Fulwood Hall Hospital
Quality Account
2014-15
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement From The General Manager
1.2
Hospital Accountability Statement
PART 2
2.1
Clinical Priorities 2014/15 (looking back)
2.2
Clinical Priorities 2015/16 (looking forward)
2.3
Mandatory Statements Relating To The Quality Of NHS Services Provided
2.3.1
Review of Services
2.3.2
Participation in Clinical Audit
2.3.3
Participation in Research
2.3.4
Goals Agreed with Commissioners
2.3.5
Statement from the Care Quality Commission
2.3.6
Statement on Data Quality
2.4
Stakeholders’ Views
PART 3
3.1
The Core Quality Account Indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audit Programme 2014/15
Welcome to Ramsay Health Care UK
Fulwood Hall Hospital is part of Ramsay Health Care UK
The Ramsay Health Care Group, was established in 1964 and has grown to become
a global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health
Care is one of the leading providers of independent hospital services in England, with
a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the
NHS in the UK. Through a variety of national and local contracts we deliver
thousands of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, Clinical Commissioning
Groups, NHS Trusts and NHS referral management and triage services.
Statement from our Chief Executive Officer
“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 reputation as a major provider of healthcare
services across the world and of our 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
Quality Accounts 2014/15
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Introduction to Our Quality Account
This Quality Account is Fulwood Hall Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It reports on the period 1st
April 2014 to 31st March 2015 and presents our achievements in terms of clinical
excellence, effectiveness, safety and patient experience. It also demonstrates that
our managers, clinicians and staff are all committed to providing continuous,
evidence based, quality care to those people we treat. It will also show that we
regularly scrutinise every service we provide with a view to improving it and ensuring
that our 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, developed by our Corporate Office, summarised
and reviewed quality activities across every hospital within Ramsay Health Care UK.
It was recognised that this didn’t provide enough in-depth information for the public
and for commissioners about the quality of services within each individual hospital
and how this relates to the local community it serves. Therefore, each site within the
Ramsay Group now develops its own Quality Account, which includes some Groupwide initiatives, but also describes the many excellent local achievements and quality
plans that we would like to share.
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Part 1
1.1 Statement On Quality From The General Manager
Fulwood Hall Hospital, established in 1986, has become an integral part of NHS
healthcare provision in Lancashire. Today the hospital continues to deliver high
quality care under Contract from local Clinical Commissioning Groups and a key
reason for the hospital’s continued role in local NHS healthcare provision is the high
standard of care provided.
This is the fifth Quality Account to be submitted by Fulwood Hall Hospital and has
been produced to demonstrate our commitment to measuring all feedback from
patients about their experience, clinical treatment and clinical outcomes. This allows
us to continually review, reflect on and improve the patient’s journey.
Patient safety is our highest priority and our robust recruitment processes and
training programmes ensure that staff are competent and fully trained in all aspects of
service provision.
We achieve consistently high patient satisfaction scores and, by studying results
throughout the year, we constantly seek ways to further improve the patient
experience.
Whilst patient feedback and involvement is extremely important to us, we also rely
heavily on other measures of safety and clinical effectiveness which we use to satisfy
ourselves that treatment is evidence-based and delivered by appropriately qualified
and experienced doctors, nurses and other key healthcare professionals. Examples
of these are detailed in this Quality Account.
As General Manager of Fulwood Hall Hospital, I am passionate about ensuring that
high quality patient care is our number one priority. Our Quality Account is an
accurate representation of our performance and our ongoing initiatives to
continuously improve the quality of our services.
Amy Simpson, General Manager
Fulwood Hall Hospital
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Amy Simpson, General Manager
Fulwood Hall Hospital, Ramsay Health Care UK
This report has been reviewed and approved by:
NHS Greater Preston Clinical Commissioning Group
Mr Ben Shaw, Consultant Surgeon and Chair Medical Advisory Committee,
Fulwood Hall Hospital
Quality Accounts 2014/15
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Welcome to Fulwood Hall Hospital
Since 1986, Fulwood Hall Hospital has provided surgical services and diagnostics
from its location near the M55 / M6 motorway link in Preston. Today, the hospital has:
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a consultant body of over 150 across a full mix of specialities
six private consulting rooms
an outpatient treatment room for minor procedures
three ultra clean, laminar flow theatres
endoscopy suite
a close care ward for higher risk patients
twelve day-case bays for ambulatory care
22 single-bedded and 3 two-bedded, en-suite bedrooms for overnight stays
a fully equipped physiotherapy gymnasium
onsite MRI, X-ray and Ultrasound
ophthalmology suite
The hospital has had a continuous relationship with local Trusts and Commissioners
to support NHS capacity issues and now provides NHS patients with a range of
Choose and Book services in order to support the achievement of 18 week referral to
treatment timescales. NHS surgical services provided at the hospital in the year
2014/15 were Ear Nose and Throat, General Surgery, Gynaecology, Ophthalmology,
Oral Surgery, Orthopaedics, Spinal Surgery and Urology.
The hospital also treats patients from 3 years of age and provides specialist
paediatric nurses to ensure children (and their parents) receive full reassurance and
support throughout their stay.
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2.1 Clinical Priorities - April 2014 to March 2015 (looking
back)
2.1.1 Never Events
Fulwood Hall Hospital had one Never Event in the reporting period – a wrong size
prosthesis during a total hip replacement in October 2014 which was revised within
24 hours. Following investigation the Standard Policy being implemented relating to
‘Checking of Prosthesis and Implants’ Policy No. TH11 was amended. In addition to
the existing three step check of correct prosthesis and verbal confirmation from the
surgeon, a further check of implant packaging was added. The Consultant Surgeon
now also incorporates a final check before the end of the procedure. These lessons
have been shared by clinical leads across the Ramsay group.
2.1.2 Surgical Safety Checklist
This is a set of criteria produced by the Word Health Organisation designed to
improve the safety of surgery.
Audits were undertaken throughout the period with an expectation of 100%
compliance and reviewed by the hospital’s Clinical Governance and Medical Advisory
Committees. Any non-compliances are recorded and required actions set in place.
Briefing and debriefing sessions after all operating sessions continue and give
opportunity for shared learning, recommendations for future practice and aim to
encourage autonomy for all members of the team.
2.1.3 VTE Assessment
A VTE risk assessment is completed for all patients to reduce the incidence of postoperative Venous Thromboembolism (VTE), in accordance with Ramsay’s CM 001
VTE policy. This requires Consultants to complete a risk assessment of patients prior
to procedure. During this period, documentation has been updated to enable
Consultants to document any change in a patient’s status during surgery.
2.1.4 Staffing
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Retention and recruitment of clinical staff in theatre has been an issue over the
period as it has been nationally across the healthcare sector. A strong recruitment
drive was launched in this period to attract staff from the UK and internationally. This
has enabled Fulwood to fill the majority of its vacancies.
The electronic rostering software Allocate which was adopted by Ramsay in 2014,
continues to ensure that staffing hours are maintained at optimal levels for patient
safety.
The focus on staff education remains high and the Ramsay Academy, the company’s
national resource for training, continues to provide learning and development
opportunities for all staff in terms of:
mandatory training to maintain clinical competences
development of individuals’ skills to enable succession planning and career
development
non-clinical training to support the delivery of individuals’ roles and career
development
2.1.5 Endoscopy Standards
The Global Rating Scale was created nationally in 2004 by the JAG or Joint Advisory
Group (a national group representing several Royal Medical colleges to improve
standards and training in gastrointestinal endoscopy) as a quality improvement and
assessment tool to measure the quality of gastrointestinal endoscopy services.
Unlike some providers, Fulwood’s endoscopy services are accredited to the JAG’s
quality standards and is measured twice per year, demonstrating compliance against
the four areas of:
clinical quality
quality of patient experience
workforce
training
2.1.6 Patient Experience
In the period, Fulwood Hall continued to encourage patients to provide feedback
using various methods which included our:
Web based satisfaction survey
Friends and family paper survey
‘We value your opinion’ paper surveys
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Endoscopy specific paper surveys
Our surveys cover all departments to ensure the whole hospital was included. Patient
feedback is recorded then reported at meetings of the following hospital groups:
Clinical Governance Group
Medical Advisory Committee
Quality Group
Patients’ comments are also shared with staff and actions set to ensure lessons are
learnt if necessary.
Contrary to plans for 2014/15, we have not introduced a patient focus group in the
period and will carry this forward to introduce in 2015/16.
2.1.7 CQUINS 2014/15
The Commissioning for Quality and Innovation (CQUIN) payment framework enables
NHS commissioners to reward excellence, by linking a proportion of a healthcare
provider’s income to the achievement of quality improvement goals. Our hospital had
2 national CQUINS for this period, and 3 local CQUINS as outlined below.
National CQUINS
Friends and Family Test
The hospital undertook Friends & Family testing with both inpatient and day case
patients in the period, achieving a 50% response rate and a 99% rate for
‘Extremely likely to recommend’.
The hospital undertook Friends & Family testing with staff in the period, achieving
a 83% response rate and a 97.5% rate for ‘Extremely Likely to recommend’. This
CQUIN has moved to the standard contract for 2015/16.
NHS Safety Thermometer
This is a national measure which allows healthcare providers to check for
potential ‘harms’ for patients during their treatment. Fulwood Hall Hospital has
been 100% compliant with data submission and will continue to submit this data
in relation to pressure ulcers, falls and urinary tract infection in those with a
catheter. This CQUIN has moved to the standard contract for 2015/16.
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Local CQUINS
Equality and Diversity
Fulwood Hall Hospital was one of the first private hospitals to work on NHS
England’s EDS2 initiative to ensure that the services we provide for patients
and that the working environment we provide to staff is free of discrimination.
This reporting was very new to us and a challenge looking at our service in
accordance with the nine protected characteristics under the Equality Act
2010; age, disability, gender reassignment, marriage and civil partnership,
pregnancy and maternity, race, religion and belief, gender and sexual
orientation. Although compliant in many areas we were able to introduce some
changes to the hospital. This will continue as a CQUIN in 2015/16.
Advancing Quality
This initiative, managed by the NHS body - Advancing Quality Alliance, is
aimed at improving the quality of care and patients’ experiences. It is a local
CQUIN where Fulwood Hall Hospital submits data regarding Deep Vein
Thrombosis (DVT) and the prevention of infection using antibiotic therapy (also
known as antibiotic prophylaxis). The hospital complies with the expectation of
internally completing data in 95% of incidences. This will continue as a CQUIN
in 2015/16.
Patient Reported Outcome Measures (PROMS)
PROMs is a NHS initiative to measure the health gain in patients undergoing
hip replacement, knee replacement, varicose vein and groin hernia surgery in
England, based on responses to questionnaires before and after surgery. Our
hospital has been monitored in the period in terms of patient response rates,
with the benefit being that the hospital can then investigate cases where
patients felt their health had not improved following treatment.
A new process has been introduced in the period to improve response rates,
whereby physiotherapists actively encourage patients to complete the survey
post operatively to support the investigation of outcomes. After discussion with
Greater Preston CCG it has been decided that PROMs will not continue as a
CQUIN in 2015/16 or move to a requirement of the standard contract.
However Ramsay is continuing this measure to support quality improvement.
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2.2 Clinical Priorities for 2015/2016 (looking forward)
On an annual cycle, Fulwood Hall Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in partnership
with the NHS ensuring that those services commissioned to us result in safe, quality
treatment for all NHS patients whilst they are in our care. We constantly strive to
improve clinical safety and standards by a systematic process of governance
including audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the hospital’s Senior Management Team taking into
account patient feedback, audit results, national guidance and the recommendations
from various hospital committees which represent all professional and management
levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
2.2.1 Quality Management
Fulwood Hall started 2015 with a new staff position ‘Quality Improvement Manager’
consolidating the control of all aspects of quality within the hospital under one
manager. This role works closely with the hospital’s clinical manager and the
departmental managers to ensure there are continuous improvement processes in
place which achieve sound and effective outcomes.
The Quality Improvement Manager focuses on the following areas:
• Clinical governance
•
CQC
• Policies
•
CQUINS
• Audit Programme
•
Communication
• Customer satisfaction
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Risk
• Quality Accounts
•
Complaints
The role is responsible for:
Coordinating the Clinical Governance agenda
Ensuring audits are undertaken
Ensuring investigations take place regarding incidents or complaints and that
actions arising are completed and changes made
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Supporting and developing clinical managers in analysing trends for their
department and identifying areas for improvement in order to drive an effective
quality improvement cycle.
Acting as a role model ensuring the highest levels of professional standards.
Preparing reports for external bodies related to quality and NHS contract
performance
Providing support to the hospital’s Clinical Governance Committee and
subcommittees by ensuring incident reports are up to date and available.
Reviewing all clinical incidents in conjunction with clinical managers to ensure that
reports submitted are thorough, objective and accurate and that investigations
and actions are documented.
Lead the compilation of the Hospital Quality Account and ensure a high quality for
publication.
The role’s measurable outcomes are:
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Reports available as required by internal and external organisations
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Clinical Governance committees have all documentation required
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Action plans are documented as a result of audit results
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All incidents or complaints are responded to within set time frames and
documented according to Ramsay policy
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A Quality Account for the hospital is published annually
2.2.2 Staff Retention and Development
Staffing and retention of staff is key to clinical quality and remains a key focus area
for Ramsay. A comprehensive and effective induction is critical in supporting
employees to fulfil their responsibilities and helps nurture staff for the future so a new
staff induction handbook and process has been developed and is to be implemented
in 2015/16.
Ensuring we maintain the correct numbers of appropriately skilled staff available to
care for our patients is another key focus and Ramsay’s national Academy provides a
dedicated, learning resource consisting of national and regional training courses
using internal and external trainers; e-learning tools and support towards formal
qualifications. Mandatory training for clinical competencies are incorporated into a
training matrix for staff and complemented with webinars and external training.
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Ramsay’s Management Development Framework also provides opportunity for
aspiring leaders of the future to develop their skills and knowledge.
All staff undergo a Personal Development Review (PDR) every year to appraise their
performance and in 2015/16 all hospital managers will also receive a 360 degree
collation of feedback regarding their performance from colleagues.
Following on from the introduction of a new code of practice from the Nursing and
Midwifery Council in March 2015, the hospital’s clinical lead is to collate a programme
of education to introduce the new code to all nursing staff, highlighting what is
involved and how the hospital will support them in achieving their goals.
2.2.3 Information Security
Fulwood Hall Hospital has achieved the independently audited Information Security
quality standard ISO 27001 and will continue to ensure standards are maintained.
2.2.4 Safeguarding / PREVENT
Safeguarding vulnerable adults and children is high on our agenda at Fulwood Hall
and we pride ourselves in having a proactive safeguarding/PREVENT team within the
hospital. Our team have strong links outside the hospital and sit on the local
Safeguarding Adults Leadership Group (SALNET) and the group of NHS Lancashire
Prevent Leads.
A calendar is in place for the coming 12 months whereby relevant topical information
is displayed on the hospital’s Safeguarding noticeboard and cascaded to all staff with
resources for learning and practice development. Safeguarding training is included in
all employees’ annual mandatory training and mandatory e-learning modules.
Monthly mini safeguarding audits are designed and are to be carried out to determine
employees’ understanding and knowledge in order to form gap analysis.
2.2.5 NICE Guidance / Alerts
Fulwood has a robust system to receive, review and action all medical alerts which
are circulated by the NHS National Patient Safety Agency and will continue to make
this a clinical priority. Medical alerts may cover a wide range of topics, from vaccines
to patient identification. Types of alerts include Rapid Response Reports, Patient
Safety Alerts and Safer Practice Notices.
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2.2.6 Patient Experience
We will continue to encourage patients to provide feedback using our independently
collated, web based satisfaction survey. This online survey has been expanded to
include outpatients (including physiotherapy and radiology) and also now has specific
endoscopy questions. This reduces the need for paper surveys in these areas and
duplication of patient questionnaires.
Due to an increasing number of patients being invited to comment (and the
subsequent increase in data and analysis), the independent company that is
contracted to undertake the survey for Ramsay, QA Research, will now produce two
reports every month and every quarter – one collective report for all Ramsay
hospitals and one for each hospital’s own results. ‘Hot Alerts’ i.e. a patient comment
that requires immediate management attention are received and reviewed by the
hospital’s General Manager, Clinical Lead, and Operations Manager with action
being taken where there are areas identified for improvement. Lessons learnt from
patients’ comments and the subsequent introduction of new processes are shared in
the hospital and across Ramsay’s other hospitals. All comments, positive and
negative, are shared with clinical and non-clinical teams. Compliments and
complaints are also reviewed at the hospital’s Clinical Governance and Medical
Advisory Committees.
We will continue to monitor posts on NHS choices and remain committed to retaining
our five star recommendation rating. We also aim to enhance our patient input by
introducing a patient focus group this year and will continue including patients in
hospital PLACE audits.
2.2.7 Preoperative assessment and daycase projects
This project for implementation in 2015/16 reviews the patient’s journey through preoperative assessment and through admission of daycase procedures to optimise
safety and efficiency for our patients.
2.2.8 Patient electronic records
Nationally, Ramsay will introduce a new patient records software package in 2015/16
which is a comprehensive electronic patient records system. It will simplify theatre
recording processes, consolidate patient information and provide a direct booking
capability for our insured patients. We will also be piloting the integration of voice
recognition and integration of medical devices (e.g. blood pressure monitors) into the
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recording software; if successful these capabilities will allow us to reduce our
dependence on the use of paper-based patient records and improve service eg.
enabling the provision of SMS (text) reminders, self-registration kiosks for patients
and electronic prescribing.
2.2.9 CQUINS 2015/16
The national CQUINs are not applicable to Ramsay hospitals for this year for the
reasons given below:
1. Identification and early treatment of sepsis – the total number of patients
presenting to the Emergency Department who were screened for sepsis.
Not applicable to Ramsay, emergency care only.
2. Care of patients with Acute Kidney Injury – percentage of patients with AKI
treated in hospital whose discharge summary includes the response to 4 key
questions regarding post op care.
Rarely would Ramsay treat a patient with AKI due to our contracted case mix.
3. Improving urgent and emergency care across local health communities.
All indicators under this scheme relate to urgent and emergency care services
and are therefore not applicable to Ramsay.
Local CQUINS
The hospital has given great consideration to local CQUINs in order to ensure that
they make a difference to our practice and the quality of service that we deliver. The
4 local CQUINs for 2015/16 are:
1. Advancing Quality (AQ4) – Hip and Knee Replacement
This CQUIN will focus on the Appropriate Care Score (ACS) which aggregates the
delivery of several underlying clinical interventions into a single measure of quality.
The process measures for Hip & Knee Replacement patients are:
Prophylactic antibiotic received within one hour prior to surgical incision
Prophylactic antibiotic selection for surgical patients
Prophylactic antibiotics discontinued within 24 hours after surgery end time
Recommended Venous Thromboembolism prophylaxis ordered
Appropriate Venous Thromboembolism prophylaxis administered within 12
hours of surgery end time
Appropriate duration of VTE administration post-surgery
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2.
Sepsis
This CQUIN focuses on staff at Ramsay being made aware of the early signs of
Sepsis and implementing the nationally recognised Sepsis Six pathway to treat
patients effectively. A leaflet is to be produced to make patients and carers aware of
the early signs of Sepsis and the correct action to take.
3. Reducing Health Inequalities
a) Better Health Care Outcomes
The policies set for Ramsay hospitals are designed to meet the health needs of
the local community that are within their contractual requirements, by focusing on
their protected characteristics, in particular:
• Individual people's health needs are assessed and met in appropriate and
effective ways
• Transitions from one service to another, for people on care pathways, are
made smoothly with everyone well-informed
• When people with protected characteristics use Ramsay hospitals for their
services, their safety is prioritised and they are free from mistakes,
mistreatment and abuse
b) Improved patient access and experience
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•
•
Patients and carers will be able to readily access Fulwood’s services and will
not be denied access on unreasonable grounds
Patients will be informed and supported to be as involved as they wish to be
in decisions about their care
Complaints about services will be handled respectfully and efficiently
4. Patient Enquiry Phone Calls
The aim of this CQUIN is to improve discharge communication for patients by
monitoring post-operative phone calls received from patients in order to identify
themes and trends and rectify gaps in information given while patients are within the
hospitals.
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2.3 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by NHS England.
2.3.1 Review of Services
During 2014/15 Fulwood Hall Hospital provided eight NHS services.
Fulwood Hall 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 1st April 2014 to 31st March
2015 represents 100% per cent of the total income generated from the provision of
NHS services by Fulwood Hall Hospital for 1st April 2014 to 31st March 2015.
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard are
reviewed each year. The scorecard is reviewed each quarter by the hospital’s senior
managers together with Regional and Corporate Managers and Directors. The
balanced scorecard approach has been an extremely successful tool in helping us
benchmark against other 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
Staff Cost % Net Revenue
HCA Hours as % of Total
Nursing
Agency Cost as % of Total Staff
Cost
Ward Hours PPD
% Staff Turnover
% Sickness
% Lost Time
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff
Injuries
Patient
Formal Complaints per 1000
HPD's
Patient Satisfaction Score
Significant Clinical Events per
1000 Admissions
Readmission per 1000
Admissions
Quality
Workplace Health & Safety
Score
Infection Control Audit Score
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2.3.2 Participation in clinical audit
During 1st April 2014 to 31st March 2015, Fulwood Hall Hospital participated in three
national clinical audits.
The national clinical audits that Fulwood Hall Hospital participated in, and for which
data collection was completed during 1st 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
National Joint Registry (NJR)
100%
Hip 100%
Knee 96%
Elective surgery (National PROMs Programme)
Varicose Veins
52%
Hernia 49%
Medical and surgical clinical outcome review programme:
National confidential enquiry into patient outcome and death
0% - no deaths in
period
The reports of these national clinical audits were reviewed by the hospital’s Clinical
Governance Committee.
Local Audits
The reports of local clinical audits from 1st April 2014 to 31st March 2015 (schedule
attached in Appendix 2) were also reviewed by the hospital’s Clinical Governance
Committee.
2.3.3 Participation in Research
There were no patients recruited during 2014/15 to participate in research.
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2.3.4 Goals agreed with our Commissioners using CQUINs
A proportion of Fulwood Hall Hospital’s income from 1 April 2014 to 31st March 2015
was conditional on successfully achieving CQUIN measures
2.3.5 Statements From The Care Quality Commission (CQC)
Fulwood Hall Hospital is required to register with the Care Quality Commission and its
current registration status on 12th May 2015 is registered without conditions.
The hospital has not participated in any special reviews or investigations by the CQC
during the reporting period.
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2.3.6 Data Quality
The hospital continues to take the following actions to improve data quality:
Regular training to ensure staff understand the importance of accurate data
input and have sufficient technical competence
Employment of a clinical coder to improve accuracy of recording
Supporting national Ramsay projects to ensure data accuracy
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
Clinical Coding Error Rate
The 2014/15 Clinical Coding Audit for Fulwood Hall Hospital showed the hospital to
reach recommended levels of accuracy for its coding in three of four areas – coding of
primary diagnosis, primary procedure and secondary procedure. Coding of
secondary diagnosis scored 1% less than the recommended level therefore the
hospital is to be re-audited in May 2015.
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2.4 Stakeholders’ Views on Fulwood Hall Hospital
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Jan Ledward, Chief Officer - Greater Preston Clinical Commissioning Group
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Part 3: Review of quality performance
2014/2015
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 develops ways of working
which assure that the quality of patient care is central to the organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care. Clinicians
are enabled to provide that care and the organisation can satisfy itself that we are
doing the right things in the right way.
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.
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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
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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.
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3.1 The Core Quality Account Indicators
The following tables and graphs show comparisons regarding key data between the
following:
•
•
•
•
The best scoring hospital for this quality indicator based on all England
hospitals providing NHS services
The worst scoring hospital for this quality indicator based on all England
hospitals providing NHS services
The average score for this quality indicator
Fulwood Hall Hospital
Mortality Rates
The Summary Hospital-level Mortality Indicator (SHMI) is an indicator which reports on
mortality at Trust level across the NHS in England.
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
Fulwood
NVC07
0
NVC07
0
Readmission Rates
This measures the percentage of surgical patients being readmitted to hospital
following treatment. This data does not include emergency readmissions.
Period
2010/11
2011/12
Best
Multiple
0.0
Multiple
0.0
Worst
5P5
22.76
5NL
41.65
Average
Eng
11.43
Eng
11.45
Period
2010/11
2011/12
Fulwood
NVC07
6.93
NVC07
6.36
VTE Assessment
This measures the provider’s compliance with recording information on admitted adult
patients who have been risk assessed for Venous Thromboembolism.
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
Fulwood
NVC07
99.9%
NVC07
99.6%
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Serious Untoward Incidents
This measures incidence of severe/death patient safety incidents per 1000 admissions
(Oct13-Mar14) and per 1000 bed days (Apr-Sep14).
Period
Best
Oct 13 - Mar 14
RBD
Apr - Sep 14
Several
0
0
Worst
R1F
3.72
RBZ
1.09
Average
Eng
0.43
Eng
0.17
Period
Oct13-Mar14
Apr-Sep14
Fulwood
NVC07
0.00
NVC07
0.20
Friends and Family Test
This measures the percentage of patients that would recommend the hospital.
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
Fulwood
NVC07
100.0%
NVC07
100.0%
Incidence of C.Difficile
This measures the incidence of this infection per 100,000 bed days.
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
Fulwood
NVC07
0.0
NVC07
0.0
Responsiveness to personal needs
This percentage measure is taken from the patient satisfaction survey.
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
2012/13
2013/14
Fulwood
NVC07
93.5
NVC07
92.1
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Patient Reported Outcome Measures (PROMs)
* (volumes too low to report)
Hernia
Period
Apr13 - Mar14
Apr14 - Sep14
Best
NT415
0.139
RXR
0.125
Worst
NVC11
0.008
Several
0.009
Average
Eng
0.085
Eng
0.081
Period
Apr13 - Mar14
Apr14 - Sep14
Fulwood
NVC07
0.088
NVC07
*
Worst
NT350 -16.849
RWA
-16.762
Average
Eng
-8.698
Eng
-9.479
Period
Apr13 - Mar14
Apr14 - Sep14
Fulwood
NVC07
*
NVC07
*
Worst
RQX
17.634
RJD
18.357
Average
Eng
21.34
Eng
21.922
Period
Apr13 - Mar14
Apr14 - Sep 14
Fulwood
NVC07
20.531
NVC07
*
Worst
NV323
12.049
RXF
14.416
Average
Eng
16.248
Eng
16.702
Period
Apr13 - Mar14
Apr14 - Sep14
Fulwood
NVC07
18.901
NVC07
*
Varicose Veins
Period
Apr13 - Mar14
Apr14 - Sep14
Best
RTH
RYJ
11.292
-4.567
Primary Hip Replacement
Period
Apr13 - Mar14
Apr14 - Sep14
Best
NT441
24.444
RCB
25.418
Primary Knee Replacement
Period
Apr13 - Mar14
Apr14 - Sep14
Best
NT404
19.762
RWP
20.44
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3.2 Patient Safety
We are a progressive hospital and focussed on stretching our performance every year,
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. Local mini local audits which
cover health and safety, safeguarding, and fire are carried out monthly
3.2.1 Infection Prevention and Control
Fulwood Hall Hospital has a very low rate of hospital acquired infection and has had
no reported MRSA Bacteraemia in the past 6 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 provides mandatory training in different areas of
infection control on an annual basis to all staff. This year the focus is on needle stick
injuries and infectious patients. She also completes a hand hygiene training session
on staff induction for all new staff.
Hand hygiene awareness days are led by the infection control link nurse involving
staff, patients and visitors and information in waiting areas.
Observational hand hygiene audits are also undertaken by the Infection Control Link
Nurse
Our infection control rate remains very low and our reporting and investigation
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of potential infections has improved in the last year. Any patient presenting signs of an
infection is reviewed by the infection control link nurse and a root cause analysis
completed to determine any possible trends with results being presented at our
quarterly infection control committee meetings. There have not been any trends
identified in the period.
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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 Fulwood Hall Hospital, providing us with a
patient’s eye view of the buildings and facilities, giving us a clear picture of how the
people who use our hospital see it and how it can be improved. The Hospital scored
96% for the four areas of cleanliness, food, privacy and the condition of facility during
the period. An action plan was compiled and managed by senior management to
ensure feedback was acted upon and facilities remain of a high standard.
Nationally, the main findings are as follows including comparable stats from 2013
(please see additional note below*), followed by FHH scores;
The National Average for Cleanliness was 97.25% (2013 = 95.75%); FHH 100%
The National Average for Food and Hydration was 88.79% (2013 = 85.41%); FHH
98.07%
The National Average for Privacy Dignity and Wellbeing was 87.73% (2013 = 88.90%);
FHH 93.02%
The National Average for Condition Appearance and Maintenance was 91.97% (2013
= 88.78%). FHH 100%
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 a high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient safety.
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.
In addition to mandatory training the Health and Safety Coordinator has coordinated
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. There
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is a hospital Health and safety board which covers a different topic every month
helping to raise staff awareness.
3.3 Clinical effectiveness
Fulwood Hall hospital has a Clinical Governance committee that meet regularly
through the year to monitor quality and effectiveness of care. Clinical incidents
together with patient and staff feedback are systematically reviewed to determine any
trends that require further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital management
and the hospital’s Medical Advisory Committee 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 NHS 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.
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3.4 Patient Experience
All feedback from patients regarding their experiences with Ramsay Health Care is
welcomed and inform service development in various ways dependent on the type of
experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also fed back to the relevant
staff directly. All staff are aware of our complaints procedures should our patients be
unhappy with any aspect of their care.
Patients’ experiences are fed back via the various methods below, and are standard
agenda items on local Governance Committees for discussion, trend analysis and
further action where necessary. Escalation and further reporting to Ramsay Corporate
and NHS England bodies occurs as required and according to NHS policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Via a web based survey invitation
‘Hot alerts’ are received within 48hrs of a patient making a comment on the web
survey
Friends and family questions asked on patient discharge
The hospital’s ‘We value your opinion’ leaflet which is given to all admitted
patients
Verbal feedback from patients to hospital staff - including Consultants, Matron,
and General Manager whilst visiting patients and also during CQC visit
feedback
Written feedback via letters and emails from patients
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of
care
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 patients’ views.
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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. The below graph
shows the percentage of patients that were satisfied with the hospital’s service.
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Appendix 1
Services covered by this quality account
Services Provided
Treatment of
Disease,
Disorder
Or injury
Cosmetics, Dermatology,
Ear, Nose and Throat (ENT),
General surgery,
Gynaecological, Ophthalmic,
Orthopaedic, Physiotherapy,
Rheumatology, Sports
medicine, Urology, Spinal,
Pain Management
Peoples Needs Met for:
All adults 18 yrs and over
Children 3 years and above
All adults 18 yrs and over excluding:
Surgical
Procedures
Breast surgery, Cosmetics,
Day and Inpatient Surgery,
Dermatology, Ear, Nose and
Throat (ENT), General
surgery, Gynaecological,
Ophthalmic, Oral
maxillofacial surgery,
Orthopaedic, Urology,
Spinal
Patients with blood disorders (haemophilia, sickle
cell, thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA screen are
deferred until negative
Patients who are likely to need ventilatory support
post operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission to ITU
post surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild exertion
e.g. from kitchen to bathroom or dyspnoea at rest)
Poorly controlled asthma (needing oral steroids or has
had frequent hospital admissions within last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal
activity e.g. 1 flight of stairs or angina at rest)
CVA in last 6 months
However, all patients will be individually assessed and we
will only exclude patients if we are unable to provide an
appropriate and safe clinical environment.
Children 3 years and above
Diagnostic
and
Screening
Imaging services,
Phlebotomy, Urinary
Screening and Specimen
collection.
All adults 18 yrs and over
Children 3 years and above
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Appendix 2 – Clinical Audit Programme 2014/15
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Fulwood Hall Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Telephone: 01772 704111
www.fulwoodhallhospital.co.uk
Quality Accounts 2014/15
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