Contents
Introduction Page
2
Welcome to Ramsay Health Care UK
3
Welcome to The Yorkshire Clinic
4
Introduction to our Quality Account
5
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
6
1.2
Hospital accountability statement
7
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2010/11 (looking back)
8
2.1.2 Clinical Priorities for 2011/12 (looking forward)
10
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
15
2.2.2 Participation in Clinical Audit
16
2.2.3 Participation in Research
17
2.2.4 Goals agreed with Commissioners
17
2.2.5 Statement from the Care Quality Commission
18
2.2.6 Statement on Data Quality
18
2.2.7 Stakeholders views on 2010/11 Quality Accounts
20
PART 3 – REVIEW OF QUALITY PERFORMANCE
24
3.1
Patient Safety
25
3.2
Clinical Effectiveness
29
3.3
Patient Experience
31
3.4
Case Study
35
Appendix 1 – Services Covered by this Quality Account
36
Appendix 2 – Clinical Audits
37
Appendix 3 – Glossary of Abbreviations
38
Quality Accounts 2010/11
Page 2 of 39
Welcome to Ramsay Health Care UK
The Yorkshire Clinic is part of the Ramsay Health Care
Group
The Ramsay Health Care Group was established in 1964 and has grown to become
a global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay
Health Care is one of the leading providers of independent hospital services in
England, with a network of 22 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the
NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of
NHS patient episodes of care each month working seamlessly with other healthcare
providers in the locality including GPs, PCTs and acute Trusts.
“Ramsay Health Care UK is committed to establishing an organisational
culture that puts the patient at the centre of everything we do. As Chief
Executive of Ramsay Health Care UK, I am passionate about ensuring that
high quality patient care is at the centre of what we do and how we operate all
our facilities. This relies not only on excellent medical and clinical leadership in
our hospitals but also upon our overall continuing commitment to drive year on
year improvement in clinical outcomes.
“As a long standing and major provider of healthcare services across the
world, Ramsay has a very strong track record as a safe and responsible
healthcare provider and we are proud to share our results. Delivering clinical
excellence depends on everyone in the organisation. It is not about reliance
on one person or a small group of people to be responsible and accountable
for our performance.”
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with every
year we set our targets higher, working on every aspect of our service to bring
a continuing stream of improvements into our facilities and services.
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2010/11
Page 3 of 39
Introduction to our Quality Account
This Quality Account is The Yorkshire Clinics 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
localised 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 2011 onwards, which will include some Group wide initiatives, but will also
describe the many excellent local achievements and quality plans that we would like
to share.
Quality Accounts 2010/11
Page 4 of 39
Part 1
1.1 Statement on quality from the General
Manager
Rachel Bradbury, General Manager,
The Yorkshire Clinic
“The Yorkshire Clinic is committed to being a leading provider of healthcare
services by delivering high quality outcomes for patients.”
This is the first Quality Account to be submitted by The Yorkshire Clinic and has
been produced to demonstrate our commitment to measuring all feedback from
patients about their experience, clinical treatment and clinical outcomes. This
allows us to continually review, reflect and improve the patient’s journey.
Patient safety is our highest priority and our robust recruitment processes and
training programmes ensure that staff are competent and fully trained in all
aspects of service provision.
The Yorkshire Clinic continually achieves consistent patient satisfaction scores
and, by studying results throughout the year, we constantly seek ways to further
improve the patient experience.
The Yorkshire Clinic is committed to ensuring that patients are kept fully informed
about their treatment, which is also a significant factor associated with improving
treatment outcomes. We involve our patients in treatment decisions at the earliest
stage so that the options and benefits are fully discussed before patients consent
to treatment. Our medical and clinical teams recognise the importance of devoting
time to patient preparation for surgery, which not only reduces risk but also
improves patient understanding and confidence, reduces anxiety, improves rates
of recovery and shortens lengths of hospital stay.
Whilst patient feedback and involvement is extremely important to us, we also rely
heavily on other measures of safety and clinical effectiveness which we use to
satisfy ourselves that treatment is evidence-based and delivered by appropriately
qualified and experienced doctors, nurses and other key healthcare professionals.
Examples of these are detailed in this Quality Account.
The Yorkshire Clinic is accustomed to the disciplines of regulatory and contractual
requirements to assure healthcare commissioners of our clinical performance and
to report complaints and serious incidents to regulators and commissioners. We
also maintain a Risk Register and systematically review specific actions to
achieve risk reduction.
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.
Rachel Bradbury
General Manager
The Yorkshire Clinic
Ramsay Health Care UK
This report has been reviewed and approved by:
Professor Peter O’Donovan – MAC Chairman
Mr James Halstead - Clinical Governance Chair
Mr Stefan Andrejczuk – Regional Director North
Quality Accounts 2010/11
Page 6 of 39
Welcome to The Yorkshire Clinic
The Yorkshire Clinic is a private hospital situated in the grounds of Cottingley Hall in
Bingley, West Yorkshire. The hospital offers care to patients with private medical
insurance, patients who wish to fund their own treatments and patient referred
through the NHS Patient Choice Scheme.
The hospital provides a full range of high quality services, these include, outpatient
consultation, outpatient procedures, investigations/diagnostics, surgery and follow up
care. During the last 12 months the hospital has treated 12,606 patients, 60% of
which were treated under the care of the NHS. All NHS patients treated at the
hospital must be over 18 years of age as defined by the Standard Acute Contract.
Currently, 219 specialist Consultants work from the facility and are supported by a
team of 65 Nursing staff, split between 65 Nursing staff, 28 Health Care Assistants,
58 support staff which includes porters/ hotel services plus 55 administration staff.
The hospitals Resident Medical Officer is on site 24 hours a day, working alongside
these teams.
The hospital has built excellent working relationships with Bradford Teaching
Hospitals NHS Trust, Leeds Teaching Hospital NHS Trust and Airedale Foundation
Trust in order to deliver a joint approach to patient care delivery across the patient
economy.
Our GP Liaison Officer provides links to local General Practitioners to ensure that
their needs and expectations are managed and through these links referral
processes are developed in order to streamline processes.
The Yorkshire Clinic also works with local charities within the local community,
hosting events in their support.
Quality Accounts 2010/11
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Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
On an annual cycle, The Yorkshire Clinic develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our patients and work in partnership with the NHS
ensuring that those services commissioned to us, result in safe, quality treatment for
all patients whilst they are in our care. We constantly strive to improve clinical safety
and standards by a systematic process of governance including audit and feedback
from all those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the 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
•
•
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. In
preparation for this The Yorkshire Clinic electronically prints all patient identity
bands as per the NPSA ‘Standardising Wrist Bands Alert’ 2007
Safer Surgery Checklists – further work was undertaken and two more
speciality specific checklists for radiology and cataracts have been
implemented to further reduce the risk of wrong site surgery.
Quality Accounts 2010/11
Page 8 of 39
•
Cleanliness – A environmental audit was completed and added to the Ramsay
audit programme in July 2010. As per High Impact Intervention VIII (DoH
‘Saving Lives: Reducing Infection; Delivering Clean and Safe Care. 2007) this
evidences two new areas implemented in the year, equipment cleaning
compliance and mattress audit compliance. A cleaning matrix has been written
and is available throughout the hospital identifying equipment to be cleaned;
when; with what and by whom. The ‘green label system’ is used to evidence
cleanliness to patients and staff. PEAT (Patient Environment Action Team)
audits were also repeated and
The Yorkshire Clinic showed an improvement of 13% in the twelve months
to April 2011.
• The Yorkshire Clinic opened a new Endoscopy Suite in September 2009. We
participate in the Global Rating Score audit system (GRS) and are working
towards a Joint Advisory Group (JAG) accreditation. Our endoscopy team have
all successfully achieved their endoscopy competencies to enable The
Yorkshire Clinic to meet the National Endoscopy Standards.
• As part of Ramsay’s National Project for Ambulatory Day Care services The
Yorkshire Clinic has: 1. Undertaken a full Pre-Operative Assessment (POA) review; the
individualised patient care pathways are commenced at POA involving the
patient in all areas of their journey from pre-admission to discharge. To
continually improve and measure the service we offer, a quarterly audit of
the POA documentation is carried out at The Yorkshire Clinic.
2. To ensure we provide and maintain a high standard of pre-operative care,
all qualified POA staff have successfully completed Pre-assessment
training (A & L Healthcare) and the Day Surgery Sister is a member of the
British Association of Day Care Surgery (BADS).
3. In order to facilitate the ambulatory process we strive to place ambulatory
day care patients first on operating lists or, as clinically indicated. The
majority of patients attending for local anaesthesia procedures are
allocated to The Lodge Theatre which is a dedicated day surgery unit.
4. The Yorkshire Clinic have introduced, where appropriate, staggered
admission times to improve the patient experience, aiming to reduce the
waiting time from admission to procedure.
5. To further enhance efficiencies at The Yorkshire Clinic a nurse led
discharge service is operational within our Ambulatory Units.
6. On discharge, patients are provided with contact details should they have
any post operative problems. All ambulatory patients receive a post
discharge phone call within 48 hrs of admission.
• Releasing time to care – the Productive Ward project was successfully trialled
at 5 Ramsay sites during 2010. An instruction manual has been developed by
the project team and roll out sessions are being held regionally throughout the
first half of 2011. In June 2011 The Yorkshire Clinic will be commencing this
scheme.
Quality Accounts 2010/11
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2.1.2 Clinical Priorities for 2011/12
Patient Safety
1. Falls – ‘each year around 282,000 patient falls are reported to the National
Patient Safety Agency (NPSA) from hospitals and other health units.’ (Jan
2011, NHS NPSA/20111RRR001). At The Yorkshire Clinic a project was
undertaken during 2010 to monitor the number of patient falls, identify the risks
and formulate an action plan to minimize slips/trips and falls: To maximize patient safety all patients are asked to complete a medical
questionnaire which is assessed by the POA team to identify any potential
risks prior to admission. On admission a “risk of falls assessment” is performed
for every patient by the admitting nurse, this is reviewed daily and care altered
accordingly.
Information for patients on how to minimize the risk of falls following
surgery/procedures is available in the patient information folder in every room.
Any slip/trip or fall is reported through our robust Risk
Management Committee identifying any trends, formulating and
implementing action plans across the hospital to help improve patient safety.
Slip/trips/falls recorded/reported during 2008 totaled 12, during 2009 – 21 and
during 2010 – 7. The increase in 2009 was due to major development works
throughout the hospital as the recorded incidents include staff, contractors,
visitors and patients. The reduction during 2010 is clear and wholly attributed
to the introduction of a comprehensive action plan.
2. ‘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
There are 25 recognised ‘never events’ of which 5 have been identified as core
events: • Wrong site surgery – The Yorkshire Clinic have implemented the World
Health Organisation (WHO) recommendations for Safer Surgery checklist. The
checklist is a tool used throughout the peri-operative period by the relevant
clinical team to improve the safety of surgery by reducing complications,
ensuring anaesthetic safety and correct site surgery, avoiding surgical site
infections and greatly improving communications within the team.
• Retained instrument post-operation – WHO checklist introduced as above
plus the surgical count procedure including all swabs, needles and instruments
used during surgery to eliminate this risk.
• Wrong route administration of Chemotherapy – The Yorkshire Clinic has
patient specific chemotherapy prescription charts which clearly define route of
administration. The chemotherapy is checked by two senior staff members
prior to administration by our Oncology Nurse Specialist.
Quality Accounts 2010/11
Page 10 of 39
•
•
Misplaced naso or orgastric tube not detected prior to use – rarely used at
The Yorkshire Clinic, however, a pH test is undertaken prior to use of any
naso- or oro-gastric tube
Intravenous administration of mis-selected concentrated potassium
chloride – stored in Pharmacy as a controlled drug only. Ordered, recorded
and prescribed as a controlled drug. To discourage the use of the concentrated
solution The Yorkshire Clinic pharmacy stock a dilute form of potassium and
are working towards removing the concentrated solution from their stock.
The Yorkshire Clinic has experienced zero ‘Never Events’ in the last two years.
3.
VTE risk assessment – The Yorkshire Clinic carry out a VTE risk
assessment on all admitted surgical patients as per Ramsay Policy No
CM001 and adhering to National Institute for Clinical Excellence (NICE)
Guidance 2010.
All pre-assessment staff have completed VTE competency assessment via
DoH on line assessment tool and The Yorkshire Clinic aim to have all ward
based nurses through this competency package in 2011.
From 1st April 2011 The Yorkshire Clinic has entered into a contract for the
provision of NHS services through the Commissioning for Quality & Innovation
Payment Framework (CQUINs). Payment is conditional on achieving quality
improvement and innovation goals, this includes VTE risk assessment.
Compliance is audited through a robust corporate and local audit programme
and results/action plans reviewed through Clinical Governance.
Compliance results are benchmarked through the National Statistics at
http://www.dh.gov.uk/en/publicationsandstatistics/Publications/Publicati
onsStatistics/DH
4. Infection Control -A comprehensive infection control audit programme has
been undertaken throughout 2010, the main focus being to increase infection
prevention and control awareness throughout the hospital. Audits undertaken
were: 1. Central venous catheter care
2. Surgical Site Infection
3. Hand hygiene
4. Peripheral Venous catheter care
5. Urinary catheter care
6. Isolation
7. PEAT – Patient environment action team.
8. Sharps
Hand hygiene remains high on the Infection Control agenda at The
Yorkshire Clinic for 2011. Aseptic Non Touch Technique (ANTT) will be
introduced throughout the year aiming to reduce risk through staff training
and transparency of care.
Quality Accounts 2010/11
Page 11 of 39
5. Real time incident reporting – The Yorkshire Clinic strives to report any
incidents in real time through the Risk Information Management System
(RIMS). The system immediately reports any incident into the Corporate Risk
Management Team therefore trends can be identified throughout the Ramsay
organisation. Locally all incidents are reported through Risk Management and
Clinical Governance groups and action plans developed and implemented at a
local level to improve safety.
Other National reporting mechanisms e.g. MHRA; CQC; local NHS network
are used as required following specific incidents alerting nationally recognised
organisations of identified risks.
6. National Joint Registry – The Yorkshire Clinic participates in the National
Joint Registry audit programme (NJR). Patients undergoing hip or knee
replacement surgery are asked to consent to their information being placed
upon the NJR including details of their prosthesis. The NJR provide a quarterly
report to the Hospital regarding compliance. The Yorkshire Clinic exceeds the
90% benchmark figure for completion.
7. Pulse Staff satisfaction – Ramsay staff undertake an anonymous survey
annually to identify areas where staff satisfaction can be improved upon. One
area for action at The Yorkshire Clinic is ‘staff training and development.’ Our
previous results show 2009 – 53.4%; 2010 – 57.7% A ‘Pulse action group’
was formed and a plan formulated to improve these results. In 2010 Ramsay
e-learning training courses were introduced these can be accessed easily by
all staff either at work or at home. Training is now an agenda item on all team
meetings to raise awareness of both the Ramsay training programmes and
external courses.
8. Acute Care Competencies / Vulnerable Adult training – ensuring safe,
competent staff are available to care for patients. The Yorkshire Clinic staff
complete annual mandatory training programmes and receive in-house
practical training. An electronic training register is kept to monitor staff
completion.
Clinical Effectiveness
1. Ambulatory Day Care – better outcomes and improving patient
experience –
• Ambulatory Care (or Day Surgery Care) is the admission of selected patients
(both medical and surgical) to hospital for a planned procedure, returning
home the same day i.e. the patient does not incur an overnight stay.
• Over recent years, partly due to medical advances the number of day surgery
patients has increased compared to those requiring in-patient care. In 2010
the percentage of day surgery patients we treated was 78.7%.
Quality Accounts 2010/11
Page 12 of 39
•
•
•
At the Yorkshire Clinic we aim to ensure that 100% of our Ambulatory Day
Care patients will be treated in one of our ambulatory care facilities.
In order to achieve this The Yorkshire Clinic provides patients with a more
efficient pathway through the hospital. We have a dedicated day surgery
facility that is separate from our in-patient facility, best practice has shown that
this improves waiting times and recovery periods are reduced.
We will monitor the ambulatory day care experience through our patient
satisfaction surveys.
2. Group pre-operative assessments for major joint replacements – The
Yorkshire Clinic hold pre-operative group physiotherapy sessions for patients
who are coming into hospital for joint replacements; this gives information in an
environment which encourages group interaction and discussion. The
Yorkshire Clinic is taking part in the Ramsay pilot scheme to further enhance
the POA for our patients.
3. Improve National Benchmarking It was recognised that we needed more transparency between ourselves
and other independent sector providers/the NHS in order to monitor and
improve our services. This is even more important now we are working in
partnership with the NHS, e.g. benchmarking in the following areas:
Hellenic
• Hellenic will provide national benchmark figures for key performance
indicators (such as activity/volumes, mortality, day case rates,
unplanned readmissions, average length of stay, unplanned transfers,
returns to theatre).
VTE risk assessment compliance
• Benchmarking through the national stats website. Link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Pu
blicationsStatistics/DH
PROMS results
• Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1
937&category
Patient satisfaction figures
• Using CQUIN indicators common to both NHS survey and our own
Ramsay Healthcare ‘The Leadership Factor’ survey. The Yorkshire
Clinic asks all patients to complete a ‘We Value Your Opinion’ leaflet to
enable us to collate patient opinion and act immediately upon any
concerns.
Quality Accounts 2010/11
Page 13 of 39
4. 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. This initiative asks for staff
suggestions for ways in which they could improve the hospital environment and
processes empowering them to make changes essential to give them more
time to care.
5. Improved patient information
It was recognised from our patient satisfaction survey results that our patients
were not always receiving adequate written information. This is important as
even though we always tell our patients everything they need to know pre and
post-admission, a written reminder ensures that they have the same
information should they need to refer to it at a later date.
At The Yorkshire Clinic all written communications were reviewed and our
survey results show an improvement with pre-operative information between
Q4 2010 and Q1 2011 from 89% to 91.8%. However, our discharge information
satisfaction according to our survey results in Q4 2010 to Q1 2011 has
decreased from 91.4% to 90.5%. Actions are underway to improve this result.
Patient experience – informing patient choice
1. Increasing the use of Patient Reported Outcomes Studies (PROMs) – The
Yorkshire Clinic use the National PROMS results for hip, knee, hernias,
varicose vein and cataract surgery. These are used to gain a better
understanding of treatment outcomes from a patient point of view. Results are
shared with Consultants on an individual basis at our quarterly Medical
Advisory Committee (MAC), and Clinical Governance meetings. All members
of the multi-disciplinary team are encouraged to review the PROMs outcomes
and changes made as required to improve the patient experience.
2. Patient Satisfaction survey – An area for development from our patient
satisfaction survey was that patients were not always aware of staff hand
washing. A pro-active approach was implemented to ensure patients were
either able to view staff washing their hands or were informed that this was to
happen. Staff were also provided with pocket hand-gel to further enhance the
awareness of the importance of hand hygiene. This resulted in an
improvement in patient recognition from 95% in Q4 2010 to 100% Q1 2011.
Quality Accounts 2010/11
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Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2010/11 the Yorkshire Clinic provided and/or subcontracted 17 NHS services.
The Yorkshire Clinic continually reviews all the data available to them on the quality
of care provided.
The income generated by the NHS services reviewed from 1 April 2010 to 31 March
2011 represents 60% per cent of the total income generated from the provision of
NHS services by The Yorkshire Clinic from 1 April 2010 to 31 March 2011.
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 a % of Total Nursing hours is 18.2%
Agency Hours as % of Total Hours is 0.3%
5.4% Staff Turnover
4.84% Sickness
Mandatory Training = 85%
Staff Satisfaction Score = 90%
Number of Significant Staff Injuries = 1
Patient
Formal complaints 1st April 2010 to 31st March 2011 = 0.4%
94.8% Patient Satisfaction Score
2 significant reportable clinical events per 13.851 patients during 2010 = 0.0%.
29 Readmissions per 12,606 patients in 2010
0 EMSA (Eliminating Mixed Sex Accommodation) breaches
Quality Accounts 2010/11
Page 15 of 39
Quality
A comprehensive Health, Safety and Facilities audit was carried out at the Yorkshire
Clinic by the Estates Manager at the end of 2010. This internal audit returned a score
of 87% compliance and an action plan has been developed to correct the key areas
identified. A Disability Discrimination Act audit was carried out in March 2011.
2.2.2 Participation in Clinical Audit
During 1 April 2010 to 31 March 2011, 5 national clinical audits covered NHS
services that The Yorkshire Clinic provides.
The national clinical audits and national confidential enquiries that The Yorkshire
Clinic was eligible to participate in during 1 April 2010 to 31March 2011 are as
follows: -
National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Cardiac arrest (National Cardiac Arrest Audit)
Elective procedures
Hip, knee and ankle replacements (National Joint
Registry)
Elective surgery (National PROMs Programme)
Blood transfusion
O neg blood use (National Comparative Audit of Blood
Transfusion)
Platelet use (National Comparative Audit of Blood
Transfusion)
Additional Audits
National Surveillance Programme (HPA)
PEAT
Participation
(NA, Yes, No)
YES
YES
YES
N/A
% cases
submitted
O%
100%
100%
Numbers
insufficient
for Audit
N/A
Numbers
insufficient
for Audit
YES
YES
YES
YES
The reports of 5 national clinical audits from 1 April 2010 to 31 March 2011 were
reviewed by the Clinical Governance Committee at The Yorkshire Clinic.
Quality Accounts 2010/11
Page 16 of 39
Local Audits
The Yorkshire Clinic participates in the Ramsay Corporate Audit programme (the
schedule can be found in appendix 2) and also carries out a number of local clinical
audits all of which go through the Clinical Governance Committee and actions taken
to improve the quality of the healthcare provided:•
•
•
•
•
•
•
•
MEWS – medical early warning score
Cardiac Arrest Scenario
Waterlow
Pregnancy test
Pre-operative assessment documentation
Critical Care Trolley
WHO – surgical safety check
VTE assessment
The MEWS audit identified a failure by recovery staff to record a MEWS score prior
to the patient returning to the ward. This issue was addressed at Theatre Team
meetings and ward staff were informed not to accept patients for transfer until a
score had been documented. Further audit following implementation of the action
plan has seen a substantial improvement in our compliance rate as illustrated below:
December 2010
January 2011
March 2011
72% compliance
84% compliance
93% compliance
2.2.3 Participation in Research
There were no patients recruited during 2010/11to participate in research approved
by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
The Yorkshire Clinic income from 1 April 2010 to 31 March 2011 was not conditional
on achieving quality improvement and innovation goals through the Commissioning
for Quality and Innovation payment framework because patient safety is our highest
priority and we provide sufficient qualified and trained staff to deliver the service in a
safe environment. We ensure that our staff are competent through a robust
recruitment process and training programmes. We believe it is essential to provide
the right person in the right role at the right time to deliver safe and effective
treatment and care. Staff are trained on all the equipment they are required to use.
They are not allowed to use equipment until they have been trained and deemed
competent.
Quality Accounts 2010/11
Page 17 of 39
2.2.5 Statements from the Care Quality Commission (CQC)
The Yorkshire Clinic is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions
The Care Quality Commission has not taken enforcement action against The
Yorkshire Clinic during 2010/11.
The Yorkshire Clinic has not participated in any special reviews or investigations by
the CQC during the reporting period.
2.2.6 Data Quality
The Yorkshire Clinic will be taking the following actions to improve data quality.
Data quality is one of our highest priorities to ensure we produce clean and accurate
electronic data.
At The Yorkshire Clinic our electronic data quality is checked at every phase of the
patient journey by our staff and monitored constantly by a dedicated data quality
team using multiple reporting mechanisms and various checks to enable us to ensure
the data is of the highest standard.
NHS Number and General Medical Practice Code Validity
The Yorkshire Clinic 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;
98.7% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was:
99.9 % for admitted patient care;
99.7% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
Quality Accounts 2010/11
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Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report overall score for
2010/11 was 79% and was graded ‘green’ (satisfactory).
Clinical coding error rate
The Yorkshire Clinic was subject to the Payment by Results clinical coding audit
during 2010/11 by the Audit Commission and the error rates reported in the latest
published audit for that period for diagnoses and treatment coding (clinical coding)
were:
% Primary
Diagnosis
Incorrect
7
% Secondary
Diagnosis
Incorrect
20.8
% Primary
Procedures
Incorrect
5.2
% Secondary
Procedures
Incorrect
0.7
The Yorkshire Clinic employs a full time Clinical Coder who is responsible for all
procedure coding and is actively involved in all audit processes. All areas for
improvement identified as part of the audit now completed. NHS Bradford and
Airedale were present at the audit feedback and supportive of our action plan.
Quality Accounts 2010/11
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2.2.7 Stakeholders views on 2010/11 Quality Account
The Yorkshire Clinic
2010-2011 Quality Accounts
Statement by Bradford District LINk - Care Quality Working Group
(CQWG)
Bradford LINk CQWG welcomes this opportunity to submit a statement on the Yorkshire Clinic (YC)
Quality Accounts [QAs]. We wish to thank the management of the Yorkshire Clinic for their prompt
response to a number of queries we had about this QA and for their readiness to meet with us in the
course of the coming year to discuss their service.
The YC’s contribution to health care provision is the District is clearly explained and their approach to
managing the quality of care is well set out in this QA
QAs are intended to provide readily accessible information to the public and the Department of Health
[DH] have asked local LINks to consider carefully “whether or not the Accounts are presented in a patient
friendly way”. We welcome the inclusion of a glossary in this QA.
Whilst we appreciate the clarity of the document’s language and much of the detail provided we have
some suggestions that might further improve the usefulness of the information published.
We were disappointed that some information about the quality of care was not clearly set out in the
report for example:
•
it was unclear to us what the PROMs data in section 3.3.2. amounted to and whilst the provision of
web links is useful it is not by itself adequate – not all of the public have readily available web
access and not all of the public have the skills to navigate a site such as Hospital Episode Statistics
on-line. The publication of some clearly explained data is also necessary.
•
Similarly, it would be useful to publish more detail from patient satisfaction surveys (referred to
on page 13) beyond the headline statistic quoted on page 29.
The LINk team express deep concern that, within the timescale proscribed by the DH, they had not been
able to give more detailed consideration to YC’s Quality Accounts, nor to meet members of the Trust
responsible for compilation of the Accounts. They urge DH to reassess the timescale, with a view to
permitting the level of consideration which Quality Accounts clearly justify and to recognise, and reduce,
the ‘bunching’ that occurs where a number of Provider organisations request LINk consultations in the
same short time window and from a small pool of highly skilled, and available, LINk (unpaid) volunteers.
Quality Accounts 2010/11
Page 20 of 39
NHS Bradford and Airedale commissioner statement re: The Yorkshire Clinic
(Ramsay Health Care UK) Quality Account 2010/11
NHS Bradford and Airedale (NHSBA), as lead commissioner, welcome the
opportunity to comment on The Yorkshire Clinic Quality Account for 2010/11 – the
second from the Ramsay Health Care Group since the national introduction of
Quality Accounts and the first to provide localised information pertaining specifically
to The Yorkshire Clinic.
As a commissioner of care services on behalf of the local population, we believe this
account demonstrates a commitment to quality improvement and high quality
services. The operating framework for the NHS in England requires quality to
encompass three areas of safety, effectiveness and patient experience. The Quality
Account provides an overview of these areas and is a fair reflection of achievement
against delivery of quality in services.
The Yorkshire Clinic has reviewed the priorities for improvement in 2010 – 2011 and
has provided evidence that the majority have been achieved whilst highlighting
particular areas for improvement. The Yorkshire Clinic has made progress over the
past 12 months and demonstrates through the Quality Account 2010/11 that it places
quality at the heart of the services that it provides. NHSBA are especially pleased to
note the following achievements:
•
Patient identity wrist bands are being printed electronically in accordance with
National Patient Safety Agency (NPSA) guidance.
•
Specialist specific checklists have been developed for radiology and cataract
surgery.
•
Environmental audits have been extended further in relation to equipment
cleaning and mattresses and a cleaning matrix has been developed along with a
‘green label’ identification system.
•
There was a 13% improvement in the Patient Environment Action Team (PEAT)
audit from the previous year.
•
All endoscopy staff members have achieved competences that meet national
standards.
•
Ambulatory day care services have been enhanced through a range of measures
including a full pre-operative assessment (POA) review, quarterly documentation
audits, staff training, consideration of optimal listing of operations and timing of
admissions, nurse-led discharge and post-discharge follow up calls.
NHSBA welcomes the above achievements and looks forward to the benefits and
positive outcomes for patients envisaged by The Yorkshire Clinic.
Quality Accounts 2010/11
Page 21 of 39
In reviewing the draft Quality Account, NHSBA would recommend that consideration
is given to the following:
•
A total of fifteen priorities have been identified for 2011/12. Whilst laudable, the
commissioner would question whether it will be possible to achieve such an
ambitious programme.
•
It would be helpful to reference all of the national clinical audits and national
confidential enquiries with an explanation as to which were applicable to The
Yorkshire Clinic or otherwise and why any relevant audits or enquiries were not
undertaken.
•
There appears to be only one explicit reference to safeguarding adults and this
was in relation to training. The report could be strengthened by demonstrating
how the range of patient safety and quality initiatives link with safeguarding
adults.
•
It would be helpful to know what the potential outcomes of the proposed
improvements for 2011/12 are expected to be and how these will be measured
and reported next year. An action plan detailing the improvements planned with
target dates would have been useful.
•
There are some really good examples of how The Yorkshire Clinic uses feedback
to identify potential improvements however the document would benefit from
providing examples of specifically what improvements have been identified.
•
In relation to seeking ways to improve patient experience, it would be useful to
include evidence of where this has happened, or a link to where evidence of this
has been included elsewhere in the account, in order to underline the importance
accorded by the provider to patient feedback.
•
It is stated that “The Yorkshire Clinic hospital rates in the top 2-3% of
organisations” but, without any explanation, this statistic has little meaning. It
would be helpful if a description of what this indicates could be included in the
final Quality Account.
•
To make the account more readable to members of the public, it would be helpful
to provide explanation of some of the clinical terms used. Some of the charts and
graphs would benefit from clearer ledgers. It is noted that the case study
presented described an event as a serious untoward incident and indeed the
incident was investigated as such, however it is more accurate to say that this
was a ‘near miss’ event and the patient came to no harm. The useful learning
from this has resulted in more robust processes in relation to access to supplies
of blood for transfusion in emergency situations.
NHSBA is pleased that data quality is one of the priorities for improvement as this
has been an area of concern to the commissioner for which an action plan is
currently being implemented by The Yorkshire Clinic.
Quality Accounts 2010/11
Page 22 of 39
Overall, this is a well presented report demonstrating that The Yorkshire Clinic is
committed to providing high quality care for service users. NHSBA supports the
future priority areas identified for 2011 – 2012 and agree with their relevance to and
representation of services.
NHS Bradford and Airedale commend the work of The Yorkshire Clinic over the last
year and support their continued commitment to quality improvement.
Simon Morritt
Chief Executive
NHS Bradford and Airedale
Quality Accounts 2010/11
Page 23 of 39
Part 3: Review of quality performance 2010/2011
Statements of quality delivery
Matron, Sue Swaine.
Acting Matron, Sue Broadbent.
Review of quality performance 1 April 2010 - 31 March 2011
Introduction
“Ramsay operates a quality framework to ensure the organisation is
accountable for continually improving the quality of their services and
safeguarding high standards of care by creating an environment in which
excellence in clinical care will flourish.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health
Care UK)
Ramsay Clinical Governance Framework 2011
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis at the Yorkshire Clinic 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:
Quality Accounts 2010/11
Page 24 of 39
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
The Matron at the Yorkshire Clinic actively promotes clinical governance and
collaborates with NHS partners to ensure that the Yorkshire Clinic is informed of
relevant initiatives to continually improve the safety and excellence of the services
offered. Matron attends a number of district meetings to nurture relationships with
key stakeholders/NHS/PCTs these include – Quality Performance Group, Serious
Untoward events group, District dignity group and Drug Intelligence Network group.
Quality Accounts 2010/11
Page 25 of 39
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).
The Yorkshire Clinic 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
The Yorkshire Clinic is a progressive hospital focussed on improving its performance
every year, particularly with regard to 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 demonstrated below: -
3.1.1 Infection prevention and control
The Yorkshire Clinic 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, Clostridium difficile and E coli infections with a programme to reduce
incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and The Yorkshire Clinic remains below the lowest
percentile for infection rates.
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.
The Yorkshire Clinic has its own Infection Prevention and Control Committee which
meets quarterly to endorse all local Infection Control Policies, procedures and
guidance. It provides advice and support for the implementation of corporate policies
and infection prevention and control training to all staff.
Quality Accounts 2010/11
Page 26 of 39
Programmes and activities within our hospital include:
Hospital Acquired Infections 2009
6
0.7%
5
0.6%
0.4%
3
0.3%
2
0.2%
1
0
HAI's Number
HAI's Rate
Rate
0.5%
4
Number
0.1%
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
5
3
0
2
0
0
0
1
0
3
0
0.0%
0.6%
0.3%
0.0%
0.2%
0.0%
0.0%
0.0%
0.1%
0.0%
0.3%
0.0%
0.0%
Hospital Acquired Infections 2010
2.5
0.2%
0.2%
2
0.1%
0.1%
1.5
0.1%
Rate
•
All staff undertake mandatory annual infection prevention and control training.
Our consultant Microbiologist also holds two training sessions a year for
clinical staff. All training is logged on to our electronic training register which
then identifies any shortfalls in an individual’s professional development which
can then be addressed.
Healthcare associated infections (HCAI) are acquired as a result of healthcare
intervention. High standards of Infection Prevention and Control practice
minimise the risk of occurrence and as can be seen from the bar chart below
The Yorkshire Clinic has decreased its HCAI rate annually for the past 2 years
and is well below the National Average of 28%.
Number
•
0.1%
1
0.1%
0.0%
0.5
0.0%
0
HAI's Number
HAI's Rate
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
1
0
2
0
0
0
0
0
1
0
0
0.0%
0.1%
0.0%
0.2%
0.0%
0.0%
0.0%
0.0%
0.0%
0.1%
0.0%
0.0%
0.0%
Quality Accounts 2010/11
Page 27 of 39
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.
The graph below shows our patient satisfaction of the environment over the last 3
years, the areas of concern have been identified and action plans developed and
implemented to improve the hospital environment.
96
94
92
90
88
86
84
82
80
78
76
2009
2010
2011
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 The Yorkshire Clinic 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.
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 as soon as received 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 Managers who ensure
we keep up to date with all safety issues.
Adverse Incidents reported at the Yorkshire Clinic:
• 2008 = 100
• 2009 = 91
• 2010 = 103
Adverse incidents reported are comparative with the numbers of patients, visitors,
staff, sub-contractors who utilise the Yorkshire Clinic every year. The above figures
show an increase in incident reporting, reflecting a raised awareness of the
importance of safety in the workplace.
Quality Accounts 2010/11
Page 28 of 39
3.2 Clinical effectiveness
The Yorkshire Clinic 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.
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.
Quality Accounts 2010/11
Page 29 of 39
3.5
0.4%
3
0.4%
2.5
0.3%
0.3%
2
0.2%
1.5
Rate
Number
Unplanned Returns to Theatre 2009
0.2%
1
0.1%
0.5
0.1%
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
0
1
2
0
3
1
1
2
1
0
2
1
Unplanned Return to Theatre Number
0.0%
0.0% 0.1% 0.2% 0.0% 0.4% 0.1% 0.1% 0.2% 0.1% 0.0% 0.2% 0.1%
Unplanned Return to Theatre Rate
0.4%
3
0.3%
2.5
0.3%
2
0.2%
1.5
0.2%
1
0.1%
0.5
0.1%
Rate
Number
Unplanned Returns to Theatre 2010
3.5
0
0.0%
Jan
Unplanned Return to Theatre Number
Unplanned Return to Theatre Rate
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
1
1
2
1
2
2
3
0
1
0
0
0.1%
0.1%
0.1%
0.2%
0.1%
0.2%
0.2%
0.3%
0.0%
0.1%
0.0%
0.0%
As can be seen in the above graphs our returns to theatre rate has remained the
same over the last 2 years. These figures are constantly monitored throughout the
year via our clinical governance and medical advisory committee framework.
3.2.2 Readmission to hospital
Monitoring rates of re-admission 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.
Quality Accounts 2010/11
Page 30 of 39
0.9%
7
0.8%
6
0.7%
0.6%
5
0.5%
4
0.4%
3
Rate
Number
Unplanned Re-admissions 2009
8
0.3%
2
0.2%
1
0.1%
0
Jan
Feb
5
7
Unplanned Re-admissions Number
0.5% 0.8%
Unplanned Re-admissions Rate
Mar
Apr
May
4
2
2
0.4% 0.2% 0.2%
Jun
Jul
Aug
5
2
2
0.5% 0.2% 0.2%
Sep
Oct
Nov
2
1
4
0.2% 0.1% 0.3%
Dec
0.0%
0
0.0%
0.7%
7
0.6%
6
0.5%
5
0.4%
Rate
Number
Unplanned Re-admissions 2010
8
4
0.3%
3
0.2%
2
0.1%
1
0
Unplanned Re-admissions Number
Unplanned Re-admissions Rate
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2
0
1
2
5
7
1
3
3
2
3
1
0.2%
0.0%
0.1%
0.2%
0.4%
0.6%
0.1%
0.2%
0.3%
0.2%
0.3%
0.1%
0.0%
As can be seen in the above graphs our readmission to hospital rate has changed
little over the last 2 years. These figures are constantly monitored throughout the
year via our clinical governance and medical advisory committee framework.
3.3 Patient experience
All feedback from patients regarding their experiences at The Yorkshire Clinic 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 on
notice boards. Managers ensure that positive feedback from patients is recognised
and any individuals mentioned are praised accordingly.
All negative comments or suggestions for improvement are also communicated 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.
Quality Accounts 2010/11
Page 31 of 39
Patient experiences are fedback via the various methods below, and are regular
agenda items on Local Governance Committtees for discussion, trend analysis and
further action where necessary. Escalation and further reporting to Ramsay
Corporate and DoH bodies occurs as required and according to Ramsay and DoH
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 – patients are encouraged to read and participate in their plan of
care.
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called
‘The Leadership Factor‘(TLF). They print and supply a set number of questionnaire
packs to our hospital each quarter which contain a self addressed envelope
addressed directly to TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also
separately for NHS and private patients). The results are available for patients to
view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel they
receive excellent quality of care and service in The Yorkshire Clinic hospital. To
record a satisfaction index over 92%, 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%.
Quality Accounts 2010/11
Page 32 of 39
As can be seen in the above graph our Patient Satisfaction rate has increased over
the last year from 90.0% to 92.6%. The Yorkshire Clinic hospital for patient
satisfaction rates in the top 2-3% of organisations.
3.3.2 Patient Reported Outcome Measures (PROMs)
The Yorkshire Clinic 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.
The graph below shows the PROMs data for NHS patients from May 2009 to April
2011.
Quality Accounts 2010/11
Page 33 of 39
Access to the Yorkshire Clinic and Ramsay PROMs results can be found at the following website:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&category
Quality Accounts 2010/11
Page 34 of 39
3.4 The Yorkshire Clinic Hospital Case Study
Patient admitted to The Yorkshire Clinic for routine surgery in October 2010. Whilst
undergoing the procedure the surgical team observed an unusual amount of
bleeding. The consultant performing the procedure called a Consultant colleague for
assistance and they worked together to stabilise the patient. All appropriate action
was taken by the theatre team as per the Emergency Surgery Protocol and blood
transfusion was informed immediately.
The Hospital stock of O Rh negative blood was given and at 17.00 hrs the
transfusion team ordered additional blood supplies from Leeds Blood Transfusion
Centre as per our Service Level Agreement (SLA). Despite a ‘blue light’ request for
the blood from Leeds it still took over an hour and a half to arrive because of the
‘rush hour traffic.’ The patient in theatre was at no time at risk as she had received
the transfusion she required and subsequently made a full recovery. The incident
identified that the delay in receiving further blood stock left both ward and other
theatre patients vulnerable.
The case was tabled at The Bradford & Airedale Clinical Review Group Serious
Untoward Incident Subcommittee and even though no harm was caused to the
patient it was agreed that a full investigation and report would be carried out. The
Serious Untoward Incident was reported to the CQC, PCT and the SHA.
A Level 1 concise investigation took place at The Yorkshire Clinic by The Clinical
Services Manager; Theatre Manager and Pathology Manager. The Root Cause
Analysis demonstrated that work place environmental factors were the main cause.
A review of the incident was carried out by all stakeholders and discussed via our
robust Clinical Governance framework; Risk Management Committee; Blood
Transfusion Committee and Medical Advisory Committee. By working in collaboration
with a Consultant Haematologist; the pathology staff and Airedale General Hospital
the decision was made that the SLA with the Leeds Transfusion Centre would
remain, and a further SLA has been agreed with Airedale General Hospital to supply
The Yorkshire Clinic with units of blood in emergency situations.
Report, actions and recommendations following this incident have been shared with
all staff within The Yorkshire Clinic, our local PCT/NHS providers, all other Ramsay
Units and our Corporate Clinical Governance Group.
The above incident highlighted a previously unknown risk at the Yorkshire Clinic. As
a result, working in collaboration with all parties we have improved our existing
processes to create a safer more reliable service for our patients.
Quality Accounts 2010/11
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Appendix 1
Services covered by this quality account
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
§
Anaesthetics
Audiology
Cardiology
Cosmetic
Dermatology
Dietetics
Endocrinology
ENT
Gastroenterology
General Medicine
General Surgery
Gynaecology
Haematology
Nephrology
Neurology
Neurophysiology
Oncology
Ophthalmology
Oral Surgery / Restorative Dentistry
Oral and Maxillo Facial
Orthopaedics
Orthotics
Paediatrics
Pain Management
Pathology
Psychology
Radiology
Respiratory Medicine
Rheumatology
Sleep Studies
Speech Therapy
Urology
Vascular
Venerology
Quality Accounts 2010/11
Page 36 of 39
Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2010/11
Page 37 of 39
Appendix 3
GLOSSARY OF ABBREVIATIONS
ANTT
Aseptic Non Touch Technique
BADS
British Association Day Care Surgery
CAS
Central Alert Agency
CQC
Care Quality Commission
CQUINS
Commissioning for Quality and Innovation
EMSA
Eliminating Mixed Sex Accommodation
GRSA
Global Rating Score
HCA
Health Care Assistant
HCAI
Health Care Associated Infection
IPC
Infection Prevention and Control
ISB
Information Standards Board
JAG
Joint Advisory Group
MEWS
Medical Early Warning System
MHRA
Medicines & Healthcare Products Regulatory Agency
MRSA
Methicillin-resistant Staphylococcus Aureus
NICE
National Institute for Clinical Excellence
NJR
National Joint Registry
NPSA
National Patient Safety Agency
PEAT
Patient Environment Action Team
POA
Pre-Operative Assessment
PROMS
Patient Reported Outcome Studies
PW
Productive Ward
RIMS
Risk Information Management System
SHA
Strategic Health Authority
SLA
Service Level Agreement
TLF
The Leadership Factor
VTE
Venous Thromboembolism
WHO
World Health Organisation
Quality Accounts 2010/11
Page 38 of 39
The Yorkshire Clinic
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:
01274 550600
www.theyorkshireclinic.co.uk
Neurological Centres
Quality Accounts 2010/11
Page 39 of 39