Quality
Account
2010/11
People caring for people.
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Pinehill 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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Welcome to Ramsay Health Care UK
Pinehill Hospital is part of the Ramsay Health Care
Group
The Ramsay Health Care Group, was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 22 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, PCTs and acute Trusts.
“Ramsay Health Care UK is committed to establishing an organisational
culture that puts the patient at the centre of everything we do. As Chief
Executive of Ramsay Health Care UK, I am passionate about ensuring that
high quality patient care is at the centre of what we do and how we operate
all our facilities. This relies not only on excellent medical and clinical
leadership in our hospitals but also upon our overall continuing
commitment to drive year on year improvement in clinical outcomes.
“As a long standing and major provider of healthcare services across the
world, Ramsay has a very strong track record as a safe and responsible
healthcare provider and we are proud to share our results. Delivering
clinical excellence depends on everyone in the organisation. It is not about
reliance on one person or a small group of people to be responsible and
accountable for our performance.”
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with
every year we set our targets higher, working on every aspect of our
service to bring a continuing stream of improvements into our facilities and
services.
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2010/11
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Introduction to our Quality Account
This Quality Account is Pinehill Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
The previous Quality Account for 2009/10 was developed by our Corporate Office
and summarised and reviewed quality activities across every hospital and centre
within the Ramsay Health Care UK. It was recognised that this didn’t provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group will develop
its own Quality Account from this year onwards, which will include some Group
wide initiatives, but will also describe the many excellent local achievements and
quality plans that we would like to share.
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Part 1
1.1 Statement on quality from the General
Manager
Mr Paul Tempest, General Manager,
Pinehill Hospital, Hitchin
Ramsay Healthcare UK is committed to establishing an organisational culture that
puts the patient at the centre of everything we do. As the General Manager, I am
passionate about ensuring that high quality patient care is at the centre of what
we do and how we operate our hospital. This relies not only on excellent medical
and clinical leadership but also on our overall continuing commitment to drive
year on year improvement in clinical outcomes.
Pinehill Hospital has a tradition of working closely with Consultants and patients
to ensure the best quality healthcare is consistently being delivered.
Our hospital staff are fully trained in the latest procedures and thus maintain all
areas to the highest standards. Working within the Department of Health
guidelines we focus on patient safety and cleanliness to minimise infection. Any
patient who wants to satisfy themselves on the quality of the hospital and its’
Consultants can be reassured by the Care Quality Commission (CQC) Audits
undertaken by the Department of Health which support the hospital’s excellent
reputation. As General Manager of Pinehill Hospital, I take great pride in the
service we offer our patients and relatives; this is only achieved through a
cohesive team effort and approach.
Our Quality Account is information for our patients and commissioners to assure
them we are committed to sharing our progressive achievements from one year
to the next. As a long standing and major provider for healthcare services across
the world, Ramsay has a very strong record as a safe and responsible healthcare
provider and we are proud to share our results. Our emphasis is to ensure
patients receive safe and effective care, that they feel valued and respected in
decisions about their care ensuring they are fully informed about their treatment
Quality Accounts 2010/11
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at each step of their pathway. We especially value patient’s feedback about their
stay, treatment and clinical outcome.
The Pinehill Hospital Vision Statement is to be a leading provider of health care
services by delivering high quality outcomes for patients and ensuring long term
profitability. This vision is reflected throughout the Quality Report in that the
hospital will constantly strive to improve the quality and suitability of its services to
patients by ensuring there are adequate core policies and skills, effective
feedback mechanisms on the quality and efficacy of its activities and processes in
place to effect improvement at all levels of the organisation.
In preparing this report, the hospital has taken into account the views of a wide
range of stakeholders in the hospital’s activities, including staff, consultants and
the Ramsay organisation, but most importantly the views of patients and their
families which have been sought though questionnaire survey, comment sheets
and focus groups. Furthermore, you are invited to feedback on this document by
sending any comments in writing to me at the hospital.
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Paul Tempest
General Manager
Pinehill Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Adam Frosh, Medical Advisory Committee Chair
Signature...................................................
Date...........................................................
Mr Peter Hope, Clinical Governance Chair
Signature...................................................
Date...........................................................
Richard Parsons, Regional Director
Signature...................................................
Date...........................................................
Commissioner/PCT and other external bodies
PCT Commissioner
Signature..................................................
Date...........................................................
Quality Accounts 2010/11
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Welcome to Pinehill Hospital
Pinehill Hospital
Pinehill Hospital is a beautifully converted (see newspaper clipping in office)
It is set in excellently maintained gardens on the edge of a residential housing
estate. Access to Pinehill Hospital is via Hitchin and is well signposted.
Pinehill has 23 in-patient bedrooms, 2 of which are twin-bedded. All rooms have
en-suite facilities to ensure privacy and dignity. Additionally there is a detached
Day Care Unit with 7 patient bays and 8 further bedrooms. The Hospital has 3
main theatres and a minor theatre/endoscopy suite.
The out-patient department has 10 consulting rooms with 2 treatment rooms, a
physiotherapy department with gym, an imaging department with x-ray,
ultrasound and digital mammography. A CT/MRI van is at the Hospital site 2 or 3
times per week.
All 137 Consultants are subject to strict vetting procedures to ensure only those
with the appropriate experience and qualifications are granted Practising
Privileges and offer treatment at Pinehill Hospital.
The staff at Pinehill are professional and friendly, delivering high levels of
customer service. Together we provide fast, convenient and high quality
treatment for patients of all ages (children over the age of 3 years as inpatients),
whether medically insured, self funded or via the NHS.
Patients can self refer for Vive Cosmetic Surgery consultation, and for some
physiotherapy services.
Medical and surgical procedures are provided for most specialties, including
gynaecology, urology, orthopaedic, ophthalmology, dental, dermatology,
physiotherapy. We also provide diagnostic services such as radiology and some
pathology on site.
Last year (April 2010 – March 2011), Pinehill admitted a total of 5317 patients of
which 2029 (38%) were NHS funded.
Quality Accounts 2010/11
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A well qualified and experienced Resident Medical officer is on site 24 hours/day
to provide high quality medical care to patients under the direction of their
Consultant.
We are very progressive in ensuring that we follow Best Practice wherever
possible, constantly developing our staff in order that services are constantly
reviewed and further improved according to national guidelines. This also results
in high retention and low turnover due to general satisfaction and challenge for
all staff.
We have an active recruitment programme, ensuring that replacement staff are
recruited into new roles and existing vacancies without unnecessary delay, this
results in continuity within the Hospital team, both clinically and otherwise. We
have recently recruited clinical staff with expired clinical qualifications with the
intention of returning these staff to practice, supporting them through the
appropriate re-training courses.
Whilst there is a national shortage of registered nurses, we are committed to
developing our Health Care Assistants (HCAs) through clinical competencies to
enable them to undertake more nursing duties and support the registered staff in
maintaining clinical standards throughout the patient journey.
Permanent hospital staff include Registered Nurses, Health Care Assistants,
Operating Department Practitioners, Physiotherapists, Pharmacists,
Radiographers, administrative staff, caterers, housekeepers, porters and an
engineer.
Pinehill Hospital is home to the Hertfordshire Phototherapy Centre, providing
PUVA and TL01 light therapy for dermatological conditions and Iontophoresis.
We accept direct referrals to the Hospital services from GPs into Endoscopy and
ophthalmology.
We are part of the Eastern Region of Ramsay Health Care and enjoy the services
of a GP Liaison Officer, ensuring that the GPs are always in touch with us and
informed as to the services that we offer and are developing at any time. We have
5 GP seminars planned for this financial year, with the first two being attended by
around 25 GPs at each. Our resuscitation officer trains the GP surgery staff in the
skills of Basic Life Support.
Quality Accounts 2010/11
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Pinehill Hospital works closely with local Primary Care Trusts in Hertfordshire to
support commissioning of healthcare services for the local population. We have
close links with the East and North Herts NHS Trust, including histopathology,
blood transfusion services and emergency transfer provision.
Pinehill has a very high spirit of community within our team and participate in
community activities. This will be the second year that a team has been entered
into the ‘Race for Life’ event in the cause of Cancer Research. Pinehill also
supports the Garden Hospice at Letchworth by sending them an annual donation
collected from any fundraising event that is organised, including the Moonlight
Walk in September.
Pinehill has developed close relationships with the local schools, providing
educational visits for the students and support junior football teams.
Pinehill also provides swift radiological diagnostic services to team players of
Stevenage Football Club.
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Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
On an annual cycle, Pinehill 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.
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 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. This is already
being encouraged between us and our blood transfusion supplier and will
assist in obtaining laboratory results, and electronic record keeping.
• 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.
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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 overall score of 84.7%, with a working group
focusing on reviewing our Food Score achievement.
Meeting endoscopy standards – we are currently registered with the Global
Rating Score (GRS) and our dedicated endoscopy team are working
towards achieving JAG accreditations.
Investment in day surgery facilities – patients undergoing day surgery
procedures are cared for within our new Day Surgery Unit, comprising of
7cubicles and 8 bedrooms. Our smooth and rapid process means that
patients are here for only a few hours prior to discharge.
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.
2.1.2 Clinical Priorities for 2011/12 (looking forward)
Patient safety
1. ‘Never Events’ are serious, largely preventable patient safety incidents
that should not occur if the available preventative measures have been
implemented.
For further details see:
http://www.nrls.npsa.nhs.uk/resources/collections/never-events/
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 never event list has recently been extended to 25 never events, of
which 21 affect Ramsay – but it is recommended that the core events
should be addressed initially.
2. VTE risk assessment - we have successfully improved our VTE rates,
obtaining 100% for the latter part of the year. All admitted patients are VTE
assessed on admission, using the DH assessment tool. All ward and DSU
staff have completed the DH VTE assessment competency training.
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3. Medical Gas Alert – Our engineers and portering staff have all undertaken
training on the safe and efficient use of medical gases. We now have plans
to further this with training and assessment for our clinical staff.
4. Real time incident reporting – although adverse incident forms are
completed in a timely fashion, the details need to be entered onto the
Corporate spreadsheet as soon as possible after the event. This will
ensure any common denominators within the Group so that lessons can be
shared and prevention for further incidents, be put in place. This data will
be entered by the Clinical Lead to ensure completeness with knowledge
and authority.
5. Pulse results for your hospital – Our Hospital staff survey showed an
improvement this year with results rising from ?? to ??.Low achievement
levels such as inter-departmental communication has improved with Heads
of Department having a set time for a short weekly meeting to discuss
ongoing issues and as a support mechanism. Informal staff forums have
been introduced to ensure ownership and participation.
We plan to develop this further with comments being noted in the absence
of the management team, and action feedback to staff at subsequent
forums.
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. within 23hrs 59mins.
• Over recent years, partly due to medical advances the number of day
surgery patients has increased compared to those requiring inpatient care.
In 2010 the percentage of day surgery patients we treated was 74%. We
need to ensure that our hospital facilities and patient flows better to meet
the case mix we now deliver.
• We will aim to ensure that 89% of all day care patients are treated in our
ambulatory care facilities, cared for by staff who are highly skilled in this
type of care delivery.
• In order to do this and provide our patients with a more efficient patient
pathway through the hospital, we will be separating the day surgery patient
from our inpatients. Best practice has shown that by doing this, patient
care will improve as waiting time and recovery period are reduced and
patients maintain and retain their independence as soon as possible within
their home environment.
Quality Accounts 2010/11
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•
This activity will be monitored through the use of specific codes, and the
increased, improved use of our IT systems. The patient satisfaction scores
and comments will illustrate satisfaction of patients.
2. Improve National Benchmarking – how do we compare? e.g.
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
Patient satisfaction figures
• Using CQUIN indicators common to both NHS survey and our own
(e.g. % recommended, same sex accommodation, infection rates)
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, with a failure
rate of 27.6% in quarter 4, that our patients were not always receiving
written discharge information on discharge. This is important as even
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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. Ramsay have
since published a wealth of patient information, which is now routinely
given to patients on discharge. We continue to monitor results.
5. Improve Patient Outcome
By developing strong links with our local Trust, we can ensure staff gain
valuable experience by cross-working and developing new and improved
skills, whilst maintaining quality care delivery through a network of
professionals with extended knowledge.
Access to professional courses and therefore qualifications is vital and
narrows boundaries between healthcare teams.
Patient experience – informing patient choice
1. Increasing the use of Patient Reported Outcomes Studies (PROMs)
• Better use of the national PROMs results for Hip, Knee, Varicose
Veins and Hernia surgery. Encouraging their use in identifying poor
outcomes and examining practice if and where this exists, via
Clinical Governance and Speciality meetings.
• Sharing results with Surgeons (and physiotherapists) and
encouraging them to use them to review their practice. This will be
achieved through Medical Advisory Committee meetings, specialty
meetings and Clinical Governance, Expanding our use of PROMS
surveys to cover more procedures will enable better understanding
of treatment outcomes from the patients view point.
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 40.5% of our patients felt that the delay from
admission time to procedure was too long. 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. This also ties in with the revised ambulatory day
case service we are redesigning as it is hoped that wait times will further
reduce to the more streamlined service.
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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 Pinehill Hospital provided and/or subcontracted 18 NHS
services.
The income generated by the NHS services reviewed in 1 April 2010 to 31st
March 11 represents 100% per cent of the total income generated from the
provision of NHS services by the Pinehill hospital/centre for 1 April 2010 to 31st
March 11
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 HPD's
Patient Satisfaction Score
Number of Significant Clinical Events
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
Infection Control Audit Score
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Consultant Satisfaction Score
2.2.2 Participation in clinical audit
During 1 April 2010 to 31st March 2011, Pinehill Hospital participated in all
national clinical audits to which it was invited and was eligible. Nil returns were
sometimes submitted eg. The Cardiac Arrest Study.
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National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Participation
(NA, Yes, No)
Paediatrics
NA
Acute care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic
Society)
Non invasive ventilation (NIV) - adults (British Thoracic
Society)
Pleural procedures (British Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
Vital signs in majors (College of Emergency Medicine)
Adult critical care (Case Mix Programme)
Potential donor audit (NHS Blood & Transplant)
NA
% cases
submitted
NA
NA
NA
NA
NA
NA
NA
Long term conditions
NA
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Cardiothoracic transplantation (NHSBT UK Transplant
Registry)
Liver transplantation (NHSBT UK Transplant Registry)
Coronary angioplasty (NICOR Adult cardiac interventions
audit)
Peripheral vascular surgery (VSGBI Vascular Surgery
Database)
Carotid interventions (Carotid Intervention Audit)
CABG and valvular surgery (Adult cardiac surgery audit)
Yes
98%
Yes
NA
90%
NA
NA
NA
NA
NA
Cardiovascular disease
NA
Renal disease
NA
Cancer
NA
Trauma
NA
Psychological conditions
NA
Blood transfusion
O neg blood use (National Comparative Audit of Blood
Transfusion)
Noinsufficient
numbers to
meet criteria
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Local Audits
There is a local audit system in place, based on a Group-wide template, covering
areas such as medical records, infection prevention and control, consent,
controlled drugs and radiology. THE LOCAL Clinicla Governance Committee
reviews audit results and recommends/supports appropriate action plans. For
example it was identified that the Anaesthetists were inadequately completing the
anaesthetic chart of patients. The committee wrote to this group of Consultants
with the result of a significant improvement in score.
2.2.3 Participation in Research
There were no patients recruited during 2010/11to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Pinehill Hospital’s income in from 1 April 2010 to 31st March 2011
was conditional on achieving quality improvement and innovation goals agreed
between them and any person or body they entered into a contract, agreement or
arrangement with for the provision of NHS services, through the Commissioning
for Quality and Innovation payment framework. Measures included VTE
Assessment and outpatient follow up rates.
2.2.5 Statements from the Care Quality Commission (CQC)
Pinehill Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is full registration without conditions.
The Care Quality Commission has not taken any enforcement action against
Pinehill Hospital during 2010/11.
Pinehill Hospital has not participated in any special reviews or investigations by
the CQC during the reporting period.
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2.2.6 Data Quality
Pinehill Hospital will be taking the following actions to improve data quality.
High quality data is considered fundamental to the delivery of high quality
services to patients. The hospital is focused on ensuring that high standards are
set in all areas of data recording and reporting supported by regular audit of
manual and IT systems.
As members of the Eastern Region of Ramsay, our medical notes are audited for
coding inaccuracies with this region being commended on the accuracy of our
data recording.
Pinehill Hospital will be taking the following actions to continue to improve data
quality.
• Regular audit
• Ongoing review of procedures and processes
• Training and development of staff
• Ensure lessons learned are effectively communicated.
NHS Number and General Medical Practice Code Validity
Pinehill 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:
98.63% for admitted patient care;
98.52% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
the General Medical Practice Code was:
99.98% for admitted patient care;
99.69% 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).
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Clinical coding error rate
Pinehill Hospital was not subject to the Payment by Results clinical coding audit
during 2010/11 by the Audit Commission.
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2.2.7 Stakeholders views on 2010/11 Quality Account
Awaiting comments.
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Part 3: Review of quality performance 2010/2011
Statements of quality delivery
Mary Barrett, Matron
Introduction
“Ramsay operates a quality framework to ensure the organisation is
accountable for continually improving the quality of their services and
safeguarding high standards of care by creating an environment in which
excellence in clinical care will flourish.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2011
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
•
•
•
Infrastructure
Culture
Quality methods
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•
•
•
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 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.
3.1.1 Infection prevention and control
Pinehill 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:
A ‘live’ scenario set up in a patient bedroom with intentional faults, issues and
concerns to be identified by hospital staff. Approximately 65% of staff visited this
training area, with varying results. This will be repeated in 2011, and a
comparison made as to lessons earned.
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From surveys, it was apparent that patients did not observe staff cleansing of
hands prior to care delivery. Therefore extra training has been provided to raise
awareness of staff so that hands are cleansed where they can be easily
observed. Our HAI rate indicates that hand hygiene is scrupulously followed at all
times.
3.1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits.
These assessments include rating of privacy and dignity, food and food service,
access issues such as signage, bathroom / toilet environments and overall
cleanliness. In 2010 the results for Pinehill Hospital were:
Environment – good (86.01%)
Food – acceptable (69.57%)
Privacy and dignity – excellent (100%)
Our infection control team has met with all housekeepers and delivered training
on the importance of high standard achievement.
3.1.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety. Our record in workplace safety as illustrated by Accidents per 1000
Admissions demonstrates the results of safety training and local safety initiatives.
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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 and
then the hospital teams which ensures we keep up to date with all safety issues.
Our local Safety Committee has devolved departmental audits for completion on
a quarterly basis ensuring safety of staff and hospital visitors at all times.
3.2 Clinical effectiveness
Pinehill hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole. Incident and near-miss
reporting is encouraged to ensure effective learning in a no-blame culture.
3.2.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures
and so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure. Every surgical intervention
carries a risk of complication so some incidence of returns to theatre is normal.
The value of the measurement is to detect trends that emerge in relation to a
specific operation or specific surgical team. Ramsay’s rate of return is very low
consistent with our track record of successful clinical outcomes.
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3.2.2 Readmission to hospital
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be
addressed. Ramsay rates of readmission remain very low and this, in part, is due
to sound clinical practice ensuring patients are not discharged home too early
after treatment and are independently mobile, not in severe pain etc.
As can be seen from the above graph our readmissions to hospital rate has
significantly reduced over the 12 month period as a response to staff
development and awareness.
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This is also as a result of proactivity in the screening of our patients prior to
admission, with anaesthetic assessment and referrals to other specialists as
appropriate.
3.3 Patient experience
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
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called
‘The Leadership Factor‘ (TLF). They print and supply a set number of
questionnaire packs to our hospital each quarter which contain a self addressed
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.
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Patient satisfaction scores for overall quality show the majority of patients feel
they receive excellent quality of care and service in Pinehill hospital. To record a
satisfaction index over 90% a very high proportion of our patients have scored 9
or 10 out of 10 for their satisfaction with all the requirements. This is underlined
by comparing our hospitals Satisfaction Index against those achieved by other
organisations across all sectors of the UK economy where the full range of
customer satisfaction is 50% to 95% with the median just below 80%.
Pinehill’s index is 91.65% and rates in the top 2-3% of organisations.
Pinehill actively review these results as they become available and compile an
action plan each time which is shared with key staff members in order to establish
improvement.
3.3.2 Patient Reported Outcome Measures (PROMs)
Pinehill 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.
Website to access Pinehill Hospital PROMs scores:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryI
D=1295
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3.4 Pinehill Hospital Case Study
It was identified by Pinehill physiotherapy staff and consultants that there weer
difficulties in accommodating all our post operative patients within the department
due to lack of space, with delays between treatment s as a result.
Therefore an alternative area was sourced at a local gymnasium within Hitchin
and so patients are offered the choice of Pinehill attendance or more locally for
them, thus enabling timely and effective rehabilitation in a gymnasium to support
them back to a healthy lifestyle.
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Appendix 1
Services covered by this quality account
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
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Pinehill hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
01462 422 822
www.pinehill-hospital.co.uk
Neurological Centres
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