Fitzwilliam Hospital
Quality Account
2014/15
Contents
Introduction Page
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
2.1.1 Review of clinical priorities 2014/15
10
2.1.2 Clinical Priorities for 2015/16
12
2.2
Mandatory statements relating to the quality of NHS services provided
2.2.1 Review of Services
14
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
3.1
The Core Quality Account indicators
27
3.2
Patient Safety
31
3.3
Clinical Effectiveness
34
3.4
Patient Experience
36
3.5
Case Study
38
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Fitzwilliam 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.
Introduction
Statement from Mark Page, Chief Executive Officer, Ramsay Healthcare 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 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.”
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Introduction to our Quality Account
This Quality Account is Fitzwilliam 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 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
Fitzwilliam Hospital
As the General Manager of the Fitzwilliam 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 Fitzwilliam 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 detailed within the Quality
Account.
As General Manager, I am aware of all aspects of clinical quality and NHS services provided at the
Fitzwilliam 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
Fitzwilliam Hospital, Ramsay Health Care UK
This report has been reviewed and approved by:
The report has also been shared with the following groups for their review and comment prior to
submission.
Lincolnshire Clinical Commissioning Group
Peterborough & Cambridge Clinical Commissioning Group
Health Watch – Peterborough
Patient & Public Involvement Group Chair
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Welcome to Fitzwilliam Hospital
The Fitzwilliam Hospital has been part of the local community for thirty two 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, day surgery or a major procedure we want
them to feel that they are cared for by compassionate and highly trained staff that provide skilled
care 24 hours a day.
Over the past thirty two 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 listened to the feedback
from our patients and strived to make improvements to enhance the patient experience. We have
over 75 highly trained nursing staff who alongside a wide variety of other healthcare professionals
to deliver the best possible care.
At the Fitzwilliam 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 10,018 patients, 75% of which were NHS. On average an additional
1,000 patients were seen per week in our outpatient department by one of our 132 consultants.
We offer a wide range of services covering orthopaedic and general medicine right through to
aspirational medical procedures such as breast augmentation, liposuction, weight loss management
and facial plastic surgery. Not only do we have some of the state of the art medical equipment, but
our staff of 132 consultants includes some of the best in the country. At Fitzwilliam 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 also employed a Quality Improvement
Manager during the financial year to invest in our commitment to quality to provide our patients with
the best clinical care and patient experience. We also continue to foster good relationships with our
local NHS Trust, Peterborough City Hospital. This affiliation promotes a robust governance process
which in turn enhances patient safety.
We also work closely with many charities and organisations such as Sue Ryder, selling Christmas
Cards and supporting the annual Dragon Boat race event. During 2014/15 we supported a local
cricket team at Easton on the Hill, raising money for their cricket nets and additional equipment. The
Theatre team participated in a cycle marathon, which we also supported for a number of good
causes.
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Part 2
2.1 Quality priorities for 2014/2015
Plan for 2014/15
On an annual cycle, Fitzwilliam 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.
2.1.1 A review of clinical priorities 2014/15
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. During 2014/15 we conducted a number of patient surveys to gauge the success of the
work we had completed regarding communications. The audit showed an increase in patient
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satisfaction of 3.7%, with patient satisfaction over 88%. This work will be extended during 2015/16
with the development of patient information leaflets regarding discharge medications.
During 2014/15 we further developed the Public Patient Involvement Group. The group meet
biannually to discuss hospital developments and new service lines, in order to obtain the reviews
and feedback from those who have experienced our services. The group also participate in
departmental visits to review patient services and participate in the NHS PLACE audit annually.
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 hip and knee replacements, groins 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.
Safety Thermometer
We continued with the national initiative of the safety thermometer throughout 2014/15 which
monitors falls, Venous Thromboembolism, pressure tissue damage and urinary tract infections.
With continued support from our clinicians and nursing staff we recorded a harm free position for
the financial year, which demonstrates the importance and ongoing assurance of safe care
provision.
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, we exceeded the 98% target set for 2014/15.
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During 2014/15 our continued efforts to minimise the number of VTE events was positive with 50%
fewer reported cases than the previous year. A full RCA was completed within the required
timescales and shared with our Clinical Commissioning Group for continued monitoring and lessons
learnt.
Early Warning Score (EWS)
As part of ongoing work following the CQUIN from 2013/14 it was identified t
hat a further suite of training materials and the monitoring 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 the Fitzwilliam Hospital implemented a further
change to the EWS chart incorporating national guidance, with a commitment to train staff in the
use of new charts and monitor compliance with escalation of the deteriorating patient, the
Fitzwilliam 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 that underpins every priority at the Fitzwilliam
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.
As feedback is important to us, we plan to review the way in which “HOT” alerts and informal patient
feedback is addressed and lessons learned where possible to improve the services we offer our
patients.
Continuing from our CQUIN work in 2014/15 in relation to pain management, we aim to develop a
suite of patient information leaflets to provide patients on discharge from hospital. The project
derived from sharing lessons with our sister site at Boston West Hospital. We hope from looking on
at their success with the introduction of patient information leaflets, we can mirror that success and
provide patients with a better understanding of their discharge medications.
Clinical Effectiveness
Sharing findings from governance information and learning lessons is key, in order to progress the
effectiveness of the hospital. During 2014, we conducted lessons learned presentation events for
key clinical staff, to provide an opportunity to share lessons learned through adverse events.
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During 2015/16 we will be introducing display boards within each department which will highlight
key governance activity and performance.
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 above 96%.
We hope to continue this momentum and build on an already sound culture. During 2015/16 we
have attached some CQUIN activity (page 19) 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.
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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 Fitzwilliam Hospital provided and/or subcontracted 35 NHS services.
The Fitzwilliam 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
63% per cent of the total income generated from the provision of NHS services by the Fitzwilliam
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 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 16% due to the time to take
new starters through the recruitment process and existing staff notice period. The recruitment drive
will continue through 2015/16, once this process is complete, the hospital will be less reliant on
agency staff. Long term sickness, maternity leave, new starter induction and training contributed to
lost hours. Staff hours worked per hospital day were 20.16 and staff costs as a percentage of net
revenue were 16%.
Levels of sickness saw a slight upturn in 2013/14. On review of the 2014/15 this remains similar
with a slight increase of 0.3%. We continue to work with our “Wellbeing Service” to support
employees both in the workplace and as part of a structured return to work service.
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The total skill mix calculation for the Fitzwilliam Hospital was completed by reviewing the contracted
and bank hours for registered nursing staff and healthcare assistants. In the previous financial year
we planned to review the skill mix in the outpatient department based on a workforce review that
had been undertaken.

68% of staff caring for patients are Registered Nurses

31% of staff are Health Care Assistants
The Fitzwilliam 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
support and implement change in the Hospital.
There were no RIDDOR event(s) reported at the Fitzwilliam Hospital during this period.
Patient Services
The hospital reported 0.67 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 Fitzwilliam Hospital on a regular basis.
The Fitzwilliam 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, areas which require improvement are reviewed and actions taken accordingly.
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

Food choice available to patients

Friendly welcome on arrival to hospital

Cleanliness

Patients felt they were given enough privacy and dignity when being examined
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
Patients felt they were provided with answers they could understand from both the nursing
staff and our consultants when raising questions about their clinical care.
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.
It is unusual for patients to require readmission to hospital following their procedure, when a patient
is readmitted they are reviewed by the duty doctor and a treatment plan is initiated. The statistics
regarding readmissions to the Fitzwilliam are reviewed on a bi-monthly basis at the Medical
Advisory Committee and Clinical Governance Committee, the data is also benchmarked against the
wider Ramsay group to review our individual hospital performance within group. In percentage
terms the readmission rate relates to 0.17% of our inpatient stays during 2014/15.
Quality
Our annual workplace health and safety score was 95% which was an improvement of 4% from the
previous year. A number of refurbishment works have been undertaken during 2014/15 with new
carpets in the communal areas, the refurbishment of the ward clinical preparation room, 24
additional mattresses were purchased to replace mattresses which no longer met patient needs.
During 2014 90% of all general waste at the hospital was recycled. Based on the workplace health
and safety audit findings and patient feedback, a large project to upgrade the patient call bell
system is planned during 2015/16.
The proposed refurbishments to the car parking facilities that were identified in 2014 have been
agreed by the City Council planning department and work is planned to commence in June 2015.
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. A number of local audits are also undertaken,
the yearly mattress audit was completed and following the audit 24 new mattresses were
purchased.
The Fitzwilliam Hospital has a governance process which monitors significant clinical events.
During the period 2014/15 our overall percentage for reported serious significant events (death or
severe harm) was 0.26% per 1000 hospital days.
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2.2.2 Participation in Clinical Audit
During 1 April 2014 to 31 March 2015 Fitzwilliam Hospital participated in four (NJR, JAG, PROMS,
National Comparative Blood Audit) 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 Fitzwilliam 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.
Cases
submitted
Name of audit / Clinical Outcome
Review Programme
870
National Joint Registry (NJR)
853
Elective surgery (National PROMs Programme)
0
Severe sepsis & septic shock*
7
National Comparative Audit of Blood Transfusion programme
The reports of one national clinical audits from 1 April 2014 to 31 March 2015 were reviewed by the
Clinical Governance Committee and Fitzwilliam 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 Fitzwilliam Hospital. The clinical audit schedule can be found
in Appendix 2.
During 2014/15 we have seen an improvement with our VTE compliance, the audit findings were
shared with the consultant body and training was provided to the Pre-assessment team as identified
gaps in practice were highlighted and actions taken.
The Fitzwilliam Hospital implemented a number of initiatives following learning from audit results. All
audit information is disseminated to both the local teams and the consultant body for action and
learning.
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Areas identified for improvement from audit has resulted in specialist training materials being
created for staff, to support their learning and development in specific areas. The ward teams have
a “topic of the week” notice board where key topics from governance intelligence is shared and
displayed.
Audit is discussed at departmental meetings and feedback is given to staff, each audit that requires
any improvement has an action plan attached. It was identified that there was a need to ensure all
quality information and actions from audit was cascaded to the wider consultant body, to ensure key
areas of focus were being shared. A consultant newsletter has been published and the publication
has been well received by the consultant body.
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 Fitzwilliam Hospital’s income from 1 April 2014 to 31 March 2015 was conditional on
achieving quality improvement and innovation goals agreed by Fitzwilliam 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.
Local / National Goals 2014/15
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
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
Pain
Management
Post-operative pain
management


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
Local 2015/16 CQUIN Goals
The Ramsay group will not be participating in the National CQUIN goals for this financial year. The
table below shows the local CQUIN which has been agreed with the Clinical Commissioning group
for 2015/16.
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

Safety Culture assessment for surgical team
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2.2.5 Statements from the Care Quality Commission (CQC)
Fitzwilliam Hospital is required to register with the Care Quality Commission and its current
registration status on 31 March 2015 is registered without conditions.
Fitzwilliam 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).
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Information Governance Toolkit Attainment Levels
Ramsay Group Information Governance Assessment Report score overall for 2014/15 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 Fitzwilliam Hospital successfully passed the ISO Information Governance Audit (27001) during
2014/15.
Clinical Coding Error Rate
Fitzwilliam 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
Fitzwilliam
May 14
TBC
96.6%
94.9%
98.3%
96.8%
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2.2.7 Stakeholders views on 2014/15 Quality Account
NHS South Lincolnshire CCG Commentary for Ramsay Fitzwilliam Quality Account 2014/15
NHS South Lincolnshire CCG’s main priority is to ensure that services are safe and of a high
quality. The Fitzwilliam 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 Fitzwilliam 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. 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 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 very positive patient experience
feedback.
South Lincolnshire CCG notes that the Fitzwilliam 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 Fitzwilliam since its
registration.
South Lincolnshire CCG can verify that Ramsay Fitzwilliam 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 Fitzwilliam 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 Fitzwilliam Account in particular the development of a suite of patient
information leaflets to support safer discharge from hospital. The CCG notes the CQUIN scheme
Quality Accounts 2014/15
Page 22 of 42
this year will continue to maintain emphasis on patient safety through the implementation of
National Patient Safety Agency ‘five steps to safer surgery’.
The South Lincolnshire CCG CQUIN scheme for 2015/16 will consist of the following:
Implementation of Surgical Site Infection Bundle
•
•
•
•
•
To reduce harm to patients by removing hair around incision site using correct intervention
To reduce surgical site infection by ensuring that prophylactic antibiotics are given on time
and discontinued on time.
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
Surgical Team Communication and Safety Culture Assessment
South Lincolnshire CCG endorses the accuracy of the information presented within the Ramsay
Fitzwilliam Quality Account and the overall quality programme performance will be reviewed
through the formal contract quality review process and triangulation through patient experience
surveys.
NHS Cambridgeshire & Peterborough CCG Commentary for Ramsay Fitzwilliam Quality
Account 2014/15
No comments received
Healthwatch Peterborough
This statement has been made behalf of Healthwatch Lincolnshire. We are pleased to have been
asked by the Fitzwilliam Hospital to contribute to the Quality Account; however given that this is our
first account with Ramsay Healthcare 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 Healthcare does not use
abbreviations wherever possible. (NVC06 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 Care 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 and are encouraged that across the organisation it has
Quality Accounts 2014/15
Page 23 of 42
appears to have a clear openness to learning best practice from differing sites and implementing
them as appropriate as is demonstrated by the pain management work learned from Boston West.
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.
Patient & Public Involvement Chair Commentary on Fitzwilliam Quality Account 2014/15
No comments received
Quality Accounts 2014/15
Page 24 of 42
Part 3: Review of Quality Performance 2014/2015
Statements of Quality Delivery
Matron, Jane Groom
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 Accounts 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
Quality Accounts 2014/15
Page 26 of 42
National Guidance
Ramsay also complies with the recommendations contained in technology appraisals issued by the
National Institute of 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. The Fitzwilliam
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.
Fitzwilliam 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.
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 figured 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
Fitzwilliam
NVC06
0
NVC06
0.01
The Fitzwilliam Hospital considers the data is a true reflection of activity for the following reason.

Death is rare and as illustrated below the national average. Any death is investigated and
reported to the Care Quality Commission and local Clinical Commissioning Groups.
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.
Quality Accounts 2014/15
Page 27 of 42
Hips
Period
Apr13 - Mar14
Apr14 - Sep14
Best
NT441
24.444
RCB
25.418
Worst
RQX
17.634
RJD
18.357
Average
Eng
21.34
Eng
21.922
Period
Apr13 - Mar14
Apr14 - Sep 14
Fitzwilliam
NVC06
20.025
NVC06
*
Best
NT404
19.762
RWP
20.44
Worst
NV323
12.049
RXF
14.416
Average
Eng
16.248
Eng
16.702
Period
Apr13 - Mar14
Apr14 - Sep14
Fitzwilliam
NVC06
17.633
NVC06
*
Knees
Period
Apr13 - Mar14
Apr14 - Sep14
The Fitzwilliam Hospital considers the data is a described for the following reasons



Lack of data release for April 2014-September 2014 therefore no data available for analysis
for reporting period.
Patient Participation
Need for improved process around capturing patient questionnaires at pre assessment
phase
The Fitzwilliam 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.
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
RF4
0.0
RF4
0.0
Worst
RYR
15.8
RYR
15.8
Average
Eng
11.04
Eng
11.08
Period
2010/11
2011/12
Fitzwilliam
NVC06
7.84
NVC06
7.13
The Fitzwilliam 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.
Fitzwilliam Hospital will continue to provide patients with support with aftercare advice and
encourage patients to return where clinically indicated.
Quality Accounts 2014/15
Page 28 of 42
Responsiveness
This data set looks at the positive experiences of care provided by Fitzwilliam Hospital. The data
has been extracted from the Care Quality Commissions inpatient survey. The latest data release
form the CQC has been reported.
Period
2012/13
2013/14
Best
RPC
RPY
88.2
87.0
Worst
RJ6
68.0
RJ6
67.1
Average
Eng
76.5
Eng
76.9
Period
2013/14
2014/15
Fitzwilliam
NVC06
91.5
NVC06
91.4
The Fitzwilliam Hospital consider this data a true reflection of activity. The scores are currently
reported above the national average, showing patients have a positive experience, due to the
emphasis on customer excellence training, staff to patient ratio’s and taking action on feedback
from patients when they have not had a positive experience.
The Fitzwilliam 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
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
Fitzwilliam
NVC06
97.0%
NVC06
96.7%
The data shows the Fitzwilliam as exceeding national benchmarking data, with consistent
performance. Analysis of 2014/15 shows an overall compliance percentage of 96.7%.
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 2014/15 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.
Quality Accounts 2014/15
Page 29 of 42
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. The 2014/15 data sets are yet to be published for the NHS.
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
Fitzwilliam
NVC06
0.0
NVC06
0.0
From the data Fitzwilliam are amongst the best performing organisations in the country for CDifficile rates.
The hospital considers the data as 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 Fitzwilliam Hospital intends to continue its current
practice to remain one of the best performing hospitals for their C-Difficile rates.
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
Fitzwilliam
NVC06
100.0%
NVC06
98.2%
The Fitzwilliam 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 slight
decline in patient satisfaction between January and February 2015. Further analysis shows that the
average patient satisfaction score for the duration of 2014/15 was 98.4%. This is supported by the
overall scores as Fitzwilliam Hospital are performing above the national benchmark for patient
satisfaction.
The Fitzwilliam 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.
Quality Accounts 2014/15
Page 30 of 42
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
Fitzwilliam Hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 4 years.
Fitzwilliam Hospital are proud to report a zero rate of both MRSA Bacteraemia and Clostridium
Difficile during 2013/14, making the hospital one of the best performing hospitals against national
benchmarking for the prevention of infection.
Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint
surgery. Infection Prevention and Control management is very active within our hospital. An annual
strategy is developed by the Corporate level Infection Prevention and Control (IPC) Committee and
group policy is revised and re-deployed every two years. The 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 Fitzwilliam 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.
The Infection Control Nurse participated in the national antibiotic awareness day which
involved both staff at the hospital and our patients. Posters and Leaflets were made
available to all, quizzes were provided to clinical staff and a stand was available throughout
the day with key information and messages regarding antibiotic use.
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.
Quality Accounts 2014/15
Page 31 of 42
The graph below shows the infection rates as a total percentage of the Fitzwilliam Hospital’s
admissions. The graph demonstrates a 1.1% reduction in infections from the previous year.
In comparison to the national average the Fitzwilliam Hospital are performing above national
benchmarks, demonstrating the infection prevention and control measures in place are effective.
There is an active local IPC committee which is chaired by a microbiologist with clinical
engagement actively working hard to identify trends during 2013/14 to reduce the number of
infections, although compared to the national average, these remain relatively low. We aim to build
on our positive work carried out in 2014/15 and progress this into 2015/16.
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 Fitzwilliam 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.
In 2014/15, the members of the Fitzwilliam Hospital Patient and Public Involvement Forum
Committee formed part of the PLACE inspection team in addition to members from Peterborough
Health Watch organisation. The inspection team provided feedback and raised any issues
regarding the findings of the inspection.
Quality Accounts 2014/15
Page 32 of 42
The diagrams below illustrates the 2013/14 and 2014/15 comparisons for the audit.
In 2014 a noted improvement in the overall scores for cleanliness, food and condition appearance
and maintenance of estates was achieved. Although there were still a number of minor
improvements needed with the estate, the inspectors noted the progress and improvements made
from the previous audit.
Further projects are planned for 2015/16 including additional parking facilities, new carpets in
communal areas, improvements to the outpatient consulting rooms, refurbishment of ward corridors
which includes a lighting upgrade. Work has also been carried out to improve the television system
in the patient bedrooms.
A large project was undertaken by Ramsay in 2014/15 to modernise the menu offered to patients,
providing patients with wider variety and choice for their meals. In addition special dietary
requirements were reviewed and the menu also took into consideration those patients with
additional dietary needs, to again provide patients with more choice. During the audit, the
inspectors provided positive feedback on the changes made to the menu, which was reflected in the
overall score for food improving by 6% during 2014/15 from the previous year.
Quality Accounts 2014/15
Page 33 of 42
Although privacy, dignity and wellbeing percentage was recorded at 91.43%, this still remains
above the national average. Work is ongoing with the clinical staff via patient feedback at team
meeting to reflect on practice.
Having the same group of patients from the public and patient involvement group, offered us the
chance to demonstrate to the group that we had listened and engaged with patients and service
users, to implement change and inform and improve the service we deliver to our patients.
We will continue to make progress and implement our future projects into 2015/16.
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.
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
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 Fitzwilliam Hospital undertake regular thematic reviews in relation to their governance and
audit activity. Regular national audits are undertaken to enable performance to bench marked
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 bimonthly basis at the Medical Advisory Committee, to ensure clinicians are aware of the latest
national guidance to provide safe and effective care and treatment.
Quality Accounts 2014/15
Page 34 of 42
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. In addition to
the Governance group the Fitzwilliam Hospital appointed a Quality Improvement Manager during
2014/15, this appointment shows our continued commitment to improving the quality of care and
experience for our patients. The Quality Improvement Manager is supporting the Senior
Management Team, developing governance monitoring systems and ensure actions from audit,
incidents, complaints and other information data sets are followed up and lessons have been
learned.
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 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 Fitzwilliam Hospitals return to theatre performance comparing the last 3
financial years activity. The graph shows the Fitzwilliam Hospital currently have a 0.05% return to
theatre rate.
Quality Accounts 2014/15
Page 35 of 42
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 feedback 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 feedback 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
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
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 (admitted 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.
Quality Accounts 2014/15
Page 36 of 42
The graph below shows the patient satisfaction index scores for the last 2 financial years.
As the number of patients we see and treat at the Fitzwilliam 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 90% 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 changes.
Quality Accounts 2014/15
Page 37 of 42
3.5 Fitzwilliam Hospital Case Study
Case Study 1
A falls leaflet has been created during 2014, to support patients and their relatives by provide
information for reducing patient falls in hospital. Following a falls risk assessment, those patients
who are deemed to be at a moderate to high risk of falling, are provided with the falls information
leaflet in addition to the advice and support on the ward. Since the introduction of the leaflet, the
ward have experienced a reduction in their falls rate.
Reducing Patient Falls
Advice for patients, carers and relatives
As a patient you can help us to reduce the risk of falling by doing the
following:













Be honest with our nurses or physiotherapy staff if you feel anxious about moving around
Keep the nurse call bell within reach and use it if you need assistance to move around the ward
Be careful when standing up or getting out of bed
Please do not use hospital furniture such as bed table to assist with standing
Wear lightweight shoes or well fitting slippers
Take your time when moving
If you have a walking aid make good use of it
Listen to the advice of the therapies team and nursing staff
Remember hospital is not as familiar to you as home
Keep any personal items you wish to use within reach
If you normally wear prescription glasses, please ensure they are available for use.
Inform staff if you feel unsteady or unwell before you begin to mobilise
Drink plenty of fluids, unless otherwise advised, as the hospital environment tends to be warm
and you can easily become dehydrated
If you are a relative, carer or friend you can help by doing the following:





Share any information you may have on previous falls
When you visit please put the chair away in a safe place
Make sure the patient has access to the nurses call bell when you leave
If possible, bring well fitting clothes and light weight footwear for the patient to wear
Inform the nursing staff if you have any concerns
If a patient is at a high risk of falling we may;



Put the bed in a different position
Move the patient to a high observable room on the ward
Put falls prevention measures in place
Quality Accounts 2014/15
Page 38 of 42
Case Study 2
To ensure lessons are learned and key messages are disseminated throughout the consultant body
at the Fitzwilliam Hospital, a dedicated Consultant newsletter has been published to provide all
registered consultants with governance information and key messages. A copy of the newsletter
with commercially sensitive information extracted can be viewed below.
Quality Accounts 2014/15
Page 39 of 42
Appendix 2
Services covered by this Quality Account
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
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Adult Bunion Surgery NHS clinic
Adult Carpel Tunnel Syndrome and \Trigger Finger Clinic
Adult Hip Arthroscopy NHS Clinic
Adult Ligament and Cartilage (Menisculus) Injury Clinic
Cataract Clinic
Chiropody
Colorectal Surgery
Colorectal Medical
Dermatological Lasers
Dietician
ENT Clinic (excluding Audiology)
Endoscopy
Foot & Ankle Clinic (exclusions apply)
Gall Stone & Gall Bladder Clinic
Gastrointestinal Clinic
General Medicine
General Oral & Maxillofacial Clinic
General Urology Clinic
Gynaecology including Female Consultant
Haematology (non-clinical)
Hand & Wrist Clinic
Hernia Repair Clinic
Knee Arthroscopy Clinic
Knee Clinic
Lumps and Bumps Minor Skin Surgery Clinic
MRI Diagnostic Imaging Service
Pain Management Services
Shoulder & Elbow Clinic
Shoulder Only Clinic
Spinal Assessment Clinic
Spine & Back Pain Clinic
Urogynaecology/Adult Incontinence Clinic
Quality Accounts 2014/15
Page 40 of 42
Quality Accounts 2014/15
Page 41 of 42
Fitzwilliam 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:
01733 261717
Hospital Website
www.fitzwilliamhospital.co.uk
Quality Accounts 2014/15
Page 42 of 42