Quality
Account
2010/11
Contents
Introduction Page
Welcome to Ramsay Health Care UK and West Midlands Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2010/11 (looking back)
2.1.2 Clinical Priorities for 2011/12 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2010/11 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
3.4
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Quality Accounts 2010/11
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Welcome to Ramsay Health Care UK
West Midlands 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 West Midlands 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 patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
The previous Quality Account for 2009/10 was developed by our Corporate Office
and summarised and reviewed quality activities across every hospital and centre
within the Ramsay Health Care UK. It was recognised that this didn’t provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group will develop
its own Quality Account from this year onwards, which will include some Group
wide initiatives, but will also describe the many excellent local achievements and
quality plans that we would like to share.
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Part 1
1.1 Statement on quality from the General
Manager
Gloria Kerrigan,
General Manager,
West Midlands Hospital
As the General Manager of West Midlands Hospital I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
Our Vision;
“As a committed team of professional individuals we aim to maintain high
standards of services with patient care remaining our focus for everything we do.”
West Midlands Hospital is a long standing healthcare provider in the area. We
offer a range of services to private and NHS patients, ensuring that patient care is
at the centre of what we do. This is delivered through a commitment to teamwork
and professionalism between all parties.
We have a strong track record as a safe and responsible provider, and our
outcomes are shared with our private and NHS providers through regular
meetings and reviews.
At West Midlands Hospital we believe that each member of staff plays a part in
the success of the unit. Regular training and development ensures best practice
is delivered at all times.
The quality accounts give all parties and providers access to quality activities and
patient treatment outcomes at West Midlands Hospital. If you would like to
comment or provide me with feedback then please feel free to contact me on the
following number or via email;
01384 560123 ext 601 or E-mail Gloria.kerrigan@ramsayhealth.co.uk
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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.
Gloria Kerrigan
General Manager
West Midlands Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Neil Molony - MAC Chair
Dr Lee Plant - Clinical Governance Committee Chair
Mr James Beech – Regional Director Ramsay Health Care UK
Coordinating NHS Commissioners – Dudley PCT
Quality Accounts 2010/11
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Welcome to West Midlands hospital
West Midlands Hospital is a 34 bedded Hospital situated on the outskirts of
Birmingham, in a residential area of Halesowen.
We provide fast, convenient, effective and high quality treatment for patients of all
ages (excluding children below the age of 3 years), whether medically insured,
self-pay, or from the NHS sector.
West Midlands Hospital Provides NHS and Private Services including :Out Patient Consultation
Nurse led Clinics in Aesthetics, Oncology and Pre Assessment
Radiological Services including X-ray, MR Imaging, ultrasound and
mammography.
Physiotherapy Services including sports injury/acupuncture and women’s health
34 In patient beds with en-suite facilities
2 Operating theatres including 1 Laminar Flow
1 endoscopy / minor ops theatre
Services offered at the hospital include the following specialties,
Orthopaedics, Endoscopy, Gynaecology, ENT, General Surgery, Cosmetic
Surgery, Ophthalmic, Urology and Oncology.
All of our services are Consultant delivered and are supported by Clinical Nurse
Leads in key areas such as Oncology, Aesthetics, Endoscopy, Ward, Theatres
and Out Patients.
Both our Physiotherapy and Radiology departments provide a direct referral
service for self pay patients, with the radiology service including mammography,
ultrasound, MRI and general radiography.
For the period March 2010 - April 2011 the total number of patients treated was
3558, of which 1629 (45%) were NHS and 1929(55%) were private referrals.
Currently we employ a total of 90 contracted staff; and this includes
clinical, nurses, physiotherapists and radiographers, as well as support staff;
administration, hotel services, porters, receptionists and medical secretaries.
We have a Resident Medical Officer on site 24hours a day seven days a week to
support the consultant and nursing team deliver safe and effective care to all our
patients
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We have good links with our local PCT at Dudley and as the Coordinating
Commissioner for the West Midlands region they are an important partner in the
local health economy.
We hold educational sessions with local GP practices, with the help of our
consultant body and clinical staff, and provide workshops for practice staff to
attend to support the referral processes.
Invites to educational sessions facilitated by our orthopaedic surgeons are held
bi- monthly for Local Physiotherapists and GPs to attend. At West Midlands
Hospital we feel it is important to maintain excellent links with local GPs and work
together for the benefit of our patients.
As a hospital we support local charities, and in 2010 the staff raised funds for
Acorns Children Hospice and the Multiple Sclerosis Society.
During 2011 we are raising funds for Rainbow Breast Reconstruction Group and
Dudley Olympics.
Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
On an annual cycle, West Midlands 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 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 who experience our
services.
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To achieve these aims, we have various initiatives underway which remain
ongoing as we are consistent in our approach.
.
The priorities are determined by the hospitals Senior Management Team taking
into account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2010/11 (looking back)
• Bar coding for patient identity bands – this priority did not progress last
year, as the Department of Health’s Information Standards Board (ISB)
advance notice was not followed up with a formal notice for
implementation. Consequently the project was put on hold until further
advice was received from the ISB. However, this is still on Ramsay’s
agenda and will be introduced this year as it is still considered best
practice and will prepare us for many patient care initiatives which will
require patients to have a barcode on their wristbands.
• Safer Surgery Checklists – we have introduced the WHO checklists into
our theatre department to ensure wrong site surgery does not occur.
Further work was undertaken and two 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 we scored a 84.25% in the environment section, 91.3%
in Food Section and 100% for Privacy and dignity. This was an
improvement on the previous years audit and is above the nationally
published average.
• Investment in day surgery facilities– this project is in its infancy at West
Midlands Hospital but throughout 2011/2012 we will be working towards
improving the pathway for Day case patients as part of the national project
to offer the most efficient and effective patient journey.
2.1.2 Clinical Priorities for 2011/12 (looking forward)
Patient safety
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1. Falls - Ramsay Health Care has adopted a corporate approach to the
Shattered Lives Campaign. All slips trips and falls for all staff and visitors
are reported through the central risk management reporting network and
the West Midland actions are monitored centrally and reviewed following
any incidents. In addition to this all patient falls are reported to the risk
management group where they are collated and reviewed before being
reported to the Clinical Governance Committee. This committee is in the
process of developing a corporate strategy to minimise the potential risks
to patients. Following a review of falls at West Midlands Hospital we have
placed notices in our patient bedrooms to remind patients before they get
out of bed to ring for assistance to help them walk to the bathroom. There
were a total of 7 slips, trips and falls for 2010, 6 patient falls and 1 staff, a
ratio of 0.19%.
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/
From the list of core never events, there are 5 that could 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.
3. Infection Control – Reducing the number of infections in a sustainable
manner requires all parts of the hospital teams and wards to work together
and focus on priority areas.Further infection prevention and control audits
were introduced as planned during 2010 Action plans developed locally
where necessary to ensure the standards are met and maintained. PEAT
(Patient Environment Action Team) audits were also repeated and showed
continued high levels of achievement for our environment, food and
maintaining our patients dignity and privacy. This is now an embedded part
of our audit process and will continue in future years.
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4. West Midlands Hospital Staff Survey (Pulse) results were good overall,
with 67.5% of staff stating that they enjoy their work compared to 57.6% in
2009. 87.5% of staff stated they have a good working relationship with
their immediate manager, and 87.4% felt that their immediate manager
showed commitment to his/ her work. The results are important to us as
satisfied, well trained and competent staff will ensure patient safety risks
are reduced.
We have chosen 3 key areas where we have scored relatively lower as
areas for improvement:•
•
•
A total of 60.4% of staff felt they received regular feed back on their
performance and our aim is to improve this for 2011 with a target
score of 65%. To reach this we will ensure that all staff have a
Performance Development Review (PDR), and will also commence
a review at the monthly Heads of Department meetings to highlight
any staff that deserve particular individual recognition and thanks
using the Ramsay recognition and reward scheme as the formal
process to note this.
Another key area for staff improvement is ensuring that staff have
sufficient time to complete all their work duties. A total of 56.3% of
staff felt they did and we aim to improve this to 60% in the 2011
survey. To achieve this we will endeavor to ensure all staff are able
to prioritise their workloads, ensure any problems preventing
completion of work duties are reported to line managers, and utilize
staff across departments where skills are transferable. Senior
Management will maintain their high profile in the unit and monitor
daily the workload and resourcing issues within the hospital to better
support the teams in this area – the newly implemented Manpower
Policy facilitates this principle.
Our last focus area will be improving communication between
different teams and & departments in the workplace as the current
score of 51.3% of staff feeling this is currently good we feels needs
improvement and we aim to increase the score to above 55%. To
achieve this we will be displaying bullet points from Quality, Health
and Safety, Infection Control, and HODs meetings for all staff to
have access. A review the use of e-mails is ongoing as this was
highlighted as not the most ‘user friendly’ route of communication,
and promote face to face interaction. We are also ensuring that
Senior Management on their daily walk round the hospital includes
any important information or messages for that day to the team on
duty for instant feedback and interaction.
5. Acute Care Competencies / Vulnerable Adult training – All qualified
staff through out the West Midlands Hospital have access and training in the
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Both the ward and the theatre staff are
currently working through their Acute Critical Care Competencies and
assessments. This is supported by our Critical Care Lead who is also our
Ward Charge Nurse and our Regional Trainer
protection of Vulnerable Adults.
Clinical effectiveness
1. Ambulatory Day Care – better outcomes and improving patient
experience
• Ambulatory Care (or Day Surgery Care) is the admission of selected
patients (both medical and surgical) to hospital for a planned
procedure, returning home the same day i.e. the patient does not incur
an overnight stay)
• Over recent years, partly due to medical advances the number of day
surgery patients has increased compared to those requiring inpatient
care.
• In 2010 the percentage of day surgery patients we treated was 70% of
all of our admissions. We need to ensure that our hospital facilities and
patient pathways flow better to ensure we support the case mix we now
deliver.
• Whilst we are at present unable to provide a separate Ambulatory Care
facility, we will achieve this improvement by providing our patients with
a more efficient patient pathway through the hospital.
• Best practice has shown that by doing this, patient care will improve as
waiting time and recovery period are reduced and patient satisfaction
with their treatment overall increases.
• Our long term aim will be to develop an Ambulatory Care facility where
all of our day care patients will be treated in the most effective efficient
and appropriate way.
2. Improve National Benchmarking – how do we compare?
It was recognised that we needed more transparency between ourselves
and other independent sector providers and the NHS in order to monitor
and improve our services.
This is even more important now we are working in partnership with the
NHS. We now for example benchmark in the following areas alongside all
independent and NHS providers:
Hellenic
• Hellenic will provide national benchmark figures for key
performance indicators (such as activity/volumes, mortality, day
case rates, un planned readmissions, average length of stay,
unplanned transfers, returns to theatre).
VTE risk assessment compliance
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•
Benchmarking through the national statistics website. Link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publi
cationsStatistics/DH_122283
PROMS results
• Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=19
37&categoryID=1295
Patient Satisfaction figures
• Using CQUIN indicators common to both NHS survey and our own
Ramsay patient satisfaction survey data.
3. The Productive Ward – Releasing time to care.
This project is an NHS Initiative developed by the Institute for Innovation and
Improvement (2008).
It has been successfully trialled at 5 Ramsay sites. It focuses on the way
ward teams work together and organise themselves, in order to reduce the
burden of unnecessary activities, and releasing more time to care for
patients in a reliable and safe manner within existing resources.
The approach is very much ‘bottom up’ with all ward staff suggesting ideas
and ways in which they could improve their environment and processes.
West Midlands Hospital now has a lead for this project and it will be rolled
out here during 2011.
Patient experience – informing patient choice
1. Increasing the use of Patient Reported Outcomes Studies (PROMs)
• Better use of the national PROMs results for Hip, Knee, and Hernia
surgery. Encouraging their use in identifying poor outcomes and
examining practice if and where this exists.
• Sharing results with Surgeons (and physiotherapists) and
encouraging them to use them to review their practice.
• Expanding our use of PROMS surveys to cover more procedures to
enable better understanding of treatment outcomes from the
patients view point.
2. Patient Satisfaction Survey
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During quarter1 2010 it was recognised from the question related to patient
information given prior to treatment that we were not satisfying the patients
expectations in this area.
Our average score for this question showed that 16.3% of our patients
were not satisfied with information given regarding their proposed
treatment. We therefore undertook a review of our procedures for giving
written information at the time of out patient consultation. We reviewed the
EIDO patient information leaflets and engaged the consultants and OPD
staff to improve the process of giving patients written information before
leaving the department. We saw an increase in the score over the next 2
quarters.
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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 West Midlands Hospital provided and subcontracted 17 NHS
services.
The West Midlands Hospital has reviewed all the data available to them on the
quality of care in the NHS services we provide.
The income generated by the NHS services reviewed in 1 April 2010 to 31st
March 11 represents 45% per cent of the total income generated from the
provision of NHS services by the West Midland 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 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 HPD's
Patient Satisfaction Score
Number of Significant Clinical Events
Readmission per 1000 Admissions
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Quality
Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
2.2.2 Participation in clinical audit
During 1 April 2010 to 31st March 2011, we participated in 2 national clinical
audits and 1 national confidential enquiry covering NHS services that West
Midlands Hospital provides.
During that period West Midlands Hospital participated in the 100% national
clinical audits and 1 national confidential enquiry of the national clinical audits and
national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that West Midlands
Hospital was eligible to participate in during 1 April 2010 to 31st March 2011 are
as follows:
• Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
The national clinical audits and national confidential enquiries that West Midlands
Hospital participated in, and for which data collection was completed during 1
April 2010 to 31st March 2011, are listed below alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
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National Clinical Audits (NA = not applicable to the services provided)
Participation
(NA, Yes, No)
% cases
submitted
Peri- and Neonatal Children
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)
NA
NA
NA
NA
NA
NA
NA
Yes
NA
NA
NA
NA
0
NA
NA
NA
Long term conditions
Diabetes (National Adult Diabetes Audit)
NA
NA
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Yes
100%
Yes
93%
Psychological conditions
NA activity
Blood transfusion
O neg blood use (National Comparative Audit of Blood
Transfusion)
Platelet use (National Comparative Audit of Blood Transfusion)
NA
NA
NA
NA
Name of Audit
Local Audits
The reports of 26 ( which includes 9 Infection prevention and control, 4
transfusion, 3 physiotherapy and 2 radiology) local clinical audits from 1 April
2010 to 31st March 11 were reviewed by the Clinical Governance Committee and
West Midlands Hospital intends to take the following actions to improve the
quality of healthcare provided. The clinical audit schedule can be found in
Appendix 2.
Medical Records Audit
At West Midlands Hospital we have been targeting our consultants and nurses to
improve our scores for the Medical records audit. The patient notes are
completed by various hospital staff from Physiotherapists to Theatre and Ward
staff. To improve our scores we have reminded the teams to ensure that all pages
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of the records have patient labels on, that the signature sheet which records staff
who are involved in the patients care is completed, and that all operation notes
are dated and timed.
We have seen an improvement in our audit score from 85% to 95%.
Discharge Audit
Discharge planning has to commence prior to admission as patients may have
other medical conditions which require further tests or assistance at home on
discharge. It was highlighted by audit results that improvements needed to be
made with regard to discharge time being discussed with the patient at the time of
pre-assessment and or admission we discussed this with the relevant nursing
staff to ensure this was done. The other area we were able to improve on was
ensuring the nurses signed the discharge checklist in the care pathway.
We saw an improvement in our scores from 86% to 94%.
Infection control and Prevention
Hand Hygiene
Healthcare-associated infections are of concern to all of us whether we are
patients, visitors or healthcare workers: it is in everyone’s interest to ensure that
healthcare is as safe as possible.
Hand hygiene is a crucial part of our efforts to prevent and control healthcareassociated infections.
Our hand Hygiene audits showed a dip in scores and our Lead Infection Control
Nurse has instigated a robust monthly teaching programme for all of our staff to
attend.
We have since seen an improvement of the audit score back to 98% from its
previous dip to 84%.
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
West Midlands Hospital income from 1 April 2010 to 31st March 2011was not
conditional on achieving quality improvement and innovation goals through the
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Commissioning for Quality and Innovation payment frame work as there were no
CQUINS allocated.
2.2.5 Statements from the Care Quality Commission (CQC)
West Midlands Hospital 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
West Midland hospital during 2010/11.
West Midland Hospital has not participated in any special reviews or
investigations by the CQC during the reporting period.”
2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your
Data Quality
West Midlands Hospital will be taking the following actions to improve data
quality.
•
•
Continue to audit and review clinical documentation including operation
notes
Monitor and audit information gathered using our electronic patient
administration system ensuring all details correct at time of consultation
NHS Number and General Medical Practice Code Validity
West Midlands 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:
[93.72%] for admitted patient care;
[96.5%] 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:
[97.48%]for admitted patient care;
[98.78%]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
West Midlands Hospital was not subject to the Payment by Results clinical coding
audit during 2010/11 by the Audit Commission.
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2.2.7 Stakeholders views on 2010/11 Quality Account
Dudley PCT as Lead Coordinating Commissioners have had the opportunity to
review this document and at time of publishing have not requested any feedback
be added.
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Part 3: Review of quality performance 2009/2010
Statements of quality delivery
Terri Burkett Matron
Review of quality performance 1st April 2010 - 31st March 2011
Introduction
“Ramsay operates a quality framework to ensure the organisation is
accountable for continually improving the quality of their services and
safeguarding high standards of care by creating an environment in which
excellence in clinical care will flourish.”
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2011
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation.
In developing this framework for Ramsay Health Care UK we have gone back to
the original Scally and Donaldson paper (1998) as we believe that it is a model
that allows coverage and inclusion of all the necessary strategies, policies,
systems and processes for effective Clinical Governance. The domains of this
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model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
NICE / NPSA guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the National Patient Safety Agency
(NPSA).
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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.
Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns but
more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs below.
3.1.1 Infection prevention and control
West Midland hospital has a very low rate of hospital acquired infection and
has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
•
Locally we hold quarterly local infection control meetings, where link
personnel from all departments attend and we have links with our local
NHS Trust Microbiologist and work closely with local NHS Trust Infection
Control Nurses
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•
E-Learning and Mandatory training sessions held for all clinical staff by our
infection control nurse.
•
Actively involving the infection control nurse in working in the clinical
environments to audit and advise staff members and consultants in
infection control issues including hand hygiene.
•
Our lead Infection control nurse advises staff on reporting mechanisms for
infections /wound problems using examples of reporting tools and policies
available.
Total Number of Infections
6
4
2
2010/11
Infection rate
2009/10
0
2008/09
Number of
Patients
8
Year
•
•
As can be seen in the above graph our infection rate has increased in the last
3 years, however this is as a result of more robust reporting systems
throughout the hospital and as an overall percentage of admissions in each
period this represents 0.06%, 0.09%, and 0.21% respectively.
We have had no reported MRSA in the hospital throughout the 3 years.
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.
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Overall Cleanliness
100%
95%
90%
85%
80%
75%
2009
•
•
2010
2011
As can be seen in the above graph our overall cleanliness rate has
increased over the last year from but remains lower than in 2009. This is
mainly due to some areas of the hospital awaiting refurbishment, some of
which are patient bedrooms. We plan further refurbishment in 2011.
To ensure we maintain high levels of cleanliness throughout the hospital
we have introduced regular spot checks, and these are carried out by the
Housekeeping Supervisor and the Infection Control Lead Nurse.
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.
The reporting mechanism includes a tool where all actions and responses
taken as a result of the alert are recorded and collated centrally and is part
of the General Managers responsibilities in this area to ensure all updates
and notices are cascaded and actioned as appropriate.
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30
26
23
25
20
17
15
Total number
of incidents
10
5
0
2008/09
2009/10
2010/11
• As can be seen in the above graph our adverse events rates appeared to
have increased in 2009/10. One of the reasons we had for this was the
increase in staff awareness of reporting any adverse event, staff are
actively encouraged to report incidents as by doing this we can identify
areas for improvement. All incidents are then reviewed by the Health and
Safety Team, root cause analysis is carried out and any trend and or
recommendation is acted upon. They are also reported into the central
reporting tool to ensure trends and key issues are highlighted group wide
and lessons shared/actions taken across the company where necessary in
a timely and structured fashion.
• All incidents that are reported on are divided into subsections separating
clinical from non-clinical, with clinical incidents coming under the umbrella
of clinical effectiveness.
3.2 Clinical effectiveness
West Midlands Hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole.
All local reports are also reviewed centrally as outlined previously.
The results highlighted in the graphs demonstrate the effectiveness of this
approach over the last three years.
3.2.1 Return to theatre
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Ramsay is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures
and so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure. Every surgical intervention
carries a risk of complication so some incidence of returns to theatre is normal.
The value of the measurement is to detect trends that emerge in relation to a
specific operation or specific surgical team. Ramsay’s rate of return is very low
consistent with our track record of successful clinical outcomes.
.
Total number of Unexpected Returns to Theatre
6
5
4
3
2
1
0
2008/09
2009/10
2010/11
Year
As can be seen in the above graph our return to theatre rate is very low
and has decreased since 2009/2010. When these numbers are considered
as a percentage of our total admissions, our return to theatre rates were
0.03%, 0.16% and 0.08% respectively.
•
Each patient that is returned to theatre has a full review of the records and
the findings discussed at MAC, with an action plan implemented and
monitored if indicated
.
3.2.2 Readmission to hospital
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be
addressed. Ramsay rates of readmission remain very low and this, in part, is due
to sound clinical practice ensuring patients are not discharged home too early
after treatment and are independently mobile, not in severe pain etc.
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7
6
5
4
Readmissions
3
2
1
0
2008/9
•
•
2009/10
2010/11
As can be seen in the above graph our readmissions to hospital rate have
fluctuated over the three years. When these numbers are considered as a
percentage of our total admissions, our readmission rates are 0.16%,
0.23% and 0.08% respectively.
Every readmission is fully reviewed to identify the causative factor for the
readmission and these are discussed and practice changed if required.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are fedback via the various methods below, and are regular
agenda items on Local Governance Committtees for discussion, trend analysis
and further action where necesary. Escalation and further reporting to Ramsay
Corporate and Dept of Health bodies occurs as required and according to
Ramsay and DH policy.
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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
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
For 2011 we are hoping to have a patient focus group.
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called
‘The Leadership Factor‘ (TLF). They print and supply a set number of
questionnaire packs to our hospital each quarter which contain a self addressed
envelop addressed directly to TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also
separately for NHS and private patients). The results are available for patients to
view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel
they receive excellent quality of care and service in West Midlands Hospital. To
record a satisfaction index over 94%, 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%.
96.5
96
95.5
95
94.5
94
93.5
93
92.5
92
2008
2009
2010
1st Qtr
•
2nd Qtr
3rd Qtr
4th Qtr
As can be seen in the above graph our Patient Satisfaction rate has remained
between 90 & 97% currently our hospital rates in the top 2-3% of
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•
•
organisations. Although we score high in areas relating to staffing, cleanliness
and treating our patients with dignity and respect, we still have areas where
we can improve and these are discharge information, food/refreshment and
ensuring that our patients receive copies of any correspondence between their
Consultant and General Practitioner.
We have now produced written discharge information which is given to all
patients, and a copy of the GP discharge information is given to them on
discharge.
These initiatives have helped to improve our satisfaction scores.
3.3.2 Patient Reported Outcome Measures (PROMs)
Average reductions in disability scores over post-operative period
West Midlands Hospital participates in the Department of Health’s PROMs
surveys for hip and knee surgery, hernias.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs
surveys specifically for private patients.
Three result areas have been reviewed, comparing the West Midlands Hospital
against the national average for:
•
•
•
EQ VAS = patients score their health from 0 – 100, with 0 indicating poor
health
Oxford Hip score = a score generated from questionnaire responses
ranging from 0 – 48 with a low score indicating poor health
Oxford knee score = a score generated from questionnaire responses
ranging from 0 – 48 with a low score indicating poor health.
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PROMS Response rate
80.00%
75.00%
West Midlands
70.00%
National
Knee
response
Rate
60.00%
Hip
Response
rate
65.00%
Hernia
Response
rate
% response rate
85.00%
EQ Vas results
100
80
60
West Midlands
40
National
Dudley PCT
20
0
Hernia EQ Vas
Hip EQ Vas
Knee EQ Vas
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Oxford Score
40
30
West Midlands
20
National
Dudley PCT
10
0
Oxford Hip
•
•
Oxford Knee
As can be seen in the above graphs our PROMs scores for hip, knee, and
hernia in comparison to the national average is mostly in line with or higher
than the National average.
This is due to our pre-assessment nurses involvement in completing the
PROMs questionnaires at time of pre-assessment with the patients, ensuring
they are aware of the reasons why this information I required and how it is
used to shape services in the future.
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3.4 West Midlands Hospital Case Study
West Midlands Hospital prides itself in working closely with consultants to ensure
patients are offered the latest advances in medical technology. During 2010 –
2011 we have looked at developing a wide range of treatments and services for
self paying, insured and NHS patients.
One such advance has been the introduction of the Computer Navigation System
which provides cutting edge technology for those patients requiring hip and knee
replacement.
The Computer Navigation System provides precise information on the position of
the new replacement joint. This information is used during the operation to
provide the surgeon with detailed information on how to orientate the new joint to
work optimally with the bones, muscle, ligaments, and other structures around it.
The computer calculates the difference in positions and displays the information
on the screen, allowing the surgeon to ensure that any replacement joints or
implants are perfectly positioned.
In England and Wales last year, only 3% of knee replacements were performed
using computer navigation, with only 2% of hip resurfacings and less than 1% of
hip replacements.
Mr Edward Davis, a Consultant Orthopaedic Surgeon, working at The Royal
Orthopaedic Hospital, Northfield and Russell’s Hall Hospital, Dudley and founder
of the West Midlands Hospital centre for computer navigation; specialises in
performing Computer Navigated Joint Replacement and Revision, of hips and
knees.
Mr Davis is one of only a few surgeons in the country who uses
Computer Navigation technology routinely to perform hip and knee replacements
and hip resurfacing. He is one of the only surgeons in the world using the latest
technology to insert the hip replacement in an “optimal position” that is calculated
by the computer, depending on the patient’s own anatomy.
Mr Davis says that since using the computer navigation system, he can be
satisfied that he will not be upset by the post-operative x-rays, “this is not only
good for me but is even better for the patients!” It soon became clear to him that
one position can’t possibly fit all patients and that the position of the new hip had
to be modified to accommodate for differences in bone shape between different
individuals.
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Appendix 1
Services covered by this quality account
Breast care
Cardiology
Cosmetics
Dermatology
Ear, nose and throat (ENT)
Gastroenterology
General Medicine
Gynaecology
Ophthalmology (inc laser)
Orthopaedic medicine
Pain management
Podiatry
Physiotherapy
Rheumatology
Sports medicine
Urology
Vascular
Diagnostics
Laser treatments
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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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West Midlands 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:
01384 560123
www.westmidlandshospital.co.uk
Neurological Centres
Quality Accounts 2010/11
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