Quality
Accounts
2010 /11
Contents
Contents Page
2
Welcome to Ramsay Health Care UK
4
Welcome to Clifton Park NHS Treatment Centre
5
Introduction to our Quality Account
6
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
7
1.2
Hospital accountability statement
9
PART 2 – QUALITY PRIORITIES AND MANDATORY STATEMENTS
2.1
Quality Priorities
10
2.1.1 Review of clinical priorities 2010/11 (looking back)
10
2.1.2 Clinical Priorities for 2011/12 (looking forward)
11
2.2
Mandatory statements relating to the quality of NHS services
provided
16
2.2.1 Review of Services
16
2.2.2 Participation in Clinical Audit
19
2.2.3 Participation in Research
21
2.2.4 Goals agreed with Commissioners
22
2.2.5 Statement from the Care Quality Commission
22
2.2.6 Statement on Data Quality
22
2.2.7 Stakeholders views on 2010/11 Quality Accounts
25
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.0
Review of quality performance
26
3.1
Patient Safety
28
3.1.1 Infection prevention and control
28
3.1.2 Cleanliness and hospital hygiene
30
3.1.3 Safety in the workplace
30
3.2
31
Clinical Effectiveness
3.2.1 Return to theatre
31
Quality Accounts 2010/11
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3.2.2 Readmission to hospital
32
3.3
Patient Experience
33
3.3.1 Patient satisfaction surveys
34
3.3.2 Patient reported outcome measures (PROMS)
36
3.4
38
Case Study
Appendix 1 – Clinical Audits
40
Appendix 2 – CQUIN schedule
41
Quality Accounts 2010/11
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Welcome to Ramsay Health Care UK
Clifton Park NHS Treatment Centre 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 22 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, PCTs and acute Trusts.
“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.
“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.
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2010/11
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Welcome to Clifton Park NHS Treatment Centre
Clifton Park NHS Treatment Centre was purpose built and opened in January 2006
as part of the national GC4 contract to deliver elective NHS activity for a 5 year
period. All GC4 patients were referred via North Yorkshire and York Primary Care
Trust (85%) and East Riding of York Primary Care Trust (15%). In October 2010 the
hospital secured a further three year standard acute contract (SAC) with NHS NYY
and NHS ERY to deliver orthopaedic services.
In addition to this SAC activity, additional orthopaedic activity from York Trust is
undertaken. The hospital is also recognised by most major insurance companies and
undertakes self pay and insured work.
Brief description of unit and facilities
Clifton Park NHS Treatment Centre is a 24 bedded in patient unit providing a wide
range of elective orthopaedic surgical procedures including treatments for problems
with hips, knees, shoulders, hand, wrist and elbow and foot and ankle. The hospital
has a large out patients department, on-site x-ray and physiotherapy (including a
small gym), mobile MRI, a day case unit, two laminar flow theatres and a restaurant
which is open to staff, patients and visitors.
The hospital provides a full range of high quality orthopaedic services, these include,
outpatient consultation, outpatient procedures, investigations/diagnostics, surgery
and follow up care for all patients of 18 years and above. From 1st April 2010 to 31st
March 2011 the hospital has treated 2896 admitted patients, 95% of which were
treated under the care of the NHS.
The hospital has a unique structured secondment agreement with York Teaching
Hospitals NHS Foundation Trust who provide 40 specialist consultant orthopaedic
surgeons and anaesthetists to work from the facility. The hospital also has a training
agreement with York Trust, enabling registrars and extended scope practitioners to
work alongside consultants at the hospital. Our seconded clinicians are supported by
a team of 41 Nursing staff, 17 Health Care Assistants, 10 Allied Health Professionals
and 39 support staff which includes porters, hotel services and 20 administration
staff. The hospital’s Resident Medical Officer is on site 24 hours a day, working
alongside these teams. Our staff-to-patient ratios are managed on a daily basis to
meet the individual clinical requirements of our patients.
As well as our secondment agreement with York Teaching Hospitals NHS
Foundation Trust, we have in place several service level agreements with them to
facilitate our service delivery and ensure continuity of care.
During 2010 we strengthened our links with GP groups by the Chairman of York
Health Group becoming a member of our monthly Contract Management Board.
Quality Accounts 2010/11
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Introduction to our Quality Account
This Quality Account is Clifton Park NHS Treatment Centre’s annual report to the
public and other stakeholders about the quality of the services we provide. It presents
our achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people we
treat. It will also show that we regularly scrutinise every service we provide with a
view to improving it and ensuring that our patient’s treatment outcomes are the best
they can be. It will give a balanced view of what we are good at and what we need to
improve on.
The previous Quality Account for 2009/10 was developed by our Corporate Office
and summarised and reviewed quality activities across every hospital and centre
within the Ramsay Health Care UK. It was recognised that this didn’t provide enough
localised 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 will develop its own Quality Account
from this year onwards, which will include some Group wide initiatives, but will also
describe the many excellent local achievements and quality plans that we would like
to share.
Quality Accounts 2010/11
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Part 1
1.1 Statement on quality from the General Manager
Debbie Craven, General Manager,
Clifton Park NHS Treatment Centre
“Clifton Park NHS Treatment Centre successfully delivered the GC4 contract
from January 2006 to September 2010. In October 2010 we commenced a three
year standard acute contract, commissioned by NHS NYY and NHS ERY
following a tender process where we demonstrated our continuing high level of
quality service delivery.”
This is the first Quality Account to be submitted by Clifton Park NHS Treatment
Centre (CPTC) and has been produced to demonstrate our commitment to
measuring all feedback from patients about their experience, clinical treatment and
clinical outcomes. This allows us to continually review, reflect and improve the
patient’s journey.
Our hospital vision statement, which will be reflected throughout this report, is that:
“Clifton Park NHS Treatment Centre is committed to being a leading provider of
orthopaedic health care services by delivering high quality outcomes for patients at
efficient cost ensuring profitability.”
Patient safety is our highest priority and our robust recruitment processes and
training programmes ensure that staff are competent and fully trained in all aspects
of service provision.
Clifton Park NHS Treatment Centre continually achieves consistently high patient
satisfaction scores and, by studying results throughout the year, we constantly seek
ways to further improve the patient experience.
Clifton Park NHS Treatment Centre 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 to patient preparation 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.
Quality Accounts 2010/11
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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.
Clifton Park NHS Treatment Centre 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.
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Debbie Craven
General Manager
Clifton Park NHS Treatment Centre
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Ian Whitaker – MAC Chairman
Mrs Gwenn Mather - Clinical Governance Chair
Mr Stefan Andrejczuk – Regional Director North
Quality Accounts 2010/11
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Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
On an annual cycle, Clifton Park NHS Treatment Centre develops an operational
plan to set objectives for the year ahead.
We have a clear commitment to our patients and, as an NHS Treatment Centre we
work in close partnership with the NHS, ensuring that those services commissioned
to us result in safe, quality treatment for all 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 ongoing at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the recommendations
from various hospital committees which represent all professional and management
levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2010/11
•
•
•
Bar coding for patient identity bands – this priority did not progress last year,
as the Department of Health’s Information Standards Board (ISB) advance
notice was not followed up with a formal notice for implementation.
Consequently the project was put on hold until further advice was received from
the ISB. However, this is still on Ramsay’s agenda and will be introduced this
year as it is still considered best practice and will prepare us for many patient
care initiatives which will require patients to have a barcode on their wristbands.
In preparation for this Clifton Park NHS Treatment Centre electronically prints
all patient identity bands as per the NPSA ‘Standardising Wrist Bands Alert’
2007
Safer Surgery Checklists – further work was undertaken and the process is
now fully embedded into our operational pathways and monitored through
regular audit to further reduce the risk of wrong site surgery.
Cleanliness – Further infection prevention and control audits were introduced
as planned and these are now being undertaken at all Ramsay sites and action
plans developed locally where necessary to ensure the standards are met.
PEAT (Patient Environment Action Team) audits were also repeated and
Quality Accounts 2010/11
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•
showed an improvement of 3% to achieve 99% compliance, towards the end of
this quality account period a programme of refurbishment was implemented.
More time to care - Improve ward efficiency by adopting the Productive Ward
initiative. The Productive Ward (PW) Project is an NHS Initiative developed by
the Institute for Innovation and Improvement (2008). It focuses on the way ward
teams work together and organise themselves, in order to reduce the burden of
unnecessary activities, and releasing more time to care for patients in a reliable
and safe manner within existing resources. The approach is very much ‘bottom
up’ with all ward staff suggesting ideas and ways in which they could improve
their environment and processes.
The Productive Ward project was successfully piloted at Clifton Park NHS
Treatment Centre during 2010. The main areas of focus were: Effective use of
resource and facilities; Medication rounds; Mealtimes and Communication. The
staff embraced and implemented the changes they identified with commitment
and enthusiasm to enable them to achieve the objective of releasing time for
hands on clinical care, in turn improving the patient experience
2.1.2 Clinical Priorities for 2011/12
Patient Safety
•
Falls - ‘each year around 282,000 patient falls are reported to the National
Patient Safety Agency (NPSA) from hospitals and other health units.’ (Jan
2011, NHS NPSA/20111RRR001). From October 2010 monitoring and
reporting of patient falls has been included in Schedule 3 part 4: Quality
Requirements and Nationally Specified Events as a quality requirement that
Clifton Park are required to report against quarterly to NHS NYY and NHS ERY.
The threshold is 14 falls per year, should the number of falls exceed this then a
remedial action plan would be agreed following which any subsequent breach
would result in 2% of the monthly revenue been withheld until the threshold is
met.
At Clifton Park NHS Treatment Centre a project was undertaken during 2010 to
monitor the number of patient and staff falls, identify the risks and formulate an
action plan to minimize slips/trips and falls. To maximize patient safety all
patients are asked to complete a medical questionnaire which is assessed by
the POA team to identify any potential risks prior to admission. On admission a
“risk of falls assessment” is performed for every patient by the admitting nurse,
this is reviewed daily and care altered accordingly.
Information for patients on how to minimize the risk of falls following
surgery/procedures is displayed in all patient bedrooms. Any slip/trip or fall is
reported through our robust Risk Management Committee and at our quarterly
Quality and Performance meeting. We identify any trends, formulating and
implementing action plans across the hospital to help improve patient safety.
Quality Accounts 2010/11
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Slip/trips/falls recorded/reported
Year
2008/09
2009/10
2010/11
Patient
Falls
14
6
8
Per 1000
admits
4.0
1.7
2.6
Staff
falls
0
1
0
Per 1000
admits
0
0.3
0
The improvement seen since 2008/09 is attributed to the introduction of a
comprehensive action plan focusing on assessment and patient information to
reduce the risk of falling. Focus will once again in 2011/12 be placed on patient
fall reduction as the falls per 1000 admits shows an increase in 2010/11.
VTE risk assessment – Clifton Park NHS Treatment Centre carries out a VTE
risk assessment on all admitted surgical patients as per Ramsay Policy No
CM001 and adhering to National Institute for Clinical Excellence (NICE)
Guidance 2010.
All nursing staff are undergoing VTE competency assessment via DoH on line
assessment tool.
From 1st October 2010, Clifton Park NHS Treatment Centre entered into a
contract for the provision of NHS services through the Commissioning for
Quality & Innovation Payment Framework (CQUIN). Payment is conditional on
achieving quality improvement and innovation goals, this includes VTE risk
assessment. Compliance is audited through a robust corporate and local audit
programme and results/action plans reviewed through Clinical Governance.
VTE compliance results are benchmarked through the National Statistics at
http://www.dh.gov.uk/en/publicationsandstatistics/Publications/Publicatio
nsStatistics/DH
National Joint Registry (NJR) – Clifton Park NHS Treatment Centre
participates in the National Joint Registry audit programme. Patients undergoing
hip or knee replacement surgery are asked to consent to their information being
placed upon the NJR including details of their prosthesis. The NJR provide a
quarterly report to the hospital regarding compliance.
Clifton Park exceeds the national 90% benchmark figure for NJR consent as
demonstrated in the results below, however NJR consent compliance has fallen
in the last 2 quarters an action plan will be developed to address this. As was
previously the case for submission of BMI rate which has increased over the
past year as tabled.
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Clifton Park NHS
Treatment centre
Consent & linkability %
BMI Rate %
2009/10 2010/11 2010/11 2010/11 2010/11
Q4
Q1
Q2
Q3
Q4
100
100
100
99
94
31
75
97
100
99
This information was able to be of assistance in the following Metal on Metal hip
replacement recall. On 22nd April 2010 the Medicines and healthcare products
Regulatory Agency (MHRA) issued a Medical Device Alert Ref MDA/2010/033
relating to all metal-on-metal (MoM) hip replacements. The MHRA had received
reports of revisions of MoM replacements involving soft tissue reactions. Further
guidance was issued by the MHRA on 7th September 2010 ref MDA/2010/069
relating specifically to DePuy ASR hip replacement implants. At Clifton Park
since opening in 2006 347 ASR hip replacement operations had taken place.
The aim at Clifton Park is to ensure 100% of patients who have received a
DePuy ASR MoM hip replacement are followed up as per the guidance. The
guidance in the above Medical Device Alerts has been commenced and update
status is reported at the units Clinical Governance meetings to date 85% of
patients have attended for follow up since this alert was issued.
Further detail on the process and action can be found in section 3.4 CPTC case
study.
Clinical Effectiveness
Better outcomes and improving Patient experience
•
Ambulatory Day care is the admission of selected patients to hospital for a
planned procedure, returning home the same day. It is our aim that 90% of our
day surgery patients are treated in our Ambulatory care facilities.
At present our following day case statistics are:
Knee arthroscopy
Bunion surgery
Dupuytrens
Carpal Tunnel
Overall
= 95%
= 63.6%
= 96.5%
= 99.2%
= 71%
The low % on bunion surgery is due to late surgery combined with another foot
procedure; however this is being addressed as follows:
As part of Ramsay’s National Project for Ambulatory Day Care services, Clifton
Park NHS Treatment Centre has:
•
Appointed an Ambulatory Care lead nurse who is a member of the
British Association of Day care Surgery (BADS).
Quality Accounts 2010/11
Page 13 of 56
•
•
•
Facilitated the ambulatory process by aiming to place day care patients
first on operating lists or as clinically indicated.
Developed an action plan to implement staggered admission times
where appropriate to improve the patient experience, aiming to reduce
the waiting time from admission to procedure.
Further enhanced efficiencies at Clifton Park NHS Treatment Centre by
implementing a nurse led discharge service within our Ambulatory day
care unit.
On discharge, patients are provided with contact details should they have any
post operative problems and receive a post discharge phone call within 48 hrs of
discharge.
Pain control - Patients have the right to care that promotes comfort and
minimizes pain. Ramsay Healthcare set up a committee of experienced
Clinicians to develop guidelines and protocols for pain control following surgery.
A member of Clifton Park Treatment Centre’s clinical team was part of this
committee and we were also a pilot site for the policy implementation.
Taking into account NICE and other best practice guidance, (Australian and New
Zealand College of Anaesthetists and Faculty of Pain Medicine (2020); Nursing
and Midwifery Council (2007) Standards for Medicine Management) the following
were introduced.
A policy on “Acute post-operative pain management in Adults”; a pain
assessment tool, and a patient information leaflet “Managing your Pain after your
operation” supported by a full training programme for relevant staff to be
completed by end of June 2011
Patient experience – informing patient choice
•
Patient Satisfaction survey - Improved patient information
It was recognised from our patient satisfaction survey results, that our patients
were not always receiving written information about their proposed surgery. We
do have a very comprehensive “Eido” information library; however it does not
cover some of the more complex procedures undertaken by our Consultants. We
are now in the process of creating further patient information leaflets in
partnership with our Consultants. This is important as, even though the
Consultants discuss the procedure in depth during the consultation, written
information ensures that the patients have something to refer to should they need
to at a later date.
Quality Accounts 2010/11
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Written information about proposed treatment before admission
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
92.90%
90.80%
Q4 2010
Q1 2011
40.00%
30.00%
20.00%
10.00%
0.00%
•
Increasing the use of Patient Reported Outcomes Studies (PROMs) – Clifton
Park NHS Treatment Centre uses the National PROMS results for hip and knee
replacements. These are used to gain a better understanding of treatment
outcomes from a patient point of view. Results are shared with Consultants at our
Clinical Governance meetings. All members of the multi-disciplinary team are
encouraged to review the PROMs outcomes and changes made as required to
improve the patient experience.
Compliance rate of submitting completed consented forms:
Hips
Knees
76.3%% (Nationally 79.6%)
79.5%% (Nationally 81.9%)
Clifton Park Treatment Centre was also a POIS pilot site and, until recently, ran
the Oxford Hip and Knee Score Audit, through The Leadership Factor, collating
five years of outcome data.
Quality Accounts 2010/11
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Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2010/11 Clifton Park NHS Treatment Centre provided Elective Orthopaedic
NHS services.
Clifton Park NHS Treatment Centre continually reviews all the data available to them
on the quality of care provided.
The income generated by the NHS services reviewed from 1 April 2010 to 31 March
2011 represents 95% per cent of the total income generated from the provision of
NHS services by Clifton Park NHS Treatment Centre from 1 April 2010 to 31 March
2011.
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 Managers. 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 2010/11, the indicators on the scorecard which affect patient safety
and quality were:
Human Resources
•
•
•
•
•
•
•
•
HCA Hours as a % of Total Nursing hours is 21.2%
Agency Hours as % of Total Hours is 0.7%
7.9% Staff Turnover
2.97% Sickness
Mandatory Training = 85% completed in last 12 months
Number of Significant Staff Injuries = 0
Appraisals = 85% completed in last 12 months
Staff Satisfaction Score = 2009 92.1% and 2010 96.7%
Ramsay undertakes an annual staff satisfaction survey known as the PULSE survey.
Following this survey a local hospital team is formed and an action plan developed to
improve staff satisfaction.
Quality Accounts 2010/11
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The graphs below show the increases in staff satisfaction from 2009 to 2010.
I enjoy my work 2010
I enjoy my work 2009
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I have clear goals and objectives 2010
I have clear goals and objectives 2009
In addition to this survey in 2010, Clifton Park NHS Treatment Centre participated in
the Healthcare 100 awards. The awards, researched by Ipsos MORI on behalf of
HSJ and Nursing Times, and supported by the Department of Health and NHS
Employers, is based on the results of an exclusive poll of the employees of
registering organisations. Open to both NHS and independent healthcare providers
in the acute, primary care, mental health and ambulance sectors, the winners and
representatives of all those included in the top 100 list celebrated at a special Awards
evening held at the London Hilton on Park Lane on Wednesday, July 7, 2010. Clifton
Park NHS Treatment Centre was included in the top 100 list.
Quality Accounts 2010/11
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Patients
19 x Formal complaints 1st April 2010 to 31st March 2011 = 0.6%
93.7% Patient Satisfaction Score
0 significant reportable patients during 2010 = 0.0%.
9 Readmissions patients in 2010 = 3 readmissions per 1000 Admissions
0 EMSA (Eliminating Mixed Sex Accommodation) breaches
Quality
A comprehensive Health, Safety and Facilities audit is carried out annually. This
internal audit returned a score of 86% compliance and an action plan has been
developed to correct the key areas identified.
A Disability Discrimination Act audit was carried out in March 2011.
Our overall Infection Control Audit score is 98%.
2.2.2 Participation in Clinical Audit
During 1 April 2010 to 31 March 2011, five national clinical audits and National
Confidential Enquiries covered NHS services that Clifton Park NHS Treatment Centre
provides.
The national clinical audits and national confidential enquiries that
Clifton Park NHS Treatment Centre was eligible to participate in during 1 April 2010
to 31March 2011 are as follows: National Clinical Audits and National Confidential Enquiries (NA = not
applicable to the services provided)
Name of Audit
Participation
(NA, Yes, No)
% cases
submitted
Peri- and Neonatal
Children
Paediatric pneumonia (British Thoracic Society)
Paediatric asthma (British Thoracic Society)
Paediatric fever (College of Emergency Medicine)
Childhood epilepsy (RCPH National Childhood Epilepsy Audit)
Paediatric intensive care (PICANet)
Paediatric cardiac surgery (NICOR Congenital Heart Disease
Audit)
Diabetes (RCPH National Paediatric Diabetes Audit)
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Acute care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic
Society)
Non invasive ventilation (NIV) - adults (British Thoracic
Society)
NA
NA
NA
NA
NA
NA
Quality Accounts 2010/11
Page 19 of 56
Pleural procedures (British Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
Vital signs in majors (College of Emergency Medicine)
Adult critical care (Case Mix Programme)
Potential donor audit (NHS Blood & Transplant)
NA
NA
YES
O%
NA
NA
NA
NA
NA
NA
Long term conditions
Diabetes (National Adult Diabetes Audit)
Heavy menstrual bleeding (RCOG National Audit of HMB)
Chronic pain (National Pain Audit)
Ulcerative colitis & Crohn’s disease (National IBD Audit)
Parkinson’s disease (National Parkinson’s Audit)
COPD (British Thoracic Society/European Audit)
Adult asthma (British Thoracic Society)
Bronchiectasis (British Thoracic Society)
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
YES
YES
100%
100%
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Cardiothoracic transplantation (NHSBT UK Transplant
Registry)
Liver transplantation (NHSBT UK Transplant Registry)
Coronary angioplasty (NICOR Adult cardiac interventions
audit)
Peripheral vascular surgery (VSGBI Vascular Surgery
Database)
Carotid interventions (Carotid Intervention Audit)
CABG and valvular surgery (Adult cardiac surgery audit)
Cardiovascular disease
Familial hypercholesterolaemia (National Clinical Audit of Mgt
of FH)
Acute Myocardial Infarction & other ACS (MINAP)
Heart failure (Heart Failure Audit)
Pulmonary hypertension (Pulmonary Hypertension Audit)
Acute stroke (SINAP)
Stroke care (National Sentinel Stroke Audit)
Renal disease
Renal replacement therapy (Renal Registry)
Renal transplantation (NHSBT UK Transplant Registry)
Patient transport (National Kidney Care Audit)
Renal colic (College of Emergency Medicine)
Cancer
Lung cancer (National Lung Cancer Audit)
Bowel cancer (National Bowel Cancer Audit Programme)
Head & neck cancer (DAHNO)
Trauma
Hip fracture (National Hip Fracture Database)
Severe trauma (Trauma Audit & Research Network)
Quality Accounts 2010/11
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Falls and non-hip fractures (National Falls & Bone Health
Audit)
NA
Psychological conditions
NA activity
Blood transfusion
O neg blood use (National Comparative Audit of Blood
Transfusion)
Platelet use (National Comparative Audit of Blood Transfusion)
NA
NA
NA
NA
YES
YES
100%
N/A
Additional Audits
National Surveillance Programme (HPA)
PEAT
NA
The reports of five national clinical audits from 1 April 2010 to 31 March 2011 were
reviewed by the Clinical Governance Committee at Clifton Park NHS Treatment
Centre.
Local Audits
Clifton Park NHS Treatment Centre participates in the Ramsay Corporate Audit
programme (the schedule can be found in appendix 2) all of which go through the
Clinical Governance Committee and actions taken recorded to improve the quality of
the healthcare provided:The following actions were indicated by the outcomes of the following audits that fell
below 90%
•
•
•
Pharmacy Audit 87% compliance – fridge temperatures were not always reset,
therefore further training was given and instructions placed on fridge doors (to
re-audit May 2011).
Peripheral Intravenous Cannula Care Bundle 88% compliance – Not all
Anesthetists wear gloves for cannulating – discussed with head of Anesthetics
at Clinical Governance and to re-audit to assess compliance.
Prescribing 88% - Drug omissions not always recorded with a code and Clinical
reasons for omission not always documented. Discussed with nursing team and
for further audit in May 2011.
2.2.3 Participation in Research
Corporate Clinical Governance granted permission for Clifton Park NHS Treatment
Centre to participate into Ethics Committee Approved research of “Clinical Evaluation
of Deep Dish Rotating Platform”. However no patients have been entered into the
trial to date.
Quality Accounts 2010/11
Page 21 of 56
We also obtain consent from patients to donate bone samples to York University to
aid their research into osteoporosis this has been approved by research ethics
committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Clifton Park’s income from 1 April 2010 to 31st March 2011 (1st
October 2010 – 31st March 2011) was conditional on achieving quality improvement
and innovation goals through the Commissioning for Quality and Innovation payment
framework.
See Appendix 2 for our Schedule.
2.2.5 Statement from the Care Quality Commission (CQC)
Clifton Park NHS Treatment Centre is required to register with the Care Quality
Commission and its current registration status on 31st March is registered without
conditions
The Care Quality Commission has not taken enforcement action against Clifton Park
NHS Treatment Centre during 2010/11.
Clifton Park NHS Treatment Centre has not participated in any special reviews or
investigations by the CQC during the reporting period.
2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your Data
Quality
Data Quality is taken very seriously at Clifton Park NHS Treatment Centre. The
quality of our data, whether this is in the form of local audits, paper records, or data
submitted to the DoH or PCTs, reflects directly on the quality of the services provided
at the hospital.
As part of our Standard Acute Contract, we are required to demonstrate that we
monitor and improve data, to support care quality. This is undertaken through our
Clinical Audit programme, part of our audit programme covers medical records and
anaesthetic records audits ensuring that key information is recorded throughout the
patient journey. The actions required for each audit are documented and discussed
at various hospital committee meetings
Quality Accounts 2010/11
Page 22 of 56
Audit results for anaesthetic records:
Audit
Anaesthetic records
Feb 2010
93%
Aug 2010
99%
Audit results for medical records audit:
.
Audit
April 2010 July 2010
Medical records audit
100%
99%
Feb 2011
98%
Sept 2010
100%
Feb 2011
99%
Secondary Uses Service (SUS) submissions - Since the commencement of the
Standard Acute Contract, Clifton Park’s SUS submissions have been improving
month-on-month. Over the entire period of the SAC, submissions were running at
99.4%. However, for the last three months of the 2010/2011 financial year, Clifton
Park’s submissions were 100%. This is directly attributable to the hospital’s
dedicated data quality team who work alongside all departments in the hospital to
ensure that all data is entered correctly and also the suite of reporting tools available
through Ramsay’s corporate IS team.
NHS Number and General Medical Practice Code Validity
Clifton Park NHS Treatment Centre submitted records during 2010/11 to the
Secondary Uses service for inclusion in the Hospital Episode Statistics which are
included in the latest published data. The percentage of records in the published data
which included:
The patient’s valid NHS number was:
100% for admitted patient care;
100% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was:
99.9% for admitted patient care;
99.7% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
Quality Accounts 2010/11
Page 23 of 56
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report overall score for
2010/11 was 79% and was graded ‘green’ (satisfactory).
Clinical coding error rate
Clifton Park NHS Treatment Centre was subject to the Payment by Results clinical
coding audit during 2010/11 carried out by the Audit Commission.
The following two paragraphs are quoted directly from the final Audit document,
which explains the variance between what was audited and what was actually
required of the Treatment Centre by the GC4 contract the hospital was working to.
Relevant passages are highlighted.
1
Our audit is undertaken using the HRG4 grouper. Activity at Clifton
Park was under the GC4 contract until September 2010 which is
reported and billed under HRGv3.5. If we grouped this activity
using HRGv3.5 the HRG error rate would have been 3 per cent –
which would place the provider in the best performing 20 per
cent of Trusts using the 2009/10 audits.
2
However, for the purpose of this audit we group the financial
outcome of any errors in HRG 4. This is consistent across all
independent sector providers audited this year and makes no
reference to any locally or nationally agreed prices with the providers.
% Primary
Diagnosis
Incorrect
17
% Secondary
Diagnosis
Incorrect
29.7
% Primary
Procedures
Incorrect
47
% Secondary
Procedures
Incorrect
5.6
Clifton Park NHS Treatment Centre employs a Clinical Coder who has undertaken
the Connecting for Health Clinical Coding Foundation Course in 2011 and is
responsible for all diagnostic and procedure coding and is actively involved in audit
processes. All areas for improvement identified as part of the audit are now
completed. NHS North Yorkshire and York were present at the audit feedback and
were supportive of our action plan.
Quality Accounts 2010/11
Page 24 of 56
2.2.7 Stakeholders views on 2010/11 Quality Account
Copies of this quality account for comment prior to publication have been sent to:
Involvement Network (LINk),
Overview and Scrutiny Committee (OSC)
Lead commissioning primary care trust (PCT)
Comments received are published below.
CLIFTON PARK NHS TREATMENT CENTRE
QUALITY ACCOUNT STATEMENT 2011
NHS North Yorkshire and York is the lead Commissioner for Clifton Park NHS Treatment Centre and
we are pleased to be able to review and comment on their Quality Account for 2010/11 in conjunction
with our Associate Commissioner, NHS East Riding of Yorkshire.
Over the past 12 months we have worked together as Commissioners and Providers to improve the
quality of orthopaedic health care services for the residents of York and the East Riding. Through the
contract management process the Clifton Park NHS Treatment Centre has provided assurance to us
as Commissioners by sharing a breadth of data and quality metrics which have assured us of the
quality of patient services.
The Quality Account for Clifton Park NHS Treatment Centre provides an accurate and honest account
of the quality of patient care provided. We are especially pleased to note the following
achievements:• 93.7% Patient Satisfaction Score - Clifton Park NHS Treatment centre consistently achieves
high patient satisfaction scores and, by studying the results, constantly seek ways to further
improve the patient experience.
• Nil EMSA (Eliminating Mixed Sex Accommodation) breaches.
• Excellent results for data quality for anaesthetic and medical records audit
• Clifton Park NHS Treatment Centre was included in the top 100 list for the Healthcare 100
awards.
• Strengthening links with GP groups – the Chair of York Health Group is a member of the
Contract Management Board
The priorities detailed in the Quality Account for 2011/12 clearly identify the three elements of quality
i.e. patient safety, clinical effectiveness and patient experience and have a real synergy with what we
are seeking to achieve across the whole of NHS North Yorkshire and York. Clifton Park NHS
Treatment Centre has identified the following priorities for 2011/12:• Bar coding for patient identify bands
• Safer Surgery Checklists
• Cleanliness – infection prevention and control audits
• More time to Care – adopting the Productive Ward initiative
• Falls – on admission a ‘risk of falls assessment’ is performed for every patient.
• VTE risk assessment is carried out on all admitted surgical patients.
• Pain Control – patients have the right to care that promotes comfort and minimizes pain.
• Patient Satisfaction Survey – improved patient information
As a commissioner we commend this Quality Account for its accuracy, honesty, and openness in its
performance assessment. We recognise that Clifton Park NHS Treatment Centre is a top performing
trust, and we would like to congratulate them on their many quality achievements in 2010/11 and look
forward to working collaboratively with the organisation in 2011/12.
Bill Redlin
Director of Standards
NHS North Yorkshire and York
Quality Accounts 2010/11
Page 25 of 56
Part 3
Statements of quality delivery
Matron, Gwenn Mather
3.0 Review of quality performance 1 April 2010 - 31 March
2011
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.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2011
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:
Quality Accounts 2010/11
Page 26 of 56
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
The Matron at Clifton Park NHS Treatment Centre actively promotes clinical
governance and collaborates with NHS partners to ensure that Clifton Park NHS
Treatment Centre is informed of relevant initiatives to continually improve the safety
and excellence of the services offered. Matron attends a number of district meetings
to nurture relationships with key stakeholders/NHS/PCTs these include – Quality
Performance Group, Deprivation of Liberty Group; Local Intelligence Network for
Controlled Drugs group.
Quality Accounts 2010/11
Page 27 of 56
NICE / NPSA 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 National Patient Safety Agency (NPSA).
Clifton Park NHS Treatment Centre 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 Patient safety
Clifton Park NHS Treatment Centre is a progressive hospital focussed on improving
its performance every year, particularly with regard to 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 demonstrated below: -
3.1.1 Infection prevention and control
Clifton Park NHS Treatment Centre has a very low rate of hospital acquired
infection and has had no reported MRSA Bacteraemia in the past 5 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia, Clostridium difficile and E coli infections with a programme to reduce
incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and Clifton Park NHS Treatment Centre remains below the
lowest percentile for infection rates.
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.
Clifton Park NHS Treatment Centre has its own Infection Control Link Nurse and
IPCC is included in our Clinical Governance agenda.
Quality Accounts 2010/11
Page 28 of 56
Programmes and activities within our hospital include:
All staff undertake mandatory annual infection prevention and control training.
Infection Control Audit
In–house training i.e. hand washing
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 and as can be seen from the bar chart below
Clifton Park Treatment Centre has had a low HCAI rate annually for the past 2
years and is well below the National Average of 28%.
1.2
0.6%
1
0.5%
0.8
0.4%
0.6
0.3%
0.4
0.2%
0.2
0.1%
0
Jan
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
0
0
1
0
0
0
1
0
0
0
0
0.0%
0.0%
0.0%
0.4%
0.0%
0.0%
0.0%
0.5%
0.0%
0.0%
0.0%
0.0%
HAI's Number
HAI's Rate
Feb
Rate
Number
Hospital Acquired Infections 2009
0.0%
Hospital Acquired Infections 2010
0.5%
1.2
0.4%
1
0.4%
0.8
0.3%
0.3%
Rate
Number
•
•
•
•
0.6
0.2%
0.4
0.2%
0.1%
0.2
0
HAI's Number
HAI's Rate
0.1%
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
0
0
0
0
0
0
0
0
0
0
1
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.4%
0.0%
Quality Accounts 2010/11
Page 29 of 56
3.1.2 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.
The graph below shows our PEAT scores over the last 3 years. The latest result
indicates improved scoring following the implementation of the redecorating
programme demonstrating the improvement to the hospital environment.
PEAT Audit results 2009 - 2011
100
99
99
98
97
96
96
95
95
94
93
2009
2010
2011
3.1.3 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. Staff at Clifton Park NHS Treatment Centre
have a high awareness of safety which 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 as soon as received 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 Managers who ensure
we keep up to date with all safety issues.
Adverse Incidents and near misses reported at Clifton Park Treatment Centre:
•
•
•
2009 = 8.6 per 1000 admits
2010 = 14.5 per 1000 admits
2011 = 12.5 per 1000 admits (to March 31st)
Quality Accounts 2010/11
Page 30 of 56
The incidents reported include patients, visitors, staff and sub-contractors who utilise
and access the Treatment Centre. The above figures indicate that we encourage the
reporting of all incidents no matter how minor, reflecting a raised awareness of the
importance of safety in the workplace.
3.2 Clinical effectiveness
Clifton Park NHS Treatment Centre has a Clinical Governance team and committee
that meet regularly through the year to monitor quality and effectiveness of care. Key
performance indicators, clinical incidents and complaints, patient and staff feedback,
training and development and infection control 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.
3.2.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or
specific surgical team. Ramsay’s rate of return is very low consistent with our track
record of successful clinical outcomes.
1
Number
0.8
0.6
0.4
0.2
0
Unplanned Return to Theatre Number
Unplanned Return to Theatre Rate
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
0
0
0
0
0
0
0
0
0
0
0
100.0%
90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
Rate
Unplanned Returns to Theatre 2009
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Quality Accounts 2010/11
Page 31 of 56
Unplanned Returns to Theatre 2010
1.2
0.8%
0.7%
1
0.6%
0.5%
Rate
Number
0.8
0.6
0.4%
0.3%
0.4
0.2%
0.2
0.1%
0
Jan
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
1
0
0
0
0
0
1
0
0
0
0
0.0%
0.3%
0.0%
0.0%
0.0%
0.0%
0.0%
0.7%
0.0%
0.0%
0.0%
0.0%
Unplanned Return to Theatre Number
Unplanned Return to Theatre Rate
Feb
0.0%
As can be seen in the above graphs our returns to theatre rate remains very low.
These figures are constantly monitored throughout the year via our clinical
governance and medical advisory committee framework.
3.2.2 Readmission to hospital
Monitoring rates of re-admission 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.
1.2%
2
1.0%
0.8%
1.5
0.6%
1
0.4%
0.5
0
Unplanned Re-admissions Number
Unplanned Re-admissions Rate
Rate
Number
Unplanned Re-admissions 2009
2.5
0.2%
Jan
Feb
Mar
Apr
May
1
2
1
1
1
0.4% 0.9% 0.3% 0.4% 0.3%
Jun
Jul
Aug
Sep
Oct
Nov
0
0
2
1
1
0
0.0% 0.0% 1.0% 0.3% 0.4% 0.0%
Dec
0.0%
0
0.0%
Quality Accounts 2010/11
Page 32 of 56
Unplanned Re-admissions 2010
3.5
1.2%
3
1.0%
0.8%
2
Rate
Number
2.5
0.6%
1.5
0.4%
1
0.2%
0.5
0
Unplanned Re-admissions Number
Unplanned Re-admissions Rate
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2
3
0
0
1
1
1
0
0
0
0
0
0.7%
1.0%
0.0%
0.0%
0.3%
0.3%
0.4%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
As can be seen in the above graphs our readmission to hospital rate has changed
little over the last 2 years. These figures are constantly monitored throughout the
year via our clinical governance and medical advisory committee framework.
3.3 Patient experience
All feedback from patients regarding their experiences at Clifton Park NHS Treatment
Centre 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 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.
Patient experiences are fed back 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 DoH bodies occurs as required and according to Ramsay and DoH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Patient satisfaction surveys
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Quality Accounts 2010/11
Page 33 of 56
Written feedback via letters/emails
PROMs surveys
Care pathways – patients are encouraged to read and participate in their plan of
care.
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called
‘The Leadership Factor‘(TLF). They print and supply a set number of questionnaire
packs to our hospital each quarter which contain a self addressed envelope
addressed directly to TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also
separately for NHS and private patients). The results are available for patients to
view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel they
receive excellent quality of care and service in Clifton Park NHS Treatment Centre.
To record a satisfaction index over 92%, a very high proportion of our patients have
scored 9 or 10 out of 10 for their satisfaction with all the requirements. This is
underlined by comparing our hospitals 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%.
Patient Satisfaction Levels Q4 2011 v Q1 2011
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
95.60%
93.70%
Q4 2010
Q1 2011
40.00%
30.00%
20.00%
10.00%
0.00%
As can be seen in the above graph our Patient Satisfaction rate decreased from
95.6% in Q4 of 2010 Oct – Dec to 93.7% in Q1 of 2011 Jan - Mar. Clifton Park NHS
Treatment Centre rates in the top 2-3% of organisations.
From the patient satisfaction survey it is possible to identify both areas for
improvement as well as areas where we excel. Following the publication and
communication of the results an action plan is developed.
Quality Accounts 2010/11
Page 34 of 56
Examples of areas for improvement:
Enough explanation of medicines given before discharge
100%
90%
80%
70%
60%
50%
95%
90.60%
40%
30%
20%
10%
0%
Q4 2010
Q1 2011
Despite being previously identified as an area for improvement this result shows a
decline.
Action to be taken includes additional written information regarding possible side
effects to be provided to all patients. An explanation of medication given is to be
added to our discharge checklist.
Satisfaction with cleanliness
100%
90%
80%
70%
60%
50%
100%
96.90%
Q4 2010
Q1 2011
40%
30%
20%
10%
0%
Although the last results show a high score this has declined from the previous
quarter.
Action: Support Services Manager undertaking review with housekeeping team to
identify possible reason for lower result.
Quality Accounts 2010/11
Page 35 of 56
3.3.2 Patient Reported Outcome Measures (PROMs)
Clifton Park NHS Treatment Centre participates in the Department of Health’s
PROMs surveys for hip and knee surgery for NHS and Private patients.
The graph below shows the PROMs data for NHS patients from May 2009 to April
2011.
Hip replacement patients
Participation, linkage and return rates Clifton Park NHS
Treatment Centre
HES episodes
632
Pre-operative questionnaires
482
Participation rate
76.3%
Linked questionnaires
331
Linkage rate
68.7%
Post-operative questionnaires sent
356
Issue rate
73.9%
Post-operative questionnaires returned
304
Response rate
85.4%
National
113,968
90,711
79.6%
65,629
72.3%
67,631
74.6%
53,957
79.8%
Hip Replacement - Oxford Hip Score - Adjusted Health Gain
22
21.5
21
20.5
20
19.5
19
18.5
18
17.5
17
CLIFTON PARK NHS
TREATMENT CENTRE
National
National
Quality Accounts 2010/11
Page 36 of 56
Knee Replacement Patients
Participation, linkage and return rates Clifton Park NHS
Treatment Centre
HES episodes
755
Pre-operative questionnaires
600
Participation rate
79.5%
Linked questionnaires
407
Linkage rate
67.8%
Post-operative questionnaires sent
457
Issue rate
77.8%
Post-operative questionnaires returned
390
Response rate
83.5%
National
127,982
104,853
81.9%
70,667
67.4%
77,304
73.7%
61,999
79.2%
Knee Replacement - Oxford Knee Score - Adjusted Health Gain
20
18
16
14
12
10
8
6
4
2
0
CLIFTON PARK NHS TREATMENT
CENTRE
National
National
Access to Clifton Park NHS Treatment Centre and Ramsay’s PROMs results can be
found at the following website:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&category
Quality Accounts 2010/11
Page 37 of 56
3.4 Clifton Park NHS Treatment Centre
Case Study
The Depuy ASR metal on metal hip replacement recall process
Background
On 22nd April 2010 the Medicines and Healthcare products Regulatory Agency
(MHRA) issued a Medical Device Alert (Ref MDA/2010/033) relating to all metal-onmetal (MoM) hip replacements. The MHRA had received reports of revisions of MoM
replacements involving soft tissue reactions, and that these reactions may be
associated with unexplained hip pain.
Following the guidance issued on 22nd April, Clifton Park ceased using the DePuy
ASR implant and MoM hip replacement surgery was only undertaken where it was
deemed clinically necessary by the Consultant.
Further guidance was issued on 25th May 2010 (Ref MDA/2010/044) regarding
DePuy ASR acetabular cups used in hip resurfacing arthroplasty and total hip
replacement. The problem was identified as having received higher than anticipated
rates of revision for ASR acetabular cups. These initial alerts stated that the action
which needed to be taken was to put systems in place for follow up of patients
implanted with MoM hip replacements including, where appropriate, blood metal ion
measurements and cross sectional imaging.
Initial Actions
•
•
•
•
•
Following this guidance Clifton Park stopped using the DePuy ASR implant and
MoM hip replacement surgery was only undertaken where it was deemed
clinically necessary by the Consultant.
The National Joint Registry (NJR), where details of all hip replacement surgery
and prosthesis used are recorded, was contacted.
The NJR were able to provide a spreadsheet detailing all MoM implants that
had been used since Clifton Park opened in January 2006.
These patients were then sent individual letters providing information regarding
the medical device alert produced by DePuy (prosthesis manufacturer) and
also information produced by the British Hip Society.
A follow up was not routinely booked unless the patient had not attended follow
up in the previous 12 months. However, the patients were asked to contact the
Treatment Centre directly if they had any concerns.
Quality Accounts 2010/11
Page 38 of 56
Further guidance was issued by the MHRA on 7th September 2010 (Ref MDA/2010/
069) relating specifically to DePuy ASR hip replacement implants. The action
required was: not to implant the DePuy ASR hip replacements; return all used
implants to the manufacturer; inform all patients with the implanted ASR hip about
this recall and schedule a follow up visit.
Further actions
Following this alert Clifton Park then contacted all patients who had not been in for
review since the previous MHRA notice and booked a follow up appointment. All
patients who attended their follow up were booked a Consultant appointment and xrays, cobalt and chromium ion blood tests were undertaken.
•
•
•
If the patients’ blood tests were raised, but they had no symptoms, then an
appointment was made to repeat these tests in 3 months’ time.
If the patients’ blood tests were raised, and they were symptomatic, then further
investigations were ordered i.e. MRI and/or ultrasound.
If blood levels and x-rays were asymptomatic, then further follow up was
booked for 1 year.
The majority of patients who received the DePuy ASR implant at Clifton Park were
funded by the NHS. The funding for these additional follow up appointments,
pathology and imaging is claimed from DePuy via their appointed solicitors
Broadspire.
Update
At Clifton Park, since opening in 2006, 347 ASR hip replacement operations had
taken place. The aim at Clifton Park is to ensure 100% of patients who have
received a DePuy ASR MoM hip replacement are followed up as per the MHRA
guidance. The guidance in the above Medical Device Alerts has been implemented
and update status is reported at the unit’s Clinical Governance meetings. To date
85% of patients have attended for follow up since this alert was issued.
Quality Accounts 2010/11
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Appendix 1 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2010/11
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Appendix 2 – CQUIN Schedule
Goals and Indicators National and Regional
Goal
no.
Description of goal
Quality
Domain(s)
Indicator
number
Indicator name
National or
Regional
indicator
1
Reduce avoidable death,
disability and chronic ill
health from Venousthromboembolism (VTE)
Safety
1
VTE risk
assessment
Nationally
mandated
2
Improve responsiveness to
personal needs of patients
Patient
Experience
2
Composite indicator
on responsiveness
to personal needs
from the Adult
Inpatient Survey
Nationally
mandated
3
Reduction in post operative
infection rates, reduce use of
unnecessary antibiotics,
lower rates of Venus
Thrombosis
Patient
Safety
3
Hip and knee
replacement best
practice bundle
Regional
Improve the focus on the
care of the patients, in line
with Essence of Care. Use of
validated nutritional indicator
screening tool will be
encouraged to reduce rates
of malnutrition and
associated adverse
outcomes
Patient
Safety
4
Care and
Compassion –
Nutritional
screening
Regional
Improvement in pressure
ulcer prevention and
management in line with
essence of care
Patient
Safety
5
Care and
Compassion –
Improvement of
Pressure Ulcers
Regional
4
5
Effectiveness
Patient
Experience
Indicator
weighting
Effectiveness
Patient
Experience
Effectiveness
Quality Accounts 2010/11
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Goals and Indicators Local
Goal
no.
Description of goal
Quality
Domain(s)
Indicator
number
Indicator name
National or
Regional
indicator
6
Protection from infection
Patient
Safety
6
To reduce % of
number of hospital
acquired UTI’s from
indwelling
catherisation.
Local
7
Improve the
identification of
deterioration in
condition
Local
Patient
Experience
Indicator
weighting
Clinical
Effectiveness
7
Reduce the degree of harm
through improved
identification and response
to a deterioration in condition
Patient
Safety
Patient
Experience
Improve the
response to
identified
deterioration in
condition
Clinical
Effectiveness
To reduce % of
number of crash
calls
To increase
number of rapid
response calls per
month
To increase the %
of patients who
triggered that
received an
appropriate
response
8
Secure safe, high quality, coordinated care focused on
hospital discharge
arrangements
Patient
Safety
Patient
Experience
Clinical
Effectiveness
8
Help to ensure safe
discharge
procedures and any
unnecessary delays
in discharge or
potential grounds
for re-admission
Local
Quality Accounts 2010/11
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Detail of Indicator (to be completed for each indicator)
Indicator 1 – VTE risk assessment
% of all adult inpatients who have had a VTE risk assessment on admission
to hospital using the national tool
Description of indicator
Numerator
Number of adult inpatient admissions reported as having had a VTE risk
assessment on admission to hospital using the national tool
Denominator
Number of adults who were admitted as inpatients (includes day cases,
maternity and transfers; both elective and non-elective admissions)
VTE is a significant patient safety issue, however outcome data on VTE is
poor – post mortem studies suggest that only 1-2 in every 10 fatal pulmonary
emboli is diagnosed. Whilst work is underway to improve reliability of
outcome data, the process measure of VTE risk assessment will set an
effective foundation for appropriate prophylaxis. This gives the potential to
save thousands of lives each year.
Rationale for inclusion
Data source
collection
Organisation
collection
and
frequency
responsible
Frequency
of
Commissioner
of
Monthly return through Unify
for
data
Provider
reporting
to
Monthly
Baseline period / date
Quarter 1
Baseline value
Final indicator period / date (on which
payment is based)
Quarter 4
Final indicator
threshold)
90% achievement required
value
Final indicator reporting date
(payment
0.15% of National 0.3%
Quarter 4
Indicator 2 – Composite indicator on responsiveness to personal needs
Quality Accounts 2010/11
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The indicator will be a composite, calculated from 5 survey questions.
Each describes a different element
“responsiveness to personal needs :
of
the
overarching
theme:
Description of indicator
• Involved in decisions about treatment/care
• Hospital staff available to talk about worries/concerns
• Privacy when discussing condition/treatment
• Informed about medication side effects
• Informed who to contact if worried about condition after leaving hospital
Numerator
Index-based score reflecting positive responses to the 5 questions within the
composite indicator
Denominator
N/A
Rationale for inclusion
The indicator incorporates questions which are known to be important to
patients and where past data indicates significant room for improvement
across England.
Data source
collection
Organisation
collection
and
frequency
responsible
Frequency
of
Commissioner
of
for
data
reporting
to
Adult inpatient survey, from the CQC nationally coordinated patient survey
programme. The survey is conducted annually between October and
January for patients who had an inpatient episode between July and August.
Provider
Annually:
1) Early local data (mid-January 2011)
2) Published data. (April-May 2011)
Baseline period / date
Adult inpatient survey 20010/11 (based on inpatient episodes between
October and March 2011)
Baseline value
To be confirmed
Final indicator period / date (on which
payment is based)
Adult inpatient survey 2010/11 (based on inpatient episodes between July
and August 2010)
Final indicator
threshold)
To be agreed
value
(payment
Final indicator reporting date
To be confirmed
Detail of Indicator 3 – Hip and Knee
Description of indicator
Hip and knee replacement best practice bundle
Quality Accounts 2010/11
Page 44 of 56
Denominator 1
Total number of hip or knee replacements carried out in the quarter
(If sampling has been used for this indicator then provide details of how a
random sample has been taken to provide representative data for hip or
knee replacement patients)
Denominator 2
Denominator 2 is the size of random sample of (Denominator 1) taken
during the quarter. (if sampling has not been used Denominator 2 =
Denominator 1)
Numerator 1
Number of these (Denominator 2) receiving prophylactic antibiotic within 1
hour prior to surgical incision (Measure 45)
Numerator 2
Total number of (Denominator 2) excluded from Measure 45
Numerator 3
Number of (Denominator 2) where Measure 45 is not known and patient
not excluded
Numerator 4
Number of these (Denominator 2) where prophylactic antibiotics are
discontinued within 24 Hours after surgery end time (Measure 47)
Numerator 5
Number of (Denominator 2) excluded from Measure 47
Numerator 6
Number of (Denominator 2) where Measure 47 is not known and patient
not excluded
Numerator 7
Number of these (Denominator 2) who received appropriate venous
thromboembolism prophylaxis within 24 hours prior to surgery to 24 hours
after surgery (Measure 49)
Numerator 8
Number of (Denominator 2) excluded from Measure 49
Numerator 9
Number of (Denominator 2) where Measure 49 is not known and patient
not excluded
Rationale for inclusion
Reduced postoperative infection rates, reduce use of unnecessary
antibiotics, lower rates of Venous Thromboembolism
Data source and frequency of
collection
Provider Quarterly returns
Organisation responsible for data
collection
Provider
Frequency of reporting to
commissioner
At end of each quarter
Baseline period / date
2009/10 outturn
Baseline value
Quality Accounts 2010/11
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Final indicator period / date (on which
payment is based)
Quarter 4
Final indicator value (payment
threshold)
0.042 of the Regional 0.5%
Final indicator reporting date
Quarter 4
Rules for partial achievement of
indicator at year-end
Rules for any agreed in-year
milestones that result in payment
Trusts are expected to have at least 95% compliance with all elements of
the best practice bundle to achieve payment
Rules for delayed achievement
against final indicator period/date
and/or in-year milestones
Detail of Indicator 4 – Nutrition
Description of indicator
Care and Compassion – Nutritional
Denominator 1
By ward and by age band 18-64 and 65+: The number of patients admitted
and remaining for more than 48 hours during the quarter
Numerator 1
(i) By ward and by age band 18-64 and 65+: The number of admitted
patients who underwent nutritional screening at admission
(ii)By ward and by age band 18-64 and 65+: The number of patients (of
Numerator 1) where appropriate action was followed, in accordance with
essence of care, after screening
Denominator 2
By ward and by age band 18-64 and 65+: The number of patients
discharged during the quarter
Numerator 2
(i) By ward and by age band 18-64 and 65+: The number of patients
undergoing nutritional screening prior to discharge
(ii) By ward and by age band 18-64 and 65+: The number of admitted
patients (of Numerator 2i) who were at ‘High’* nutritional risk at discharge
(iii) By ward and by age band 18-64 and 65+: The number of patients
assessed as ‘high’ nutritional risk with appropriate referrals/continuing care
plans in place
Numerator 3
Delivery of essence of care Action plan to be agreed by commissioner
Trust to ensure that there is an action plan in place which demonstrates
how the following indicators will be met to best practice standards in
“Essence of Care”pp51-64 DH June 2009
Quality Accounts 2010/11
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1. Screening and
assessment
2. Planning,
implementation,
evaluation and
revision of care
3. Monitoring
4. Environment
5. Assistance
People receive the care and assistance they
require with eating and drinking
6. Information
People and carers have sufficient information to
enable them to obtain their food and drink
People are provided with food and drink that
meets their individual needs and preferences
7. Provision
Rationale for inclusion
People who are screened on initial contact and
identified at risk receive a full nutritional
assessment
People's care is planned, implemented,
continuously evaluated and revised to meet
individual needs and preferences for food and
drink
People's food and drink intake is monitored and
recorded
People feel the environment is conducive to
eating and drinking
8. Availability
People can access food and drink at any time
according to their needs and preferences
9. Presentation
People's food and drink are presented in a way
that is appealing to them
10. Promoting
People are encouraged to eat
health
Improved focus on the care of the patients. Use of a validated nutritional
indicator screening tool will be encouraged to reduce rates of malnutrition
and associated adverse outcomes.
Data source and frequency of
collection
Provider quarterly
Organisation responsible for data
collection
Provider
Quarter 1 - submit data (baseline)
Frequency of reporting to
commissioner
Quarter 2 – submit data and submit agreed Action plan
Quarter 3 – submit data
Quarter 4 – submit data showing achievement against baselines showing
improvement against each numerator.
Baseline period / date
Quarter 1
Baseline value
Action plan must be approved by commissioner and progress reported
quarterly
Final indicator period / date (on which
payment is based)
Quarter 4
Final indicator value (payment
threshold)
0.042 of the Regional 0.5%
Quality Accounts 2010/11
Page 47 of 56
Final indicator reporting date
Quarter 4
Rules for partial achievement of
indicator at year-end
Submission of Action plan
Rules for any agreed in-year
milestones that result in payment
Providers must agree their evidence based tool with their PCT
commissioner accordingly.
Rules for delayed achievement
against final indicator period/date
and/or in-year milestones
The data on malnutrition will only be required from PCT Providers with
bedded areas.
If trusts change their validated nutritional indicator screening tool they
must then agree this with commissioners before re-submitting.
Additional Information
“High” risk is defined as MUST - Score 2 and above(or equivalent if
a different screening tool is used)
Detail of Indicator 5 – Pressure Ulcers
Description of indicator
Inpatients experience care that maintains or improves the condition of their
skin and underlying tissues for all ages
Denominator 1
Submitted as Denominator 1 in Indicator 13
Numerator 1
Total number of patients (of Denominator 1) who have one or more
existing pressure ulcers on admission of Grade II and above.
Numerator 2
The number of incident forms completed for grade II ulcers and above
Numerator 3
The number patients with one or more pressure ulcers, with the highest
ulcer having NICE Trigger Grading II
Numerator 4
The number patients with one or more pressure ulcers, with the highest
ulcer having NICE Trigger Grading III
Numerator 5
The number patients with one or more pressure ulcers, with the highest
ulcer having NICE Trigger Grading IV
Numerator 6
The number of root cause analysis investigations undertaken for patients
with NICE Grade III pressure ulcers
Numerator 7
Number of patients acquiring a pressure ulcer within 10 days of admission
Numerator 8
Ensure an action plan is in place which demonstrates how the following
indicators will be met to best practice standards in “Essence of
Quality Accounts 2010/11
Page 48 of 56
Care”pp75-84 DH June 2009
Rationale for inclusion
Factor
Best practice
1. Screening and
Assessment
People who are screened on initial contact and
identified at risk of developing pressure ulcers
receive a full assessment of their risk
2. Information
People and carers have ongoing access to
evidence-based information concerning pressure
ulcer prevention and management
3. Planning,
implementation,
evaluation and
revision of care
People's care is planned, implemented,
continuously evaluated and revised to meet their
individual needs and preferences concerning
pressure ulcer prevention and management
4. Prevention repositioning
People are repositioned to reduce the risk, and
manage the care, of pressure ulcers
5. Prevention pressure
redistribution
People are cared for on pressure redistributing
support surfaces to reduce the risk, and manage
the care, of pressure ulcers
6. Prevention resources and
equipment
People have the resources and equipment
required to reduce the risk, and manage the care,
of pressure ulcers
Improve pressure ulcer prevention and management.
Data source and frequency of
collection
Quarterly
Organisation responsible for data
collection
Provider
Frequency of reporting to
commissioner
Quarterly
Baseline period / date
Quarter 1
Baseline value
Action plan must be approved by commissioner and progress reported
quarterly
Final indicator period / date (on which
payment is based)
Action Plan must be approved by the commissioner and then progress
reported at Quarter 4
Final indicator value (payment
threshold)
0.042 of the Regional 0.5%
Final indicator reporting date
Quarter 4
Rules for partial achievement of
Quality Accounts 2010/11
Page 49 of 56
indicator at year-end
(i) Providers must reduce the grading of pressure ulcers setting a
downward trajectory for NICE Grade III and above, agreed locally.
Rules for any agreed in-year
milestones that result in payment
(ii) Providers must also have 100% root cause analysis of pressure ulcers
with NICE Triggers Grading III and above.
(iii) Providers must submit Action Plans detailing delivery of Essence of
Care by end of Quarter 2.
(iv) Payment will be based on (i),(ii) and (iii) all being achieved
Rules for delayed achievement
against final indicator period/date
and/or in-year milestones
Detail of Indicator 6 – Infection
Description of indicator
To reduce % of number of hospital acquired UTI’s
from indwelling catherisation.
Numerator
Number of patients who have a hospital acquired UTI
Denominator
All patients who have indwelling catheter inserted
throughout hospital stay including all specialities both
elective and non elective
Urinary Tract Infections (UTI) are the second largest
single group of healthcare associated infections in the
UK and make up 20% of all hospital acquired infections.
UTI’s lead to longer stays in hospital for patients and for
pregnant women the development of a UTI can be
especially problematic leading to pre-term delivery,
anaemia and a low birth weight baby.
Rationale for inclusion
UTIs have been found to extend the average length of
hospital stay by 6 days, and UTIs may account for an
extra 798,000 bed days annually. It has been estimated
that the 1994/95 costs of treating UTIs in the NHS were
in the order of £124 million, a reduction in UTIs through
improved monitoring and management in an attempt to
prevent unnecessary catheterisation, prompt daily review
of patients with catheter and removal of catheter ASAP
would provide better standards and quality of care,
reduction in healthcare associated infections and
prevention of costs for treating catheter associated
urinary tract infections.
80% of UTIs occurring in hospital can be traced to
indwelling urinary catheters and lead to longer length of
stay in hospital (average 6 days longer)
Quality Accounts 2010/11
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Quarter One
Agree % decrease from baseline data collected in
quarter one of all patients who have catheter inserted
during their hospital stay.
Data source and frequency of collection
Quarter Two, three and four
Receive data which demonstrates % decrease in number
of acquired UTI’s following catherisation.
Receive at end of each quarter action plan
demonstrating work being undertaken to decrease
number.
Organisation responsible for data collection
Acute provider
Community provider
Frequency of reporting to commissioner
End of each quarter
Baseline period / date
Quarter One
Baseline value
To be confirmed
Final indicator period / date (on which payment is
based)
10 days after the end of quarter one
Final indicator value (payment threshold)
To be confirmed
Final indicator reporting date
10 days after March 2011
Rules for partial achievement of indicator at year-end
Not apply
Rules for any agreed in-year milestones that result in
payment
To be confirmed
Rules for delayed achievement against final indicator
period/date and/or in-year milestones
To be confirmed
Detail of Indicator 7 – Reduction in harm
The provider will demonstrate 10% reduction in harm,
through improved identification and response to
deterioration in condition (for adults and children)
This will be achieved through
Description of indicator
Improving the identification of deterioration
1. % of patients with a complete record of observations
2. Implementation of a NICE compliant track and trigger
system (where this is not already in place)
Quality Accounts 2010/11
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Improving response to deterioration , including
3. No. of cardiac arrest calls per month
4. No. of rapid response calls per month
5. % of patients who triggered that received an
appropriate response
Number of wards where Implementation of a NICE compliant
track and trigger system is in place
Number of patients with a complete set of observations
Improving response to deterioration , including:
Numerator
•
Number of cardiac arrest calls per month
•
Number of rapid response calls per month
•
Number of patients who triggered that received an
appropriate response
Agreed sample of wards
Agreed sample of adults inpatients
Denominator
Agreed sample of patients with a recorded trigger
assessment which identified a need for an appropriate
response
In 2005, 66 deaths reported to the NRLS were classified as a
result of failure to recognise or act upon deterioration in
patient’s condition.
There were a number of areas which were identified as
failures in process including;
Rationale for inclusion
•
not taking appropriate observations
•
non recognition of early signs of deterioration
•
poor communication and response to observations
causing concern
All of which are measures being reported under this indicator,
which aims for an overall 10% reduction in harm from
unrecognised or not acted upon deterioration.
Further information available from
http://www.nrls.npsa.nhs.uk/resources/?EntryId45=59828
and
http://www.nrls.npsa.nhs.uk/resources/?entryid45=59834
Data source and frequency of collection
Provider organisation incident reporting systems,
NLRS/NPSA reporting, which should be collected and
reviewed monthly. Then presented quarterly at relevant CRG
Bi annual audit (reportable through the relevant Clinical Risk
or Clinical Governance Group) of the measures set out in
Quality Accounts 2010/11
Page 52 of 56
description of indicator
Full participation in NCEPOD (available from
http://www.ncepod.org.uk/about.htm)
Organisation responsible for data collection
Acute
Frequency of reporting to commissioner
Please see data source and frequency of collection
Baseline period / date
Within 6 months, development of an audit protocol to support
data collection for the measures set out in description of
indicator
Baseline value
To be confirmed
Final indicator period / date (on which payment is
based)
March 2011
Final indicator value (payment threshold)
The provider will demonstrate 10% reduction in harm,
through improved identification and response, as a result of
deterioration in condition
Final indicator reporting date
April 2011
Rules for partial achievement of indicator at yearend
To be agreed
Rules for any agreed in-year milestones that result
in payment
To be agreed
Rules for delayed achievement against final
indicator period/date and/or in-year milestones
N/A
Final indicator value (payment threshold)
To be confirmed
Final indicator reporting date
10 days after March 2011
Detail of Indicator 8 – Secure safe, high quality, co-ordinated care focused on hospital discharge
arrangements
a) The Provider will demonstrate a 5%
improvement in response scores to
Questions 57 and 65 in the Adult National In
Patient survey relating to hospital discharge
arrangements
Description of indicator
b) The provider will demonstrate a 5%
improvement in their top 5 areas of
improvement highlighted within their Patient
Experience Action Plans from the 2009 Adult
Inpatient Survey and other Patient Survey
data
Quality Accounts 2010/11
Page 53 of 56
This will be achieved by
•
supporting co-ordinating care planning for
hospital discharge arrangements
•
ensuring that all patients are made aware of
danger signals to watch for when being
discharged
•
identifying and developing specific actions plans
in response to the top 5 areas for improvement
on patient experience
Safe, High Quality, Co-ordinate Care domain as part of
the patient experience within the national adult inpatient
survey. % of people responding positively to following
questions:
A) 5% improvement in positive responses to:
Q57 – “On the day you left hospital, was your discharge
delayed for any reason?’
Numerator
B) 5% improvement in positive responses to:
Q65 – “Did a member of staff tell you about any danger
signals you should watch for after you went homes?’
C) 5% improvement in positive responses to:
The top 5 areas of improvement in patient experience, as
agreed with the commissioner and reflecting data from
2009 patient survey and other benchmarked patient
experience data
Denominator
2010 Inpatient Survey Data plus other agreed data
sources
Delayed discharges contribute significantly to the
efficiency of bed management and are a critical
determinant of positive patient experiences for coordinated care across the health and social care
economy.
Rationale for inclusion
Ensure patients are aware of danger signals on
discharge links to question 4 & 5 within the national
patient experience CQUIN and presents extra stretch to
demonstrate providers are supporting the continuum of
care for adult patients discharged from hospital care.
All providers are required to develop current and focused
action plans on Patient Survey to secure year-on-year
improvements in patient experience
Data source and frequency of collection
Agree processes on data sources over and above
national patient survey data for 2010 & 2011. To be
agreed at contract setting and ensuring dynamic and
periodic review of progress.
Quality Accounts 2010/11
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Organisation responsible for data collection
Acute
Frequency of reporting to commissioner
Quarterly (unless evident concerns about performance)
Baseline period / date
To be confirmed
Baseline value
To be based upon 2010 Adult Inpatient Survey data
Final indicator period / date (on which payment is
based)
September 2011
Final indicator value (payment threshold)
To be confirmed
Rules for partial achievement of indicator at year-end
To be agreed
Rules for any agreed in-year milestones that result in
payment
N/A
Final indicator value (payment threshold)
To be confirmed
Final indicator reporting date
10 days after September 2011
Quality Accounts 2010/11
Page 55 of 56
Clifton Park NHS Treatment Centre
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:
01904 464 550
www.cliftonparktreatmentcentre.co.uk
Neurological Centres
Quality Accounts 2010/11
Page 56 of 56