Boston West Hospital
Quality Account
2014/15
Contents
Introduction Page
3
Welcome to Ramsay Health Care UK
3
Introduction to our Quality Account
4
PART 1 – STATEMENT ON QUALITY
5
1.1
Statement from the General Manager
5
1.2
Hospital accountability statement
7
PART 2
12
2.1
12
Priorities for Improvement
2.1.1 Review of clinical priorities 2014/15 (looking back)
12
2.1.2 Clinical Priorities for 2015/16 (looking forward)
14
2.2
15
Mandatory statements regarding quality of NHS services
2.2.1 Review of Services
15
2.2.2 Participation in Clinical Audit
17
2.2.3 Participation in Research
18
2.2.4 Goals agreed with Commissioners
18
2.2.5 Statement from the Care Quality Commission
20
2.2.6 Statement on Data Quality
20
2.2.7 Stakeholders views on 2014/15 Quality Accounts
22
PART 3 – REVIEW OF QUALITY PERFORMANCE
25
3.1
The Core Quality Account indicators
27
3.2
Patient Safety
30
3.3
Clinical Effectiveness
33
3.4
Patient Experience
34
3.5
Case Studies
37
Appendix 1 – Services Covered by this Quality Account
39
Appendix 2 – Clinical Audits
40
Appendix 3 – Glossary
41
Welcome to Ramsay Health Care UK
Boston West Hospital is part of the Ramsay Health Care Group
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
and Clinical Commissioning Groups.
Introduction
Statement from Mark Page, Chief Executive Officer, Ramsay Health Care UK
“The provision of high quality patient care is and will always be the highest priority of Ramsay
Health Care UK. Of course our team of clinical staff and consultants are very much at the forefront
of achieving this but there is also very much an organisation wide commitment to ensure that we
continue to improve our outcomes every day, week, month and year.
Delivering clinical excellence depends on everyone in the organisation. Clinical excellence cannot
be the responsibility of just a few, it takes all of us to be responsible and accountable for our
performance in the various roles we all play. Having an organisational culture that puts the patient
at the centre of everything we do is key to ensuring we enable everyone to perform at their peak to
attain great outcomes.
Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends, we will continue to strive to get ever better.
I am very proud of our long standing and major provider of healthcare services across the world and
of our Ramsay very strong track record as a safe and responsible healthcare provider. It gives us
pleasure to share our results with you.”
Quality Account 2014/15
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Introduction to our Quality Account
This Quality Account is Boston West Hospitals 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 and 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 patient’s 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 was developed by our Corporate Office and summarised and
reviewed quality activities across every hospital and treatment centre within the Ramsay Health
Care UK. It was recognised that this didn’t provide enough in depth information for the public and
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 Group wide initiatives, but also describes the many excellent
local achievements and quality plans that we would like to share.
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Part 1
1.1 Statement on Quality from the General Manager
Carl Cottam, General Manager
Boston West Hospital
As the General Manager of the Boston West Hospital I am passionate about ensuring that we
deliver consistently high standards of care to all our patients.
Our Vision is that
“As a committed team of professional individuals we aim to consistently deliver quality holistic care
for all our patients across a full range of care services. We believe we are able to achieve this by
continually updating our key skills and knowledge enabling us to deliver evidence based clinical
practice throughout the Hospital.”
Our Quality Account details the actions that we have taken over the past year to ensure that our
high standards in delivering patient care remain our focus for everything we do. Through our
vigorous audit regime and by listening to our stakeholders, including patient feedback, we have
been able to identify areas of good practice and where we can improve the care patients receive.
This has enabled us to refine some of our processes to make improvements to the service we offer
our patients.
We have enhanced our training and education plan throughout the year involving both the
administrative and clinical teams. It is important we have robust training programs to deliver
excellent care and service standards.
Our Quality Account provides information about how we monitor and evaluate the quality of the
service that we deliver.
We hope to share our progressive improvements over the past year. The Boston West Hospital has
a very strong track record as a safe and responsible provider of health care services and we are
proud to share our results.
Our Quality Account has been developed with the involvement of our staff who have been
instrumental in developing a systems approach to risk management, which focuses on providing
safe quality care to mitigate the risk of adverse events.
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To ensure we have a coordinated approach to the delivery of the care we provide we have our
Clinical Governance Committee and Medical Advisory Committee who monitor the adherence to
professional standards and legislative requirements. The committee’s review the hospitals clinical
performance and activity on a quarterly basis.
The committees have reviewed and agree with the content and actions details within the quality
account.
As General Manager, I am aware of all aspects of clinical quality and NHS services provided at
Boston West Hospital and can confirm the accuracy of this document.
If you would like to comment or provide feedback regarding the content of the Quality Account,
please do not hesitate to contact me at carl.cottam@ramsayhealth.co.uk or telephone 01733
842308.
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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.
Carl Cottam
General Manager
Boston West Hospital, Ramsay Health Care UK
This report has been reviewed and approved by:

BWH Medical Advisory Committee Chair – Mr Nazeer Dahar, Consultant Urologist

BWH Clinical Governance Committee Chair – Dr Marian Necas, Consultant Anaesthetist

BWH Medical Director – Mr Viktor Csok, Consultant General Surgeon

Regional Director - Mr James Beech
The report has also been shared with the following groups for their review and comment prior to
submission.
 Lincolnshire Clinical Commissioning Group
 Health Watch Lincolnshire and Lincolnshire Health Scrutiny Committee
 Boston West Hospital Patient Participation Group
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Welcome to Boston West Hospital
Boston West Hospital is part of the Ramsay Health Care Group
The Boston West Hospital has been part of the local community for 10 years. We have a dedicated
workforce that is committed to making each and every patient feel secure and safe. Whether our
patients are coming in for a consultation or day surgery we want them to feel that they are cared for
by compassionate and highly trained staff that provide skilled care to our patients.
Boston West Hospital is a purpose built facility which provides services for assessment, diagnosis
and treatment of common medical conditions, and has a suite of outpatient and treatment rooms
which have recently been refurbished to create an additional spacious consultation room. A wellequipped modern theatre undertakes a range of surgical procedures and endoscopic (diagnostic)
investigations. Support services include a three stage Sterile Services Unit, which meets the
stringent standards set by the Department of Health.
The Hospital provides a wide range of services covering NHS and private day case facilities for the
following specialties:







Orthopaedic
Ophthalmology
General Surgery
Pain Management
Gynaecology
Gastroenterology
Urology
Quality Account 2014/15
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


Physiotherapy
Cosmetic Surgery
ENT
Our full list of services can be found in Appendix 1.
We provide safe, convenient, effective and high quality treatment for adult patients (excluding
children below the age of 18 years), whether privately insured, self-pay, or from the NHS. A high
percentage of our patients have come from the NHS sector, patients choosing to use our facility
through ‘Choose and Book’. Our services help to ease the pressure on The Pilgrim NHS Hospital,
Lincoln County Hospital and other local NHS facilities. We have worked closely with our NHS
Clinical Commissioners, Lincolnshire South CCG, to ensure improved access for patients requiring
day case surgery.
Over the past 10 years our establishment has grown from strength to strength. From our friendly
reception staff to our highly skilled surgeons, patient care and opinions are what matters most; and
our positive feedback from our patients gives our entire team great pride. Not only do we continue
to have positive feedback from our service users we have recently developed a suite of patient
information leaflets to provide patients additional information and support regarding take home
medications on discharge. From review of our patient feedback, since the implementation of the
leaflets we have scored 100% in this area for patient satisfaction. We have over 16 highly trained
nursing staff who, alongside a wide variety of other healthcare professionals, deliver the highest
level of care.
At the Boston West Hospital, we provide medical and surgical services for privately insured, selfpaying and NHS patients. We strive to offer the same level of outstanding care to all our patients.
Last year we admitted a total of 2,980 patients, 95% of which were NHS. An additional 590 patients
were seen per week in our outpatient department by one of our 35 Consultants. At Boston West
Hospital we offer consultant led care, meaning that all our patients are seen by a Consultant at
each step of their patient care pathway.
We consistently engage with local general practitioners to update them regarding the services we
offer and the most current pathways for patient care. This has resulted in our ability to tailor care to
meet the needs of patients and improve quality. We have the support of a Quality Improvement
Manager during the last financial year to invest and support our commitment to quality to provide
our patients with the best clinical care and patient experience. We also continue to foster good
relationships with other local healthcare providers. This affiliation promotes a robust governance
process which in turn enhances patient safety.
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We also work close with a nominated charity
each year, this year we have supported LIVES
and Marie Curie Cancer care. Over the past
year Hospital staff have been working
together with patients to raise funds for
charity. Ramsay Health Care has donated
resources and staff have volunteered time to
arrange fundraising activities.
Patient engagement and involvement continues to be a high priority as we strive to keep patients at
the heart of everything we do.
The Boston West Hospital Patient Group plays the valuable role of ‘critical friend’ to the Hospital
and supports in a number of ways including undertaking regular reviews of patient communication
and conducting our annual Patient Led Assessment of the Care Environment (PLACE) audit.
In addition to patient involvement our GP Liaison Officer works closely with GP Practices, Opticians
and communities across the county to ensure that both referrers and patients are aware of our
services and that these services meet the needs of local people.
We provide a programme of free clinical education and training to support health professionals in
their continued professional development (CPD). This is well received by GPs and Optometrists
and also helps us strengthen relationships and improve communication between our Consultants
and local clinicians. These educational sessions have been delivered by our Consultants and
Clinical Leads at GP Practices throughout Lincolnshire and at Boston West Hospital.
Boston West Hospital is approved by the General Optical Council as a provider of Continued
Education and Training (CET) enabling us to deliver accredited training to Optometrists, dispensing
Opticians and support staff.
2015 marks 10 years since Boston
West Hospital first began providing
healthcare to the people of
Lincolnshire. Many of the team
have been working at the Hospital
since it opened including Matron,
Sue Harvey and Medical Director,
Viktor Csok.
Ramsay Health Care recognises and rewards long service and is keen to retain and develop its
work force investing widely in training and offering development opportunities. Boston West
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Hospital has recently taken on several apprentices who will be learning new skills within both our
clinical and administrative departments.
“Being an apprentice at Boston West Hospital has given me a fantastic
opportunity to gain the hands-on experience I wanted. To be able to
work with such a hard-working and friendly team has really helped me
feel welcome, at ease and part of the team. It has given me a great step
forward at the beginning of my career”
Beth Barai – Apprentice HCA
Patients tell us how important good customer service is to their experience of healthcare in our
hospital. In response Ramsay Health Care have introduced a Customer Service Excellence
programme (CSE) to encourage excellence in our staff and recognise members of the Boston West
Hospital team who demonstrate excellent customer service. Staff who deliver exceptional care,
attention and support can be nominated by patients, carers, visitors and colleagues and work their
way to bronze, silver and the ultimate gold CSE award. To date members of our clinical,
administration, housekeeping and sterile services departments have achieved bronze, silver and
gold awards.
Part 2
Samantha Bisby, Health care Assistant (HCA), of Boston
West Hospital is the first member of staff within Ramsay
Health Care UK to achieve her prestigious gold award
having received over 36 nominations from patients and
colleagues for demonstrating exceptional customer
service.
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2.1 Quality priorities for 2014/2015
Plan for 2014/15
On an annual cycle, Boston West 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 on going at any one time. The priorities are
determined by the hospitals 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.
Priorities for Improvement
2.1.1 A review of clinical priorities 2014/15 (Looking Back)
Patient Experience
Patient Satisfaction
During 2014/15 we pledged to continue to focus on fostering an environment that enables us to
learn from patient feedback as we value our patients’ feedback in order to develop and grow the
services we offer. We commissioned a scheme to promote quality and innovation in conjunction
with our Clinical Commissioning groups to monitor and measure our patient feedback through audit
and patient satisfaction surveys.
The key objective during 2014/15 was to focus on patient pain management at the point of
discharge. The indicator set out to improve communication about pain management for all admitted
patients, ensuring that all in-patients have relevant and appropriate literature and advice on
discharge including the provision of ‘Managing Your Pain After Your Operation’ leaflet. During
2014/15 we conducted a number of patient surveys to gauge the success of the work we had
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completed regarding communications. The patient satisfaction survey scores for the questions
covering information on discharge regarding the management of pain showed an increase in patient
satisfaction of 67%, with patient satisfaction scoring 100%. This work will be extended during
2015/16 to ensure the provision of the leaflets to patients along with full explanations given at both
the Pre Admission Assessment and on discharge is embedded into our practice to maintain patient
satisfaction in this area.
Friends & Family Test
The successful implementation of the friends and family test in our outpatient areas was also
achieved.
Clinical Effectiveness
It is important for patients who chose to be treated by our clinicians that the procedures they
undergo are effective and appropriate. We measure and record how effective we are by publishing
data to inform and benchmark.
Patient Recorded Outcome Measures (PROMs)
Our clinical priority was to improve our response rate for groin hernia repair and varicose veins. The
outcome measures enable healthcare professionals to measure the overall benefit of undertaking
surgical procedures and the clinical effectiveness following that procedure.
Patient Safety
It is important for patients to know they are being cared for in a safe environment by staff who have
the appropriate knowledge and skills. We also have a contractual requirement with our Clinical
Commissioning Groups to achieve high standards of clinical safety. This is monitored through
numerous audits, reports and inspections.
Venous Thromboembolism (VTE)
Our aim was to ensure that over 98% of patients have a completed VTE risk assessment and
appropriate prophylaxis is provided. Throughout the year we have monitored our progress to review
the standard of assessment. On review 100% of patients had a completed risk assessment during
2014/15.
Early Warning Score (EWS)
As part of ongoing work following the CQUIN from 2013/14 it was identified that a further suite of
training materials was required and audits to be undertaken to monitor the effectiveness of the
training following the release of new national guidelines. All staff were trained and further monitoring
was carried out to analyse the effectiveness of the training. In 2014 Boston West Hospital
implemented a further change to the EWS chart incorporating national guidance, with a
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commitment to train staff in the use of new charts and monitor compliance with escalation of the
deteriorating patient, Boston West Hospital achieved their target for this improvement with a
compliance score of 97%
2.1.2 Clinical Priorities for 2015/16 (looking forward)
Patient Experience
Patient experience continues to be a key focus to ensure we deliver the highest level of patient care
at Boston West Hospital. Fostering an environment that enables us to learn from patient feedback is
critical to the growth and development of our services.
Our aim in 2015/16 is to improve the process for patients who do not attend the hospital for their
appointment concentrating on key services. The process aims to reduce waits and provide a more
streamlined process for those services with high demand, which in turn will provide patients with a
better experience, looking specifically into the area of endoscopy.
As feedback is important to us, we plan to review the way in which “HOT” alerts and informal patient
feedback is addressed to ensure all feedback is addressed and lessons learned where possible to
improve the services we offer our patients.
In 2015/16 we aim to develop a Consultant Newsletter to ensure the clinicians are aware of our
activity in relation to governance and quality sharing lessons learned from the wider Ramsay group
and highlighting key information from clinical audit and national guidelines to promote best practice.
Clinical Effectiveness
Sharing our findings from governance information and learning lessons is key, in order to progress
the effectiveness of the hospital. During 2015/16 we will be introducing display boards within each
department which will highlight key governance activity and performance.
We will also be sharing lessons with key clinical staff regarding adverse events and sharing lessons
from the wider Ramsay group for learning.
Patient Safety
2014/15 has seen the theatre team build on their safety culture, with the sound implementation and
ongoing review of the WHO checklist. Monthly clinical audits are completed to review clinical safety
and effectiveness. The average compliance rate for these audits during 2014/15 was 98% and
during 2015/16 we would like to build on these findings.
We hope to continue this momentum and build on an already sound culture. During 2015/16 we
have attached CQUIN activity (detailed on page 17) to theatres which we hope will provide ongoing
improvements and enhance the good work which is already evident, when looking back on the
previous year.
Quality Account 2014/15
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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 2014/15 the Boston West Hospital provided and/or subcontracted 9 NHS services.
The Boston West Hospital 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 1 April 2014 to 31 March 15 represents
95% of the total income generated from the provision of NHS services by the Boston West Hospital
for 1 April 2014 to 31 March 15
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 hospitals Senior Managers together with Regional and
Corporate Senior Managers and Directors. The balanced scorecard approach has been an
extremely successful tool in helping us to benchmark against other hospitals and identifying key
areas for improvement.
In the period for 2014/15, the indicators on the scorecard which affect patient safety and quality
were:
Human Resources
In 2014/15 our expectation was to continue to recruit to permanent positions and retain permanent
staff in order to continue to reduce the percentage of agency use. In 2013/14 our percentage use of
agency was 4.92%, in 2014/15 the percentage of agency costs was 9%. Long term sickness,
maternity leave, new starter induction and training contributed to lost hours. Staff hours worked per
hospital day were 14.9 and staff costs as a percentage of net revenue were 20%.
Levels of sickness saw a slight upturn in 2013/14. On review of the 2014/15 sickness saw a slight
decrease by 0.5%. We continue to work with our “Well Being Service” to support employees both in
the workplace and as part of a structured return to work service.
The total skill mix calculation for the Boston West Hospital was completed by reviewing the
contracted and bank hours for registered nursing staff and healthcare assistants. In the previous
Quality Account 2014/15
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financial year we planned to review the skill mix in the outpatient department based on a workforce
review that had been undertaken.

9 Registered Nurses caring for patients

4 Health Care Assistants caring for patients

1 Health Care Apprentice
The Boston West Hospital has a robust mandatory training program and regular monitoring of
training compliance is completed. This allows us to meet contractual obligations as well as ensuring
staff are compliant with requirement and can provide care competently.
The Senior Management team are pleased to announce that the implementation of the employee
engagement group has been positive and well received by the staff, proving a platform for staff to
drive change in the Hospital.
There were no (0) RIDDOR event(s) reported at the Boston West Hospital during this period.
Patient Services
The hospital reported 0.01% complaints per 1000 hospital patient days during 2014/15. The themes
and trends of the complaints are reviewed by the Clinical Governance Committee and Medical
Advisory Committee on a regular basis. Lessons learned from complaints are discussed in
departmental meetings to offer staff an opportunity to reflect on the complaint and collectively
discuss where improvements could be made. Ramsay also has an overarching view of governance
and provides feedback and benchmarking information to the Boston West Hospital on a regular
basis.
The Boston West Hospital utilise an external organisation to gather unbiased data from patients
about their experience and satisfaction with the services they have received. The data set is
released on a quarterly basis in addition to the Friends and Family.
The number of patients who required readmission following their discharge from hospital is
reviewed on a monthly basis. In percentage terms the readmission rate relates to 0% of our day
case stays during 2014/15. Feedback from our patients is important to us, based on the feedback
during 2014, we have maintained or made improvements with an average compliance score of over
90% in the following areas

Quality of Care

Friendly welcome on arrival to hospital

Cleanliness
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
Patients felt they were given enough privacy and dignity when being examined

Information on discharge
Ramsay also has two further patient feedback mechanisms the first being, “We Value Your Opinion”
which allows patients to comment on their stay at discharge. The patient completes a questionnaire
allowing free text for any comments or feedback. This feedback is reviewed by the Senior
Management Team and areas identified for improvement are considered. The second mechanism
is the “Hot Alert” this is a web based feedback questionnaire, allowing patients to comment on any
aspect of their stay. All “Hot Alerts” are reviewed by the General Manager and Matron, the patient
receives a written response based on their comment, to highlight any actions taken by the hospital
to make improvements to the services we offer.
Quality
Our annual workplace health and safety score was 97%.
The annual audit program is inclusive of reviewing infection prevention and control with periodic
audits looking at a range of infection prevention and control activities including hand hygiene,
isolation, surgical site surveillance, peripheral venous cannula care bundles, urinary catheter
bundles and infection control environmental audits.
The Boston West Hospital has a governance process which monitors significant clinical events.
During the period 2014/15 our overall percentage for reported significant events was 0% per 1000
hospital days.
2.2.2 Participation in Clinical Audit
During 1 April 2014 to 31 March 2015 Boston West Hospital participated in two (JAG & PROMS)
national clinical audits and one national confidential enquiries of the national clinical audits and
national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Boston West Hospital
participated in, and for which data collection was completed during 1 April 2014 to 31 March 2015,
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
Elective surgery (National PROMs Programme)
No cases
submitted
87
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The reports of one national clinical audits from 1 April 2014 to 31 March 11 2015 were reviewed by
the Clinical Governance Committee and Boston West Hospital intends to take the following actions
to improve the quality of healthcare provided.

Continue to improve the process around PROMs compliance for Hernia patients
Local Audits
The reports of 70 local clinical audits from 1 April 2014 to 31 March 2015 were reviewed by the
Clinical Governance Committee and Boston West Hospital. The Hospital intends to take the
following actions to improve the quality of healthcare provided. The clinical audit schedule can be
found in Appendix 2.
Feedback of audit results has been a focus of our work during 2014/15 ensuring findings and
results are shared with the wider team for learning and improvement. During 2014/15 we have seen
an improvement with our consent compliance.
The Boston West Hospital have departmental meetings and feedback is given to staff regarding
audit compliance, each audit that requires any improvement has an action plan attached.
The clinical team have a “topic of the week” notice board where key topics from governance
intelligence is shared and displayed, sharing the findings and lessons learned from audit.
2.2.3 Participation in Research
There were no patients recruited during 2014/15 to participate in research approved by a research
ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning
for Quality and Innovation) Framework
A proportion of Boston West Hospital’s income from 1 April 2014 to 31 March 2015 was conditional
on achieving quality improvement and innovation goals agreed by Boston West Hospital and any
person or body they entered into a contract, agreement or arrangement with for the provision of
NHS services, through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2014/15 and for the following 12 month period are available
below.
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Goal Name
Indicator Name
Friends &
Family Test
Early Implementation
NHS Safety
Thermometer
Dementia
Improve falls in
hospital
Find, assess and
investigate
Indicator Description

Implement the Friends & Family
recommendations tests to the outpatient
department

Increase the questionnaire response rate for
inpatient and daycase services

Maintain falls performance throughout 14/15

All patients >75 years old undergo a face to face
pre assessment, the proportion of patients
identified as potentially having dementia are
appropriately assessed and referred to a
specialist if required.
Nominate a named lead for dementia and
provide training and education to staff.
Ensure patients pain score is assessed in line
with a nationally recognized pain assessment
tool.
Ensure pain assessments are recorded in line
with policy and procedure

Pain
Management
Post-operative pain
management


2015/16 CQUIN Activity
Goal Name
Indicator Name
Indicator Description
Surgical
Safety
Surgical site infection
bundle
Reduce harm to patients by 
Removing hair around incision site

Reduce surgical site infections by ensuring
prophylactic antibiotics are given on time and
discontinued on time, during and after the operative
phase.

To maintain normal body temperature by ensuring that
a core temperature is recorded as per Ramsay policy

Maintain normal serum glucose in known diabetics
and avoiding surgery

Ensure a team brief and debrief is completed prior to
and after the theatre list
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
Safety Culture assessment for surgical team
2.2.5 Statements from the Care Quality Commission (CQC)
Boston West Hospital is required to register with the Care Quality Commission and its current
registration status on 31 March 2015 is registered without conditions.
Boston West Hospital has not participated in any special reviews or investigations by the CQC
during the reporting period.
2.2.6 Data Quality
The annual audit program reviews the quality of our data via clinical systems together with medical
and paper records.
In 2015/16 a key goal is to improve the process regarding the capture of patient data



Produce a quality dashboard to review key KPI’s and Governance issues via a traffic light
system and report by exception
Review and improve the PROMS data collection process to ensure all patients eligible to
participate in the questionnaire are provided with a questionnaire.
Continue to provide comprehensive reports regarding activity to the Medical Advisory
Committee and Clinical Governance Committee which are supported by clinical audit.
NHS Number and General Medical Practice Code Validity
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2014/15 to the Secondary Users Service for inclusion
in the Hospital Episode Statistics which are included in the latest published data. The percentage of
records in the published data included:
The patient’s valid NHS number:
 99.97% for admitted patient care;
 99.96% for outpatient care; and
 Accident and emergency care N/A (as not undertaken at Ramsay hospitals).
The General Medical Practice Code:
 100% for admitted patient care;
 100% for outpatient care; and
 Accident and emergency care N/A (as not undertaken at Ramsay hospitals).
Quality Account 2014/15
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Information Governance Toolkit Attainment Levels
Ramsay Group Information Governance Assessment Report score overall for 2014/5 was 75% and
was graded ‘green’ (satisfactory).
This information is publicly available on the DH Information Governance Toolkit website at:
https://www.igt.hscic.gov.uk
The Boston West Hospital successfully passed the ISO Information Governance Audit (27001) during
2014/15.
Clinical Coding Error Rate
Boston West Hospital was subject to the Payment by Results clinical coding audit during 2014/15,
by the Audit Commission. The results are shown in the table below; no concerns were raised in
relation to coding error rates during the audit.
Hospital Site
Audit
Date
Next Audit
Date
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
Boston NHS TC
Jan 14
April 15
98.28%
91.96%
93.10%
97.78%
Quality Account 2014/15
Page 21 of 42
2.2.7 Stakeholders Views on 2014/15 Quality Account
NHS South Lincolnshire CCG Commentary for Ramsay Boston West Hospital
Quality Account 2014/15
NHS South Lincolnshire CCG’s main priority is to ensure that services are safe and of a high
quality. The Boston West Quality Account highlights areas of service that demonstrate high quality
care using the three key areas of effectiveness, safety and patient experience. As part of the
national CQUIN for last year Boston West Hospital achieved the early implementation of the
Friends and Family Test in the outpatient department and the hospital exceeded the 98% VTE risk
assessment goal set for 2014/15 with 100% of patients being risk assessed. Further, to enhance
patient safety during 2014/15, additional work was undertaken to update the Early Warning System
to reflect national guidance and this was again supported with a comprehensive training package
and compliance checks to ensure the clinical process was embedded.
The focus on high quality clinical care and patient experience is welcomed by the CCG and the
additional commitment to quality through the development of the shared Quality Improvement
Manager during 2014/15 is supported. The CCG has conducted a review visit to the hospital during
2014 and there were a number of areas of good practice noted including demonstrable learning
from incidents.
South Lincolnshire CCG notes that the Boston West Hospital is required to register with the Care
Quality Commission and its current registration status on 31 March 2015 has no restrictions. The
Care Quality Commission has not undertaken any enforcement action against Boston West since
its registration.
South Lincolnshire CCG can verify that Ramsay Boston West Hospital has reported against all the
mandated statements within the Quality Account where data is available.
In terms of performance against the CQUIN scheme for 2014/15 Boston West Hospital fully
achieved the following:





Friends and Family Test
NHS Safety Thermometer
Dementia - Find, Assess, Investigate and Refer
Pain Management
Early Warning Score – Compliance
The CCG endorses the areas identified for improvement for 2015/16 and the associated initiatives
as detailed within the Ramsay Boston West Account in particular the development of a consultant
newsletter to support the sharing of best practice and lessons learned . The CCG notes the CQUIN
scheme this year will continue to maintain emphasis on patient safety through the implementation of
National Patient Safety Agency ‘five steps to safer surgery’.
Quality Account 2014/15
Page 22 of 42
The South Lincolnshire CCG CQUIN scheme for 2015/16 will consist of the following:


Implementation of Surgical Site Infection Bundle
o To reduce harm to patients by removing hair around incision site using correct
intervention
o To reduce surgical site infection by ensuring that prophylactic antibiotics are given
on time and discontinued on time.
o To maintain normal body temperature by ensuring that a core temperature is
recorded as per Ramsay policy
o Maintain normal serum glucose in known diabetics and avoiding surgery
Surgical Team Communication and Safety Culture Assessment
South Lincolnshire CCG endorses the accuracy of the information presented within the Ramsay
Boston West Quality Account and the overall quality programme performance will be reviewed
through the formal contract quality review process and triangulation through patient experience
surveys.
Statement on Boston West Hospital
Ramsay Health Care Quality Report for 2014/15
This statement has been made behalf of Healthwatch Lincolnshire. We are pleased to have been asked by
Boston West Hospital to contribute to the Quality Account; however given that this is our first account with
Ramsay Health Care we feel it only pertinent to comment in the broadest way, due to time constraints we
have not had opportunity to discuss more fully, a review of last year’s priorities or the forthcoming years
areas of focus and development. We found the report well produced and is easy to understand, this is
critical when communicating and engaging with the general public, however we would ask that wherever
possible Ramsay Health Care does not use abbreviations wherever possible. (NVC27 means nothing to the
lay reader and only confuses)
Priorities for 2015-16
Healthwatch Lincolnshire support the 3 priorities for 2015/16. However we would liked to have seen a
greater explanation of how Ramsay Health involved partners and members of the public in developing these
priorities, however we have no reason to believe there are any gaps within the priorities for this forthcoming
year.
Quality Account 2014/15
Page 23 of 42
Priorities for 2014-15
We acknowledge the work and progress made with priorities for 2014/15 and would hope to be assured that
although targets were achieved, they will continue to be regularly reviewed to maintain the standards
achieved in 2014/15
Finally it is noted that independent patient experience feedback from Healthwatch Lincolnshire given to
Ramsay has always been received in a positive and proactive manner and where appropriate patient views
have influenced change. We welcome and support Ramsay in proactively seeking feedback from patients
both internally and externally.
Healthwatch Lincolnshire look forward to continuing engagement with the Ramsay Health Care, and its
continued improvement in the services provided to patients.
(This was a joint statement on behalf of Healthwatch and Health Scrutiny Committee for Lincolnshire)
Boston West Hospital Patient Participation Group (PPG) Comments on Quality
Account 2014 15
“I thought it was a very comprehensive report with excellent information for whoever
needs to know that amount of detail on the hospital” (PPG Representative)
Quality Account 2014/15
Page 24 of 42
Part 3: Review of Quality Performance 2013/2014
Statements of Quality Delivery
Matron, Sue Harvey
Review of Quality Performance 1 April 2014 - 31 March 2015
Introduction
“This publication marks the sixth 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.”
(Vivienne Heckford, Director of Clinical Services, Ramsay Health Care UK)
Ramsay Clinical Governance Framework 2015
The aim of clinical governance is to ensure that Ramsay develop ways of working which assure that
the quality of patient care is central to the business of 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.
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.
Quality Account 2014/15
Page 25 of 42
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
National Guidance
Ramsay also complies with the recommendations contained in technology appraisals issued by the
National Institute for Clinical Excellence (NICE) and Safety Alerts as issued by the NHS
Commissioning Board Special Health Authority.
Quality Account 2014/15
Page 26 of 42
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. The Boston West
Hospital review all National Guidance released from the National Institute of Clinical Excellence at
the Medical Advisory Committee, all guidance releases from Ramsay are also issues to the
Consultant Body to ensure they are aware of recent releases and requirements.
3.1 The Core Quality Account indicators
All acute hospitals are required to report against the indicators below as part of the Quality Account.
Boston West Hospital have only included indicators relevant to the services provided by the
hospital.
Data sets are routinely submitted to NHS and Non-NHS bodies via the Health and Social Care
Information Centre, a comparison of the numbers, percentages, values, scores or rates of the NHS
Trust and non-NHS bodies (as applicable) are included for each of those listed in the tables below.
NVC27 is the code used for Boston West Hospital on the data information websites.
Mortality
The table below shows the Mortality data, the latest data release from the Health & Social Care
Information Centre (HSCIC) the mortality data is a Summary Hospital-level Mortality Indicator
(SHMI). The figures below have been extracted from the most recent data sets available. The data
submission is to prevent people from dying prematurely and enhancing quality of life for people with
long-term conditions as part of the NHS outcomes framework.
Period
Jan13-Dec13
Apr13-Mar14
Best
RKE
RKE
0.62
0.54
Worst
RXL
1.18
RBT
1.20
Average
Eng
1
Eng
1
Period
2013/14
2014/15
Boston West
NVC27
0
NVC27
0
The Boston West Hospital considers the data is a true reflection of activity.
Patient Reported Outcome Measures (PROMS)
The information in the table below shows reviews data in relation to helping people to recover from
episodes of ill health or following injury. The domain reviews patients feedback and the measure is
the adjusted health gain described by the patient. The HSCIC data for PROMS includes private
providers, with the most recent data release covering the period April 2013 – March 2014.
Hernia
Period
Apr13 - Mar14
Apr14 - Sep14
Best
NT415
0.139
RXR
0.125
Worst
NVC11
0.008
Several
0.009
Average
Eng
0.085
Eng
0.081
Period
Apr13 - Mar14
Apr14 - Sep14
Boston West
NVC27
0.135
NVC27
*
Quality Account 2014/15
Page 27 of 42
The Boston West Hospital continually review the PROMS process at hospital level to increase
patient participation and ensure the process is capturing the patient data at pre assessment.
Further work is required to engage and communicate with patients regarding the NHS outcome
measure.
Varicose Veins
Period
Apr13 - Mar14
Apr14 - Sep14
Best
RTH
RYJ
11.292
-4.567
Worst
NT350 -16.849
RWA
-16.762
Average
Eng
-8.698
Eng
-9.479
Period
Apr13 - Mar14
Apr14 - Sep14
Boston West
NVC27
*
NVC27
*
There has been insufficient returns to pull benchmarking data from the PROMS submission, due to
the low activity in this area.
Further work is required to engage and communicate with patients regarding the NHS outcome
measure.
Readmissions
The table below shows the data set reviewing patients aged 16 or over, who were readmitted to
hospital within 28 days of being discharged. The latest data sets available from SUS have been
reported on for this quality account.
Period
2010/11
2011/12
Best
Multiple
0.0
Multiple
0.0
Worst
5P5
22.76
5NL
41.65
Average
Eng
11.43
Eng
11.45
Period
2010/11
2011/12
Boston West
NVC27
0
NVC27
0
The Boston West Hospital considers the data is as described for the following reasons:



Readmissions are below the national average and could be attributed to good standards of
clinical care and treatment preventing readmission.
Patients could also choose to represent at another provider
Patients are provided with key information at the point of discharge about care services
following their procedure.
The Boston West Hospital will continue to provide patients with support with aftercare advice and
encourage patients to return where clinically indicated.
Responsiveness
This data set looks at the positive experiences of care provided by Boston West Hospital. The data
has been extracted from the Care Quality Commissions inpatient survey. The latest data release
form the CQC has been reported, no data set was made available for independent sectors for this
reporting period.
The Boston West Hospital reviewed their feedback mechanisms in 2014/15 ensuring all feedback
which comes via the hospital patient feedback forms is acted upon and the patient is provided with
Quality Account 2014/15
Page 28 of 42
a written acknowledgement of the issues raised. We will continue to listen and act upon feedback
to improve responsiveness score despite exceeding the national average, as patient feedback is
vital in enabling the hospital to make improvements to the services offered to patients.
VTE Assessment
The VTE assessment domain reviews data to see if patients are being treating and cared for in a
safe environment and are being protected from avoidable harm. The data looks at all patients who
have had an adequate risk assessment prior to admission in relation to the prevention of postoperative VTE events.
Period
14/15 Q2
14/15 Q3
Best
Several
100%
Several
100%
Worst
RNL
86.4%
NT322
85.1%
Average
Eng
96.2%
Eng
96.0%
Period
14/15 Q2
14/15 Q3
Boston West
NVC27
98.8%
NVC27
99.7%
The data shows the Boston West Hospital as exceeding national benchmarking data, with
consistent performance.
The VTE management of patients post operatively has been reviewed via periodic audits during
2014/15, to ensure the best possible care is being delivered to patients, during 2013/14 postoperative assessments were introduced. Any changes to the treatment plan are noted and
documented, treatment is then provided in accordance with the post-operative assessment, to
mitigate patients from any avoidable harm.
C-Difficile Rates
The table below highlights the C-Difficile rates for the reporting period 2013/14 with a comparison
available for the previous year.
Period
2012/13
2013/14
Best
Several
Several
0
0
Worst
RVW
30.8
RMP
32.5
Average
Eng
17.4
Eng
14.7
Period
2012/13
2013/14
Boston West
NVC27
0.0
NVC27
0.0
From the data Boston West Hospital are amongst the best performing organisations in the country
for C-Difficile rates
The Hospital considers the data described as the scores show consistent practice in pre
assessment procedures. The antibiotic local policy to access antibiotic use in patients who access
our services from a residential setting was implemented in 2014/15, the results show the policy has
been well supported throughout 2014/15, maintaining a 0% rate in C-Difficile cases.
The scores reflect good practice from clinical staff in the ability to isolate patients which required,
promoting good infection control processes. The Boston West Hospital intends to continue its
current practice to remain one of the best performing hospitals for their C-Difficile rates.
Quality Account 2014/15
Page 29 of 42
Friends & Family Test
The NHS domain for the Friends and Family tests aims to seek the opinion of service users;
ensuring patients have a positive experience of care.
Period
Jan-15
Feb-15
Best
Several
100%
Several
100%
Worst
RPA02
51.2%
RHU10
75%
Average
Eng
94.0%
Eng
94.7%
Period
Jan-15
Feb-15
Boston West
NVC27 100.0%
NVC27
99.3%
The Boston West Hospital considers the data to be as described. The hospital places great
emphasis on patient satisfaction and the friends and family test encompasses this. There has been
consistent outstanding performance in patient satisfaction during the period of data analysis. This
is supported by the overall scores as Boston West Hospital is performing above the national
benchmark for patient satisfaction.
The Boston West Hospital aim to continue its commitment in ensuring patients have a positive
experience when they visit hospital and aim to build on the positive results experienced in 2014/15
during 2015/16 to maintain 100% patient satisfaction.
3.2 Patient Safety
We are a progressive hospital and focussed on improving our performance in all aspects of the
business, with a focus on 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
key performance indicators.
3.2.1 Infection Prevention and Control
Boston West Hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 4 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. At Boston West
Hospital, this is demonstrated with our higher than average performance against national
benchmarking data.
Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint
surgery and these are also monitored.
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.
Quality Account 2014/15
Page 30 of 42
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 Boston West Hospital have a dedicated Infection Control Nurse who is responsible for
the delivery of the Ramsay annual strategy for infection control. The annual plan is
inclusive of training, audit, surveillance and screening programmes.
Discussion of infection activity at the Infection Prevention and Control Committee, key
items from the meeting are further disseminated through the medical advisory committee
and clinical governance committee.
A specific training module in respect of infection prevention and control is delivered on our
induction programs, mandatory training and via an e-learning package, staff are required to
be 100% compliant with their training.
The dedicated infection control nurse attends the annual infection control and prevention
conference to update on current practice and policy in relation to infection.
The graph below shows the infection rates as a total percentage of the Boston West Hospital
admissions. The graph demonstrates a 0.23% reduction in infections from the previous year.
The decrease in infection rates could be attributed to better reporting of confirmed infections. In
comparison to the national average the Boston West Hospital are performing above national
benchmarks, demonstrating the infection prevention and control measures in place are effective.
We aim to build on our positive work carried out in 2014/15 and progress this into 2015/16.
Quality Account 2014/15
Page 31 of 42
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 Boston West Hospital, providing us with a patient’s eye
view of the buildings, facilities and food we offer, giving us a clear picture of how the people who
use our hospital see it and how it can be improved.
The main purpose of a PLACE assessment is to get the patient view. The graph below shows
the patient feedback from the most recent audit completed in 2014/15.
Our 2014 PLACE highlighted a number of actions which we have now been implemented to
improve the environment for our patients. The actions we have taken include a drop off point in
the car park near the main entrance, a programme of redecoration, new seating and air
conditioning in the patient waiting area, additional wheelchairs have been purchased for patient
use and a new drinks machine has been placed in the patient waiting area, providing free hot and
cold beverages for patients and visitors.
The focus of PLACE in 2015 was to further develop a dementia friendly environment, with this in
mind we have created better colour contrast in our patient toilets, installed dementia friendly
signage and included large faced clocks, calendars and location signs in our pre-operative and
recovery areas.
Quality Account 2014/15
Page 32 of 42
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, by having no (0) accidents per 1000
admissions, demonstrates the effectiveness 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 we keep up to date with all safety issues.
During 2014/15 we completed a number of safety initiatives:






Risk reporting training program delivered to staff at both mandatory training and induction
Governance information within each department highlighting incidents, safety alert and
policy updates
Lessons learned sessions with Theatre from adverse events within the Ramsay Group
Regular meetings undertaken by the Hospital Health and Safety Committee to ensure
robust systems are in place for the monitoring and review of safety issues.
Multiple updates to key staff relating to drugs/equipment/policy changes and updates
Policy updates issued on a monthly basis to ward staff
3.3 Clinical Effectiveness
The Boston West Hospital undertakes regular thematic reviews in relation to their governance and
audit activity. Regular national audits are undertaken to enable performance to benchmark against
national parameters (as described in section 3.1 of this report.)
The National Institute of Clinical Excellence (NICE) guidance information is reviewed locally on a bi
monthly basis at the Medical Advisory Committee, to ensure clinicians are aware of the latest
national guidance to provide safe and effective care and treatment.
To ensure governance processes and activity is reviewed the Clinical Governance Committee meet
bi-monthly to review all aspects of governance and policy to provide a robust review.
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
Quality Account 2014/15
Page 33 of 42
surgical intervention carries a risk of complication therefore 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 specific surgical team. Ramsay’s rate of return is very low consistent with our track
record of successful clinical outcomes.
The graph below shows the Boston West Hospital’s return to theatre performance comparing the
last 3 financial years activity. The graph shows the Boston West Hospital currently have a 0.02%
return to theatre rate.
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
Local Governance Committees for discussion, trend analysis and further action where necessary.
Escalation and further reporting to Ramsay Corporate and DH bodies occurs as required and
according to Ramsay and DH policy.
Quality Account 2014/15
Page 34 of 42
Feedback regarding the patient’s experience is encouraged in various ways via:













Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web survey
Yearly CQC patient surveys
Friends and family test questions asked at point of discharge
‘We Value Your Opinion’ leaflet – local patient feedback mechanism
Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst
visiting patients
Provider/CQC visit feedback.
Written feedback via letters/emails
Patient & Public Involvement Group
PROMs surveys
Healthwatch patient feedback
NHS Choices website
Care pathways – patients are encouraged to read and participate in their plan of care and have
the opportunity to document their experience prior to discharge.
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 patient’s views.
Every patient (inpatient or outpatient) is asked their consent to receive an electronic survey or
telephone call after they leave 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 48 hours of receiving them so
that a response can be made to the patient as soon as possible.
The graph below shows the patient satisfaction index scores for the last 2 financial years.
Quality Account 2014/15
Page 35 of 42
As the number of patients we see and treat at Boston West Hospital grows year on year ensuring
we maintain high levels of patient satisfaction is important to the entire team and is an ongoing
priority. The hospital is committed to an ongoing training program delivered in house regarding
customer service, staff continue to be recognised through a reward program for exceptional levels
of customer service.
During 2015/16 we aim to ensure our feedback remains above 98% satisfaction and will continually
review the themes and trends identified by our patients, to promote good practice and make any
improvements where necessary. Feedback to staff about what our patients say about the services
we offer will be an area of focus during the coming year at team meetings, to allow staff the
opportunity to reflect on patient’s experience and make positive change.
Quality Account 2014/15
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3.5 Boston West Hospital Case Studies
Case Study 1 – Patient information leaflets on medication side effects
Based on patient feedback Boston West
Hospital wanted to improve their patient
satisfaction scores with regards to patients
receiving information on discharge medications.
The Hospital developed a range of information
leaflets for their most common medication
prescribed on discharge. These leaflets are now
provided to all patients during the discharge
process. Included is a copy of the Naproxen
medication leaflet as an example.
The dissemination of the new information
leaflets has resulted in patients feeling 100%
satisfied with information provided to them on
discharge about medication side effects to
watch out for. This is a significant increase in
our patient satisfaction score for this measure
from 33% to 100%, demonstrating the
effectiveness of these leaflets.
Due to our success, the use of the leaflets have
now been rolled out to all Ramsay Hospitals.
Case Study 2 – JAG Re-accreditation
Boston West Hospital was the very first Private Hospital in the country to achieve JAG (Joint
Advisory Group) accreditation back in February 2009 for our Gastro Intestinal (GI) Endoscopy
Services. We have maintained our JAG status throughout since that date to present, consistently
achieving level A in all measures of the 3 relevant GRS (Global Rating Scale) domains – Clinical
Quality, Quality of the Patient Experience and Workforce, submitting our web based GRS census
online annually in April and our Annual Report Card in October each year for review and approval
by the JAG office. The GRS is a tool that enables units to assess how well they provide a patientcentred service.
In October 2014 we had a full day inspection by a JAG assessment team, which happens every 5
Quality Account 2014/15
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years. We were very proud of the outcome of this visit, achieving an outright pass for JAG reaccreditation for a further 5 years. This was the result of a lot of hard work, commitment and
dedication of the whole team. Extracts of the final inspection report are shown below:
“To be congratulated on:
The service have a substantive Clinical Lead who, with
the Matron and Service Manager, have established
excellent systems for open sharing of clinical
information and the development of endoscopists with
the NHS Trust.
There are excellent processes in place for supporting and
advising patients post discharge.
There is excellent communication both between the
clinical teams and the management of the hospital. Staff
feel happy, have high morale and feel well supported to
provide a quality service.”
Mr Viktor Csok, Consultant General Surgeon and
Clinical Consultant Lead for JAG at Boston West
Hospital
.
Quality Account 2014/15
Page 38 of 42
Appendix 1
Services covered by this Quality Account

Orthopaedic

Ophthalmology

General Surgery

Pain Management

Gynaecology

Gastroenterology

Urology

Physiotherapy

Cosmetic Surgery

ENT
Quality Account 2014/15
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Quality Account 2014/15
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Glossary of Abbreviations
ACCP
AIM
ALS
CAS
CCG
CQC
CQUIN
DDA
DH
EVLT
GP
GRS
HCA
HPD
H&S
IHAS
IPC
ISB
JAG
LINk
MAC
MRSA
MSSA
NCCAC
NHS
NICE
NPSA
NVC27
ODP
OSC
PEAT
PPE
PROM
RIMS
SAC
SMT
STF
SUI
TLF
ULHT
VTE
American College of Clinical Pharmacology
Acute Illness Management
Advanced Life Support
Central Alert System
Clinical Commissioning Group
Care Quality Commission
Commissioning for Quality and Innovation
Disability Discrimination Audit
Department of Health
Endovenous Laser Treatment
General Practitioner
Global Rating Scale
Health Care Assistant
Hospital Patient Days
Health and Safety
Independent Healthcare Advisory Services
Infection Prevention and Control
Information Standards Board
Joint Advisory Group
Local Involvement Network
Medical Advisory Committee
Methicillin-Resistant Staphylococcus Aureus
Methicillin-Sensitive Staphylococcus Aureus
National Collaborating Centre for Acute Care
National Health Service
National Institute for Clinical Excellence
National Patient Safety Agency
Code for Boston West Hospital used on the data information websites
Operating Department Practitioner
Overview and Scrutiny Committee
Patient Environmental Action Team
Personal Protective Equipment
Patient Related Outcome Measures
Risk Information Management System
Standard Acute Contract
Senior Management Team
Slips, Trips and Falls
Serious Untoward Incident
The Leadership Factor
United Lincolnshire Hospitals Trust
Venous Thromboembolism
Quality Account 2014/15
Page 41 of 42
Boston West 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 Number01205 591860
Hospital websitewww.bostonwesthospital.co.uk
Boston West Hospital,
Boston West Business Park,
Sleaford Road,
Boston,
Lincolnshire.
PE21 8EG
Quality Account 2014/15
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