Rowley Hall Hospital
Quality Account
2014/15
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Rowley 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, with a network of 33 hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, Clinical Commissioning
Group.
CEO and Director of Clinical Services Statements
Statement from Mark Page
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.
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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
4
Introduction to our Quality Account
This Quality Account is Rowley Hall Hospital’s annual report to the public and
other stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t
provide enough in depth information for the public and commissioners about the
quality of services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
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Part 1
1.1 Statement on quality from the General Manager
It was a great pleasure to be appointed as the General Manager at Rowley Hall
Hospital in November 2014 to continue the great work of my predecessor
Gloria Kerrigan who will now be focussing all her time at our West Midlands
Hospital.
Rowley Hall Hospital understands that patients have a choice and is committed to
being the leading healthcare provider for local patients by delivering high quality
care and excellent clinical outcomes. I’m delighted to say that the number of
patients who choose Rowley Hall Hospital as their health care provider of choice
continues to increase. We have also provided additional support during the year
to other local Hospitals so that as a health community we minimise the amount of
time patients need to wait for their care and treatment.
We are aware that patients can be nervous about coming into hospital and
understand that providing reassurance is important to both patients and their
families. 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 Rowley Hall Hospital.
Taking great care of the increasing number of patients has not been without its
challenges but our staff have embraced the opportunity to maintain the highest
quality service and clinical care that we are all extremely proud of and we
continue to enjoy a NHS Choices rating of 5 Star’s. At the time of writing our
Quality Account during the previous month 100% of our patients who stayed with
us overnight following surgery were ‘extremely likely’ to recommend Rowley Hall
Hospital to their Friends and Family.
We are however not complacent, we see every comment provided by our patients
as an opportunity to improve what we do. As the hospital gets busier car parking
6
becomes more of a challenge, we have introduced the Cycle to Work scheme
and 2015 will see all staff members parking off site at another location freeing up
space and making access to the hospital for our patients and visitors much
easier.
We have increased the number of Consultants across almost all Specialities
which not only helps to keep wait times for care as short as possible but has also
increases the patients choice of which Consultant they wish to provide their care
for them.
Ramsay Health Care UK has continued to invest in Rowley Hall Hospital, we
have now completed an extensive refurbishment of our Out Patient Department
which is fantastic and provides a much brighter modern environment. We have
also created two new additional dedicated Preoperative Assessment Clinic
Rooms for patients who will go on to receive surgery. During 2015 we will be
extending our Day Surgery Unit to accommodate an additional 4 day beds,
currently 6, which will again allow us to treat more patients in our hospital.
M A Lacey
Mark Lacey, General Manager
Rowley Hall Hospital
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Mark Lacey
General Manager
Rowley Hall Hospital
This report has been reviewed and approved by:
Medical Advisory Committee Chair; Mr Ishan Bhoora,
Clinical Governance Committee Chair; Mrs Julie Maddock, Matron
Regional Director; Mr James Beech
Staffordshire and Surrounds Clinical Commissioning Group
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Welcome to Rowley Hall hospital
The Rowley Hall Hospital is situated in the centre of Stafford with easy access to
public transport.
The main hospital is housed in a listed building, with a smaller building adjacent
to the rear car park which houses our administration team, physiotherapy service
and nurse led laser hair service.
The hospital consists of two operating theatres both with laminar flow and 11
inpatient bedrooms (13 overnight beds) with en-suite facilities, and a 6 bay Day
Surgery Unit.
Our Staff have been carefully selected for their friendly and caring approach as
well as their efficiency and professionalism. A Resident Doctor is available 24
hours a day. The restful atmosphere and high level of personal attention combine
to aid patient recovery. The first patients were admitted in August 1987 and the
hospital has continued to grow and develop since this date.
In 1999 the first floor was converted to accommodate our outpatient services
including the X-ray and physiotherapy departments.
In 2007 due to growth of our services refurbishment of “the old schoolhouse”
allowed us to re house the business office and our physiotherapy department.
This also allowed us to locate our non-invasive cosmetic services within this
environment, with a dedicated consulting room for our cosmetic nurses to deliver
laser hair removal.
In 2013/2014 we treated a total 4348 patients with 86% being NHS patients (1 st
April 2013 to 31st March 2014)
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The hospital provides a comprehensive range of services. These include;

Medical,

Orthopedic,

Spinal,

Podiatry,

General Surgical,

Ophthalmology,

Ear, Nose and Throat,

Urology,

Gynecology

Cosmetic services.
The Hospital has mobile CT and MRI service which is offered to both privately
insured and NHS patients. We offer a direct access service for both MRI service
and CT for NHS patients referred by their GP.
To ensure that patients are at the centre of everything we do and receive the
highest standard of care, we have 75 dedicated Consultants, working alongside
95 permanent staff and 59 Bank members including nursing, radiology,
physiotherapy, supported by administration, housekeeping, and maintenance and
catering staff.
At Rowley Hall Hospital we work closely with our colleagues at the Clinical
Commissioning Groups and local NHS Trust to ensure our services meet the
needs of the patients we serve, including shared services such as: pathology,
pharmacy, decontamination and some diagnostic services.
We also work in partnership with our GP’s in the area supporting them with
educational needs by organising specialist training sessions with the help of our
Consultant body.
At Rowley Hall Hospital we feel it is important to maintain
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excellent links with local GP’s and work together for the benefit of all our patients.
We have a dedicated GP liaison officer to foster these links and relationships.
Rowley Hall Hospital supports several charities including Katherine House
Hospice, Children in Need, Comic Relief, The British Heart Foundation and
Meningitis UK
Developments continue at the Hospital and during 2015 further work continues
which includes:
Refurbishment of OPD department

Addition of new day-case pods which will increase our day case capacity
to 10.
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2014/15
On an annual cycle, Rowley hall hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives 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.
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Priorities for improvement
2.1.1 A review of clinical priorities 2013/14 (looking back)
Patient safety
Patient safety is a key priority for the Rowley Hall Hospital and in 2014/15
we will continue to improve the safety of our patients by putting
mechanisms in place to ensure that we continue to reduce the risk of
patients suffering a blood clot post- surgery and ensure safe, competent
staff are available to care for patients by ensuring they receive appropriate
training and clinical updates.

VTE Risk Assessment
We ensure that all our patients have the appropriate venous thrombus risk
(blood clots in either the leg or the lung) risk assessment performed prior
to undergoing surgery using the national risk assessment tool where
clinically indicated. This ensures that appropriate treatment is given to any
patients who are at risk. Our staff have undergone training in carrying out
this risk assessment and we audit our records to ensure this has been
carried out. This is in line with quality requirements of our local Clinical
Commissioning Group’s and is a national initiative for all health providers.
Our current compliance is 100% and any reported potential incidents are
investigated thoroughly, the findings of which are discussed through our
clinical governance meetings and Medical Advisory Committee.
This
information is also fed back to our commissioners via our CQRM.
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Clinical effectiveness

Meeting endoscopy standards
Rowley Hall has undertaken a review of our Endoscopy service within our
build project this will ensure that we can provide an excellent service for
our patients. Along with staff training this will help us to work towards Joint
Advisory Group (JAG) accreditation.

Training
Ensuring well trained, competent staff are available to care for patients is a
high priority at Rowley Hall Hospital. We continue to develop our Health
Care Assistants. This ensures they hold the knowledge skills to support the
delivery of care to our patients. Ramsay Health Care has developed a
Clinical Skills Portfolio specifically for Health Care Assistants. The Clinical
Skills Portfolio is a tool to measure our Health Care Assistants ability to
recognise and respond to patients undergoing clinical procedures,
confidently and competently.
To enable our safe patient culture, it is imperative that we have
appropriately trained staff. We have supported our staff to achieve the
Acute Care Competencies specific to their role. Our regional trainer who
has experience of critical care is working alongside our staff to provide
specific training sessions that will help staff to recognise the early signs of
a patient who is becoming unwell, including the onset of sepsis. We
introduced the Acute Illness Management (AIM) course which supports our
staff in recognising the acutely ill patient and provides a strategy for
immediate action and ongoing care. Training records and competency
booklets are recorded for all relevant staff members to allow us to review
progress and act as part of our staff personal development program. To
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steer this agenda we have a dedicated critical care lead in post that also
works with all clinical staff to achieve clinical competencies appropriate to
their roles.
We have also introduced a Drugs Calculations package whereby all
registered nurses are required to achieve 100% score in the test after
relevant refresher coaching where required.
Patient experience

Investment in day surgery facilities
Our day surgery facility has been a tremendous success and through
innovative ways of working we are delivering care for various day case
procedures without breaching same sex accommodation. This ensures
dignity and privacy agenda is met at all times. We are particularly proud of
our highly efficient successful and efficient pathways for cataracts,
endoscopy, podiatry and pain management.

Cleanliness
Further infection prevention and control audits were introduced as planned
and these are now being undertaken at all Ramsay sites and action plans
developed locally where necessary to ensure the standards are met.
PLACE (Patient Lead Assessment of a Clinical Environment) audits
involving our patients and public were carried out this year and showed
continued high level of achievement for environments, food and are
excellent record in maintaining patient’s privacy and dignity.
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
Friends and family feedback
We sought the views of patients on their experience throughout the year
and invited a patient group to help us to design a questionnaire for patients
undergoing cataract surgery. Our patients are very satisfied with the care
they receive and on occasions where something hasn’t been quite right,
patients are happy that it has been addressed quickly.

Employee engagement
We have actively sought feedback from our staff to find out what we could
do differently to make working for us even better. Staff completed a survey
based on 8 factors;
o Leadership
o My Company
o My Manager
o Personal growth
o My Team
o Wellbeing
o Fair deal
o Giving something back.
We achieved an average score of 4.3 out of a possible 7 and an action
plan has been drawn up outlining activities and forums that will improve
staff engagement by enhancing communication, ensuring staff feel listened
to and supported.

Outpatient Refurbishment
Our Outpatients department has received a complete overhaul, which has
brought our facilities up to date, enabling patients and staff to enjoy a
much improved environment. Early feedback from patients has been very
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positive and we look forward to making full use of the improved
environment and facilities

Improved patient information
We recognised from our patient satisfaction survey results that the
discharge information given to patients was not always clear and we have
worked hard to address this by staff training, reviewing of patient
information and supporting patients with follow up discharge telephone
calls.
Throughout the year we have talked to our patients through holding patient
forums and interviews and have used feedback to make informed
changes.
Through involving our patients, we are currently developing a new Patient
Information booklet that will be provided to patients prior to admission that
will include all of the useful information that patients tell us would be most
helpful to them.

Informing patient choice
Our patients’ perception of us matters. We pride ourselves in our
reputation and high standards of care. We welcome all feedback and use it
to take action where required. We have invited patients into the hospital for
afternoon tea and cakes whereby the patient forum is used to gather
detailed feedback about their experience and asked their opinion on the
format of a proposed questionnaire. We intend to utilise patient feedback in
future events during 2015 both in patient group format and also by inviting
individuals to come and speak at our monthly Leadership meetings to tell
us about their experience, whether great or poor. We intend to utilise this
initiative where a patient has complained or their experience has been
particularly unsatisfactory in order to learn from their experience.
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Our patient experience feedback is mostly very positive, particularly about
the care they receive and we feed this back to the staff. When individual
members of staff are mentioned we record this and have implemented a
recognition and reward scheme whereby we present a bronze, silver and
gold award to staff. This scheme includes all staff, clinical and non -clinical

Cleanliness/Hand Hygiene
On review of our customer feedback it was apparent that our patients were
not aware of hand washing being carried out by our staff. It was felt that
as staff washed their hands in patient bathrooms when in patient rooms it
needs to be highlighted to our patients that our staff are carrying out hand
hygiene prior to performing any treatments and care therefore we have
raised awareness for staff and patients by focusing on this topic with the
support of our infection control nurse.
We have posters advising our
patients that it is ok to ask staff if they have washed their hands. We have
Alcogel available outside all of our patient rooms for staff and relatives to
use. The Infection Prevention and Control Link Nurse has carried out a
focus event on best practice and will plan more events throughout the
year, in order to remind staff about best practice in hand-washing
technique as well as utilising quizzes with prizes and other means in order
to raise awareness of infection prevention and control measures.
We will be also be carrying out spot check audits on hand washing for staff
and consultants, and will be able to evidence improvements by audit and
customer satisfaction results. Our audit results have already shown an
improvement over the year and currently we are achieving an average of
85% and have recently achieved 100% for our spot audit on handwashing.
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2.1.2 Clinical Priorities for 2014/15 (looking forward)
Clinical priorities for 2014/15 have been chosen to improve our performance
across the following domains:
o Patient safety
o Clinical effectiveness
o Patient experience
Our Priorities for 2014/15 will focus on;
1. Embedding new E Rostering system
2. Development of the Rowley Hall Administration team
3. The Ramsay Clinical Audit Programme
4. Development of the workforce
5. Preparedness for revalidation for consultants and nurses
6. Increasing the day case capacity
7. Reduction of New to Follow ratio
1. Embedding the new E Rostering system
The E Rostering system has been implemented which will enable managers to
see duty rotas at a glance. It enables the viewer to take action when required
to ensure that staffing levels are safe, and that the skill mix of staff and senior
cover within the hospital is managed to ensure the safety of our patients can
be met at all times.
The E Rostering system enables mangers to ensure we have the right people
in the right place at the right time. It enables the manger to ensure man hours
are used to their most effectiveness ensuring levels are increased during busy
times and reduced when not required
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From a patient experience point of view it is essential our staffing levels are
flexed to the demands of the service to ensure our patients are treated or
attended to promptly and efficiently adding to their experience of Ramsay as a
health care provider.
Progress on achieving efficiency and safe staffing levels is monitored by each
Head of Department, and in turn is overseen by Matron for all clinicians to
ensure clinical safety. The Finance Manager and General Manager monitor to
ensure adherence to efficiency requirements.
Progress is reported monthly at the Leadership meeting, chaired by the
General Manager, and communicated to all staff via their team or
departmental meetings.
2. Development of the Rowley Hall Administration team
Rowley Hall Hospital recognises the significance of the infrastructure that
supports the clinical teams. As the demand on our service increases, we will
need to re-engineer our administrative processes and patient pathways to be
more effective and efficient.
After reviewing our administration processes we intend to;

Improve our process for transferring patients to another provider if not
clinically suitable to be treated at Rowley Hall

Improve our communication with patients regarding their planned care

Improve our utilisation of our theatre capacity and Day Surgery Unit

Increase the utilisation of available beds

Improve the flow of our outpatient clinics including our scanning
facilities for MRI and CT

Involve Consultants more in managing the 18 week pathway
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Our patient experience begins before our patients enter the hospital, our patients
tell us that their clinical care is exceptional and we wish to emulate this with their
experience of our written and verbal communication.
We have recruited to a new Bookings Lead position which has been filled by an
experienced manager whose aim is to streamline the bookings processes to
ensure all elements of the patient journey are inextricably linked and seamless.
Progress will be measured by;

identifying a reduction in the number of complaints relating to the
booking process or other non-clinical related parts of the patient
journey

reduction in the number of surgery cancellations (for non-clinical
reasons)

increase in the number of bed spaces fulfilled monthly

reduction in the number of 18 week breaches
3. The Ramsay Clinical Audit Programme
Our current audit programme helps us benchmark and measure our compliance
with best practice and clinical care.
Last year we recognised that our compliance in completing the audits in a timely
manner could be improved upon. It will be our priority this year to implement the
agreed actions that our teams have developed to ensure we meet this objective
Measuring our clinical practice enables us to benchmark our standards in both
practice and compliance in relation to clinical care. The results allow us to
compare against other hospitals in the Ramsay group and share learning.
Our audit programme is part of our governance structure enabling us to take
action in any areas of concern within the care we provide. This proactive way of
21
managing practice and compliance ensures we have the information at hand to
drive improvements required before they impact on patient safety
Auditing practice and compliance allows us to question local processes that have
little value on patient care and experience and review those processes to ensure
our time is spent adding value instead.
Our aim is to achieve 100% compliance in completing the audits on time for each
department and also to be able to demonstrate an improved % score for each
audit.
In order to achieve this we have appointed a Quality Improvement Manager who
will manage and coordinate the completion of the audit programme and monitor
the completion of improvement actions identified. The following actions will be
taken during 2015;

Appropriate auditors identified within each department for the year ahead.

Training on audit completion for staff to develop their auditing skills

Comprehensive action plans developed by the Quality Improvement
Manager in consultation with each department lead. These are made
available to all Department Leads.

Action plans are discussed, reviewed and progress updated at the Clinical
Governance meetings and department meetings.
We will report progress on improvements and changes made at the monthly
Leadership meeting which is chaired by the General Manager.
Our audit programme also informs us of the areas we need to implement further
training and development of our staff and so any learning needs analysis that are
generated are shared with the training team as well as linking to individual
appraisals.
Delivering care in an environment that is constantly striving to improve its
compliance with best practice improves and enhances patient experience. It gives
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reassurance to our patients that we care enough to regularly check what we are
doing, how we are doing it and we need to do to make it better
4. Development of the workforce
Our priority for 2014/2015 will be to think creatively at how we deliver care.
Existing models of staffing including traditional roles appointed to have been
increasingly difficult to sustain. Our staff will be encouraged to undertake training
to develop a more flexible workforce within the hospital.
Our aim for this priority is to develop our Health Care Support Workers (HCA’s) to
be able to competently deliver care in a supervised environment and encourage
them to take the opportunity to work in several clinical areas.
We will do this by;

Exposing HCA’s to all areas of clinical care

Encourage them to undertake more formal training through our Ramsay
academy

Support them through the use of a Mentor to achieve the new HCA
competencies that cover every aspect of the basic role and also some
specific to specialist roles eg; venepuncture and ECG recording for a preoperative assessment role.
We will monitor progress through the use of 121 meetings with Line Managers
and Mentors and link development needs to appraisals so that learning is tailored
to individual need.
Having a workforce fit for purpose including the right number of staff with the right
skill mix is essential to delivering safe and effective care. To date our excellent
clinical outcomes with minimal length of stay in hospital have been testament to
achieving this. However, we recognise that health care as a whole is becoming
23
increasing difficult to recruit to and so we are taking the initiative of ‘growing our
own’
A skilled flexible workforce is key to ensuring we keep pace with innovation and
technology in healthcare. Being open to new ideas and taking a more flexible
approach in how we deliver pathways enables us to be clinically effective.
Progress will be reported through Line Managers and through HR and we will be
able to measure success from the level of confidence our patients have in our
HCA’s as well as feedback from HCA’s on job satisfaction, improved retention of
staff and feedback from our patients on their overall experience.
Confidence in the workforce who are looking after our patients from their first
telephone conversation through to discharge is our overall aim ensuring our
patient experience continues to enhance our already excellent reputation.
5. Preparedness for revalidation for consultants and nurses
The Nursing and Midwifery Council (NMC) has approved a new revised code
which is centred on four topics;

Prioritise people

Practise effectively

Preserve safety

Promote professionalism
The NMC revalidation model intends to take the Code further and position it at the
heart of everyday nursing practise and bring back reflection on practice as a
method of upholding professional standards.
Our aim for this priority is to enable our clinical staff to be fully prepared for revalidation, we will be ensuring that best practise is achieved throughout and that
learning takes place at every opportunity in all environments.
We will do this by the following activity;
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
Communicate the requirement to all clinical staff

Include revalidation as a standard agenda item to be discussed and
monitored at senior manager and team meetings.

Encourage learning at every opportunity by utilisation of the reflection log
found within the revalidation documents. Use of the reflection log will be
encouraged at team meetings and other events that staff routinely attend
as well as planned formal learning activity. In this way, staff are able to
challenge the practise of others and learn from experience of others.

Utilisation of Peer review sessions for staff where learning from sharing
situations or scenarios with colleagues takes place either at planned
sessions, 1 to 1 meetings or during team meetings.

Linking the reflective log with appraisals and individual objectives.
By incorporating these activities into our everyday practise and behaviours, it is
anticipated that a cultural change will take place that will ensure that clinicians
assume individual as well as corporate responsibility for ensuring that the NMC
standards are met and that they fully understand and appreciate their
professional responsibilities.
Progress will be monitored by Line Managers through conducting 1 to 1 meetings
and appraisal review meetings where learning from reflection, peer review and
experiences can be discussed.
Progress will also be monitored by Department Leads and reported on at monthly
Leadership meetings.
6. Increasing the day case capacity
At Rowley Hall Hospital we are continuing to promote the Day Surgery Unit which
is the admission of selected patients to hospital for a planned procedure and
returning home the same day i.e. the patient does not incur an overnight stay.
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Over recent years, partly due to medical advances, the number of day surgery
patients has increased compared those that require inpatient care. During
2013/2014 the percentage of day surgery patients we treated was 83%. We need
to ensure that our hospital facilities and patient flows meet the case mix we now
deliver and to enable us to achieve this.
This has proved to be a very efficient way of treating this group of patients and
the feedback has been very positive. Results from our customer feedback survey
continue to support this model of care as being very satisfactory to our patient
minimising time spent in hospital.
In 2015 our aim is to increase our capacity to care for day patients and so we
plan to increase our purpose built Day Surgery Unit from 6 bays to 10 bays,
housing recliner chairs.
It is a major building project that will transform our ability to ensure efficient and
safe flow of patients through the day case patient pathway and also allow for
better utilisation of our theatre time.
A senior manager will be appointed as a project manager to manage and monitor
progress throughout the build. Any potential issues or risks will be identified and
escalated as required in order to minimise disruption to patients and staff and to
ensure safety for all.
Progress will be reported at our daily management ‘huddle’ meetings and at
monthly Leadership meetings.
Success will be measured by;

Identifying level of patient comfort and satisfaction

Increase in numbers of patients cared for as day patients

Financial metrics
7. Reduction of New–to-Follow-up ratio or Outpatient Appointments
It has been identified that best practise for most procedures is to ensure that
patients are only asked to attend hospital for the minimum number of
appointments required to manage their condition.
26
It has been common practise for some Consultants to review the progress of their
patients more often than is absolutely necessary, however, Consultants will now
be asked to adhere to best practice and protocol when considering whether a
follow-up appointment is really necessary. If however an additional appointment is
requested by the patient this will be provided.
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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 2013/14 the Rowley Hall hospital provided and/or subcontracted 3733
NHS services.
The Rowley Hall hospital has reviewed all the data available to them on the
quality of care in these NHS services.
The income generated by the NHS services reviewed in 1 April 2013 to 31st
March 14 represents 73 per cent of the total income generated from the provision
of NHS services by the Rowley Hall hospital for 1 April 2013 to 31st March 14
The Balanced Scorecard
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 2013/14, the indicators on the scorecard which affect patient
safety and quality were:
Human Resources
Staff Cost 28.6% Net Revenue
Agency Cost as 0.5% of Total Staff Cost
Ward Hours PPD – 4.73
4.36% Sickness
15.4% Lost Time
28
Mandatory Training 70%
Staff Satisfaction Score 4.3
Number of Significant Staff Injuries 0
Patient
Formal Complaints per 1000 HPD's - 23
Patient Satisfaction Score – 100%
Significant Clinical Events per 1000 Admissions - 2
Readmission per 1000 Admissions - 1
Infection Control Audit Score – ave 85%
2.2.2 Participation in clinical audit
The national clinical audits and national confidential enquiries that Rowley Hall
hospital participated in, and for which data collection was completed during 1
April 2013 to 31st March 2014, are listed below alongside the % 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)
% cases
submitted
100%
100%
Local Audits
The reports of 70 local clinical audits from 1 April 2013 to 31st March 2014 were
reviewed by the Clinical Governance Committee and Rowley Hall hospital intends
to take actions to improve the quality of healthcare provided. Local Audits have
29
been selected as one of priorities for 2015 and is described in detail later in this
document. The clinical audit schedule can be found in Appendix 2.
2.2.3 Participation in Research
There were no patients recruited during 2013/14 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of the Rowley Hall Hospital income during 1 April 2013 to 31st March
2014 was conditional on achieving quality improvement and innovation goals
agreed with Rowley Hall Hospital and our NHS Commissioners.
The CQUIN’s agreed for 2013/14 were;
 Friends and Family Feedback
o Inpatient care
o Improved response
o Staff
Feedback from our patients tells us that they feel that the care they receive is
exceptional. Positive comments extend across all departments.

Endoscopy services
o Compliance with Endoscopy pathway
o Improved comfort scores
The audit findings show that we are 99% compliant with the pathway and that we
have improved the comfort scores for patients undergoing endoscopy to around
45% across the year. This relates to a comfort score of 1 from the doctor and
nurse and where the patient’s perception is that the procedure was better or the
same as expected. Of the remaining scores, most patients reported that the
procedure was better or same as expected but where the doctor or nurse rated
their comfort at a slightly higher level. Very few patients reported that the
procedure was worse than expected. This may be in part due to the
implementation of a pre-operative assessment being carried out by a specialist
endoscopy nurse who is trained to prepare the patient well for the procedure.
30

Cataract services
o Quality of Life questionnaire
o Pilot Visual Function questionnaire
We provided patients due to undergo cataract procedure with a questionnaire to
establish their quality of life in general, pre and post procedure in order to identify
whether having the procedure had a positive impact on their quality of life.
We involved patients in deciding which questionnaire to use by holding a patient
forum. The patients helped to create an adapted version of currently used tools
and this was used to collect the data.
A short pilot was also implemented using a Visual Function Outcome tool which
focused on activities that were directly related to being able to see adequately.
All three CQUIN’s have been achieved.
2.2.5 Statements from the Care Quality Commission (CQC)
Rowley hall Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March is registered without conditions
The Care Quality Commission has not taken enforcement action against
Rowley hall Hospital during 2013/14.
Rowley Hall hospital has not participated in any special reviews or investigations
by the CQC during the reporting period.
31
2.2.6 Data Quality
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
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall
score for 2013/14 was 83% and was graded ‘green’ (satisfactory).
Audit
Date
Next Audit
Date
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
Jan 14
April 15
96.67%
86.57%
100%
96.04%
Clinical coding error rate
Rowley Hall hospital was not subject to the Payment by Results clinical coding
audit during 2013/14 by the Audit Commission. There are plans to conduct this
audit soon.
32
Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Statement from Vivienne Heckford, Director of Clinical Services
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
33
Statement from Julie Maddock, Matron, Rowley Hall Hospital
As Matron of Rowley Hall I am proud to see the hospital grow from strength to
strength in all areas. Our reputation for delivering excellent care has driven a
higher demand for our services as the local population chooses us. This increase
in activity has not altered the outstanding patient feedback we continue to have
and the quality of care has remained high. Our low infection rates and postoperative complications indicate a continuing track record of patient safety. We
will not become complacent about our successes and recognise that we do not
always get it right in a minority of cases. We have created a learning culture as a
team and will strive to improve wherever we can. Being open and honest about
our failings is as important as celebrating our achievements.
Julie Maddock
Matron
Rowley Hall Hospital
34
Ramsay Clinical Governance Framework 2014
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 and estates 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
35
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.
36
3.1 The Core Quality Account indicators

Mortality rates
Mortality
Unexpected Deaths
1
100.00%
50.00%
0
0.00%
12/13
13/14
14/15
Rowley Hall Hospital
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 hospitallevel 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.
12/13
13/14
14/15
Rowley Hall Hospital
Related NHS Outcomes
Framework Domain
1: Preventing People from dying
prematurely
2: Enhancing quality of life for
people with long-term conditions
Rowley Hall considers that this data is as described for the following
reasons:
Rowley hall hospital has had no incidence of expected or unexpected death
during 2012/13 or 2013/14. This may be, in part due to adherence to exclusion
criteria agreed by the CCG and to comprehensive pre-operative assessment of
patients prior to surgery.
37
 PROMS (Patient reported outcome measures)
Hernia
Provider
ROWLEY HALL HOSPITAL
FULWOOD HALL
HOSPITAL (NVC07)
AIREDALE NHS
FOUNDATION TRUST
(RCF)
Hip-HG
KneeHG
Hip-SD
KneeSD
VeinHG
*
22.466
7.15
17.13059
8.886
-2.72515
22.6451
8.056
17.42053
7.012
*
21.5927
8.308
17.90857
7.951
14.34
-0.34151
0
VeinSD
0
*
11.34
Average health gain
EQ-5D VAS - casemix adjusted
Groin Hernia
0
-1
ROWLEY HALL HOSPITAL
(NVC17)
FULWOOD HALL HOSPITAL
(NVC07)
AIREDALE NHS FOUNDATION
TRUST (RCF)
-2
-3
Casemix Adjusted Health Gain
Varicose Veins
0
-5
-10
ROWLEY HALL HOSPITAL
(NVC17)
FULWOOD HALL HOSPITAL AIREDALE NHS FOUNDATION
(NVC07)
TRUST (RCF)
-15
-20
-25
-30
38
Adjusted average health gain
Oxford Hip Score
35
30
25
20
15
10
5
0
ROWLEY HALL HOSPITAL
(NVC17)
FULWOOD HALL HOSPITAL
(NVC07)
AIREDALE NHS FOUNDATION
TRUST (RCF)
Adjusted average health gain
Oxford Knee Score
30
25
20
15
10
5
0
ROWLEY HALL HOSPITAL
(NVC17)
FULWOOD HALL HOSPITAL
(NVC07)
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.
AIREDALE NHS FOUNDATION
TRUST (RCF)
3: Helping people to recover from
episodes of ill health or following
injury
39
Rowley Hall hospital considers that this data is as described for the
following reasons:
Rowley Hall hospital participates in the Department of Health PROM’s survey for
hip and knee replacement for NHS & private patients only. Compliance for
PROM’s participation for Rowley Hall Hospital is above the national average.
Increasing the use of Patient Reported Outcomes Studies (PROMs)
By sharing and using the results of the national PROMs results for Hip, Knee, and
Hernia surgery we are able to identify any areas of poor patient outcome and
examine practice if and where this exists. This will be facilitated through the
medical advisory committee, clinical governance reporting, and review of
practising privileges for our consultants.
This audit program allows us to benchmark our outcomes against the local NHS
trust; it also allows visibility of our results to other providers.
 Readmissions
Absolute numbers;
Rate per 100 discharges;
Readmissions
Readmissions
3
0.06%
2
0.04%
1
0.02%
0
12/13
13/14
14/15
0.00%
Rowley Hall Hospital
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
12/13
13/14
14/15
Rowley Hall Hospital
3: Helping people to recover from
episodes of ill health or following
injury
40
trust within 28 days of being discharged from a
hospital which forms part of the trust during the
reporting period.
Rowley Hall Hospital considers that this data is as described for the
following reasons:
Monitoring rates of readmission to hospital is 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.
Rowley Hall Hospital rates of readmission remain very low (just 1 patient in the
last 2 years) and is mostly due to appropriate pre-operative preparation, sound
clinical practice and governance, ensuring patients are not discharged home too
early after treatment, are independently mobile and are provided with individual
discharge information.
 Responsiveness to Personal Needs of Patients
Period
2012/13
Best
RPC 88.2
Worst
RJ6
68.0
Average
Eng
76.5
Period
2012/13
Rowley
NVC17 92.5
2013/14
RPY
RJ6
Eng
2013/14
NVC17
87.0
67.1
76.9
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.
93.7
4: Ensuring that people have a
positive experience of care
Rowley Hall hospital considers that this data is as described for the following
reasons:
Rowley Hall hospital takes feedback from patients and relatives seriously and acts on
complaints, sharing learning and making improvements where required.

Venous thromboembolism
Period
Best
14/15 Q2
Several 100%
Worst
RNL
86.4%
Average
Eng
96.2%
Period
14/15 Q2
Rowley
NVC17
41
99.0%
14/15 Q3
Several 100% NT322
85.1%
Eng
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.
96.0%
14/15 Q3
NVC17
98.4%
5: Treating and caring for people in
a safe environment and protecting
them from avoidable harm
Rowley Hall hospital considers that this data is as described for the following
reasons:
Rowley Hall hospital 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 start a VTE competency assessment prior to
admission. This is reviewed on admission and added to by the consultant where
treatment may be prescribed
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.
3.2.1 Infection prevention and control
C. Diff
Period
Best
rate:
per
2012/13 Several 0
100,000
bed days 2013/14 Several 0
Worst
Average
RVW
30.8
Eng
17.4
RMP
32.5
Eng
14.7
Period
Rowley
2012/13
NVC17
0.0
2013/14
NVC17
0.0
42
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.
5: Treating and caring for people in
a safe environment and protecting
them from avoidable harm
Rowley Hall Hospital considers that this data is as described for the
following reasons:
Rowley Hall hospital has a very low rate of hospital acquired infection and has
had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a Corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
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.
Rowley Hall hospital has taken the following actions to maintain the quality
of its services

Infection Control issues are discussed and reviewed at the local Clinical
Governance Committee which meets every two months to oversee
43
implementation of corporate policies and National guidance and review
clinical audit & practice.

All staff undertake mandatory infection prevention and control (IPC)
training annually

Completion of Corporate clinical audits, where action plans are discussed
at alternate Clinical Governance meetings

Robust mandatory training programme compliance

Information sharing at Clinical Governance level locally, corporately and
through local Medical advisory committee

Monthly audit of IPC activity and reporting via Riskman

IPC selected as a hot topic for staff to focus on during selected months
throughout the year, whereby the IPC Lead and Link Nurses will share
information, provide quizzes and related activity to raise awareness.

Reporting of potential infections on Riskman is seen as crucial to ensuring
we have the full picture and so staff have been reminded at team meetings
and refresher training has been delivered where needed.
Infection Rates
(percentage of
Admissiosns)
Infection Rates
1.2
1
0.8
0.6
0.4
0.2
0
2012/13
2013/14
Rowley Hall Hospital
2014/15
44
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 Rowley hall 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.
During 2014/15 Rowley Hall Hospital will take 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 at Rowley Hall hospital was in May 2014
The results of the audit are given below:
Subject
Score
Cleanliness
95.15%
Food
83.56%
Privacy and Dignity
75.76%
Facilities
76.71%
The privacy and dignity score is reflective of the outpatients department that is
in much need of refurbishment and lacks areas to ensure privacy, for example
the location of the reception area. In response, a refurbishment programme was
agreed which has just been completed.
The Hospital is a grade 2 listed building. This provides several challenges to
accommodate some patient groups which contributed to the score for facilities.
45
In response, plans have been agreed to increase the number of day patient
beds.
3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety. Our record in workplace safety as illustrated by Accidents per 1000
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.
At Rowley hall hospital we take health and safety seriously and have refreshed
the knowledge of health and safety for all managers by enabling them to attend a
workshop on Control of Substances Hazardous to Health (COSHH)
We have also ensured that there is a suitable person appointed as health and
safety representative within each department and hold monthly meetings to
discuss concerns and activity related to health and safety.
The Health and Safety agenda is also part of the rolling agenda in all meetings
within the hospital.
46
3.3 Clinical effectiveness
Rowley Hall hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole.
3.3.1 Return to theatre
Retrnn to Theatre
(Percentage of Admissiosns)
Return to Theatre Score
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0
2012/13
2013/14
2014/15
Rowley Hall Hospital
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.
47
3.4 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards.
Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback.
All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:

Continuous patient satisfaction feedback via a web based invitation

Hot alerts received within 48hrs of a patient making a comment on their web
survey

Yearly CQC patient surveys

Friends and family questions asked on patient discharge

‘We value your opinion’ leaflet

Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
48

Written feedback via letters/emails

Patient focus groups

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 (inpatient or outpatient) is asked their consent to receive an
electronic survey or phone call after they leave 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.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
100
80
60
40
95.0
93.1
2013/14
2014/15
20
0
Rowley Hall Hospital
Friends and Family Test – Patient. The data
made available by National Health Service Trust or
4: Ensuring that people have a
positive experience of care
49
NHS Foundation Trust by the Health and Social
Care Information Centre for all acute providers of
adult NHS funded care, covering services for
inpatients and patients discharged from Accident
and Emergency (types 1 and 2)
This indicator is not a statutory
requirement.
As can be seen in the above graph our Patient Satisfaction rate has decreased
very slightly over the last year, however, the satisfaction score for March was
100%.
Patients tell us that the care they experience on the ward or in the ambulatory unit is
excellent but that they are sometimes unhappy about having their admission postponed.
We aim to address this concern by increasing our capacity to treat patients during the
day and is one of our objectives for improvement discussed earlier in this Account.
As a direct result of the comments received from patient satisfaction surveys the
following are some examples of how we endeavour to provide patients with an excellent
experience at Rowley Hall Hospital.

Our Chefs regularly visit patients following admission to discuss and receive
feedback on the quality of food and the options available.

Health Care staff to ensure that they emphasise the fact that they have washed
their hands prior to any patient treatment.

We have appointed to a new lead role in the Bookings department in order
ensure a more seamless bookings process and result in fewer cancellations.
50
Appendix 1
Services covered by this quality account
Rowley Hall Hospital is registered with the Care Quality Commission to provide the
following activities;



Treatment of disease disorder or injury
Surgical Procedures
Diagnostic and screening
51
Appendix 2 – Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in each month.
52
Rowley Hall hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Mark Lacey, General Manager
Tel 01785 238608
http://www.rowleyhallhospital.co.uk/
53