Registration Imperial College Healthcare Trust (ICHT) is registered with the Care Quality Commission (CQC) to provide healthcare services at 5 sites:•St Mary’s •Hammersmith•Queen Charlotte’s and Chelsea Hospital•Charing Cross •Western EyeAll sites are ‘registered without conditions’

CQC inspection of all sites within 2 yrs. First inspection of Charing Cross in January 2010•Initial feedback positive, no major concerns, report awaited

CQC Quality and Risk Profile • Quality & Risk (Q&R) Profiles’: Extensive report, varied data

sources (e.g. individual comments from CQC local engagement NHS Choices website, national survey data, NHSLA assessments, HES data, HSMRs and DH performance data, including waiting times)

• December 2010 Q&R profile: Overall risk rating green – low risk of breeches to compliance

• Areas for improvement within the profile were:– Further improving patient experience – Workforce and supporting staff– Quality of records

Performance: April 2010 – Jan 201118 weeks referral to treatment times• Admitted: achieving 93.3% (90% target) and median wait 11 weeks

• Non-admitted: achieved 97.2% (95% target), median wait 6.2 weeks

Cancer referral to treatment times• Best in class (2009/10) for 4 out of 5 indicators in CQC national benchmarking

• Performance maintained in 10/11

• New indicator for breast symptomatic achieved from October 10 onwards

Accident and Emergency• Achieving 98.1% (98% target) attendances seen within 4 hours

Healthcare associated infections• MRSA: 17 cases (ceiling 13), but reduced from 37 in 2009/10

• Clostridium Difficile: 152 cases (ceiling 309)

Eliminating mixed sex accommodation• Achieving 99.3% (target 95%), improvement from 96.3% in 2009/10

Patient experience Reporting of the national inpatient results takes place in three stages:

1. Patient survey (June 2008)

2. Picker Institute stage of reporting (Jan 2009) which enables ICHT to compare results with previous years and other Picker trusts. (74 other Trusts use the Picker Institute as their survey organisation).

3. Care Quality Commission reporting (April/May 2009) which enables comparison with all other trusts through national benchmarking for each question.

ICHT ‘Picker’ inpatient results Jan 2010

Comparing 2010 Picker results with 2009 CQC results, ICHT has:

• performed significantly better on 13 questions and significantly worse on no questions;

• performed significantly worse than the Picker Trusts average on 18 questions, compared to significantly worse than the average for 67 questions in the previous year.

Addressing 2009 results ICHT has improved on all issues identified in the report to members with the exception of posters or leaflets where the problem score is the same.

National inpatient survey questions

Felt threatened by other patients or visitors Improved

No posters or leaflets asking patients/visitors to wash their hands or use gel Improved

Hand gels not available or empty Improved

Doctors talked in front of you as if they were not there Improved

Nurses talked in front of you as if they were not there Same

Risks and benefits not fully explained Improved

Next Steps1) Awaiting publication of Care Quality Commission results in April/May.

2) Focus on the areas that require more progress:

Improving patient experience of admission – e.g. review all outpatient and inpatient letters.

Improving experience of discharge – we have recently developed a new discharge policy which includes a patient discharge ticket. Aiming to launch on 5 April following external consultation in March.

Improving patient information – we recently launched a substantial programme of work to review all generic and disease-specific patient information. The first output from this work is a new outpatient booklet which will be sent to all new outpatients from April.