North Downs 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
Priorities for Improvement
2.1.1 Review of clinical priorities 2014/15 (looking back)
2.1.2 Clinical Priorities for 2015/16 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2014/15 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
3.5
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
North Downs Hospital is part of the Ramsay Health Care Group
Introduction
The provision of high quality patient care is and will always be the highest priority of Ramsay
Health Care UK. Of course our team of clinical staff and consultants are very much at the
forefront of achieving this but there is also very much an organisation wide commitment to ensure
that we continue to improve out outcomes every day, week, month and year.
Delivering clinical excellence depends on everyone in the organisation. Clinical excellence cannot
be the responsibility of just a few, it takes all of us to be responsible and accountable for our
performance in the various roles we all play. Having an organisational culture that puts the patient
at the centre of everything we do is key to ensuring we enable everyone to perform at their peak
to attain great outcomes.
Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism on
which excellence in clinical practice depends, we will continue to strive to get ever better.
I am very proud of our long standing and major provider of healthcare services across the world
and of our Ramsay very strong track record as a safe and responsible healthcare provider. It
gives us pleasure to share our results with you.
Mark Page
Chief Executive officer
Ramsay Health Care UK
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Introduction to our Quality Account
This Quality Account is North Downs Hospital’s annual report to the public and
other stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t
provide enough in depth information for the public and commissioners about the
quality of services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
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Part 1
1.1 Statement on quality from the
General Manager North Downs Hospital
I am delighted to present my third North Downs Quality Account which is the
hospital’s fifth edition.
The data within this quality account has been prepared with input from a wide
range of sources including our staff, consultants and commissioners. At the
hospital we have a strong focus on ensuring our care remains safe and effective
and patient outcomes and experience is the best it can be.
As you will see from the detail within the account the hospital has a strong focus
on ensuring our care is safe and effective but we recognise that there is always
improvements we can make to our service and this is embedded within our team.
We have a range of processes in place to review and monitor our standards in
these areas in order to identify areas of concern, or where improvements could
be made. These processes also ensure that we are accurately recording and
reporting the data needed to satisfy ourselves that these reviews are giving us a
complete and transparent picture of the hospital performance. These also allow
us to benchmark our performance against other providers both within Ramsay
and against a wider national picture.
These benchmarking exercises show us that generally our NHS services are very
well thought of by our patients and their families and our clinical data shows we
have no outliers.
We use these reviews to create detailed action plans on the areas we need to
improve on and these are detailed within the account under our clinical priorities.
We have treated an increasing number of patients this year and are very proud of
the part we play in the local healthcare economy. Whilst our patient numbers
have increased I am pleased that our safety, effectiveness and efficiencies have
not been affected.
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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.
Stuart Emerson
General Manager
North Downs Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Khalid Drabu, Orthopaedic Consultant and Chair of Medical Advisory Committee
Mr John Campbell, Orthopaedic Consultant and Chair of Clinical Governance Committee
Mr Stefan Andrejczuk, Regional Director South, Ramsay Health Care UK
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Welcome to North Downs Hospital
North Downs Hospital was established 41 years ago this year and is one of
Surrey’s leading private hospitals. Located in a quiet residential area of
Caterham, it provides a comprehensive range of surgical and medical services
together with the highest standards of patient care. North Downs Hospital retains
its reputation for delivering such care in a welcoming, clean and comfortable
environment.
The hospital is regulated by the Care Quality Commission; our latest report can
be viewed at www.cqc.org.uk or by request to the General Manager.
The facility currently has 14 individual and 1 double inpatient bedrooms, all with
en-suite facilities to ensure complete privacy. We also have a 5 bay day
procedure facility. Ramsay Health Care has invested in advanced medical
technology, particularly in our operating theatres, and offers a wide range of
treatments and services. The hospital has designated one room as a Close
Observation Room which facilitates caring for a patient who requires closer
monitoring.
Through the year we have continued our refurbishment of the hospital with
continued refurbishment of our public areas such as corridors and waiting rooms.
Future plans also include development of our Ambulatory Care facility.
We also have Physiotherapy and Radiology Departments. Other services which
include MRI, CT and Dexa scans are provided by our sister hospital in Ashtead.
We have a close relationship with Surrey and Sussex NHS Trust who provide us
with Blood Transfusion and other pathology services (we are able to carry out a
range of point of care tests (POCT) on site), as well as access to Level 3 critical
care services if required. We also work closely with Croydon Health Services
NHS Trust
Services provided at North Downs Hospital include both medical and surgical
specialities including orthopaedics, general surgery, ophthalmology, dermatology
and gynaecology. A full list of specialities carried out is included in the Appendix 1
at the end of the Quality Account.
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We provide safe, convenient, flexible, effective and high quality care and
treatment for patients above the age of 3, whether medically insured, self-funding
or publically funded.
We are working with the CCG’s to provide a wide range of services to meet the
needs of the local healthcare community. We are keen to ensure that patients
can have treatment at their local hospital where appropriate. We take great pride
in our ability to innovate and develop new ways of working, ensuring that all care
is delivered in the best and most efficient way, whilst also ensuring we deliver
consistently good outcomes.
We have a total of 88 Consultants and 36 Anaesthetists who practice at North
Downs. All our consultants undergo rigorous vetting procedures prior to
commencing practice at the hospital and regular review through our clinical
governance framework to ensure the highest possible clinical care.
Total number of patient admissions in the past year to April was 3,693 of which
70% (2,613) were NHS patients
Our staff complement as of April 2014 is 57 whole time equivalents (WTE) and 21
bank members of staff.
Qualified Nurses – 13.9 WTE
Health care assistants - 6.2 WTE
Radiographers - 1.4 WTE
Porters – 2.0 WTE
Administration Staff – 21.4 WTE
Support services – 6.2 WTE
Operating Department Practitioners – 6.0 WTE
Our pharmacy, decontamination and supplies services are provided by Ashtead
Hospital. Our Business Office and accounting functions work across both sites.
Having this close working relationship ensures that we regularly share best
practice and lessons between hospitals ensuring we provide the best possible
service to all users of our hospital.
The Resident Medical Officers are on site 24 hours per day. They play an active
part in the clinical team and are available to support the Consultants and provide
ongoing care for the patients.
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We host monthly open events which offer an opportunity for the public to see our
facilities whilst finding out about a specific subject of interest. Our GP Liaison
Office visits local GP surgeries to regularly update all practice staff on our
services and assist them with any issues. We regularly arrange ‘Lunch & Learns’,
taking consultants into GP Surgeries to offer training and latest development
awareness as well as running monthly evening GP Education Seminars. Our
NHS Services Directory is frequently updated and redistributed to the GPs to
ensure their information is always current.
Additionally, we have a GP representative on the hospital’s Medical Advisory
Committee. We value our contact with GPs as “customers” and strive to ensure
we actively work in partnership to enhance patient care.
We are proud of the part we play in delivering NHS Services and consistently
receive positive patient feedback in our ‘We value your opinion’ leaflets, online at
NHS Choices, the Friends and Family Test, and through our patient satisfaction
survey.
We have worked on our local community relationships during the year and
continue to work closely with local groups such as the Caterham Rotary.
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Part 2
2.1 Quality priorities for 2014/2015
Plan for 2014/15
On an annual cycle, North Downs Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives on going at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2014/15 (looking back)
Patient safety
‘Never Events’
These are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented. Following
two events in 2012/13 in relation to ineffective communication with patients we
implemented a number of changes to our processes. This has improved our
performance with no further events occurring.
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WHO Surgical Safety Checklist
The World Health Organisation Surgical Safety Checklists were introduced into
Ramsay following the release of a patient safety alert from the National Patient
Safety Association. The tool is used to verify and check essential care
interventions before, during and following surgical procedures. The tool has been
shown to improve communication between all members of the Theatre Team
which in turn reduces the risk of errors.
We have continued to make good progress in implementing all the component
parts of this checklist and we have increased our scores on our compliance
audits. A training video demonstrating best practice has been developed by the
theatre team at another Ramsay hospital and we will continue to use this going
forwards to induct new staff to the correct process. The introduction of this system
has improved communication within the theatre team and involves the whole
team at each stage. Ongoing monitoring by our Theatre Manager will be required
to ensure the process remains embedded into every day practice and we will do
this by auditing every 3 months.
Our new Theatre Manager is now committed to develop the process further with
her team and is working to improve the quality of the debrief phase of the system.
Clinical effectiveness
Ambulatory Care – better outcomes and improving patient experience
Ambulatory Care (or Day Surgery Care) is the admission of selected patients
(both medical and surgical) to hospital for a planned procedure, returning home
the same day i.e. the patient does not incur an overnight stay).
In 2014/15 the percentage of day surgery patients we treated was 77%.
The current facility at North Downs does not have sufficient capacity for all of
these patients to be treated through our day-care unit and we therefore have to
make use of our inpatient bedrooms. We have continued to look at plans for
developing this area in order to create a better patient flow but as yet have not
finalised the scope or timeframe of this development.
We continue to review our pathways and particularly our administration processes
in order to identify areas where we can reduce visits to the hospital, waiting times
for patients and improve discharge arrangements. We continue to work with
Consultants to reduce waiting by staggering admissions and have had some
further successes this year.
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Meeting endoscopy standards
We have achieved our JAG accreditation in the year and continue to work
towards further improvements against the standards.
Figure 1: Clinical Quality
Figure 2: Quality of Patient Experience
We have continued to work with our Colorectal and Gastroenterology Consultants
to improve the patient experience throughout their care episode. The use of
Entonox for suitable patients has not only ensured that patients have a more
comfortable experience but has also reduced their need to stay after the
procedure. As activity increases the possibility of compiling single sex lists
becomes a more realistic option and this may help us to further improve our
privacy rating for which we continue to score a B.
Enhanced recovery
North Downs Hospital has been enrolled in the Enhanced Recovery Pathway for
hip and knee replacement patients for the past 3 years. We were awarded the
most improved independent sector provider by the Kent, Surrey and Sussex
Academic Health Science Network.
Our joint school has continued to develop with more of our physiotherapists now
trained to take these group sessions. The patient feedback remains outstanding
with other hospitals looking to consider this model. We now have dedicated
sessions for knees and hips.
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Patient experience
Waiting times
We continue to make further improvements into the time patients wait for their
procedure from admission to time of surgery with the cooperation of our Theatre
Team and Consultants. This will always remain a focus for us as we strive to
improve the patient’s experience.
Customer Care
Customer care is an integral part of what we do and we are keen to continue to
make improvements in our approach. We continue to provide mandatory training
for all of our staff and will review the content and delivery method of this for the
current year.
We have identified that perhaps our internal communication with our teams has
some room for improvement in that some key messages around improving the
customer experience are not fully understood. We aim to address this in the
forthcoming year with a more open and transparent approach to sharing
learnings.
PLACE audit (Patient Led Assessment of the Care Environment)
Our first PLACE audit took place in May 2014 and assesses:




Cleanliness
Food
Privacy, Dignity and Wellbeing
Appearance and Condition
This audit was led by a patient of the hospital and is based on their opinion of
these areas.
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This audit highlighted that we were slightly below national averages in terms of
privacy, dignity and wellbeing but above national averages in all other areas.
Since the date of this audit considerable effort has been made to improve the
privacy, dignity and wellbeing of patients and appearance and condition of the
hospital by improving communal areas and refurbishing a number of areas,
enabling inpatients to spend more time away from their individual room, improving
availability for quiet spaces for private conversations.
Patient Safety
Hand Hygiene
There have been some improvements with patient’s perception of our staff
washing their hands. We have raised awareness at all of our departmental
meetings and provided gel toggles for staff to carry. Verbalising to patients that
staff members are washing their hands before they do so appears to be
improving results in this area.
Sign up to safety
We continue to have a relatively low level of safety incidents within the Hospital
but we constantly strive to reduce numbers of events by reviewing our practice
and establishing new ways of doing things. We have signed up to the ‘Sign up to
Safety’ Campaign and have set objectives to reduce the overall number of events
by 50%. The specific areas we will focus on are as follows:
 Reduction of patient falls
 Drug administration errors
 Provision of effective equipment training for all relevant staff
 Improving access for our disabled customers
 Reducing the number of information governance incidents relating to
patient sensitive data.
Patient Discharge Medication
We have demonstrated further improvements in our audit results this year with
changes made to literature provided to patients and a focus on nurse training to
improve interaction with the patient prior to and at the time of discharge.
Clinical Effectiveness
Ambulatory Care
As a company Ramsay is focused on constantly improving the pathway for day
case patients. We are assessed regularly in terms of pathway and length of stay
and we work closely with our surgeons and anaesthetists to ensure that the
patients have a good experience. We will continue to work on aspects of our
pathway such as staggering admit times and standardisation of protocols.
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Improving Clinical Data Usage to improve outcomes
We collect vast amounts of data within the hospital and we are always looking for
new ways keen to develop better ways of using this data in order to improve the
outcomes for patients. We have re-established a regional Matrons group which
now meets monthly and a regular agenda item is for us to review funnel charts
detailing all aspects of incident reporting and analysing any outlier trends and to
share knowledge and learnings from incidents.
Patient Experience
Pain Management
We have been working towards improving our patient experience in relation to
pain control this year. Results have improved with the introduction of Entonox
now being widely used by the gastroenterologist for endoscopy procedures. We
have not made any significant improvements in relation to standardisation of
regimes by consultants and anaesthetists and will carry forward this objective for
the forthcoming year. We are looking to increase our pharmacist’s hours to
enable us to improve our service to patients.
Discharge Planning
We continue to focus on this aspect of care which is particularly important as the
length of stay for patient’s decreases. Our Discharge Liaison HCA continues to
work with patients, their families and other care providers to ensure that all
aspects of their discharge are carefully managed and planned prior to admission.
There have been no events this year where patients discharge has been delayed
by ineffective planning.
Improving patient feedback
We continue to receive a vast array of patient feedback through different sources,
including but not limited to, Friends and Family Test, verbal and written feedback
from patients and our own independent patient satisfaction survey. Most of the
feedback we receive remains very positive and our compliments continue to
outweigh our complaints. We have been talking with groups of staff about how we
manage complaints and have agreed a change of strategy to more actively
involve staff in resolving patient complaints. We hope that this will help to prevent
similar mistakes recurring
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Clinical Priorities for 2015/16 (looking forward)
Patient Safety
Hand Hygiene
We plan to renew our ANTT training for all of our relevant clinical staff this year
which will also help to raise awareness of our staff.
We have purchased some patient information leaflets relating to effective hand
hygiene for patients and we also hope will encourage patients to become involved
in their own care.
Patient Discharge Medication
We will continue to work on improving our levels of patient satisfaction around this
aspect of care. Individual medication leaflets are being developed to support the
existing literature details side effects and key information. The nursing team will
use these to review the discharge medications prior to the patient going home.
We are considering increasing our pharmacist input to assist us with this process.
Care of patients with Dementia or patients requiring memory support
We are working with the CCG to improve levels of screening for patients over the
age of 75. Patients will be requested to complete a single page questionnaire to
test their memory levels and then a score applied accordingly. This will enable us
to identify those patients who perhaps have not been previously highlighted as
having memory problems and result in a referral to their GP for further
assessment.
We will be also be adopting some aspects of the Blue Butterfly scheme to help to
highlight those patients needing support to staff. Blue pillow cases will be used to
subtlety identify patients with dementia or memory loss so that all our staff can
easily identify a patient who may require extra support.
Clinical Effectiveness
Ambulatory Care
We will continue to work closely with consultants and staff to make further
improvements to our patient pathway using the data provided by local and
corporate audits to benchmark against our peers and sharing best practice with
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colleagues. We measure the patient’s journey time through the hospital and can
then review against data by procedure of our colleagues.
We are planning to introduce some direct access services to include
gastroenterological procedures avoiding the need for an initial consultation with
the consultant. This will ensure patients can have their procedure carried out on a
single day and as such a more convenient service.
Improving Medical Records workflow
North Downs is a trial site for the new Electronic Patient Record which is being
introduced in April 2016. The new form of records will improve the patient
experience as well as ensuring that records are kept in accordance with national
guidance. This new system will see all patient records maintained electronically
in one secure location.
As a trial site the teams are currently involved in the planning of the system and
will receive full training on the relevant applications during the year.
Patient Experience
We are amending the current structure of our patient feedback group this year to
encourage more patients to meet face to face with us to discuss their
experiences, good and bad and to review their suggestions for how we can
improve aspects of care. We see the value of patient feedback and plan to use
this approach to gain ideas of what needs changing and how best to address it.
Improving the nutrition and hydration of our patients
We review our patient menus frequently but we will focus this year on improving
the quality of our food providing a comprehensive choice of healthy foods with the
aim of improving nutritional value.
We will be adopting the Royal College of Nursing’s ‘Water for Health’ toolkit to
improve practice and training for all our clinical and catering teams. Patient
education will be a key factor in making these improvements and we are looking
at available literature to support this project.
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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 North Downs Hospital provided and/or subcontracted 29 NHS
services. North Downs Hospital has reviewed all the data available to them on the
quality of care in 29 of these NHS services.
The income generated by the NHS services reviewed in 1 April 2014 to 31st
March 2015 represents 100% per cent of the total income generated from the
provision of NHS services by North Downs Hospital for 1 April 2014 to 31st March
2015.
Ramsay uses a balanced scorecard approach to give an overview of audit results
and key performance indicators 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
Indicator
Staff cost as % of Net Revenue
HCA Hours as % of Total Nursing Hours
Agency Hours as % of Total Hours
Ward Hours per patient day
% Staff Turnover
% Sickness
Lost Days
Appraisal %
Mandatory Training
Staff Satisfaction Score
Number of Significant Staff Injuries
Outcome
25%
17%
2.5%
4.9
21.9%
3.8%
1,735
92%
96%
92%
0
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Patient
Indicator
Formal Serious Complaints per 1000
admissions
Patient Satisfaction Score
Number of Significant Clinical Events per 1000
admissions
Number of Readmissions per 1000 admissions
Outcome
0
93%
0.49
0.36
Quality
Indicator
Workplace Health and Safety Score
Infection Control Audit Score
Outcome
95%
99%
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2.2.2 Participation in clinical audit
During 1 April 2014 to 31st March 2015 North Downs Hospital participated in 0
national clinical audits and 0 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 North Downs
Hospital participated in, and for which data collection was completed during 1
April 2014 to 31st March 2015, are listed below alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
Name of audit / Clinical Outcome
Review Programme
% cases submitted
National Joint Registry (NJR)
Hips
Knees
Shoulders
100%
80%
71%
Elective surgery (National PROMs Programme)
Hernia
Inadequate number of
procedures
Varicose Veins
Inadequate number of
procedures
Hips
Knees
91.1%
54.5%
Medical and surgical clinical outcome review programme:
National confidential enquiry into patient outcome and death
Severe sepsis & septic shock*
National Comparative Audit of Blood Transfusion programme
No eligible patient data
to submit, however
responses completed
relating to service
provision
No eligible patient data
to submit
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The reports of 0 national clinical audits from 1 April 2014 to 31st March 2015 were
reviewed by the Clinical Governance Committee.
Local Audits
The local audits carried out at North Downs are detailed on the template,
appendix
All audits continue to be reviewed at the local Clinical Governance Committee as
well as relevant departmental meetings, the Medical Advisory Committee and
other committees as appropriate. We intend to undertake more focused audits in
2015/16 in order to be able to identify areas of practice that require particular
attention. Two specific areas relate to the Nutrition and Hydration audit and the
MEWs audit. We have identified Nutrition and Hydration as a CQUIN this coming
year.
2.2.3 Participation in Research
There were no patients recruited during 2014/15to 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 North Downs Hospital income in from 1 April 2014 to 31st March
2015 was conditional on achieving quality improvement and innovation goals
agreed between North Downs 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 electronically
2.2.5 Statements from the Care Quality Commission (CQC)
North Downs Hospital is required to register with the Care Quality Commission
and its current registration status on 31st March is registered without
conditions/registered with conditions.
The Care Quality Commission has not taken enforcement action against North
Downs Hospital during 2014/15.
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North Downs Hospital has not participated in any special reviews or investigations
by the CQC during the reporting period.
North Downs Hospital was last inspected by the Care Quality Commission on the
27 February 2014. The full report is available via www.cqc.org.uk. The report
demonstrates full compliance with the outcomes assessed. The following
outcomes were inspected:






Consent to care and treatment
Care and welfare of people who use service
Cleanliness and infection control
Supporting workers
Assessing and monitoring the quality of service provision
All standards were found to have been met.
2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your
Data Quality
North Downs Hospital will be taking the following actions to improve data quality.
As can be seen from the data below our data quality is generally very good.
However we do recognise that there is some room for improvement. We realize
that a clear focus on data quality will assist with the overall safety, effectiveness
and efficiency of the service we provide.
In order to continue to monitor and improve our process we will continue to audit
our records. This includes manual audits of our medical records, as well as
automated data quality audits of our electronic records. These audits allow us to
identify where issues have occurred and provide opportunities for correction of
the records and training for specific issues.
As mentioned in the clinical effectiveness section above we are keen to use our
data more frequently and in different ways to continue to drive improvement in our
service and therefore data quality is vital in this. Through more regular usage of
the data we will also identify any data quality issues that need to be resolved.
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:
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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
Audit Date
Primary Diagnosis
December 2014
93.3%
Secondary
Diagnosis
95.0%
Primary
Procedure
100%
Secondary
Procedure
96.4%
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2.2.7 Stakeholders views on 2013/14 Quality Account
NHS East Surrey CCG as Lead Coordinating Commissioners have had the
opportunity to review this document and at time of publishing have not shared any
feedback to be added.
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Part 3: Review of quality performance 2014/2015
Statements of quality delivery
Review of quality performance 1st April 2014 - 31st March 2015
Introduction
This publication marks the sixth successive year since the first edition of Ramsay Quality
Accounts. Through each year, month on month, we analyse our performance on many levels, we
reflect on the valuable feedback we receive from our patients about the outcomes of their
treatment and also reflect on professional opinion received from our doctors, our clinical staff,
regulators and commissioners. We listen where concerns or suggestions have been raised and, in
this account, we have set out our track record as well as our plan for more improvements in the
coming year. This is a discipline we vigorously support, always driving this cycle of continuous
improvement in our hospitals and addressing public concern about standards in healthcare, be
these about our commitments to providing compassionate patient care, assurance about patient
privacy and dignity, hospital safety and good outcomes of treatment. We believe in being open
and honest where outcomes and experience fail to meet patient expectation so we take action,
learn, improve and implement the change and deliver great care and optimum experience for our
patients.”
Vivienne Heckford
Director of Clinical Services
Ramsay Health Care UK
Ramsay Clinical Governance Framework 2014/15
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.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
Quality Accounts 2014/15
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implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
Quality Accounts 2014/15
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National Guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the NHS Commissioning Board Special
Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
3.1 The Core Quality Account indicators
Mortality:
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
North Downs
NVC11
0
NVC11
0
North Downs Hospital considers that this data is as described for the following
reasons; the services commissioned are planned surgical procedures and as
such remain low risk, we have an extensive and effective pre-operative screening
process ensuring patient co morbidities can be managed. We have trained more
of our nurses this year to ensure that we are able to quickly identify risks which
require consideration. We use the MEWS scoring system allowing us to quickly
identify patients who may have deteriorated post operatively to limit any negative
outcomes, we have an robust clinical governance framework which allows us to
learn and improve.
North Downs Hospital will continue to closely monitor the above preventative
measures to ensure they remain appropriate and we continue to prevent
unnecessary mortality.
PROMS:
Period
Hernia Apr13 - Mar14
Apr14 - Sep14
Worst
NVC11
0.008
Several
0.009
Average
Eng
0.085
Eng
0.081
Period
Apr13 - Mar14
Apr14 - Sep14
North Downs
NVC11
0.008
NVC11
*
11.292
-4.567
Worst
NT350 -16.849
RWA
-16.762
Average
Eng
-8.698
Eng
-9.479
Period
Apr13 - Mar14
Apr14 - Sep14
North Downs
NVC11
NVC11
PROMS:
Period
Hips 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
North Downs
NVC11
21.419
NVC11
*
PROMS:
Period
Knees Apr13 - Mar14
Apr14 - Sep14
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
North Downs
NVC11
15.659
NVC11
*
PROMS:
Period
Veins Apr13 - Mar14
Apr14 - Sep14
Best
NT415
0.139
RXR
0.125
Best
RTH
RYJ
Quality Accounts 2014/15
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North Downs Hospital considers that this data is as described for the following
reasons in the period covered by the report unfortunately the hospital has not
submitted sufficient data to be included in the national comparisons. We have
local reports that allow us to compare and benchmark with other Ramsay
Hospitals.
North Downs Hospital has taken steps to improve the return rate, and will
continue to monitor this aspect of data collection. We continue to by working
collaboratively with the external PROMs co-ordinator to improve the return rates
of the post-operative surveys and thus enable a larger sample size(volume).
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
North Downs
NVC11
5.59
NVC11
7.28
North Downs Hospital considers that this data is as described for the following
reasons; due to the method of our data submissions to SUS and the inability to
accurately compare data. Our Information Services Team are working with SUS
to improve this data quality over the coming year.
The number of readmissions appears to have increased due to the hospital staff
bringing patients who have experienced complications back to the hospital so that
these can be addressed. Previously patients may have gone to their GP or to the
local Trust via A&E. This remains a relatively small number of incidents and there
is no identifiable trend of note.
Ensuring that patients who have experienced post discharge problems will
continue to be encouraged to, where appropriate, return to the hospital for
treatment.
VTE Assessment:
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
North Downs
NVC11
97.6%
NVC11
97.1%
North Downs Hospital considers that this data is as described for the following
reasons; our manual processes require some further refinement in order to
ensure that all data entry is logged into our administration system in a timely
manner.
North Downs Hospital has continued to improve this percentage, and so the
quality of its services, by highlighting the importance of collecting this data to the
relevant teams and implementing further checking processes earlier in the data
collection period.
Quality Accounts 2014/15
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C. Diff rate:
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
North Downs
NVC11
0.0
NVC11
0.0
North Downs Hospital considers that this data is as described for the following
reasons; due to the patient demographic treated at the hospital, the effective
infection prevention controls in place, the primarily single patient bedrooms and
the comprehensive pre-assessment screening in place.
We will continue to monitor this to ensure that we have robust controls to maintain
this level.
SUIs:
Period
Best
(Severity 1 only) 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
North Downs
NVC11
0.00
NVC11
0.00
North Downs Hospital considers that this data is as described for the following
reasons; we continue to maintain active and transparent approach to reporting
incidents, however minor to ensure that we are learning and improving our
services and the safety of all users. As can be seen from the table there have
been no serious events in the period under review.
North Downs Hospital will continue to encourage all staff to report any event that
had the potential or has caused harm to any service user and the senior
managers of the hospital will continue to review and analyse this data and trends
and implement effective preventative measures. Sharing of serious events across
the company has been a focus this year for the Matrons regional groups.
F&F Test:
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
North Downs
NVC11
100.0%
NVC11
100.0%
North Downs Hospital considers that this data is as described for the following
reasons; due to the infrastructure and caring team we have at the hospital we are
able to provide for individuals needs creating a more holistic experience for
patients and their families / carers. Alongside this score our senior management
team review the anonymous comments made by patients which reflect the high
level of recommendation.
North Downs Hospital intends to maintain this score, and as such the quality of its
services, by continuing to encourage all service users to complete the survey,
improving the feedback process with our patients so that they understand what
influence their feedback has, continuing to share the feedback with all our staff to
ensure lessons are learnt.
Quality Accounts 2014/15
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3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety.
Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns but
more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs below.
3.2.1 Infection prevention and control
Infection Rates
Infection Rates
(percentage of Admissiosns)
1.4
1.2
1
0.8
0.6
0.4
0.2
0
2012/13
2013/14
2014/15
North Downs Hospital
North Downs Hospital continues to have a very low rate of hospital acquired
infection and has had no reported MRSA Bacteraemia in the past 3 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.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
Quality Accounts 2014/15
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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 Local IPC meeting is held
on a quarterly basis and is led by Dr Bruce Stewart, Consultant Microbiologist
from East Surrey Hospital.
All infections are reviewed on an individual basis to identify any trends of
changes to practise that may be required.
As can be seen by the graph the number of reported infections overall has
dropped in this reporting year. We continue to encourage patients to return to the
hospital with any post discharge concerns as we feel that it is crucial that these
patients are seen quickly for assessment and early intervention if required.
We work closely with our local GPs and encourage active reporting of any
concerns that they may have when reviewing patients post discharge.
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 North Downs Hospital, providing us with
a patient’s eye view of the buildings, facilities and food we offer, giving us a
clear picture of how the people who use our hospital see it and how it can be
improved.
The main purpose of a PLACE assessment is to get the patient view. The
scores can be seen in the looking back section of this document.
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
Hospital patient days demonstrates the results of safety training and local safety
initiatives.
Quality Accounts 2014/15
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3.5
3
2.5
2
14/15
1.5
13/14
1
0.5
0
Safety Incidents per 1000 HPDs
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 the year we have introduced further safer sharps products for staff and
consultants to use including safety cannulae, hypodermic needles and blunt
needles for drawing up medications. The products are evolving and improving
and as such we have already changed to an improved brand of hypodermic
needle for injections. These products reduce the number of sharps injuries with
further plans to introduce other products as they become available including safer
surgical blades for use by surgeons during operations.
It is apparent that there is no trend in any particular category of safety incident.
The data also demonstrates that the vast majority of incidents are low severity in
nature.
3.3 Clinical effectiveness
North Downs Hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
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management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole.
3.3.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures
and so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure. Every surgical intervention
carries a risk of complication so some incidence of returns to theatre is normal.
The value of the measurement is to detect trends that emerge in relation to a
specific operation or specific surgical team. Ramsay’s rate of return is very low
consistent with our track record of successful clinical outcomes.
As can be seen from the graph above our return to theatre continues to reduce
which may be an indication that we are learning from these events in order to
prevent similar events occurring.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
Quality Accounts 2014/15
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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 questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their
plan of care
How to make a complaint leaflets are on display in waiting areas
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3.3.1 Patient Satisfaction Surveys
3.3.1 Patient Satisfaction
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
100
80
60
40
93.0
93.8
2013/14
2014/15
20
0
North Downs Hospital
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently
of the hospital so we receive a true reflection of our patient’s views.
Every patient is asked for their consent to receive either an electronic survey or
phone call following their discharge from the hospital. The results from the
questions asked are used to influence the way the hospital seeks to improve its
services. Any text comments made by patients on their survey are sent as ‘hot
alerts’ to the Hospital Manager within 48hrs of receiving them so that a response
can be made to the patient as soon as possible.
The comprehensive report enables us to drill down to the key issues that matter
to patients who are able to tell us where we do things well or aspects of care that
need improvement. We have recently commenced the introduction of new groups
of patients who are surveyed using this format, including Endoscopy patients,
Radiology patients, Out-patients and Physiotherapy patients. This more targeted
approach ensures that each department are clear on issues that affect them
directly.
We have demonstrated a slight improvement in overall level of satisfaction this
year. The main area of concern remains the perception of patients in relation to
whether staff wash their hands appropriately. We have increased our score this
year but still have room for improvement.
Quality Accounts 2014/15
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We are also really proud that we have consistently been in the top 10 hospitals in
the country in relation to our Friends and Family Scores.
3.4 Hospital Case Study
A 19 year old severely autistic man required bilateral foot surgery. It was evident
at the first Outpatient appointment that this patient did not have capacity to
consent and though accompanied by his mother it would be necessary to hold a
best interests meeting. The patient connected well with the Outpatient nurse and
was able to communicate to a degree and also demonstrated that he is quite
intelligent, but was able to retain very little information. The OPD Nurse later
visited him at the residential care facility and was able to assess his physical
needs for surgery. The Mental Capacity Toolkit was referenced also.
A best interests meeting was then arranged with the Consultant Surgeon,
Ward/Outpatient Manager, Outpatient Staff Nurse, the patient and his mother.
At this meeting it was clear that the patient had some understanding: he
recognised the Consultant from the Clinic appointment and also reconnected very
well with the OPD Staff Nurse. A discussion was then held between all parties
with regard to the proposed treatment and it was evident that this surgery was
necessary to improve the patient's mobility and ultimately his quality of life. His
mother explained that he used to enjoy going for long walks but now declined as
his feet hurt. She also said that shoe-fitting was now proving to be a real problem.
Consent Form 4 was completed along with the mental capacity assessment form
in conjunction with all parties, having decided that no other options were
available. We also decided that the OPD Nurse would be available to help look
after the patient on the day of surgery and follow him through to theatre and
Recovery, and that his mother could be actively involved also. The patients
mother who was clearly devoted to her son, had very little experience of the legal
implications surrounding mental capacity issues and was very appreciative and
understanding of the time taken to establish the decision to treat.
We have further training on the Mental Capacity Act planned for our nursing staff
to ensure that all of our team become familiar with these processes and feel more
confident in assessing individual patient’s needs.
Quality Accounts 2014/15
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Appendix1
Services covered by this quality account
Regulated Activities – North Downs Hospital
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Peoples Needs Met for:
Aesthetics (including laser),
Cardiology, Dermatology,
Colorectal, Endocrinology,
Fertility, Gastrointestinal, General
medicine, Gynaecological,
Neurology, Nurse led
sclerotherapy, Ophthalmic,
Paediatrics, Pain Management,
Physiotherapy, Podiatry,
Psychiatry (OPD only),
Rheumatology, Sexual Health,
Sports medicine, Urology,
Vascular
All adults
Ambulatory, Cosmetic, Colorectal,
Dermatology, Ear, Nose and
Throat (ENT), General Medicine,
General surgery, Gynaecological,
Ophthalmic, Orthopaedic, Pain
Management, Podiatric surgery,
Urology, Vascular, Day and
Inpatient Surgery
All adults
Adolescents 16-18 yrs
Children 3-16 yrs outpatients appointments only
Adolescents 16-18 yrs excluding:
















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
New pacemaker in last 6 months
BMI 40+
Newly diagnosed or unstable diabetes
Newly diagnosed atrial fibrillation
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.
Diagnostic and
screening
GI physiology, Endoscopy, Allergy
testing, Imaging services
(including Dexa scans, Nuchal
scans, and obstetric ultrasounds),
Phlebotomy, Urinary Screening
All adults and children 16 yrs and over
Outpatients appointments only - 3 yrs and above
Quality Accounts 2014/15
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(including urodynamics) and
specimen collection
Family Planning
Services
Gynaecology patient pathway,
insertion and removal of inter uterine
devices for medical as well as
contraception purposes
All adults 18 years and over as clinically indicated
Quality Accounts 2014/15
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Appendix 2
Clinical Audit Programme 2014/15
Quality Accounts 2014/15
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North Downs 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:
01883 348981
www.northdownshospital.co.uk
Quality Accounts 2014/15
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