Park Hill Hospital Quality Account 2014/15 Contents Introduction Page Welcome to Ramsay Health Care UK 3 Introduction to our Quality Account 4 PART 1 – STATEMENT ON QUALITY 1.1 Statement from the General Manager 5 1.2 Hospital accountability statement 7 PART 2 2.1 Priorities for Improvement 9 2.1.1 Review of clinical priorities 2013/14 (looking back) 10 2.1.2 Clinical Priorities for 2014/15 (looking forward) 12 2.2 Mandatory statements relating to the quality of NHS services provided 2.2.1 Review of Services 14 2.2.2 Participation in Clinical Audit 17 2.2.3 Participation in Research 19 2.2.4 Goals agreed with Commissioners 19 2.2.5 Statement from the Care Quality Commission 20 2.2.6 Statement on Data Quality 21 2.2.7 Stakeholders views on 2010/11 Quality Accounts 23 PART 3 – REVIEW OF QUALITY PERFORMANCE 3.1 The Core Quality Account indicators 27 3.2 Patient Safety 35 3.3 Clinical Effectiveness 39 3.4 Patient Experience 40 Appendix 1 – Services Covered by this Quality Account 45 Appendix 2 – Clinical Audits 46 Welcome to Ramsay Health Care UK Park Hill Hospital is part of the Ramsay Health Care Group The Ramsay Health Care Group was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health Care is one of the leading providers of independent hospital services in England. Ramsay has a network of over 30 private hospitals as well as three neurological units. We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, Clinical Commissioning Group. The provision of high quality patient care is and will always be the highest priority of Ramsay Health Care UK. Of course our team of clinical staff and consultants are very much at the forefront of achieving this but there is also very much an organisation wide commitment to ensure that we continue to improve out outcomes every day, week, month and year. Delivering clinical excellence depends on everyone in the organisation. Clinical excellence cannot be the responsibility of just a few, it takes all of us to be responsible and accountable for our performance in the various roles we all play. Having an organisational culture that puts the patient at the centre of everything we do is key to ensuring we enable everyone to perform at their peak to attain great outcomes. Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends, we will continue to strive to get ever better. I am very proud of our long standing and major provider of healthcare services across the world and of our Ramsay very strong track record as a safe and responsible healthcare provider. It gives us pleasure to share our results with you. Mark Page Chief Executive officer Ramsay Health Care UK Quality Accounts 2014/15 Page 3 of 46 Introduction to our Quality Account This Quality Account is Park Hill Hospitals annual report to the public and other stakeholders about the quality of the services we provide. It presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience and demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. It will also show that we regularly scrutinise every service we provide with a view to improving it and ensuring that our patient’s treatment outcomes are the best they can be. It will give a balanced view of what we are good at and what we need to improve on. Quality Accounts 2014/15 Page 4 of 46 Part 1 1.1 Statement on Quality from the General Manager Dawn Abbott, General Manager Park Hill Hospital “Park Hill Hospital understands that you have a choice and is committed to being the leading healthcare provider of choice by delivering high quality care and outcomes for patients.” This is the fourth Quality Account to be submitted by Park Hill 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 and improve the patient’s journey with the aim of becoming the healthcare provider of choice for all patients. We are aware that patients can be nervous about coming into hospital and understand that providing reassurance is important to you the patient and your family. This starts with patient safety, which is our highest priority. To this end we recruit, induct and train our team to the highest standard in all aspects of care. This approach extends to family and visitors in ensuring they are made to feel welcome at Park Hill Hospital. Quality Accounts 2014/15 Page 5 of 46 Park Hill Hospital is committed to ensuring that patients are kept fully informed about their treatment, which is also a significant factor associated with improving treatment outcomes. We involve our patients in treatment decisions at the earliest stage so that the options and benefits are fully discussed before patients consent to treatment. Our medical and clinical teams recognise the importance of devoting time preparing patients for surgery, which not only reduces risk but also improves patient understanding and confidence, reduces anxiety, improves rates of recovery and shortens length of hospital stay. 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. Park Hill Hospital is accustomed to the disciplines of regulatory and contractual requirements to assure healthcare commissioners of our clinical performance and to report complaints and serious incidents to regulators and commissioners. We also maintain a Risk Register and systematically review specific actions to achieve risk reduction. Park Hill Hospital continually achieves consistent patient satisfaction scores of over 93.5% recommendation to others and for overall satisfaction and at time of writing is showing one of the highest Friends and Family scores for any hospital Private or NHS. By analysing the results throughout the year, we constantly seek ways to further improve the patient experience. Quality Accounts 2014/15 Page 6 of 46 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. Dawn Abbott General Manager Park Hill Hospital Ramsay Health Care UK This report has been reviewed and approved by: Stephen Bruce Bittiner, Medical Advisory Committee Chair Antony Wilkinson, Clinical Governance Committee Chair Helen White, Regional Director (North) Doncaster Clinical Commissioning Group Quality Accounts 2014/15 Page 7 of 46 Welcome to Park Hill Hospital Park Hill Hospital is one of South Yorkshire’s leading private hospitals with an excellent reputation for delivering high quality healthcare treatments and services. Located on the site of the Doncaster & Bassetlaw Hospitals NHS Foundation Trust site, Park Hill Hospital opened in April 1995. The ward consists of 21 beds, 17 of which are in single rooms, all with en-suite facility. The outpatient department consists of 6 consulting rooms and a minor procedure treatment area. The hospital provides a full range of quality services, these include, outpatient consultation, outpatient procedures, investigations/diagnostics, surgery and follow up care. During the last 12 months, the hospital has treated 2,967 patients, 72% of which were treated under the care of the NHS. All NHS patients treated at the hospital must be over 18 years of age as defined by the Standard Contract. Currently, over 90 specialist Consultants work from the hospital, supported by a team of 56 staff (29 nursing/physiotherapy and 27 administration/support services). We also have a Resident Medical Officer (RMO) 24 hour emergency support. Park Hill Hospital has a very close working relationship with Doncaster & Bassetlaw Hospitals NHS Foundation Trust and has access to support services through various service level agreements with the Trust. Quality Accounts 2014/15 Page 8 of 46 Part 2 2.1 Quality Priorities for 2014/2015 Plan for 2014/15 On an annual cycle Park Hill 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. Quality Accounts 2014/15 Page 9 of 46 Priorities for Improvement 2.1.1 A review of clinical priorities 2013/14 (looking back) 1. Clinical Effectiveness Clinical effectiveness was chosen in order to evidence that Park Hill is striving to strengthen governance by encompassing the following key areas: 1. 2. 3. 4. 5. Improved incident reporting Continual & spot Audit NHS Safety Thermometer Audit PROMS ( Patient Reported Outcome Measure Studies) Cavendish Report and the strengthening of Health Care Assistant Roles Action Taken: We have seen an increase in reporting of incidents, as well as the number of staff that now feel confident and competent to report incidents and complaints using the Riskman system. The audit calendar is used as planned, and different members of staff perform the audits which improves the objectivity of each audit. NHS Safety Thermometer surveys were completed each month, and the results submitted to Health & Social Care Information Centre. PROMS surveys have continued to be returned by patients undergoing the relevant procedures Health Care Assistants (HCAs) are an important part of the team, and we have looked to train our own, through an apprenticeship scheme with North Hertfordshire College. Two apprentices commenced through the apprenticeship scheme in September 2014. Quality Accounts 2014/15 Page 10 of 46 2. Incident Reporting Incident and near-miss reporting is encouraged to ensure effective learning in a no blame culture. Park Hill Hospital instigated Lessons Learnt forums following incidents and complaints to ensure that all staff fully understood what they could have done differently to prevent the incident or complaint. The outcomes will then be reported onto the Riskman system and attached to individual incidents evidencing a robust investigation and satisfactory outcome. Action Taken: Implementation of Lessons Learnt Forums, with improved sharing of issues that caused the incident / complaint and discussion of what needs to happen to ensure that a recurrence of the incident / complaint is prevented. 3. Patient Experience We aimed to measure feedback from patients about their experience, clinical treatment and clinical outcomes. Our goal was to evidence compliance in the following key areas: 1. Patient Feedback 2. Customer Service Training 3. Telephone Handling Action Taken: Continual review of patient feedback and how we are meeting our patient’s expectations. Customer Service Excellence training was delivered to all staff regularly throughout the year. 4. Customer Excellence / Mandatory Training Park Hill’s aim was to raise continued staff awareness of patient perception and expectation, reminding them of the importance of consistent excellence in customer care. Action Taken: All staff completed refresher customer service e-learning modules as part of their mandatory training. The pass mark for this training is 100%. Regular refresher customer service excellence training was delivered with good attendance by all departments Quality Accounts 2014/15 Page 11 of 46 5. Patient Safety Our aim was to improve upon patient safety initiatives already embedded within the hospital and we have continued to focus on improving our performance. Action Taken: Improved communication relating to patient safety initiatives in departments through regular meetings and training forums ensuring staff and consultants fully understand lessons learnt and plan actions accordingly in order to address issues identified. 2.1.2 Clinical Priorities for 2015/16 (looking forward) 1. Daycase Project Park Hill Hospital is committed to improving upon the care pathways that our patients experience and have chosen to review how we manage our daycase patient journey. As part of our review of the patient journey, we aim to look at: Reducing the length of time a patient is in hospital prior to their operation time through refining of staggered admissions concept Improved use of our daycase trollies and recliner chairs Daycase pathway utilisation for all daycase procedures Type of anaesthetic used during daycase procedure to reduce incidence of post-operative nausea and vomiting 2. Competency packages & further development of HCA’s All HCA’s are embarking upon a full package of clinical competencies aimed at increasing the skill set at Park Hill Hospital. Clinical competencies are continually updated throughout the year and all training includes theoretical and practical assessment and all HCA’s are allocated a mentor to support them in their learning and development requirements. Daycase competencies Phlebotomy competencies Pre-assessment competencies for HCA’s Quality Accounts 2014/15 Page 12 of 46 3. HCA Apprenticeships In addition, in 2014 Park Hill Hospital joined the apprenticeship scheme and has successfully trained and developed 2 HCA’s who have now both achieved permanent positions at the hospital. Due to the success of the apprenticeship scheme, Park Hill Hospital intends to continue to support the scheme and is considering other roles within the hospital, i.e. administration. 4. Improving average length of stay for daycase patients to reduce stay in hospital Park Hill Hospital is committed to improving our average length of stay for our daycase patients, through management of efficient streamlined pathways. This process ensures a reduction in fasting time which improves outcomes and aids recovery, and provides a better patient experience with less disruption and time commitment for the patient, this reduces the stress associated with a hospital stay. Quality Accounts 2014/15 Page 13 of 46 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 Park Hill Hospital provided and/or subcontracted four NHS services. Park Hill Hospital has reviewed all the data available to them on the quality of care in all of these NHS services. Orthopaedics - including Podiatry General Surgery Pain Management Minor Plastics The income generated by the NHS services reviewed in 1st April 2014 to 31st March 2015 represents 100% per cent of the total income generated from the provision of NHS services by Park Hill 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 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 Patient Quality Quality Accounts 2014/15 Page 14 of 46 Human Resources 31 March 2013 Clinical Headcount 32 31 March 2014 30 31 March 2015 29 Total WTE Nursing (RN & HCA) Total Headcount 28.78 27.51 26.6 55 56 56 Rolling Sickness Absence 4.56% 4.46% 1.71% Rolling Employee Turnover 3.7%% 3.7% 23.0% Number of Significant Staff Injuries (RIDDOR reportable) Agency Cost as a % of total staff cost eLearning 0 0 0 6.42% 0.64% 52% Staff Appraisal 58% The ratio of Qualified Nurses to Health Care Assistants has altered recently due to improvements in training and recruitment of Health Care Assistants to provide additional competency skilled ability to more effectively support the Registered Nurses to deliver a higher quality of care. All staff members at Park Hill must complete a Mandatory training programme which includes clinical and non-clinical aspects. Staff compliance is recorded and the table below shows current compliance (as at March 2015). Training is provided internally and externally, the topics covered are: Course Type Basic Life Support Safeguarding Children Elearning Customer Care Data Protection Elearning Fire Safety Training Induction Health and Safety Elearning Infection Control Elearning % Trained 76.5 70.6 70.6 80.4 64.7 100 76.5 78.4 Information Security Manual Handling Safeguarding of Vulnerable Adults SOVA Equality Diversity Food Hygiene Intermediate Life Support 78.4 74.5 74.5 88.2 62.5 66.7 Blood Transfusion update / training TOTAL 75.0 74.9 Quality Accounts 2014/15 Page 15 of 46 Staff performance development reviews are carried out annually and objectives set for the new financial year. Any additional training needs are identified by the staff and their line managers. At Park Hill Hospital we believe that training and professional development is a core activity, providing opportunities for our staff to learn, to develop and succeed whilst fully supporting our business priorities. Ramsay Health Care developed the Ramsay Academy which reflects the organisations continuing passion for ensuring that all staff has the chance to achieve their full potential whilst working for Ramsay Health Care. The Ramsay Academy Prospectus provides training opportunities in the following areas: Staff satisfaction, derived from The Best Companies, Employee Surveys was completed in November 2013. The table shows the units highest and lowest scores. Highest Score 5.82 Park Hill 5.09 Lowest Score 3.86 0 5 10 This was completed by 76% of Park Hill staff and our Satisfaction Score overall was 5.09%. The maximum score possible was 7 and the minimum 1. This was an excellent result for Park Hill Hospital who achieved the highest satisfaction score of all the 37 units within Ramsay Health Care UK and was also an increase of 0.2% from the previous survey. From these results staff at Park Hill are happy to work for Ramsay Health Care, and enjoy working within their respective teams. Quality Accounts 2014/15 Page 16 of 46 2.2.2 Participation in Clinical Audit During 1st April 2014 to 31st March 2015 Park Hill Hospital participated in 4 national clinical audits and 1 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 Park Hill 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. The national clinical audits and national confidential enquiries that Park Hill 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) Elective surgery (National PROMs Programme) % compliance 97.3 100 Medical and surgical clinical outcome review programme: National confidential enquiry into patient outcome and death 100 SSIS – Surgical Site Surveillance 100 NHS Safety Thermometer 100 The reports of the applicable national clinical audits from 1st April 2014 to 31st March 2015 were reviewed by the Clinical Governance Committee and Park Hill Hospital intends to take the following actions to improve the quality of healthcare provided. Quality Accounts 2014/15 Page 17 of 46 Local Audits The reports of 62 local clinical audits from 1st April 2014 to 31st March 2015 were reviewed by the Clinical Governance Committee and Park Hill Hospital intends to take the following actions to improve the quality of healthcare provided. The clinical audit schedule can be found in Appendix 2. Infection Prevention Audits: Park Hill Hospital has followed the corporate audit programme throughout the year and results have shown improvement in hand hygiene and care of peripheral venous catheter with scores rising to 100% respectively. WHO – Surgical Safety Check Audit: This is incorporated into the care record for every patient and there is an additional audit to monitor compliance with the checklist. The audit assesses that clinical staff are routinely checking that the correct patient, receives the correct surgery on the correct site, and the patient has been appropriately prepared and consented for the procedure planned. Consent Audit: Assesses the consent process in 2 stages. Stage one ensures that patients are provided with sufficient information to provide informed consent. Stage two confirms that the patient is happy to proceed having had time to consider the information provided Medical Records: Pre-operative telephone calls have been implemented to be made within 48 hours of admission by a member of the clinical team, to confirm admission and discharge plan. These are audited regularly and encouraging improvements month on month. Controlled Drugs Audit: The controlled drugs audit has scored an average score of 95.6%, having been audited 3 times in the year. Improvements made include: o Improved completion of the key log o Review of local standard operating procedures to ensure compliance with local policies o Refresher training for all clinical staff on controlled drugs administration Quality Accounts 2014/15 Page 18 of 46 2.2.3 Participation in Research There were no patients receiving NHS services provided or sub-contracted by Park Hill Hospital in 2014/15 that were recruited during that period to participate in research. 2.2.4 Goals agreed with our Commissioners using the CQUIN (Commissioning for Quality and Innovation) Framework A proportion of Park Hill Hospital’s income in from 1st April 2014 to 31st March 2015 was conditional on achieving quality improvement and innovation goals agreed with Park Hill 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. CQUIN SCHEME: 1. Friends and Family Test i) early implementation for outpatient and daycase patients ii) phased expansion to daycase patients and patients undergoing an outpatient procedure iii) Increased or maintained response rate (target of 30%) 2. NHS Safety Thermometer Ensure that the prevalence of pressure ulcers is at or below the national baseline less 25% 3. Increase pre-admission confirmation of attendance Phased improvement in completion rates of pre-admission telephone calls to confirm attendance in order to reduce cancellations on day of surgery and increase efficiency and patient satisfaction Quality Accounts 2014/15 Page 19 of 46 2.2.5 Statements from the Care Quality Commission (CQC) Park Hill Hospital is required to register with the Care Quality Commission and its current registration status on 31st March is registered without conditions. Park Hill Hospital has not participated in any special reviews or investigations by the CQC during the reporting period. Park Hill was last inspected on 30th January 2014, this was an unannounced visit. An Inspector attended the site visit and the following 5 standards were inspected: Standard Consent to care and treatment Outcome CQC Judgement Standard Met People's privacy, dignity and independence were respected. People's views and experiences were taken into account in the way the service was provided and delivered in relation to their care. Care and treatment was planned and delivered in a way that was intended to ensure people's safety and welfare. People were protected from the risk of infection because appropriate guidance had been followed. People were cared for in a clean, hygienic environment. There were effective recruitment and selection processes in place. Care and Welfare of people Standard Met who use services Cleanliness and Infection Control Standard Met Requirements relating to workers Records Standard Met Standard Met People were protected from the risks of unsafe or inappropriate care and treatment because accurate and appropriate records were maintained. Park Hill was found to be fully compliant with each of the standards inspected and some of the patient feedback received on the day were; “You are not a number you are treated as an individual”. “You can’t fault the staff or care provided it is excellent”. “All the staff are great they look after us very well”. “I have been very pleased with the service; I have been looked after properly”. “Staff speak to you in terms you understand, even the consultants”. Quality Accounts 2014/15 Page 20 of 46 2.2.6 Data Quality Statement on relevance of Data Quality and your actions to improve your Data Quality Park Hill hospital will be taking the following actions to improve data quality. Good quality information underpins the effective delivery of patient care and is essential if improvements in quality of care are to be made. Improving data quality, which includes the quality of ethnicity and other equality data, will improve patient care and improve value for money. On induction our staff are trained on how to obtain and input data correctly onto our electronic systems and also how to handle confidential data, staff are monitored on correct data capture via internal reports and data quality training is updated regularly throughout the hospital. At Park Hill hospital data quality is one of our highest priorities to ensure we produce clean and accurate electronic data which we can use to monitor and improve our quality of care and service. Throughout the year we have updated and strengthened our processes to capture data in a timely manner and to audit data prior to submission. We are constantly looking to improve data capture and reporting processes supported by a dedicated corporate quality team. NHS Number and General Medical Practice Code Validity The Ramsay Group submitted records during 2014/15 to the Secondary Users Service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data included: The patient’s valid NHS number: 99.97% for admitted patient care; 99.96% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals). The General Medical Practice Code: 100% for admitted patient care; 100% for outpatient care; and Accident and emergency care N/A (as not undertaken at Ramsay hospitals). Information Governance Toolkit attainment levels Ramsay Group Information Governance Assessment Report score overall for 2014/5 was 75% and was graded ‘green’ (satisfactory). This information is publicly available on the DH Information Governance Toolkit website at: https://www.igt.hscic.gov.uk Quality Accounts 2014/15 Page 21 of 46 Clinical coding error rate Park Hill Hospital had a clinical coding audit in February 2014, our next audit is scheduled to be performed by Julie Gibbs, National Clinical Coding Lead, in May 2015. Site Park Hill NHS TC Audit Date Feb 14 Next Audit Primary Diagnosis May 15 100% Secondary Diagnosis 96.55% Primary Procedure 100% Secondary Procedure 98.73% Quality Accounts 2014/15 Page 22 of 46 2.2.7 Stakeholders views on 2014/15 Quality Account Our Quality Account was submitted to: Stephen Bruce Bittiner, Medical Advisory Committee Chair Antony Wilkinson, Clinical Governance Committee Chair Helen White, Regional Director (North) Doncaster Clinical Commissioning Group No comments were received. Quality Accounts 2014/15 Page 23 of 46 Part 3: Review of Quality Performance 2013/2014 Statements of quality delivery General Manager/Matron, Dawn Abbott Review of quality performance 1st April 2014 - 31st March 2015 This publication marks the sixth successive year since the first edition of Ramsay Quality Accounts. Through each year, month on month, we analyse our performance on many levels, we reflect on the valuable feedback we receive from our patients about the outcomes of their treatment and also reflect on professional opinion received from our doctors, our clinical staff, regulators and commissioners. We listen where concerns or suggestions have been raised and, in this account, we have set out our track record as well as our plan for more improvements in the coming year. This is a discipline we vigorously support, always driving this cycle of continuous improvement in our hospitals and addressing public concern about standards in healthcare, be these about our commitments to providing compassionate patient care, assurance about patient privacy and dignity, hospital safety and good outcomes of treatment. We believe in being open and honest where outcomes and experience fail to meet patient expectation so we take action, learn, improve and implement the change and deliver great care and optimum experience for our patients.” Vivienne Heckford Director of Clinical Services Ramsay Health Care UK Quality Accounts 2014/15 Page 24 of 46 Ramsay Clinical Governance Framework 2015 The aim of clinical governance is to ensure that Ramsay develop ways of working which assure that the quality of patient care is central to the business of the organisation. The emphasis is on providing an environment and culture to support continuous clinical quality improvement so that patients receive safe and effective care, clinicians are enabled to provide that care and the organisation can satisfy itself that we are doing the right things in the right way. It is important that Clinical Governance is integrated into other governance systems in the organisation and should not be seen as a “stand-alone” activity. All management systems, clinical, financial, estates etc, are inter-dependent with actions in one area impacting on others. Several models have been devised to include all the elements of Clinical Governance to provide a framework for ensuring that it is embedded, implemented and can be monitored in an organisation. In developing this framework for Ramsay Health Care UK we have gone back to the original Scally and Donaldson paper (1998) as we believe that it is a model that allows coverage and inclusion of all the necessary strategies, policies, systems and processes for effective Clinical Governance. The domains of this model are: • • • • • • Infrastructure Culture Quality methods Poor performance Risk avoidance Coherence Quality Accounts 2014/15 Page 25 of 46 Ramsay Health Care Clinical Governance Framework 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. Quality Accounts 2014/15 Page 26 of 46 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 Prescribed Information The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to— (a) the value and banding of the summary hospital-level mortality indicator (“SHMI”) for the trust for the reporting period; and (b) The percentage of patient deaths with palliative care coded at either diagnosis or specialty level for the trust for the reporting period. *The palliative care indicator is a contextual indicator. Average Eng 1 Eng 1 Period 2013/14 2014/15 Park Hill NVC14 0 NVC14 0 Related NHS Outcomes Framework Domain 1: Preventing People from dying prematurely 2: Enhancing quality of life for people with long-term conditions Park Hill considers that this data is as described for the following reasons: In addition to providing surgical care and treatment, Park Hill Hospital has no recorded deaths in 2013/14 and 2014/15. Quality Accounts 2014/15 Page 27 of 46 PROMS (Patient reported outcome measures) 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 Park Hill NVC14 NVC14 11.292 -4.567 Worst NT350 -16.849 RWA -16.762 Average Eng -8.698 Eng -9.479 Period Apr13 - Mar14 Apr14 - Sep14 Park Hill NVC14 NVC14 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 Park Hill NVC14 * NVC14 * 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 Park Hill NVC14 18.506 NVC14 * PROMS: Period Veins Apr13 - Mar14 Apr14 - Sep14 Best NT415 0.139 RXR 0.125 Best RTH RYJ (* denotes insufficient data for publishing from the 2 questionnaires following case-mix adjustment by the NHS data centre, which could be as a result of insufficient return of one of both of the questionnaires, in completed questionnaires, NHS number omission) The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s patient reported outcome measures scores for— (i) groin hernia surgery, (ii) varicose vein surgery, (iii) hip replacement surgery, and (iv) knee replacement surgery, during the reporting period. 3: Helping people to recover from episodes of ill health or following injury Park Hill Hospital considers that this data is as described for the following reasons: Park Hill Hospital participates in the Department of Health PROM’s survey for hip and knee replacement surgical procedures for NHS & private patients. Compliance for PROM’s participation for Park Hill Hospital is above the national average. Quality Accounts 2014/15 Page 28 of 46 Readmissions Readmissions: Period 2010/11 2011/12 Best Multiple 0.0 Multiple 0.0 Worst 5P5 22.76 5NL 41.65 The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients aged— (i) 0 to 14; and (ii) 15 or over, Readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the trust during the reporting period. Average Eng 11.43 Eng 11.45 Period 2010/11 2011/12 Park Hill NVC14 x NVC14 x 3: Helping people to recover from episodes of ill health or following injury Park Hill Hospital considers that this data is as described for the following reasons: Monitoring rates of readmission to hospital is another valuable measure of clinical effectiveness & outcomes. As with return to theatre, any emerging trend identified with a specific surgical operation or surgical team may identify contributory factors to be addressed. Ramsay rates of readmission remain very low and this, in part, is due to sound clinical practice & governance ensuring patients are not discharged home too early after treatment, are independently mobile and that patients are fully informed of individual discharge information. Responsiveness to Personal Needs of Patients Responsiveness: to personal needs Period 2012/13 2013/14 Best RPC RPY 88.2 87.0 Worst RJ6 68.0 RJ6 67.1 The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s responsiveness to the personal needs of its patients during the reporting period. Average Eng 76.5 Eng 76.9 Period 2013/14 2014/15 Park Hill NVC14 92.5 NVC14 91.6 4: Ensuring that people have a positive experience of care Quality Accounts 2014/15 Page 29 of 46 Park Hill Hospital considers that this data is as described for the following reasons: Feedback from patients regarding their experience at Park Hill Hospital is encouraged and is essential to inform our staff how care can be enhanced or adjusted to meet individual patient satisfaction. All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour – letters and cards are recorded on the Riskman system and displayed for staff to see on notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly. All negative comments or suggestions for improvement are also communicated 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. Every complaint received is given immediate attention of the General Manager/Matron on the day it is received, following which a thorough investigation is commenced into the concerns raised as per Ramsay Complaints Policy. Patient experiences are received from the various routes listed below, and are regular agenda items on Local Governance Committees for discussion, trend analysis and further actions as necessary. Escalation and further reporting to the Ramsay Corporate Governance Team, our stakeholders and regulatory bodies occurs as required in line with Public Health England. Park Hill Hospital has taken the following actions to improve this score, and so the quality of its services, by: Feedback regarding the patient’s experience is received through the following routes: Patient satisfaction surveys We value your opinion questionnaire leaflet Direct verbal feedback to Ramsay staff. Internal Ramsay audit /inspection processes. CQC inspection feedback. Written feedback via letters/emails/complaints PROMs surveys Care pathways – patients are encouraged to read and participate in their plan of care. Annual PLACE patient audit Quality Accounts 2014/15 Page 30 of 46 Venous Thromboembolism (VTE) VTE Assessment: Period 14/15 Q2 14/15 Q3 Best Several 100% Several 100% Worst RNL 86.4% NT322 85.1% The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients who were admitted to hospital and who were risk assessed for venous thromboembolism during the reporting period. Average Eng 96.2% Eng 96.0% Period 14/15 Q2 14/15 Q3 Park Hill NVC14 97.5% NVC14 98.2% 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Park Hill Hospital considers that this data is as described for the following reasons: Park Hill Hospital clinical staff carry out a VTE risk assessment on all admitted patients as per Ramsay policy which is based upon the National Institute for Clinical Excellence (NICE) Guidance 2010. Our pre assessment team complete a VTE competency assessment via the Department of Health on line assessment tool. Park Hill Hospital has taken the following actions to improve upon and maintain this score by: Completion of Corporate audits, incident investigation, reporting, root cause and gap analysis Robust mandatory training programme compliance Information sharing at Clinical Governance level locally, corporately and with our commissioners. Also through local Medical advisory committee and Risk management meetings. Strict adherence to infection control policies Quality Accounts 2014/15 Page 31 of 46 Clostridium Difficile Infection 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 The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the rate per 100,000 bed days of cases of C difficile infection reported within the trust amongst patients aged 2 or over during the reporting period. Average Eng 17.4 Eng 14.7 Period 2012/13 2013/14 Park Hill NVC14 0.0 NVC14 0.0 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Park Hill Hospital considers that this data is as described for the following reasons: An annual strategy for Infection Prevention and Control (IPC) is developed at a corporate level by the Group IPC and policies are revised and redeployed every two years. IPC programmes are designed to bring about improvements in performance and practice. A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and best clinical practice. Healthcare associated infections (HCAI) are acquired as a result of healthcare intervention. High standards of Infection Prevention and Control practice minimise the risk of occurrence of HCAIs. Quality Accounts 2014/15 Page 32 of 46 Park Hill Hospital has taken the following actions to maintain this score, and so the quality of its services, by: Infection Control issues are discussed and reviewed at the local Clinical Governance Committee which consists of representatives from all areas of the hospital. The committee meets quarterly to oversee implementation of corporate policies and National guidance and review clinical audit & practice. Minutes from local meetings develop and review action plans to address issues identified in both the corporate and local annual strategy/plan for infection control. All staff undertake mandatory infection prevention and control (IPC) training annually plus the clinical staff receive bi-annual Infection Prevention and Control training/updates from our Consultant Microbiologist Completion of Corporate clinical audits, incident reporting, identifying trends and identification of further training requirements Robust mandatory training programme compliance Information sharing at Clinical Governance level locally, corporately and with our commissioners. Also through local Medical advisory committee and Risk management meetings. Incident Rate and Patient Safety SUIs: Period Best (Severity 1 only) Oct 13 - Mar 14 RBD Apr - Sep 14 Several 0 0 Worst R1F 3.72 RBZ 1.09 The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death Average Eng 0.43 Eng 0.17 Period Oct13-Mar14 Apr-Sep14 Park Hill NVC14 0.00 NVC14 0.43 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Park Hill Hospital considers that this data is as described for the following reasons: Park Hill Hospital strives to report any incidents or near misses in real time through an electronic incident reporting tool called “Riskman”. Every incident is promptly reviewed by General Manager/Matron and an investigation process, root cause analysis and action plan implemented where appropriate. Quality Accounts 2014/15 Page 33 of 46 The Riskman system immediately reports incidents directly to the Corporate Risk Management Team allowing the identification of trends at Park Hill Hospital and throughout the Ramsay organisation to further identify trends and outlying data. Locally all incidents are reported through Health & Safety and Clinical Governance committees, learning’s and action plans are developed and implemented at a local level to improve safety. Other National reporting mechanisms e.g. MHRA; CQC; NHS England CAS alerts and local NHS networks are used via the Ramsay CAS alert process to share information with frontline staff as and when this is updated. We recognise that we have scored above the national average due to robust processes in place however; Park Hill Hospital has taken the following actions to improve upon this score, and so the quality of its services, by: Maintaining a robust staff induction and mandatory training programme Bi-Monthly Health and Safety and Clinical Governance meetings are instigated where risk key performance indicators and incidents are discussed and disseminated Continuing staff training in risk assessment of patients specifically related to movement and sensation of all aspects affecting limbs after surgery. Effective implementation of the new falls risk assessment for all ward staff Competency training provided by physiotherapists for all nurses & health care assistants in specific risk assessment relating to the effects of regional anaesthesia. Induction training on the use of Riskman. Friends and Family Test F&F Test: Period Jan-15 Feb-15 Best Several 100% Several 100% Worst RPA02 51.2% RHU10 75% Friends and Family Test - Question Number 12d – Staff – The data made available by National Health Service Trust or NHS Foundation Trust by the Health and Social Care Information Centre ‘If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation' for each acute & acute specialist trust who took part in the staff survey. Average Eng 94.0% Eng 94.7% Period Jan-15 Feb-15 Park Hill NVC14 100.0% NVC14 100.0% 4: Ensuring that people have a positive experience of care Quality Accounts 2014/15 Page 34 of 46 Park Hill Hospital considers that this data is as described for the following reasons: A NHS-wide ‘friends and family’ test to improve patient care and identify the best performing hospitals in England was announced in 2012 by the Prime Minister. All patients at Park Hill Hospital are routinely invited to take part in this anonymous survey. By completing a simple questionnaire asking whether they would recommend our hospital to their family and friends. Scores are published on the NHS Choices Website www.gov.uk Alongside providing clinical excellence and safe care, patient experience is the key measure of quality. Park Hill Hospital will use the information received from our patients in this survey in order to improve the service we offer. Park Hill Hospital has taken the following actions to improve this score, and so the quality of its services, by: Continue to raise awareness of staff of the importance of patient feedback by highlighting results through Clinical Governance meetings, staff meetings and Customer Care Excellence training Review the feedback and instigate action plans to address issues highlighted Track and record robust induction and mandatory training to ensure raised staff awareness of the friends and family test 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. Quality Accounts 2014/15 Page 35 of 46 3.2.1 Infection Prevention and Control Park Hill Hospital has a very low rate of Healthcare Associated Infections (HCAI) hospital acquired infection and has had one reported MRSA Bacteraemia in the past 4 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 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. As can be seen in the above graph our infection rate has reduced for 2014/15. Quality Accounts 2014/15 Page 36 of 46 Programmes and activities within our hospital include: Park Hill Hospital understands that Infection Control is a core part of an effective risk management programme, aiming to improve the quality of patient care and the occupational health of staff, in addition to the clinical need to prevent Healthcare Associated Infections (HCAI), and protect patients from harm. Park Hill Hospitals infection control processes are coordinated and led by an experienced Registered Nurse. Meetings are held quarterly and provide the hospital with infection prevention advice and guidance in conjunction with Ramsay Infection Prevention & Control Policies and Procedures and National Guidance. All staff undertake mandatory annual e-learning and practical training sessions for Infection Prevention. A comprehensive infection control audit programme has been maintained throughout 2014/2015. Audits undertaken during 2014/15 achieved average scores of: - 2013/14 2014/15 Hand hygiene 96% 96% Environment cleanliness 98.5% 99% Surgical site infection 100% 100% Peripheral venous catheter care 100% 100% Urinary catheter care 100% 54% Action plans are in place to address all of the issues raised in all the above audits where compliance is less than 100% and are regularly reviewed and monitored through Clinical Governance meetings. Actions Raised from 2013/14 Audits Hand Hygiene training Environment Quality Accounts 2014/15 Page 37 of 46 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 Park Hill 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. During 2014/15 Park Hill Hospital has taken part in Patient Led Assessment of the Care Environment (PLACE) which builds on the foundation of The Patient Environment Action Team (PEAT) assessments, with two main differences: Patients make up at least 50% of the assessment team giving patients a much stronger voice. Focus is on improvement with hospitals required to report publicly and say how they plan to improve. The last Place audit undertaken Park Hill Hospital took part in the Patient Lead Assessment of the Care Environment (PLACE) on 26th March 2014. Results of the audit are given below: Cleanliness, Condition Food Privacy Dignity and Wellbeing Appearance and Maintenance June 2014 (%) 99.70 94.38 92.86 94.44 Park Hill Hospital’s latest PLACE audit was undertaken on the 20th February 2015 by one external assessor, 2 staff assessors and 1 patient assessor – the 2015 programme is still underway and results will not be published until June 2015. The Report is available to download from http://efm.hscic.gov.uk/PLACE Quality Accounts 2014/15 Page 38 of 46 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 all have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Our record in workplace safety as illustrated by Accidents per 1000 Admissions demonstrates the results of safety training and local safety initiatives. Effective and ongoing communication of key safety messages is important in healthcare. Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues. Reporting and learning from clinical incidents Ramsay Healthcare has introduced electronic incident reporting using a system known as Riskman. This system is accessible by all members of staff and provides one tool for the reporting of all incidents, clinical and non-clinical. The implementation of this tool has enabled the hospital to share incidents and ensure that there are effective learning and action plans implemented to improve practice as required. Ramsay Health Care has a mandatory training programme which is completed on a yearly basis by all staff members. The training incorporates: General Induction Customer Care Basic Life Support Manual Handling Fire Safety Health and Safety Information Security Safeguarding Adults Safeguarding Children Infection Control Incl handwashing Informed Consent Immediate Life Support Blood Transfusion Acute Illness Management The training sessions are split between clinical and non-clinical allowing a more detailed approach. Mandatory online e-learning training is also completed on an annual basis by all staff members. Quality Accounts 2014/15 Page 39 of 46 Completion of training and any gaps in learning are reviewed and discussed in staff development reviews which are performed yearly, a review at six months; to ensure learning and development is on-going. A comprehensive Health, Safety and Facilities audit was carried out at the Park Hill Hospital by the Ramsay group Estates Manager on the 10th February 2015. This audit returned a score of 98%. This shows an increase from the previous audit which scored 96% compliance in 2014. This is mainly due to the Health and Safety Committee continuing to promote and maintain the interest of all the staff in health and safety issues, to ensure all staff realise that they are primarily responsible for the prevention of workplace accidents. Park Hill’s action plan from the latest audit is as follows: Section 1 - Workplace Administration Safety Staff completion of mandatory e learning Section 6 – COSHH Review to be undertaken of the register of Hazardous Substances and Dangerous Good for each department 3.3 Clinical Effectiveness Park Hill hospital has a Clinical Governance committee that meets regularly throughout the year to monitor quality and effectiveness of care. Clinical incidents, patient and staff feedback are systematically reviewed to determine any trends that require further analysis or investigation. More importantly, recommendations for action and improvement are presented to hospital management and medical advisory committee to ensure results are visible and tied into actions required by the organisation as a whole. Quality Accounts 2014/15 Page 40 of 46 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 in the above graph our return to theatre has reduced for 2014/15. 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 on notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly. Quality Accounts 2014/15 Page 41 of 46 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 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 PROMs surveys Care pathways – patient are encouraged to read and participate in their plan of care 3.3.1 Patient Satisfaction Surveys Our patient satisfaction surveys are managed by a third party company called ‘Qa Research’. This is to ensure our results are managed completely independently of the hospital so we receive a true reflection of our patient’s views. Every patient is asked their consent to receive an electronic survey or phone call following their discharge from the hospital. The results from the questions asked are used to influence the way the hospital seeks to improve its services. Any 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. Patient satisfaction scores can be seen in the graph on page 43. Quality Accounts 2014/15 Page 42 of 46 Park Hill Hospital asks all day case and inpatient patients at registration if they consent to Ramsay using their information to ask for feedback. Contact details of all patients that agree to take part in the survey are them supplied to Qa Research the week after they are discharged from hospital so they can be invited to take part. As a direct result of patients comments received from patient satisfaction surveys, hot alerts and complaints, the following are some examples of how we endeavor to provide patients with a good experience at Park Hill Hospital. 3.4 Patient Experience Our Chefs regularly visit patients following admission to discuss and receive feedback on the quality of food and the options available. The catering team work closely with the ward hostess team to ensure a consistent service is delivered to a high standard. A full review of menu choice has been reviewed which is to be launched midApril 2014. The new menu offers a greater choice to patients in addition to this the new options will be listed on an updated menu card. Relocation of hand wash gels available for patients and visitors. Health Care staff to ensure that they emphasise the fact that they have washed their hands prior to any patient treatment. Quality Accounts 2014/15 Page 43 of 46 Appendix 1 Services covered by this quality account Services Provided Treatment of Disease, Disorder Or injury Surgical Procedures Dermatology Ear Nose and Throat (ENT) General surgery Gynaecological Neurology Ophthalmic Orthopaedic Pain management Physiotherapy Rheumatology Sports medicine Urology Day and Inpatient Surgery Dermatology Cosmetic/plastic Ear, Nose and Throat (ENT) Gastrointestinal, General surgery Gynaecological Neurology Ophthalmic Oral maxillofacial Orthopaedic Pain management Physiotherapy Rheumatology Sports medicine Urology Vascular Peoples Needs Met for: All adults 18 yrs and over Children 3 yrs and over - outpatients only All adults 18 yrs and over 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 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 Phlebotomy, Urinary Screening and Specimen collection. Services subcontracted to the Trust hospital include medical imaging, MRI/CT, ultrasound and echocardiography. Quality Accounts 2014/15 Page 44 of 46 Appendix 2 Clinical Audit Programme 2014/15 Each arrow links to the audit to be completed in each month. Audit Programme v7.0 2014/15 Hospital Name: Park Hill Implemented: July 2014 Authors: R. Saunders / A. Shannon / N. Carre / A. Blake For review: June 2015 Use arrow symbol to locate required audit JUL Medical Records 95 AUG Consent Pre admission / Discharge SEP 91% OCT 97% 99% JAN 91% FEB VTE MAR 98% 95% APR Med Rec MAY VTE JUN N&H 99% 94% 94% Prescribing 99% 97% Medicines Management 99% N/A Physiotherapy 99% 86% N/A N/A 90% 92% 87% Infection Prevention and Control* 78% Infection Prevention and Control - Environmental Audit 99% Transfusion 79% N/A N/A N/A 92% 83% UCCB None N/A MRI 100 90% 96% Traffic light score 94% 99% Controlled Drugs Theatre DEC 33% 98 Care Pathways and Variance Tracking Radiology NOV 80% Organisat 88% ional N/A SSI Green 100% Cool Amber 90 - 99% Amber 80 - 89% Hot Amber 70 - 79% Red 69% and under CT 92 Anaesthe tic Peri op Hand hygiene Promotion Pt Satisfaction Surgical Safety Clin Effect PVCCB UCCB 98% Environ 99% Environ A llo geneic Traceability A uto lo go us Traceability *Key: CVCCB = Central Venous Catheter Care Bundle SSI = Surgical Site Infection PVCCB = Peripheral Venous Cannula Care Bundle UCCB = Urinary Catheter Care Bundle Det Pt = Deteriorating Patient N&H = Nutrition and Hydration VTE = Venous Thromboembolism Quality Accounts 2014/15 Page 45 of 46 Park Hill 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. 01302 553321 For further information please contact: 01302 730300 www.parkhillhospital.co.uk Quality Accounts 2014/15 Page 46 of 46