Cobalt Hospital
Quality Account
2014/15
Contents
Welcome to Ramsay Health Care UK
4
Introduction to our Quality Account
5
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
6
1.2
Hospital accountability statement
8
PART 2
2.1
Priorities for Improvement
10
2.1.1 Review of clinical priorities 2014/15 (looking back)
10 - 12
2.1.2 Clinical Priorities for 2015/16 (looking forward)
12 - 14
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
15 - 16
2.2.2 Participation in Clinical Audit
16 - 17
2.2.3 Participation in Research
17
2.2.4 Goals agreed with Commissioners
17
2.2.5 Statement from the Care Quality Commission
17
2.2.6 Statement on Data Quality
18
2.2.7 Stakeholders views on 2015/16 Quality Accounts
19
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
20 - 25
3.2
Patient Safety
25 - 28
3.3
Clinical Effectiveness
28 - 29
3.4
Patient Experience
30 - 31
3.5
Case Study
32
Appendix 1 – Services Covered by this Quality Account
33
Appendix 2 – Clinical Audits
34
Welcome to Ramsay Health Care UK
Cobalt 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
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs and Clinical
Commissioning Groups.
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 out
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.
Mark Page
Chief Executive officer
Ramsay Health Care UK
Quality Accounts 2014/15
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Introduction to our Quality Account
This Quality Account is Cobalt 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.
Quality Accounts 2014/15
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Part 1
1.1 Statement on quality from the General
Manager
“Cobalt Hospital is committed to being a leading provider of outpatient,
diagnostic and day case services by delivering high quality outcomes
and an excellent patient experience.”
I am delighted to introduce our Quality Account for 2015/16 which demonstrates
our commitment to delivering high quality care. The report focuses upon our
performance over the last year and describes our priorities for 2015/16.
Our approach to quality is having in place a robust framework which enables us
to monitor and measure outcomes and experience, using this information to drive
further improvement in patient safety, patient experience and clinical outcomes.
Our team is at the forefront of delivering a quality service. “ People caring for
people” remains our philosophy and we are committed to training and developing
our workforce and ensuring attitudes and behaviour aligned to our values.
2014/15 has been a successful year with a wider number of GPs referring to our
services and an increased number of patients choosing to access our hospital.
Our mission remains, to be expert in delivering elective day case services
to patients in our local community and beyond, delivering services we would be
happy to receive ourselves. We have had our commitment to quality recognised
this year in a number of key achievements:
 The number of patients who have taken time to enter reviews on NHS
choices and it is particularly pleasing to see that the hospital has an overall
5 star rating
 In addition, all of our patient feedback mechanisms show consistently high
satisfaction
 We meet all CQC standards
 Only four complaints received in the last 12 months
 Maintaining Joint Advisory Group (JAG) accreditation for endoscopy
services
.
Quality Accounts 2014/15
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Despite these accolades we are not complacent and our priorities for 2015/16 are
focused upon ensuring continuous improvement, creating services centred
around the patient, getting it right first time and putting patient safety at the heart
of everything we do.
Donna Thornton
General Manager, Cobalt Hospital
Quality Accounts 2014/15
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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.
Donna Thornton
General Manager
Cobalt Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Peter Hodgkinson Medical Advisory Group Chair
Alex Clason Clinical Governance Committee Chair
Helen White Regional Director
North Tyneside CCG on behalf of Newcastle Gateshead CCG Alliance and
Northumberland CCG
Quality Accounts 2014/15
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Welcome to Cobalt Hospital
Cobalt Hospital, formally Cobalt Treatment Centre, was built in 2005 and is a
modern, purpose-built unit designed for the diagnosis, assessment and treatment
of conditions on a day case basis for adults aged 18 years and over. The hospital
is a single level building comprising of a modern and airy reception area, an
outpatient unit with a suite of consulting rooms and a surgical unit housing two
theatres and dedicated recovery areas. Located within the Cobalt Business Park
there is ample free car parking, good public transport links and easy access to
main road networks.
Cobalt Hospital currently provides NHS services for the following specialties: GI
endoscopy, general surgery, orthopaedics and plastic surgery. Patients who self
pay or have private medical insurance are seen under our Premium Care scheme
for the following specialties: cosmetic surgery, GI endoscopy, general surgery,
orthopaedics and plastic surgery.
North of Tyne Clinical Commissioning Group were our lead commissioner of
NHS Services for 2014/15, on behalf of neighbouring clinical commissioning
groups, with regular service review meetings held to discuss performance.
Patients were referred and travelled from Northumberland, North Tyneside,
Newcastle, Sunderland, South Tyneside and Gateshead.
Referral to the hospital for NHS services is direct from GP via Choose and Book
and we have dedicated Choose and Book Co-ordinators and a GP Liaison team
to facilitate the referral process. We hold regular Choose and Book workshops at
the hospital inviting medical secretaries from local GP practices. These events
give an opportunity to tour the facilities and experience the ‘patient pathway’ first
hand.
This year saw over 4400 patient procedures at Cobalt Hospital with a breakdown
of work being 96% NHS patients and 4% private patients. In terms of workforce
there are 40 members of staff employed at Cobalt Hospital, a mix of full time and
part time, of which 53% are clinical posts and 47% support staff.
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Part 2
2.1 Quality priorities for 2015/2016
Plan for 2015/16
On an annual cycle, Cobalt 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)
Surgical Safety Checklist – There were no Never Events’ in the period at Cobalt
Hospital. Quarterly audits of the WHO surgical safety checklist continued with
100% compliance demonstrated. A WHO training DVD was produced by Ramsay
and this was shared with all clinical and medical staff demonstrating a gold
standard approach to the process.
VTE risk assessment – We audited our compliance and results were submitted
to UNIFY and national health data base. The results confirm that more than 98%
of patients were risk assessed where indicated. However additional quarterly
audits of ten random patient records showed some poor compliance in accuracy
in documentation by medical staff with scores ranging from 64% to 87%.
Consultants were identified and additional training given with improvement targets
Quality Accounts 2014/15
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set. Audit results were reviewed at Clinical Governance and Medical Advisory
Committees with poor practice identified and action plans for improvement
supported by the committee chairs. Compliance continues to be a focus both at a
local and national level with the Group Medical Director leading expectations in
terms of the clinicians across the Ramsay Group.
Staffing – Electronic rostering tool ‘Allocate’ has been in use since February
2014 and supports an annualised hours approach to managing staffing hours
allowing flexibility for both the service and staff. The staff satisfaction survey is
completed biannually and a staff engagement group was formed to review the
results from the end of 2013. Overall feedback was very positive with staff
endorsing Cobalt Hospital as a great place to work. An action plan was developed
and included the introduction of an improved induction program for new staff,
regular team briefs by department heads and a social events calendar to
encourage team building across the hospital. Staff have continued to utilise the
Ramsay Academy to develop skills and knowledge in their field. We have
increased the number of Health Care Assistant (HCA) within the endoscopy
department with HCAs completing competency assessments in decontamination
and day case pathways. The Team Leaders have all completed a heads of
department development program specifically tailored to identified learning
needs; this was completed over a six month period with excellent feedback.
Clinical effectiveness
Maintaining Endoscopy Standards – Following successful JAG (Joint Advisory
Group on Gastrointestinal Endoscopy) accreditation in 2013 annual submission to
GRS (Global Rating Score) was completed at the end of March 2015 with 99% of
standards at level A and the remaining 1% at level B. This tool enables us to
assess how well we provide a patient-centered service. Demonstrating
compliance against the four domains:
clinical quality
quality of patient experience
workforce
training
We hold quarterly endoscopy user group meetings with medical and clinical
representation and annual patient representation to ensure our patient’s views on
the service are heard. In the annual endoscopy patient survey 50% of patients
rated their care as excellent, 33% very good and 17% good and 100% of patients
confirmed they would recommend the service to friends and family.
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Patient experience – informing patient choice
Patient satisfaction survey – We continue to encourage patients to provide
feedback using our web based satisfaction survey in a bid to improve our average
response rate of 46%. Overall satisfaction rates remain high at 96.6% with 100%
of patients likely to recommend the hospital to friends and family. Patients who
choose to give individual feedback do so via a ‘hot alerts’ section in the
questionnaire and this feedback has been reviewed by the General Manger and
Matron as well as the lead CCG and action taken where there are areas identified
for improvement. A trend in poor communication of delays in endoscopy was
identified this year and an improvement plan put in place, this will also be a focus
for a CQUIN scheme in 2015-16 to ensure improvements are made. All ‘hot
alerts’ have been shared with the whole team along with a monthly patient
satisfaction dashboard. We continue to monitor posts on NHS choices and are
pleased to have retained our five star rating.
Friends and Family Test - This national CQUIN indicator was met with early
implementation of F&F in outpatients and day case departments achieved ahead
of the target date of 31st October 2014. Patients have been invited to complete a
paper questionnaire at the end of their hospital visit and many have included
additional comments on their experience. A monthly report is generated and
shared with all staff and where individual team members are named in a patient
comment a customer service nomination is made in line with the customer service
excellence program. Our response rates have been low and an action plan to
improve by modifying the process for requesting and encouraging patients to
complete is ongoing with both clinical and administration teams. The average
recommendation rate for day case is 96% and 86% for outpatients. The lower
score for outpatients is affected by low participation rates.
Patient comments:
‘One of the best hospitals I have visited. Quick, clean, professional with good
access and excellent staff from reception to consultancy and bookings’
‘Highly impressed at all visits and consultations’
‘Fantastic customer service, really helpful, highly recommend the staff and facility’
‘Second visit to Cobalt, always clean, efficient, friendly 10/10’
‘Quick, efficient and friendly’
Patient reported outcome measures studies (PROMS) – We continued to
monitor patient response rates as part of a local CQUIN indicator with a
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graduated quarterly target to achieve 75% compliance by March 2015. We have
exceeded this target each quarter with quarterly response rates ranging from 93%
to 100%. This improvement on previous years is as a result of the surgeon
ensuring patients are fully informed and inviting patients to take part in the survey
by completing a questionnaire prior to their surgery.
2.1.2 Clinical Priorities for 2015/16 (looking forward)
For 2015-16 Cobalt Hospital will strive to continue delivering a safe, high
quality experience for all patients. In particular we will focus on:
Patient Safety
VTE risk assessment – We will continue to audit our compliance and submit our
results to UNIFY and national health data base. Additional quarterly audits of
compliance with accuracy of documentation by medical staff will be a focus to
ensure improvements are made with an improvement target set of 95%
compliance.
Care of the deteriorating patient – Audit of compliance with Ramsay policy
identified some training needs in September 2014 which were addressed with all
registered staff completing AIM training and additional training for HCAs in
recognition of the deteriorating patient and documentation requirements. A further
audit in March 2015 identified some examples of poor documentation in
completion of the EWS chart. Additional training and supervision of nonregistered
staff has been put in place and we plan to carry out quarterly audits of compliance
in the next year to ensure improvements are made.
Staff training – We will continue to ensure good levels of compliance with
mandatory training to ensure that patients are cared for by well trained,
competent staff. As part of our CQUIN indicators we are committed to 100% of
our staff completing PREVENT training to ensure they are well placed to support
and protect vulnerable people who could be at risk of radicalisation whilst
receiving NHS care.
Patient Experience
We will continue to work hard to ensure that those who use our service have a
positive experience. We will monitor this through ratings in the patient satisfaction
survey and national ‘Friends and Family’ test for both day case and outpatient
services. We will focus on improving response rates in both surveys and
maintaining the overall level of satisfaction at greater than 90% as well as
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maintaining recommendation rates of over 90%.
As part of our CQUIN indicators we will ensure improvements are made in
communication of unavoidable delays to waiting endoscopy patients. A trend has
been identified in feedback given via ‘hot alerts’ completed within the patient
survey this year. An action plan and improvement targets will be set and reported
at quarterly CCG contract meetings.
Clinical effectiveness
We will be recruiting a Quality Improvement Lead in June 2015 who will ensure all
audits are undertaken in a timely manner and who will implement new systems
where the requirement arises to improve levels in both participation and results.
We will be able to monitor our improvement using statistical evidence. This
priority will support improvement within the domains of patient safety and clinical
effectiveness.
Progress against all of these priorities will be monitored by the Senior
Management Team and reported to our local Clinical Governance and Medical
Advisory Committees.
Quality Accounts 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 Cobalt Hospital provided NHS services across four specialties.
Cobalt 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 31st
March 15 represents 100 per cent of the total income generated from the
provision of NHS services by Cobalt Hospital for 1 April 2014 to 31st 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 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 Resource
Staff Cost % Net Revenue
16.3%
HCA Hours as % of Total Nursing
Agency Cost as % of Total Staff Cost
Admitted Care Hours Worked PPD
Staff Turnover
Sickness
Lost Time
Appraisal %
Mandatory Training %
23%
0.0016%
4.19
17.1%
4.37%
18%
85%
80%
Staff Satisfaction Score
Biannual survey
2013-14 score
4.46
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Number of Significant Staff Injuries
Patient
Formal Complaints in year
Patient Satisfaction Score
Significant Clinical Events
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
No significant staff
injuries
4
96.6%
1 – level 2
1reported
94%
2.2.2 Participation in clinical audit
The national clinical audits and national confidential enquiries that Cobalt Hospital
participated in, and for which data collection was completed during 1 April 2014 to
31st 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
% cases
submitted
Elective surgery (National PROMs Programme)
Small surgical
volumes
The reports of the national clinical audit from 1 April 2014 to 31st March 2015
were reviewed by the Clinical Governance Committee and Cobalt Hospital has
significantly improved participation rates for preoperative surveys for inguinal
hernia repair by consultant engagement with patients preoperatively.
Local Audits
The reports of over 70 local clinical audits from 1 April 2014 to 31st March 2015
were reviewed by the Clinical Governance Committee and Cobalt Hospital
ensures action plans are written with clear time frames for improvement and
responsibilities assigned.
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Over all good compliance is demonstrated and action plans are completed to
ensure improvements are made. Our focus for 2015/16 is to further improve
record keeping in relation to VTE compliance and compliance with documentation
in EWS charts in the management of the deteriorating patient.
The clinical audit schedule can be found in Appendix 2.
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 Cobalt Hospitals income from 1 April 2014 to 31st March 2015 was
conditional on achieving quality improvement and innovation goals agreed. Cobalt
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. All CQUIN targets were met in the
period.
2.2.5 Statements from the Care Quality Commission (CQC)
Cobalt Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March 2015 is registered without conditions. On
the most recent CQC inspection 11th November 2013 Cobalt Hospital was
inspected on outcomes 1, 4, 8, 12 and 21 and full compliance was awarded.
Cobalt Hospital has not participated in any special reviews or investigations by
the CQC during the reporting period.
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2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your
Data Quality
Cobalt Hospital works hard to ensure accurate data quality is at the heart of
everything we do, evidenced by excellent SUS submission rates.
Where applicable, using findings from the internal audit programme, the hospital
works to develop data capture and validation methods, ensuring continuous
improvement in quality standards.
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).
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
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Clinical coding error rate
A clinical coding audit was completed in February 2015 with the following
findings.
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
98.3%
98.2%
100%
98.8%
An action plan was developed to ensure that all the documented relevant comorbidities and complications within the episode of care are included in the
assigned clinical codes.
2.2.7 Stakeholders views on 2014/15 Quality Account
Statement from North Tyneside CCG on behalf of Newcastle Gateshead
CCG Alliance and Northumberland CCG regarding the Quality Accounts
dated 2014/15 for Ramsay Health Care UK:
NHS North Tyneside CCG as the lead commissioner for services at Cobalt
Hospital welcomes the opportunity to review and comment on their Quality
Accounts for 2014/15 and would like to offer the following commentary.
North Tyneside CCG aims to commission safe and effective services that provide
a positive experience for patients and carers. Commissioners of health services
have a duty to ensure that the services commissioned are of good quality. This
responsibility is taken very seriously and is considered to be an essential
component of the commissioning function.
Throughout 2014/15, quarterly clinical quality review meetings with representation
from the CCG have taken place with Cobalt Hospital. These are a wellestablished mechanism to monitor the quality of the services provided and to
encourage continuous quality improvement. The CCGs feel that these meetings
have become a valuable forum through which both organisations can gain
assurance and work collaboratively to understand the quality systems in place
within the hospital.
The CCG has worked successfully with the hospital to develop the
Commissioning for Quality & Innovation (CQUIN) scheme for 2015/16. There will
be a continued focus on improving the communication of delays related to the
endoscopy service.
We recognise the achievements made by the hospital across the priority areas
identified for 2014/15. In particular demonstrating 100% compliance with the
World Health Organisation (WHO) surgical safety checklist and continuing to
have a very low return to theatre rate when compared to the national figure. The
CCG would also like to commend the hospital for consistently exceeding their
target for patient reported outcome measures studies (PROMS).
High patient satisfaction scores which are reflected in the patient satisfaction
survey and Friends and Family Test (FFT) are to be commended and whilst it is
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noted that the FFT response rates have been low, there is an action plan in place
to improve this.
The CCG does however feel that, in those priority areas where performance has
not quite met expectations, the quality account should provide more details as to
why that performance was lacking and how this has been resolved. For example
the staff satisfaction score and the results from the privacy, dignity and wellbeing
element of the Patient-Led Assessments of the Care Environment (PLACE) have
both deteriorated when compared to the previous year.
Whilst the hospital has been above the national average for the completion of
VTE risk assessments, it is noted that an audit identified poor compliance in the
accuracy of assessment documentation. The CCG note that this has been
addressed with the medical staff and will continue to be monitored via the
2015/16 audit plan.
The CCG welcomes the specific priorities for 2015/16 which are highlighted in the
report and feel that they are appropriate areas to target for continued
improvement. They also link with the CCG commissioning priorities. The quality
account also provides assurance that Cobalt Hospital is committed to improving
clinical effectiveness by regularly undertaking clinical audits and it is noted that
the focus for 2015/16 is to further improve record keeping in relation to VTE
compliance
It is felt overall that the report is well written and presented and is reflective of
quality activity and aspirations across the organisation for the forthcoming year.
The CCG looks forward to continuing to work in partnership with Cobalt Hospital
to assure the quality of services commissioned in 2015/16.
Lesley Young Murphy
Executive Director of Nursing & Transformation
NHS North Tyneside CCG
8th June 2015
Quality Accounts 2014/15
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Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Review of quality performance 1st April 2014 - 31st 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
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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 2014/15
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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.
3.1 The Core Quality Account indicators
National Mortality Rates:
Period
Jan13-Dec13
Apr13Mar14
Best
Worst
Average
RKE
0.62
RXL
1.18
Eng
1
RKE
0.54
RBT
1.20
Eng
1
Cobalt Hospital:
Period
Cobalt
2013/14
NVC29
0
2014/15
NVC29
0
Cobalt Hospital considers that this data is as described, we have had no reported
deaths.
National PROMs: Hernia repair
Period
Apr13 Mar14
Apr14 Sep14
Best
Worst
Average
NT415
0.139
NVC11
0.008
Eng
0.085
RXR
0.125
Several
0.009
Eng
0.081
Cobalt Hospital
Period
Apr13 Mar14
Apr14 Sep14
Cobalt
NVC29
0.099
NVC29
*
Cobalt Hospital considers that this data is as described as we have low volumes
of patients admitted for inguinal hernia repair.
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National PROMs Varicose veins
Period
Apr13 Mar14
Apr14 Sep14
Best
Worst
Average
RTH
11.292
NT350
-16.849
Eng
-8.698
RYJ
-4.567
RWA
-16.762
Eng
-9.479
Cobalt Hospital
Period
Apr13 Mar14
Apr14 Sep14
Cobalt
NVC29
*
NVC29
*
Cobalt Hospital considers that this data is as described as we have low volumes
of patients admitted for varicose vein surgery, as the policy around procedures of
limited value are followed.
National Readmissions
Period
Best
Worst
Average
2010/11
Multiple
0.0
5P5
22.76
Eng
11.43
2011/12
Multiple
0.0
5NL
41.65
Eng
11.45
Cobalt Hospital
Period
Cobalt
2010/11
NVC29
0
2011/12
NVC29
x
Cobalt Hospital considers that this data to be incomplete compared to SUS
readmission reports. This is because we are not always notified of a readmission
into another facility.
National VTE assessment
Period
Best
Worst
Average
14/15 Q2
Several
100%
RNL
86.4%
Eng
96.2%
14/15 Q3
Several
100%
NT322
85.1%
Eng
96.0%
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Best
Worst
Average
Cobalt Hospital
Period
Cobalt
14/15 Q2
NVC29
99.9%
14/15 Q3
NVC29
100.0%
Cobalt Hospital considers that this data is as described. We consistently maintain
compliance above the national average.
National C Difficile rate
Period
Best
Worst
Average
2012/13
Several
0
RVW
30.8
Eng
17.4
2013/14
Several
0
RMP
32.5
Eng
14.7
Cobalt Hospital
Period
Cobalt
2012/13
NVC29
0.0
2013/14
NVC29
0.0
Cobalt Hospital considers that this data is as described as there have been no
reported cases of C Difficile. Cobalt Hospital intends to maintain this rate by
ensuring robust infection control measures are in place.
National SUI’s Severity level 1
Period
Oct 13 - Mar
14
Apr - Sep 14
Best
Worst
Average
RBD
0
R1F
3.72
Eng
0.43
Several
0
RBZ
1.09
Eng
0.17
Cobalt
Period
Oct13Mar14
Apr-Sep14
Cobalt
NVC29
0.00
NVC29
0.00
Cobalt Hospital considers that this data is as described, there have been no level
1 severity incidents reported. Cobalt Hospital intends to maintain this rate by
ensuring an effective clinical governance framework.
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3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and 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
Cobalt 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.
The consultant microbiologist has provided training sessions for the infection
control link nurse on a number of subjects including blood borne viruses and
Carbapenamase-producing Enterobacteriaceae (CPE) to allow dissemination of
knowledge to the wider clinical team.
Our annual hand hygiene awareness day was held in May and was lead by the
infection control link nurse and this involved staff, patients and visitors visiting an
Quality Accounts 2014/15
Page 26 of 37
information stand in the waiting area. Demonstrations were given and patients
and staff were given individual hand hygiene gel dispensers for their own use.
Observational hand hygiene audits were undertaken by the Consultant
Microbiologist and Infection Control Link Nurse resulting in additional gel
dispensers being placed in the unit. A poster campaign targeting staff to ‘gel in
and gel out’ was successful in increasing patient satisfaction scores in questions
relating to staff hand hygiene but further improvements targets have been set. A
local CQUIN target has been set for the coming year to improve patient
perception of staff hygiene practice with stretched targets up to 65% compliance
set.
Infection Rates
(percentage of Admissiosns)
Infection Rates
0.18
0.16
0.14
0.12
0.1
0.08
0.06
0.04
0.02
0
2012/13
2013/14
2014/15
Cobalt Hospital
The above graph suggests a slight increase in infection rates however the actual
numbers remain very low and this is reflective of improved reporting and
investigating of potential infections. Patients presenting with signs of an infection
are logged on our reporting system and is reviewed by the infection control link
nurse and a root cause analysis 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. Cobalt Hospital has been
invited to attend Gateshead and North Tyneside Health Care Acquired infection
Reduction Partnership to ensure we are fully informed of regional issues in terms
of HCAI across the region.
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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 Cobalt 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 main
purpose of a PLACE assessment is to get the patient view.
2014 PLACE results:
Cleanliness – 99.71% up 3.93%
Condition, Appearance and Maintenance – 96.55% up 6.17%
Privacy, Dignity and Wellbeing – 72.73% down 5.76%
An action plan was completed, as a day case facility patients do not have access
to TV radio or internet this reflected a low score for privacy and dignity. The
patient assessors on the day did not reflect any concerns in terms of privacy and
dignity and we determine that this element is not effectively assessed or scored
using the current tool. It is pleasing to see the maintenance programme
introduced following the 2013 assessment has had a positive impact on the
condition and maintenance of the facilities.
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 we keep up to date with all safety issues.
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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.
3.3 Clinical effectiveness
Cobalt hospital has a Clinical Governance 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 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)
0.3
0.25
0.2
0.15
0.1
0.05
0
2012/13
2013/14
2014/15
Cobalt Hospital
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Cobalt Hospital continues to have a very low return to theatre rate as a
percentage of overall admissions. There were no trends identified and the rate
remains below the national average and has reduced further on the previous
year.
3.3 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.
Any 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.
Complaints management training was completed by all heads of department with
a focus on resolving at the time of complaint wherever possible.
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.
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
Friends and family questions asked on patient discharge
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
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3.3.1 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 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
additional comments made by patients on their survey are sent as ‘hot alerts’ to
the Hospital Manager and Matron within 48hrs of receiving them so that a
response can be made to the patient as soon as possible if appropriate.
We have consistently maintained a moving quarterly average patient satisfaction
score above 96% and proactively seek patient feedback to ensure we maintain
high levels of patient satisfaction.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
97.0
97.1
2013/14
2014/15
20
0
Cobalt Hospital
What our patients say:
‘First class treatment many thanks’
‘Excellent care with a knowledgeable doctor and nurses, I chose not to be
sedated and they made me as comfortable as possible. They talked me through
every step as it was carried out. Excellent customer service and very down to
earth. Really satisfied with my care, can't find any fault.’
‘I would definitely use this hospital again given the option.’
‘It was very efficient and professional, a really good service throughout and I
would recommend the hospital to anyone.’
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3.4 Cobalt Hospital Case Study
GP Education - effective and timely referral
Ramsay Health Care actively encourages
hospitals to engage with the GP community and facilitate educational events in
areas that GPs have expressed an interest in learning and development needs.
Cobalt Hospital has delivered two GP education events with the remit to introduce
new consultants to GPs and allow them to network whilst being updated on what
and when to refer and an overview of the latest surgical techniques.
Last October saw Mr Venkatachalam and Mr Cloke, Consultant Orthopaedic
Surgeons deliver an interactive session for GPs on shoulder conditions. The
session included a practical demonstration on how to assess a patient’s condition
to determine the most appropriate referral route.
This was followed earlier this year with an event presented by Mr Davey, a
Vascular Consultant, who explained the advancements in vascular surgery. The
audience of GPs took the opportunity to ask questions and seek guidance on
patient scenarios.
Both sessions were well received by GPs who seem to appreciate the informal
format, focused topic and opportunity to engage with consultants and network
with colleagues – topics for future events have been identified by the GPs and
Cobalt will look to develop these going forward.
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Appendix 1
Services covered by the Quality Account
Specialty
General Surgery
GI Endoscopy
Orthopaedic Surgery
Plastic Surgery
Service
Minor Skin
Varicose Veins
Hernia Repair
Rectal Surgery
Colonoscopy
Flexible Sigmoidoscopy
Gastroscopy
Hand
Knee
Shoulder
Wrist
BCC
Skin lesions/cysts
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Appendix 2 – Clinical Audit Programme 2014/15. Each arrow links to the audit to be completed in each month.
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Cobalt 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:
Cobalt Hospital
Silverlink North
Cobalt Business Park
North Tyneside
NE27 0BY
Tel: 0191 2703 250
www.cobalthospital.co.uk
Quality Accounts 2014/15
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Centres
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