cataract centre ltd · the cataract centre was established by its founding surgeon in 1993 with the...

Cataract Centre Ltd

Quality Accounts 2013 - 2014

QUALITY ACCOUNT 2013-14

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SECTION 1: INTRODUCTION AND STATEMENT FROM

MANAGEMENT BOARD

WHAT IS A QUALITY ACCOUNT?

These are The Cataract Centre Ltd quality accounts to the public about the quality of

services we offer. The Health Act 2009 and corresponding regulations place a legal

obligation on providers of NHS healthcare services in England to publish these on an

annual basis.

Our quality accounts are reviewed by our commissioning Clinical Commissioning

Group and published electronically on NHS Choices website and a copy is also sent

to the Secretary of State.

PURPOSES OF THE QUALITY ACCOUNT:

One of the key aims of the account is to:

Improve transparency and accountability to the public.

Engage key stakeholders both internal and external in quality improvement

Drive and enable providers to review services and identify where

improvement is needed.

Create and share quality improvement plans

Provide information on the quality of services to the public.

A requirement of the quality account is to include a statement from the management

board summarising the quality of NHS services provided, the organisation‟s priorities

for quality for the forthcoming year, a series of statements from the board which are

set out in the regulations and a review of the quality of services provided during the

year.

In developing a quality account and setting priorities for the future there is an

expectation that we will engage with staff, external stakeholders, commissioners,

and patients including their carers and relatives.


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QUALITY STATEMENT FROM THE MANAGEMENT BOARD

The Cataract Centre Ltd is pleased to introduce its first set of quality accounts for the

year 2013-14. We are fully committed to fostering an organisational culture that puts

the patient first and foremost and at the heart of everything we do.

The Cataract Centre was established by its founding surgeon in 1993 with the vision

to demonstrate the highest levels of patient safety, quality, excellence in clinical

outcomes and positive patient experience and satisfaction. This vision has formed

the heart and soul of the Cataract Centre and is reflected in the dedication and the

highest levels of quality shown by our team and reflected in the care received by our

patients.

The Cataract Centre was registered with CQC in March 2012 with no conditions, as

a provider who specialises in Ophthalmology services across the London Borough of

Enfield, with a view to expanding our services further across London. As Clinical

Director of The Cataract Centre, I am passionate about being committed to:

Delivering consistently high quality patient care

Excellent patient outcomes with year on year improvement

Excellent medical and clinical leadership

Supporting all staff to ensure they are equipped to deliver continuously high standards of service

Involving patients in decision making so they can influence the delivery of their care.

Measuring and demonstrating the impact we make.

2013-14 was a significant year for The Cataract Centre, as we have progressed to expanding our range of services and clinics in the community and surgical capacity with our partner Trust namely Barnet and Chase Farm Hospitals NHS Trust. In 2013-14 we have seen over 9000 patients in community outpatient clinics, and undertaken over 2000 surgical procedures which include: Cataract surgery, glaucoma surgery, squint surgery, adnexal surgery, and YAG laser procedures for glaucoma and post cataract opacification. The year has seen us transform our booking processes, and we have become a unified service with a single accountability and governance structure for patient pathways. This begins from referral to community service, management of chronic disease in the community to surgical intervention where required. In 2013 we have designed and implemented a new administrative structure for the organisation.


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As part of good governance we have documented clinical and quality policies that are reviewed annually and we keep abreast of requirements from the CQC and other national regulatory bodies. We ensure our services are delivered by the most appropriate qualified clinicians and nurses with the relevant skills required. An important part of this transformation is the establishment of quality meetings with Enfield Clinical Commissioning Group, where quality performance, service delivery and patient experience are all discussed and improvement plans assessed. Discussions are also afoot with local patient participation groups. In addition this the year saw the recruitment of a new dedicated service manager with a clinical background in Ophthalmology, further enhancing the development and improvement work being undertaken and also to improve the overall patient experience. The Cataract Centres internal transformation ran parallel to significant changes within the local health economy and in line with ever increasing demand for the service. We are immensely proud in the determination and manner in which our staff have focused towards meeting the needs of the organisation in ever-changing dynamic and pressured times, ensuring excellence in patient service. We continually monitor changes and review our performance so we can drive improvements for the benefit of all our patients. The need to ensure clinical excellence is the role of all in the organisation and is not based on the reliance of solely one or two people. At The Cataract Centre we nurture an ethos of close team work and collaborative working and professionalism. We believe in investing in our staff, our clinics and equipment to ensure safe and consistent delivery of care at all times and to keep up with technological enhancements in service delivery. We encourage staff, partners and commissioners to view our quality accounts to get an overview of what we do well and what we intend to improve in the coming 12 months. Patient feedback is extremely important to us and we have continued to undertake patient experience programmes and in 2013-14 we also incorporated the national friends and family test questions into our programme. The Cataract Centre is accustomed to the disciplines of regulatory compliance with the CQC and contractual requirements as set by our commissioners, to regularly report, where applicable: performance, complaints and serious incidents. The organisation maintains a log of all complaints and incidents with actions being undertaken to resolve issues or reduce risk. To the best of our knowledge, the information contained within this quality account is accurate and a fair representation of the quality of services delivered. Dr Raymond Lobo, Clinical Director - The Cataract Centre Ltd


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THE CATARACT CENTRE LTD

The Cataract Centre Ltd is a private Ophthalmology services provider situated in

North London in the Borough of Enfield. The organisation offers services to NHS

patients and those who wish to fund their own treatments.

The Cataract Centre Ltd provides a full range of ophthalmic services, including:

Community outpatient consultations and treatment

Diagnostics

Surgery

Long term conditions management

Follow-up care

During the period 2013-14 the service has seen over 9000 patients in the community

through its community ophthalmology service and has carried out surgical

procedures on over 2000 patients.

Currently 16 specialist ophthalmic consultants and specialist doctors work for the

service and are supported by 37 clinical staff, a skills mix of Nurses, most of whom

are ophthalmic specialty trained, Healthcare technicians, Orthoptists, Optometrists,

18 Administration staff and some dedicated facilities and housekeeping support.

The service has been commissioned by Enfield Clinical Commissioning Group to

provide community ophthalmology services and has a partnership agreement with

Barnet and Chase Farm Hospitals NHS Trust (BCFH) to undertake surgical

procedures where required and they have been chosen by patients as their preferred

choice of location.

The service has built excellent relationships with BCFH NHS Trust, commissioners

and referring GP‟s and clinical commissioning leads over the last 20years.

Our recently recruited service manager with a background in ophthalmology nursing

provides vital relationships to the optometry community and GP‟s to ensure their

needs and expectations are being managed through a clear and effective referral

process and streamlined pathways for subsequent patient choice referrals.


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SECTION 2

PROGRESS AGAINST 2013-14 IMPROVEMENT PRIORITIES

Our improvement priorities have been decided upon by evaluating and acting upon

our governance processes and learning from our patients experience programme

and staff feedback. We have a clear commitment to our patients and we work in

partnership with the NHS both in terms of CCG, GP‟s and Acute Hospital Trusts to

ensure our services are safe and of high quality in meeting local requirements. We

constantly strive to improve clinical safety and standards by a process of

governance, including audit and feedback from all stakeholders participating and

experiencing in our services.

PATIENT SAFETY

A. Never Events

These are serious and in most cases preventable patient safety incidents that should

never occur if adequate preventable measures have been put in place. There are 25

nationally recognised never events of which 4 are core to the service.

Wrong site surgery – The Cataract Centre has implemented early on the

World Health Organisation (WHO) recommendation for safer cataract surgery

checklist. The checklist is a tool used throughout cataract surgery to improve

the safety of surgery by driving good communication and setting out safety

checks throughout the perioperative process. The service had achieved a

100% compliance rate for completion of the checklist in 2013&14.

Wrong Implant – “Wrong intraocular lens implant; learning from reported

patient safety incidents” (SP Kelly Feb 2011) showed that a large percentage

of incidents of wrong implantation of IOL were due to wrong IOL selection.

The Cataract Centre did not have any never events relating to this in 2013/14.

The service has a thorough pre-operative setup with robust lens check

protocol in place ensuring that all lenses are clearly available, identified and

prepared the day prior to surgery and labelled appropriately with pre-surgery

biometry information and patient details. Further to this lenses are double

checked prior to being used in the operating for each patient. For clarity there

are three separate checks in place before the lens is implanted in a patient‟s

eye.

Retained Foreign Object Post Operation - this rarely occurs due to the

nature of our surgery. However due vigilance is undertaken due to the tiny


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microscopic sutures often used, most ophthalmic surgery is performed under

a microscope which gives a good view of the operating field and thus prevents

any foreign bodies from inadvertently entering the eye. This is also mitigated

through the effective use the WHO Surgical Safety checklist process.

Overdose of Midazolam during conscious sedation – minimal invasive

procedures require the need for sedation for some of the surgical care

delivered by The Cataract Centre, particularly for anxious and nervous

patients. No incident of this nature occurred in 2013-14, but the use will be

monitored and reported under policy guidelines.

B. VTE Risk Assessments

Due to the nature of services delivered, i.e. surgery that is less than 90 minutes in

duration, the need to assess for VTE risk is minimal. A series of elimination

questions are used by nursing staff in the pre-operative assessment process to

determine any possible risk to VTE and all patients undergoing surgical intervention

are assessed in accordance with NICE guidance.

PATIENT EXPERIENCE

We have built on our patient experience programme from previous years and

expanded the scope of patient experience to cover the entire pathway from

outpatient phase to inpatient surgical phase and follow-up care. In addition to this

we have incorporated the national NHS friends and family test (FFT) questions into

our programme. Patient Experience feedback was one of the service CQUINs for

2013/14.

Overall, feedback was positive and results echoed the positive feedback and

compliments clinicians and administrative staff received in person from patients.

Results found that patient perception of the service is good and confidence in the

service has been established with over 75% of community patients and 90% of

surgical patients surveyed stating that they would use the service again and rating

the service as either „Excellent‟ or „Good‟. In addition to this over 60% of

community patients and 85% of surgical patients stated they would be „extremely

likely‟ or „likely‟ to recommend the service to their friends and family.

In addition to the above and following the unannounced CQC inspection at the end

of 2012/13, The Cataract Centre was found to be compliant against all standards

assessed. The Cataract Centre Ltd had another unannounced inspection undertaken

by the CQC on 10th January 2014. The CQC assessed The Cataract Centre for


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compliance against a number of Essential Standards of Quality and Safety and

found the service to be meeting all the standards assessed.

Some salient comments from patients to CQC assessors on the day of the visit

included:

Following surgery - A patient described the outcome as a "miracle”.

"before the operation they (clinical staff) explained what I was having done and I

signed a consent form. They asked if I was happy with everything."

"Patients attending the clinic for their six week post operation check-up, told us they

were happy with the care and treatment they had received and that this was

explained to them in a way they understood"

"one patient who had a cataract operation on one eye told us staff had been

"brilliant, so good I want the other one done."

A patient told us "they are an amazing team and brilliant at their jobs.

CLINICAL EFFECTIVENESS

The Cataract Centre Ltd has Integrated Governance/Clinical Quality Review

meetings with CCG: contractual, clinical and quality leads on a quarterly basis

throughout the year to monitor quality and effectiveness of care.

All complaints, incidents, near misses, patient and staff feedback are reviewed to

determine any trends that may require further root cause analysis investigations, and

subsequent action plans for remedial action. Remedial action plans are presented to

the group where lessons learned and progress is shared and disseminated. We also

review and assess progress internally on a monthly basis.

In addition to this the service adheres to the governance and complaints

policies/processes for services delivered on behalf of BCFH Trust. We pro-actively

share details of any incidents and promote collaborative action and learning. We

have found that this helps to promote our culture of being open and honest, patients

safety incident reporting and aids in disseminating lessons learnt and aligning best

practice.


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PRIORITIES FOR 2014-15

PATIENT SAFETY

Never Events – to ensure the service maintains quality delivery and does not

have any never events in 2014-15.

To ensure compliance against the WHO surgical checklist.

To implement and deliver enhanced community patient administration system.

This will allow us to pro-actively monitor and deliver our service to patients in

an effective and safe manner. It will also enhance management of follow-up

care and long term conditions,

PATIENT EXPERIENCE

To implement learning and actions from our 2013-14 patient experience programme

feedback. Key actions include:

To run a series of Patient & Carer Focus groups to identify areas for

improvement directly from both patients and their carers. This is to be done

for both community and for acute care/surgical patients following initial review

in the community.

To implement an internal service CQC mock inspection programme to ensure

continual compliance with essential standards of quality and safety. This will

also enhance awareness amongst staff and improve organisational

governance processes.

To recruit additional medical staff to work in the community.

To increase clinic resource in the community.

To increase weekend clinic capacity.

To respond to the increased demand from relatives/carers and parents for

increased clinics during out of hours, weekends and the holiday period. This

in particular will minimise any disruption to children‟s education.

To improve FFT response rates and scores

CLINICAL EFFECTIVENESS

To undertake a series of local clinical audits to include:

Cataract surgery outcomes audit

Documentation audit

WHO surgical safety checklist audit

Clinic environment audit


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STAFF DEVELOPMENT

The Cataract Centre Ltd appreciates the importance of staff development and voice

in ensuring the continued delivery of a high quality service and care for our patients.

Staff are also instrumental in the service improvement process, thus it is essential

that we understand how our staff feel and any recommendations they may have. In

view of this in 2014-15 we aim to undertake the following:

Staff satisfaction survey.

Bi-annual staff appraisal and objective review programme.

Staff Development Day – with key sessions on team building, sharing best

practice, and ideas forum for staff to share ideas and agree goals for

quality/service improvement.


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STATEMENTS OF ASSURANCE

In line with NHS requirements, the following are a series of statements that all

providers must include in their quality account. In reflection of this The Cataract

Centre Ltd make the following statements of assurance:

REVIEW OF SERVICE

During 2013-14 The Cataract Centre provided Ophthalmology services to the NHS

through the agreed NHS Standard Acute Contract. It did not subcontract out any of

those services.

The Cataract Centre has reviewed all the data available to them on the quality of

care in all of these NHS services

The income generated by the NHS services reviewed in 2013-14 represents 100% of

the total income generated from the provision of NHS services by The Cataract

Centre Ltd for 2013-14.

PARTICIPATION IN CLINICAL AUDITS

During 2012/13 no national clinical audits or national confidential enquiry covered

NHS services that The Cataract Centre Ltd provides.

However, even though there were no national clinical audits directly relevant to the service, The Cataract Centre Ltd plans to undertake a series of local audits in 2014/15 to identify areas and set actions for specific quality improvement.

PARTICIPATION IN CLINCIAL RESEARCH

The number of patients receiving NHS services provided by The Cataract Centre in

2013-14 that were recruited during that period to participate in research approved by

a research ethics committee was zero.

USE OF THE CQUIN PAYMENT FRAMEWORK

The Cataract Centre LTD income in 2013-14 was conditional on achieving quality

improvement and innovation goals through the Commissioning for Quality and

Innovation payment framework. The Cataract Centre Ltd achieved CQUIN goals for

2013-14.


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REGISTRATION WITH THE CARE QUALITY COMMISSION

The Cataract Centre Ltd is required to register with the Care Quality Commission

and is currently fully registered with no condition to provide the following services for

everyone:

diagnostic and screening procedures

treatment of disease, disorder or injury,

surgical services

The Cataract Centre had an unannounced CQC inspection on 10th January 2014

and was found to be fully compliant against all inspected outcomes.

The Care Quality Commission has not taken enforcement action against The

Cataract Centre during 2013-14.

The Cataract Centre has not participated nor required to do so in any special reviews

or investigations by the CQC during the reporting period.

Dr Raymond Lobo is the registered manager for the provision of the above and also

the clinical director of the organisation.

DATA QUALITY

Statement on relevance of Data Quality and your actions to improve Data Quality

The Cataract Centre collates and tracks community patient data on a local system in

line with the data protection act and NHS information governance toolkit.

For all activity undertaken on behalf of BCFH NHS Trust, our staff have completed

the Trust statutory and mandatory training to include information governance. The

service tracks and outcomes patient data using the Trust Cerner PAS system, in line

with the BCFH Trust information governance guidelines. All staff have been suitably

trained on all systems.

We will be taking the following actions to improve data quality:

The Cataract Centre Ltd is in the process of developing an enhanced patient

administration database, which tracks patient referral status, appointment history and

outcomes.


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PATIENT SAFETY INCIDENTS

The Cataract Centre has had no patient safety incidents in 2013-14. We

acknowledge this to our continued vigilance and continual focus on patient safety

underpinned by procedures relating to estate and equipment safety, effective patient

record keeping and information. .


KPI No. KPI Threshold Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Comments

1100% of patient’s waiting no longer than 4 weeks for an

appointment<= 28 days 32 34 35 30 32 30 19 13 11 12 14 14

2

100% of patient’s who cannot be contacted with choice of

appointment automatically given an appointment within 5

working days of receipt of referral

100%Action: We propose to commissioners, that where we are unable to contact patients on

a maximum of 3 times on different days that we discharge back to the GP.

390% of routine patients, referred via SCAS, assessed and

treated in the community service90% 78.4% 78.7% 72.6% 76.4% 78.0% 77.3% 73.6% 75.5% 78.5% 80.6% 71.0% 78.7%

We aim to treat as many patients in the community as possible. Many patients elect to

continue further treatment or on-going management with other acute providers, for

which due to the right of patient choice we have limited control over.

Action: There are a number of treatements currently undertaken in secondary care,

which we beleive can be undertaken in the community, with the added benefit of giving

commissioner substantial cost savings. These are currently being proposed to you and

are due for discussion.

4100% of routine referrals sent to the Enfield Referral Service

triaged within 3 working days100% Met Met Met Met Met Met Met Met Met Met Met Met

5

100% of patients, where the community service is deemed to

be inappropriate for the patients needs, returned to the Enfield

Referral Service within 2 days of triage.

100% Met Met Met Met Met Met Met Met Met Met Met Met

6

Outcome of patient appointments (for 95% of patients)

communicated to the referring healthcare professional within 5

days

95% Met Met Met Met Met Met Met Met Met Met Met Met

This is largely the case. However as mentioned in previous correspndence we cannot

account for postal delays.

Action: We are currently scoping the possibil ity of emailing outcome letters to GP

practices, but this does have a number of logistical challenges and also would require

the buy in of GP practices. We will initially pilot this with a small cohort of practices

and assess the benefits. We will inform you of progress in due course.

795% of provider performance reports produced to agreed

format within 10 working days following the end of each month

We recognise and acknowledge the delays that the commisioners have experience in

receiving the activity report.

We have increased our adminitstrative resource and have made some investment into IT

reporting processes that will improve the turnaround of this. We envisage to be

compliant with this indicator from April 2014.

8 1st to Follow ratio capped to 1:1 ( Cumulative 2013/14) <=1 0.46 0.45 0.49 0.55 0.64 0.63 0.63 0.64 0.66 0.71 0.73 0.76

9Less than 10% of outpatients converting into a secondary care

referral< 10% 21.65% 21.30% 27.40% 23.55% 22.01% 22.66% 26.42% 24.46% 21.54% 19.42% 29.00% 21.30%

This is somewhat of a duplication of KPI.3, as those that are not seen and treated in the

community service are referred into secondary care.

Action : We propose to commissioners that we have one indicator.

1090% of the patients rating the community service as good or

excellent.90%

We undertake patient experience survery as an on-going process throughout the year

but form them as part of bi-annual patient experience exercises, where we group finding

and develop action plans in responses to areas for development. We continue to make

service improvements to ultimately improve the quality of care we deliver and the

experience of our patients.

We are currently triall ing a process of giving patients an appointment if we are unable to

establish contact. However, we are not doing this in all cases, due to the risk of increasing

number of DNAs. This is in consideration of our demographic and considering the elderly

nature of the majority of our patients, of which a large proportiong require a chaperone. Early

assesment shows that this is not productive, it results in high number of reschedules and also

has resulted in high number of DNAs. This is both in-efficient use of clinic resource, and has a

negative financial impact on the service as patients DNA, but we stil l have to pay for clinicians

time and clinic room charge.

As per Q1&Q2 Patient Experience exercise : 79% rated the service as

good or excellent ( Excellent = 55%, Good = 24%)

93% rated Excellent to Satisfactory.

As per Q3&Q4 Patient Experience exercise : 77% rated the service as

good or excellent ( Excellent = 64%, Good = 13%)

92% rated Excellent to Satisfactory.

2013-14 – Overview of Performance against commissioned Quality KPIs


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STATEMENT FROM COMMISSIONERS

The Cataract Centre final v5 NHS Enfield Clinical Commissioning Group (CCG) has reviewed the Quality Account for 2013/14 published by The Cataract Centre. This statement has been reviewed by the chair of the CCG‟s Quality and Safety Committee, to whom its approval has been delegated by the committee, having in turn been delegated the duty to review and endorse Quality Accounts by its Governing Body. The Quality Account in general complies with governance as set out by both Monitor (for NHS Foundation Trusts) and the Department of Health (to all other NHS trusts and commissioned service providers). However not all priorities are focused on areas where deficient performance requires improvement. For example, the provider is already compliant with national guidance for zero tolerance of never events and therefore does not need to focus on it. As an example, the provider has reported in-year challenges in meeting some waiting time targets. A more clearly specified priority could be identified based on the current % of waiting times met within target together with an indication of expected further improvement by year end. The CCG acknowledges the design and implementation of a new administrative structure for the organisation, previously prompted by earlier delays in arranging first appointments following receipt of referrals. The Quality Account could have better detailed its success. It would also have been useful to see further detail on numbers of complaints, issues that underpin them, themes and trends and actions taken to help prevent re-occurrence. Commissioners will be expecting some improvement in this area next year. In conclusion, the CCG looks forward to continuing to work in partnership with the provider to monitor priorities and progress. In particular it will be discussing some more rigorous baselines and targets for achievement to report next year. It will also ensure that any learning is embedded, and reflected where necessary to inform its commissioning decisions. NHS Enfield Clinical Commissioning Group


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The Cataract Centre Ltd

134 Lots Road

Fulham

London

SW10 0RJ

Email: [email protected]

Limited Company Registered in England & Wales Number: 03336479

CQC Registration Reference: 1-368009263

Director: Mr Richard Vaughan

CQC Registered Manager and Clinical Director: Dr Raymond Lobo

mailto:[email protected]

cataract centre ltd · the cataract centre was established by its founding surgeon in 1993 with the...

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