Oaklands Hospital
Quality Account
2013/14
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement From The General Manager
1.2
Hospital Accountability Statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of Clinical Priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (looking forward)
2.2
Mandatory Statements Relating To The Quality Of NHS
Services Provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals Agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders Views on 2013/14 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account Indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Oaklands Hospital is part of Ramsay Health Care
The Ramsay Health Care Group, was established in 1964 and has grown to become
a global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health
Care is one of the leading providers of independent hospital services in England, with
a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the
NHS in the UK. Through a variety of national and local contracts we deliver
thousands of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, Clinical Commissioning
Groups, NHS Trusts and NHS referral management and triage services.
“As Chief Executive of Ramsay Health Care UK, I am passionate about
ensuring that high quality patient care is our number one goal. This relies not
only on excellent medical and clinical leadership in our hospitals but also upon
an organisation-wide commitment to drive year on year improvement in patient
satisfaction and clinical outcomes.
Delivering clinical excellence depends on everyone in the organisation. It is
not about reliance on one person or a small group of people to be responsible
and accountable for our performance. It is essential that we establish an
organisational culture that puts the patient at the centre of everything we do
and as a long standing and major provider of healthcare services across the
world, Ramsay has a very strong track record as a safe and responsible
healthcare provider and we are proud to share our results.
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with every
year we set our targets higher, working on every aspect of our service to bring
a continuing stream of improvements into our facilities and services.”
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2013/14
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Introduction to our Quality Account
This Quality Account is Oaklands Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience. It also demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people we
treat. It will also show that we regularly scrutinise every service we provide with a
view to improving it and ensuring that our patients’ treatment outcomes are the best
they can be. It will give a balanced view of what we are good at and what we need to
improve on.
Our first Quality Account in 2010, developed by our Corporate Office, summarised
and reviewed quality activities across every hospital within Ramsay Health Care UK.
It was recognised that this didn’t provide enough in-depth information for the public
and for commissioners about the quality of services within each individual hospital
and how this relates to the local community it serves. Therefore, each site within the
Ramsay Group now develops its own Quality Account, which includes some Groupwide initiatives, but also describes the many excellent local achievements and quality
plans that we would like to share.
Quality Accounts 2013/14
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Part 1
1.1 Statement on Quality from the General Manager
This is the fourth Quality Account to be submitted by Oaklands Hospital and has
been produced to demonstrate our commitment to measuring all feedback from
patients about their experience, clinical treatment and clinical outcomes. This allows
us to continually review, reflect on and improve the patient’s journey.
Patient safety is our highest priority and our robust recruitment processes and
training programmes ensure that staff are competent and fully trained in all aspects of
service provision.
We achieve consistently high patient satisfaction scores and, by studying results
throughout the year, we constantly seek ways to further improve the patient
experience.
Whilst patient feedback and involvement is extremely important to us, we also rely
heavily on other measures of safety and clinical effectiveness which we use to satisfy
ourselves that treatment is evidence-based and delivered by appropriately qualified
and experienced doctors, nurses and other key healthcare professionals. Examples
of these are detailed in this Quality Account.
As General Manager of Oaklands Hospital, I am passionate about ensuring that high
quality patient care is our number one priority. Our Quality Account is an accurate
representation of our performance and our ongoing initiatives to continuously improve
the quality of our services.
Helen Rocca, General Manager
Oaklands Hospital
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Helen Rocca, General Manager
Oaklands Hospital, Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Henry Maxwell, Consultant Surgeon and Chair Medical Advisory Committee,
Oaklands Hospital
Stefan Andrejczuk, Regional Director, Ramsay Health Care
Quality Accounts 2013/14
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Welcome to Oaklands Hospital
Oaklands Hospital is one of Greater Manchester's leading private hospitals with a
reputation for delivering high quality healthcare treatments and services. Located in
Salford, the hospital is close to the A580 and the M602. The hospital opened in 1990
and currently has 15 single rooms all with en- suite facilities and a six bedded,
dedicated day case facility.
Oaklands Hospital provides fast, convenient, effective and high quality treatment for
patients of all ages (excluding children below the age of three years for inpatient
care) whether medically insured, self funding or from the NHS. The Hospital offers a
comprehensive range of treatments and services including ENT procedures,
Maxillofacial Surgery, Cosmetic Dentistry, Plastic Surgery, Dermatology
Gynaecology, General Surgery, Orthopaedics, Ophthalmics and Urological
procedures.
Diagnostic facilities include CT, barium studies, ultrasound, MRI and DEXA for bone
density, in addition to general radiology.
All of the Hospital’s consultants are highly experienced and have patient care and
comfort as their highest priority. All patients have the reassurance that a resident
doctor is available 24 hours/day.
Our physiotherapy clinic is staffed with Chartered, HCPC registered physiotherapists.
Oaklands Hospital is part of the Greater Manchester Critical Care Network and has a
Service Level Agreement in place with Royal Manchester Children’s Hospital if
transfer of a child is required.
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Part 2
2.1 Quality Priorities for 2014/2015
On an annual cycle, Oaklands Hospital develops an operational plan to set objectives
for the year ahead.
We have a clear commitment to our private patients as well as working in partnership
with the NHS ensuring that those services commissioned to us, result in safe, quality
treatment for all NHS patients whilst they are in our care. We constantly strive to
improve clinical safety and standards by a systematic process of governance
including audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the hospital’s Senior Management Team taking into
account patient feedback, audit results, national guidance and the recommendations
from various hospital committees which represent all professional and management
levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
2.1.1
A review of clinical priorities 2013/14 (looking back)
Surgical Safety Checklist - There have been no ‘Never Events’ at Oaklands
Hospital in the period and audit of compliance maintains a key focus with monthly
audit of WHO safety checklists.
VTE Assessment – There has been continued compliance with completion of VTE
documentation for patients where appropriate. Support from Ramsay’s Group
Medical Director included a presentation to the Medical Advisory Committee on
clinician responsibilities in the completion of VTE risk assessments. Quarterly audit
scores have demonstrated that compliance remains a focus across the whole of the
Ramsay Group.
Infection Control – We have had no reportable infections and no outbreaks reported
in the period. We continue to screen patients for MRSA where appropriate in line with
NHS England guidelines and training for staff on hand hygiene is mandatory. The
infection control team have worked to improve standards in environmental cleaning in
the period with the Clinical Lead leading quarterly environmental audits in the period.
Quality Accounts 2013/14
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Internal audits demonstrate that compliance remains high, achieving between 97%
and 100% in the period.
PLACE (Patient led assessment of the care environment) – The first PLACE
assessment was carried out in the year, with patient representatives performing the
assessment with members of Oaklands Hospital management, scoring an average of
% for the four areas of cleanliness, food, privacy and the condition of facility. The
current scoring system of recording NA (Not Applicable) for some sections under
Privacy and Dignity are under review as this gives a negative score.
Incident Reporting – The Ramsay Group risk management system ‘RiskMan’ is
used to report clinical incidents, health and safety incidents, staff wellbeing and
absence together with patient feedback. Additional training has been given to all staff
to ensure timely, comprehensive and effective reporting and compliance with
reporting has been good. There has been one serious untoward incident reported in
the period. This was investigated and identified as a recognised complication of
surgery.
Competency Training – Competency assessment tools have been completed for all
clinical staff appropriate to their area of practice.
Preoperative Assessment – The preoperative assessment policy is followed and
provides safe and efficient assessment of all patients following their outpatient clinic
appointment. Patients complete a medical questionnaire which is reviewed by
nursing staff to determine the level of preoperative assessment required to ensure
the appropriate needs of the patient are met.
Patient Satisfaction Survey – The web based satisfaction survey has been in place
since February 2013 and response rates have gradually increased over the period
with a response rate of 45.7% at the end of March 2014. The overall satisfaction rate
for the year was 90.5%.
Patient Reported Outcome Measures Studies (PROMS) – the hospital has
encouraged patients to participate in PROMs surveys to monitor patient assessed
outcomes of surgery regarding varicose veins, hip and knee replacement and
inguinal hernia.
Information Security – Oaklands Hospital has achieved the information security
accreditation ISO 27001. The process of raising the importance of data protection
and information security has been successful and fully embraced by our staff.
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Clinical Documentation Audits - Remain a priority in all areas with a corporate
Ramsay focus set for 2014/15 on theatre safety checks and physiotherapy
documentation checks.
Local CQUINS

Patient Shared Decision Making – this continued for THR patients as per last
year and TKR and Carpel tunnel release were added.

Care Planning Protocol – care pathways for Laparoscopic Cholecystectomy
and Scarf Osteotomy were reviewed and implemented from 1st April 2014.

Use of Digital Technology – work continues with the IT teams at the CCG and
SRFT to enable the installation of Docman.
National CQUINS

Friends and Family Test – The hospital undertook Friends & Family testing with
both inpatient and day case patients in the period, achieving a 42% response
rate with a 100% rate for ‘Extremely Likely to Recommend’ from Inpatients and
98% of day cases reporting a “ Likely or Extremely Likely to Recommend”.

VTE risk assessment – The hospital was set a compliance target of 95%, the
national target being 95%, and continuously achieved this reaching 100%
compliance in April 2014.

Safety Thermometer- continued to submit to NST on a monthly basis with no
adverse events reported.

Advancing Quality- this initiative is aimed at improving the quality of care and
patient experience. In 2014 Oaklands Hospital was recognized with an award for
best performing trust participating in one clinical focus area.
2.1.2
Clinical Priorities for 2014/15 (looking forward)
Patient Safety
Surgical Safety Checklist - Never Events’ are serious, largely preventable patient
safety incidents that should not occur if the available preventative measures have
been implemented as standard practice. Monthly audits will continue to be
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undertaken with an expectation of 100% compliance; where this is not achieved
actions plans will be developed and responsibilities communicated with the teams.
Briefing and debriefing sessions after all operating sessions continue and give
opportunity for shared learning, recommendations for future practice and aim to
encourage autonomy for all members of the team. Compliance will be monitored by
regular audit and reviewed by the hospital’s Clinical Governance and Medical
Advisory Committees.
NHS Safety Thermometer - The NHS Safety Thermometer is a national CQUIN to
measure, monitor and analyse patient harms and ensure 'harm free' care. Oaklands
Hospital has been 100% compliant with data submission and will continue to submit
this data in relation to pressure ulcers, falls and urinary tract infections in those with a
catheter.
VTE Assessment - A VTE risk assessment is completed for patients according to
CM 001 VTE policy and requires consultants to review and complete a written
assessment prior to procedure. This remains a focus at Oaklands Hospital with
quarterly audits completed to maintain standards. Results are reviewed and actions
determined at both the hospital’s Clinical Governance and Medical Advisory
Committees.
Staffing – To ensure adequate numbers of skilled staff are available to care for our
patients staff rosters are prepared in advance. An electronic rostering tool ‘Allocate’
was introduced in December 2013 taking into account the necessary skill mix for
scheduled patient activity.
The Ramsay Academy provides learning and development opportunities for all staff
and the Management Development Framework provides opportunities for our leaders
to develop skills and knowledge. We recognise the value of the Health Care Assistant
(HCA) within Ramsay and competency assessments are in place to allow all HCAs to
reach their full potential. Acknowledging the Cavendish review we are adopting the
‘productive team’ model ensuring ‘a holistic approach to care, focused on ensuring
the best possible outcomes for the patient, staff and the organisation’. We promote a
culture of support and mentoring in developing our existing staff and will be
introducing apprenticeships across different job roles in the next year.
Clinical Effectiveness
Maintaining Endoscopy Standards – Oaklands Hospital will be working towards
successful JAG (Joint Advisory Group on Gastrointestinal Endoscopy) accreditation
in 2015; biannual submission to GRS (Global Rating Score) continues. This tool
enables us to assess how well we provide a patient-centred service, demonstrating
compliance against the four domains:
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 clinical quality
 quality of patient experience
 workforce
 training
Patient Experience – informing patient choice
Patient Satisfaction Survey – We will continue to encourage patients to provide
feedback using our web based satisfaction survey. ‘Hot alerts’ received following
completion of the survey will be reviewed by the hospital’s General Manger and
Matron and action taken where there are areas identified for improvement. All
comments positive and negative are shared with the whole team along with a
monthly patient satisfaction dashboard. Compliments and complaints are reviewed at
the hospital’s Clinical Governance and Medical Advisory Committees and lessons
shared with the hospital’s departments. We will also continue to monitor posts on
NHS Choices. We have added to current patient feedback mechanisms by including
patients in hospital PLACE audits.
Friends and Family Test - The Friends and Family Test has been extended to
include Outpatients from April 2014. Patients will be invited to complete a paper or
electronic questionnaire following their visit to the hospital. Results from this survey
will be reviewed and shared with the hospital’s departments.
Patient Reported Outcome Measures Studies (PROMS) – This is a national
indicator providing important information regarding the effectiveness of surgery as
perceived by the patient. We will continue to monitor patient response rates. The
consultant surgeons will continue to ensure patients are fully informed and invited to
take part in the survey by completing a questionnaire prior to their surgery.
Advancing Quality – Aimed at improving quality of care and patient experience is a
local CQUIN where Oaklands Hospital submits data regarding DVT and antibiotic
prophylaxis. Compliance with the best practice pathway is monitored via internal
submission of data onto the Clarity database and externally audit of patient records.
Equality Delivery System – Oaklands Hospital will be one of the first private
hospitals to work on NHS England’s EDS2 initiative to ensure that the services we
provide for patients and that the working environment we provide to staff is free of
discrimination, in accordance with the nine protected characteristics under the
Equality Act 2010; age, disability, gender reassignment, marriage and civil
partnership, pregnancy and maternity, race, religion and belief, gender and sexual
orientation.
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2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2013/14 Oaklands Hospital provided seven NHS services and has reviewed
the data available to them on the quality of care in all of these NHS services.
The income generated by NHS services reviewed in 1st April 2013 to 31st March 2014
represents 100% per cent of the total income generated from the provision of NHS
services by Oaklands Hospital for 1st April 2013 to 31st March 2014.
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard are
reviewed each year. The scorecard is reviewed each quarter by the hospital’s senior
managers together with regional and corporate Managers and Directors. The
balanced scorecard approach has been an extremely successful tool in helping us
benchmark against other Ramsay hospitals and identifying key areas for
improvement.
In the period for 2013/14, the indicators on the scorecard which affect patient safety
and quality were:
Human Resources











Staff Cost % Net Revenue
HCA Hours as % of Total
Nursing
Agency Cost as % of Total Staff
Cost
Ward Hours PPD
% Staff Turnover
% Sickness
% Lost Time
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff
Injuries
Patient




Formal Complaints per 1000
HPD's
Patient Satisfaction Score
Significant Clinical Events per
1000 Admissions
Readmission per 1000
Admissions
Quality



Workplace Health & Safety
Score
Infection Control Audit Score
Consultant Satisfaction Score
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2.2.2 Participation In Clinical Audit
During 1st April 2013 to 31st March 2014, Oaklands Hospital participated in three
national clinical audits which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Oaklands Hospital
participated in, and for which data collection was completed during 1st April 2013 to
31st March 2014, are listed below alongside the number of cases submitted to each
audit or enquiry as a percentage of the number of registered cases required by the
terms of that audit or enquiry.
Name of audit / Clinical Outcome
Review Programme
National Joint Registry (NJR)
Elective surgery (National PROMs Programme)
Medical and surgical clinical outcome review programme: National
confidential enquiry into patient outcome and death
% cases
submitted
100%
63%
0% - no
deaths in
period.
PROMs for elective surgery figure of 63% was affected by no national code for the
prosthesis used in computer aided surgery. This has now been rectified.
The reports of national clinical audits from 1st April 2013 to 31st March 2014 were
reviewed by the hospital’s Clinical Governance Committee.
Local Audits
The reports of local clinical audits from 1st April 2013 to 31st March 2014 (schedule
attached in Appendix 2) were reviewed by the hospital’s Clinical Governance
Committee.
2.2.3 Participation in Research
There were no patients recruited during 2013/14 to participate in research.
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2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning
for Quality and Innovation) Framework
A proportion of Oaklands Hospital’s income from 1 April 2013 to 31st March 2014 was
conditional on achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation payment framework.
2.2.5 Statements from the Care Quality Commission (CQC)
Oaklands Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March 2014 is registered without conditions.
The hospital has not participated in any special reviews or investigations by the CQC
during the reporting period.
Quality Accounts 2013/14
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2.2.6 Data Quality
The hospital continues to take the following actions to improve data quality:



Regular training to ensure staff understand importance of accurate data input
and have sufficient technical competence
Employment of clinical coder to improve accuracy of recording
Supporting national projects to ensure data accuracy
NHS Number and General Medical Practice Code Validity
Oaklands Hospital submitted records during 2013/14 to the Secondary
Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are
included in the latest published data. The percentage of records in the published data
which included:
The patient’s valid NHS number:



99.97% for admitted patient care;
99.96 for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code:



100% for admitted patient care;
100% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit Attainment Levels
Ramsay Group Information Governance Assessment Report scored 83% for 2013/14,
and was graded ‘green’ (satisfactory).
Clinical Coding Error Rate
Oaklands Hospital was not subject to the Payment by Results clinical coding audit
during 2013/14 by the Audit Commission.
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2.2.7 Stakeholders’ Views on Oaklands Hospital’s Quality Account 2013/14
Feedback from the hospital’s lead Clinical Commissioning Group is as follows:We have been working closely with the hospital during the year, gaining assurance of
the delivery of safe and effective services. Their quality and performance is monitored
through regular contracts meetings where data is reviewed and discussed. We are
pleased to see that the information presented within the Quality Accounts is consistent
with information supplied to the commissioners throughout the year. The CCG
recognises the commitment of the Oaklands to quality improvement in achieving the
CQUIN targets set for the year.
We acknowledge the focus on improving safety within the organisation as evidenced
through the use of the surgical safety checklist, the use of VTE assessments and data
collection for the safety thermometer. The CCG welcomes the hospital’s continued
commitment to this important area.
The emphasis on listening to patients about their experience of using services is
evident in the information presented and we are pleased to see the initiatives outlined
on how this area is being developed. Positive feedback by patients is demonstrated in
the levels of satisfaction outlined in the patient survey results. It would be useful to see
this information triangulated with data on the numbers of complaints including any
themes or trends along with actions taken as a result of any such negative feedback in
the Quality Accounts for 2014/15
Participation of patient representatives in the assessment of the environment through
the PLACE assessments demonstrates the organisation’s commitment to patient
engagement. This is further evidenced by encouraging the involvement of patients in
their care in terms of participating in care plans and the use of patient CCG Draft
response to Oaklands Quality Accounts
NHS Salford Clinical Commissioning Group (CCG) welcomes the opportunity to
reported outcome measures (PROMs). Whilst the return rate on PROMs is outlined
within the accounts it would be helpful to see some comparative data presented in
relation to the content of these outcomes in future reports.
The information outlined in relation to participation in national and local audits and
provides evidence that the organisation is committed to benchmarking and monitoring
performance against agreed standards. It would be helpful to see evidence of how the
result of this work has translated into improved outcomes for people using services in
future reports.
We will continue to work in collaboration with the hospital in driving forwards further
changes and improvement over the coming year; through our regular contracts and
performance meetings
Francine Thorpe
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Head of Quality & Innovation
Part 3: Review of quality performance 2013/2014
Statements of Quality Delivery – Rhona Davis, Matron Oaklands Hospital
Introduction
“This publication marks the fifth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our
performance on many levels, we reflect on the valuable feedback we receive
from our patients about the outcomes of their treatment and also reflect on
professional opinion received from our doctors, our clinical staff, regulators and
commissioners. We listen where concerns or suggestions have been raised and,
in this account, we have set out our track record as well as our plan for more
improvements in the coming year. This is a discipline we vigorously support,
always driving this cycle of continuous improvement in our hospitals and
addressing public concern about standards in healthcare, be these about our
commitments to providing compassionate patient care, assurance about patient
privacy and dignity, hospital safety and good outcomes of treatment. We believe
in being open and honest where outcomes and experience fail to meet patient
expectation so we take action, learn, improve and implement the change and
deliver great care and optimum experience for our patients.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develops ways of working
which assure that the quality of patient care is central to the organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care, clinicians
are enabled to provide that care and the organisation can satisfy itself that we are
doing the right things in the right way.
Quality Accounts 2013/14
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It is important that Clinical Governance is integrated into other governance systems in
the organisation and should not be seen as a “stand-alone” activity. All management
systems, clinical, financial, estates etc are inter-dependent with actions in one area
impacting on others.
Several models have been devised to include all the elements of Clinical Governance
to provide a framework for ensuring that it is embedded, implemented and can be
monitored in an organisation. In developing this framework for Ramsay Health Care
UK we have gone back to the original Scally and Donaldson paper (1998) as we
believe that it is a model that allows coverage and inclusion of all the necessary
strategies, policies, systems and processes for effective Clinical Governance. The
domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
Quality Accounts 2013/14
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Quality Accounts 2013/14
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National Guidance
Ramsay also complies with the recommendations contained in technology appraisals
issued by the National Institute for Health and Clinical Excellence (NICE) and Safety
Alerts as issued by the NHS Commissioning Board Special Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
Quality Accounts 2013/14
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3.1 The Core Quality Account Indicators
National Mortality Rates
Period
Best
Worst
Average
2012/13
RKE
0.65
RXL
1.17
Eng
1
2013/14
RKE
0.63
RBT
1.15
Eng
1
Oaklands Mortality Rates
Period
Oaklands
2012/13
NVC12
0
2013/14
NVC12
0
National Expected Deaths
Period
Best
Worst
Average
Apr12 - Mar13
RBA
0.1
RWH
44.0
Eng
20.4
Jul12 - Jun13
RBA
0.0
RWH
44.1
Eng
20.2
Oaklands Expected Deaths
Period
Oaklands
2012/13
NVC12
0.0
2013/14
NVC12
0.0
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PROMs
Oaklands Hospital has taken action to improve the returns rate of PROMs questionnaires
and so the quality of its services, by actively involving consultants in the PROMs process
in encouraging patient participation.
National PROMs (Hernia)
Period
Best
Worst
Average
Apr12 - Mar13
NT415
0.157
NVC27
0.015
Eng
0.085
Apr13 - Sep13
RTG
0.138
RNA
0.019
Eng
0.086
Oaklands PROMs (Hernia)
Period
Oaklands
Apr12 - Mar13
NVC12
*
Apr13 - Sep13
NVC12
*
National PROMs (Veins)
Period
Apr12 - Mar13
Apr13 - Sep13
Best
RV8
RTD
5.14
-9.74
Worst
NT350
-15.92
RLN
-10.52
Average
Eng
-8.374
Eng
-9.46
Oaklands PROMs (Veins)
Period
Apr12 - Mar13
Apr13 - Sep13
Oaklands
NVC12
NVC12
*
*
National PROMs (Hips)
Period
Apr12 - Mar13
Apr13 - Sep13
Best
NT209
24.68
NT318
25.44
Worst
RKE
17.21
RHQ
18.34
Average
Eng
21.32
Eng
21.61
Quality Accounts 2013/14
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Oaklands PROMs (Hips)
Period
Apr12 - Mar13
Apr13 - Sep13
Oaklands
NVC12
NVC12
*
*
National PROMs (Knees)
Period
Apr12 - Mar13
Apr13 - Sep13
Best
NT219
RDE
Worst
20.37
20.09
RAP
RM1
12.46
14.32
Average
Eng
16.01
Eng
16.74
Oaklands PROMs (Knees)
Period
Apr12 - Mar13
Apr13 - Sep13
Oaklands
NVC12
NVC12
14.901
*
* Volumes were too low to be reported.
National Readmissions
Period
Best
Worst
Average
2010/11
RF4
0.0
RYR
15.8
Eng
11.04
2011/12
RF4
0.0
RYR
15.8
Eng
11.08
Oaklands Readmissions
Period
Oaklands
2012/13
NVC12
6.76
2013/14
NVC12
8.89
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National VTE Assessment
Period
Best
Worst
Average
13/14 Q3
Several
100%
NT244
63.2%
Eng
95.8%
13/14 Q4
Several
100%
NT205
67.0%
Eng
96.0%
Oaklands VTE Assessment
Period
13/14 Q3
13/14 Q4
Oaklands
NVC12
99.9%
NVC12
96.9%
National C-Difficile Rate
Period
Best
Worst
Average
2012/13
Several
0
RNA
58.2
Eng
22.2
2013/14
Several
0
RVW
30.8
Eng
17.3
Oaklands C-Difficile Rate
Period
Oaklands
2012/13
NVC12
0.0
2013/14
NVC12
0.0
National Patient Safety Incident Rate
Period
Best
Worst
Average
2011/12
RP6
2.6
TAJ
84.4
Eng
13.5
2012/13
RRF
2.0
RAT
85.6
Eng
14.8
Oaklands Patient Safety Incident Rate
Period
Oaklands
2012/13
NVC12
3.36
2013/14
NVC12
6.37
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National SUIs (Severity Level 1)
Period
Best
Worst
Average
Jul - Sep 12
NA
NA
NA
Oct11 - Sep12
NA
NA
Eng
11,563
Oaklands SUIs (Severity Level 1)
Period
Oaklands
2012/13
NVC12
0.0%
2013/14
NVC12
0.0%
National Friends and Family Test
Period
Best
Worst
Average
Jan-14
Several
100
RPA02
27
Eng
73
Feb-14
Several
100
RPA02
18
Eng
73
Oaklands Friends and Family Test
Period
Oaklands
2012/13
NVC12
100
2013/14
NVC12
100
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3.2 Patient Safety
We are a progressive hospital and focussed on stretching our performance every year
in all performance respects, and certainly in regards to our track record for patient
safety.
Risks to patient safety come to light through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more
routinely from tracking trends in performance indicators.
3.2.1 Infection Prevention and Control
Oaklands Hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 5 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents
year on year.
Infection Prevention and Control management is very active within our hospital. An
annual strategy is developed by a corporate level Infection Prevention and Control
(IPC) Committee and group policy is revised and re-deployed every two years. Our
IPC programmes are designed to bring about improvements in performance and in
practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
The infection control link nurse has provided training in hand hygiene to all staff and
completes a hand hygiene training session during the staff induction day for all new
staff.
Hand hygiene awareness days are led by the infection control link nurse involving
staff, patients and visitors and information in waiting areas.
Observational hand hygiene audits were undertaken by the infection control link nurse
resulting in additional gel dispensers being placed in the unit.
Our infection control rate remains very low and our reporting and investigating of
potential infections has improved in the last year. Any patient presenting signs of an
infection is reviewed by the infection control link nurse and a root cause analysis
Quality Accounts 2013/14
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completed to determine any possible trends, results are presented at our quarterly
infection control committee meetings. There have not been any trends identified in the
period.
Infection Rates
Infection Rates
(percentage of Admissiosns)
0.25
0.2
0.15
0.1
0.05
0
2011/12
2012/13
2013/14
Oaklands Hospital
3.2.2 Cleanliness and Hospital Hygiene
Assessments of safe healthcare environments also include Patient-Led Assessments
of the Care Environment (PLACE).
PLACE assessments occur annually at Oaklands Hospital, providing us with a
patient’s eye view of the buildings and facilities, giving us a clear picture of how the
people who use our hospital see it and how it can be improved. The Hospital scored
87% for the four areas of cleanliness, food, privacy and the condition of facility. The
current scoring system is under review as recording NA (not applicable) in the Privacy
and Dignity section gives a negative score.
An action plan was compiled and managed by senior management to ensure feedback
was acted upon and facilities remain of a high standard.
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3.2.3 Safety In The Workplace
Safety hazards in hospitals are diverse, ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient safety.
Our record in workplace safety as illustrated by Accidents per 1000 Admissions
demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the Ramsay
Central Alert System (CAS). Safety alerts, medicine / device recalls and new and
revised policies are cascaded in this way to our General Manager which ensures that
we keep up to date with all safety issues.
In addition to mandatory training the Health and Safety Coordinator has coordinated
sharps awareness programmes throughout the year ensuring the use of sharps-safe
devices where these are available. There has also been training on waste
management ensuring the correct segregation of waste taking into account the effect
on the environment and raising staff awareness on this issue. We have supported a
team member to complete a training course to enable them to provide manual
handling training to all of our staff.
3.3 Clinical Effectiveness
Oaklands Hospital has a Clinical Governance team and committee that meet regularly
through the year to monitor quality and effectiveness of care. Clinical incidents, patient
and staff feedback are systematically reviewed to determine any trend that requires
further analysis or investigation. More importantly, recommendations for action and
improvement are presented to hospital management and medical advisory committees
to ensure results are visible and tied into actions required by the organisation as a
whole.
3.3.1 Return to Theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or
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specific surgical team. Ramsay’s rate of return is very low, consistent with our track
record of successful clinical outcomes.
Return to Theatre Score
Retrnn to Theatre
(Percentage of Admissiosns)
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
2011/12
2012/13
2013/14
Oaklands Hospital
3.4 Patient Experience
All feedback from patients regarding their experiences with Ramsay Health Care are
welcomed and inform service development in various ways dependent on the type of
experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also fed back to the relevant
staff using direct feedback. All staff are aware of our complaints procedures should our
patients be unhappy with any aspect of their care.
Patient experiences are fed back via the various methods below, and are regular
agenda items on the local Governance Committees for discussion, trend analysis and
further action where necessary. Escalation and further reporting to Ramsay Corporate
and NHS bodies occurs as required and according to Ramsay and NHS England
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:

Web based survey with a web based invitation
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






Hot alerts received within 48hrs of a patient making a comment on their web
survey
Friends and Family questionnaire
‘We value your opinion’ leaflet provided to patients on discharge
Verbal feedback to Ramsay staff - including Consultants, Matrons and General
Manager whilst visiting patients
Written feedback via patient letters and emails
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of
care
3.4.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently of the
hospital so we receive a true reflection of our patients’ views.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked are
used to influence the way the hospital seeks to improve its services. Any text
comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital
Manager within 48hrs of receiving them so that a response can be made to the patient
as soon as possible.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
95.4
89.0
2012/13
2013/14
20
0
Oaklands Hospital
We have consistently maintained a high satisfaction rate and proactively seek patient
feedback to ensure we maintain this. Please note; a change of satisfaction survey in
early 2013 means the year on year data is not comparable.
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Appendix 1
Services covered by this quality account
Services Provided
Treatment of Disease,
Disorder
Or injury
Cosmetics, Dermatology, Ear,
Nose and Throat (ENT),
General surgery,
Gynaecological, General
medicine, Ophthalmic,
Orthopaedic, Physiotherapy,
Rheumatology, Sports
medicine, Urology
Peoples Needs Met for:
All adults 18 yrs and over
Children 3 years and above
All adults 18 yrs and over excluding:





Surgical
Procedures
Breast surgery, Cosmetics,
Day and Inpatient Surgery,
Dermatology, Ear, Nose and
Throat (ENT), General
surgery, Gynaecological,
Ophthalmic, Oral
maxillofacial surgery,
Orthopaedic, Urology







Patients with blood disorders (haemophilia,
sickle cell, thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA
screen are deferred until negative
Patients who are likely to need ventilatory
support post operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission to
ITU post surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild
exertion e.g. from kitchen to bathroom or
dyspnoea at rest)
Poorly controlled asthma (needing oral steroids
or has had frequent hospital admissions within
last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal
activity e.g. 1 flight of stairs or angina at
rest)
CVA in last 6 months
However, all patients will be individually assessed and
we will only exclude patients if we are unable to
provide an appropriate and safe clinical environment.
Children 3 years and above
Diagnostic and
screening
Imaging services,
Phlebotomy, Urinary
Screening and Specimen
collection.
All adults 18 yrs and over
Children 3 years and above
Quality Accounts 2013/14
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Appendix 2 – Clinical Audit Programme 2013/14.
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Oaklands Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Telephone: 0161 787 7700
www.oaklands-hospital.co.uk
Quality Accounts 2013/14
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