Quality
Account
2010/11
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Fitzwilliam Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2010/11 (looking back)
2.1.2 Clinical Priorities for 2011/12 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2010/11 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
3.4
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Appendix 3 – Glossary of Terms
Quality Accounts 2010/11
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Welcome to Ramsay Health Care UK
Fitzwilliam Hospital is part of the Ramsay Health Care
Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 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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Introduction to our Quality Account
This Quality Account is Fitzwilliam Hospital's annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
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 in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group 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.
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Part 1
1.1 Statement on Quality from the General
Manager
Paul Mc Partlan, General Manager,
Fitzwilliam Hospital
As the General Manager of the Fitzwilliam Hospital I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
Our Vision is that:“As a committed team of professional individuals we aim to consistently deliver
quality holistic care for all of our patients across a full range of care services. We
believe we are able to achieve this by continually updating our key skills and
knowledge enabling us to deliver evidence based clinical practice throughout the
Hospital. The Fitzwilliam Hospital is a recognised Centre of Excellence for the
delivery of orthopaedic services”.
Our Quality Account details the actions that we have taken over the past year to
ensure that our high standards in delivering patient care remain our focus for
everything we do. Through our vigorous audit regime and by listening to all our
stakeholders including patient feedback we have been able to identify areas of
good practice and where we can improve the care our patients receive. This has
enabled us to refine some of our processes which have resulted in making further
improvements.
To ensure that we deliver clinical excellence depends on the whole team. We
have an excellent training and education plan which involves all members of our
administrative and clinical teams.
Every individual member of staff is crucial to the success of our hospital and we
value the contribution that they make in delivering great customer care.
Our Quality Account has been produced to provide information about how we
monitor and evaluate the quality of the services that we deliver.
We hope to be able to share with the reader our progressive achievements that
have taken place over the past 2-3 years. The Fitzwilliam Hospital has a very
Quality Accounts 2010/11
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strong track record as a safe and responsible provider of health care services and
we are proud to share our results.
Our Quality Accounts have been developed with the involvement of our staff who
have been instrumental in developing a systems approach to risk management
which focuses on making every effort to reduce the likelihood and consequence
of an adverse event or outcome associated with treatment of a patient.
To ensure a coordinated approach to the delivery of care for patients and to
monitor the adherence to professional standards and legislative requirements the
Clinical Governance Committee and Medical Advisory Committee meet on a
quarterly basis to review the clinical and safety performance of the Hospital.
These committees have reviewed and agree with the content and action details
within these Quality Accounts.
If you would like to comment or provide me with feedback then please do contact
me on Paul.McPartlan@ramsayhealth.co.uk . Or contact me on 01733 842329
Quality Accounts 2010/11
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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.
Paul Mc Partlan, General Manager
Location: Fitzwilliam Hospital
Ramsay Health Care UK
Address:
Milton Way,
South Bretton,
Peterborough PE3 9AQ
Tel: 01733 261717
paul.mcpartlan@ramsayhealth.co.uk
This report has been reviewed and approved by:
Medical Advisory Committee. Chair:
Mr R Hartley
Clinical Governance Committee Chair:
Mr S Lewis
Regional Director:
Mr James Beech
The content has also been discussed and shared with Commissioner/PCT
representatives from Peterborough, LINCS and CAMBS.
Welcome to Fitzwilliam Hospital
Fitzwilliam Hospital is registered for 54 beds and
provides services for inpatients and day case. The
Fitzwilliam Hospital has been established for 25
years, building a reputation for high standards both
private and NHS across a wide range of clinical
specialities. We are regarded by many of our patients
and stakeholders as an Orthopaedic Centre of
Excellence.
To support the activity we currently undertake, we have 2 theatres (with laminar
flow); a day case suite/endoscopy unit and a large outpatient suite. The outpatient
facilities include 14 outpatient consultation rooms, 3 treatment rooms, Radiology
Suite, Physiotherapy Department, Pathology Service, Mobile MRI/ CT, and local
POCHI.
Following a review last year of our activity and high demand for our services, we
have embarked on a major building project. This includes the development of a
third theatre and dedicated ambulatory care suite and expansion to the radiology
department.
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Demand for physiotherapy services is also very high, so we hold satellite
Physiotherapy Clinics at Sheepmarket Surgery in Stamford and Advance
Performance to enable patients to have greater ease of access to services within
a local setting.
Over the last 18 months we have developed an excellent spinal assessment
service not offered by any other provider in the local area and patients can
receive direct referral from GP’s for radiology services.
We provide in-patient services to all adult patients who are stable ASA3.
Patients requiring level 2 care can still receive care here at the Fitzwilliam and are
treated and cared for by a well trained team of staff in a dedicated level 2 facility.
As a hospital, we are committed to providing patients and other customers with
the very highest level of care and services in a variety of specialities: cosmetics,
plastics, general surgery, ENT, gynaecology and urology.
Locally we are a major player in orthopaedic services, hosting 5 solely private
orthopaedic consultants dedicated to working at the Fitzwilliam, whilst respecting
individual needs.
From July 2009-2010 we facilitated care for over 6,600 patients last year. This
care, we believe, was provided in a safe, convenient, effective manner and to a
very high quality. Currently our workload has an average split of 50/50 between
private patients and NHS.
The majority of our NHS patients are referred to us through ‘Choose and Book’.
Our rationale to support the NHS is to ensure that choice is offered to patients
both in access and location of services. Our contribution does help to relieve
some of the pressures on other local NHS providers.
We have worked closely with 4 PCTs: Peterborough, Lincolnshire,
Cambridgeshire and Northampton PCTs and General Practitioner Practices to
ensure patients have improved access to our Hospital. This has been achieved
by providing information, training and liaison.
Staffing
To support the delivery of clinical care all of our services are supported by a team
of Consultant Surgeons, Consultant Anaesthetists and Consultant Radiologists.
We also have a resident Medical Officer who remains in the hospital at all times
that is, 24 hours per day, 7 days per week.
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Currently our Consultant Surgeons, Consultant Anaesthetists and
Consultant Radiologists all apply for practising privileges and are re-
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•
validated every 2 years, following the appraisal process including a full
review of practice outcomes.
The Hospital is managed by the Senior Management Team which consists
of General Manager, Matron/Clinical Services Manager, Finance Manager,
Marketing Manager and Support Services/Estates Manager.
As an organisation, we employ the following staff at the Fitzwilliam Hospital:
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29 HTE Registered Nurses who work in the ward/out patient department
9 WTE Health Care Assistants.
8 WTE Physiotherapists
16 Registered Nurses who work in theatre with 4 Operating Department
Practitioners and 5 Health Care Assistants
2 Technicians
26 WTE Administration staff supporting Reception, Bookings, Enquiry
Handling and Business Office
1 PA for the General Manager and Regional Director
1 HR administrator and PA to Matron..
6 Housekeepers
2 Chefs and 6 Catering Assistants/Pantry staff
1 Supply Coordinator
2 HTE Engineers
2 HTE porters
GP Liaison Officer
The Fitzwilliam Hospital employs a GP Liaison Officer who maintains and
establishes relationships with GP’s and the practice staff from the Peterborough,
Lincolnshire and Cambridge surgeries. These surgeries are contacted and visited
every month. GP’s are sent regular newsletters and updates via email and
hardcopy are also delivered. Information packs containing information about the
Hospital and how to refer are distributed via mail or during the visits held at the
surgeries. Educational visits are set up during practice learning times whereby the
Consultant and GP Liaison Officer will visit GP’s with a topic of interest for a
“Lunch & Learn” session. GP Educational evenings are also held at the Hospital.
GP’s, Practice Managers and Medical Secretaries are invited and attend regular
Choose and Book workshops at the Treatment Centre.
Local Support. The Fitzwilliam Hospital has been involved in local exhibitions,
press releases including the Evening Telegraph and Stamford Living Magazine,
and we sponsor many local charities and events including The Great Eastern
Show.
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Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
On an annual cycle, Fitzwilliam Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS, ensuring that those services commissioned to us result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the hospital's 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 (looking back)
• Safer Surgery Checklists – Initially the WHO check list process was
implemented into theatres very successfully last year including the team
Huddle process. We audit all lists and found it an excellent method to
reduce the likelihood of near misses happening. It was so successful that
we have implemented the same process for all lists including Scopes and
Radiology procedures. 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 showed an improvement from
92% in 2009 to 94% in 2010, therefore overall environmental cleanliness
remains a focus this year.
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In line with the Ramsay Ambulatory Care Project we are reviewing our
existing patient pathway
Whilst we have a dedicated Day Case Unit known as the Braithwaite Suite
(BWS ), it has limited capacity and no laminar air flow.
Over the last year we have reviewed our numbers, bed capacity and local
demand and have embarked on a major development to build an
incorporate additional theatre and purpose built ambulatory suite.
This will enable us to carry out more procedures as day cases in a purpose
built environment.
As an interim measure we have started staggered admission times on
some lists in BWS.
A major review of Discharge processes has occurred especially access to
TTO’s and District Nurse support. It is hoped this will introduce a smoother
patient experience.
We are currently participating in the Productive Ward Project. We are
reviewing the way supplies are managed on the ward and where they are
located. This will reduce the time nurses need to take for the preparation of
clinical procedures that are carried out on the ward.
We have set up emergency boxes known as grab boxes containing
everything that is required to deal with urgent situations - hypoglycaemia,
blood loss, anaphylaxis and so forth.
We have introduced a central patient related activity board for ease of
reference and to improve communication between clinical and support
services on the ward.
We have also introduced pre-op theatre boxes to avoid the habit of
chasing notes at time of admission.
Electronic Patient ID bands are due to be implemented during this next
year.
2.1.2 Clinical Priorities for 2011/12 (looking forward)
Patient Experience
• In Quarter 4 2010 Ramsay Health Care UK's survey of patient experience,
capturing views of both private and NHS patients, showed that patients'
experience at Fitzwilliam Hospital is that 100% of patients would rate their
care from good, very good to excellent and that 98.6% would either
definitely or probably recommend our hospital to a friend. Despite these
excellent results the survey still showed some areas for improvement
around reducing time prior to procedure, pre-op information from
consultants and post discharge support and follow up. Bringing overall
score to 90.8% YTD 93.8%.
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Patient safety/Clinical effectiveness
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All patients who undergo a procedure at Fitzwilliam Hospital, whether it
is General Anaesthetic or with sedation are at risk of developing a
thrombosis (blood clot). This blood clot could have serious medical
consequences. For that reason all of our patients at Fitzwilliam have a
risk assessment completed to ascertain their level of risk of developing
a blood clot. This risk assessment is based on NICE guidelines,
published in January 2010. Patients receive information at their preassessment clinic so that they have a greater understanding on how to
reduce their own risks of developing a blood clot prior to admission and
post operatively. We may apply compression stockings to minimise the
risk or we may administer medication if this is clinically indicated.
If we were to have any patients develop a blood clot this would be
reported through the Clinical Governance Reporting framework.
Patient safety
1. Falls – Ramsay Health Care has adopted a corporate approach to the
Shattered Lives Campaign. All slips trips and falls for all staff and visitors
are reported through the central risk management reporting network and
the Hospital actions are monitored centrally and reviewed following any
incidents. In addition to this all patient falls are reported to the risk
management group where they are collated and reviewed before being
reported to the Clinical Governance Committee. This committee is in the
process of developing a corporate strategy to minimise the potential risks
to patients. Following our local review of falls in the hospital we have
increased patient awareness and asked them before they get out of bed to
ring for assistance to help them walk to the bathroom.
2. ‘Never Events’ - are serious, largely preventable patient safety incidents
that should not occur if the available preventative measures have been
implemented. From the core list of "Never Events", there are five that
might predominantly affect Fitzwilliam patients due to the procedures
undertaken here. These five are set out below:
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Wrong site surgery
Retained instrument post-operation
Wrong route administration of chemotherapy
Misplaced nasal or gastric tube not detected prior to use
Intravenous administration of mis-selected concentrated potassium
chloride
If we should experience any untoward incidents then these would not
only be reported through the Ramsay reporting systems but we would
also inform the patient's GP and PCT and CQC.
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3. VTE risk assessment - We follow the NICE (2010) VTE prevention
Guidelines so that all of our patients undergo the VTE Risk Assessment
and, in addition to this, all of our patients who under go Hip Replacement
or Knee Replacement procedures are routinely given prophylactic
anticoagulation therapy in accordance with the Department of Health
Guidelines on VTE prevention. Each set of notes holds the evidence to
show scores gained and actions taken.
4. Infection Control – The Fitzwilliam Hospital currently has an infection rate
of 0.6%. During this reporting period to the best of our knowledge we have
not had any patients develop MRSA post-operatively acquired in hospital.
One reason for this is that our hospital only carries out elective planned
surgery. This means that we are able to screen all of our patients for
MRSA before they come into our hospital to have their procedure. Any
patients who are found to be MRSA positive are treated with a course of
antibiotics. Then the MRSA screen is repeated and only when the patient
is clear of MRSA do we then arrange to perform the patient’s procedure at
our Hospital. All our patients are cared for in single room environment and
we have excellent infection rate and good practices.
5. Medical Gas Alert – We have not experience any problems with our
medical gasses during this reporting period.
6. Real time incident reporting – The Fitzwilliam Hospital has recently
improved our reporting systems by the inclusion of our Hospital on to the
Ramsay electronic data base system called RIMS. Matron is now able to
report any incidents electronically in a more timely fashion to Ramsay
Corporate Team. We are also able to bench mark our Hospital against
other Ramsay Hospitals.
7. National Joint Registry – The Fitzwilliam Hospital is part of the National
Joint Service Register. This is a national data base which monitors patient
out come measures against the type of prosthesis they have inserted.
Patients have to give their consent to participate. Our Patient Consent rate
is high and currently at from 81% to 100%. When we identified that our
consent rate needed to be improved we established a plan that involved
patient information from pre-assessment. The ward checking procedures
and collating of the patients consent documentation.
8. Staff Satisfaction Survey - Staff Satisfaction Survey – The overall results
from the survey were good and staff commented on the exceptional
training that they received and how they were proud of the excellent
customer service and rapport that was held with patients. Staff
commented that communication between departments could be improved
therefore we have now implemented a daily huddle from where staff of any
level can inform the hospital wide team of daily issues. This is in addition
Quality Accounts 2010/11
Page 13 of 43
to the weekly operations meeting. As part of the monthly Head of
Department meetings we ask HODs to cascade down to all staff key
points raised and have designed a form to help with this, which includes a
part for departmental feedback to HODS and SMT.
9. Recently we started a bimonthly quality meeting. Staff satisfaction is now
an item on the agenda and staff are encouraged to join this meeting to
discuss any issues they may have.
10. Staff are also encouraged to fill out an anonymous staff suggestion form to
help improve the hospital with constructive suggestions.
11. Acute Care Competencies / Vulnerable Adult training / ILS – All
qualified staff throughout the hospital have access and training in Acute
Care skills and Vulnerable Adult protection. The ward and theatre staff are
currently working through their critical competency assessments.
Clinical Effectiveness
1. Ambulatory Day Care – better outcomes and improving patient
experience
• We have recently undertaken a review of how we manage our patients
who are suitable to undergo surgery care. We carefully select those
patients prior to admission There are a number of patients who plan to
undergo a range of procedures which require a relatively short time in
theatre and recovery and who are deemed suitable for admission to our
day case unit. However, experience has shown that for a variety of
reasons patients undergoing a moderate range of procedures will require
an overnight admission. The criteria for this careful patient selection have
been developed with input from the Clinical team, Consultant Surgeons
and Consultant Anaesthetists and takes place during the Pre-Assessment
review so patients can be informed prior to their admission to our Hospital.
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Why the service needs to be redefined (e.g. Over recent years, partly due
to medical advances, the number of day surgery patients has increased
compared to those requiring inpatient care. In 2010 the percentage of day
surgery patients we treated was 73%. We need to ensure that our hospital
facilities and patient flows better meet the case mix we now deliver.
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By separating our inpatient and day case patients we are able to provide
our patients with a more efficient patient pathway through the hospital.
Best practice has shown that by doing this, patient care will improve as
waiting time and recovery period are reduced.
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2. Improve access to and sharing National Benchmarking – how do we
compare?
It was recognised that we needed more transparency between ourselves and
other independent sector providers/the NHS in order to monitor and improve
our services. This is even more important now that we are working in
partnership with the NHS. e.g. benchmarking in the following areas:
Hellenic
• Hellenic will provide national benchmark figures for key
performance indicators, such as activity/volumes, mortality, and day
case rates, and unplanned readmissions, average length of stay,
unplanned transfers, and returns to theatre.
VTE risk assessment compliance
• Benchmarking through the national stats website. Link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publi
cationsStatistics/DH_122283
PROMS results
• Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=19
37&categoryID=1295
Patient satisfaction figures
• Using CQUIN indicators common to both NHS survey and our own,
e.g. % recommended, same sex accommodation, VTE assessment.
3. Improve ward efficiency by adopting the Productive Ward initiative –
more time to care
As stated earlier, we are involved in The Productive Ward (PW) Project. This
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.
4. Improved patient information
In our recent patient satisfaction survey results it was recognised that our
patients would like more support following discharge. We now phone all of our
patients within 48 hours of discharge.
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Patient experience – informing patient choice
1.
Increasing the use of Patient Reported Outcomes Studies (PROMs)
• This is a key target. Better use of the national Oxford Hip and Knee
scores and encouraging their use in identifying poor outcomes and
examining practice occurs as a regular item at our orthopaedic centre of
excellence meetings. Currently our results are excellent - they are about
national and PCT rates in 3 areas across 3 PCT providers.
• We share the results with Consultant Orthopaedic Surgeons and
physiotherapists and encourage them to use the data to review their
practice and feedback to patients.
• Similar results are seen in our outcomes for private patients too.
2.
Staff satisfaction Survey - Fitzwilliam Hospital - Pulse Results
The overall results for the survey were good. Employees at the Fitzwilliam
Hospital are very positive about their jobs. In particular, the vast majority
(95.5%) enjoy their work, feel they have clear goals and objectives, know
what they are responsible for and know how their work contributes to
Ramsay’s success.
Staff also commented on the exceptional training that they received and
how they were proud of the excellent customer service and rapport with
patients and 91% of staff had received an appraisal in the last year.
Staff members felt that communication within their teams and department
was good at 79%. However only 63% felt that communication between
different teams and departments in the workplace was good.
This was identified as an area for development. As a way of addressing
this, the Monthly Head of Department meetings are now cascaded down to
all staff.
The Pulse Action Group was established and HODS were encouraged to
visit each other's departments to gain a greater understanding of their
workload, expectations and demands.
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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 2009/2010 and currently 2010/11, the Fitzwilliam Hospital has reviewed all
the data available to them on the quality of care of their NHS services.
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 hospital's senior managers, together with regional
and corporate managers. The balanced scorecard approach has been an
extremely successful tool in helping us to 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
Agency Hours as % of Total Hours: 1.17%
% Staff Turnover: 10.3%
% Sickness: 4.44%
Total Lost Worked Days: 556.4
Appraisal: 68% - at the time of printing, this is an annual event for staff, so will
never be 100%
Mandatory Training is high at 94%
Staff Satisfaction Score: 91.5% of staff said they either agreed or strongly agreed
that they enjoyed their work and 87.7% said they had clear goals and objectives.
Number of Significant Staff Injuries: 0
Patient Complaints
All our patient complaints are logged as received, whether verbal or written. Each
complaint is investigated and comments and statements are obtained when
required. All patients receive feedback within 21 days and the complaint is
escalated quickly if the initial resolution is not achieved. We monitor trends, have
local actions in place and review at SMT and HOD level. The numbers of
complaints and trends are also shared with Ward and Theatre teams where
relevant so that lessons can be learnt and processes changed or reviewed if
necessary. Progress on complaints and the outcomes is fed into PCTs and GPs
on a regular basis.
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Formal Complaints per 1000 HPD's
Complaints per 1000 HPD's
11.20
11.00
10.80
10.60
10.40
10.20
10.00
9.80
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
Number of complaints
Patient Satisfaction Score
Patient satisfaction
93%
93%
92%
92%
91%
Patient satisfaction score
91%
90%
90%
89%
Jan - Dec 09
Jan - Dec 10
Jan - May 11
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Number of Significant Clinical Events
Readmission per 1000 HPDs
Readmissions per 1000 HPD's
6.00
5.00
4.00
3.00
Readmissions per 1000 HPD's
2.00
1.00
0.00
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
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Number of Patient Returns to Theatre
Returns to theatre
0.35%
0.30%
0.25%
0.20%
Returns to theatre as a % of discharges
0.15%
0.10%
0.05%
0.00%
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
Results for other Quality indicators.
Workplace Health & Safety Score: 99%
Infection Control Audit Score PEAT Audit Score: 96%
Surgical site audit score: 99%
The PEAT audit showed an improvement from 95% the previous year to 96%.
The areas identified for improvement were the high surface cleaning which has
been addressed in the revised room cleaning schedules.
The store room in the physiotherapy department has been included on the
housekeeping cleaning schedules.
The need for attention to detail has been addressed with our housekeeping staff.
2.2.2 Participation in clinical audit
During 1 April 2010 to 31st March 2011, Fitzwilliam participated in nearly 50
national Ramsay Health Care clinical audits and 2 national confidential enquiries.
The national ones are low as the Fitzwilliam Hospital does not provide services
that are included in the enquiries. However, during that period, Fitzwilliam
Hospital participated in two national clinical audits: the Oxford Hip Score and the
Oxford Knee Score results are excellent.
The patient outcome benefits of surgery can be evidenced in the improvements
patients report from their pre-operative scores, which include immobility, pain and
quality of life indicators. The post-operative recovery scores demonstrate the
improvements in patients' mobility pain and life indicators. The higher the score
pre operatively, the poorer quality of life the patient experiences.
Quality Accounts 2010/11
Page 20 of 43
We have worked with patients in order to achieve the positive consent and
completion rates for Fitzwilliam patients The scores demonstrate that patients'
post-operative symptoms are improving, not only from their pre-operative status,
but are continuing to improve as the months progress, post-operatively.
The National clinical audits and national confidential enquiries that Fitzwilliam
Hospital participated in, and for which data collection was completed during 1
April 2010 to 31st March 2011 are listed below, alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Participation
(NA, Yes, No)
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
Acute care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic
Society)
Non invasive ventilation (NIV) - adults (British Thoracic
Society)
Pleural procedures (British Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
NA
NA
Yes
Vital signs in majors (College of Emergency Medicine)
Adult critical care (Case Mix Programme)
Potential donor audit (NHS Blood & Transplant)
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
% cases
submitted
NA
NA
NA
NA
NA
NA
NA
NA
1 in time
frame
NA
NA
NA
NA
NA
NA
NA
Quality Accounts 2010/11
Page 21 of 43
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)
YES
THR
TKR
YES
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Trauma
Hip fracture (National Hip Fracture Database)
Severe trauma (Trauma Audit & Research Network)
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
The reports of Quarterly national clinical audits from 1 April 2010 to 31st March 11
were reviewed by the Clinical Governance Committee.
Quality Accounts 2010/11
Page 22 of 43
Local Audits
Over the last 18 months we have actively supported our local PCT with 3 clinical
audits to measure compliance to surgical threshold policy.
Good results and outcomes were shown after local action plan was implemented
following initial feedback from PCT.
The Orthopaedic Centre of excellence committee is always supporting local
audits:
•
•
•
Pain management in shoulder patients,
Review by the Tissue Licensing Authority, with excellent results
Patient compliance and outcome measures for patients with new
prosthesis in foot and ankle surgery.
2.2.3 Participation in Research
There were no patients recruited during 2010/11to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
The CQUINN framework was not in place for 2010/11. However a number of
National and local CQUINN schemes have been agreed for 2011/12 and these
will be reported upon in next year's report.
2.2.5 Statements from the Care Quality Commission (CQC)
Fitzwilliam Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March has no restrictions.
The Care Quality Commission has not taken enforcement action against
The Fitzwilliam Hospital, during 2010/11or at any other time over last 5 years and
we have not had to participate 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
Fitzwilliam Hospital was audited last year under 3 types of data quality:
•
•
•
•
Under information security, we achieved ISO/IEC27001:2005
Clinical threshold compliance and evidence in the notes
Appropriate coding.
SUS data management by the local PCT, with 100% compliance
Quality Accounts 2010/11
Page 23 of 43
Clinical coding is a key focus. In order to improve the quality of our data capture
our Clinical Coder is undertaking the Foundation Coding Qualification training
undertaken, also:
•
Pre assessment staff, theatre team and Consultants have been given
training and advice on their precise documentation at both preassessment and when writing the operation notes.
•
Coding takes place from the medical records.
•
There is a weekly data report which highlights any identified areas which
are addressed by the coder. This is addressed before the data is
submitted.
•
Consultant records are also subject to a regular audit with individual
consultant feedback being given as required.
The numbers of missing NHS numbers and practice codes are very few and will
be for exceptional reasons. NHS numbers and practice codes are always
missing when treating MOD patients or prisoners.
2.2.7 Stakeholders views on 2010/11 Quality Account
NHS Lincolnshire Commentary for Ramsay Fitzwilliam Hospital Quality
Account 2010/11
It is worthy to note that each site within Ramsay Group are developing their own
Quality Account to ensure the local community which it serves, receives detailed
information about each individual hospital. This Quality Account presents details
of achievements within the 3 domains of quality ie clinical effectiveness, patient
safety and patient experience. NHS Lincolnshire particularly welcomes the focus
placed on Safer Surgery Checklists, Cleanliness - including infection prevention
and control. It also endorses the participation trialling Productive Ward –
releasing more time to care for patients. Also, the introduction emergency boxes,
known as grab boxes, which contain everything that is required to deal with
urgent situations for example - hypoglycaemia, blood loss, and anaphylaxis.
NHS Lincolnshire notes that the Trust’s current registration status with the Care
Quality Commission has no restrictions. The Care Quality Commission has not
taken enforcement action against the Fitzwilliam Hospital, during 2010/11.
The Fitzwilliam Hospital was not conditional on achieving quality improvement
and innovation goals through the Commissioning for Quality and Innovation
payment framework during 2010/11. However a CQUIN scheme has been put in
place for 2011/12 to achieve the following:
Quality Accounts 2010/11
Page 24 of 43
Reducing avoidable death, disability and chronic ill health from venous
thombo-embolism (VTE)
2. Improving responsiveness to patients
3. Smoking cessation – identification of risk, education and referral
4. Weight management – identification of risk, education and referral
1.
Areas for Improvement 2011/12
NHS Lincolnshire endorses the areas identified for improvement for 2011/12 and
the associated initiatives as detailed within the Fitzwilliam Hospital Account as:
Patient Safety
• VTE risk Assessment
• Real time incident reporting
• Acute care competencies
Clinical effectiveness
• Implementation of Productive Ward initiative - to focus efficiency releasing
more time for direct patient care.
• Participation in National Joint Registry
Patient Experience
• Increasing the Patient Reported Outcome Measures (PROMs) for Hip and
Knee operations
• Patient satisfaction survey to ensure focus and avoid complacency.
NHS Lincolnshire endorses the accuracy of the information presented within the
Ramsay Fitzwilliam Quality Account and the overall quality programme
performance will be reviewed through the formal contract quality review process
and triangulation through patient experience surveys.
Quality Accounts 2010/11
Page 25 of 43
Part 3: Review of quality performance 2009/2010
Statements of quality delivery
Matron, Caroline Yarnell-Smith
Review of quality performance 1st April 2010 - 31st 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 assures 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.
Quality Accounts 2010/11
Page 26 of 43
The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
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).
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
Quality Accounts 2010/11
Page 27 of 43
3.1 Patient safety
We are a progressive hospital and focused on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety. When risks to patient safety come to light through a number of
routes including routine audit, complaints, litigation, adverse incident reporting,
any concerns raised are routinely reviewed 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.
3.1.1 Infection prevention and control
Fitzwilliam Hospital has a very low rate of hospital acquired infection and
has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in the mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a Corporate level Infection Prevention and
Control (IPC) Committee and Group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
•
We achieved 94% for the IPC initiatives the areas identified for
improvement were:-
•
A review of the ward mattress policy has taken place. A process for
checking that the mattress and covers are fit for purpose has been
implemented and as a result 9 mattresses have been replaced. The
checking process has been incorporated in to the housekeeping schedule.
•
On review of our local audits we have made some major improvements
this year in areas of medical/consultant involvement in infection risks ie
cannulation and evidence of handwashing in clinics
Quality Accounts 2010/11
Page 28 of 43
•
The bar graphs below show local infection rates as less than 0.8 % of
admissions for the last 4 years.
Hospital infections as a % of admissions
0.90%
0.80%
0.70%
0.60%
0.50%
0.40%
% infections
0.30%
0.20%
0.10%
0.00%
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
We are able to maintain low post-operative infection rates as all our patients are
nursed in single rooms. We have excellent, robust daily cleaning schedules. We
screen all of our patients for MRSA, whether private or NHS, prior to admission
for elective surgery. We also have a vigorous hospital surveillance programme
and data collection and an effective ongoing Infection control education
programme, which includes hand washing techniques for all of our staff. Our
small but effective committee has representation from all departments.
3.1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits. The undertaking of the PEAT audits is led by
our Infection Control Nurse who involves the Housekeeping Lead and Catering
Manager. Areas for improvement are identified, with action plans being developed
and implementation is then reported to the Treatment Centre clinical governance
committee.
These assessments include rating of privacy and dignity, food and food service.
Access issues such as signage, bathroom / toilet environments and overall
cleanliness are inspected. In 2009 our result was 93%; 2010 was 94% and 2011
was 96%. We have particularly seen an improvement in the standard of high level
dusting.
Quality Accounts 2010/11
Page 29 of 43
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. 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 management of adverse events per 1000 admissions
demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and
new and revised policies are cascaded in this way to our General Manager,
ensuring that we keep up to date with all safety issues.
•
Bar graph showing adverse events per 1000 admissions scores for last 3
Years
Adverse Events per 1000 HPD's
Adverse Events per 1000 HPD's
16.00
14.72
14.00
12.00
10.00
8.00
6.37
6.00
5.05
5.23
Jan - Dec 09
Jan - Dec 10
4.00
2.00
0.00
Jan - Dec 08
Jan - May 11
All adverse events are reported initially using the adverse event form and
investigated by the Departmental Manager. Matron reviews all events with the
General Manager in order to identify lessons that we can learn. Severe adverse
events and outcomes are reported to the Ramsay Clinical Governance Group and
Risk Management Group.
Quality Accounts 2010/11
Page 30 of 43
3.2 Clinical effectiveness
Fitzwilliam Hospital has a Clinical Governance team and committee that meet
regularly throughout 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 the Medical Advisory Committees to ensure that results are
visible and tied into actions required by the organisation as a whole.
The results highlighted in the graphs demonstrate the effectiveness of this
approach over the last three years.
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.
•
Bar graph showing return to theatre scores for last 4 years.
Returns to theatre
0.35%
0.30%
0.25%
0.20%
Returns to theatre as a % of discharges
0.15%
0.10%
0.05%
0.00%
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
As can be seen in the above graph, our return to theatre rate has decreased over
the last year and over last 4 years is still very low. Again, all patients who need to
return to theatre are reviewed through the clinical governance processes. The
Quality Accounts 2010/11
Page 31 of 43
CEC team reviews any matters of concern and each case is reviewed at the time
of the event. Any trends with Consultants or procedures are audited and findings
reviewed by MAC and CEC.
3.2.2 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.
•
Bar graph showing readmission to scores for last 3 years
Readmissions per 1000 HPD's
6.00
5.00
4.00
3.00
Readmissions per 1000 HPD's
2.00
1.00
0.00
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
As can be seen in the above graph, our readmission to hospital rate has
decreased over the last year despite higher case load. All patients who are
readmitted again undergoes a case review.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and improve service development in various ways, dependent on
the type of experience (both positive and negative) and action required to address
them. All positive feedback is relayed to the relevant staff to reinforce good
practice and behaviour – letters and cards are displayed for staff to see in staff
rooms and notice boards. Managers ensure that positive feedback from patients
is recognised and any individuals mentioned are praised accordingly.
Quality Accounts 2010/11
Page 32 of 43
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures, should our patients be unhappy with any aspect of their care.
The Fitzwilliam has recently established a Quality Group to review all quality
indicators, especially our patients experience scores.
Patient experiences are fed back via the various methods below, and are regular
agenda items on local Governance Committtees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy. Feedback regarding the patient’s experience is encouraged in various
ways via:
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.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care.
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by 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 that the majority of patients
feel they receive excellent quality of care and service in Fitzwilliam Hospital –
graph showing Satisfaction Index scores for the last 3 years (from patient
satisfaction reports).
Quality group now established.
Patient satisfaction
93%
93%
92%
92%
91%
Patient satisfaction score
91%
90%
90%
89%
Jan - Dec 09
Jan - Dec 10
Jan - May 11
Quality Accounts 2010/11
Page 33 of 43
3.3.2 Patient Reported Outcome Measures (PROMs)
Fitzwilliam Hospital participates in the Department of Health’s PROMs surveys for
hip and knee surgery for NHS patients. The Oxford Hip and Oxford Knee scores
are based on patients' self completion survey. The survey assesses the level of
difficulty that patients have completing 12 routine tasks as the following stages,
pre-operative, list follow up and 1 year after surgery. A summary of the scores is
reported above; the report contains a more detailed review of each individual
question and the difference in scores.
HIP REPLACEMENT
Oxford Hip Score
Modelled questionnaire count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative score
Average post-operative score
Oxford Hip Score
Modelled questionnaire count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative score
Average post-operative score
Oxford Hip Score
Modelled questionnaire count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative score
Average post-operative score
Peterborough
PCT
108
106
*
*
22.61
19.899
17.187
17.389
37.796
Lincolnshire
Teaching PCT
819
781
8
30
20.466
19.466
18.466
16.759
37.239
Cambridgeshire
PCT
631
604
*
*
20.534
19.465
18.395
18.594
38.086
National
Fitzwilliam
45,622
43,735
289
1,598
19.852
19.722
19.592
18.077
37.8
National
107
100
*
*
22.478
19.773
17.068
18.617
38.495
Fitzwilliam
45,622
43,735
289
1,598
19.852
19.722
19.592
18.077
37.8
National
107
100
*
*
22.478
19.773
17.068
18.617
38.495
Fitzwilliam
45,622
43,735
289
1,598
19.852
19.722
19.592
18.077
37.8
107
100
*
*
22.478
19.773
17.068
18.617
38.495
Quality Accounts 2010/11
Page 34 of 43
KNEE REPLACEMENT
Oxford Knee Score
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
KNEE REPLACEMENT
Oxford Knee Score
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
KNEE REPLACEMENT
Oxford Knee Score
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
Peterborough
PCT
National
Fitzwilliam
148
134
*
*
17.283
14.841
12.4
49,258
45,155
688
3,415
14.875
14.741
14.607
76
68
*
*
18.958
15.573
12.188
18.764
18.754
20.539
33.446
33.494
36.855
Lincolnshire
Teaching PCT
National
Fitzwilliam
807
747
12
48
16.138
15.095
14.051
49,258
45,155
688
3,415
14.875
14.741
14.607
76
68
*
*
18.958
15.573
12.188
18.372
18.754
20.539
33.69
33.494
36.855
Cambridgeshire
PCT
National
515
475
6
34
15.615
14.374
13.133
49,258
45,155
688
3,415
14.875
14.741
14.607
76
68
*
*
18.958
15.573
12.188
19.023
18.754
20.539
33.751
33.494
36.855
Fitzwilliam
Quality Accounts 2010/11
Page 35 of 43
GROIN HERNIA
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
GROIN HERNIA
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
GROIN HERNIA
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
Peterborough
PCT
National
Fitzwilliam
89
47
29
13
0.164
0.107
0.049
31,741
16,112
10,071
5,558
0.087
0.084
0.081
37
24
*
*
0.195
0.137
0.079
0.796
0.791
0.786
0.895
0.875
0.945
National
Fitzwilliam
603
324
186
93
0.109
0.087
0.066
31,741
16,112
10,071
5,558
0.087
0.084
0.081
37
24
*
*
0.195
0.137
0.079
0.785
0.791
0.786
0.883
0.875
0.945
Cambridgeshire
PCT
National
Fitzwilliam
408
192
145
71
0.114
0.087
0.061
31,741
16,112
10,071
5,558
0.087
0.084
0.081
37
24
*
*
0.195
0.137
0.079
0.818
0.791
0.786
0.894
0.875
0.945
Lincolnshire
Teaching PCT
Quality Accounts 2010/11
Page 36 of 43
HIP REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
HIP REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
HIP REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
Peterborough
PCT
National
Fitzwilliam
93
78
7
8
0.49
0.426
0.361
41,310
36,013
2,623
2,674
0.415
0.411
0.407
99
87
*
*
0.494
0.413
0.332
0.332
0.349
0.354
0.77
0.759
0.778
National
Fitzwilliam
746
655
45
46
0.435
0.405
0.375
41,310
36,013
2,623
2,674
0.415
0.411
0.407
99
87
*
*
0.494
0.413
0.332
0.319
0.349
0.354
0.745
0.759
0.778
Cambridgeshire
PCT
National
Fitzwilliam
570
496
35
39
0.433
0.4
0.367
41,310
36,013
2,623
2,674
0.415
0.411
0.407
99
87
*
*
0.494
0.413
0.332
0.374
0.349
0.354
0.762
0.759
0.778
Lincolnshire
Teaching PCT
Quality Accounts 2010/11
Page 37 of 43
KNEE REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
KNEE REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
KNEE REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
Peterborough
PCT
National
Fitzwilliam
136
100
17
19
0.358
0.273
0.187
45,180
35,287
4,902
4,991
0.302
0.298
0.294
73
59
6
8
0.382
0.299
0.216
0.393
0.402
0.497
0.672
0.7
0.765
National
Fitzwilliam
754
616
59
79
0.342
312
0.282
45,180
35,287
4,902
4,991
0.302
0.298
0.294
73
59
6
8
1382
0.299
0.216
0.386
0.402
0.497
0.706
0.7
0.765
Cambridgeshire
PCT
National
Fitzwilliam
469
367
52
50
0.352
0.309
0.267
45,180
35,287
4,902
4,991
0.302
0.298
0.294
73
59
6
8
0.382
0.299
0.216
0.423
0.402
0.497
0.715
0.7
0.765
Lincolnshire
Teaching PCT
Quality Accounts 2010/11
Page 38 of 43
3.4 Fitzwilliam Hospital Case Study
Fitzwilliam Hospital, Milton Way, South Bretton, Peterborough, PE3 9AQ
Orthopaedic Surgery - Case Study
A retired yet very active gentleman from Peterborough, Mr RG was recently an
NHS patient at the Fitzwilliam Hospital.
Mr RG was always been quite fit by walking and gardening. Unfortunately, in
August he pulled up some heavy roots and developed sudden back pain, which
also referred into buttocks, upper posterior thigh and calves, and he developed
numbness in his feet. The numbness he had put down to his recent diagnosis of
diabetes.
Mr RG tried to control the pain with medication initially until the pain became
unbearable and he could no longer carry out his daily tasks.
Mr RG was referred by his GP to our Spinal Assessment Service in February.
This service is offered as a multi- disciplinary team approach. It is led by Mr
Siôn Lewis, an experienced Orthopaedic Surgeon who specialises in backs, also
Dr Hany Elmadbouh, Consultant Radiologist, and Helen Mumby-Croft, an
Extended Scope Practitioner who supports the pathway at the Fitzwilliam
Hospital.
Mr RG attended his initial out-patients appointment, with Helen Mumby-Croft who
completed a full assessment, which was followed by an MRI. The MRI showed a
large central L4/5 disc prolapse. This confirmed that physiotherapy and epidural
alone would not ease the problem. He was referred on to Mr Lewis who
performed a L4/5 discectomy with partial laminectomies for safe access. Surgery
was performed 5 weeks later,
Mr RG Quoted, “Excellent service. The whole team were brilliant. Mr Lewis is an
excellent surgeon - what first class treatment from everyone. Even the
physiotherapist was good, which I wasn’t looking forward to”.
Mr RG finished this pathway with the physiotherapists as an outpatient and he
recovered fully from this operation in no time at all.
Mr RG also remarked that he had received a 100% flawless experience at the
Hospital and he had nothing but praise for Mr Lewis, Jo Donovan and the
professional and friendly staff at the Hospital.
We continually receive praise and thanks for our care which are shared with staff.
Quality Accounts 2010/11
Page 39 of 43
Appendix 1
Services covered by this quality account
Elective Orthopaedic Services to adults over the age of 18 years.
Anaesthetics
Bariatric surgery
Dermatology
Ear, Nose & Throat
Endoscopy
General Surgery
Gynaecology
Histopathology
Neurology
Oncology
Ophthalmology
Oral / Maxillo Facial
Orthopaedic
Orthopaedic Medicine
Non invasive procedures in OPD
which may be carried out on a child
under 3 years old.
Plain x-ray
Ultrasound
Peak Flow
Height and Weight
Hearing Tests
Tympanometry
Audiometry
Application or removal of orthopaedic
casts
Venepuncture performed by a
paediatrician or appropriately trained
paediatric nurse.
Administration of eye drops
Vital signs
Urinalysis.
Paediatrics – all ages as
Outpatients
Inpatients - Over 12 years of
age
(Please see below for full
details)
Physicians
Plastic / Cosmetic Surgery
Psychology
Radiology
Rheumatology
Sports Medicine
Urology
Invasive procedures in OPD
which may not be carried out on
any child
Circumcision
Injections
Skin Testing
Invasive radiology
Cryotherapy
Electro-cautery and diathermy
Quality Accounts 2010/11
Page 40 of 43
Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2010/11
Page 41 of 43
Appendix 3
Glossary of Terms
ASA 3
ASA is an anaesthetic
classification score used to
assess anaesthetic risk status.
An ASA3 is someone who has
a co-morbidity, i.e. diabetes,
heart disease, but is managed
effectively with medication and
remains stable
WTE
Whole Time Equivalent
BWS
Braithwaite Suite
TTO
To Take Home
HODs
Heads of Departments
SMT
Senior Management Team
HPDs
Hospital Patient Days
Level 2 Care in a dedicated
Level 2 Building
An area designed for close
observation and one-to-one
care for a patient who is
critically ill but stable and does
not require ventilation
Quality Accounts 2010/11
Page 42 of 43
Fitzwilliam Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
phone number
01733 261717
Hospital website
www.ramsayhealth.co.uk
Neurological Centres
Quality Accounts 2010/11
Page 43 of 43
Quality
Account
2010/11
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Fitzwilliam Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2010/11 (looking back)
2.1.2 Clinical Priorities for 2011/12 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2010/11 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
3.4
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Appendix 3 – Glossary of Terms
Quality Accounts 2010/11
Page 2 of 43
Welcome to Ramsay Health Care UK
Fitzwilliam Hospital is part of the Ramsay Health Care
Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 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
Page 3 of 43
Introduction to our Quality Account
This Quality Account is Fitzwilliam Hospital's annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
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 in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group 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
Page 4 of 43
Part 1
1.1 Statement on Quality from the General
Manager
Paul Mc Partlan, General Manager,
Fitzwilliam Hospital
As the General Manager of the Fitzwilliam Hospital I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
Our Vision is that:“As a committed team of professional individuals we aim to consistently deliver
quality holistic care for all of our patients across a full range of care services. We
believe we are able to achieve this by continually updating our key skills and
knowledge enabling us to deliver evidence based clinical practice throughout the
Hospital. The Fitzwilliam Hospital is a recognised Centre of Excellence for the
delivery of orthopaedic services”.
Our Quality Account details the actions that we have taken over the past year to
ensure that our high standards in delivering patient care remain our focus for
everything we do. Through our vigorous audit regime and by listening to all our
stakeholders including patient feedback we have been able to identify areas of
good practice and where we can improve the care our patients receive. This has
enabled us to refine some of our processes which have resulted in making further
improvements.
To ensure that we deliver clinical excellence depends on the whole team. We
have an excellent training and education plan which involves all members of our
administrative and clinical teams.
Every individual member of staff is crucial to the success of our hospital and we
value the contribution that they make in delivering great customer care.
Our Quality Account has been produced to provide information about how we
monitor and evaluate the quality of the services that we deliver.
We hope to be able to share with the reader our progressive achievements that
have taken place over the past 2-3 years. The Fitzwilliam Hospital has a very
Quality Accounts 2010/11
Page 5 of 43
strong track record as a safe and responsible provider of health care services and
we are proud to share our results.
Our Quality Accounts have been developed with the involvement of our staff who
have been instrumental in developing a systems approach to risk management
which focuses on making every effort to reduce the likelihood and consequence
of an adverse event or outcome associated with treatment of a patient.
To ensure a coordinated approach to the delivery of care for patients and to
monitor the adherence to professional standards and legislative requirements the
Clinical Governance Committee and Medical Advisory Committee meet on a
quarterly basis to review the clinical and safety performance of the Hospital.
These committees have reviewed and agree with the content and action details
within these Quality Accounts.
If you would like to comment or provide me with feedback then please do contact
me on Paul.McPartlan@ramsayhealth.co.uk . Or contact me on 01733 842329
Quality Accounts 2010/11
Page 6 of 43
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.
Paul Mc Partlan, General Manager
Location: Fitzwilliam Hospital
Ramsay Health Care UK
Address:
Milton Way,
South Bretton,
Peterborough PE3 9AQ
Tel: 01733 261717
paul.mcpartlan@ramsayhealth.co.uk
This report has been reviewed and approved by:
Medical Advisory Committee. Chair:
Mr R Hartley
Clinical Governance Committee Chair:
Mr S Lewis
Regional Director:
Mr James Beech
The content has also been discussed and shared with Commissioner/PCT
representatives from Peterborough, LINCS and CAMBS.
Welcome to Fitzwilliam Hospital
Fitzwilliam Hospital is registered for 54 beds and
provides services for inpatients and day case. The
Fitzwilliam Hospital has been established for 25
years, building a reputation for high standards both
private and NHS across a wide range of clinical
specialities. We are regarded by many of our patients
and stakeholders as an Orthopaedic Centre of
Excellence.
To support the activity we currently undertake, we have 2 theatres (with laminar
flow); a day case suite/endoscopy unit and a large outpatient suite. The outpatient
facilities include 14 outpatient consultation rooms, 3 treatment rooms, Radiology
Suite, Physiotherapy Department, Pathology Service, Mobile MRI/ CT, and local
POCHI.
Following a review last year of our activity and high demand for our services, we
have embarked on a major building project. This includes the development of a
third theatre and dedicated ambulatory care suite and expansion to the radiology
department.
Quality Accounts 2010/11
Page 7 of 43
Demand for physiotherapy services is also very high, so we hold satellite
Physiotherapy Clinics at Sheepmarket Surgery in Stamford and Advance
Performance to enable patients to have greater ease of access to services within
a local setting.
Over the last 18 months we have developed an excellent spinal assessment
service not offered by any other provider in the local area and patients can
receive direct referral from GP’s for radiology services.
We provide in-patient services to all adult patients who are stable ASA3.
Patients requiring level 2 care can still receive care here at the Fitzwilliam and are
treated and cared for by a well trained team of staff in a dedicated level 2 facility.
As a hospital, we are committed to providing patients and other customers with
the very highest level of care and services in a variety of specialities: cosmetics,
plastics, general surgery, ENT, gynaecology and urology.
Locally we are a major player in orthopaedic services, hosting 5 solely private
orthopaedic consultants dedicated to working at the Fitzwilliam, whilst respecting
individual needs.
From July 2009-2010 we facilitated care for over 6,600 patients last year. This
care, we believe, was provided in a safe, convenient, effective manner and to a
very high quality. Currently our workload has an average split of 50/50 between
private patients and NHS.
The majority of our NHS patients are referred to us through ‘Choose and Book’.
Our rationale to support the NHS is to ensure that choice is offered to patients
both in access and location of services. Our contribution does help to relieve
some of the pressures on other local NHS providers.
We have worked closely with 4 PCTs: Peterborough, Lincolnshire,
Cambridgeshire and Northampton PCTs and General Practitioner Practices to
ensure patients have improved access to our Hospital. This has been achieved
by providing information, training and liaison.
Staffing
To support the delivery of clinical care all of our services are supported by a team
of Consultant Surgeons, Consultant Anaesthetists and Consultant Radiologists.
We also have a resident Medical Officer who remains in the hospital at all times
that is, 24 hours per day, 7 days per week.
•
Currently our Consultant Surgeons, Consultant Anaesthetists and
Consultant Radiologists all apply for practising privileges and are re-
Quality Accounts 2010/11
Page 8 of 43
•
validated every 2 years, following the appraisal process including a full
review of practice outcomes.
The Hospital is managed by the Senior Management Team which consists
of General Manager, Matron/Clinical Services Manager, Finance Manager,
Marketing Manager and Support Services/Estates Manager.
As an organisation, we employ the following staff at the Fitzwilliam Hospital:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
29 HTE Registered Nurses who work in the ward/out patient department
9 WTE Health Care Assistants.
8 WTE Physiotherapists
16 Registered Nurses who work in theatre with 4 Operating Department
Practitioners and 5 Health Care Assistants
2 Technicians
26 WTE Administration staff supporting Reception, Bookings, Enquiry
Handling and Business Office
1 PA for the General Manager and Regional Director
1 HR administrator and PA to Matron..
6 Housekeepers
2 Chefs and 6 Catering Assistants/Pantry staff
1 Supply Coordinator
2 HTE Engineers
2 HTE porters
GP Liaison Officer
The Fitzwilliam Hospital employs a GP Liaison Officer who maintains and
establishes relationships with GP’s and the practice staff from the Peterborough,
Lincolnshire and Cambridge surgeries. These surgeries are contacted and visited
every month. GP’s are sent regular newsletters and updates via email and
hardcopy are also delivered. Information packs containing information about the
Hospital and how to refer are distributed via mail or during the visits held at the
surgeries. Educational visits are set up during practice learning times whereby the
Consultant and GP Liaison Officer will visit GP’s with a topic of interest for a
“Lunch & Learn” session. GP Educational evenings are also held at the Hospital.
GP’s, Practice Managers and Medical Secretaries are invited and attend regular
Choose and Book workshops at the Treatment Centre.
Local Support. The Fitzwilliam Hospital has been involved in local exhibitions,
press releases including the Evening Telegraph and Stamford Living Magazine,
and we sponsor many local charities and events including The Great Eastern
Show.
Quality Accounts 2010/11
Page 9 of 43
Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
On an annual cycle, Fitzwilliam Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS, ensuring that those services commissioned to us result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the hospital's 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 (looking back)
• Safer Surgery Checklists – Initially the WHO check list process was
implemented into theatres very successfully last year including the team
Huddle process. We audit all lists and found it an excellent method to
reduce the likelihood of near misses happening. It was so successful that
we have implemented the same process for all lists including Scopes and
Radiology procedures. 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 showed an improvement from
92% in 2009 to 94% in 2010, therefore overall environmental cleanliness
remains a focus this year.
Quality Accounts 2010/11
Page 10 of 43
•
•
•
•
•
•
•
•
•
•
•
In line with the Ramsay Ambulatory Care Project we are reviewing our
existing patient pathway
Whilst we have a dedicated Day Case Unit known as the Braithwaite Suite
(BWS ), it has limited capacity and no laminar air flow.
Over the last year we have reviewed our numbers, bed capacity and local
demand and have embarked on a major development to build an
incorporate additional theatre and purpose built ambulatory suite.
This will enable us to carry out more procedures as day cases in a purpose
built environment.
As an interim measure we have started staggered admission times on
some lists in BWS.
A major review of Discharge processes has occurred especially access to
TTO’s and District Nurse support. It is hoped this will introduce a smoother
patient experience.
We are currently participating in the Productive Ward Project. We are
reviewing the way supplies are managed on the ward and where they are
located. This will reduce the time nurses need to take for the preparation of
clinical procedures that are carried out on the ward.
We have set up emergency boxes known as grab boxes containing
everything that is required to deal with urgent situations - hypoglycaemia,
blood loss, anaphylaxis and so forth.
We have introduced a central patient related activity board for ease of
reference and to improve communication between clinical and support
services on the ward.
We have also introduced pre-op theatre boxes to avoid the habit of
chasing notes at time of admission.
Electronic Patient ID bands are due to be implemented during this next
year.
2.1.2 Clinical Priorities for 2011/12 (looking forward)
Patient Experience
• In Quarter 4 2010 Ramsay Health Care UK's survey of patient experience,
capturing views of both private and NHS patients, showed that patients'
experience at Fitzwilliam Hospital is that 100% of patients would rate their
care from good, very good to excellent and that 98.6% would either
definitely or probably recommend our hospital to a friend. Despite these
excellent results the survey still showed some areas for improvement
around reducing time prior to procedure, pre-op information from
consultants and post discharge support and follow up. Bringing overall
score to 90.8% YTD 93.8%.
•
•
Quality Accounts 2010/11
Page 11 of 43
Patient safety/Clinical effectiveness
•
•
All patients who undergo a procedure at Fitzwilliam Hospital, whether it
is General Anaesthetic or with sedation are at risk of developing a
thrombosis (blood clot). This blood clot could have serious medical
consequences. For that reason all of our patients at Fitzwilliam have a
risk assessment completed to ascertain their level of risk of developing
a blood clot. This risk assessment is based on NICE guidelines,
published in January 2010. Patients receive information at their preassessment clinic so that they have a greater understanding on how to
reduce their own risks of developing a blood clot prior to admission and
post operatively. We may apply compression stockings to minimise the
risk or we may administer medication if this is clinically indicated.
If we were to have any patients develop a blood clot this would be
reported through the Clinical Governance Reporting framework.
Patient safety
1. Falls – Ramsay Health Care has adopted a corporate approach to the
Shattered Lives Campaign. All slips trips and falls for all staff and visitors
are reported through the central risk management reporting network and
the Hospital actions are monitored centrally and reviewed following any
incidents. In addition to this all patient falls are reported to the risk
management group where they are collated and reviewed before being
reported to the Clinical Governance Committee. This committee is in the
process of developing a corporate strategy to minimise the potential risks
to patients. Following our local review of falls in the hospital we have
increased patient awareness and asked them before they get out of bed to
ring for assistance to help them walk to the bathroom.
2. ‘Never Events’ - are serious, largely preventable patient safety incidents
that should not occur if the available preventative measures have been
implemented. From the core list of "Never Events", there are five that
might predominantly affect Fitzwilliam patients due to the procedures
undertaken here. These five are set out below:
•
•
•
•
•
•
Wrong site surgery
Retained instrument post-operation
Wrong route administration of chemotherapy
Misplaced nasal or gastric tube not detected prior to use
Intravenous administration of mis-selected concentrated potassium
chloride
If we should experience any untoward incidents then these would not
only be reported through the Ramsay reporting systems but we would
also inform the patient's GP and PCT and CQC.
Quality Accounts 2010/11
Page 12 of 43
3. VTE risk assessment - We follow the NICE (2010) VTE prevention
Guidelines so that all of our patients undergo the VTE Risk Assessment
and, in addition to this, all of our patients who under go Hip Replacement
or Knee Replacement procedures are routinely given prophylactic
anticoagulation therapy in accordance with the Department of Health
Guidelines on VTE prevention. Each set of notes holds the evidence to
show scores gained and actions taken.
4. Infection Control – The Fitzwilliam Hospital currently has an infection rate
of 0.6%. During this reporting period to the best of our knowledge we have
not had any patients develop MRSA post-operatively acquired in hospital.
One reason for this is that our hospital only carries out elective planned
surgery. This means that we are able to screen all of our patients for
MRSA before they come into our hospital to have their procedure. Any
patients who are found to be MRSA positive are treated with a course of
antibiotics. Then the MRSA screen is repeated and only when the patient
is clear of MRSA do we then arrange to perform the patient’s procedure at
our Hospital. All our patients are cared for in single room environment and
we have excellent infection rate and good practices.
5. Medical Gas Alert – We have not experience any problems with our
medical gasses during this reporting period.
6. Real time incident reporting – The Fitzwilliam Hospital has recently
improved our reporting systems by the inclusion of our Hospital on to the
Ramsay electronic data base system called RIMS. Matron is now able to
report any incidents electronically in a more timely fashion to Ramsay
Corporate Team. We are also able to bench mark our Hospital against
other Ramsay Hospitals.
7. National Joint Registry – The Fitzwilliam Hospital is part of the National
Joint Service Register. This is a national data base which monitors patient
out come measures against the type of prosthesis they have inserted.
Patients have to give their consent to participate. Our Patient Consent rate
is high and currently at from 81% to 100%. When we identified that our
consent rate needed to be improved we established a plan that involved
patient information from pre-assessment. The ward checking procedures
and collating of the patients consent documentation.
8. Staff Satisfaction Survey - Staff Satisfaction Survey – The overall results
from the survey were good and staff commented on the exceptional
training that they received and how they were proud of the excellent
customer service and rapport that was held with patients. Staff
commented that communication between departments could be improved
therefore we have now implemented a daily huddle from where staff of any
level can inform the hospital wide team of daily issues. This is in addition
Quality Accounts 2010/11
Page 13 of 43
to the weekly operations meeting. As part of the monthly Head of
Department meetings we ask HODs to cascade down to all staff key
points raised and have designed a form to help with this, which includes a
part for departmental feedback to HODS and SMT.
9. Recently we started a bimonthly quality meeting. Staff satisfaction is now
an item on the agenda and staff are encouraged to join this meeting to
discuss any issues they may have.
10. Staff are also encouraged to fill out an anonymous staff suggestion form to
help improve the hospital with constructive suggestions.
11. Acute Care Competencies / Vulnerable Adult training / ILS – All
qualified staff throughout the hospital have access and training in Acute
Care skills and Vulnerable Adult protection. The ward and theatre staff are
currently working through their critical competency assessments.
Clinical Effectiveness
1. Ambulatory Day Care – better outcomes and improving patient
experience
• We have recently undertaken a review of how we manage our patients
who are suitable to undergo surgery care. We carefully select those
patients prior to admission There are a number of patients who plan to
undergo a range of procedures which require a relatively short time in
theatre and recovery and who are deemed suitable for admission to our
day case unit. However, experience has shown that for a variety of
reasons patients undergoing a moderate range of procedures will require
an overnight admission. The criteria for this careful patient selection have
been developed with input from the Clinical team, Consultant Surgeons
and Consultant Anaesthetists and takes place during the Pre-Assessment
review so patients can be informed prior to their admission to our Hospital.
•
Why the service needs to be redefined (e.g. Over recent years, partly due
to medical advances, the number of day surgery patients has increased
compared to those requiring inpatient care. In 2010 the percentage of day
surgery patients we treated was 73%. We need to ensure that our hospital
facilities and patient flows better meet the case mix we now deliver.
•
By separating our inpatient and day case patients we are able to provide
our patients with a more efficient patient pathway through the hospital.
Best practice has shown that by doing this, patient care will improve as
waiting time and recovery period are reduced.
Quality Accounts 2010/11
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2. Improve access to and sharing National Benchmarking – how do we
compare?
It was recognised that we needed more transparency between ourselves and
other independent sector providers/the NHS in order to monitor and improve
our services. This is even more important now that we are working in
partnership with the NHS. e.g. benchmarking in the following areas:
Hellenic
• Hellenic will provide national benchmark figures for key
performance indicators, such as activity/volumes, mortality, and day
case rates, and unplanned readmissions, average length of stay,
unplanned transfers, and returns to theatre.
VTE risk assessment compliance
• Benchmarking through the national stats website. Link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publi
cationsStatistics/DH_122283
PROMS results
• Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=19
37&categoryID=1295
Patient satisfaction figures
• Using CQUIN indicators common to both NHS survey and our own,
e.g. % recommended, same sex accommodation, VTE assessment.
3. Improve ward efficiency by adopting the Productive Ward initiative –
more time to care
As stated earlier, we are involved in The Productive Ward (PW) Project. This
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.
4. Improved patient information
In our recent patient satisfaction survey results it was recognised that our
patients would like more support following discharge. We now phone all of our
patients within 48 hours of discharge.
Quality Accounts 2010/11
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Patient experience – informing patient choice
1.
Increasing the use of Patient Reported Outcomes Studies (PROMs)
• This is a key target. Better use of the national Oxford Hip and Knee
scores and encouraging their use in identifying poor outcomes and
examining practice occurs as a regular item at our orthopaedic centre of
excellence meetings. Currently our results are excellent - they are about
national and PCT rates in 3 areas across 3 PCT providers.
• We share the results with Consultant Orthopaedic Surgeons and
physiotherapists and encourage them to use the data to review their
practice and feedback to patients.
• Similar results are seen in our outcomes for private patients too.
2.
Staff satisfaction Survey - Fitzwilliam Hospital - Pulse Results
The overall results for the survey were good. Employees at the Fitzwilliam
Hospital are very positive about their jobs. In particular, the vast majority
(95.5%) enjoy their work, feel they have clear goals and objectives, know
what they are responsible for and know how their work contributes to
Ramsay’s success.
Staff also commented on the exceptional training that they received and
how they were proud of the excellent customer service and rapport with
patients and 91% of staff had received an appraisal in the last year.
Staff members felt that communication within their teams and department
was good at 79%. However only 63% felt that communication between
different teams and departments in the workplace was good.
This was identified as an area for development. As a way of addressing
this, the Monthly Head of Department meetings are now cascaded down to
all staff.
The Pulse Action Group was established and HODS were encouraged to
visit each other's departments to gain a greater understanding of their
workload, expectations and demands.
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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 2009/2010 and currently 2010/11, the Fitzwilliam Hospital has reviewed all
the data available to them on the quality of care of their NHS services.
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 hospital's senior managers, together with regional
and corporate managers. The balanced scorecard approach has been an
extremely successful tool in helping us to 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
Agency Hours as % of Total Hours: 1.17%
% Staff Turnover: 10.3%
% Sickness: 4.44%
Total Lost Worked Days: 556.4
Appraisal: 68% - at the time of printing, this is an annual event for staff, so will
never be 100%
Mandatory Training is high at 94%
Staff Satisfaction Score: 91.5% of staff said they either agreed or strongly agreed
that they enjoyed their work and 87.7% said they had clear goals and objectives.
Number of Significant Staff Injuries: 0
Patient Complaints
All our patient complaints are logged as received, whether verbal or written. Each
complaint is investigated and comments and statements are obtained when
required. All patients receive feedback within 21 days and the complaint is
escalated quickly if the initial resolution is not achieved. We monitor trends, have
local actions in place and review at SMT and HOD level. The numbers of
complaints and trends are also shared with Ward and Theatre teams where
relevant so that lessons can be learnt and processes changed or reviewed if
necessary. Progress on complaints and the outcomes is fed into PCTs and GPs
on a regular basis.
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Formal Complaints per 1000 HPD's
Complaints per 1000 HPD's
11.20
11.00
10.80
10.60
10.40
10.20
10.00
9.80
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
Number of complaints
Patient Satisfaction Score
Patient satisfaction
93%
93%
92%
92%
91%
Patient satisfaction score
91%
90%
90%
89%
Jan - Dec 09
Jan - Dec 10
Jan - May 11
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Number of Significant Clinical Events
Readmission per 1000 HPDs
Readmissions per 1000 HPD's
6.00
5.00
4.00
3.00
Readmissions per 1000 HPD's
2.00
1.00
0.00
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
Quality Accounts 2010/11
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Number of Patient Returns to Theatre
Returns to theatre
0.35%
0.30%
0.25%
0.20%
Returns to theatre as a % of discharges
0.15%
0.10%
0.05%
0.00%
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
Results for other Quality indicators.
Workplace Health & Safety Score: 99%
Infection Control Audit Score PEAT Audit Score: 96%
Surgical site audit score: 99%
The PEAT audit showed an improvement from 95% the previous year to 96%.
The areas identified for improvement were the high surface cleaning which has
been addressed in the revised room cleaning schedules.
The store room in the physiotherapy department has been included on the
housekeeping cleaning schedules.
The need for attention to detail has been addressed with our housekeeping staff.
2.2.2 Participation in clinical audit
During 1 April 2010 to 31st March 2011, Fitzwilliam participated in nearly 50
national Ramsay Health Care clinical audits and 2 national confidential enquiries.
The national ones are low as the Fitzwilliam Hospital does not provide services
that are included in the enquiries. However, during that period, Fitzwilliam
Hospital participated in two national clinical audits: the Oxford Hip Score and the
Oxford Knee Score results are excellent.
The patient outcome benefits of surgery can be evidenced in the improvements
patients report from their pre-operative scores, which include immobility, pain and
quality of life indicators. The post-operative recovery scores demonstrate the
improvements in patients' mobility pain and life indicators. The higher the score
pre operatively, the poorer quality of life the patient experiences.
Quality Accounts 2010/11
Page 20 of 43
We have worked with patients in order to achieve the positive consent and
completion rates for Fitzwilliam patients The scores demonstrate that patients'
post-operative symptoms are improving, not only from their pre-operative status,
but are continuing to improve as the months progress, post-operatively.
The National clinical audits and national confidential enquiries that Fitzwilliam
Hospital participated in, and for which data collection was completed during 1
April 2010 to 31st March 2011 are listed below, alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Participation
(NA, Yes, No)
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
Acute care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic
Society)
Non invasive ventilation (NIV) - adults (British Thoracic
Society)
Pleural procedures (British Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
NA
NA
Yes
Vital signs in majors (College of Emergency Medicine)
Adult critical care (Case Mix Programme)
Potential donor audit (NHS Blood & Transplant)
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
% cases
submitted
NA
NA
NA
NA
NA
NA
NA
NA
1 in time
frame
NA
NA
NA
NA
NA
NA
NA
Quality Accounts 2010/11
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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)
YES
THR
TKR
YES
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Trauma
Hip fracture (National Hip Fracture Database)
Severe trauma (Trauma Audit & Research Network)
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
The reports of Quarterly national clinical audits from 1 April 2010 to 31st March 11
were reviewed by the Clinical Governance Committee.
Quality Accounts 2010/11
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Local Audits
Over the last 18 months we have actively supported our local PCT with 3 clinical
audits to measure compliance to surgical threshold policy.
Good results and outcomes were shown after local action plan was implemented
following initial feedback from PCT.
The Orthopaedic Centre of excellence committee is always supporting local
audits:
•
•
•
Pain management in shoulder patients,
Review by the Tissue Licensing Authority, with excellent results
Patient compliance and outcome measures for patients with new
prosthesis in foot and ankle surgery.
2.2.3 Participation in Research
There were no patients recruited during 2010/11to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
The CQUINN framework was not in place for 2010/11. However a number of
National and local CQUINN schemes have been agreed for 2011/12 and these
will be reported upon in next year's report.
2.2.5 Statements from the Care Quality Commission (CQC)
Fitzwilliam Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March has no restrictions.
The Care Quality Commission has not taken enforcement action against
The Fitzwilliam Hospital, during 2010/11or at any other time over last 5 years and
we have not had to participate 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
Fitzwilliam Hospital was audited last year under 3 types of data quality:
•
•
•
•
Under information security, we achieved ISO/IEC27001:2005
Clinical threshold compliance and evidence in the notes
Appropriate coding.
SUS data management by the local PCT, with 100% compliance
Quality Accounts 2010/11
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Clinical coding is a key focus. In order to improve the quality of our data capture
our Clinical Coder is undertaking the Foundation Coding Qualification training
undertaken, also:
•
Pre assessment staff, theatre team and Consultants have been given
training and advice on their precise documentation at both preassessment and when writing the operation notes.
•
Coding takes place from the medical records.
•
There is a weekly data report which highlights any identified areas which
are addressed by the coder. This is addressed before the data is
submitted.
•
Consultant records are also subject to a regular audit with individual
consultant feedback being given as required.
The numbers of missing NHS numbers and practice codes are very few and will
be for exceptional reasons. NHS numbers and practice codes are always
missing when treating MOD patients or prisoners.
2.2.7 Stakeholders views on 2010/11 Quality Account
NHS Lincolnshire Commentary for Ramsay Fitzwilliam Hospital Quality
Account 2010/11
It is worthy to note that each site within Ramsay Group are developing their own
Quality Account to ensure the local community which it serves, receives detailed
information about each individual hospital. This Quality Account presents details
of achievements within the 3 domains of quality ie clinical effectiveness, patient
safety and patient experience. NHS Lincolnshire particularly welcomes the focus
placed on Safer Surgery Checklists, Cleanliness - including infection prevention
and control. It also endorses the participation trialling Productive Ward –
releasing more time to care for patients. Also, the introduction emergency boxes,
known as grab boxes, which contain everything that is required to deal with
urgent situations for example - hypoglycaemia, blood loss, and anaphylaxis.
NHS Lincolnshire notes that the Trust’s current registration status with the Care
Quality Commission has no restrictions. The Care Quality Commission has not
taken enforcement action against the Fitzwilliam Hospital, during 2010/11.
The Fitzwilliam Hospital was not conditional on achieving quality improvement
and innovation goals through the Commissioning for Quality and Innovation
payment framework during 2010/11. However a CQUIN scheme has been put in
place for 2011/12 to achieve the following:
Quality Accounts 2010/11
Page 24 of 43
Reducing avoidable death, disability and chronic ill health from venous
thombo-embolism (VTE)
2. Improving responsiveness to patients
3. Smoking cessation – identification of risk, education and referral
4. Weight management – identification of risk, education and referral
1.
Areas for Improvement 2011/12
NHS Lincolnshire endorses the areas identified for improvement for 2011/12 and
the associated initiatives as detailed within the Fitzwilliam Hospital Account as:
Patient Safety
• VTE risk Assessment
• Real time incident reporting
• Acute care competencies
Clinical effectiveness
• Implementation of Productive Ward initiative - to focus efficiency releasing
more time for direct patient care.
• Participation in National Joint Registry
Patient Experience
• Increasing the Patient Reported Outcome Measures (PROMs) for Hip and
Knee operations
• Patient satisfaction survey to ensure focus and avoid complacency.
NHS Lincolnshire endorses the accuracy of the information presented within the
Ramsay Fitzwilliam Quality Account and the overall quality programme
performance will be reviewed through the formal contract quality review process
and triangulation through patient experience surveys.
Quality Accounts 2010/11
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Part 3: Review of quality performance 2009/2010
Statements of quality delivery
Matron, Caroline Yarnell-Smith
Review of quality performance 1st April 2010 - 31st 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 assures 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.
Quality Accounts 2010/11
Page 26 of 43
The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
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).
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
Quality Accounts 2010/11
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3.1 Patient safety
We are a progressive hospital and focused on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety. When risks to patient safety come to light through a number of
routes including routine audit, complaints, litigation, adverse incident reporting,
any concerns raised are routinely reviewed 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.
3.1.1 Infection prevention and control
Fitzwilliam Hospital has a very low rate of hospital acquired infection and
has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in the mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a Corporate level Infection Prevention and
Control (IPC) Committee and Group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
•
We achieved 94% for the IPC initiatives the areas identified for
improvement were:-
•
A review of the ward mattress policy has taken place. A process for
checking that the mattress and covers are fit for purpose has been
implemented and as a result 9 mattresses have been replaced. The
checking process has been incorporated in to the housekeeping schedule.
•
On review of our local audits we have made some major improvements
this year in areas of medical/consultant involvement in infection risks ie
cannulation and evidence of handwashing in clinics
Quality Accounts 2010/11
Page 28 of 43
•
The bar graphs below show local infection rates as less than 0.8 % of
admissions for the last 4 years.
Hospital infections as a % of admissions
0.90%
0.80%
0.70%
0.60%
0.50%
0.40%
% infections
0.30%
0.20%
0.10%
0.00%
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
We are able to maintain low post-operative infection rates as all our patients are
nursed in single rooms. We have excellent, robust daily cleaning schedules. We
screen all of our patients for MRSA, whether private or NHS, prior to admission
for elective surgery. We also have a vigorous hospital surveillance programme
and data collection and an effective ongoing Infection control education
programme, which includes hand washing techniques for all of our staff. Our
small but effective committee has representation from all departments.
3.1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits. The undertaking of the PEAT audits is led by
our Infection Control Nurse who involves the Housekeeping Lead and Catering
Manager. Areas for improvement are identified, with action plans being developed
and implementation is then reported to the Treatment Centre clinical governance
committee.
These assessments include rating of privacy and dignity, food and food service.
Access issues such as signage, bathroom / toilet environments and overall
cleanliness are inspected. In 2009 our result was 93%; 2010 was 94% and 2011
was 96%. We have particularly seen an improvement in the standard of high level
dusting.
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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. 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 management of adverse events per 1000 admissions
demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and
new and revised policies are cascaded in this way to our General Manager,
ensuring that we keep up to date with all safety issues.
•
Bar graph showing adverse events per 1000 admissions scores for last 3
Years
Adverse Events per 1000 HPD's
Adverse Events per 1000 HPD's
16.00
14.72
14.00
12.00
10.00
8.00
6.37
6.00
5.05
5.23
Jan - Dec 09
Jan - Dec 10
4.00
2.00
0.00
Jan - Dec 08
Jan - May 11
All adverse events are reported initially using the adverse event form and
investigated by the Departmental Manager. Matron reviews all events with the
General Manager in order to identify lessons that we can learn. Severe adverse
events and outcomes are reported to the Ramsay Clinical Governance Group and
Risk Management Group.
Quality Accounts 2010/11
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3.2 Clinical effectiveness
Fitzwilliam Hospital has a Clinical Governance team and committee that meet
regularly throughout 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 the Medical Advisory Committees to ensure that results are
visible and tied into actions required by the organisation as a whole.
The results highlighted in the graphs demonstrate the effectiveness of this
approach over the last three years.
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.
•
Bar graph showing return to theatre scores for last 4 years.
Returns to theatre
0.35%
0.30%
0.25%
0.20%
Returns to theatre as a % of discharges
0.15%
0.10%
0.05%
0.00%
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
As can be seen in the above graph, our return to theatre rate has decreased over
the last year and over last 4 years is still very low. Again, all patients who need to
return to theatre are reviewed through the clinical governance processes. The
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CEC team reviews any matters of concern and each case is reviewed at the time
of the event. Any trends with Consultants or procedures are audited and findings
reviewed by MAC and CEC.
3.2.2 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.
•
Bar graph showing readmission to scores for last 3 years
Readmissions per 1000 HPD's
6.00
5.00
4.00
3.00
Readmissions per 1000 HPD's
2.00
1.00
0.00
Jan - Dec 08
Jan - Dec 09
Jan - Dec 10
Jan - May 11
As can be seen in the above graph, our readmission to hospital rate has
decreased over the last year despite higher case load. All patients who are
readmitted again undergoes a case review.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and improve service development in various ways, dependent on
the type of experience (both positive and negative) and action required to address
them. All positive feedback is relayed to the relevant staff to reinforce good
practice and behaviour – letters and cards are displayed for staff to see in staff
rooms and notice boards. Managers ensure that positive feedback from patients
is recognised and any individuals mentioned are praised accordingly.
Quality Accounts 2010/11
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All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures, should our patients be unhappy with any aspect of their care.
The Fitzwilliam has recently established a Quality Group to review all quality
indicators, especially our patients experience scores.
Patient experiences are fed back via the various methods below, and are regular
agenda items on local Governance Committtees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy. Feedback regarding the patient’s experience is encouraged in various
ways via:
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.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care.
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by 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 that the majority of patients
feel they receive excellent quality of care and service in Fitzwilliam Hospital –
graph showing Satisfaction Index scores for the last 3 years (from patient
satisfaction reports).
Quality group now established.
Patient satisfaction
93%
93%
92%
92%
91%
Patient satisfaction score
91%
90%
90%
89%
Jan - Dec 09
Jan - Dec 10
Jan - May 11
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3.3.2 Patient Reported Outcome Measures (PROMs)
Fitzwilliam Hospital participates in the Department of Health’s PROMs surveys for
hip and knee surgery for NHS patients. The Oxford Hip and Oxford Knee scores
are based on patients' self completion survey. The survey assesses the level of
difficulty that patients have completing 12 routine tasks as the following stages,
pre-operative, list follow up and 1 year after surgery. A summary of the scores is
reported above; the report contains a more detailed review of each individual
question and the difference in scores.
HIP REPLACEMENT
Oxford Hip Score
Modelled questionnaire count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative score
Average post-operative score
Oxford Hip Score
Modelled questionnaire count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative score
Average post-operative score
Oxford Hip Score
Modelled questionnaire count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative score
Average post-operative score
Peterborough
PCT
108
106
*
*
22.61
19.899
17.187
17.389
37.796
Lincolnshire
Teaching PCT
819
781
8
30
20.466
19.466
18.466
16.759
37.239
Cambridgeshire
PCT
631
604
*
*
20.534
19.465
18.395
18.594
38.086
National
Fitzwilliam
45,622
43,735
289
1,598
19.852
19.722
19.592
18.077
37.8
National
107
100
*
*
22.478
19.773
17.068
18.617
38.495
Fitzwilliam
45,622
43,735
289
1,598
19.852
19.722
19.592
18.077
37.8
National
107
100
*
*
22.478
19.773
17.068
18.617
38.495
Fitzwilliam
45,622
43,735
289
1,598
19.852
19.722
19.592
18.077
37.8
107
100
*
*
22.478
19.773
17.068
18.617
38.495
Quality Accounts 2010/11
Page 34 of 43
KNEE REPLACEMENT
Oxford Knee Score
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
KNEE REPLACEMENT
Oxford Knee Score
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
KNEE REPLACEMENT
Oxford Knee Score
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
Peterborough
PCT
National
Fitzwilliam
148
134
*
*
17.283
14.841
12.4
49,258
45,155
688
3,415
14.875
14.741
14.607
76
68
*
*
18.958
15.573
12.188
18.764
18.754
20.539
33.446
33.494
36.855
Lincolnshire
Teaching PCT
National
Fitzwilliam
807
747
12
48
16.138
15.095
14.051
49,258
45,155
688
3,415
14.875
14.741
14.607
76
68
*
*
18.958
15.573
12.188
18.372
18.754
20.539
33.69
33.494
36.855
Cambridgeshire
PCT
National
515
475
6
34
15.615
14.374
13.133
49,258
45,155
688
3,415
14.875
14.741
14.607
76
68
*
*
18.958
15.573
12.188
19.023
18.754
20.539
33.751
33.494
36.855
Fitzwilliam
Quality Accounts 2010/11
Page 35 of 43
GROIN HERNIA
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
GROIN HERNIA
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
GROIN HERNIA
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
Peterborough
PCT
National
Fitzwilliam
89
47
29
13
0.164
0.107
0.049
31,741
16,112
10,071
5,558
0.087
0.084
0.081
37
24
*
*
0.195
0.137
0.079
0.796
0.791
0.786
0.895
0.875
0.945
National
Fitzwilliam
603
324
186
93
0.109
0.087
0.066
31,741
16,112
10,071
5,558
0.087
0.084
0.081
37
24
*
*
0.195
0.137
0.079
0.785
0.791
0.786
0.883
0.875
0.945
Cambridgeshire
PCT
National
Fitzwilliam
408
192
145
71
0.114
0.087
0.061
31,741
16,112
10,071
5,558
0.087
0.084
0.081
37
24
*
*
0.195
0.137
0.079
0.818
0.791
0.786
0.894
0.875
0.945
Lincolnshire
Teaching PCT
Quality Accounts 2010/11
Page 36 of 43
HIP REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
HIP REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
HIP REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
Peterborough
PCT
National
Fitzwilliam
93
78
7
8
0.49
0.426
0.361
41,310
36,013
2,623
2,674
0.415
0.411
0.407
99
87
*
*
0.494
0.413
0.332
0.332
0.349
0.354
0.77
0.759
0.778
National
Fitzwilliam
746
655
45
46
0.435
0.405
0.375
41,310
36,013
2,623
2,674
0.415
0.411
0.407
99
87
*
*
0.494
0.413
0.332
0.319
0.349
0.354
0.745
0.759
0.778
Cambridgeshire
PCT
National
Fitzwilliam
570
496
35
39
0.433
0.4
0.367
41,310
36,013
2,623
2,674
0.415
0.411
0.407
99
87
*
*
0.494
0.413
0.332
0.374
0.349
0.354
0.762
0.759
0.778
Lincolnshire
Teaching PCT
Quality Accounts 2010/11
Page 37 of 43
KNEE REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
KNEE REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
KNEE REPLACEMENT
National Adjusted
Modelled questionnaire
count
Increase
Same
Decrease
Upper Confidence interval
Adjusted health gain
Lower confidence interval
Average pre-operative
score
Average post-operative
score
Peterborough
PCT
National
Fitzwilliam
136
100
17
19
0.358
0.273
0.187
45,180
35,287
4,902
4,991
0.302
0.298
0.294
73
59
6
8
0.382
0.299
0.216
0.393
0.402
0.497
0.672
0.7
0.765
National
Fitzwilliam
754
616
59
79
0.342
312
0.282
45,180
35,287
4,902
4,991
0.302
0.298
0.294
73
59
6
8
1382
0.299
0.216
0.386
0.402
0.497
0.706
0.7
0.765
Cambridgeshire
PCT
National
Fitzwilliam
469
367
52
50
0.352
0.309
0.267
45,180
35,287
4,902
4,991
0.302
0.298
0.294
73
59
6
8
0.382
0.299
0.216
0.423
0.402
0.497
0.715
0.7
0.765
Lincolnshire
Teaching PCT
Quality Accounts 2010/11
Page 38 of 43
3.4 Fitzwilliam Hospital Case Study
Fitzwilliam Hospital, Milton Way, South Bretton, Peterborough, PE3 9AQ
Orthopaedic Surgery - Case Study
A retired yet very active gentleman from Peterborough, Mr RG was recently an
NHS patient at the Fitzwilliam Hospital.
Mr RG was always been quite fit by walking and gardening. Unfortunately, in
August he pulled up some heavy roots and developed sudden back pain, which
also referred into buttocks, upper posterior thigh and calves, and he developed
numbness in his feet. The numbness he had put down to his recent diagnosis of
diabetes.
Mr RG tried to control the pain with medication initially until the pain became
unbearable and he could no longer carry out his daily tasks.
Mr RG was referred by his GP to our Spinal Assessment Service in February.
This service is offered as a multi- disciplinary team approach. It is led by Mr
Siôn Lewis, an experienced Orthopaedic Surgeon who specialises in backs, also
Dr Hany Elmadbouh, Consultant Radiologist, and Helen Mumby-Croft, an
Extended Scope Practitioner who supports the pathway at the Fitzwilliam
Hospital.
Mr RG attended his initial out-patients appointment, with Helen Mumby-Croft who
completed a full assessment, which was followed by an MRI. The MRI showed a
large central L4/5 disc prolapse. This confirmed that physiotherapy and epidural
alone would not ease the problem. He was referred on to Mr Lewis who
performed a L4/5 discectomy with partial laminectomies for safe access. Surgery
was performed 5 weeks later,
Mr RG Quoted, “Excellent service. The whole team were brilliant. Mr Lewis is an
excellent surgeon - what first class treatment from everyone. Even the
physiotherapist was good, which I wasn’t looking forward to”.
Mr RG finished this pathway with the physiotherapists as an outpatient and he
recovered fully from this operation in no time at all.
Mr RG also remarked that he had received a 100% flawless experience at the
Hospital and he had nothing but praise for Mr Lewis, Jo Donovan and the
professional and friendly staff at the Hospital.
We continually receive praise and thanks for our care which are shared with staff.
Quality Accounts 2010/11
Page 39 of 43
Appendix 1
Services covered by this quality account
Elective Orthopaedic Services to adults over the age of 18 years.
Anaesthetics
Bariatric surgery
Dermatology
Ear, Nose & Throat
Endoscopy
General Surgery
Gynaecology
Histopathology
Neurology
Oncology
Ophthalmology
Oral / Maxillo Facial
Orthopaedic
Orthopaedic Medicine
Non invasive procedures in OPD
which may be carried out on a child
under 3 years old.
Plain x-ray
Ultrasound
Peak Flow
Height and Weight
Hearing Tests
Tympanometry
Audiometry
Application or removal of orthopaedic
casts
Venepuncture performed by a
paediatrician or appropriately trained
paediatric nurse.
Administration of eye drops
Vital signs
Urinalysis.
Paediatrics – all ages as
Outpatients
Inpatients - Over 12 years of
age
(Please see below for full
details)
Physicians
Plastic / Cosmetic Surgery
Psychology
Radiology
Rheumatology
Sports Medicine
Urology
Invasive procedures in OPD
which may not be carried out on
any child
Circumcision
Injections
Skin Testing
Invasive radiology
Cryotherapy
Electro-cautery and diathermy
Quality Accounts 2010/11
Page 40 of 43
Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2010/11
Page 41 of 43
Appendix 3
Glossary of Terms
ASA 3
ASA is an anaesthetic
classification score used to
assess anaesthetic risk status.
An ASA3 is someone who has
a co-morbidity, i.e. diabetes,
heart disease, but is managed
effectively with medication and
remains stable
WTE
Whole Time Equivalent
BWS
Braithwaite Suite
TTO
To Take Home
HODs
Heads of Departments
SMT
Senior Management Team
HPDs
Hospital Patient Days
Level 2 Care in a dedicated
Level 2 Building
An area designed for close
observation and one-to-one
care for a patient who is
critically ill but stable and does
not require ventilation
Quality Accounts 2010/11
Page 42 of 43
Fitzwilliam Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
phone number
01733 261717
Hospital website
www.ramsayhealth.co.uk
Neurological Centres
Quality Accounts 2010/11
Page 43 of 43