.CaringMaximise valuable feedback captured and learn from patient’s experience of careIncrease quantity of patient feedback received across every departmentPatient experience results remain consistently good, however it is important to enable as many people as possible to leave possible in order that Sulis can design and adapt services to meet all our user’s needs. Well LedRespond to learning from Staff SurveyImprovement across key lower-performing areas from staff survey.Support staff retention by addressing areas of concern and building upon successes

12. QUALITY PRIORITIES for 2023-24CQC DomainPriorityMeasureRationale for inclusionResponsiveTransition to the Patient Safety Incident Response Framework (PSIRF)PSIRF Implemented, SI Framework (2015) no longer usedNational change to incident management across providers of NHS-funded healthcareEffectiveDevelop Research Programme at SulisIncrease number of patients recruited to research trials at SulisWork with research companies and RUH research team to identify research trials appropriate for Sulis. EffectiveSurvey consultants and learn from their experience of working at SulisConsultant Survey completed during 2023-24By understanding what we do well and we can do better from a consultant’s perspective, we can use this information to improve services for patientsWell-LedIncrease workforce resilience and health and wellbeing provisionReduced staff turnover, sickness and absenceLower staff turnover and fewer vacancies will enable Sulis to ensure services can continue to be delivered in the event of sickness and absenceResponsiveImprove staff knowledge and provision of services for patients with learning disabilities, dementia and autismNumber of staff receiving further training in these areas. Compliance with Oliver McGowan training >90%All patient facing staff to complete the training in 23/24.ResponsiveContinue to reduce the length of time patients have to wait for treatment at SulisContinue to treat the backlog of elective recovery patients in the region due to the pandemicReduce number of patients with >52 week waitNumber of patients treated for the RUH and across the BSW region by Sulis to aid the elective recovery programme. In line with NHS priorities, Sulis are committed to further reducing the length of time that elective patients have to wait for treatment.Opening of SEOC new theatres , dsu pods, ipu beds to deliver an increased activity.

13. MANDATORY STATEMENTS 2021-22Participation in Clinical Audits & National Confidential EnquiriesDuring 2022-23, two national clinical audits and zero national confidential enquiries covered NHS Services that Sulis Hospital provides.The national clinical audits which Sulis Hospital Bath participated in and for which data collection was completed during 2022-23 are listed overleaf alongside the number of cases submitted to each audit as a percentage of registered cases required by the terms of that audit or enquiry.The reports of three national clinical audits were reviewed by the provider in 2022-23 and Sulis Hospital Bath intends to take the following actions to improve the quality of healthcare provided:Proactively support all departments and services to ensure participation in national clinical audit and national confidential enquiries where eligible.Encourage and promote learning from national clinical audit and national confidential enquiries where they are applicable to the services we offer.Share the outcome of national clinical audit and national confidential enquiries at the Clinical Governance & Risk Management Committee (CGRMC) to encourage staff engagement, share the learning and ensure continuous quality improvement of all our services.The reports of 22 local clinical audits were reviewed by the provider in 2022-23 and Sulis Hospital Bath intends to take the following action to improve the quality of healthcare provided:Continue to proactively support all departments and services to develop annual clinical audit plansUtilise the outcome of local clinical audits to build upon the quality of service provision and improve the experience of patients using our servicesShare the outcome of local clinical audits at the CGRMC or appointed sub-committees to encourage staff engagement, share learning and ensure continuous quality improvement of all our servicesIn addition to participating in national clinical audits, national confidential enquiries and local clinical audits, Sulis undertake a hospital-wide programme of audits in relation to the following areas: Health & SafetyInfection Prevention & ControlMedicines ManagementInformation GovernancePatient SafetyThese audits are collected monthly and the responses are monitored through CGRMC, Infection Prevention Control (IPC) Committee, Medicines Management Committee (MMC) and Health and Safety (H&S) Committee meetings.

14. MANDATORY STATEMENTS 2021-22Audit NameCategoryComplete/ OngoingPercentage of cases submittedNational Joint Registry (NJR)OrthopaedicsComplete>99%Elective surgery (National PROMs Programme)Orthopaedic surgery, cosmetic surgery and OphthalmologyCompleteLinkage rate for all procedures:Sulis - 52%National - 58%Sulis Hospital Bath participated in the following National Audits and Enquiries during 2022-23

15. MANDATORY STATEMENTS 2021-22SiteRegulated CategoryConditionsCQC RatingSulis Hospital BathFoxcote Avenue,Bath Business Park, Peasedown St John,Bath, Avon,BA2 8SQTreatment of disease, disorder or injuryDiagnostic or screening proceduresSurgical ProceduresNoneGood (April 2017)Mr Adewale Kadiri is responsible for these services.Mr Simon Richard Milner is the registered manager for these services at this location.Care Quality Commission

16. PART THREE

17. REVIEW of QUALITY PERFORMANCE 2022-23During 2022-23 Sulis Hospital have delivered a number of key projects which have significantly improved the quality, volume and availability of services to patients.Building upon the successes in 2021-22, Sulis continued to support the elective recovery efforts in the region by removing over 1400 patients from regional trusts’ waiting lists, while maintaining referral to treatment (RTT) times for any new referrals and existing care pathways at Sulis.In 2023-24 we are expanding this support and reaching out to other ICBs and Trusts in the south-west including Dorset, Devon and Cornwall to enable patients from these locations to have their treatment at Sulis. Improving access to services has been a key focus for Sulis Hospital over the last year, and this work has been complemented by the establishment of the Digital Mutual Aid System (DMAS) which will allow patients from all over the country to choose to be seen at Sulis or any other site across the country, based upon their waiting times, enabling patients to access treatment sooner. 2022-23 also saw the launch of Sulis’ private GP service, which provided around 500 patients direct and expedited access to experienced GMC-Registered Private Doctors, relieving pressure from already-stretch NHS primary care services.In addition to improving access to services at the hospital, staff have worked hard to increase the capacity to treat patients at Sulis and oversaw the installation of a fifth, modular theatre on the hospital site. The project capitalised on the unique relationship between the RUH and Sulis and through joint partnership working has enabled year-round elective orthopaedic surgery by RUH surgeons to take place at Sulis, utilising existing capacity within Sulis’ nursing and recovery departments to care for patients before and after surgery. Increasing capacity at Sulis also extended to the Radiology department, which expanded significantly with the installation of a new CT suite and MRI scanner, increasing the number of patients that can come to Sulis for their diagnostic scans. Through ongoing work to establish Sulis as a Community Diagnostic Centre (CDC) Hub, we have been able to offer out this additional resource to the wider health system, further reducing the waiting times for patients in the region. One of the innovative ways in which Sulis has been able to increase our capacity on site without the need for further infrastructure or equipment has been through the enhanced recovery project which reduced the amount of time patients needs to spend in hospital following certain hip and knee arthroplasty procedures. As a direct result of the new pathway, Sulis have been able to increase the number of these procedures completed each month by 60%. While the focus of the last year has been on increasing capacity and access to services at Sulis, quality has remained at the heart of everything we do. The team at Sulis have begun the process of pursuing formal accreditation of our anaesthetic services through ACSA, and were assessed by the ‘Getting It Right First Time’ (GIRFT) team for accreditation as an Elective Surgical Hub, the first independent hospital in the country to be reviewed. The formal report from GIRFT remains in draft at time of writing, but initial feedback was very positive, praising many areas with particular note made of our safe care and reduced length of stay for joint replacement patients.

18. Regulation and AccreditationThe JAG accreditation standards have been established with the gastrointestinal (GI) community and are intended to provide service users, healthcare professionals and senior leaders with assurance of the quality of the service provided. The standards cover all aspects of a high-quality clinical service and are organised into four domains; Clinical Quality, Patient Experience, Workforce and Training. Sulis are proud to have held accreditation from JAG (Joint Advisory Group) since 2016, and successfully completed our 5 year assessment during 2021. The Radiology department at Sulis Hospital Bath continues to invest in the latest diagnostic equipment so that our consultants can quickly refer, diagnose and treat with reassured accuracy. The department is registered with the Health and Safety Executive (HSE) to maintain compliance for working under the Ionising (Medical Examinations) Radiation Regulations 2017. It undertakes radiation protection and quality audits monthly to maintain high standards of care to patients but also comply with current legislation and regulations as upheld and inspected by the CQC.Sulis Hospital are partnered with Bupa until 2025, providing assurance to that we are committed to being the provider of choice for our private patient offering.Bupa recognition is a mark of quality, reassuring our customers that they’re getting quality healthcare from doctors who are competent and experts in their field. Bupa recognised doctors meet the medical professional standards set by the General Medical Council (GMC) and any relevant specialist bodies. BUPA recognition is built on criteria that are in line with legal and regulatory requirements to practise in the UK. REVIEW of QUALITY PERFORMANCE 2022-23

19. Regulation and Accreditation ContinuedData Security and Protection Toolkit (DSPT)The Data Security and Protection Toolkit is an online self-assessment tool that allows organisations to measure their performance against the National Data Guardian’s 10 data security standards.All organisations that have access to NHS patient data and systems must use this toolkit to provide assurance that they are practising good data security and that personal information is handled correctly. Sulis’ self-assessment against the 2022-23 Data Security and Protection Toolkit demonstrated compliance in all areas, with a status of ‘Standards Met’. In June 2023, Sulis Hospital Bath were again recognised as an ‘NJR Quality Data Provider’ for 2022/23.The NJR Quality Data Provider scheme has been devised to offer hospitals public recognition for achieving excellence in supporting the promotion of patient safety standards through their compliance with the mandatory National Joint Registry (NJR) data submission quality audit process. This unique award demonstrates the high standards met by Sulis Hospital, achieving over 99% audit compliance within the year.REVIEW of QUALITY PERFORMANCE 2022-23

20. Regulation and AccreditationContinuedHCPG’s compliance audit is 154 questions and covers all of the CSP Quality Assurance Standards (2012) and the HCPC Standards of conduct, performance and ethics and the standards of proficiency for physiotherapists (2013).On the final compliance audit Sulis demonstrated that we:Have all the required policies which are version controlled, up to date, understood and available to our staffUnderstand and are able to evidence all legal and ethical requirementsHave up to date mandatory training in place for all staffDeliver evidence based practice Manage patient safety through a robust audit programme covering health and safety, infection prevention and control, documentation, clinical peer review, safe recruitmentEnsure all staff have training in place to develop and maintain competencies in their roleComply with all GDPR requirementsHave a robust Complaints process and understand Duty of CandourGather patient feedback and act upon the findingsUndertake and understand the importance of risk assessmentsSulis services achieved a score of 92.6% and this rates our service as OUTSTANDINGREVIEW of QUALITY PERFORMANCE 2022-23

21. Our commitment to incident reporting demonstrates a commitment to our patients and their safety. This is recognised by the Care Quality Commission Essential Standards of Quality & Safety and further reinforced by the Report of the Mid Staffordshire NHS Foundation Trust chaired by Robert Francis QC (February 2013). An organisation with a high reporting rate of no harm incidents is a safe place to be. During 2022-23, Sulis Hospital staff reported a total of 813 incidents, consistent with the 834 incidents, reported during 2021-22. This equates to 1.14% of activity, a slight decrease from 1.22% of activity in 2021-22,*‘Activity’ definition used is the number of outpatient, daycase and inpatient appointments attended by patients that year.Serious Incidents and Never EventsNHS England define serious incidents as ‘[…] events in health care where the potential for learning is so great, or the consequences to patients, families and carers, staff or organisations are so significant, that they warrant using additional resources to mount a comprehensive response. Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare.’During 2022-23 one incident reported at Sulis Hospital met the threshold of a serious incident and was reported to the Integrated Care Board (IC) and the care quality commission (CQC) as per usual practice.Incident ReportingAn organisation with high incident reporting is a mark of a ‘high reliability’ organisation. Research shows that organisations with significantly higher levels of incident reporting are more likely to demonstrate features of a stronger safety culture, such as a high patient satisfaction rate, positive peer review assessments and a low number of clinical negligence claims. Never Events are defined as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented’. Sulis had zero harm incidents reported at Sulis in 2022-23 that met Never Event criteria. The top 5 incident categories for 2022-23 were:Infection controlMedical Device/ EquipmentPatient’s case notes or recordsAppointmentAdmissionSafety AlertsFour safety alerts received during 2022-23 were assessed as relevant to Sulis Hospital. This included one CMO messaging alert, two MHRA Medicines Recall alerts, and one NPSA alert. Sulis complied with all relevant safety alerts, and these were actioned within the required time periods.Medical Advisory Committee (MAC) & Specialty MeetingsThe Medical Advisory Committee and individual Specialty meetings continued to meet regularly in 2022-23 having recommenced in 2021 following the Covid-19 pandemic. The groups reviewed quality metrics such as trends in adverse incidents, learning from root cause analysis reports, patient feedback, best practice guidelines, clinical outcomes and activity levels. New procedures were discussed and evaluated at the specialty meetings and MAC prior to being offered at Sulis, and robust challenge by the committee members is encouraged within these forums.REVIEW of QUALITY PERFORMANCE 2022-23

22. InfectionsDuring 2022-23 the following confirmed infections were reported at Sulis Hospital BathReducing the risk of infectionIn 2021-22 Sulis established a surgical site infection monitoring system to investigate each confirmed infection and compare the care provided against the best-practise standards laid out in NICE NG125 in order to identify themes and trends across the different cases. Sulis continued to use this methodology to review infections during 2022-23 and RCA investigations were also conducted for any return to theatre or readmission due to infection. All learning identified through the reviews was shared the learning through the relevant governance and specialty meetings. Sulis Hospital maintain strong links with the local health community and attend regular IPC committee meetings at the RUH and with the wider BSW region in order to share best practice and learning for issues related to infection prevention and control.During 2022-23 the most frequent type of infections reported were superficial MSSA infections following orthopaedic surgery. The Quality & Assurance Team at Sulis regularly benchmark infection rates against regional and national levels to provide assurance that the numbers and types of infections are consistent with those of other hospitals and any spikes are identified quickly and acted upon.Q1Q2Q3Q4Sepsis0011MRSA0010Clostridium difficile0000RCA reports into C. diff related deaths0000MSSA Bacteraemia0000Norovirus0000Central Venous Catheter Infections0000Peripheral Venous Catheter Infections0000Coagulese Negative Staphylococus1001Pseudomonas Aeruginosa0100Coliform0001REVIEW of QUALITY PERFORMANCE 2022-23

23. Patient ExperiencePatient ConnectThe Patient Connect programme was re-launched in Q1 2021. Its aim is to provide patients with a quick, efficient mechanism by which they can raise concerns, and most importantly, have these addressed during their stay. Patient connect Champions come from a range of teams, both clinical and non-clinical. New members receive support in learning how to approach patients, request feedback and how and when to escalate concerns. Every patient is visited by a Patient Connect Champion at least once during their Inpatient stay to ask about their wellbeing and if anything could be done improve it. They will discuss any compliments, complaints or issues that the patient has and pass them on to the relevant staff member or Department lead as appropriate to help resolve. Patient Connect Champions keep a record of the conversation with the patient and document the visit in the Care Pathway. Each month, the feedback is collated, and shared with the Quality & Assurance team to review themes and present any learning at the Quality Improvement Steering Group (QISG) meetings.Friends & Family TestDuring 2022-23, Sulis received 2920 feedback cards from patients, a significant increase from 1,949 in 2021-22. Of these, 98% of patients described their overall experience as Very Good or Good. Complaints, Concerns, Comments & Compliments (4Cs)In addition to the 2920 feedback cards received, Sulis also received an additional 188 pieces of feedback in the form of 52 complaints, 16 concerns, 60 comments, and 60 compliments. Complaints represented just 1.78% of all feedback received during 2022-23. NHS patient complaints accounted for 58%, and private patient complaints 42% of those received.Most complaints were isolated in their subjects, however two themes were noted during the 2022-23 year:Patients dissatisfied with their consultant’s diagnosis and/ or the treatment options offeredCommunication or information received by the patient.The learning from complaints is reviewed at the monthly clinical governance and risk management committee and any actions arising to address issues identified are monitored through the quality improvement steering group held monthly.ClaimsOne new claims of clinical negligence was received by Sulis during 2022-32 from an NHS patient. This was escalated to Sulis’ legal team for further investigation and management.REVIEW of QUALITY PERFORMANCE 2021-22

24. SafeguardingSafeguarding means protecting a citizen’s health, wellbeing and human rights; enabling them to live free from harm, abuse and neglect. It is an integral part of providing high-quality health care. Safeguarding children, young people and adults is a collective responsibility.Those most in need of protection include:Children and young peopleAdults at risk, such as those receiving care in their own home, people with physical, sensory and mental impairments, and those with learning disabilities.All staff, whether they work in a hospital, a care home, in general practice, or in providing community care, and whether they are employed by a public sector, private, or not-for-profit organisation, have a responsibility to safeguard children and adults at risk of abuse or neglect in the NHS.Knowledge AuditsMental Capacity Act (MCA) Audits are completed by the Head of Nursing & AHP’s to provide assurance of staff understanding, and as a tool for learning. The scenario-based audits raise awareness of the escalation and referral processes which staff are required to follow and the results are shared through the clinical governance and risk management committee (CGRMC).ReferralsNo safeguarding referrals were made to the local authority during the 2022-23 year however several concerns were escalated to the Safeguarding Leads on site by members of staff. Upon further investigation, none met the threshold for a formal referral, however demonstrated a keen awareness of safeguarding issues amongst the workforce.TrainingAs of March 2023, substantive Sulis Hospital had an overall Safeguarding Training completion rate of 97.8%, and with bank staff achieving 71.9%. For substantive staff, mandatory training compliance is linked with the annual performance review and staff are required to achieve 100% on their training in order to progress to the next point on the pay spine. Work continues to improve bank staff training rates and shifts are offered for the purpose of completing training to those staff whose compliance is low. Freedom to speak up GuardiansFreedom to Speak Up Guardians support workers to speak up when they feel that they are unable to in other ways. Sulis Hospital increased the number of freedom to speak up guardians on site again in 2022-23, covering both clinical and support services. This extra availability has led to an increase in the number of staff accessing this service compared with the previous year. REVIEW of QUALITY PERFORMANCE 2021-22

25. JARGON BUSTERTerminologyExplanationBaNESBath and North East SomersetBSWBaNES, Swindon & WiltshireCCG (Clinical Commissioning Group)NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England.CGRMCA monthly meeting where clinical leads, lead nurses, administration staff and senior management team meet together to develop, implement and oversee the clinical governance and clinical/non-clinical risk management processes in the Hospital. Also for providing assurance to both the Executive Board and the Integrated Governance Committee about the robustness and effectiveness of the risk management and governance processes within the Circle Bath.CQCThe Care Quality Commission is the independent regulator of health and adult social care in England.CT (Computerised Tomography)Scan that uses X-rays and a computer to create detailed images of the inside of the body.DashboardsAn easy read, often single page, real-time user interface, showing a graphical presentation of the current status (snapshot) and historical trends of an organisation’s key performance indicators (KPIs) to enable instantaneous and informed decisions to be made at a glance.DNADid not attendGMCThe General Medical Council is a public body that maintains the official register of medical practitioners within the United KingdomH&SHealth and SafetyHQIP (Healthcare Quality Improvement Partnership) National Clinical Audit and Patient Outcomes Programme) is a set of national clinical audits, registries and outcome review programmes which measure healthcare practice on specific conditions against accepted standards.

26. JARGON BUSTERTerminologyExplanationHRHuman ResourcesHSEHealth and Safety Executive. A UK government agency responsible for the encouragement, regulation and enforcement of workplace health, safety and welfare, and for research into occupational risks in Great BritainICBIntegrated Care Board (formerly Clinical Commissioning Group). Integrated care boards replaced clinical commissioning groups in the NHS in England from 1 July 2022IHEEMInstitute of Healthcare Engineering and Estates Management.ILSIntermediate Life Support IPCInfection Prevention & ControlIPMSInternational Property Management Standards.IR(ME)RIonising Radiation (Medical Exposure) Regulations ISASImaging Services Accreditation SchemeJAG The Joint Advisory Group (JAG) on Gastrointestinal Endoscopy operates within the Clinical Standards Department of the Royal College of Physicians. JAG has a wide remit and its cores objectives include: to agree and set acceptable standards for competence in endoscopic procedures and, to quality assure endoscopic units, training and services.KPIKey Performance IndicatorMMCMedicines Management CommitteeMRI (Magnetic Resonance Imaging)A type of scan that uses strong magnetic fields and radio waves to produce detailed images of the inside of the body.National Early Warning Score 2 (NEWS2)A tool used to monitor patients’ vital signs and identify patients whose health is deterioratingNHSNational Health Service

27. JARGON BUSTERTerminologyExplanationNICENational Institute for Health & Care Excellence is an executive non-departmental body of the Department of Health & Social Care that publishes guidance relating to the use of health technologies, clinical practice, health promotion and social care services.NJRThe National Joint Registry collect and analyse data about joint replacement surgery in order to provide timely warnings of issues relating to patient safetyONSOffice of National StatisticsPALSPatient Advice and Liaison ServicePartnership SessionsEducational, discussion and solution focused sessions held within clinical units and open to all staff involved in the patient pathway. The purpose of the sessions is to improve competence and educate staff, enable discussions of any issues that have arisen and provide the opportunity to develop realistic and effective solutionsPHINPrivate Healthcare Information NetworkPTLPatient Tracking ListQISGQuality Improvement Steering Group RRPPSRadiology Physics and Protection ServiceRUHThe Royal United Hospital BathSWARMA term used to refer to a gathering of the relevant staff in order to discuss propose solutions and agree actions following an issue which has arisen. WHOWorld Health Organisation

28. Thank you for taking the time to read our Quality Account.We hope you found it interesting and useful in understanding our continued commitment to quality for our patients.Should you have any further questions, please contact us via QandA@SulisHospital.com THANK YOU