Quality Account
2010/11
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Rivers 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
Page 2 of 36
Welcome to Ramsay Health Care UK
Rivers 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 the Rivers Hospital 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 patients’ 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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Part 1
1.1 Statement on quality from the General
Manager
Mr Andy Haysman, General Manager,
Rivers Hospital
Ramsay Healthcare UK is committed to establishing an organizational 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.
Rivers 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 minimize 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 Rivers 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
at each step of their pathway. We especially value patient’s feedback about their
stay, treatment and clinical outcome.
Quality Accounts 2010/11
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The Rivers 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 affect 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
Quality Accounts 2010/11
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Mr Andy Haysman
General Manager
Rivers Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Bernard Potluri,FRCS, Consultant Urologist, MAC Chair
Medical Advisory Committee Chair
Signature………………………………………………….. Date………………………..
Dr Dev Dutta Consultant Anaesthetist
Clinical Governance Committee Chair
Signature………………………………………………….. Date…………………………
Mr Richard Parsons, Regional Director East
Signature………………………………………………….. Date………………………..
Commissioner/PCT and other external bodies
PCT Commissioner
Signature…………………………………………………. Date…………………………
Signature…………………………………………………. Date…………………………
Quality Accounts 2010/11
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Welcome to Rivers hospital
The Rivers is a private hospital set in quiet landscaped grounds in
Sawbridgeworth, Hertfordshire. It is one of the largest hospitals within
Ramsay Health Care UK. It opened in March 1992, and has become
popular with patients from the Hertfordshire and Essex region. It is easily
accessible with ample free car parking.
The Rivers has 59 in patient bedrooms; all have en-suite bathrooms to
ensure patient comfort and privacy. Additionally there is a dedicated day
case suite with 9 bays, and a minor ops theatre. The hospital has four
operating theatres, which are well equipped with the latest surgical
technology.
The out-patient department has 13 Consulting rooms and 3 private
treatment rooms, with a modern equipped physiotherapy department and
gym, a well equipped imaging department with x-ray, ultrasound, CT &
MRI scanning facilities, Digital Mammography and a DEXA scanning.
All 223 Consultants are subject to strict vetting procedures to ensure only
those with the appropriate experience and qualifications are granted
Practising Privileges and hence can offer treatment at Rivers Hospital.
The Staff at the Rivers are professional and friendly, and deliver high
levels of customer service. In 2010 the hospital won the Harlow and
District Business Awards for Customer Care and has also been successful
in achieving Top 10 places in the Healthcare 100 Best Employer Awards
(IPSOS Mori) over recent years.
We provide fast, convenient, effective and high quality treatment for
patients of all ages (children over the age of 3 years as inpatients),
whether medically insured, self-pay, or NHS funded.
Patients can self refer for Vive Cosmetic Surgery consultation, and for
Physiotherapy services.
The Rivers offers a range of elective surgical, non-surgical and outpatient
treatments across the following specialities: Allergy Clinic, Breast /Reconstructive surgery, Cardiology (Cardio-thoracic
Surgery at Orwell Suite), Colo-rectal surgery, Cosmetic surgery,
Dermatology, Diabetes/Endocrinology, Diagnostic Services, Dietician,
Ear, Nose and Throat, Endoscopy, Fertility services, Gastro-enterology,
General Medicine, General surgery, Gynaecology, Haematology, Health
Screening, Laparoscopic Surgery, Neurology, Neuro-Radiology, Oncology,
Ophthalmology, Oral and Maxillo-Facial Surgery, Orthopaedic Surgery,
Paediatric Services, Pain Medicine, Pharmacy, Physiotherapy, Plastic
Quality Accounts 2010/11
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Surgery, Private GP & Practice Nurse service, Psychiatry, Psychotherapy,
Rheumatology, Spinal Surgery , Urology including Brachytherapy, ,
Vascular, Weight loss Clinics (Bariatric surgery at Springfield Hospital).
The Hospital attracts referrals from sister hospitals within Ramsay Eastern
region as a specialized centre for services such as Brachytherapy
(Prostate Cancer), Chemotherapy services (Cancer), DEXA scanning
(Osteoporosis), Phototherapy (Skin conditions), and on site CT scanning
(Diagnostic Imaging).
The Rivers acts as a satellite for other centres to offer services through a
hub & spoke system. These include Fertility services (Bridge Fertility
Centre), Cardio-thoracic surgery (Ramsay Orwell Suite) and Weight Loss
Surgery (Springfield Hospital).
Last Year the Rivers admitted a total of 10,631 Patients.
Of these 6020 were Private Patients (56.7%) and 4,611 were NHS
Patients (43.3%)
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 Consultants.
Permanent hospital staff include Registered Nurses, Health Care
Assistants, Operating Department Practitioners, Physios, Pharmacists,
Radiographers, administrative staff, caterers, housekeepers and porters.
All clinical and support staff have the relevant training and skills to fulfill
their roles and this is an on going process. There is also a Rivers Hospital
Staff Bank which provides extra support and flexibility to the service where
needed.
The Rivers works closely with local Primary Care Trusts in Hertfordshire
and West Essex, to support commissioning of healthcare services for the
local NHS population. The hospital also has close links with Princess
Alexandra NHS Trust (Harlow) and East and North Herts NHS Trust
Hospitals (WGC and Stevenage), including histopathology services and
emergency transfer provision.
The Rivers employs a GP liaison officer to ensure local GPs are well
informed about the services offered at the hospital.
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The hospital also provides a programme of educational seminars for
healthcare professionals including specialist sessions and basic life
support.
The Rivers is closely associated with the Helen Rollason Cancer Charity,
which has a Holistic therapy centre and offices within the hospital site.
The hospital supports local schools, charities and associations through
sponsorship and fund raising events throughout the year.
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Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
On an annual cycle Rivers 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)
•
•
•
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.
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 results for Rivers Hospital were:
Environment – good (91.45%)
Food – good (85.5%)
Privacy and dignity – excellent (100%)
A major refurbishment project in 2010 provided an improved Day Care
facility to increase efficiency and quality of care for our Ambulatory Care
Quality Accounts 2010/11
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•
patients. This is in keeping with the new Ramsay Ambulatory Policy, with
which Rivers Hospital is compliant.
Releasing time to care – the Productive Ward project was successfully
trialled at 5 Ramsay sites including Rivers Hospital . Examples of
improvements made include the re-organisation of a Clinical Room and a
storage area. An instruction manual has been developed by the project
team and roll out sessions have been held, with Rivers Hospital leading for
the Eastern Region.
2.1.2 Clinical Priorities for 2011/12 (looking forward)
Patient safety
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.
‘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.
Incidents and near-misses will continue to be reported and investigated through a
robust Clinical Governance system, with lessons learned to reduce the risk of
future incidents and the impact of them.
Pulse (Staff satisfaction) survey
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The latest survey shows favourable results, with 91.6% of staff stating that
they enjoy their work, 91.4 % having had an appraisal within the previous
12 months and 86.2% feeling that they are treated fairly and with respect
by their line manager. Communication could be improved between teams
and Depts and each HOD has identified ways in which this could be
achieved.
Clinical effectiveness
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 care.
Approximately 78% of patients are now treated on a day care basis. We need
to ensure that our hospital facilities and patient flows continue meet the case
mix we now deliver.
Our newly refurbished Day Unit has enabled us to provide a higher quality and
more efficient level of service to those patients undergoing day care
procedures. We will continue to monitor this through a variety of methods such
as reporting tools, patient and Consultant feedback and clinical KPIs eg. Readmission rates and returns to Theatre.
Benchmarking
We will continue to take part in surveys such as National Joint Registry (NJR),
PROMS (Patient Reported Outcome Measures) and TLF (The Leadership
Factor patient satisfaction survey). We will use the data provided to benchmark
against other Ramsay sites, to maintain our positive outcomes and to identify
areas for development. The working relationships between Ramsay sites, and
the availability of Group-wide data, enables the sharing of best practice and
learning from each other.
Improved patient information
It was recognised from our patient satisfaction survey results that our patients
were not always receiving written discharge information on discharge, or did
not realise that they had been given it. 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.
- In Quarter 3 2010 (July-September) responses to the question “Did you
receive written information about how to look after yourself at home?”
showed a 26.4% failure rate.
Quality Accounts 2010/11
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-
-
Steps were taken to reduce this rate, including reviewing the literature
available and ensuring the patient took it home and did not
inadvertently leave it in the room on discharge.
In Quarter 4 2010 (October –December) the failure rate to this question
had reduced to 23.4% and an action plan has been implemented to
reduce this rate further.
Patient experience – informing patient choice
1. Increasing the use of Patient Reported Outcomes Studies (PROMs)
We will make better use of the national PROMs results for Hip, Knee,
Varicose Veins and Hernia surgery by sharing their results with Surgeons
(and physiotherapists) and encouraging them to use them to review their
practice via Speciality and Departmental 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 50% of our patients waited over 2 hours for their
procedure. Similar results were obtained across the Group. However we
identified that this did not take into account patients’ expectations 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 is an
important factor for patients and links with the Ramsay Ambulatory Care
Policy.
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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 Rivers Hospital provided and/or subcontracted 35 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 Rivers Hospital 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 and their teams, 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
Consultant Satisfaction Score
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2.2.2 Participation in clinical audit
During 1 April 2010 to 31st March 2011, Rivers 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
Paediatrics
Participation
(NA, Yes, No)
% cases
submitted
NA
NA
Acute care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic
Society)
Non invasive ventilation (NIV) - adults (British Thoracic
Society)
Pleural procedures (British Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
Vital signs in majors (College of Emergency Medicine)
Adult critical care (Case Mix Programme)
Potential donor audit (NHS Blood & Transplant)
n/a
n/a
Yes
n/a
n/a
n/a
Long term conditions
n/a
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
n/a
90%
n/a
n/a
nil
n/a
n/a
n/a
n/a
n/a
Cardiovascular disease
n/a
Renal disease
n/a
Cancer
n/a
Trauma
n/a
Psychological conditions
n/a
Blood transfusion
O neg blood use (National Comparative Audit of Blood
Transfusion)
No –
Platelet use (National Comparative Audit of Blood Transfusion)
No –
insufficient
numbers to
meet criteria
insufficient
numbers to
meet criteria
Local Audits
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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. Further audits include paediatric care and cosmetics. The local Clinical
Governance Committee reviews audit results and recommends/supports appropriate
action. For example, it was identified that there was room for improvement in
documentation of the 2nd stage of the consent process. An action plan was implemented
to improve this, including information and support for the medical and nursing teams, and
this led to a rise in the consent audit results.
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 Rivers 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)
Rivers 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
Rivers Hospital during 2010/11.
Rivers 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
Statement on relevance of Data Quality and your actions to improve your
Data Quality
Rivers 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. A recent Audit Commission visit provided evidence of
the general approach in commenting that the “coding accuracy at Rivers was one
of the best examples they had come across”.
They rated as excellent the
following:
Achievement of 99.4% accuracy of coding primary diagnosis.
Achievement of100% accuracy of coding primary procedure
Policies and Procedures
Internal audit practice
Training of staff
Medical notes
Culture of transparency and learning
It is considered these values and high standards are embedded across all
systems in the hospital.
Rivers 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
Rivers 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:
98.9% for admitted patient care;
99.3% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
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the General Medical Practice Code was:
99.9% for admitted patient care;
99.9% for out patient care; and
0% for 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
% Primary
Procedures
Incorrect
% Secondary
Procedures
Incorrect
Rivers
% Secondary
Diagnosis
Incorrect
Site
% Primary
Diagnosis
Incorrect
As previously highlighted Rivers Hospital 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:
0.6
3.1
0
0.6
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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
Monica Clarke, 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.
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.
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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.
3.1.1 Infection prevention and control
H.A.I
0.5
% of admissions
0.4
0.3
0.2
0.1
0.1
0
0.1
0
Q1
0
Q2
Q3
Q4
Rivers Hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 5 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia 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.
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A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice. We have
excellent links with the IPC team at the local Trust and these assist us in all our
IPC practices.
Programmes and activities within our hospital include:
•
•
•
Training (eg. Handwashing awareness), audits, campaigns.
Surveillance of all infections including the participation in hip/knee studies
with the Health Protection Agency.
Close monitoring of any infections including causes, trends and actions.
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 Rivers Hospital were:
Environment – good (91.45%)
Food – good (85.5%)
Privacy and dignity – excellent (100%)
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.
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.
3.2 Clinical effectiveness
Rivers Hospital has a Clinical Governance team and committee that meets
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
Quality Accounts 2010/11
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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. In
2010 an incident/near- miss rate of 1.42% of activity was logged.
3.2.1 Return to theatre
Return to Theatre
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.3
0.2
0.1
0.17
0.1
0
Year 2008
Year 2009
Year 2010
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Unplanned returns to theatre
1
0.9
% of Admissions
0.8
0.7
0.6
0.5
0.4
0.3
0.3
0.2
0.2
0.1
0.1
0.1
0
Q1
Q2
Q3
Q4
2010
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
Unplanned Re-admission
0.7
0.6
0.6
0.6
0.5
0.5
0.4
0.3
0.2
0.1
0.1
0
Q1
Q2
Q3
Q4
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.
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 and kept on their file. Positive comments are shared widely via the
HODs team , in written format for sharing, with the patient’s details anonymised.
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 shared with the
relevant staff. All staff are aware of our complaints procedures should our
patients be unhappy with any aspect of their care.
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Patient experiences are fed back via the various methods below, and are regular
agenda items on Local Governance Committtees and HODs meetings 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 group
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
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3.3.1 Patient Satisfaction Surveys
Patients who would recommend Rivers Hospital to others (TLF)
100.5
100%
100
99.5
99.2%
% of patients
99
98.5
98
97.5%
97.5
97%
97
96.5
96
95.5
Q1
Q2
Q3
Q4
2010
Rivers Hospital Patient Satisfaction Index (2010)
100%
100
99.5
99.1%
99
98.5
98.1%
98
97.5
97
96.7%
96.5
96
95.5
95
Q1
Q2
Q3
Q4
Overall Satisfaction % (Good, V Good, Excellent)
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Rivers Hospital Satisfaction Index 2010
100
% Satisfaction Index
98
96
94.8%
93.6%
94
92.6%
92
91.9%
90
88
86
Q1
Q2
Q3
Q4
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 Rivers 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%.
With an overall satisfaction score of 93%, Rivers Hospital is rated in the top 2-3%
of organisations.
In 2010 the questionnaire used was adapted to ensure the most effective
feedback from patients was obtained.
Areas for improvement have been identified as:
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Our patients were not always receiving written discharge information on
discharge, or did not realise that they had been given it. 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.
- In Quarter 3 2010 (July-September) responses to the question “Did you
receive written information about how to look after yourself at home?”
showed a 26.4% failure rate.
- Steps were taken to reduce this rate, including reviewing the literature
available and ensuring the patient took it home and did not
inadvertently leave it in the room on discharge.
- In Quarter 4 2010 (October –December) the failure rate to this question
had reduced to 23.4% and an action plan has been implemented to
reduce this rate further.
Despite low levels of infection and a high satisfaction score regarding cleanliness,
an area for improvement was found to be the visibility of staff using hand gel or
washing their hands, with a failure rate of 8.8%. Hand hygiene audits have
demonstrated that staff are doing so, however it appears that not all patients are
aware of this. The IPC Link Nurse has therefore undertaken to raise awareness –
for eg. encouraging staff to explain that they have/are about to wash their hands
or use gel. The location of gel dispensers, placed outside patient rooms where
patients cannot see their use, is also under review for 2011/2012.
3.3.2 Patient Reported Outcome Measures (PROMs)
Rivers 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.
To access Rivers Hospital PROMs scores:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryI
D=1295
3.4 Rivers Hospital Case Study
PHOTOTHERAPY SERVICE
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In September 2010, we were approached by the local PCT about being able to provide a
Phototherapy Service for their dermatology patients.
Historically there had been a Phototherapy Service run at Herts & Essex, Epping and Saffron
Walden Hospitals but these had all stopped their service. Their patients were either having to
travel to Cambridge or received expensive drugs as an alternative treatment.
In Keats House, a local GP Practice, the PCT still owned a UVA/UVB combined machine which
had been sitting there for several years with no-one to run the service.
From being asked and agreeing to set up the service, the machine has been transported to The
Rivers Hospital and installed in the Physiotherapy Department, in an air conditioned room to
meet with all Health and Safety requirements.
Two therapists have been trained to run the service and all protocols established with the
Consultant Dermatologist in line with the guidelines set by St Thomas and Guys Hospital, who
lead Phototherapy in the South East of England.
The first patients were treated on the 1st March 2011, having been referred from the local Clinic
run by the two Consultant Dermatologists based at Princess Alexandra Hospital. Each patient is
referred for 18 sessions of UVB-narrowband treatment. The follow up clinic for discharge is run
fortnightly at The Rivers by the Dermatology Department.
At present, we have received 58 referrals of which 15 have completed their treatment and have
been discharged.
In terms of outcome measures we have examples of the following successes.
An 18 year old girl who has felt able to go on holiday with friends for the first
time.
A professional sportsman back competing who has not been able to for
several years as his arms were so sore.
New referrals arrive weekly and we have a target to get a first appointment allocated within two
weeks of receiving the referral.
Appendix 1
Services covered by this quality account
Regulated Activities – Rivers Hospital
Quality Accounts 2010/11
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Regulated Activities – Rivers Hospital
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Bariatrics, Breast care, Cardiology,
Clinical neuro physiology, Colorectal,
Continence care, Cosmetics,
Dermatology, Dietetics, Elderly care,
Endocrinology, Fertility,
Gastroenterology, General Medicine,
Haematology, Manual lymphatic
drainage, Medicine, Nephrology,
Neurology, Nurse led sclerotherapy,
Oncology, Ophthalmic, Orthoptics,
Orthopaedic, Out patient satellite
clinics, Paediatrics, Pain management,
Physiotherapy, Podiatry, Private GP
services, Prosthetics services,
Psychiatry (OPD only), Psychology,
Psychotherapy, Renal medicine,
Rheumatology, Sexual health, Speech
therapy, Sports medicine
Breast surgery, Brachytherapy,
Colorectal, Cosmetics inc laser, Day
and Inpatient Surgery, Dermatology,
Ear, Nose and Throat (ENT) inc laser,
Gastrointestinal, General surgery,
Gynaecology inc laser, Neurosurgery,
Ophthalmic inc laser, Oral
maxillofacial, Orthopaedic, Plastic
Surgery, Sentinel node biopsy,
Urological inc laser, Vascular
Peoples Needs Met for:
All adults 18 yrs and over
Children - 3 -12 yrs ambulatory and day surgery only. 12 yrs and above,
inpatients included.
Children 0-3 yrs, outpatients only.
All adults 18 yrs and over and children 3 yrs and above excluding:
•
•
•
•
•
•
•
•
•
•
•
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Patients who are likely to need ventilatory support post
operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission to ITU post
surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild exertion e.g.
from kitchen to bathroom or dyspnoea at rest)
Poorly controlled asthma (needing oral steroids or has had
frequent hospital admissions within last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal activity e.g. 1
flight of stairs or angina at rest)
CVA in last 6 months
Patients with serious mental health illness
However, all patients will be individually assessed and we will only
exclude patients if we are unable to provide an appropriate and safe
clinical environment.
Diagnostic
and
screening
Termination of
Pregnancy
Allergy testing, Audiology, Aortic
aneurysm screening, CT (inc heart
scan), Dexa scanner, Echocardiology,
Endoscopy, GI physiology, Health
screening, Imaging services,
Mammography, MRI, Nerve conduction
and EMG, Neuroradiology, Nuchal
scans, Obstetric Ultrasound,
Pathology, PET and CT scanner,
Phlebotomy, Urinary Screening Aortic
aneurysm screening, and Specimen
collection, Urodynamics
Surgical Termination of
Pregnancy
Children - 3 yrs and above ambulatory and day surgery only. 12 yrs and
above, inpatients included.
All adults 18 yrs and over
All children 0-18 yrs, outpatients appointments only
All patients aged 16 yrs and over
Quality Accounts 2010/11
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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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Rivers 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:
01279 600282
www.rivers-hospital.co.uk
Neurological Centres
Quality Accounts 2010/11
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