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
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.
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.
ISO 9001
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.
Bupa accreditations
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
Paediatrics
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 healthcare 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.
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.