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
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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.
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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.
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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
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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.
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
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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
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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
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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.
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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
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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
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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.
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2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2014/15 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
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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
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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.
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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.
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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
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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
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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”.
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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
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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%
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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
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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
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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
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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.
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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