Oaklands Hospital
Quality Account
April 2014 – March 2015
Prepared May 2015
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
Review of Clinical Priorities 2014/15 (looking back)
2.2
Clinical Priorities for 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
2.3.7 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
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Oaklands 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 Oaklands 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 reports on the period 1st April 2014 to 31st March 2015. 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 patients’ 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.
Quality Accounts 2014/15
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Part 1
1.1 Statement on Quality from the General Manager
This is the fifth Quality Account to be submitted by Oaklands 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 Oaklands 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.
Helen Rocca, General Manager
Oaklands Hospital
Quality Accounts 2014/15
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Helen Rocca, General Manager
Oaklands Hospital, Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Henry Maxwell, Consultant Surgeon and Chair Medical Advisory Committee,
Oaklands Hospital
Helen White, Regional Director, Ramsay Health Care
Quality Accounts 2014/15
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Welcome to Oaklands Hospital
Oaklands Hospital is one of Greater Manchester's leading private hospitals with a
reputation for delivering high quality healthcare treatments and services. Located in
Salford, the hospital is close to the A580 and the M602. The hospital opened in 1990
having two operating theatres and 15 single rooms all with ensuite facilities. In 2014
a 12 month, £4.6m redevelopment commenced to add an additional operating
theatre, minor operations/endoscopy room and a dedicated day case ward as well as
a full refurbishment.
Oaklands Hospital provides fast, convenient, effective and high quality treatment for
patients of all ages (excluding children below the age of three years for inpatient
care) whether medically insured, self-funding or from the NHS. The Hospital offers a
comprehensive range of treatments and services including ENT procedures,
Maxillofacial Surgery, Cosmetic Dentistry, Plastic Surgery, Dermatology
Gynaecology, General Surgery, Orthopaedics, Ophthalmics and Urological
procedures.
Diagnostic facilities include CT, barium studies, ultrasound, MRI and DEXA for bone
density, in addition to general radiology.
All of the Hospital’s consultants are highly experienced and have patient care and
comfort as their highest priority. All patients have the reassurance that a resident
doctor is available on site 24 hours/day.
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Part 2
2.1 Performance against our Clinical Priorities for
2014/2015 (looking back)
2.1.1 Surgical Safety Checklist
This is a set of criteria produced by the World Health Organisation (WHO) to improve
the safety of surgery and monthly audits are undertaken to ensure compliance.
Audits are reviewed by the Hospital’s Clinical Governance and Medical Advisory
committees with any non- compliances recorded and action plans put in place.
2.1.2 Never Events
These are serious, largely preventable patient safety incidents that should not occur if
the available preventative measures have been implemented. For further details
see:http://www.nrls.npsa.nhs.uk/resources/collections/never-events/
There have been no ‘Never Events’ at Oaklands Hospital in the period
2.1.3 VTE Assessment
A VTE assessment is completed for all patients to reduce the incidence of postoperative Venous Thromboembolism (VTE), this is in accordance with Ramsay Policy
CM 001 VTE policy and during the past year documentation has been improved to
enable Consultants to document any change to patient’s status that occurs during
surgery.
2.1.4 Infection Control
During this period we have had no reportable infections and no outbreaks reported.
Screening of patients for MRSA continues where appropriate in line with NHS
England guidelines and training for staff on hand hygiene is mandatory. The infection
control team have worked to improve standards in environmental cleaning in the
period with the Clinical Lead leading quarterly environmental audits in the period.
Internal audits demonstrate that compliance remains high, achieving between 97%
and 100% in the period.
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2.1.5 Preoperative Assessment
The preoperative assessment policy is followed in line with NICE guidelines. This
provides safe and efficient assessment of all patients following their outpatient clinic
appointment and before surgery. Patients complete a medical questionnaire to
determine the appropriate level of preoperative assessment to ensure consistent
safety for patients.
2.1.6 Patient Satisfaction Survey
In the period, Oaklands Hospital has 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
2.1.7 Information Security
Oaklands hospital has achieved the independently audited ISO27001 Information
and Security quality standard relating to data protection and continued compliance
remains a focus area.
2.1.8 Patient Reported Outcome Measures Studies (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.
The hospital has encouraged patients to participate in PROMs surveys to monitor
patient assessed outcomes of surgery, led by the Pre Assessment Lead Nurse who
ensures that patients are fully informed and invited to take part in the survey prior to
surgery.
2.1.9 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
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provider’s income to the achievement of quality improvement goals. Our hospital had
3 local CQUINs for this period, and 3 national CQUINs as outlined below.
Local CQUINS
Advancing Quality - This initiative, managed by the NHS body Advancing Quality Alliance, is aimed at improving the quality of care and
patients’ experiences. The Hospital submits data regarding Deep Vein
Thrombosis (DVT) and the prevention of infection using antibiotic therapy
(also known as antibiotic prophylaxis). External audit took place and
Oaklands Hospital were compliant with no recommendations for
improvement.
Clinical Effectiveness – This initiative is to improve care relating to
deteriorating patient by focusing on earlier recognition and treatment. Staff
training has been implemented throughout the year with quarterly audits
demonstrating consistent compliance with best practice.
Patient safety - This CQUIN was introduced to improve and sustain
change from Lessons Learned instances, from areas such as serious
incidents, claims, complaints or serious case reviews. Oaklands Hospital
has a Lessons Learnt forum where appropriate incidents are analysed and
action plans put in place and shared.
National CQUINS
Friends and Family Test – The hospital undertook Friends & Family
surveys with both inpatient and daycase patients in the period, achieving a
35% response rate with 95.3% of respondents rating their opinion as
‘extremely likely to recommend’ the hospital.
NHS Safety Thermometer- This is a national measure which allows
healthcare providers to check for potential ‘harms’ for patients during their
treatment. Oaklands continued to submit measurement data on a monthly
basis with no adverse events. Oaklands l 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.
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VTE risk assessment – The hospital was set a compliance target of 95%,
and continuously achieved this reaching 98% compliance.
.
2.1.10 Equality Delivery System
Oaklands Hospital has been 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, in accordance
with the nine protected characteristics under the Equality Act 2010; age, disability,
gender reassignment, civil marriage, pregnancy and maternity, race, religion and
belief, gender and sexual orientation. In line with expectations, the hospital continues
to ensure that employees work to comprehensive policies regarding the fair treatment
of patients and employees.
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2.2 Quality Priorities for 2015/2016 (looking forward)
On an annual cycle, Oaklands 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 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 our patients.
2.2.1 Patient Safety
Surgical Safety Checklist
Monthly audits will continue to be undertaken with an expectation of 100%
compliance; where this is not achieved actions plans will be developed and
responsibilities communicated with the teams. 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. Monthly audits will be reviewed by the hospital’s Clinical Governance
and Medical Advisory Committees.
NHS Safety Thermometer – Oaklands will continue to submit this data in relation to
pressure ulcers, falls and urinary tract infections in those with a catheter.
VTE Assessment - VTE risk assessments remain a focus at Oaklands Hospital with
quarterly audits to maintain standards. Results are reviewed and actions determined
at both the hospital’s Clinical Governance and Medical Advisory Committees.
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Staffing
Focus as always is on staffing and retention of staff including a robust induction
programme for new staff. Training of staff remains a high priority with set training
programmes including Safeguarding and PREVENT, available via the Ramsay
Academy - the company’s national resource for training. The Ramsay Academy
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
Ramsay’s Management Development Framework also provides opportunities for our
leaders of the future to develop skills and knowledge.
To ensure adequate numbers of skilled staff are available to care for our patients,
staff rosters are prepared in advance. The electronic rostering tool ‘Allocate’
continues to take into account the necessary skill mix for scheduled patient activity.
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 introducing the new
code to all nursing staff, highlighting what is involved and how the hospital will
support them in achieving their goals.
We recognise the value of the Health Care Assistant (HCA) within Ramsay and
competency assessments are in place to allow all HCAs to reach their full potential.
Acknowledging the Cavendish review we are adopting the ‘productive team’ model
ensuring ‘a holistic approach to care, focused on ensuring the best possible
outcomes for the patient, staff and the organisation’. We promote a culture of support
and mentoring in developing our existing staff and will be introducing apprenticeships
across different job roles in the next year.
2.2.2 Clinical Effectiveness
Maintaining 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.
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Oaklands Hospital will be working towards successful JAG following the completion
of the new Endoscopy facility; and biannual submission of data to GRS (Global
Rating Score) continues. This tool enables us to assess how well we provide a
patient-centred service, demonstrating compliance against the four domains of:
clinical quality
quality of patient experience
workforce
training
2.2.3 Patient Satisfaction
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.
2.2.4 Preoperative assessment and daycase projects
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This project for implementation in 2015/16 reviews the patient’s journey through preoperative assessment and through admission of day case procedures to optimise
safety and efficiency for our patients.
2.2.5 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
recognition and integration of medical devices (e.g. blood pressure monitors) into the
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.
2.2.6 CQUINS 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. Our
local CQUIN for 2015/16 is a two year CQUIN: Pathway Redesign- and In line with
the refurbishment and extension to the Oaklands Hospital this CQUIN will focus on
increasing efficiency and improving the patient experience.
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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 the Department of Health.
2.3.1 Review of Services
During 2014/15 Oaklands Hospital provided seven NHS services and has reviewed
the data available to them on the quality of care in all of these NHS services.
The income generated by 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 Oaklands 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 Ramsay 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
Consultant Satisfaction Score
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2.3.2 Participation In Clinical Audit
During 1st April 2014 to 31st March 2015, Oaklands Hospital participated in three
national clinical audits which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Oaklands 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
National Joint Registry (NJR)
% cases
submitted
99%
Hip 100%
Knee 98%
Elective surgery (National PROMs Programme)
Varicose
Veins 49%
Hernia
54%
Medical and surgical clinical outcome review programme: National
confidential enquiry into patient outcome and death
0% - no
deaths in
period.
The reports of national clinical audits from 1st April 2014 to 31st March 2015 were
reviewed by the hospital’s Clinical Governance Committee.
The reports of local clinical audits from 1st April 2014 to 31st March 2015 (schedule
attached in Appendix 2) were 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.
2.3.4 Goals agreed with our Commissioners using CQUINs
A proportion of the 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)
Oaklands Hospital is required to register with the Care Quality Commission and its
current registration status on 10th 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 importance of accurate data input
and have sufficient technical competence
Employment of clinical coder to improve accuracy of recording
Supporting national 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).
The General Medical Practice Code:
100% for admitted patient care;
100% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit Attainment Levels
Ramsay Group Information Governance Assessment Report score overall for 2014/5
was 75% and was graded ‘green’ (satisfactory).
This information is publicly available on the DH Information Governance Toolkit
website at: https://www.igt.hscic.gov.uk
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Clinical Coding Error Rate
Following internal audit by Ramsay’s corporate auditors, Oaklands Hospital achieved
Ramsay Health Care’s Information Governance Req 505 Attainment Levels for
accuracy of coding as follows:
Primary Diagnosis
Secondary Diagnosis
Primary Procedure
Secondary Procedure
100%
96.18%
98.3%
100%
2.3.7 Stakeholders’ Views on Oaklands Hospital’s Quality Account 2014/15
Feedback from the hospital’s lead Clinical Commissioning Group is as follows:
NHS Salford Clinical Commissioning Group (CCG) welcomes the opportunity to
comment on the annual Quality Account prepared by Oaklands Hospital as the coordinating commissioner of the Trust’s services.
To the best of NHS Salford CCG’s knowledge, the information contained in the
Account is accurate
and reflects a true and balanced description of the quality of provision of services. The
hospitals quality, safety and performance is monitored continually throughout the year
through regular quality and contract meetings where data and information is
discussed. Oakland’s has achieved the both the national and local CQUIN indicators
for 2014/15.
NHS Salford CCG is pleased to note that continued involvement of patient
representatives in undertaking PLACE assessments and the focus on gathering
patient experience data through a variety of methods. The hospital should be
commended on maintaining a high patient satisfaction rate.
It would be useful to see if there is any correlation with reported complaints and
incidents and patient experience feedback, and how this has influenced improvements
in the provision of services, and what these improvements will be in the coming year.
The Account reports that Oaklands Hospital is registered with the Care Quality
Commission with no conditions and that no enforcement action had been taken during
2014/15.
NHS Salford CCG looks forward to working in partnership with them in the forthcoming
year
Francine Thorpe
Head of Quality & Innovation
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Part 3: Review of quality performance 2014/2015
Statement from our Director of Clinical Services
“This publication marks the fifth 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, Ramsay Health Care UK
Ramsay Clinical Governance Framework 2014
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.
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
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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.
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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
Oaklands 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. As data for independent sector
hospitals is not collated by the Health and Social Care Information Centre, our own is
used. However, our mortality rate is not case mix adjusted.
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
Oaklands
NVC12
0
NVC12
0
Readmission Rates
Surgical patients being readmitted to hospital within 28 days following treatment. This
data does not include patients admitted under emergency transfers.
Period
2012/13
2013/14
Best
Multiple
0.0
Multiple
0.0
Worst
5P5
22.76
5NL
41.65
Average
Eng
11.43
Eng
11.45
Period
2012/13
2013/14
Oaklands
NVC12
11.14
NVC12
8.6
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
Oaklands
NVC12
99.7%
NVC12
99.3%
Quality Accounts 2014/15
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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
Oaklands
NVC12
0.00
NVC12
0.00
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
Oaklands
NVC12
100.0%
NVC12
95.3%
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
Oaklands
NVC12
0.0
NVC12
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
Oaklands
NVC12
92.9
NVC12
92.2
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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
Oaklands
NVC12
*
NVC12
*
Worst
NT350 -16.849
RWA
-16.762
Average
Eng
-8.698
Eng
-9.479
Period
Apr13 - Mar14
Apr14 - Sep14
Oaklands
NVC12
NVC12
Worst
RQX
17.634
RJD
18.357
Average
Eng
21.34
Eng
21.922
Period
Apr13 - Mar14
Apr14 - Sep 14
Oaklands
NVC12
*
NVC12
*
Worst
NV323
12.049
RXF
14.416
Average
Eng
16.248
Eng
16.702
Period
Apr13 - Mar14
Apr14 - Sep14
Oaklands
NVC12
15.721
NVC12
*
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
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
in all performance respects, and certainly in regards to our track record for patient
safety.
Risks to patient safety come to light through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more
routinely from tracking trends in performance indicators.
3.2.1 Infection Prevention and Control
Oaklands 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.
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Programmes and activities within our hospital include:
The infection control link nurse has provided training in hand hygiene to all staff and
completes a hand hygiene training session during the staff induction day for all new
staff. Training also includes Aseptic Non Touch Technique (ANTT)).
Hand hygiene awareness days are led by the infection control link nurse involving
staff, patients and visitors and information in waiting areas.
Our infection control rate remains very low and our reporting and investigating of
potential infections continues to improve. 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, results are presented at our quarterly infection control
committee meetings. There have not been any trends identified in the period.
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 Oaklands 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 was
scored as follows:
Cleanliness 100%
Food 92.5%
Privacy, Dignity and Wellbeing 78.5%
Condition, appearance and maintenance of facility 97.5%
The hospital did score below the national average for Privacy, Dignity and Wellbeing
due to restrictions being placed on space during the building redevelopment. However
issues highlighted in the PLACE audit have been rectified.
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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.
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 that
we keep up to date with all safety issues.
In addition to mandatory training the Health and Safety Coordinator has coordinated
sharps awareness programmes throughout the year ensuring the use of sharps-safe
devices where these are available. There has also been training on waste
management ensuring the correct segregation of waste taking into account the effect
on the environment and raising staff awareness on this issue. We have supported a
team member to complete a training course to enable them to provide manual
handling training to all of our staff.
3.3 Clinical Effectiveness
Oaklands 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 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
Quality Accounts 2014/15
Page 30 of 36
specific surgical team. Ramsay’s rate of return is very low, consistent with our track
record of successful clinical outcomes.
3.4 Patient Experience
All feedback from patients regarding their experiences with Ramsay Health Care are
welcomed and inform service development in various ways dependent on the type of
experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also fed back to the relevant
staff using direct feedback. All staff are aware of our complaints procedures should our
patients be unhappy with any aspect of their care.
Patient experiences are fed back via the various methods below, and are regular
agenda items on the local Governance Committees for discussion, trend analysis and
further action where necessary. Escalation and further reporting to Ramsay Corporate
and NHS bodies occurs as required and according to Ramsay and NHS England
policy.
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Feedback regarding the patient’s experience is encouraged in various ways via:
Web based survey with a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web
survey
Friends and Family questionnaire
‘We value your opinion’ leaflet provided to patients on discharge
Verbal feedback to Ramsay staff - including Consultants, Matrons and General
Manager whilst visiting patients
Written feedback via patient letters and emails
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of
care
3.4.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently of the
hospital so we receive a true reflection of our patients’ views.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked are
used to influence the way the hospital seeks to improve its services. Any 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.
We have consistently maintained a high satisfaction rate and proactively seek patient
feedback to ensure we maintain this.
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Quality Accounts 2014/15
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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, General
medicine, Ophthalmic,
Orthopaedic, Physiotherapy,
Rheumatology, Sports
medicine, Urology
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
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
Quality Accounts 2014/15
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Appendix 2 – Clinical Audit Programme 2014/15.
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Oaklands 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: 0161 787 7700
www.oaklands-hospital.co.uk
Quality Accounts 2014/15
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