The Yorkshire Clinic
Quality Account
2014/15
Contents
Introduction Page
Welcome to Ramsay Health Care UK and The Yorkshire Clinic
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
1.3
Welcome to The Yorkshire Clinic
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2014/15 (looking back)
2.1.2 Clinical Priorities for 2015/16 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2014/15 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
3.5
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health
Care UK
The Yorkshire Clinic 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 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the
NHS in the UK. Through a variety of national and local contracts we deliver 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 The Yorkshire Clinic 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.
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.
Quality Accounts 2014/15
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Part 1
1.1 Statement on quality from the General
Manager
Debbie Craven General Manager,
The Yorkshire Clinic
“The Yorkshire Clinic 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 Quality Account by The Yorkshire Clinic 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
the Yorkshire Clinic.
The Yorkshire Clinic 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 lengths 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.
The Yorkshire Clinic 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.
The Yorkshire Clinic continually achieve consistent patient satisfaction scores of over
99% recommendation to others and for overall satisfaction and at the time of writing
Quality Accounts 2014/15
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is showing one of the highest Friends and Families scores for any hospital Private or
NHS. By analysing the results throughout the year, we constantly seek ways to
further improve the patient experience.
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.
Debbie Craven
General Manager
The Yorkshire Clinic Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr James Halstead – Medical Advisory Committee Chair
Mr Richard Grogan - Clinical Governance Chair
Helen White – Regional Director North
Quality Accounts 2014/15
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Welcome to The Yorkshire Clinic
The Yorkshire Clinic is a private hospital situated in the grounds of Cottingley Hall in
Bingley, West Yorkshire. The hospital offers care to patients with private medical
insurance, patients who wish to fund their own treatments and patient referred
through the NHS Patient Choice Scheme.
The hospital provides a full range of high quality services, these include, outpatient
consultation, outpatient procedures, investigations/diagnostics, surgery and follow up
care. During the last 12 months the hospital has treated 15,150 patients, 77% of
which were treated under the care of the NHS.
The Yorkshire Clinic has 379 members of staff with a split of 156 non-clinical staff
and 223 clinical staff.
The hospital has built excellent working relationships with our local Commissioner,
Bradford Hospitals Foundation Trust, Leeds Teaching Hospital NHS Trust and
Airedale Foundation Trust in order to deliver a joint approach to patient care delivery
across the patient economy.
Our GP Liaison Officer provides links to local General Practitioners to ensure that
their needs and expectations are managed and through these links referral
processes are developed in order to streamline processes. The GP Liaison officers
key role is to engage with local health care professionals within the community to
ensure they are fully aware of the services on offer at The Yorkshire Clinic and have
access to any information that can assist General Practitioner’s and Medical Staff
when referring into a secondary care provider. Part of the GP Liaison’s role is to coordinate the post graduate programme which runs on a monthly basis and covers a
range of topics from orthopaedic to cardiology.
The Yorkshire Clinic also works with charities within the local community, hosting
events in their support.
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Part 2
2.1 Quality priorities for 2015/16
Plan for 2015/16
On an annual cycle, The Yorkshire Clinic 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 local and national 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. The
public inquiry at Mid Staffordshire NHS Foundation Trust is a stark reminder that
patients must come first with care delivered by compassionate and dedicated staff. At
the Yorkshire Clinic the patient experience is at the heart of everything we do within
the hospital. We want to know what matters to our patients, their relatives and carers
so we can enhance the quality of our services. Our quality improvement programme
focuses on three domains: patient experience, patient safety and the clinical
effectiveness of care and treatment. Our Quality Account seeks to provide accurate,
timely, meaningful and comparable measures to allow our partners to assess our
success in delivering our vision.
Priorities for improvement
2.1.1A review of clinical priorities 2013/14 (looking back)
Clinical Effectiveness & Patient Safety
The Yorkshire Clinic has a Clinical Governance committee that meets monthly
throughout the year to monitor quality and effectiveness of care. Clinical
effectiveness was chosen as a priority in order to evidence that the Yorkshire Clinic is
striving to strengthen governance by encompassing the following key areas:
1.
2.
3.
4.
5.
Improved incident reporting and investigation.
Continual & spot Audit
NHS Safety Thermometer Audit
PROMS ( Patient reported outcome measure Studies)
Cavendish Report and the strengthening of Health Care Assistant Roles
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Incident reporting
Clinical incidents, near misses, 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.
Incident and near-miss reporting is encouraged to ensure effective learning in a no
blame culture. The Yorkshire Clinic instigate clinical feedback forums following
incidents ensuring staff fully understand lessons learnt and plan actions accordingly
in order to address issues identified. Incidents and outcomes are then reported onto
the Ramsay national incident reporting database (Riskman) and attached to
individual incidents evidencing a robust investigation and satisfactory outcome. The
national database is reviewed by Ramsay corporate clinical governance committee
and national Matron Committees to ensure share learning and practice improvement
across the company.
A quarterly governance report is produced and shared with the local Clinical
commissioning Group (CCG) detailing incidents, near misses, actions and practice
improvements.
Actions taken:
Ramsay Healthcare recognised the need for continuous quality improvement and has
appointed Quality Improvement managers (QIM’s) at many Ramsay sites. The
Yorkshire Clinic appointed a quality improvement manager in 2013 who works closely
with the Matron and multidisciplinary team to promote the culture of robust
governance and learning. The number of Clinical incidents & near misses reported in
2013/14 was 255 in 2014/15 the number reported was 222. This highlights that staff
have a good awareness of potential risk. Staff training is a high priority, and regular
staff development is managed and monitored whereby staff understand the
importance of the duty of candour. Being honest and open with regard incident
reporting along with a no blame culture policy has demonstrated our commitment to
safe effective practice.
Audit
The Yorkshire Clinic participates in the Ramsay Corporate Audit programme (the
schedule can be found in appendix 2) the audit topic and schedule is set centrally by
Ramsay Health Clinical Governance Committee to allow greater opportunity for
benchmarking. Additionally the Yorkshire Clinic also carries out a number of local
clinical audits all of which are discussed and reviewed through the Clinical
Governance Committee where actions are taken to improve the quality of healthcare
provided. The completion of local audits ensures compliance is monitored and
evaluated to ensure continuity of care and safe effective practice. The Yorkshire
Clinic intend to evaluate corporate audits and local audit practice by completing
action plans if the scores of audits fall within 95% or less of the rating score.
Actions taken:
The Yorkshire Clinic completed the corporate audit programme for 2013/14 and were
fully compliant with regard completion. Audits that scored 95% or less were reviewed
and an action plan instigated in order to address issues highlighted. 2 audits in
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February 2015 scored less than 95% highlighting the need to address issues
surrounding surgical site infection and Infection control of the environment. Action
plans were instigated with action dates scheduled to evidence compliance. The
corporate audit template is reviewed through the medical advisory committee, the
CCG and through clinical governance monthly meetings. We will continue to monitor
moving forward by completing spot checks of the environment, review staff training
compliance enabling a raised team awareness and approach to embedding a
learning culture and improving and driving audit scores to achieve improvement. The
ward team review and discuss audit findings at team brief meetings in order to raise
awareness, share lessons learnt and instigate action plans to ensure compliance and
prevent recurrence.
NHS Safety Thermometer
It was recognised that we needed more transparency between ourselves and other
independent sector providers/the NHS in order to monitor and improve our services.
The Yorkshire Clinic complete the NHS safety thermometer audit tool each month
and submit to NHS choices information services, which includes a VTE risk and falls
assessment on all admitted surgical patients. This is in line with Ramsay Policy No
CM001 and adheres to National Institute for Clinical Excellence (NICE) Guidance
2010. Compliance is audited through a robust corporate and local audit programme
and results/action plans reviewed through Clinical Governance. Compliance results
are
benchmarked
through
the
National
statistics
at:
http://transparency.dh.gov.uk/category/statistics/vte/
Actions taken:
The Yorkshire Clinic continue to risk assess all patients for VTE and the risk of falls.
All patients are routinely screened at the pre assessment stage for potential risks in
order to highlight risks to the clinical team. When risks are highlighted, an action plan
is developed with the patient in order to help prevent the risk of VTE and potential
falls. All clinical staff are suitably trained to complete both risk assessments and
actions plans as per Ramsay policy.
All ward clinical staff are trained to undertake risk assessments to enable safe clinical
care delivery.
1. The ‘Waterlow’ risk assessment tool is utilised to ensure patients at risk of
developing pressure sores have a planned care programme to ensure skin
integrity is maintained at all times.
2. The ‘Malnutrition Universal Screening Tool’ (‘MUST’) is used to identify adults
who are underweight and at risk of malnutrition, as well as those who are obese.
3. Ward clinical staff in 2015 will complete the RCN Learning Zone: NICE care:
Venous thromboembolism prophylaxis (VTE).
This resource has been
developed to support health care assistants, students and registered nurses to
implement the VTE NICE guideline. It focuses primarily on understanding and
preventing VTE, identifying patients at risk and includes an in-depth look at VTE
risk assessments.
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4. Falls risk assessments are completed to ensure all patients have an individualised
care plan ensuring the risk of falls is reduced based on findings from the risk
assessment. All ward clinical staff in 2015 will have training and education to
ensure ‘best practice’ and national guidelines are followed in relation to
preventing falls. Training Workshops for all staff to include:
Importance of completing Falls Risk Assessment and Care Planning
Where Patients are at risk of falls what actions need to be taken to reduce
the risk.
Recording Neurological observations following patient falls (using
recommendations from NICE 56: Head Injury).
Rapid Response Report (NPSA/2011)- Essential Care after an In-patient
fall
NPSA 2010: Slips, Trips and Falls in Hospital
Patient Safety First 2009: The ‘How to’ Guide for reducing harm from falls
The following actions have been addressed:
Flow chart on the management of falls to be displayed on the ward.
Staff education on prevention of falls, patients at risk, management to be
displayed on ward education board.
Environment factors that increase risk of patient falls (Foot pumps, Cot
sides, IV Fluid attachments, Oxygen attachments)
Other risk assessments include visual infusion phlebitis (VIP) score tool
for assessment of the early signs of phlebitis, along with prompt removal
of peripheral intravenous cannulas, and the early warning score track and
trigger enables early detection of the deteriorating patient enabling rapid
response to meeting patients clinical need.
PROMS
Increasing the use of Patient Reported Outcomes Studies (PROMs) – The Yorkshire
Clinic routinely issues the National PROMS questionnaires to patients undergoing
hip, knee, hernias and cataract surgery (PROMs for Hip’s, Knees and Hernia Repairs
are reported by The Yorkshire Clinic). These are used to gain a better understanding
of treatment outcomes and quality of life from a patient point of view. Compliance for
PROMS is above the national average at The Yorkshire Clinic. Consultants can
access this information within their own Trusts for all patients, including those treated
at The Yorkshire Clinic. We continue to monitor compliance return rate in order to
ensure that we continue to learn from patient feedback, we will be concentrating our
efforts on this initiative throughout 2014.
Actions Taken:
2014/2015 highlighted a poor return rate for both private and NHS PROMS. In view
of this the process of issue and collection has been reviewed changing the issue from
the ward to the Pre-assessment team and collection from the ward for all NHS &
private PROMs for joint replacement & included in notes for hernias at point of
preparation as of 15th April 2015
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Cavendish Report
Following the Cavendish report in July 2013 and recommendations made Ramsay
Healthcare have implemented core competencies for health care assistants (HCA’s)
in order to ensure the care that they provide is safe and consistent. The Yorkshire
Clinic work closely with Shipley College who provide NVQ training for support staff at
levels one, two and three. Health care assistant staff members are routinely
assessed on site and support is offered by both the college and the clinic to
encourage further development. Ramsay Healthcare has recently introduced a HCA
core competencies portfolio training package enveloping practical skills for further
development. The portfolio will be a living document containing evidence of clinical
achievements, e.g. course certificates, study day or conference attendances and will
provide evidence to support Care Quality Commission requirements. It is
transferrable within Ramsay hospitals/units and can be used as evidence for
professional registration. The core competencies are listed under the following
headings:
Observations:
Temperature
Pulse
Respirations
Blood Pressure
Oxygen Saturation
Early Warning Score
AVPU
Urine output/Fluid Balance
Blood Glucose
Nutrition and Hydration
Transfer of patients from ward to theatre
Ophthalmic pre admission tests
ECG
Basic dressing/removal of suture /clips
Venepuncture
Care of the intravenous site
End of life pathway
Documentation
Urinalysis
Height and BMI
Development is discussed at the induction stage, competencies are observed by a
mentor on a regular basis to ensure safe effective practice is achieved and at
professional development reviews which are instigated on a yearly basis with a six
monthly review to re assess development. Health Care Assistants (HCA) work
alongside designated registered nurses on duty and are assigned tasks according to
skill level. All record keeping completed in a patient’s care pathway is read, checked
and signed by the delegated responsible lead nurse as per Ramsay Corporate policy
and procedure. Ramsay Healthcare provide designated uniforms for staff members
along with a name badge which includes the individual staff members job title
ensuring that patients can easily identify individual team members.
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Actions Taken:
All ward Health Care Assistants (HCAs) are provided with ‘Nurse mentors’ and are
part of a team e.g. Orthopaedic, General Surgery, Medical or Day-care. This provides
support for HCAs and through regular one to one with their mentors clinical
supervision can be provided.
HCAs have clearly defined roles and responsibilities in line with their level of
competency. During 2015 all HCAs will have completed the Ramsay Healthcare
assistants’ competency assessments. 2015 will see HCAs play an integral part in
implementing ‘Patient comfort rounds’ at Ramsay Yorkshire Clinic the focus being
that all our patients have their fundamental care needs met to a high standard, where
we have gone the ‘extra mile’.
Following the Francis Inquiry, Camilla Cavendish was asked by the Secretary of
State to review and make recommendations on the recruitment, learning and
development, management and support of healthcare assistants and social care
support workers.
In line with recommendations from ‘The Care Certificate’ is the start of the career
journey for these staff groups and is only one element of the training and education
that will make them ready to practice within their specific sector. Although the Care
Certificate is designed for new staff, new to care and offers this group of staff their
first step on their career ladder, it is also offers opportunities for existing staff to
refresh or improve their knowledge.
The Care Certificate sets out explicitly the learning outcomes, competences and
standards of care that will be expected in both sectors, ensuring that the HCSW is
caring, compassionate and provides quality care. The Care Certificate standards are
listed below.
The Standards:
1. Understand Your Role
2. Your Personal Development
3. Duty of Care
4. Equality and Diversity
5. Work in a Person Centered Way
6. Communication
7. Privacy and Dignity
8. Fluids and Nutrition
9. Awareness of mental health, dementia and learning disabilities
10. Safeguarding Adults
11. Safeguarding Children
12. Basic Life Support
13. Health and Safety
14. Handling Information
15. Infection Prevention and Control
Ramsay Yorkshire Clinic will develop a programme for all HCAs to ensure they
complete the learning outcomes set in the ‘Care certificates’
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We have recently agreed a training contract with an established training provider who
will provide Immediate Life Support resuscitation training & Acute illness
Management (AIM) training to compliment Ramsay existing training provision The
contractor will provide a monthly training session for registered nurses and HCA staff
members. There will be a mock resuscitation scenario following each training session
in differing departments in order to evidence staff awareness & technique which will
be audited by the contractor. Training statistics, competence and audit will be
reported into Clinical Governance meetings and reviewed at quarterly Resuscitation
Committee meetings chaired by a Consultant of Intensive Care Medicine and Critical
Care Lead Nurse. Any learning’s will be reported and action plans developed in order
to address issues. Training is recorded on the training tracker in order to evidence
staff compliance and status.
A number of our health care professionals successfully completed their NVQ level 3
competency assessments and were awarded certificates from Shipley College which
were presented to them by the Matron of the hospital to acknowledge this
achievement which is a reflection of their continued learning, hard work and
commitment.
Patient Experience
The Yorkshire Clinic is committed to improving upon the service that our patients
experience. We endeavour to be the health care provider of choice for all our
patients. In order to accomplish this we actively encourage and measure feedback
from patients about their experience, clinical treatment and clinical outcomes.
We chose patient experience as a focus area looking forward in our last quality report
to evidence compliance in the following key areas:
1.
2.
3.
4.
Patient Feedback
Customer Excellence Training
Ambulatory Day Care
Telephone Handling
Actions Taken:
Patient Feedback
We obtain patient feedback through the following methods:
Web based Ramsay survey
“Family & Friends” survey
Customer complaints, informal and formal.
As a direct result of the comments received from the above feedback routes. The
following are some examples from the “friends and family survey” and how we have
improved care within the hospital:
Patient comment: ‘Very efficient and friendly staff - Clean and comfortable
rooms’
1. Our Customer Services Manager and Chef regularly visit patients following
admission to discuss and receive feedback on the quality of food and the
options available. The ward hostess team have been integrated into the
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catering team which promotes a consistent approach to service and hygiene
delivery
2. Catering facilities refurbishment has taken place including replacement of
some equipment, both in the main kitchen area and the ward serveries. The
equipment includes a new state of the art steam oven, new high powered
microwave and a new heated food distribution cabinet. In addition we have
also upgraded all of the crockery, cutlery and drinking glasses. Two new dish
washers have been fitted in each servery on ward one & two and a new
refrigeration unit is on order for the main kitchen area.
3. The staff canteen has recently been refurbished offering a discounted menu
to the staff. The refurbishment includes new privacy window blinds, table
condiments, crockery and cutlery. The canteen is undergoing further
redecoration refurbishment in a two tone colour scheme. Following staff
feedback an additional microwave has been purchased along with a high
quality stainless steel refrigeration unit for staff use
4. The corporate team are shortly to introduce a summer light bite menu in
order to run alongside the existing menu. The Yorkshire Clinic head chef is
part of the project team and this will be implemented following corporate
approval. The customer services manager has reviewed how patient & staff
food allergies are highlighted as part of our ongoing commitment to risk and
safety strategies. As a result of this, process management improvements
and the recent catering facilities refurbishment the Yorkshire Clinic has
achieved a 5 star food hygiene rating in January 2015.
5. A glass covered display notice board has been fitted on ward one & two
outside the main patient lifts as part of the ongoing commitment to provide
our patients with feedback relating to actions taken following highlighted
comments. We intend to display negative as well as positive feedback with
actions taken to prevent recurrence in order to remain honest and open with
our customers
6. The Customer Services Manager has recently purchased 6 additional
hospital standard hepa filtration vacuum cleaners
Patient comment: ‘Good level of care offered; Consultant and nurses friendly
and professional. I found parking to be difficult when attending for outpatient
appointments as the car park was very busy and there were not enough car
parking spaces available’
Additional parking has been sourced with agreement with a local business for off-site
parking for members of staff giving extra car parking spaces for our patients.
Planning permission has been requested and submitted for an additional 22 car
parking spaces. We await approval and will action accordingly. We will continue to
offer free parking to all customers and staff in order to continue to be the hospital of
choice.
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We intend to continue to monitor patient feedback in order to build upon the patient
experience at the Yorkshire Clinic. We pride ourselves as being the hospital of
choice for all our patients and fully intend to continue to provide a first class service.
We participate in the National PLACE audit, the audit was completed on Monday 13th
March These assessments include rating of privacy and dignity, food and food
service, access issues such as signage, bathroom / toilet environments and overall
cleanliness. Patients make up at least 50% of the assessment team giving them a
much stronger voice. The focus is on improvement, with hospitals reporting publicly
on how they plan to improve. Ramsay Healthcare has embraced this initiative and
value patient feedback, the findings from this audit can be found at:
http://www.england.nhs.uk/ourwork/qual-clin-lead/place/.
The results were uploaded onto the Health & Social Care Information Centre data
base and we await feedback of the results
Ramsay Healthcare is committed to improving facilities, the Yorkshire Clinic
continually strives to build upon and improve facilities for our customers and outside
stakeholders. Planning permission has been granted to extend the main reception
area at the front of the building incorporating a covered roof area for a drop
off/collection point, coffee and tea facilities along with a larger reception and patient
waiting area. With this in mind we intend to review the process surrounding the
registration of patients in order to provide a more streamlined, private service. This
refurbishment is scheduled to commence in August 2015.
Customer Excellence Training
Ramsay Healthcare has instigated a Customer Care Excellence service training
initiative throughout all Ramsay hospitals. The Yorkshire Clinic has two local
champions who attended training corporately; the first training programme for
customer care excellence was instigated locally in August 2012.
In order to raise continued staff awareness a further training session was
incorporated into the mandatory training programme as a refresher session. The
second stage of the corporate training programme was rolled out which had a
positive impact on staff awareness and attitude. Phase three has just commenced in
March 2015. This training enforces a raised awareness of patient perception and
expectation; reminding staff of the importance of consistent excellence in customer
care. The results of this training can be monitored through the patient feedback
satisfaction survey and the friends and family test. This training programme will be
instigated monthly and encompass all staff within the hospital.
Actions Taken:
Ramsay Healthcare are committed to continue to develop customer service
excellence awareness training. The third stage of training commenced in March
2015, staff attendance will be inputted onto the training tracker as evidence of
compliance.
Ambulatory Day Care: - Better outcomes and improving patient experience:
Ambulatory Care or Day Care Surgery is the admission of selected patients (both
medical and surgical) to hospital for a planned procedure, returning home the same
day where the patient does not require an overnight stay. Over recent years, partly
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due to medical advances the number of day surgery patients has increased
compared to those requiring an in-patient stay. In 2014/15 the percentage of day
surgery patients we treated was 84%.
In addition the Yorkshire Clinic has reviewed the procedures it performs as day cases
under local anaesthetic, and where appropriate has converted these procedures to
outpatient attendances to promote an earlier discharge from hospital. This includes
urological, gynaecological and some minor skin procedures.
In the last twelve months the Yorkshire Clinic has continued to develop a separate
dedicated unit for the treatment of ophthalmology patients, this ensures a walk in,
walk out service specialising in ophthalmology treatments The unit comprises of a
local anaesthetic day case ophthalmology theatre and Trio laser service to treat
patients with floaters following surgery and glaucoma.; as well as an outpatient facility
offering follow up support services. We have recently added a second consulting
room in order to build upon the outpatient service offering a number of differing
appointment availability slots for our patients. The Lodge has recently purchased a
slit lamp and Optical Coherence Tomography (OCT) machine giving us the ability to
treat patients with Lucentis injections for Wet age related macular degeneration
(AMD)
At the Yorkshire Clinic we aim to ensure that 100% of our Ambulatory Day Care
patients will be treated following one of our ambulatory care pathways. In order to
achieve this The Yorkshire Clinic provides patients with a more efficient journey
through the hospital which includes procedure specific pathways. We also have a
dedicated ambulatory suite for patients who are having procedures under local
anaesthetic to reduce waiting times for these patients ensuring a more streamlined
efficient pathway whilst maintaining the highest possible standards of care and
safety. In addition we have a dedicated day surgery facility that is separate from our
in-patient facility, best practice has shown that this shortens waiting times and
recovery periods for patients. We monitor the ambulatory day care experience
through our patient satisfaction surveys. We have recently introduced local
anaesthetic, minor surgery for lumps and bumps within the outpatient department
converting the care provision from a day case stay to an outpatient attendance. This
service is more streamlined and less time consuming for the patient. We will monitor
the quality of this service moving forward through clinical audit and reviewing “we
value your opinion” survey results and the friends and family test.
Actions Taken:
The local anaesthetic surgery pathway for lumps and bumps within the outpatient
department has proved to be very successful. We have received positive feedback
from patients with regard reduced waiting times which reflects a dedicated outpatient
nursing team who are consistent in care and service delivery. We intend to offer an
additional hysteroscopy service as an outpatient pathway within the next month.
The benefits of day surgery
Evidence from the CQC and the Modernisation Agency indicates that increasing day
surgery rates generates numerous benefits.
Clinical Outcomes - Speedier recovery is promoted;
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•
•
Better outcomes as patients are more likely to follow an evidence-based
pathway of care;
Risk of hospital acquired infection reduced (lower infection rates in day case
units).
Patient Experience
•
•
•
•
•
Patients have a preference to be treated on a day case basis with minimum
disruption to their lives;
Waiting times reduced due to better utilisation of hospital capacity;
Care provided through a patient focused pathway;
Minimally invasive procedures;
Much lower risk of hospital cancellations and guaranteed admission dates;
Increased patient satisfaction.
With this in mind Ramsay Yorkshire clinic have been focusing on improving our day
care services through a dedicated day care improvement group led by our hospital
operations manager. The areas for focus have been:
•
•
•
Daycare environment (focused area)
Patient pathway (systems and processes to ensure a seamless safe clinical
pathway)
Developing staff with expert knowledge and skills to manage patient pathway
(Day care team)
Call Handling
We have a private enquiry handling service (premium care) along with an NHS
enquiry handling service ensuring that all calls are directed to the appropriate
department in a timely and efficient manner. The call handling system directs NHS
and Private customers to separate telephone hunt groups rather than individual
extensions to allow the customer to be transferred to the next available enquiry
handler. These hunt groups consist of specialised NHS enquiry handlers and
specialised Private enquiry handlers to allow our customer groups differing needs to
be met in a timely manner and to allow consistency of service excellence. The
customers are also offered a call back option at their convenience should they be
waiting longer than 30 seconds.
Actions Taken:
The system also allows the Senior Management Team to review Key Performance
Indicators such as; call queue time, call back requests and available handlers. It also
allows additional enquiry handlers to be made available quickly during peak times.
Improvements have been seen in both queue time with a reduction of 30% and we
can now evidence 100% capture of missed calls and call back requests. We will
continue to monitor this service moving forward to ensure that we continue to offer an
excellent, efficient service.
Patient Safety
The Yorkshire Clinic is a progressive hospital focussed on improving its performance
every year, particularly with regard to patient safety. Risks to patient safety are
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identified 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.
We chose patient safety in the last report to evidence that the Yorkshire Clinic are
committed to improve upon patient safety initiatives already embedded within the
hospital by encompassing the following key areas:
1.
2.
3.
4.
5.
Falls
Never Events
Consent
Vulnerable adults/children
Prevent
Falls
To maximize patient safety our routine practice is that all patients are asked to
complete a medical questionnaire; this is assessed by the Pre-operative Assessment
Team to identify any potential risks prior to admission. Last year a more detailed falls
risk assessment was introduced and this has been in use for all patients, this is
reviewed daily and care altered accordingly. Information for patients on how to
minimize the risk of falls following surgery/ procedures is available in the patient
information folder in every room. The physiotherapy team have also provided falls
prevention leaflets and classes are available to any patient that has had a recent fall.
Any slip, trip or fall is reported through our robust electronic incident reporting
database (RISKMAN) identifying any trends, formulating and implementing action
plans across the hospital to help improve patient safety.
Slips, trips and falls recorded/reported during 2013/14 were 16; the following year in
2014/2015 there was a total of 17 falls reported throughout the hospital which shows
a minimal increase given increased activity rates. Staff are aware of the importance
of reporting all incidents including slips, trips and falls on the incident reporting
system. Despite the minimal increase in falls there are always practice changes that
can be reviewed to continue to minimise the risk of slips, trips and falls. Over the past
twelve months emphasis has been concentrated on:
Continuing staff training in risk assessment of patients specifically related to
movement and sensation of all aspects affecting limbs following surgery.
Effective implementation of the new falls risk assessment for all ward staff
Patient manoeuvres post-surgery are undertaken only following risk assessment
with two staff members of staff present.
Competency training provided by physiotherapists for all nurses & Health Care
assistants in specific risk assessment relating to the effects of regional
anaesthesia.
All falls are reported and reviewed via the Riskman data site. Lessons learnt and
actions taken are disseminated as a team approach in order to prevent
recurrence
The figures show an increase in incident reporting, reflecting a raised awareness and
improved reporting of actual incidents onto our Riskman reporting system. We will
continue to monitor incidents and review feedback in order to learn from lessons
learned and instigate actions to prevent recurrence.
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Actions Taken:
All patients falls are reported through the riskman (incident reporting) data base are
reviewed by the quality improvement manager. A robust root cause analysis is
instigated following all falls in order to identify risks and identify learning outcomes.
Findings are disseminated at team brief meetings in order to raise staff awareness
and prevent recurrence. The number of falls reported in 2014/15 was 17 incidents
Never Events
Never events are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented. The Yorkshire
Clinic continually strives to ensure that patient safety is at the forefront of every
intervention.
It is mandatory that all staff are to complete a mandatory training programme on a
yearly basis in order to reaffirm processes and to raise awareness including health &
safety, infection prevention and the reporting of incidents.
We have robust policies and procedures in place informing staff members of the
need to adhere to guidelines to ensure both staff and patient safety. These are held
on the Ramsay intranet and are available for all staff to reference, and are updated
and introduced through a CAS alert process, cascaded to all staff through Heads of
Departments.
The reporting of incidents and near misses is encouraged and recorded onto an
electronic incident reporting data base called Riskman which enforce learning’s
surrounding individual incidents. All members of staff have access to this reporting
tool.
Regrettably there was 1 never event at The Yorkshire Clinic during 2014/15.
Never Event 29th July 2014
A level 2 serious incident was reported on 29th July 2014 where a retained suture
needle was reported. The patient had undergone a successful laparoscopic nissen
procedure under general anaesthetic on the 29th July 2014. At the 3rd swab and
instrument check in the operating theatre, the registered scrub nurse noted that there
was a suture needle missing and informed the surgeon, however the skin had been
closed and the patient was awakening from the anaesthetic.
Following an immediate thorough search of the theatre environment and clothing of
the theatre team, the needle could not be located, and the surgeon was
informed. The surgeon requested an urgent x-ray that evening; The Radiologist
reported the image later that evening and identified a retained suture needle. The
surgeon was informed and the patient returned to theatre the following morning
where the needle was immediately located and successfully removed.
The patient made an uneventful recovery and was discharged home the following
day.
The patient and family were fully informed, the incident was reported to the
Governance and Risk Senior Associate at West and South Yorkshire and Bassetlaw
commissioning support unit with StEIS notification. (Strategic Executive Information
System). The incident was reported to Ramsay national Clinical Governance Lead
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via the Ramsay’s incident reporting database The Care Quality Commission was also
notified of this incident as per policy and procedure.
A thorough investigation was instigated identifying analysis, findings, root cause,
lessons learned and actions to prevent recurrence. Recommendations and an action
plan were instigated. The action plan was a live document which was continually
updated following learnings and actions taken. The action plan was reviewed by the
governance risk lead at the CCG and following further review of learnings in the
hospital, the CCG quality team have closed the case confirming that all the actions
had been implemented and evidenced.
Actions Taken:
As an organization, considering there was 1 never event, the following actions in
response have occurred.
Matron completion of the NHS England Human behaviors workshop
programme.
Specific Governance training completed by the Theatre manager.
Creation of a dedicated clinical governance lead role
Feedback forums to review incidents, audit and preventative actions.
Additional Audit (random spot check) & independent audit by external
assessors.
Introduction of a Ramsay UK wide Consultant incident database to share
incidents regarding consultant practice.
Participation in NCAS ( National clinical assessment service )
Three staff members attended the Association for perioperative practice (AfPP
) never event training at St James hospital in March 2015. The Association for
Perioperative Practice (AfPP) was established as the National Association of
Theatre Nurses, known as NATN, in 1964. It is a registered charity working to
enhance skills and knowledge within operating departments, associated areas
and sterile services departments. It aims to enhance the quality of care in the
NHS and the independent sector throughout the UK.
The course was accredited to 4 hours CPD. The course reviewed never
events locally and was an excellent venue to reflect and share learning’s. A
key learning and training experience was highlighted following the showing of
Gina’s story.
A never event experience from a patient perspective:
https://www.youtube.com/watch?v=IJfoLvLLoFo
The clip was shared across the hospital site with all clinical staff in order to
raise awareness of the importance of human factors with regard safe practice.
Serious Incident 26th September 2014
There was a serious incident reported on the 26th September, where a patient’s condition
deteriorated overnight following uneventful day case surgery, requiring transfer to the
Intensive Care unit for specialist care. The Yorkshire Clinic has thoroughly investigated this
incident and the case is currently being reviewed by the Coroner.
Quality Accounts 2014/15
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Consent
Patient consent is a further safety initiative in order to ensure the correct procedure is
consented for by individual patients enforcing safe, effective practice. Informed consent also
ensures that the patient is fully aware of the relevant procedure and the risks involved.
Ramsay Healthcare has strict guidance relating to informed consent and policies include a 2
stage consent process. It is Ramsay policy that consent will be initiated at the earliest stage
with the patient and this is evidenced as the first stage of the consent process. The first
stage of the consent form is completed confirming that the patient is in receipt of information
to allow him/her to make an informed choice of whether to proceed with the procedure and
satisfactory period of time to ask further questions or be provided with further information.
The second stage of consent will be on the day of procedure prior to the patient transfer to
the procedure/operating suite. All patients will be asked by a healthcare professional if they
have any further questions regarding the procedure and if there have been any changes in
their medical condition since receiving the information regarding their procedure. A positive
response to either of these questions will prompt the healthcare professional to request the
clinician performing the procedure to revisit the patient and reassess if the patient has been
provided with appropriate information for the procedure to proceed. The patient will also be
asked at this stage if they have received information on risks, benefits and alternatives
regarding their anaesthesia and opportunity to discuss this with the Anaesthetist and if they
require further clarification/information. When a confirmation response to the 3 questions
stating no further clarification or input is required, this will allow the healthcare professional to
sign and confirm that stage two of the consent is complete and for the patient to proceed with
their procedure as planned.
Actions Taken:
The Yorkshire Clinic measure consent by undertaking audit on a regular basis to ensure
compliance by both staff members and Consultant practitioners. Our audit scores remained
consistent throughout 2013/14. The monitoring of Informed consent will continue to be our
focus for 2015/16 to envelope and embed safe practice and standards.
Vulnerable Adults/Children
Vulnerable adult/child training ensures that our patients are safe and being cared for by
competent knowledgeable staff. The Yorkshire Clinic staff complete annual mandatory
training programmes, incorporated into this training programme is vulnerable adult training. A
flow chart has now been developed and is displayed in each department; which provides
quick access information for staff to know who to contact or what to do if they have concerns
regarding adult abuse issues. The designated lead nurse for safeguarding vulnerable adults
and children is Amanda Cokell (Quality Improvement Manager).
Actions Taken:
Safeguarding training is ongoing within the unit and was chosen as a priority in order to
ensure that we comply with the Department of Health’s requirements surrounding
safeguarding vulnerable adults and children. Our compliance is measured and reported to
the head of the safeguarding adult’s board along with the local CCG Commissioners in order
to monitor and share safe, effective practice with our stakeholders. Each department has a
safeguarding folder highlighting to staff what action to take if they have a concern regarding
safeguarding with useful telephone numbers, named lead for the hospital and local flow chart
for reporting purposes. The folder also contains information and guidance for staff on The
Mental Capacity Act 2005 and Deprivation of Liberty Safeguards (DOLs). The Yorkshire
Clinic have also scheduled face to face training for level 3 safeguarding children training on
Quality Accounts 2014/15
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the 20th May 2015 for registered staff nurses who care for children under the age of 18
years.
Prevent
The Yorkshire Clinic recognise that the Prevent agenda requires healthcare organisations to
work with partner organisations to contribute to the prevention of terrorism by safeguarding
and protecting vulnerable individuals who may be at a greater risk of radicalisation and
making safety a shared endeavour. Ramsay Healthcare acknowledge that Prevent is central
to the Safeguarding agenda and as a priority has introduced Prevent training within
Safeguarding policies, procedures and mandatory training.
Actions Taken:
Prevent training was introduced as an additional training package within the mandatory
training programme in 2014. We continue to offer this training to newly appointed staff
members within the induction programme. The hospital has a designated lead nurse for
Prevent and for Safeguarding. Mandatory staff training is tracked in order to ensure all staff
have completed the mandatory training programme; ensuring awareness and development.
Prevent training is ongoing within the unit and was chosen as a priority in order to ensure
that we comply with the Department of Health’s requirements surrounding safeguarding
vulnerable adults/children Our compliance will continue to be measured and reported to the
Head of the Safeguarding Adults Board along with the local CCG in order to monitor and
share safe, effective practice with our stakeholders.
2.1.2 Clinical Priorities for 2015/16 (looking forward)
We chose patient safety and clinical effectiveness looking forward to evidence that the
Yorkshire Clinic are committed to improve upon patient safety initiatives already embedded
within the hospital by encompassing the following key areas:
Reducing Falls
Safe administration of medicines
Safety devices
Embedding the changes included in the new NMC code (Nursing & Midwifery Code of
Conduct)
Patient Safety
Reducing falls.
The clinical staff in 2015 will have training and education to ensure ‘best practice’ and
national guidelines are followed in relation to preventing falls. Training Workshops for all staff
to include:
Importance of completing Falls Risk Assessment and Care Planning
Where Patients are at risk of falls what actions need to be taken to reduce the risk.
Recording Neurological observations following patient falls (using recommendations
from NICE 56: Head Injury).
Rapid Response Report (NPSA/2011)- Essential Care after an In-patient fall
NPSA 2010: Slips, Trips and Falls in Hospital
Patient Safety First 2009: The ‘How to’ Guide for reducing harm from falls
Flow chart on the management of falls to be displayed on the ward.
Staff education on prevention of falls, patients at risk, management to be
displayed on ward education board.
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All relevant staff will received training on the assessment of environment factors that
increase risk of patient falls (Foot pumps, Cot sides, IV Fluid attachments, Oxygen
attachments.
Safe administration of medicines
The Yorkshire clinic understands the importance of safe administration of medicines and in
view of this has developed and intend to implement an action plan in order to minimise
incidents in relation to medicines administration. This is owned and led jointly by the
Pharmacy Manager and Ward Manager and includes:
Weekly Ward Medicines ‘Top Up’
Daily Ward Rounds by Pharmacist, all patients must have drug reconciliation within
24 hours of admission and any patient’s own medications not present to be ordered
and placed in POD.
Quarterly CD audit report to Ward Manager.
New Register to be used (Completed)
Tempazepam to be included into main CD register. (Completed)
Monthly review of CDs and remove any CDs not in use (Patients own, expired).
Day case TTO’s - Ensure Day case TTOs are prescribed 24 hours prior to patient
admission and sent down to Pharmacy.
Pharmacy to prepare all TTOs and store in pharmacy.
On day of admission patient to be reviewed by Pharmacist on admission check
‘Allergies’, drug history and then dispense TTOs to patient.
Provide clear guidance to ward nursing team on:
1. VTE Prophylaxis
2. Consultant preferences
3. Local SOP.
Review training- Training to include:
1. IV Drugs Administration
2. IV Fluid Management (NICE 2013 Guidance)
3. Self-Medication
4. Out Of licence
5. Controlled Drugs
6. Patients own medications management
7. Medicines Management ‘Accountability’
8. Local and Group Polices.
9. Drug Calculation Test.
10. VTE (NICE Guidance)
All ward nurses to complete annual administration of medicines ‘competency’
assessment. Assessment to also be completed on induction for ‘new starters’.
In addition to ensure there is continual improvement a monthly medicines management
committee has been formed to monitor progress, review audit and prevent incidents from
occurring.
Safety devices
The Yorkshire Clinic will comply with The Health and Safety Executive (Sharp instruments in
healthcare) regulations 2013 where “The aim of the regulation is to contribute to a safe
working environment for healthcare workers by introducing measures to protect them from
injuries caused by sharp medical instruments”
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The Yorkshire clinic staff will comply with using safety devices where sharps usage is
unavoidable, which will include:
Compliant safety cannula
Compliant safety hypodermic needles for IM Injections/ blood gasses /other injections
into patients e.g. injection into joints/cosmetics treatments.
Phlebotomy – Compliant safety products
Compliant safety hypodermic needles for Sub cutaneous injections – or where a
sealed unit is available continue to use current products Training will be provided for
clinical staff in the use of these products and risk assessment where a safety product
cannot be used for a justifiable clinical reason.
Our practice and compliance with this will be audited and reviewed both locally and
corporately across the organisation and any incidents will be thoroughly investigated and
lessons learnt shared across the company.
Nursing and midwifery Council (NMC) The New Code of Conduct
The NMC code has been updated to reflect the needs of the public. It sets out the new
universal standards expected of registered nurses and midwives that they must uphold to be
able to practice in the UK. This is also a requirement of the Care Quality Commission, the
regulator of all health care providers. The four amended standards are as follows:
Prioritise People
Practise Effectively
Preserve Safety
Promote Professionalism and Trust
These standards have key themes which nurses and midwives must adhere to:
Treat people with compassion and ensure their physical, social and psychological
needs are assessed.
Exercise candour when errors or harm occur
Intervene professionally if an emergency occurs outside the workplace
Follow detailed new standards if they want to raise a concern
Use social media and all other communications responsibly
The Code also makes clear that responsibility for those receiving care lies not only with the
nurse or midwife providing hands-on care, but also with those nurses and midwives working
in policy, education and management roles. The code contains the professional standards
that registered nurses and midwives must uphold.
Every individual nurse has been issued with the updated code and the Yorkshire Clinic has
an implementation plan in order to ensure all our nurses understand it's importance and
incorporate the standards into their daily practice. To support this, we have also:
Facilitated staff workshops to increase awareness of why the code has been updated
and how.
Included the code on every departmental team meeting in order to measure progress
and quality
Mandated that the code is routinely included in employment interviews to assess the
understanding and therefore appropriate recruitment of the right people.
Quality Accounts 2014/15
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The corporate team have disseminated a power point presentation encompassing the
amendments and this will be presented at each Ramsay Healthcare unit. Awareness
training has been scheduled and will be implemented throughout April and May 2015.
Changes to the NMC Professional Code for Registered Nurses
The new revised Nursing and Midwifery Code came into effect in March 2015 and is a key
part to the revalidation pilot for nurses and midwives. Revalidation and appraisal will allow
nurses and midwives to reflect on the code, their continued professional development and
feedback from patients, students and colleagues to improve practice and evidence that they
are meeting standards. The purpose of revalidation is to improve public protection ensuring
nurses and midwives remain fit to practice throughout their careers. Revalidation will require
every nurse and midwife to confirm that they:
Continue to remain fit to practice by meeting the principles of the revised code
Have completed the required hours of practice and learning activity through
continuing professional development (CPD)
Have used feedback to review and improve the way that they work
Have received confirmation from someone well placed to comment on their continuing
fitness to practice
To support the embedding of the new code, we have facilitated staff workshops for staff to
reiterate there familiarity in preparation for revalidation requirements, which will apply from
the end of 2015.
Patient experience
Whilst we review trends and feedback from our customers routinely at monthly clinical
governance meetings and Medical advisory committee meetings, to enable us to share this
more widely and ensure we maintain our ‘customer focus’ we will commence a customer
focus group that meets monthly.
This will:
1. Review the monthly patient feedback provided via the Ramsay web based survey
reports and ensures actions are taken to improve on areas where low compliance has
been identified.
2. Review complaints; agree actions and report any trending of complaints to the
Clinical Governance Group.
3. Review acknowledgements and award ‘excellence in customer care’.
4. Review customer care training compliance.
5. Review customer care standards and compliance through audit scores.
6. Review and initiate audits to improve customer care and services.
7. Review any incidents and agree actions.
8. Review PLACE audit and actions
9. Review Friends and family scores
10. Assist to develop local policies to promote best customer care processes across the
hospital.
11. Review Care Quality Commission progress and inspection feedback related to
customer care as an on-going process.
All departments will be expected to develop customer care standards in line with Ramsay
patient Journey Policy to ensure all practices we undertake from meeting and greeting
patients to delivering clinical care is provided in a consistent manner throughout the hospital
to ensure patients receive a seamless journey.
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The patient focus group will provide feedback on the way our services work and how they
can be improved. As patients are the ones who experience the process or service first hand,
they have a unique, highly relevant perspective. Their input into designing services can be
invaluable as they have an experience that staff cannot access. Often, seeing services from
the patients’ point of view opens up real opportunities for improvement that may not have
been considered before. Focus on the CQC ‘Caring’ indicator to ensure we can evidence
how we deliver high standards of care which is customer focused. ‘Customer excellence
training’ will continue throughout 2015/16 to focus on local practices to ensure that we The
Yorkshire Clinic continue to be the hospital of choice for our customers.
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2.2Mandatory 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 the Yorkshire Clinic provided and/or subcontracted 17 NHS services.
The Yorkshire Clinic has reviewed all the data available to them on the quality of care in all of
these NHS services which include:
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Adult Cataract Surgery NHS Clinic
Adult Colorectal Surgery NHS Clinic
Adult Diagnostic Endoscopy Flexi Sigmoidoscopy inc Colonoscopy NHS Clinic
Adult Diagnostic Endoscopy Gastroscopy NHS Clinic
Adult Elbow Only NHS Clinic
Adult ENT (Excl Audiology) NHS Clinic
Adult Fertility & Reproductive Medicine NHS Clinic
Adult Forefoot Surgery inc Bunions NHS Clinic
Adult Gynaecology NHS Clinic
Adult Haematology NHS Clinic
Adult Hand & Wrist NHS Clinic (Complex)
Adult Hand & Wrist NHS Clinic
Adult Hernia Repair NHS Clinic
Adult Hip NHS Clinic
Adult Hip Revision Surgery NHS Clinic
Adult Incontinence/Uro-gynaecology NHS Clinic
Adult Knee Arthroscopy NHS Clinic
Adult Knee Joint Revision NHS Clinic
Adult Knee NHS Clinic
Adult Laparoscopic Hernia Repair Clinic
Adult Lumps and Bumps Surgery NHS Clinic
Adult Menstrual Disorders Bleeding NHS Clinic
Adult Shoulder only NHS Clinic
Adult Minor Breast Surgery NHS Clinic
Adult Minor Plastic Surgery NHS Clinic
Adult Oral & Maxillofacial Surgery NHS Clinic
Adult Pain Management NHS Clinic
Adult Thyroid Surgery Clinic
Adult Urology NHS Clinic
Cruciate Ligament NHS Clinic
Dermatology NHS Clinic
Direct Access CT Scan NHS Service
Direct Access MRI Diagnostic Imaging NHS Service
Direct Access Nerve Conduction Studies NHS Clinic
Direct Access Non-Obstetric Ultrasound NHS Service
Direct Access X Ray NHS Service
Gall Bladder & Gallstones Clinic (excl Apply)
Gastro Lower GI
Gastro Upper GI
Laser Unit (Argon) NHS Clinic
Neurology NHS Clinic
One Stop No Needle, No Scalpel, No Suture Vasectomy NHS Clinic
Sleep Studies NHS Clinic
YAG Laser Unit (Capsulotomy & Iridotomy) NHS Clinic
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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
2011/2012
2012/2013
2013/2014
2014/2015
Total Health Care Assistants –
whole time equivalent (WTE)
17.59
21.97
22.55
36.30
Total Registered Nurses (WTE)
56.72
56.75
53.06
53.17
Total WTE Nursing (RN & HCA)
74.31
78.72
75.61
89.47
HCA hours as a % of Total Nursing
Hours
26.67%
28%
29.8%
40.5%
Rolling Sickness Absence
4.53%
3.66%
3.89%
3.66%
Rolling Employee Turnover
4.7 %
6.0%
11.8%
20.2%
Number of Significant Staff Injuries
1
1 (RIDDOR
(RIDDOR
reportable )
reportable)
1(RIDDOR
reportable)
0(RIDDOR
reportable)
There has been a significant increase in staff turnover within the last year but no trends other
than a number of registered nurses made the decision to re locate which impacted on this
increase. In response to this we have revisited our induction and mentoring processes to
ensure there is adequate support for our staff. We have widened our recruitment methods
through recruitment fairs, and advertising and have successfully appointed some key roles,
including Ward Manager, Senior Staff Nurse, Critical Care Lead Nurse and Health Care
Assistants to support the clinical team.
We have continued to review and monitor staff sickness by instigating return to work
interviews and adhere to the Bradford factor which has successfully reduced our rolling
sickness percentage over the past twelve months.
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.
The Yorkshire Clinic complete a Mandatory training programme for all staff members
including clinical and non-clinical. Staff attendance is recorded to ensure compliance. The
training is instigated on a monthly basis throughout the year; the topics covered are:
Customer Care
Fire
Prevent
Moving and Handlin
Basic Life Support
Data Protection
Infection Prevention & Control
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The Yorkshire Clinic established a pathway to record the government friends and family
initiative within 2014/15. This has been embedded and the results have been positive. A
sample of February 2015, results are outlined below indicating that the Yorkshire clinic
achieved the highest test score of the North of England hospitals.
Friends and Family Test Score
The above table shows The Yorkshire Clinics score of patient who would recommend the
Yorkshire Clinic to friends and family against the other local providers. (February, 2015).
Formal complaints:
The Yorkshire Clinic received 72 complaints from 1 April 2014 to 31 March 2015 compared
to 47 complaints in the previous year. The 72 complaints were expressions of concern,
dissatisfaction and requests for action to be taken. Complaints received were categorised as
33 complaints about medical treatment, 5 about the clinical care and 19 about the general
hospital service. All of these were investigated thoroughly complying with CQC timeframes
for response. There were no common themes or significant concerns arising from the
complaints received. All staff are aware of our complaints procedures should our patients be
dissatisfied with any aspect of their care or treatment. Every complaint received is
considered very seriously and given the immediate attention of the General Manager and
Matron on the day it is received, following which a thorough investigation is commenced into
the concerns raised as per Ramsay Complaints Policy.
There were no EMSA (Eliminating Mixed Sex Accommodation) breaches throughout
2014/15.
‘Never Events’ Never events are serious, largely preventable patient safety incidents
that should not occur if the available preventative measures have been implemented.
For
further
details
please
visit:
http://www.nrls.npsa.nhs.uk/resources/collections/never-events.
Quality Accounts 2014/15
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The core list of “never events” includes:
Wrong site surgery
Wrong implant/prosthesis
Retained foreign object post procedure.
Wrongly prepared high risk injectable medication
Maladministration of a potassium containing solution.
Wrong route administration of chemotherapy
Wrong route administration of oral /enteral treatment
Intravenous administration of epidural medication.
Maladministration of insulin
Overdose of midazolam during conscious sedation
Opioid overdose of an opioid naive patient
Inappropriate administration of daily oral methotrexate
Transfusion of ABO incompatible blood components.
Misplaced naso or oro gastric tubes.
Wrong gas administration.
Failure to monitor and respond to oxygen saturation.
Air embolism.
Misidentification of patients
2.2.2 Participation in clinical audit
During 1 April 2014 to 31st March 2015, 5 national clinical audits and 5 national confidential
enquiries covered NHS services that the Yorkshire Clinic provides.
During that period the Yorkshire Clinic participated in 5 national clinical audits and did not
participate in any national confidential enquiries.
The national clinical audits and national confidential enquiries that the Yorkshire Clinic
participated in, and for which data collection was completed during 1 April 2014 to 31st March
2015, are listed below alongside the number of cases submitted to each audit or enquiry as a
percentage of the number of registered cases required by the terms of that audit or enquiry.
Participation
(NA, No, Yes)
% cases
submitted
Cardiac Arrest (National Cardiac Arrest Audit)
Hip, Knees and ankle replacement (National
Joint Registry)
N/A
Yes
N/A
89%
Elective Surgery (National PROMs
programme)
Yes
Outcome snapshot provided in
section 3.1
Health Protection Agency – Surgical Site
Surveillance
Yes
100% (at Feb 14)
NHS Safety Thermometer
Yes
100%
Name of Audit
Comments
Hip & Knee
Replacement
All the above reports are discussed at the local clinical governance committee meetings to
ensure no trends are developing and outliers are highlighted.
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National Audits
A list of the national clinical audits we intend to undertake within the period 01 April 2015 to
31 March 2016 are as follows:
Name of audit / Clinical Outcome Review Programme
National Joint Registry (NJR) – Per patient
Elective surgery (National PROMs Programme)
JAG Census – Quarterly
SSI – Surgical Site Surveillance – Quarterly
Local Audits
The Yorkshire Clinic participates in the Ramsay Corporate Audit programme (the schedule
can be found in appendix 2) the audit topic and schedule is set centrally by Ramsay Health
Clinical Governance Committee to allow greater opportunity for benchmarking. Additionally
the Yorkshire Clinic also carries out a number of local clinical audits all of which go through
the Clinical Governance Committee where actions are taken to improve the quality of the
healthcare provided:Infection Prevention Audits: The Yorkshire Clinic 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 98% and 99% respectively.
Emergency Trolley Audit: To ensure that emergency equipment is ready for immediate
use, a check of the defibrillator, oxygen and suction is undertaken daily. There is also a
daily audit of the critical care trolley. These audit results are discussed and reviewed at the
resuscitation committee meeting which is held bi- monthly. The results are also reported in
the CCG report and discussed at Clinical Governance
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.
Clinical Variances & Outcomes: All clinical variances identified where there is a variance
from the norm, i.e. extended length of stay, readmission to hospital or return to the
operating theatre are documented and reported, to support a review and discussion in
monthly clinical governance forums and Medical advisory committees. These forums which
are held by a group of experienced clinician’s, support the discussion of trends and
concerns relating to practice in general or the practice of an individual practitioner and
advice and changes in practice can be implemented.
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2.2.3Participation in Research
There were no patients recruited to participate during 2014/15 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 Yorkshire Clinic income in from 1 April 2014 to 31st March 2015 was
conditional on achieving quality improvement and innovation goals. The goals were agreed
between the Yorkshire Clinic hospital and the lead Clinical Commissioning Group and forms
part of a contract for the provision of NHS services. This is a national incentive scheme
based on the Commissioning for Quality and Innovation framework. .
Indicator Goal
Quality Domain
Description of
indicator
Indicator
Weighting
1
Clinical & Quality
Effectiveness
Increase the response
rate from patients
0.5%
Clinical/Quality
Effectiveness
To enable YC access to
the same standard
platform as the local GP
practices and trusts
2.0%
2
Friends and Family
: increased response
rate (FFT)
Systm One - non-ADT
EPR Core
implemented at The
Yorkshire Clinic
The 2014/15 CQUINs were 100% achieved by the Yorkshire Clinic and the hospital are
currently negotiating the 2015/16 CQUINs to ensure continuous improvement in quality and
innovation.
2.2.5 Statements from the Care Quality Commission (CQC)
The Yorkshire Clinic Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions. The hospital has
not participated in any special reviews or investigations by the CQC during the reporting
period.
The Yorkshire Clinic was last inspected on the 29 January 2014. Three inspectors; 2 CQC
inspectors & a Department of health inspector attended the site visit and inspected 5
standards:
Consent to care and treatment
Care and welfare of people who use services
Safety and suitability of premises
Staffing
Assessing and monitoring the quality of service provision
Each of these standards was fully compliant and patient feedback to the inspectors was:
"The nurses were lovely and they were happy with the whole process”
"Staff attitude is fantastic and nothing is too much trouble."
"Everything had been excellent".
"Things have been better than their previous stay four years earlier."
"There was good patient focus and the premises were very good."
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The Yorkshire Clinic are reviewed yearly by the corporate clinical team and assessed on the
following key areas:
Completion of the 2014 corporate compliance action plan
Evidence of staff audit training completed by train the trainer
Quality account progress
Walk round of the facility to include
1. Environmental cleanliness
2. Safety devices seen in place and being used
3. Resuscitation trollies secure, clean and daily checks completed
4. Drug cupboards and fluids secure
5. All clinical documentation in date and correct version used
6. All patient information in date and correct version used
7. Information security - security of PID files and notice boards
8. Medical records audit of two day case patients and two inpatients
9. Risk assessments (appropriate assessments completed and reviewed at the correct
times)
10. EWS scored correctly (including O2) and following appropriate trigger actions
11. Fluid balance charts - correctly completed and appropriate actions following
imbalances
12. Staff interviews completed and the following questions asked:
What do you understand by 'Duty of Candour'
Can you tell me about a recent incident that occurred on the ward, and what
the outcome was (including lessons learnt or changes in practice)
If you had a patient admitted that had suspicious bruising on their body - what
would you do? (safeguarding - staff aware of process / flow chart contacts)
If you had a patient admitted who was clearly confused but had been
undiagnosed with dementia, what would you do? (screening, amends to care
pathway and nursing actions, validity of consent, GP awareness , mental
capacity status, DOLs)
Policy review and implementation process (ask them to discuss the last policy
updated)
Aware of fasting times (6 and 2 rule and what to do if patient has been over
fasted)
Drug calculations completed
If you could change one thing about the ward or your working environment,
what would it be?
A report will be fed back and disseminated with a rag rated action plan to address
The Yorkshire Clinic intend to instigate an action plan in order to plan for the next Care
Quality Commission (CQC) visit. The CQC have set a standard of key lines of enquiry
(KLOE’s) which each hospital should evidence as met. The key lines of enquiry are:
Safe
Effective
Caring
Responsive
Well Led
The Yorkshire Clinic have actioned mini CQC inspections by completing an inspection with
an Orthopaedic Consultant who has admitting rights to the clinic and is a registered as a
CQC inspector for the Care Quality Commission. This has highlighted a number of issues
which have been addressed locally.
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2.2.6 Data Quality
The Yorkshire Clinic 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 thus 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 it confidentially, staff are monitored on correct
data capture via internal reports and data quality training is updated regularly throughout the
hospital.
At The Yorkshire Clinic 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
Clinical coding error rate
Information Governance
To comply with Information Governance Requirement 505 for internal clinical coding audit of
NHS coded data, HSCIC recommend a score of at least a level 2 in all 4 areas for diagnosis
and procedural coding. The table below shows the percentage accuracy scores as targets:
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Required attainment level For IG 505
Level 2
Level 3
Primary diagnosis
> 90%
>95%
Secondary diagnosis
>80%
>90%
Primary procedure
>90%
>95%
Secondary procedure
>80%
>90%
The Yorkshire Clinic were last audited in February 2014 evidencing a score rate for the
following:
Diagnosis
Score
Primary diagnosis
Secondary diagnosis
Primary procedure
Secondary procedure
98.36%
98.32%
93.44%
88.3%
As evidenced in the table above The Yorkshire Clinic achieved above average scores for
clinical coding error rate. The next audit is to be scheduled for 2015.
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2.2.7 Stakeholders views on 2014/15 Quality Account
Bradford City and Bradford District Clinical Commissioning Groups
Statement on Yorkshire Clinic Quality Account 2014/2015
Bradford City and Bradford Districts CCGs welcome the opportunity to review and report on
the Quality Account 2014/15.It is felt to be a clearly articulated and comprehensive account
of the progress regarding last year’s priorities and demonstration of the commitment to
continued safe quality services as described within the priorities for the forthcoming year.
Yorkshire Clinic has made significant improvements within their 2014/15 priorities including
the following:
 Clinical incident reporting has improved with the instigation of clinical feedback
forums following incidents reported, sharing lessons learned, increasing awareness
and appointing a Quality Improvement Manager.
 Yorkshire clinic have participated in the Ramsey Corporate Audit programme (which
allows opportunities for benchmarking), were fully compliant, providing action plans
for any audits scoring less than 95%.They have also carried out a number of local
audits. However there is a lack of reference to NICE compliance and how this
influences the quality of care delivered.
 The National safety thermometer tool is being completed for vte and falls
assessment, compliance being audited corporately developing action plans where
risks are highlighted.
 In order to address the poor return rate for patient related outcomes (PROMs) the
process for issuing and collection has been changed to ward level being the
responsibility of the pre assessment team. This has resulted in compliance being
above the National average for 2014/15.
 In line with the Cavendish report which stated that all healthcare assistants should
have a “care certificate “there is clear indication of the investment in this area of the
workforce, ensuring that staff are adequately trained and supported.
 Patient feedback is obtained via surveys, family and friends test and complaints and
the customer service manager makes regular visits to the wards Actions following
feedback have included improvements to the catering service, the introduction of a
summer light bite menu and customer excellence training.
 Whilst the Quality Account does not specifically report on complaints, it acknowledges
that Yorkshire Clinic welcome complaints (informal/formal) as part of patient
experience feedback methods, and actions are taken as a result, including actions
identified from complaints in relation to patient safety.
 Yorkshire clinic have acknowledged their Never Event in 2014-15, providing detail of
the incident and actions taken to prevent re occurrence.
 Safeguarding was also identified as a priority and now includes training regarding the
PREVENT initiatives.
Of the mandatory indicators Yorkshire clinic takes part in all those relevant, providing
data, monitoring mortality rates, PROMs, re admissions, responsiveness to personal
needs and vte assessment and scores are above average.
Quality Accounts 2014/15
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They adhere to the Ramsey annual strategy for infection prevention and control and
are able to demonstrate high standards including IC link nurses, compliance with
mandatory training and completion of clinical audits.
Yorkshire Clinic have identified the 2015/16 clinical priorities and we note that these
focus on patient safety and clinical effectiveness in order to demonstrate continued
commitment to patient safety and quality, concentrating on the following areas:
 Clinical staff will have training to ensure “best practice” and National guidance are
followed in relation to falls prevention including risk assessment and care planning.
 To implement a recently developed action plan in order to minimise incidents in
relation to medicines administration. Examples will include daily ward rounds by
pharmacy, quarterly audits, monthly review of controlled drugs, ensuring that
prescriptions are written up pre admission to allow for timely discharge, pharmacy
reviews of patients on day of admission and clear guidance regarding medicines
management for all wards and departments.
 In order to comply with the Health and Safety Executive “sharp instruments in
healthcare “methods to protect staff are being introduced and practice will be audited,
however Commissioners would expect this to be in line with core practice.
 In recognition of patient safety and impact on the workforce, the updated Nursing and
Midwifery Council (NMC) revised Code of Conduct which must be adhered to, will be
a high priority for all staff. An implementation plan is in place to increase awareness
across the organisation. This also includes the need for revalidation. Although
commended for this approach Commissioners would expect compliance as part of
service delivery.
 With regards to patient experience customer focus groups are to be introduced to
review responses, audits and incidents and feedback improvements to be made to
the relevant wards and departments. Customer care standards will be developed in
line with the Ramsey patient journey policy.
The required statements of assurance have been provided demonstrating
achievement against the essential standards including relevant participation in
National and local clinical audits.
Yorkshire clinic are on track to achieve 100% of their 2014/15 CQUIN targets.
Bradford city and Bradford District CCGs accept that the evidence within the quality
Account reflects continued commitment to the provision of a culture of safe quality
services. We commend the proactive approach towards continued improvements of
services.
Helen Hirst
Chief Officer
NHS Bradford City CCG and NHS Bradford Districts CCG
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Part 3: Review of quality performance
2014/2015
Statements of quality delivery
Matron, Jill Campbell-Ainger
Review of quality performance 1st April 2014 - 31st March 2015
Introduction
“This publication marks the sixth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our performance
on many levels, we reflect on the valuable feedback we receive from our patients
about the outcomes of their treatment and also reflect on professional opinion
received from our doctors, our clinical staff, regulators and commissioners. We listen
where concerns or suggestions have been raised and, in this account, we have set
out our track record as well as our plan for more improvements in the coming year.
This is a discipline we vigorously support, always driving this cycle of continuous
improvement in our hospitals and addressing public concern about standards in
healthcare, be these about our commitments to providing compassionate patient
care, assurance about patient privacy and dignity, hospital safety and good outcomes
of treatment. We believe in being open and honest where outcomes and experience
fail to meet patient expectation so we take action, learn, improve and implement the
change and deliver great care and optimum experience for our patients.”
Vivienne Heckford
Director of Clinical Services
Ramsay Health Care UK
Ramsay Clinical Governance Framework 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:
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Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
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.
3.1 The Core Quality Account indicators
Mortality
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Prescribed Information
(a)
(b)
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 value and banding of the summary hospitallevel mortality indicator (“SHMI”) for the trust for
the reporting period; and
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.
Related NHS Outcomes
Framework Domain
1: Preventing People from dying
prematurely
2: Enhancing quality of life for people
with long-term conditions
The Yorkshire Clinic considers that this data is as described for the following
reasons:
In addition to providing surgical care and treatment, The Yorkshire Clinic provides care and
treatment for patients with long term chronic medical conditions and end stage cancer under
the care of Consultant Oncologists and Physicians. Most of these patients choose to be
cared for at the hospital on an end of life pathway during the end stage of their disease
process. The table explains the mortality rate that has occurred at the hospital in the last
year.
The Yorkshire Clinic has taken the following actions to monitor this rate, and so the
quality of its services by:
Completion of Corporate audits, incident investigation, root cause & gap analysis of care
episodes.
Robust mandatory training programme compliance
Information sharing at Clinical Governance level locally, corporately and with our
commissioners. Governance is also shared at local Medical advisory committee and risk
management meetings.
PROMS (Patient reported outcome measures)
Outlined in table above are the patient reported outcomes for The Yorkshire Clinic. This is
compared to the national best, worst and average scores from the UK.
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The data made available to the National Health Service trust or 3: Helping people to
NHS foundation trust by the Health and Social Care Information recover from episodes of
Centre with regard to the trust’s patient reported outcome ill health or following injury
measures scores for—
(i) groin hernia surgery,
(ii) varicose vein surgery,
(iii) hip replacement surgery, and
(iv) knee replacement surgery,
during the reporting period.
The Yorkshire Clinic considers that this data is as described for the following
reasons:
The Yorkshire Clinic participates in the Department of Health PROM’s survey for hip, knee
and hernia surgery for NHS & private patients. As evidenced in the template above the
Yorkshire Clinic demonstrate compliance for PROM’s participation rate is above the national
average for both hernia and hip return rates. The return rate is slightly below the national
average knee returns. This has been investigated which highlighted the need to review
process. The process has been amended and is under surveillance to ensure an increase in
return rates. As demonstrated PROMs indicate a patient’s health status or health-related
quality of life from the patient’s perspective, based on information gathered from a
questionnaire that patients complete before and after surgery. PROMs offer an important
means of capturing the extent of patients’ improvement in health following ill health or injury.
The Yorkshire Clinic has taken the following actions to improve this score so
the quality of its services can be consistently monitored:
We continue to monitor compliance return rate in order to ensure that we continue to learn
from patient feedback, we will be concentrating our efforts on this initiative throughout 2015.
We intend to distribute the PROMS form at the pre assessment stage and the admitting
nurse will collect the returns at the admission stage.
Completion of Corporate audits, incident investigation, reporting, root cause and gap
analysis
Robust mandatory training programme compliance
Information sharing at ward level, raising staff awareness of the importance of 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
Readmissions
Period
Best
Worst
Average
Period
Yorkshire
2010/11
Multiple
0.0 5P5
22.76
Eng
11.43
2010/11
NVC20
4.64
2011/12
Multiple
0.0 5NL
41.65
Eng
11.45
2011/12
NVC20
7.69
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The data made available to the National Health Service 3: Helping people to recover
trust or NHS foundation trust by the Health and Social from episodes of ill health or
Care Information Centre with regard to the percentage of following injury
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.
The Yorkshire Clinic 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.
As evidenced in the template above the Yorkshire Clinic demonstrate readmission rates are
below the average national rate compared to other sites 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.
The Yorkshire Clinic has taken the following actions to improve this score so
the quality of its services can be consistently monitored:
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
Responsiveness to personnel needs
Period
Best
Worst
Average
Period
Yorkshire
2012/13
RPC
88.2
RJ6
68.0
Eng
76.5
2012/13
NVC20
91.6
2013/14
RPY
87.0
RJ6
67.1
Eng
76.9
2013/14
NVC20
92.7
4b Patient experience of hospital care
No data for Independent Sector
Hospitals
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Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
95.0
95.5
2013/14
2014/15
20
0
The Yorkshire Clinic
The data made available to the National Health Service 4: Ensuring that people have
trust or NHS foundation trust by the Health and Social a positive experience of care
Care Information Centre with regard to the trust’s
responsiveness to the personal needs of its patients
during the reporting period.
The Yorkshire Clinic considers that this data is as described for the following
reasons:
Feedback from patients regarding their experience at The Yorkshire Clinic 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 displayed for staff to see in staff rooms and 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 and Matron on the day it is received, following
which a thorough investigation is commenced into the concerns raised as per Ramsay
Complaints Policy. The Yorkshire Clinic has acknowledged the recently amended code of
conduct for registered nurses and has implemented training awareness workshops in order
to raise staff awareness re the changes. The code stipulates that nurses and midwives
should adhere to the duty of candour to be open and honest with colleagues, patients and
healthcare regulators when things go wrong.
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
Ramsay Healthcare and Department of Health policy.
The Yorkshire Clinic 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:
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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
Patient focus groups
PROMs surveys
Care pathways – patients are encouraged to read and participate in their plan of
care.
Annual PLACE patient audit
Venous thromboembolism (VTE)
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.
5: Treating and caring for
people in a safe
environment and
protecting them from
avoidable harm
The Yorkshire Clinic considers that this data is as described for the following
reasons:
The Yorkshire Clinic 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. As evidenced in the template above the
Yorkshire Clinic demonstrate that we are above the national average for VTE risk
assessment
The Yorkshire Clinic 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.
Clostridium Difficile Infection
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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
The Yorkshire Clinic 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. As
demonstrated in the above table this shows our high standards of infection prevention; there
have been no cases to report.
A network of specialist nurses and infection control link nurses operate across the Ramsay
organisation to support good networking and best clinical practice. Within the Yorkshire Clinic
we have infection control link nurses in all clinical areas ensuring that IPC management
remains high priority throughout the hospital.
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.
The Yorkshire clinic has taken the following actions to maintain this score, and
so the quality of its services, by:
The Local IPC Committee is chaired by our Consultant Microbiologist and 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
No independent sector data, pulled from RM
(Overall Sev 1)
Acute Non-Specialist Data From NRLS, England Average based on these sites only
Figures are severe/death patient safety incidents per 1000 admissions (13/14) or per 1000 bed days(Apr-Sep14)
Quality Accounts 2014/15
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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
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
The Yorkshire Clinic considers that this data is as described for the following
reasons:
The Yorkshire Clinic 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
Matron and an investigation process, root cause analysis and action plan implemented
where appropriate. The Riskman system immediately reports incidents directly to the
Corporate Risk Management Team allowing the identification of trends at the Yorkshire Clinic
and throughout the Ramsay organization to further identify trends and outlying data. Locally
all incidents are reported through Risk Management 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; the Yorkshire Clinic 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
Monthly Risk management 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.
Riskman introduction training updates via web based rolling programme
Friends and Family Test
Friends and Family Test - Question Number 12d – Staff – The 4: Ensuring that people have
data made available by National Health Service Trust or NHS a positive experience of care
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.
The Yorkshire clinic considers that this data is as described for the following
reasons:
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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 The Yorkshire Clinic 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. The Yorkshire Clinic will use the information received from our patients in this
survey in order to improve the service we offer.
We recognise that we have scored above the national average due to robust
processes in place however; the Yorkshire Clinic has taken the following actions to
improve upon 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
Refresh notice boards in patient areas with recent results and action plans instigated to
address issues
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.
3.2.1 Infection prevention and control
The Yorkshire Clinic 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.
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Infection Rates
Infection Rates
(percentage of Admissiosns)
0.16
0.14
0.12
0.1
0.08
0.06
0.04
0.02
0
2012/13
2013/14
2014/15
The Yorkshire Clinic
As can be seen in the above graph our infection rate reporting has increased for 2014/15.
The Yorkshire Clinic was highlighted across the company as an outlier for under reporting for
the reporting of infections. A review of nursing understanding of the definition and
recognition of hospital acquired infections was undertaken highlighting a lack of awareness
and differing views. This was discussed with the Consultant Microbiologist and the quarterly
Infection Prevention Control Committee (IPC) meeting in July 2014 and it was agreed to
instigate further staff training surrounding the infection reporting process.
We have appointed a new infection control lead nurse who is working closely with the clinical
team to ensure reporting compliance moving forward. Following this there has been an
increase in infection reports due to raised staff awareness and analytical and critical review
and root cause analysis. Any healthcare associated infections identified are now planned to
be routinely discussed and reviewed at quarterly IPC meetings with the Consultant
Microbiologist., discussed at the Medical Advisory Committee and also reviewed through
clinical governance committee meetings.
Programmes and activities within our hospital include:
The Yorkshire Clinic 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.
The Yorkshire Clinic infection control processes are coordinated and led by an experienced
Registered Nurse. The Yorkshire Clinic Infection Prevention & Control Committee comprises
of Consultant Microbiologist, Infection Control Lead; Hospital Matron; CSSD Supervisor;
Hospital Engineer; Customer Services Manager; Pharmacy Manager and Link Nurses from
Theatre, Wards, Outpatients and Endoscopy. 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 and our
Consultant Microbiologist also provides bi-annual in house training. A comprehensive
infection control audit programme has been maintained throughout 2014/2015.
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Audits undertaken during 2014/145 achieved average scores of: PLACE
96 %
Hand hygiene
96%
Environment cleanliness
95%
Surgical site infection
89%
Peripheral venous catheter care
93.5%
Urinary catheter care
99.5%
The Infection Prevention & Control Audits have shown improvement in the following areas: Staff training is currently under review with regard asepsis training compliance.
The ward manager is to lead on this project.
Staff development training for surgical site Infection data collection (SSI) has been
organised to ensure robust compliance is adhered to
The Yorkshire Clinic regularly audits surgical site infections across surgical
specialities using the Department of Health (2010) High Impact Intervention care
bundle tool, to prevent surgical site infection. This audit focuses on the preoperative and peri-operative practice. The audit results during 2014/2015 were
100% compliance.
Action plans are in place to address issues raised in all the above audits where compliance
is less than 95% and are regularly reviewed and monitored through infection prevention
meetings.
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 the Yorkshire Clinic, 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 The Yorkshire Clinic 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 following scores were accredited in our audit undertaken in July 2014.
Cleanliness:100%
Food: 91.68%
Privacy, dignity and wellbeing 80.85%
Condition, appearance and maintenance: 100%
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We completed the last PLACE audit on the 13th March 2015 and submitted the data stats.
The results have not been reported as yet.
3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents
around sharps and needles. As a result, ensuring our staff have high awareness of safety
has been a foundation for our overall risk management programme and this awareness then
naturally extends to safeguarding patient safety.
Effective and ongoing communication of key safety messages is important in healthcare.
Multiple updates relating to drugs and equipment are received every month and these are
sent in a timely way via an electronic system called the Ramsay Central Alert System (CAS).
Safety alerts, medicine / device recalls and new and revised policies are cascaded in this
way to our General Manager which ensures we keep up to date with all safety issues. All
relevant CAS alerts which require action are reviewed and discussed through Risk, Clinical
Governance and medical advisory meetings.
The Yorkshire Clinic have an occupational health nurse on site who is linked to the wellbeing
programme ensuring robust reporting and awareness is maintained. All staff members have
recently instigated a wellbeing health surveillance programme; which is directly accessed
through the Riskman reporting system. All staff members have individual logins to ensure
privacy and data protection is maintained.
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.
The Yorkshire Clinic has a mandatory training programme which is completed on a yearly
basis by all staff members. The training incorporates:
Customer Care
PREVENT Training
Basic Life Support
Data Protection
Infection Control
Manual Handling
The training sessions are split between clinical and non-clinical allowing a more detailed
approach.
Mandatory on line e-learning training is also completed on an annual basis by all staff
members who are reviewed and discussed in staff professional development reviews which
are instigated yearly with six month reviews to ensure learning and development is on-going.
The recent hospital refurbishment has improved upon patient facilities which have had a
positive impact on patient care. The hospital has refurbished the following areas:
The imaging department has been redecorated and a new carpe has been fitted in
the patient waiting area.
The mammography suite has been re decorated
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The staff corridor linking outpatients to stores and the delivery entrance has been re
painted and fit with additional wall protection
The male and female visitors toilets have been completely refurbished with new
porcelain, flooring, painting and lighting
The male and female staff toilets have been completely refurbished with new
porcelain, flooring, painting, lighting and new locker facilities
The physiotherapy department has recently been re painted
The MRI suite has been fitted with new privacy curtains and tracking
The RMO flat has had a total refurbishment including, new bathroom facilities,
lighting, new flooring, new built in furniture, blinds, bed, desk and decoration
Wall protection panels have been fitted to the walls of the entrances to the imaging
suites
A full redecoration of the theatre suites and the link corridor is planned in order to
improve, décor and hygiene standards
Clean utility on the first floor has recently been refurbished encompassing additional
secure clinical storage
HDU has recently been refurbished and fitted with new flooring, blinds, lighting and
equipment
An additional private area has been created for nursing/consultant use enabling
patient/relatives to have privacy and dignity when having difficult conversations
In order to support the day case initiative ward one now has a day case lounge which
is used for patients awaiting day case procedures. This room has been refurbished
with additional new seating.
A comprehensive Health, Safety and Facilities audit was carried out at the Yorkshire Clinic
by the Ramsay group Estates Manager in February 2015.
This audit returned a score of 95%. This shows a slight increase from the previous audit
which scored 94% compliance in 2014. This is mainly due to the audit having been modified
and now being more specific in its criteria than previous audits. The results were passed to
the Group Risk Manager prior to his upcoming visit this year.
The Yorkshire Clinic has installed a new Liquid Oxygen tank increasing oxygen capacity for
the hospital due to increased activity levels.
In April 2014 the Yorkshire Clinic were successfully recertified for compliance with
Information security ISO 27001 Compliance following an in-depth audit. ISO27001 is the
international standard describing best practice for an Information Security Management.
There were some minor non-conformity and several observations for improvements including
further increasing of awareness amongst staff and changes to the layout and security of
some of the internal rooms.
3.3 Clinical effectiveness
The Yorkshire Clinic hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical incidents,
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patient and staff feedback are systematically reviewed to determine any trend that requires
further analysis or investigation. More importantly, recommendations for action and
improvement are presented to hospital management and medical advisory committees to
ensure results are visible and tied into actions required by the organisation as a whole.
3.3.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our services grow.
The majority of our patients undergo planned surgical procedures and so monitoring
numbers of patients that require a return to theatre for supplementary treatment is an
important measure. Every surgical intervention carries a risk of complication so some
incidence of returns to theatre is normal. The value of the measurement is to detect trends
that emerge in relation to a specific operation or specific surgical team. As demonstrated in
the graph below, Ramsay’s rate of return to theatre has reduced significantly; consistent with
our track record of successful clinical outcomes.
Return to Theatre Score
Retrnn to Theatre
(Percentage of Admissiosns)
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
2012/13
2013/14
2014/15
The Yorkshire Clinic
3.3.2 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
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Hot alerts received within 48hrs of a patient making a comment on their web survey
Yearly CQC patient surveys
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers
whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of care
3.3.3 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 48hours of receiving them
so that a response can be made to the patient as soon as possible. As can be seen in the
graph below our Patient Satisfaction rate has increased over the last year.
Satisfaction Scores
Satisfaction Scores
NHS/Private Patients
120
100
80
60
40
20
0
95.5
95.0
2013/14
2014/15
The Yorkshire Clinic
3.4 Hospital Case Study
In November 2014, Ramsay Healthcare launched a Day Case Project which was developed
to review the management of day-case patients within our hospitals to ensure patients spend
less time in hospital and more time at home with family and friends. Day surgery refers to the
practice of admitting selected patients (both medical and surgical) into a unit for a planned
procedure on the day of surgery and discharging them on the same day; therefore the patient
does not incur an overnight stay. These patients require time in a recovery facility, be it via
1st/2nd Stage recovery or by resting in a recliner prior to discharge.
During the last 10 years the hospital has seen day case admissions increased by over 30%,
however the management and pathway of care for these patients has remained the same.
On review, over 10% of day-case patients were being unnecessarily admitted to a ward
bedroom which has resulted in patients attending hospital much sooner than necessary,
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creating time delays for the patent to be seen on admission resulting in much longer hospital
lengths of stay.
In March 2015, the Yorkshire Clinic reviewed the Pain Management pathway for patients
attending hospital for injections to relieve pain. These patients historically were admitted
either at 7am or 12noon and remained in hospital for a minimum of 5 hours until they were
discharged home. The clinic has actively engaged with our consultants in pain management
to develop a new pathway of care which would offer patients the same clinical treatments but
in a much smoother patient journey as these patients would no longer be admitted to
individual rooms and be required to attend hospital hours before the scheduled procedure.
All pain management patients are now admitted to a day case lounge where they are
received by a registered nurse, taken to a private room for their admission process and then
escorted to our cardiac catheterisation lab where their procedure is performed. Following the
patients procedure they are monitored and reviewed in our dedicated recovery area where
they are made comfortable until they are discharged. Our new pathway process alleviates
the requirement for patients to return to the ward post procedure and offers the patient a
much quicker discharge home.
We have received very positive feedback from patients regarding our new pathway of care,
which is now delivered through a dedicated facility with a streamlined consistent approach.
Work continues to review other day case pathways of care to ensure all appropriate patients
receive, timely, consistence, efficient care with excellent customer service.
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Appendix 1
Services covered by this quality account
Adult Cataract Surgery NHS Clinic
Adult Colorectal Surgery NHS Clinic
Adult Diagnostic Endoscopy Flexi Sigmoidoscopy Inc. Colonoscopy NHS Clinic
Adult Diagnostic Endoscopy Gastroscopy NHS Clinic
Adult Elbow Only NHS Clinic
Adult ENT (Excl Audiology) NHS Clinic
Adult Fertility & Reproductive Medicine NHS Clinic
Adult Forefoot Surgery Inc. Bunions NHS Clinic
Adult Gynaecology NHS Clinic
Adult Haematology NHS Clinic
Adult Hand & Wrist NHS Clinic (Complex)
Adult Hand & Wrist NHS Clinic
Adult Hernia Repair NHS Clinic
Adult Hip NHS Clinic
Adult Hip Revision Surgery NHS Clinic
Adult Incontinence/Urogynaecology NHS Clinic
Adult Knee Arthroscopy NHS Clinic
Adult Knee Joint Revision NHS Clinic
Adult Knee NHS Clinic
Adult Laparoscopic Hernia Repair Clinic
Adult Lumps and Bumps Surgery NHS Clinic
Adult Menstrual Disorders Bleeding NHS Clinic
Adult Shoulder only NHS Clinic
Adult Minor Breast Surgery NHS Clinic
Adult Minor Plastic Surgery NHS Clinic
Adult Oral & Maxillofacial Surgery NHS Clinic
Adult Pain Management NHS Clinic
Adult Thyroid Surgery Clinic
Adult Urology NHS Clinic
Cruciate Ligament NHS Clinic
Dermatology NHS Clinic
Direct Access CT Scan NHS Service
Direct Access MRI Diagnostic Imaging NHS Service
Direct Access Nerve Conduction Studies NHS Clinic
Direct Access Non-Obstetric Ultrasound NHS Service
Direct Access X Ray NHS Service
Direct Access Endoscopy NHS Service (pending)
Gall Bladder & Gallstones Clinic (excl Apply)
Gastro Lower GI
Gastro Upper GI
Laser Unit (Argon) NHS Clinic
Quality Accounts 2014/15
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2014/15
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The Yorkshire Clinic
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:
Hospital phone number
01274 550615
www.theyorkshireclinic.co.uk
Quality Accounts 2014/15
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