Quality
Accounts
2009 / 10
Extraordinary care needs
extraordinary people
Operating Theatre Team Ashtead Hospital
No reported MRSA Bacteraemia in the past 3 years.
Part 1
Statement on quality from the
Chief Executive Officer
Ashtead Hospital Radiology Department
P2
Quality Accounts 2009 / 10
Statement of Commitment
Chief Executive Officer, Jill Watts
This annual report presents Ramsay Health Care’s
achievements in terms of clinical excellence, effectiveness,
safety and patient experience.
Ramsay Health Care UK is
committed to establishing an
organisational culture that puts the
patient at the centre of everything
we do.
As Chief Executive of Ramsay Health
Care UK, I am passionate about
ensuring that high quality patient
care is at the centre of what we do
and how we operate all our facilities.
This relies not only on excellent
medical and clinical leadership in our
hospitals but also upon our overall
continuing commitment to drive
year on year improvement in clinical
outcomes.
I believe all healthcare organisations
should measure their performance
in areas of safety and quality and
across all our Ramsay facilities we
have a structured clinical governance
framework in place that helps us to
continually review our performance
so we can drive improvements to
benefit all patients.
Our Quality Account is information
for our patients and commissioners
to assure them we are committed
to sharing our progressive
achievements from one year to the
next. As a long standing and major
provider of healthcare services
across the world, Ramsay has a very
strong track record as a safe and
responsible healthcare provider and
we are proud to share our results.
Delivering clinical excellence
depends on everyone in the
organisation. It is not about reliance
on one person or a small group
of people to be responsible and
accountable for our performance.
Across Ramsay we nurture the
teamwork and professionalism on
which excellence in clinical practice
depends. We value our people and
with every year we set our targets
higher, working on every aspect of
our service to bring a continuing
stream of improvements into our
facilities and services.
There are inherent risks associated
with being a patient in the health
care system and it is the professional
and legal responsibility of all
health professionals and health
organisations to ensure that
every effort is made to reduce the
likelihood and consequence of an
adverse event or outcome associated
with treatment of a patient.
Ramsay UK has adopted a systems
approach to risk management. This
approach focuses on the systems
in place in which the employee
works rather than focusing on
the acts or omissions of individual
employees. Because of the inherent
risks associated with being a patient
in the health care system a key part
of the framework is to ensure that
every effort is made to reduce the
likelihood and consequence
of an adverse event or outcome
associated with treatment of a
patient. Education plays a key
component as employees must feel
free to report hazards, near misses,
and minor incidents without fear of
punitive actions.
Ramsay operates to meet long
term, not short term healthcare
objectives; we invest substantially in
our people, our hospitals and in our
equipment to ensure consistent high
quality care is delivered safely and
effectively. Our emphasis is to ensure
patients receive safe and effective
care, that they feel valued and
respected as partners in decisions
about their care. Clinicians are
enabled to provide that care and our
organisation can always satisfy itself
that the right things are being done
in the right way.
To the best of my knowledge,
as requested by the regulations
governing the publication of this
document, the information in this
report is accurate.
Jill Watts
Chief Executive Officer
Ramsay Health Care UK
Quality Accounts 2009 / 10
P3
Statement of Quality
Director Safety and Clinical Performance, Jane Cameron
“ We especially value patients’ positive feedback about their experience, clinical
treatment and clinical outcome. For example, we actively monitor results of patients’
hip and knee replacement and cataract surgery in the first year after surgery and our
patients give us their personal assessments of how their quality of life has improved
after surgery. ”
Receiving real evidence of patients’
improvement in well-being is
immensely satisfying. Patient
feedback is also important in
informing our clinical teams in their
plans for ongoing refinement and
improvement to surgical outcomes.
We continually measure all aspects
of patients’ opinion about their
care and treatment and these
results, gleaned from face to face
discussion as well as short surveys,
have been a very important part
of our overall business for over
15 years. Over this time we have
achieved consistent and high
patient satisfaction scores and, by
studying results throughout the
year, constantly seek ways to further
improve patient experience.
Ensuring patients are fully informed
about their treatment at each step
in their care 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 of treatment
are fully debated before patients
consent to treatment. Our medical
and clinical teams devote time to
patient preparation for surgery.
This not only reduces risk but also
improves patient understanding
and confidence, reduces anxiety,
improves rates of recovery and
shortens lengths of hospital stay.
So patient feedback and
P4
Quality Accounts 2009 / 10
involvement is extremely important
but in conjunction with this we
also heavily rely upon many other
measures of safety and clinical
effectiveness; we use these to
satisfy ourselves of treatment
that is evidence-based, treatment
that is delivered by appropriately
qualified and experienced doctors
and nurses and other key healthcare
professionals. Examples of these
follow in this Quality Account.
Patient safety is our highest priority
and we provide sufficient qualified
and trained staff to deliver the
service in a safe environment. We
ensure that our staff are competent
through a robust recruitment
process and training programmes.
We believe it is essential to provide
the right person in the right role at
the right time to deliver safe and
effective treatment and care. Staff
are trained on all the equipment
they are required to use, and are
not allowed to use equipment
they have not been trained for and
signed off as competent.
Ramsay is a long term partner to
private medical insurers and to
the NHS. For our private patients
and NHS patients alike we are
committed to meeting and
exceeding standards in safety and
clinical effectiveness.
Our reputation with these
organisations depends on a
track record of safety and clinical
effectiveness. Ramsay 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,
where occasionally these occur, to
regulators and commissioners.
For many years, we have
encouraged transparency and a
“no blame” culture to embed open
reporting of system failures, serious
incidents, patient complaints and
near misses. We maintain a Risk
Register and systematically review
specific actions to achieve risk
reduction.
This discipline extends to a readiness
on Ramsay’s part to enable learning
across the organisation to support
changes to clinical practice and
continual improvements to patient
safety.
In Ramsay the commitment to
quality improvement is at every level
in the organisation.
Jane Cameron
Director Safety and Clinical
Performance
Ramsay Health Care UK
Part 2
Quality priorities for 2010 / 11
Time to care - Fitzwilliam Hospital
Quality Accounts 2009 / 10
P5
Priorities for improvement
Director Safety and Clinical Performance, Jane Cameron
Plan for 2010 / 11
“ On an annual cycle, Ramsay develops an operational plan to set objectives for the year ahead.
A clear and stated objective is that we aim to be the leader in private health care by providing the
highest quality of clinical care and exceed our patients’ expectations. To meet this objective we have
set out detailed initiatives to drive safety, clinical effectiveness and improve the patient experience. ”
Priorities for improvement
“ The priorities are determined by the Executive Management Team on the recommendation of the
Clinical Governance, Risk Management and National Medical Advisory Committees. All professional
and management levels are represented on these committees. ”
1. Patient safety
2. Clinical effectiveness
Barcode for patient identity
laserbands
Meeting Endoscopy standards
In the area of patient safety, we
will continue our incremental
improvement initiatives to embed
safer surgery through bar code
enhancement to patient identity
Laserbands currently in use.
Safer surgery checklists
We will undertake further
work with specialities such as
ophthalmology to add speciality
specific enhancements to our
Safer Surgery Checklists to support
national initiatives to prevent wrong
surgery.
Cleanliness
We plan to maintain our good
track record for effective infection
prevention and control and to
improve ratings in the PEAT
(Patient Environment Action Team)
assessments. Plans for ongoing
investment in refurbishment of
our facilities will take advantage of
advances in technology and interior
design. This will lead to a gain in
performance due to better cleaning
of new wall surfacing, flooring,
ventilation and lighting.
P6
Quality Accounts 2009 / 10
This is one of our major priorities
for improvement in clinical
effectiveness. One of Ramsay’s
endoscopy centres was the first
independent sector service to
successfully complete a Pilot JAG
(Joint Advisory Group) accreditation
in 2009. In 2010 - 2011 Ramsay
will progress work to meet national
endoscopy standards through our
collaboration with Endoscopy NHS,
enrolling all of our participating
sites to submit Global Rating Score
(GRS) data on to the Endoscopy
NHS website to achieve JAG
accreditation from 2011.
3. Patient experience
Patient feedback has shown that
patients attending for day surgery
procedures are experiencing a wait
from time of arrival of up to or over
2 hours before treatment. Hence
the following two initiatives:
Investment in day surgery
facilities
Advances in surgery and
anaesthesia have reduced the
requirement for an overnight
recovery in hospital after a surgical
procedure for many patients. In
common with other healthcare
organisations, Ramsay has seen
a marked increase in day patient
admissions. Ramsay recognises
the opportunity to further improve
patient experience for day surgery.
Benefits include reduced waits from
arrival to treatment, shorter recovery
from anaesthetic times and shorter
length of stay. In conjunction with
the phased refurbishment plans
described, Ramsay will invest to
reconfigure current day surgery
facilities, create additional and
superior capacity for patients and
create improved flows for better
convenience of patients.
Releasing time to care
The new provision for day patients
will, in turn, release nursing time for
inpatients where currently nurses
manage a greater mix of day patient
and inpatient. Releasing additional
time for direct nursing care, more
time to devote at the bedside with
their patients. Ramsay will also
extend a current pilot programme
of the Productive Ward initiative to
generate maximum nursing time
with patients.
Part 3
Review of quality performance 2009 / 10
Operating Theatre Team Ashtead Hospital
Quality Accounts 2009 / 10
P7
Statements of quality delivery
Director Safety and Clinical Performance, Jane Cameron
Review of quality performance 1st April 2009 - 31st March 2010
Introduction
“ Ramsay operates a quality framework to ensure the organisation is accountable for continually
improving the quality of their services and safeguarding high standards of care by creating an
environment in which excellence in clinical care will flourish. ”
Ramsay Clinical Governance Framework 2010
Ramsay is committed to ensuring patient safety and quality of care, and minimising risk. We believe that these are best
achieved through strong effective leadership and integrated governance so that there is understanding throughout the
organisation that clinical governance is everybody’s business.
Our governance supports our quality framework and embraces these key principles:
•
•
•
•
Clarity about accountability
Drivers for improvement, innovation and change
Proficiency in financial and human resource
management
Enablers for organisational learning
•
•
•
•
Organisational focus on risk management
Disciplines in audit and information management
Partnerships with stakeholders
Investment in training and organisational development
This philosophy underpins our business strategy and monitoring of organisational performance enables balanced reviews
of business, clinical and safety priorities on an ongoing basis. This quality account has been developed from hospital safety
and performance reports for both NHS and private patients used as part of our routine clinical governance and health and
safety management across Ramsay.
Audit
Another quality assurance tool widely deployed by Ramsay is audit. This discipline of periodically assessing a service to test
compliance to healthcare standards or safety legislation is of benefit by identifying non-compliant practice.
An example of where audit directly benefits patients concerns endoscopy – diagnostic examinations of the upper
and lower bowel. In a phased programme across Ramsay, hospitals are involving patients in assessing the endoscopy
procedures by means of a Global Rating Scale (GRS). The results assist doctors in refining technique and efficacy of
endoscopy and this is helping to drive higher standards in gastroscopy and colonoscopy. Ramsay supports this study and
will now work towards accreditation status to qualify Ramsay to participate in national bowel cancer screening.
NICE guidance
Ramsay also complies with the recommendations contained in technology appraisals issued by the National Institute
for Health and Clinical Excellence (NICE). One example is guidance developed to safeguard patients from deep vein
thrombosis which can present as a serious post-operative complication of surgery. We have adopted the NICE guidance
“Venous Thromboembolism - Reducing the risk of Venous Thromboembolism in Surgery”. Ramsay’s Medical Director,
in conjunction with lead clinicians, has developed a corporate policy which gives clear instruction about the necessity
to complete a risk assessment for all patients undergoing surgery or those admitted to hospital for other conditions.
It provides guidance on treatment options for different conditions and levels of risk. Discussion with the patient and
decisions about prophylactic regimen to be used must be documented. Ramsay monitors the number of risk assessments
completed and incidence of deep vein thrombosis as an important aspect of patient safety.
Ramsay has systems in place for scrutinising all national clinical guidance and for monitoring their implementation.
P8
Quality Accounts 2009 / 10
1. Patient safety
We are a progressive organisation 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.
Our focus on patient safety has resulted in a marked
improvement in a number of key indicators as illustrated
in the graphs below.
A network of specialist nurses and infection control link
nurses operate across the Ramsay organisation to support
good clinical practice.
Programmes and activities within Ramsay include:
•
•
•
1.1 Infection prevention and control
Ramsay has a very low rate of hospital acquired infection
and has had no reported MRSA Bacteraemia in the past 3
years.
•
Infections as a percentage of admissions
•
0.25
0.2
%
0.15
•
0.1
0.05
•
0
2007
2008
2009
Year
We comply with mandatory reporting of all Alert
organisms including 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 in Ramsay. An annual strategy is developed by
a high 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.
Deployment of standard operating procedures,
such as hygiene and cleaning procedures, antibiotic
prescribing, patient screening protocols (covering
medical history and laboratory testing)
Reporting includes Surgical Site Infection surveillance
and Hospital Acquired Infection data reporting to the
Health protection Agency
Auditing tracks not only practice compliance as
set out in policy / procedures but also tracks risk
associated with hand hygiene, peripheral and central
venous line / infusions
Education of staff operates on a number of different
levels – foundation courses for clinical and nonclinical staff, for new starters, as refresher training, as
advanced training. Trainers are NHS professionals –
specialists practising at consultant level.
Patient education is developed in parallel to promote
good patient hygiene and to improve understanding
of hospital acquired infection. This includes leaflets
and website information
Patients are invited to comment through patient
experience surveys and state perception of standards
of cleanliness and staff hygiene behaviours.
Ramsay have deployed the PEAT tool to monitor
environmental standards and use the NPSA
website to trend performance / identify areas for
improvement
Ramsay has signed up to the National Patient Safety
Agency NPSA Clean Hands Campaign where posters and
information to staff, patients and visitors encourage and
promotes hand hygiene. Hand hygiene practice is audited
by observation and also by patient satisfaction survey.
Since 2008 we have also delivered a multi-million
pound investment in new disinfection, decontamination
and sterilisation facilities to process and track surgical
instrumentation to meet national decontamination
standards.
Good infection control practice is also considered at the
Ramsay National Procurement Committee in determining
procurement strategies. This is an illustration of
Quality Accounts 2009 / 10
P9
1.3 Safety in the workplace
integrated governance; experiences are shared through
joint working of multi-disciplinary teams in our key
management committees which is essential in areas such
as infection prevention and control.
Examples of year on year patient safety initiatives include:
Safety hazards in hospitals are diverse ranging from
the risk of slip, trip or fall to incidents around sharps
and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall
risk management programme and this awareness then
naturally extends to safeguarding patient safety.
Our record in workplace safety as illustrated by Group
Accidents per 1000 Admissions demonstrates the results
of safety training and local safety initiatives.
•
Adverse events per thousand admissions
Ramsay has systematically implemented patient safety
initiatives as part of a programme of targeted risk
management across the organisation.
•
5
4
1000
•
Patient centred pre-operative assessment revised and
implemented with training support – delivered in
2008
Preventing wrong site surgery by adopting Safer
Surgery Checklist in 2009
Transfusion training for all clinical staff in line with
NPSA guidance – delivered in 2009
3
2
1
0
1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include
Patient Environment Assessment Team (PEAT) audits.
These assessments include rating of privacy and dignity,
food and food service, access issues such as signage,
bathroom / toilet environments and overall cleanliness.
Ramsay scores are improving in these assessments and
reflect the investment in our facilities. Plans are in place
for further phased investment programme to deliver
refurbishments and improvements. These will also
support our infection prevention programmes to ensure
the fabric of our facilities is optimum for cleaning.
2009
2010
Year
Effective and ongoing communication of key safety
messages is important in healthcare. Multiple updates
relating to drugs and equipment are published every
month and we ensure these reach all our teams in a
timely way via a Ramsay Central Alert System. Safety
alerts, medicine / device recalls and new and revised
policies are cascaded electronically to keep each General
Manager up to date with safety issues.
Every Ramsay hospital has a clinical effectiveness team
and committee that meet regularly through the year
to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically
reviewed to determine any trend that requires
further analysis or investigation. More importantly,
recommendations for action and improvement are
presented to hospital management and medical advisory
committees to ensure results are visible and tied into
actions required by the organisation as a whole.
85.3
85.2
85.1
85
84.9
84.8
84.7
The results highlighted in the graphs demonstrate the
effectiveness of this approach over the last three years.
84.6
84.5
84.4
84.3
2007
2008
Year
P10
2008
2. Clinical effectiveness
Overall cleanliness scores from
PEAT assessments
%
2007
Quality Accounts 2009 / 10
2009
2.1 Return to theatre
Percentage readmissions by year
Ramsay is treating significantly higher numbers of
patients every year as our services grow. The majority of
our patients undergo planned surgical procedures and
so monitoring numbers of patients that require a return
to theatre for supplementary treatment is an important
measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre
is normal. The value of the measurement is to detect
trends that emerge in relation to a specific operation
or specific surgical team. Ramsay’s rate of return is very
low consistent with our track record of successful clinical
outcomes.
Percentage returns to theatre by year
0.18
0.16
0.14
0.25
0.2
%
0.15
0.1
0.05
0
2007
2008
2009
Year
3. Patient experience
Patient satisfaction scores for overall quality show the
majority of patients feel they receive excellent quality
of care and service in Ramsay facilities. To record a
satisfaction index over 90%, a very high proportion of
Ramsay’s patients have scored 9 or 10 out of 10 for their
satisfaction with all the requirements. This is underlined
by comparing Ramsay’s Satisfaction Index against those
achieved by other organisations across all sectors of
the UK economy where the full range of customer
satisfaction is 50% to 95% with the median just below
80%. Ramsay, rated against over 200 service companies
in the public and private sector, has consistently been in
the top 2-3% of UK organisations in its ability to satisfy
customers.
0.12
%
0.3
0.1
0.08
0.06
0.04
0.02
0
2007
2008
2009
Year
Patient satisfaction index of over 90% means
Ramsay rates in the top 2-3% of organisations
2.2 Readmission to hospital
Monitoring rates of readmission to hospital is another
valuable measure of clinical effectiveness. As with
return to theatre, any emerging trend with specific
surgical operation or surgical team in common may
identify contributory factors to be addressed. Ramsay
rates of readmission remain very low and this, in part,
is due to sound clinical practice ensuring patients are
not discharged home too early after treatment and are
independently mobile, not in severe pain etc.
100
90
80
70
60
%
50
40
30
20
10
0
2008
2009
Q1 2010
Year
Quality Accounts 2009 / 10
P11
3. Patient experience (continued)
Where specific questions are put to patients, 98%
of patients would recommend Ramsay and the same
proportion of patients are entirely satisfied with the
overall care they received.
Over 98% of patients would recommend
Ramsay and are entirely satisfied with
overall care
100
90
80
% of patients
70
60
50
3.1 Patient Reported Outcome Scores
PROMS
Average reductions in disability scores over
post-operative period
Ramsay uses a number of patient reported procedure
specific surveys and has been working with patients
to collect their responses for over four years since
2006. Currently we collect data about outcomes in
joint replacement surgery and cataract surgery. The
incremental improvements are benchmarked against
published data and Ramsay outcomes have
out-performed these.
Hip replacement surgery and Knee replacement
surgery
40
30
20
10
0
Q1
2009
Q2
2008
Q1
2010
Year
Would recommend Ramsay
Entirely satisfied with overall care
Patient satisfaction with treatment and care from
Ramsay medical staff and nurses is high and
consistent scores have been achieved.
Patient satisfaction with nurses and doctors
consistently high
Oxford Hip and Knee Questionnaires are used. These are
research based validated tools measuring disability – the
higher the score the higher the disability. The patient
completes the questionnaire before replacement surgery
and at a follow up examination and then again at one
year following surgery.
Hip replacement
Oxford Hip Scores - Past 3 years show
consistent improvement at follow up
(the lower the score the better the outcome)
45
40
35
100
30
90
25
80
20
15
% of patients
70
10
60
5
50
0
2008
40
30
Pre-surgery
1st follow up
1 year
20
10
0
Satisfaction with
nurses
Q2 2008
P12
Satisfaction with
Doctors
Q1 2009
Quality Accounts 2009 / 10
Q1 2010
2009
Pre-surgery
1st follow up
1 year
Q1 2010
Pre-surgery
1st follow up
1 year
Knee replacement
Oxford Knee Scores - Past 3 years show
consistent improvement at follow up
(the lower the score the better the outcome)
45
40
35
30
25
20
15
10
5
0
2008
Pre-surgery
1st follow up
1 year
2009
Pre-surgery
1st follow up
1 year
Q1 2010
Pre-surgery
1st follow up
1 year
Quality Accounts 2009 / 10
P13
Ramsay Health Care UK
Our Facilities
22 Hospitals | 11 Treatment Centres | 3 Neurological Centres
The Yorkshire Clinic, Bingley 01274 550600
Cobalt NHS Treatment Centre, Newcastle 0191 2703250
Tees Valley Treatment Centre, Middlesbrough 01642 737 855
Kendal NHS Treatment Centre, Kendal 01539 743000
Clifton Park NHS Treatment Centre, York 01904 464550
Fulwood Hall Hospital, Preston 01772 704111
Euxton Hall Hospital, Chorley 01257 276261
Park Hill Hospital, Doncaster 01302 730300
Oaklands Hospital, Salford 0161 7877700
Gainsborough NHS Treatment Centre,
Lincolnshire 01205 591860
Renacres Hospital, Ormskirk 01704 841133
Boston NHS Treatment Centre, Boston 01205 591860
Nottingham Woodthorpe Hospital, Nottingham 0115 920 9209
Rowley Hospital, Stafford 01785 223 203
Woodland Hospital, Kettering 01536 414515
The Westbourne Centre, Birmingham 0121 456 0880
Fitzwilliam Hospital, Peterborough 01733 261717
West Midlands Hospital, Halesowen 01384 560123
Horton NHS Treatment Centre, Banbury 01295 755000
Rivers Hospital, Sawbridgeworth 01279 600282
Gardens Neuro Centre, Sawbridgeworth 01279 600 201
Jacobs Neuro Centre, Sawbridgeworth 01279 600 201
Winfield Hospital, Gloucestershire 01452 331111
The Dean Neuro Centre, Gloucestershire 01452 420 200
Berkshire Independent Hospital, Reading 0118 902 8000
Oaks Hospital, Colchester 01206 752121
Springfield Hospital, Chelmsford 01245 234000
New Hall Hospital, Salisbury 01722 422333
Orwell Private Cardiothoracic Unit 01268 394217
North Downs Hospital, Surrey 01883 348981
Ashtead Hospital, Surrey 01372 221400
Pinehill Hospital, Hitchin 01462 422822
Blakelands NHS Treatment Centre, Milton Keynes 01908 334200
Mount Stuart Hospital, Torquay 01803 313881
Bodmin Treatment Centre, Bodmin 01208 262520
Duchy Hospital, Truro 01872 226100
For further information please contact:
020 7847 2850
www.ramsayhealth.co.uk