Introduction Page
Welcome to Ramsay Health Care UK and Park Hill 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
Quality Accounts 2010/11
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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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This Quality Account is Park Hill 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
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“Park Hill Hospital is committed to being a leading provider of healthcare services by delivering high quality outcomes for patients.”
As Acting General Manager of Park Hill Hospital, I am passionate about ensuring that high quality patient care is at the centre of what we do. I am committed to ensuring that Park Hill Hospital shows year on year improvements in clinical outcomes.
This is the first Quality Account to be submitted by Park Hill Hospital and has been produced to demonstrate our commitment to measuring all feedback from patients about their experience, clinical treatment and clinical outcomes. This allows us to continually review, reflect and improve the patient’s journey at Park Hill Hospital.
Patient safety is our highest priority and our robust recruitment processes and training programmes ensure that our staff are sufficiently qualified and competent to deliver our services in a safe environment.
Park Hill Hospital continually achieves consistently high patient satisfaction results, and through reviewing our customer’s feedback throughout the year, we constantly seek to further enhance the patient experience.
Whilst patient feedback and involvement is extremely important to us, we also use other measures of safety and clinical effectiveness which we use to satisfy ourselves that the care and treatments we provide are evidence-based and delivered by appropriately qualified and experienced medical staff, nurses and other key healthcare professionals.
This Quality Account provides information for our patients and commissioners to assure them of our ongoing commitment to sharing our progressive achievements from one year to the next.
Quality Accounts 2010/11
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To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate .
Dawn Abbott
General Manager
Park Hill Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Nazar Kazzazi, MAC Chairman
Mr Stefan Andrejczuk, Regional Director (North)
Quality Accounts 2010/11
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Park Hill Hospital is one of South Yorkshire’s leading private hospitals with an excellent reputation for delivering high quality healthcare treatments and services.
Located on the site of the Doncaster Royal Infirmary, Park Hill Hospital opened in
April 1995. The ward consists of 21 beds, 17 of which are single rooms, all with en-suite facility. The outpatient department consists of 6 consulting rooms and a minor procedure treatment area.
The hospital provides a full range of quality services, these include, outpatient consultation, outpatient procedures, investigations/diagnostics, surgery and follow up care. During the last 12 months, the hospital has treated 2,936 patients, 58% of which were treated under the care of the NHS. All NHS patients treated at the hospital must be over 18 years of age as defined by the Standard Acute Contract.
Currently, over 100 specialist Consultants work from the hospital who are supported by a team of 55 staff, which includes nursing, physiotherapy and administration staff. We also have a Resident Medical Officer (RMO) for 24 hour emergency support.
Park Hill Hospital has very close working relationships with Doncaster &
Bassetlaw Hospitals NHS Foundation Trust, and has access to support services through various service level agreements with the Trust.
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On an annual cycle, Park Hill 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 hospitals Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital.
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 will be introduced this year as it is still considered best practice and will prepare us for many patient care initiatives which will require patients to have a barcode on their wristbands.
•
Safer Surgery Checklists – further work was undertaken and two more speciality specific checklists for radiology and cataracts have been implemented to further reduce the risk of wrong site surgery.
Quality Accounts 2010/11
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•
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 of 3.8%, over the past three years.
•
Releasing time to care – the Productive Ward project was successfully trialled at 5 sites and adjustments made to accordingly to suit the NHS services we provide. An instruction manual has been developed by the project team and roll out sessions are to be held regionally throughout the first half of 2011. Park Hill Hospital commenced the Productive Ward project in May 2011.
2.1.2 Clinical Priorities for 2011/12 (looking forward)
1. “Never Events.” Never events are serious, largely preventable, patient safety incidents that should not occur if the available preventative measures have been implemented. From the core never events, there are
5 that affect Ramsay:
•
Wrong site surgery
•
Retained instrument post-operation
•
Wrong route administration of chemotherapy
•
Misplaced naso or orogastric tube not detected prior to use
•
Intravenous administration of mis-selected concentrated potassium chloride
The Department of Health lists twenty five “never events”, twenty one of which are relevant to Ramsay and Park Hill Hospital has robust clinical governance processes in place to mitigate the risk of such an event occurring.
2. VTE risk assessment . Park Hill Hospital submits data to evidence compliance with the National VTE Commissioning for Quality and
Innovation Goal that all patients should have a VTE risk assessment. Park
Hill Hospital’s priority for 2011/12 in this regard is to maintain the current compliance rate of 100%.
Compliance results are benchmarked through the national statistics at: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publications
Statistics/DH_122283
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3. Infection Control. A priority for 2011 is the implementation of a newly introduced infection control initiative, entitled Aseptic Non Touch
Technique (ANTT). The purpose of the ANTT technique is to reduce contamination of wounds and susceptible sites and its implementation will minimize the risk of wound infections.
A comprehensive infection control audit programme has been undertaken throughout 2010 / 2011, the main focus being to increase the awareness of infection prevention and control in all areas of the hospital. Audits undertaken were:
•
Hand hygiene
•
Peripheral venous catheter care
•
Urinary catheter care
•
PEAT – Patient Environment Action Team
4. Real time incident reporting – Park Hill Hospital strives to report any incidents in real time through the Risk Information Management System
(RIMS). The system immediately reports any incident into the Corporate
Risk Management Team, enabling trends to be identified throughout the
Ramsay organisation. Locally all incidents are reported through Risk
Management and Clinical Governance groups and action plans developed and implemented to improve patient safety.
5. ‘Pulse’ staff survey results – Ramsay staff undertake an anonymous survey annually to identify areas where staff satisfaction can be improved upon. One area of improvement for Park Hill Hospital from the 2010 survey is to ‘improve communications between different teams and departments.’
30% of staff working at Park Hill felt that communications between different departments and teams could be better.
6. Acute Care Competencies / Vulnerable Adult training – Park Hill staff complete annual mandatory training programmes and receive in-house practical training on acute care competencies, and vulnerable adults to ensure that safe and competent staff are available to care for all our patients.
Clinical Effectiveness
1. Ambulatory Day Care – better outcomes and improving patient experience
Ambulatory Care (or Day Surgery Care) is the admission of selected patients (both medical and surgical) to hospital for a planned procedure, returning home the same day i.e. the patient does not incur an overnight stay. Over recent years, partly due to medical advances the number of day surgery patients has increased compared to those requiring inpatient
Quality Accounts 2010/11
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care. In 2010 the percentage of day surgery patients we treated was 52%.
We need to ensure that our hospital facilities and patient flows better meet the case mix we now deliver. We are committed to ensuring that the patient pathway provides patients with the best standard of care.
2. Improve National Benchmarking
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 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, day case rates, unplanned readmissions, average length of stay, unplanned transfers, 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
3. 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.
4. Improved patient information
It was recognised from our patient satisfaction survey results that our patients were not always receiving written discharge 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
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ensures that they have the same information should they need to refer to it at a later date.
1. Increasing the use of Patient Reported Outcomes Studies (PROMs)
Park Hill Hospital is increasing use of the national PROMs results for hip, knee, varicose veins and hernia surgery, encouraging their use to gain a better understanding of treatment outcomes from the patient’s view point.
Results are shared with consultants and physiotherapists and they are encouraged to use them to review their practice in discussion at the regular Clinical Governance Meetings.
2. Patient Satisfaction survey
Improving our patient wait times from admission to procedure
– it was recognised that the question related to patient wait times did not give a true reflection of patient expectation. In 2010 our average score for this question showed that 34.4% of our patients waited over 2 hours for their procedure. This did not take into account patients expectation and the reasons for the wait (e.g. tests or arriving early). We therefore undertook a review of our questionnaire in order to give a clearer indication of patient expectation i.e. was the wait less or more than they expected.
Quality Accounts 2010/11
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During 2010/11 Park Hill Hospital provided 5 NHS services.
Park Hill Hospital has reviewed all the data available to them on the quality of care in all of these 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 hospitals senior managers together with regional and Corporate Managers. The balanced scorecard approach has been an extremely successful tool in helping us benchmark against other hospitals and identifying key areas for improvement.
In the period for 2010/11, the indicators on the scorecard which affect patient safety and quality were:
Human Resources
HCA Hours as % of Total Nursing
Agency Hours as % of Total Hours
% Staff Turnover
% Sickness
Total Lost Worked Days
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff Injuries
Patient
Formal Complaints per 1000 Hospital
Patient Days
Patient Satisfaction Score
Number of Significant Clinical Events
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
The national clinical audits and national confidential enquiries that Park Hill
Hospital participated in, and for which data collection was completed during 1
April 2010 to 31 st
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.
Quality Accounts 2010/11
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National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Participation
(NA, Yes, No)
% cases submitted
Acute care
Cardiac arrest (National Cardiac Arrest Audit)
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Additional Audits
National surveillance Programme
PEAT Audit
NA
Yes
Yes
NA
Yes
NA
100
100
NA
100
The reports of the applicable national clinical audits from 1 st
April 2010 to 31 st
March 11 were reviewed by the Clinical Governance Committee and Park Hill
Hospital intends to take the following actions to improve the quality of healthcare provided.
Local Audits
The reports of 24, which includes 9 infection prevention and control, 4 transfusion, and 3 physiotherapy local clinical audits from 1 April 2010 to 31 st
March 2011 were reviewed by the Clinical Governance Committee and Park Hill
Hospital intends to take the following actions to improve the quality of healthcare provided:
•
Increase awareness of good hand hygiene techniques for all staff
•
Improve written communication relating to patient treatment in the physiotherapy department through improved clinical records
The clinical audit schedule can be found in Appendix 2.
There were no patients recruited during 2010/11 to participate in research approved by a research ethics committee.
Park Hill Hospital’s income from 1 st
April 2010 to 31 st
March 2011 was not conditional on achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation payment framework because the hospital was not signed up to the Standard Acute Contract.
Quality Accounts 2010/11
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Park Hill Hospital is required to register with the Care Quality Commission and its current registration status on 31 st
March is registered without conditions.
The Care Quality Commission has not taken enforcement action against
Park Hill Hospital during 2010/11.
Park Hill Hospital has not participated in any special reviews or investigations by the CQC during the reporting period.
Quality Accounts 2010/11
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Statement on relevance of Data Quality and your actions to improve your
Data Quality
•
Park Hill Hospital will be taking action to ensure that data quality is maintained to high standards through the regular monitoring of compliance with professional standards with regard to recording of information, through the corporate audit programme.
NHS Number and General Medical Practice Code Validity
Park Hill Hospital submitted records during 2010/11 to the Secondary
Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data.
The percentage of records in the published data which included:
•
the patient’s valid NHS number was:
98.6% for admitted patient care;
98.5% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
•
the General Medical Practice Code was:
98.9% for admitted patient care;
99.7% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall score for 2010/11 was 79% and was graded ‘green’ (satisfactory).
Clinical coding error rate
Park Hill Hospital was not subject to the Payment by Results clinical coding audit during 2010/11 by the Audit Commission.
Quality Accounts 2010/11
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This Quality Account was sent to Doncaster PCT prior to publication for any comments to be inserted in this quality account.
No comments were received.
Quality Accounts 2010/11
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“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)
The aim of clinical governance is to ensure that Ramsay develop ways of working which assure that the quality of patient care is central to the business of the organisation.
The emphasis is on providing an environment and culture to support continuous clinical quality improvement so that patients receive safe and effective care, clinicians are enabled to provide that care and the organisation can satisfy itself that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance systems in the organisation and should not be seen as a “stand-alone” activity. All management systems, clinical, financial, estates etc, are inter-dependent with actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded, implemented and can be monitored in an organisation. In developing this framework for Ramsay Health Care UK we have gone back to the original Scally and Donaldson paper (1998) as we believe that it is a model that allows coverage and inclusion of all the necessary strategies, policies, systems and processes for effective Clinical Governance. The domains of this model are:
• Infrastructure
Quality Accounts 2010/11
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• Culture
• Quality methods
• Poor performance
• Risk avoidance
• Coherence
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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We are a progressive hospital and focussed on stretching our performance every year and in all performance respects, and certainly in regards to our track record for patient safety.
Risks to patient safety come to light through a number of routes including routine audit, complaints, litigation, adverse incident reporting and raising concerns but more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs below.
Park Hill Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a Corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two years. Our IPC programmes are designed to bring about improvements in performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
•
All staff undertake mandatory, annual infection prevention and control training.
Quality Accounts 2010/11
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Infection rates % of admissions for last 3 years
0.45%
0.40%
0.35%
0.30%
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
2008 2009 2010
•
As can be seen in the above graph our infection control rate has decreased year on year. In comparison to the national average it is well below, and this is due to increased general awareness of hand washing and proactive initiatives to demonstrate to patients the importance of hand washing, and the frequency with which staff wash their hands.
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits.
These assessments include rating of privacy and dignity, food and food service, access issues such as signage, bathroom / toilet environments and overall cleanliness.
PEAT
99%
98%
97%
96%
95%
94%
93%
2008 2009 2010
•
As can be seen in the above graph our overall cleanliness rate has increased over the past 3 years.
Quality Accounts 2010/11
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Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety. Our record in workplace safety as illustrated by Accidents 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 which ensures we keep up to date with all safety issues.
12
10
8
6
4
2
0
2008 2009 2010
•
As can be seen in the above graph our adverse events rates have increased over the last three years. This has been due to increased awareness of the reporting procedure, and development of a no-blame culture, where adverse events are reported in order to ensure practices are reviewed to ensure that lessons are learnt to prevent a recurrence.
Park Hill Hospital has a Clinical Governance Committee that meets 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 medical advisory committees to ensure 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.
Quality Accounts 2010/11
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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.
0.50%
0.40%
0.30%
0.20%
0.10%
0.00%
2008 2009 2010
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.
0.80%
0.70%
0.60%
0.50%
0.40%
0.30%
0.20%
0.10%
0.00%
2008 2009 2010
Quality Accounts 2010/11
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All feedback from patients regarding their experiences with Ramsay Health Care are welcomed and inform service development in various ways dependent on the type of experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour – letters and cards are displayed for staff to see in staff rooms and notice boards. Managers ensure that positive feedback from patients is recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the relevant staff using direct feedback. All staff are aware of our complaints procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular agenda items on Local Governance 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 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
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 envelop addressed directly to TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also separately for NHS and private patients). The results are available for patients to view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel they receive excellent quality of care and service in Park Hill Hospital. To record a satisfaction index over 90%, a very high proportion of our patients have scored 9
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or 10 out of 10 for their satisfaction with all the requirements. This is underlined by comparing our hospitals Satisfaction Index against those achieved by other organisations across all sectors of the UK economy where the full range of customer satisfaction is 50% to 95% with the median just below 80%.
94%
92%
90%
88%
86%
84%
2008 2009 2010
•
As can be seen in the above graph our Patient Satisfaction rate has increased over the past 3 years. This is due to continuous improvement processes in all areas of the hospital. All complaints and compliments are reviewed regularly to ensure we are meeting our customer’s expectations.
This year on year improvement shows how we listen to criticisms of our organisation, in order to improve and enhance our services.
Patient satisfaction index of over 90% means that Park Hill Hospital rates in the top 2-3% of organisations.
Park Hill Hospital participates in the Department of Health’s PROMs surveys for hip and knee surgery, hernias and varicose veins for NHS patients.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs surveys specifically for private patients.
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
DONCASTER PCT
311
289
*
*
20.043
18.124
16.205
16.042
34.669
National
45,622
43,735
289
1,598
19.852
19.722
19.592
18.077
37.8
PARK HILL HOSPITAL
113
107
*
*
22.562
19.682
16.801
17.062
37.23
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Hip Replacement - Oxford Hip Score - Adjusted Health Gain
25
20
15
10
5
0
DONCASTER PCT National PARK HILL HOSPITAL
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
DONCASTER PCT
315
281
7
27
14.81
13.01
11.209
16.654
30.013
National
49,258
45,155
688
3,415
14.875
14.741
14.607
18.754
33.494
PARK HILL HOSPITAL
144
124
*
*
14.924
12.125
9.326
17.729
30.563
Knee Replacement - Oxford Knee Score - Adjusted Health Gain
8
6
4
2
16
14
12
10
0
DONCASTER PCT National PARK HILL HOSPITAL
An adjusted measure (adjusted health gain) has been included to allow the comparison of organisations against the national adjusted health gain.
The adjusted measure, based on models developed by contractors employed by the Department of Health (CHKS Ltd in conjunction with Northgate Information
Solutions Ltd), takes into account the fact that organisations deal with patients with a differing casemix e.g. a large proportion of a provider’s patients may be in a poor state of pre-operative health before undergoing surgery compared to another provider who is treating a higher proportion of patients with high levels of pre-operative health.
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Park Hill Hospital has worked closely with the Doncaster & Bassetlaw Hospitals
NHS Foundation Trust since the unit opened on the site of the Doncaster Royal
Infirmary in April 1995.
The two parties continue to work together to ensure that all patients requiring elective surgery are seen well within the Government target of 18 weeks from GP referral. The relationship between the two hospitals has grown over the past 16 years, and the Consultants and staff of the two units continue to work closely together ensuring that patients in the local community receive a high quality clinical service that meets their needs.
Since 2007, Park Hill Hospital has had formal agreements with Doncaster &
Bassetlaw Hospitals NHS Foundation Trust to provide elective orthopaedic procedures. Over the past 3 years Park Hill Hospital has operated on over 2,000 patients under these agreements, with outcomes for hip and knee replacements comparable with the local PCT, as seen on the PROMs graphs on the previous page.
Quality Accounts 2010/11
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Appendix 1
Anaesthetics
Cardiology
Cosmetic Surgery
Dermatology
Ear, Nose and Throat
General Surgery
Gynaecology
Ophthalmology
Orthopaedic
Physiotherapy
Plastic Surgery
Podiatry
Urology
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2010/11
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Neurological Centres
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