Quality
Account
2010/11
Contents
Welcome to Ramsay Health Care UK and Horton NHS Treatment
Centre
3
Introduction to our Quality Account
4
PART 1 – STATEMENT ON QUALITY
5
1.1
Statement from the General Manager
5
1.2
Hospital accountability statement
7
PART 2
12
2.1
12
Priorities for Improvement
2.1.1 Review of clinical priorities 2010/11 (looking back)
12
2.1.2 Clinical Priorities for 2011/12 (looking forward)
13
2.2
Mandatory statements relating to the quality of NHS services
provided
19
2.2.1 Review of Services
19
2.2.2 Participation in Clinical Audit
20
2.2.3 Participation in Research
21
2.2.4 Goals agreed with Commissioners
21
2.2.5 Statement from the Care Quality Commission
22
2.2.6 Statement on Data Quality
22
2.2.7 Stakeholders views on 2010/11 Quality Accounts
24
PART 3 – REVIEW OF QUALITY PERFORMANCE
25
3.1
Patient Safety
27
3.2
Clinical Effectiveness
29
3.3
Patient Experience
30
Appendix 1 – Clinical Governance Audit Programme
37
Horton Treatment Centre Quality Account 2010/11
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Welcome to Ramsay Health Care UK
Horton Treatment Centre is part of the Ramsay Health
Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital company 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)
Horton Treatment Centre Quality Account 2010/11
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Introduction to our Quality Account
This Quality Account is Horton Treatment Centre’s annual report to the public and
other stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It aims to 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 did not 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 that they serve. 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.
Horton Treatment Centre Quality Account 2010/11
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Part 1
1.1 Statement on quality from the General
Manager
Julie Worth, General Manager,
Horton Treatment Centre
As the General Manager of the Horton Treatment Centre I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
Our Treatment Centre Vision is that:“As a committed team of professional individuals we aim to consistently deliver
quality holistic acute elective Orthopaedic Services with exemplary customer
care. This we believe we are able to achieve by continually updating our key skills
and knowledge, enabling us to deliver evidence based clinical practice throughout
our Treatment Centre. At Horton Treatment Centre we continue to strive so that
we can be recognised as a 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 our
patient’s feedback, we have been able to identify areas where we can improve
the care our patients receive. This has enabled us to make changes to our
processes with the aim of continually improving the services that we provide and
the results that we achieve.
Clinical excellence depends on everyone in our Treatment Centre. To ensure
that this is delivered, we have a training and education plan which involves all
members of our administrative and clinical teams. Every individual member of
staff is crucial to our success and they 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
Horton Treatment Centre Quality Account 2010/11
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over the past year. The Horton Treatment Centre has a strong track record as a
safe and responsible provider of Orthopaedic services and we are proud to share
our results.
Our Quality Account has been developed with the involvement of our staff. We
have developed a systems approach to risk management which focuses on
making every effort to reduce the likelihood and consequence of an adverse
event or outcome being associated with the treatment or procedure that our
patients may undergo.
In order to ensure that we have a coordinated approach to the delivery of patient
care, we have a robust audit programme in place. Each audit has been designed
to monitor our clinical team’s adherence to their professional standards and
legislative requirements.
The results of these audits are monitored and
scrutinised internally. Action plans are developed to address any areas of
concern, and are subsequently monitored to ensure that we implement the
improvements agreed upon. The audit results are also analysed centrally within
Ramsay Health Care UK, where the results are benchmarked against other
Hospitals/Treatment Centres. Any recommendations made are included in any
action plans developed.
In addition to this, Horton Treatment Centre reports on 26 ‘Key Performance
Indicators’ at our Joint Service Review meetings where representatives from
Oxfordshire PCT, General Practitioner’s (GP’s) and patients are present.
The Horton Treatment Centre holds quarterly Clinical Governance Committee
meetings and Medical Advisory Committee meetings (where the consultant body
is represented) to review our clinical and safety performance and make
recommendations. These committees have reviewed and commented on the
details within these Quality Accounts.
All significant data is also reviewed Corporately by various committees (e.g.
Infection Prevention/Control Committee or Health and Safety Committee) and any
serious clinical quality concerns are discussed at the Ramsay Group Clinical
Governance Committee who review and monitor any issues, ensuring that sites
are taking appropriate action where required.
If you would like to comment or provide me with feedback then please do contact
me on julie.worth@ramsayhealth.co.uk . Or contact me on 01295 755000.
Horton Treatment Centre Quality Account 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.
Julie Worth
General Manager
Horton Treatment Centre
Ramsay Health Care UK
This report has been reviewed and approved by:
Medical Advisory Committee (MAC) Chair: Mr B Shafighian
Clinical Governance Committee Chair: Mr B Shafighian
Clinical Governance Committee Deputy Chair: Dr D Repel
Ramsay Health Care UK Regional Director: Mr James Beech
Oxfordshire PCT and other external bodies.
Horton Treatment Centre Quality Account 2010/11
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Welcome to Horton Treatment Centre
Horton Treatment Centre is a purpose built Orthopedic Centre which opened in
2006. It was designed to combine an excellent standard of in patient and day
case facilities, with the technical equipment that modern medicine demands.
The Centre provides the following NHS and private Orthopaedic services:
• Outpatient consultation
• X-ray, MRI imaging and ultra sound scanning, including an on-site MRI
scanner
• Physiotherapy treatments, with an in-house gymnasium
• Inpatient and day care treatments, utilising 40 inpatient beds with en-suite
facilities and a day case unit
• Surgical treatments, using 3 laminar flow operating theatre suites
• Decontamination services
• Provision of meals, with a restaurant for visitors and staff
We provide safe, convenient, effective and high quality treatment for adult
patients (during the reporting period children below the age of 18 years were
excluded), whether privately insured, self-pay, or from the NHS. A high
percentage of our patients have come from the NHS sector - patients choosing to
use our facility through ‘Choose and Book’. Our services help to ease the
pressures on Horton Hospital and NHS facilities within Oxfordshire. We have
worked with Oxfordshire PCT and General Practitioner practices to ensure
patients have improved access to our Treatment Centre, by providing information,
training and liaison.
To support the delivery of clinical care, all of our services are led by Consultant
Orthopedic Surgeons, Consultant Anaesthetists and Consultant Radiologists. We
also have a Resident Medical Officer who remains in the Treatment Centre at all
times i.e. 24 hours per day, 7 days per week.
We have carried out 3,497 procedures in the past 12 months, of which 99% are
for NHS patients.
We have a Consultant led out reach clinic which is held at the Bicester Clinic on a
monthly basis.
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We hold Trauma Clinics at our Treatment Centre to support Horton Hospital to
provide additional capacity for patients who require treatment following accidents
and injuries.
We currently employ the following staff at the Horton Treatment Centre:•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Seconded Consultant Orthopedic Surgeons, Consultant Anesthetists and
Consultant Radiologists and Radiographers, nurses and administrators
from Horton Hospital.
Ramsay employed Consultant Orthopedic Surgeons and Consultant
Anaesthetists.
4 Registered Nurses who work in the out patient department with 4 Health
Care Assistants.
10 Physiotherapists
14 Registered Nurses who work on the ward with 13 Health care
Assistants.
14 Registered Nurses who work in theatres with 4 Operating Department
Practitioners and 3 Health Care Assistants
4 Decontamination Technicians
24 Administration Staff.
4 Receptionists
9 House Housekeepers
3 Chefs and 3 Catering Assistants
1 Supply Coordinator
1 Engineer
3 Porters
1 GP Liaison Officer
Our GP Liaison Officer maintains and establishes relationships with GP’s and
the practice staff from the North Oxfordshire Surgeries and the surrounding
areas, including Oxford, Warwickshire, Worcestershire, Berkshire,
Buckinghamshire and Northamptonshire (totalling over 1000 GP’s). A GP visit
schedule is maintained whereby surgeries are contacted and visited every
month. GP’s are sent regular newsletters and updates via email and
hardcopies are also delivered. Information packs containing information about
the Treatment Centre and how to refer patients to us are distributed via mail or
during the visits to 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 Treatment Centre to which GP’s, Practice Managers and
Horton Treatment Centre Quality Account 2010/11
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Medical Secretaries are invited. They also attend regular Choose and Book
workshops at the Treatment Centre.
The following table lists the surgeries in North Oxfordshire and surrounding
areas. Each surgery has been visited and has received an informational
pack about the Horton Treatment Centre.
WEST BAR SURGERY
HORSE FAIR SURGERY
HIGHTOWN SURGERY
WINDRUSH SURGERY
WOODLANDS SURGERY
NEW SURGERY,
BURDROP
THE CROPREDY
SURGERY
THE SURGERY
THE HEALTH CENTRE
WEST STREET SURGERY
THE WHITE HOUSE
SURGERY
THE WYCHWOOD
SURGERY
KIDLINGTON MEDICAL
PRACTICE
GOSFORD HILL MEDICAL
CTR.
WOODSTOCK SURGERY
MONTGOMERY HOUSE
SURGERY
VICTORIA HOUSE
SURGERY
LANGFORD MEDICAL
PRACTICE
NORTH BICESTER
SURGERY
THE HEALTH CENTRE
SPRINGFIELD SURGERY
THE HEALTH CENTRE,
BRACKLEY
WASHINGTON HOUSE
SURGERY
Outside activities illustrating our involvement in the
Community
The Horton Treatment Centre has been involved in local exhibitions and
shopping mall promotions such as the Banbury Trade & Commerce
Show (this is an exhibition held at the local Castle Quays Shopping Centre
and helps to raise the public’s awareness of the Treatment Centre and the
choice available to them). The Treatment Centre is also a member of the
Banbury Chamber of Commerce. Our staff have great team spirit and enjoy
Horton Treatment Centre Quality Account 2010/11
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taking part in fund raising opportunities for various charities in the
community, such as Race for Life, British Heart Foundation, The Red Cross
and Katherine House Hospice. The staff and consultants from the Treatment
Centre also put on an annual Christmas Show which is held at the local
Banbury Arts Theatre, raising money through ticket sales and raffles. In the
past year we have raised over £4000 for different local charities. We also
sponsor the local Oxford Rugby Club.
The Treatment Centre promotes its services to the community via
advertising in local publications such as the Banbury Guardian, Banbury
Living Magazine, Banbury Chamber of Commerce Directory and the
Retirement Magazine.
Horton Treatment Centre Quality Account 2010/11
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Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
•
On an annual cycle, Horton Treatment Centre develops an operational
plan to set objectives for the year ahead.
•
We have a clear commitment to our patients, as well as working in
partnership with the NHS, to ensure that those services commissioned
result in safe, quality treatment for all patients whilst they are in our care.
We constantly strive to improve clinical safety and standards by a
systematic process of governance, including audit and feedback from all
those experiencing our services.
•
To meet these aims, we have various initiatives ongoing at any one time.
The priorities are determined by the 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
Treatment Centre.
Priorities for improvement
2.1.1 A review of clinical priorities 2010/11 (looking back)
•
Bar coding for patient identity bands – this priority did not progress last
year, as the Department of Health’s Information Standards Board (ISB)
advance notice was not followed up with a formal notice for
implementation. Consequently, the project was put on hold until further
advice was received from the ISB. However, this is still on Ramsay’s
agenda and it is still planned for introduction this year. It is considered
best practice and will prepare us for many patient care initiatives which will
require patients to have a barcode on their wristbands.
Horton Treatment Centre Quality Account 2010/11
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•
Safer Surgery Checklists – The World Health Organisation pre and
perioperative checklists prior to performing surgery have been
implemented to further reduce the risk of wrong site surgery.
•
Cleanliness – Further infection prevention and control audits were
introduced as planned and these are now being undertaken at all Ramsay
sites. An action plan has been developed at Horton to ensure the
standards are met. PEAT (Patient Environment Action Team) audits were
also repeated and showed a Group wide improvement from 95% to 96%
from 2009 to 2010. Horton’s score was 97%.
•
Ambulatory Care - We have a dedicated Day Case Unit and have
undergone a review of our procedures and pathway in line with the
Ramsay Ambulatory Care Project. We have introduced staggered
admission times for patients (thus reducing their waiting time between
admission and operation) and reviewed our discharge processes in order
to achieve a smoother patient experience.
•
Productive Ward Project - We have participated in this national project and
consequently have made several changes including the way supplies are
managed on the ward and where they are located. This has reduced the
time nurses need to take for the preparation of clinical procedures that are
carried out on the ward and allows them to spend more time with their
patients.
Also as part of this project, we have introduced a central patient related
activity notice board for ease of reference and to improve communication
between clinical and support services on the ward.
•
Emergency ‘grab’ boxes - We have set up emergency ‘grab’ boxes
containing everything that is required to deal with urgent clinical situations
such as hypoglycaemic (low blood sugar), blood loss and other emergency
situations. This ensures that the different equipment needed to deal with
each situation is immediately to hand which enables the patient to be
treated as quickly as possible.
2.1.2 Clinical Priorities for 2011/12 (looking forward)
Patient Safety
Patient safety has always been a priority, but in 2011/12 we will work
towards the following:
1. Falls
Ramsay Health Care UK has adopted a Corporate approach to the
Shattered Lives Campaign. All slips trips and falls for all staff and visitors
Horton Treatment Centre Quality Account 2010/11
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are reported through the Ramsay Risk Management reporting system and
are reviewed at our Treatment Centre’s Clinical Governance Committee
meetings.
Following a review of falls in our Treatment Centre, we have placed
notices in our patient bedrooms to remind patients before they get out of
bed to ring for assistance to help them walk to the bathroom. We will
monitor how effective this has been by regularly reporting and reviewing
any patient falls and implementing further action where indicated.
2. Infection Control
The Horton Treatment Centre currently has a post operative infection rate
of 0.04%. During this reporting period (2010/11) to the best of our
knowledge we have had no patients develop MRSA post-operatively. One
reason for this is that our Treatment Centre 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 Treatment Centre to have their
procedure. Any patients who are found to be MRSA positive are treated
with a course of antibiotics and hygiene protocol. The MRSA screen is
then repeated and only when the patient is clear of MRSA, do we arrange
to perform the patient’s procedure. We will ensure that this continues to be
a high priority in the future.
3. Real Time Incident Reporting
The Horton Treatment Centre has recently improved our reporting
systems by the inclusion of our Treatment Centre on to the Ramsay
electronic data base system called RIMS. We are now able to report any
incidents electronically in a more timely fashion to the Ramsay Corporate
Team. We are also able to benchmark our Treatment Centre against other
Ramsay Hospitals. We will work towards entering data on incidents as
soon as possible after they happen, to ensure data is always current and
up to date.
4. Commitment to ensuring the safety and well being of our patients
All staff have a clear duty to report to their line manager at the earliest
opportunity, any concerns they may have relating to suspected abuse of
an adult. Staff must be rigorous in dealing with their suspicions – they
should act professionally, discretely and with the maximum possible
confidentiality. Ramsay has written various policies for staff to follow
should they ever be in this situation including:
• Prevention of Harassment and Bullying of Patients by Staff and or
other patients
• Safeguarding and Managing Suspected Abuse of Vulnerable Adults
• Whistle Blowing
• Raising Concerns about Patient Safety
Horton Treatment Centre Quality Account 2010/11
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We will ensure that the reporting of any concerns and taking action to
ensure a safe conclusion, remains a high priority. Training for all staff on
this issue is a compulsory part of the induction process and annual
mandatory training.
5. National Joint Registry
The Horton Treatment Centre contributes to the National Joint Service
Register (NJR). This is a national database which monitors patient
outcomes against the type of prosthesis that the surgeon has inserted.
Patients have to give their consent to participate. Our patient consent rate
was 83% at the beginning of the period. When we identified that our
consent rate needed to be improved, we established a plan that involved
patient information from pre-assessment, admission and preparation for
theatre. The ward checking procedures and collating of the patients
consent documentation were also revised. Due to our actions, the consent
rate rose to 96% at the end of the reporting period, which exceeds the
NJR Key Performance Indicator (KPI) rate by 6 percentage points.
We will aim to reach a 100% consent rate as a priority as we recognise the
importance of the NJR database and the need to help our patients
appreciate their ability to support this by giving their consent to be
included.
6. Staff Satisfaction Survey
The overall results for the staff satisfaction survey (PULSE) 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
they had with patients.
90.9% of staff members felt that communication within their teams and
department was good. 76% of staff believed that communication from
senior management was also good. Communication between different
teams and departments in the workplace was satisfactory (scored 58.2%),
but was identified as an area for development. As a way of addressing
this, the weekly Head of Department meeting discussions are now
cascaded down to all staff and a bi-monthly Quality Meeting has been set
up, where staff can join in to discuss any issues they may have. Staff
members are also encouraged to fill out an anonymous staff suggestion
form to help improve their hospital working environment with constructive
suggestions.
Employees at the Horton Treatment Centre 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.
Horton Treatment Centre Quality Account 2010/11
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We will continue as a priority to strive towards better communication
between departments.
7. Acute Care Competencies / Vulnerable Adult Training
All qualified staff throughout the Treatment Centre undertake training in
Acute Patient Care. The ward and theatre staff are currently working
through their Critical Competency Assessments. We aim in the coming
reporting period to have all our staff assessed in their Critical Care
competencies.
8. VTE risk assessment and prophylaxis processes
All patients who undergo procedures, whether requiring a general
anaesthetic, with sedation or local anaesthetic, 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 Horton Treatment
Centre have a clinical risk assessment completed prior to surgery to
ascertain their level of risk of developing a blood clot. This risk assessment
is based on the National Institute for Health and Clinical Excellence (NICE)
guidelines, published in January 2010. It includes a section for the Nurse
undertaking the assessment to sign and also a section for the Consultant
to sign stating what VTE prophylaxis he wishes the patient to receive. We
wish to further embed these processes so that record keeping of
prophylaxis given is fully complete. In order to do this, we will audit the
processes via our Clinical Governance Audit Programme, which will enable
deficiencies to be indentified and action taken to address them.
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 to undergo day case surgery, by carefully selecting those patients
who are suitable prior to admission. There are a number of patients
undergoing a range of procedures who require a relatively short time in
theatre and recovery. Many of these can safely be cared for in our day
case unit. However, experience has shown that, for a variety of reasons,
patients undergoing slightly more complicated procedures may require an
overnight admission. The criteria to ensure that the right patient is selected
for the correct length of stay have been developed with input from the
Consultant Orthopaedic Surgeons and Consultant Anaesthetists. The
selection takes place during the pre-operative assessment stage prior to
admission for the procedure. In this way, patients know what to expect
before they are admitted to our Treatment Centre.
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By separating our inpatient and day case patients, we are able to provide
our patients with a more efficient and appropriate patient pathway through
the Treatment Centre. We aim in the next reporting period to demonstrate
that this approach:
• lessens the time that patients spend waiting from admission to the
time their procedure takes place (this will be monitored using a
question on our patient satisfaction survey)
• reduces the length of time that patients take to recover from their
procedure before being discharged home (this will be monitored by
collecting data on the time difference between leaving recovery to
discharge).
2. Improve Ward Efficiency by adopting the Productive Ward initiative –
more time to care
The Productive Ward (PW) Project is an NHS Initiative developed by the
Institute for Innovation and Improvement (2008). It focuses on the way
ward teams work together and organise themselves, in order to reduce the
burden of unnecessary activities, and releasing more time to care for
patients in a reliable and safe manner within existing resources. The
approach is very much ‘bottom up’ with all ward staff suggesting ideas and
ways in which they could improve their environment and processes. This is
an ongoing initiative which will continue into the next reporting period.
3. Improved Patient Information
It was recognised from our Patient Satisfaction Survey results that our
patients were not always receiving written information on discharge. This
is important as, even though we always tell our patients everything they
need to know before going home, a written reminder ensures that they
have the same information should they need to refer to it at a later date. All
of our patients now receive a written Discharge Advice leaflet prior to their
discharge. We will continue to monitor the success of this via our patient
satisfaction surveys.
Patient Experience - Informing Patient Choice
1. Patient Satisfaction
A clinical priority for 2011/12 will be to increase our patient satisfaction
scores so we know our patients feel they are receiving quality care.
The DH National Inpatient Survey is conducted once a year - this made it
difficult to act on feedback quickly to prevent reoccurrence of any issues
identified. In order to address this, Ramsay decided to also survey their
NHS patients alongside their private patients in addition to the DH survey.
This Ramsay survey is now (from Sept 2010) conducted every quarter and
Horton Treatment Centre Quality Account 2010/11
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includes our NHS patients. It contains some comparable questions to
those in the DH Inpatient Survey to allow benchmarking. By doing this we
are able to act faster to issues that become apparent, and are also able to
see if actions taken have made a difference more quickly. The additional
surveys are managed (and the findings analysed) by an external
contractor. More detail on how we plan to increase our satisfaction scores,
can be found in Part 3 of this Quality Account.
2. Increasing the use of Patient Reported Outcomes Measures (PROMs)
PROMS are patient self assessment surveys relating to how they feel the
surgery has improved their ability to perform certain tasks. We try to
encourage our patients to participate in order to obtain as high a rate of
patient consent as possible. We share the results with Consultant
Orthopaedic Surgeons and physiotherapists and encourage them to use
the data to regularly review their practice.
At present, patients at Horton Treatment Centre are asked to contribute to
the Department of Health (DH) National PROMS programme but also to
the GC4 PROMS survey which is a requirement of our present contract
with the NHS.
The national scores for both surveys are the Oxford Hip Survey and the
Oxford Knee Survey, both relating to joint replacement surgery. Our
present DH participation rate (based on Apr 2009 to Feb 2011) is 48.9%.
It is felt that one reason for this low rate may be that patients are presently
asked to complete 2 identical surveys, one for our particular GC4 contract
and one for the DH. When this present contract ends, it is hoped that
patients will only be asked to participate in the DH survey, which we hope
will increase our return rate.
In the coming reporting period, we will aim to increase the numbers of
patients agreeing to complete the DH surveys to at least the national
average (at present this is 73.1% for hip replacement patients and 67.7%
for knee replacement patients).
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2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2010/11 the Horton Treatment Center provided elective Orthopedic
Services for adult patients.
The Horton Treatment Centre has reviewed all the data available to them on the
quality of care of these services.
The income generated by the NHS services reviewed in 1 April 2010 to 31st
March 11 represented 100 per cent of the total income generated from the
provision of NHS services by the Horton Treatment Centre for 1 April 2010 to 31st
March 11.
Balanced Scorecard
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care, comparable across all of its Hospitals.
The indicators on the Ramsay scorecard are reviewed each year. The scorecard
is reviewed each quarter by the hospitals senior managers together with regional
and Corporate Managers. The balanced scorecard approach has been an
extremely successful tool in helping us benchmark against other hospitals and
identifying key areas for improvement.
In the period for 2010/11, the indicators on the scorecard which affect patient
safety and quality were:
Human Resources
Health Care Assistant Hours as % of Total Nursing Hours: 27.1%
Agency Hours as % of Total Hours: 6.63%
% Staff Turnover: 13.7%
% Sickness: 5.4%
Total Lost Worked Days: 3,437
Appraisal: 64%
Mandatory Training: 80%
Number of Significant Staff Injuries: 2
Horton Treatment Centre Quality Account 2010/11
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Patients
Formal Complaints: 54 (1.54%)
Patient Satisfaction Score (using the question ‘Overall, how would you rate the
care you received?’) 96.5%
Number/Rate of Patient Readmissions: 12 (0.35%)
Number/Rate of Patient Returns to Theatre: 4 (0.11%)
Quality
Workplace Health & Safety Audit Score: 99%
Surgical Site Audit Score: Average 99%
Patient Environment Action Team (PEAT) Audit Score: 97%
2.2.2 Participation in Clinical Audit
During 1 April 2010 to 31st March 2011, Horton Treatment Centre participated in
two national clinical audits within the elective surgery PROMS programme (for hip
and knee replacements). We also contributed towards the National Joint Registry
database. The other national audits as below were not applicable to our patient
case mix.
We did not contribute to any National Confidential Enquiries as the Treatment
Centre does not provide services that were within the scope of these enquiries for
the time period reported.
National Clinical Audits (NA = not applicable to the services provided)
Participation
(NA, Yes, No)
Name of Audit
Peri- and Neonatal
NA
Children
NA
Acute care
NA
Long term conditions
NA
% cases
submitted
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
YES
Hip 334
Knee 578
Ankle 4
Elective surgery (National PROMs Programme)
Data is only available for the date range April 09 to Feb 11)
YES
Hip 170
Knee 202
Cardiovascular disease
NA
Horton Treatment Centre Quality Account 2010/11
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Renal disease
NA
Cancer
NA
Trauma
NA
Psychological conditions
NA
Blood transfusion
NA
Local Audits
The reports of 26 local clinical audits (which includes 9 infection prevention and
control, 4 transfusion, 3 physiotherapy and 2 radiology) from 1 April 2010 to 31st
March 2011 were reviewed by Horton’s Clinical Governance Committee. The
clinical audit schedule can be found in Appendix 1 and shows how these are
spread out across the year.
Following a recent review of our internal audit processes, we have now delegated
the development of the action plan back to the individual who carried out the
audit. In this way, there is much greater ownership in implementing the action
plan. To this effect we have seen an improvement in the targeted areas of
medical records and consent audits.
2.2.3 Participation in Research
There were no patients recruited during 2010/11 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
Horton Treatment Centre’s income from 1 April 2010 to 31st March 2011 was
conditional on achieving quality improvement and innovation goals through
Commissioning for Quality and Innovation payment framework because
Horton Treatment Centre is still operating under the GC4 contract which does
encompass the quality and innovation framework.
not
the
the
not
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2.2.5 Statements from the Care Quality Commission (CQC)
Horton Treatment Centre is registered with the Care Quality Commission.
During the time period represented by this report the conditions of Registration
were:This establishment is registered to provide treatment and care under
the following service user categories only:
Met
• Acute Hospitals (with overnight beds).
Notification in writing must be provided to the Care Quality
Commission at least one month prior to providing any treatment or
service not detailed in your Statement of Purpose.
Met
This establishment may provide overnight accommodation for a
maximum of 40 persons at any one time.
Met
This establishment may not provide treatment or services to
persons under 18 years of age.
Met
The Care Quality Commission has not taken enforcement action against The
Horton Treatment Centre during 2010/2011.
The Horton Treatment Centre has not participated in any special reviews or
investigations by the Care Quality Commission during the reporting period.
2.2.6 Data Quality
Horton Treatment Centre will be taking the following actions to improve data
quality:• Our Clinical Coder is undertaking the Foundation Coding Qualification
training in order to improve the quality of our data capture.
•
Coding now takes place from the medical records. There is a weekly data
report which highlights any areas of poor coding data, which can then be
addressed by the coder prior to submission.
•
Consultants have been given training on the quality of their documentation
at both pre-assessment clinic and when writing their operation notes.
Consultant records are also subject to a monthly audit with individual
consultant feedback being given as required.
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NHS Number and General Medical Practice Code Validity
The numbers of missing NHS numbers and practice codes are very few and will
be for exceptional reasons. NHS numbers and practice codes are not available
when treating Ministry of Defence (MOD) patients or prisoners.
Horton Treatment Centre submitted records during 2010/11 to the Secondary
Uses Service, for inclusion in the Hospital Episode Statistics which are included in
the latest published data. The percentage of records in the published data for
Ramsay Health Care in the reporting period included the following.
The patient’s valid NHS number was:
• 98.7% for admitted patient care;
• 98.5% for outpatient care; and
• 0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was:
• 99.7% for admitted patient care;
• 99.4% for outpatient care; and
• 0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit Attainment Levels
The Ramsay Group Information Governance Assessment Report score overall for
2010/11 was 79% and graded ‘green’ (satisfactory).
Clinical Coding Error Rate
Horton Treatment Centre was subject to the Payment by Results clinical coding
audit during 2010/11 by the Audit Commission and the error rates reported in the
latest published audit for that period for diagnoses and treatment coding (clinical
coding) were:% Primary
Diagnosis
Incorrect
% Secondary
Diagnosis
Incorrect
% Primary
Procedures
Incorrect
% Secondary
Procedures
Incorrect
69
66
46.5
10.2
The coding audit was based on the coding for HRG4, giving a misleading picture
of the audit outcome. Horton Treatment Centre is still subject to the GC4 contract
and is, therefore, coding to the previous HRG category, HRG3.5. Plans are being
developed within Ramsay Health Care for Horton Treatment Centre to move onto
a patient administration system that can code to the required HRG on completion
of the present contract.
The outcome of the audit identified that there were no financial implications for
either the commissioners or the providers.
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2.2.7 Stakeholders views on 2010/11 Quality Account
To be completed
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Part 3: Review of quality performance
2010/2011
Statements of quality delivery
Acting Matron, Gina Taylor
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 assure that the quality of patient care is central to the business of
the organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998), as we believe that it is a model that allows
coverage and inclusion of all the necessary strategies, policies, systems and
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processes for effective Clinical Governance. 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.
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3.1 Patient Safety
We are a progressive Treatment Centre and focussed on stretching our
performance every year and in all performance respects, and certainly in regards
to our track record for patient safety. Risks to patient safety come to light through
a number of routes including routine audit, complaints, litigation, adverse incident
reporting and raising concerns, but more routinely from tracking trends in
performance indicators. Our focus on patient safety has resulted in a marked
improvement in a number of key indicators as illustrated in the graphs below.
3.1.1 Infection Prevention and Control (IPC)
Horton Treatment Centre has a very low rate of hospital acquired infection and
has had no reported MRSA bacteraemia in the past 3 years. We are able to
maintain relatively low post operative infection rates as we screen all of our
patients prior to admission for elective surgery. We also run a vigorous, ongoing
infection prevention and control education programme, which includes hand
washing techniques for all of our Treatment Centre staff.
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. We also participate in mandatory surveillance of
surgical site infections for orthopaedic joint surgery.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by Ramsay through a Corporate level Infection
Prevention and Control (IPC) Committee and Group policy is revised and redeployed every two years. Our IPC programmes are designed to bring about
improvements in performance and 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.
Infection rates
as a % of
admissions for
the last 3 years
(comparison
data not
available).
% Infections by admission
0.45%
0.40%
0.35%
0.30%
0.25%
0.20%
% Infections
0.15%
0.10%
0.05%
0.00%
2008/9
2009/10
2010/11
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3.1.2 Cleanliness and Treatment Centre Hygiene
Assessments of safe healthcare environments include Patient Environment
Assessment Team (PEAT) audits. The undertaking of the PEAT audit is led by
our Infection Control Nurse who involves the House Keeping Lead and Catering
Manager. Areas for improvement are identified within action plans and
subsequent progress is monitored by the Treatment Centre’s 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.
The graph below shows Horton Treatment Centre’s scores over the last 2 years.
The rates show a slight improvement on the last 2 years, with both years
achieving a higher than average outcome when compared across the Ramsay
Group.
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 that our staff have
high awareness of safety has been a foundation for our overall risk management
programme. This awareness then naturally extends to safeguarding patient
safety.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and
Horton Treatment Centre Quality Account 2010/11
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new and revised policies are cascaded in this way to our General Manager which
ensures we keep up to date with all safety issues. Each alert must be
acknowledged to a Ramsay Group coordinator and actions confirmed as
appropriate.
All adverse events are reported and investigated by the Departmental Manager in
order to identify lessons learnt. All adverse events are reported to Matron and
these events and outcomes are reviewed by the General Manager. We report
adverse events as part of the Ramsay Clinical Governance Reporting procedures
and the General Manager informs the members of the Joint Service Review
meeting which are held on a quarterly basis throughout the year.
3.2 Clinical Effectiveness
Horton Treatment Centre has a Clinical Governance team that investigate and
report to the Clinical Governance Committee. 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
Committee to ensure results are visible and tied into actions required by the
organisation as a whole.
3.2.1 Return to Theatre
Ramsay and Horton are 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 return to theatre is expected.
The value of the measurement is to detect trends that emerge in relation to a
specific operation or specific surgical team. In the reporting period, although
Horton’s rate is slightly higher than the Ramsay average, it is lower than previous
years and no trends have been identified.
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3.2.2 Readmission to the Treatment Centre
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. Horton’s rates of readmission remain low and this, in part, is due to
sound clinical practice ensuring patients are not sent home too early after
treatment and meet strict discharge criteria before being discharged. In the
reporting period, although Horton’s rate is higher than the Ramsay average (by
0.23%), it is lower than previous years and no trends have been identified.
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3.3 Patient Experience
All feedback from patients regarding their experiences with Horton Treatment
Centre are welcomed and inform service development in various ways,
dependent on the type of experience (both positive and negative) and action
required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also fed back to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are fed back via the various methods below, and are regular
agenda items on Clinical Governance Committtees for discussion, trend analysis
and further action where necesary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding patient 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 and lay members of the contract management board
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
3.3.1 Patient Satisfaction Surveys
Over the last few years, Horton Treatment Centre has participated in the
Department of Health’s Adult Inpatient Survey. In each year, the NHS survey and
methodology was followed to ensure the data could be benchmarked.
Last year this involved surveying 850 NHS patients up to July 2010. The survey
consisted of 54 questions which related to the patient’s experience of their care at
the Treatment Centre.
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The Horton Treatment Centre achieved a 58.9% response rate with 501 returned
questionnaires. The average response rate within the Ramsay Group was 53.5%,
which Horton Treatment Centre exceeded by over 5%.
Last year, the question ‘Overall, how would you rate the care you received’
resulted in 96.5% of patients responding ‘good’, ‘very good’ or ‘excellent’.
The average score for the Ramsay Group was 98.6%.
The average score for the NHS was 92%*.
The graph below compares Horton Treatment centre with the Ramsay Group
as a whole and the NHS as a whole for the 2010 survey.
Overall, how would you rate the care you received?
Responses stating ‘good’, ‘very good’ or ‘excellent’.
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Last year, the question: Overall, did you feel you were treated with respect
and dignity while you were in the hospital? resulted in 88.5% of patients
responding ‘Yes, always’.
The average score for the Ramsay Group was 94.5%.
The average score for the NHS was 79%*.
The graph below compares Horton Treatment centre with the Ramsay Group
as a whole and the NHS as a whole, over the last 3 years.
Overall, did you feel you were treated with respect and dignity while
you were in the hospital?
Responses stating ‘yes, always’.
*(NHS data obtained from: DH (2011) National NHS patient survey programme.
Survey of adult inpatients 2010. Full national results with historical comparisons.
Published May 2011).
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Action plan
In order to improve the patient satisfaction scores for the Horton Treatment
Centre, we have established a Quality Group which consists of
representatives from each department. One area already identified for
improvement was maintaining the patient’s privacy and dignity whilst in the
Treatment Centre (as although 88.5% responded ‘yes, always’, there were
2% of our patients who responded to say that they felt this was not the
case).
Our action plan included:
•
Staff training - to ensure staff knocked before approaching patients who
are behind curtained areas or closed doors.
•
Addressing patients - patients to be formally asked what they would like
to be called during their stay.
•
Interpreter services - improvement to the access and engagement of
interpreter services.
•
Patient involvement in their care - special efforts are to be made to
include the patient in all areas of their care at all times.
•
Customer Care Training - all staff to receive formal customer care
training.
Additional changes to our practice have been made following the review of
our patient satisfaction survey by our Quality Groups meetings. The
following changes to practice have already been made:•
In the Out Patient Department we have resourced an additional clinical
room, so patients are taken on an individual basis behind a closed door
to have their investigations carried out eg ECGs.
•
In the Radiology Department the procedure for patients who are
undergoing Fluoroscopy investigations have been reviewed. The
patients now remain fully clothed whilst they are transported between
X-ray and the MRI rooms in the same department, thus maintaining the
patient’s privacy and dignity at all times.
•
On the ward, patients who are in our rooms with two beds are now
offered their Consultant or Nurse consultation in an alternative
individual setting, to ensure that patient privacy is maintained.
•
We have a ‘suggestion box’ where additional ideas for improving
aspects of patient care can be placed.
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We will monitor the progress of these and all other questions going forward using
further satisfaction results, as well as our suggestion box, through the Treatment
Centre’s Quality Group meetings and Clinical Governance meetings.
3.3.3 Patient Formal Complaints
In the reporting period 2010/11, Horton had 54 formal patient complaints. As can
be seen from the graph below, this is higher than the previous 2 years. We
identified that a number of complaints were received because patients had
difficulty getting through on the telephone. As a direct result of this, we had the
switch board upgraded so that there is a choice of direct dial numbers into various
hospital departments. We have received no further complaints in this respect
following the introduction of this system.
We also identified that a number of patients had been upset
staff’s attitude towards them on the ward. This matter was
with the members of staff concerned and a satisfactory
through education and training. By following the performance
the issues have been resolved.
by two members of
addressed formally
outcome achieved
management route,
Horton Treatment Centre Quality Account 2010/11
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3.3.4 Patient Reported Outcome Measures (PROMs)
Horton Treatment Centre participates in the Department of Health’s PROMs
surveys for hip and knee surgery for NHS patients.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs
surveys specifically for NHS patients within the GC4 contract.
The Oxford Hip and Oxford Knee scores are based on a patient self completion
survey. The survey assesses the level of difficulty that patients have completing
12 routine tasks, pre-operatively, at first follow up and 1 year after surgery.
A summary of the DH survey scores is reported below. They show that for both
the hip and knee scores, Horton Treatment Centre patients are reporting a health
gain greater than the national average. The health gain figures are ‘adjusted’
which takes into account varying demographics in order to make the data more
comparable between healthcare providers.
(reference: HESonline available at: http://www.hesonline.nhs.uk).
Oxford Knee Score
Modelled questionnaire count
Adjusted health gain
Average pre-operative score
Average post-operative score
Oxford Hip Score
Modelled questionnaire count
Adjusted health gain
Average pre-operative score
Average post-operative score
Horton NHS Treatment Centre
National
202
15.714
20.896
36.96
53,911
14.706
18.791
33.497
Horton NHS Treatment Centre
National
170
19.695
19.229
39.876
49,895
19.661
18.124
37.785
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Appendix 1 Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Horton Treatment Centre Quality Account 2010/11
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Horton Treatment Centre
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Treatment Centre phone number
01295 755000
Hospital website
www.ramsayhealth.co.uk
Neurological Centres
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