Quality
Account
2010/11
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Woodland
Hospital/Centre
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager – Tania Terblanche
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
Woodland 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 Woodland Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
The previous Quality Account for 2009/10 was developed by our Corporate Office
and summarised and reviewed quality activities across every hospital and centre
within the Ramsay Health Care UK. It was recognised that this didn’t provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group will develop
its own Quality Account from this year onwards, which will include some Group
wide initiatives, but will also describe the many excellent local achievements and
quality plans that we would like to share.
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Part 1
1.1 Statement on quality from the General
Manager
Tania Terblanche General Manager,
Woodland Hospital
As the General Manager of the Woodland 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 service with patient care remaining our focus for everything we do.”
Woodland Hospital is a long standing healthcare provider in the Kettering 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 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.
At Woodland Hospital we believe that each member of staff plays a part in the
success of the unit. Regular training and development ensure best practice is
followed at all times.
The quality accounts give all parties and providers access to quality activities and
patient treatment outcomes at Woodland Hospital. If you would like to comment
or provide me with feedback then please feel free to contact me on the following;
Email: tania.terblanche@ramsayhealth.co.uk or
Tel.: 01536 414 515.
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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.
Tania Terblanche
General Manager
Woodland Hospital
Ramsay Health Care UK
This report has been produced by:
Tania Terblanche – General Manager
Elaine Rowland – Matron
Lorna Dodwell – Regional Business Development Manager, Midlands Region
Caroline Derby – Finance Manager
This report has been reviewed and approved by:
Date
Name
Mr S Biswas
Role
MAC Chair
E-Signature
S Biswas
Dr J Szafranski
CGC Chair
J Szafranski
Mr J Beech
Regional Director
J Beech
Desra Robinson
Fiona Pinn
Commissioner/PCT
Lead
Woodland Hospital Management Team work in partnership with the (Medical
Advisory Committee) MAC, (Clinical Effectiveness Committee) CEC and (Clinical
Governance Committee) CGC Committees, ensuring that high quality patient care
is at the centre of what we do.
Regular meetings with the above Committees ensure best practice and sharing
results.
Quality Accounts 2010/11
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Welcome to Woodland Hospital
The Woodland Hospital, named after the famous local Woodland Pytchley Hunt,
was originally built in 1989 and was designed to combine modern technology with
the highest standard of patient care and comfort. Our staff are carefully selected
for their friendly and caring approach as well as their efficiency and
professionalism and a Resident Doctor is available 24 hours a day. The restful
atmosphere and high level of personal attention combine to help patient recovery.
The first patients were admitted in June 1990 and the hospital has continued to
grow and develop since this date.
In 1996 the hospital opened a second purpose built theatre suite and 6 new
patient bedrooms, giving a total of 37 bedrooms split across two floors. In
January 1998 the dedicated Endoscopy Suite was opened and during 1999 a
mammography service was launched. 2005 saw the introduction of a mobile MRI
screening service along with the upgrade of our X-ray equipment and department.
Major developments took place at the Hospital during 2005 and 2006, with the
opening of a two bedded independent high dependency area and an expansion of
the theatre suite that included two new recovery bays. The building of Schofield
House took place and this building contains a new and improved physiotherapy
department and administration offices. Work on the ground floor of the main
hospital also included a new conservatory and hospital entrance, two additional
consulting rooms within the outpatient department and a refurbished reception
area which includes a cash office
Schofield House is named after the late Mr James Schofield, the first Consultant
to operate at the Woodland Hospital, stands on the area previously occupied by
the Grange. The official opening was done by Mr Schofield’s children on 18 May
2006.
Further development continued and in 2008 the Laser Eye surgery service was
launched. A dedicated laser suite has been developed on the second floor of the
hospital to undertake laser eye surgery and other laser cosmetic procedures.
Electronic X-ray reporting was introduced during 2009.
To meet the growing needs of the business the Woodland Hospital provides 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. In 2010/11 we treated a total of 5700 number of patients, with 46(%)
being NHS patients.
The hospital provides a comprehensive range of services that are listed in
Appendix 1, and these include Medical, Orthopaedic, Surgical, Ophthalmology,
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Ear, Nose and Throat, Urology, Gynecology, Maxillofacial and Cosmetic services.
The Hospital also provides a range of routine and complex spinal service.
To ensure that patients are at the centre of everything we do and receive the
highest standard of care, we have 129 dedicated Consultants, working alongside
86 nursing, radiology, physiotherapy and pharmacy staff and administration,
housekeeping, maintenance and catering staff.
At the Woodland Hospital we work closely with our colleagues at the local Trust
and PCT to ensure our services meet the needs of the patients we serve,
including shared training and development programmes, infection control and
pathology services.
It is also key that we support people and services within the community, and in
2010, we signed an agreement with Kettering Rugby Club to provide the
physiotherapy services to their players. The Woodland Hospital also support
charities by selecting a charity of the year and raised over £2000 in 2010/11 for
the Warwickshire and Northamptonshire Air Ambulance.
Developments continue at the Hospital and during 2011/12 further expansion will
begin that includes:
• New waiting area,
• New conference room
• Extra outpatient consulting rooms
• Third laminar flow theatre,
• Dedicated ambulatory care (day case) unit
• New parking bays
• New high dependency unit
• Refurbished patient rooms
This extension will allow us to increase our services and the number of patients
we see, both private and NHS.
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Part 2
2.1 Quality priorities for 2010/2011
Plan for 2010/11
On an annual cycle, Woodland 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 services commissioned to us result in
safe, high 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 hospital’s 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 checklists to ensure wrong
site surgery does not occur
• 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
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•
•
•
also repeated and showed continued high levels of achievement for our
environment, food and maintaining our patients dignity and privacy.
Meeting endoscopy standards – Woodland is working towards participating
in the endoscopy audit on the GRS website.
Investment in day surgery facilities – Within the current building, we
manage our day case and in-patient patients through dedicated pathways.
This is working well in reducing length of stay where clinically appropriate.
Releasing time to care – the Productive Ward project was successfully
trialled at 5 sites and Woodland Hospital was one of the sites. By
introducing this, we have managed to streamline our pre-assessment
services to ensure that all patients have the relevant investigations,
including MRSA screening, and relevant care pathways prior to admission
and the results are known and available with all the relevant paperwork on
admission. We have also rearranged our store rooms and paperwork
ensuring that it is easily accessible to staff and changed our prescription
charts corporately to reduce waste. As part of the productive ward a new
Cytotoxic project was introduced by ward staff, enhancing the services we
provide to our patients. We have also introduced a ‘Patient status at a
Glance Board’ which provides relevant information regarding the patient,
for example, what diet they have, how they mobilise, this has reduced the
amount of questions staff were asked by many different specialities,
freeing the staff up to provide care directly to the patients
2.1.2 Clinical Priorities for 2011/12 (looking forward)
•
Patient safety
Patient safety is a key priority for the Woodland Hospital and in 2011/12
we will continue to improve the safety of our patients by putting
mechanisms in place to ensure that we continue to: reduce patient falls
post surgery, reduce the risk of patients suffering a blood clot post surgery
and maintain our current excellent infection control rates and improve
cleanliness across the hospital.
• Reducing Falls
By reviewing and analysing data relating to the causes of falls we have
changed how we prescribe analgesia (pain killers) medication and
improved the information and advice we give to our patients about the
effects of analgesia and anaesthetics, as these were identified as reasons
for patients falling.
• Reducing Never Events
On a national level we will ensure that events classed as ‘never events’
such as wrong site surgery and retained instruments post surgery, never
occur at the Woodland Hospital.
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• VTE Risk Assessment
We aim to ensure that all our patients have the appropriate venous
thrombus (blood clots in either the leg or the lung) risk assessment
performed using the national risk assessment tool where clinically
indicated. Over the past three years, we have had no patients that have
suffered a blood clot in either their leg or their lung, and we aim to continue
this over the coming year. Where patients do suffer from blood clots, they
will receive treatment that is based on national clinical guidelines.
• Cleanliness and Infection Control
Cleanliness and infection control continue to be monitored through a
robust audit calendar, and through meticulous MRSA pre-admission
screening. Over the past three years, no patient has caught MRSA whilst
being treated at the Woodland Hospital. Any patient that is found to be
MRSA positive receives advice and treatment by their GP before being
admitted.
Any patient safety incident that occurs at the hospital is reported through
our incident reporting mechanism, and these are reported locally at our
Health and Safety, Clinical Governance and Medical Advisory Committee
meetings and nationally through to Ramsay Headquarters via our monthly
clinical governance reports.
• National Joint Registry
To enable us to ensure patients undergoing joint replacement surgery are
able to be traced if a national safety alert is issued, Woodland Hospital is
part of the National Joint Registry, which enables us to trace any
prosthesis (replacement joint) that we have used at the hospital.
• Training
To support our safe patient culture, it is imperative that we have
appropriately trained staff. To support this, we have commenced an Acute
Care Competencies / Vulnerable Adult training programme which ensure
safe, competent staff are available to care for our patients. This training is
led by the Matron supported by the Regional Training Coordinator.
• Staff Satisfaction
In conjunction with educated, competent and appropriately trained staff, it
is important that are staff are satisfied and happy in the workplace as this
will ensure patient safety risks are reduced. To obtain the opinion of our
staff each member is encouraged to complete our annual Pulse survey.
Our Pulse survey results for 2011/12 identified three key areas that we
needed to improve on, which were: ensuring all staff received a Personal
Development Review, ensuring all equipment is fit for purpose and that
departments are in good decorative order.
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We are addressing these three key areas through a robust yearly appraisal
programme, replacing equipment that is no longer fit for purpose and the
introduction of a hospital wide decoration plan, linked into the development
plan. We have also introduced a working group with representatives of all
grades and specialties of staff to review all of the Pulse results and change
practice where indicated.
• Clinical Effectiveness
•
Ambulatory Day Care – better outcomes and improving patient
experience
At the Woodland Hospital we are promoting Ambulatory or Day Surgery
Care, which is the admission of selected patients (both medical and
surgical) to hospital for a planned procedure and 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 68%. We
need to ensure that our hospital facilities and patient flows meet the case
mix we now deliver and to enable us to achieve this, we are having a
purpose built ambulatory unit, and we aim to ensure that 100% of all day
care patients are treated in this unit.
In order to do this and provide our patients with a more efficient patient
pathway through the hospital, we will be separating the day surgery patient
from our inpatients, with a dedicated suite for day surgery patients and a
ward with individual rooms with en-suite facilities for inpatients. Best
practice has shown that by doing this, patient care will improve as waiting
time and recovery period are reduced
Through amended coding and reports, patient satisfaction surveys and
incident reporting we will monitor the effectiveness of this service, and
make changes were indicated.
• Group pre operative assessments for major joint replacements
At the Woodland hospital we have recognised that seeing every patient
individually was not always the most efficient way of giving the required pre
operative information to patients. We wanted to encourage patient
dialogue, interaction whilst improving the patient flow through the pre
operative service and therefore we are planning to introduce group pre
operative assessments for major joint replacements.
Initially we aim for 25% of NHS patients having joint surgery to have the
choice to undergo a group pre-operative assessment increasing
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incrementally until 95% of NHS patients having major joint surgery have
the choice to receive their pre operative assessments in a group setting.
To enable us to implement group assessments, a local action plan will be
devised and implemented with our pre assessment team leading on this,
ensuring we monitor its effectiveness and impact on patients through
patient satisfaction survey, auditing complaints and clinical incidents which
will be reported through our local and national Clinical Governance
Framework.
• Improve National Benchmarking – how do we compare?
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 and we will undertake 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
/PublicationsStatistics/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 indicators common to both NHS survey and our own, that is PROMS
and TLF
•
Improve ward efficiency by continuing with the Productive Ward
initiative – more time to care
The Productive Ward (PW) Project is an NHS Initiative developed by the
Institute for Innovation and Improvement (2008). It focuses on the way
ward teams work together and organise themselves, in order to reduce the
burden of unnecessary activities, and releasing more time to care for
patients in a reliable and safe manner within existing resources. The
approach is very much ‘bottom up’ with all ward staff suggesting ideas and
ways in which they could improve their environment and processes.
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•
Improved patient information
It was recognised from our patient satisfaction survey results that our
patients were not always receiving written discharge information on
discharge. This is important as even though we always tell our patients
everything they need to know before going home, a written reminder
ensures that they have the same information should they need to refer to it
at a later date.
In response to this, we now ensure that all of our patients receive a
discharge letter on discharge and a copy of this is faxed to the GP within
24 hours of discharge. This will be monitored on a monthly basis and
reported through to the PCT as part of a monthly report.
Patient experience – informing patient choice
•
Increasing the use of Patient Reported Outcomes Studies (PROMs)
By sharing and using the results of the national PROMs results for Hip,
Knee, Varicose Veins and Hernia surgery we are able to identify any areas
of poor patient outcome and examine practice if and where this exists.
This will be facilitated through the MAC, Clinical Governance and Theatre
Utilisation Meetings.
•
Patient Satisfaction survey
In 2010 we carried out a patient satisfaction surveys every quarter. In the
first and second quarter, the following areas were identified as areas for
improvement and our actions:
•
Written information about proposed treatment
– it was recognised that patients were not receiving the appropriate
information regarding their operation. Therefore, we reviewed the process
and introduced the EIDO leaflets being given out in out patients and this
information was then reiterated at pre operative assessment. This has
increased our satisfaction results from 87.5% in the first quarter to 100%
by the fourth quarter.
•
Written information about proposed treatment
-it was recognised that we needed to improve the information provided to
patients post discharge on how to care for themselves and who to contact.
We changed the leaflets provided by physiotherapy and insured patients
had the correct contact details. We have also, just introduced postoperative discharge phone calls for all our patients undergoing day case
surgery.
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•
Cleanliness/Hand Hygiene
-in quarter 1 our satisfaction results were 97.4 % and 86.4% respectively.
To improve this we raised it with all staff and Consultants and carried out
unannounced hand hygiene audits. In quarter 4 our results have
increased to 97.9% and 96.8% respectively. We are now planning to run
‘clean your hands’ campaign and run a monthly hand hygiene audit
calendar.
•
Received copies of letters sent between hospital doctors and family GP’s
-To ensure safe and appropriate care continues once the patient is
discharged from hospital it is imperiative that GP receives the correct
information, and the patient should be aware of the information being
shared. This question was not introduced until Quarter 2 satisfaction
survey, and our satisfaction score was 77%. We have raised this with the
Consultants and although we have seen a small increase (80%), this has
to be a key area for the forthcoming year.
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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 Woodland hospital provided and/or subcontracted 2600 NHS
services.
The Woodland hospital has reviewed all the data available to them on the quality
of care in all of these NHS services.
The income generated by the NHS services reviewed in 1 April 2010 to 31st
March 11 represents 38% per cent of the total income of Woodland Hospital.
The balanced scorecard
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard
are reviewed each year. The scorecard is reviewed each quarter by the hospitals
senior managers together with regional and Corporate Managers. The balanced
scorecard approach has been an extremely successful tool in helping us
benchmark against other hospitals and identifying key areas for improvement.
In the period for 2010/11, the indicators on the scorecard which affect patient
safety and quality were:
Human Resources
HCA Hours as % of Total Nursing
Agency Hours as % of Total Hours
% Staff Turnover
% Sickness
Total Lost Worked Days
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff Injuries
Patient
Formal Complaints per 1000 HPD's
Patient Satisfaction Score
Number of Significant Clinical Events
Readmission per 1000 Admissions
Quality
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Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
Local KPI’s are as follows:
2.2.2 Participation in clinical audit
During 1 April 2010 to 31st March 2011, 4 national clinical audits and no national
confidential enquiries covered NHS services that Woodland hospital provides.
During that period Woodland hospital participated in 100% National clinical audits
and no national confidential enquiries 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 Woodland
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)
• Blood transfusion
O neg blood use (National Comparative Audit of Blood Transfusion)
The national clinical audits and national confidential enquiries that Woodland
hospital participated in during 1 April 2010 to 31st March 11 are as follows:
• 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)
The National clinical audits and national confidential enquiries that Woodland
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)
Name of Audit
Participation
(NA, Yes, No)
% cases
submitted
Peri- and Neonatal
Children
NA
NA activity
NA
Acute care
Cardiac arrest (National Cardiac Arrest Audit)
NA Activity
Long term conditions
NA activity
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Yes
Yes
Cardiovascular disease
NA activity
Renal disease
NA activity
Cancer
NA activity
Trauma
NA activity
Psychological conditions
NA activity
Blood transfusion
O neg blood use (National Comparative Audit of Blood
Transfusion)
Platelet use (National Comparative Audit of Blood Transfusion)
100%
95% Hip,
100%
knee
Yes
NA Activity
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
Woodland hospital intends to take the following actions to improve the quality of
healthcare provided. The clinical audit schedule can be found in Appendix 2.
• Consent
-At Woodland Hospital, consent is taken in a two stage process, stage one
being taken in outpatient by the Consultant and second stage being taken on
admission by the nurse, who confirms that the patient fully understands all
aspects of consent. The area that needs improvement is first stage consent
with many Consultants explaining the details of the operation at the outpatient
appointment and then taking written consent on admission. This has been
raised at the MAC meeting, and the consultants have agreed to provide a
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copy of the clinic letter, confirming what procedure was discussed with the
patient.
• Anaesthetic standards
-This relates to documentation of the patients temperature during surgery. On
reviewing the patient records, the patient’s temperature was taken but not
recorded in the records. This has been addressed with all theatre staff, with a
reiteration of the professional and legal requirements of ensuring the patients
records reflect accurately the care delivered.
• Infection control and prevention
-This relates to ensuring staff always wear protective clothing (gloves and
apron) when inserting venflons and administering medication via the
intravenous route. This will form part of the monthly hand hygiene audit.
• Care Pathways
-Woodland hospital has specific care pathways for patients having joint
replacement surgery and has a generic pathway for other surgery as a day
case and in-patient. These pathways are now available to order via the
organizations printers and this ensures that they are not photocopied, which
could lead to information being unreadable or pages missed off.
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
There were no CQUIN’s allocated to the Woodland Hospital in 2010/11.
2.2.5 Statements from the Care Quality Commission (CQC)
Woodland 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
Woodland hospital during 2010/11.
Woodland hospital has not participated in any special reviews or investigations by
the CQC during the reporting period.”
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2.2.6 Data Quality
Woodland hospital will be taking the following actions to improve data quality.
•
•
•
•
•
•
Recording and investigating any unexpected return to theatre post surgery
Any extended length of planned stay and the reasons for this
Any unplanned death – this is reported and investigated as a serious
untoward incident
Any infections post surgery
Any transfer from the hospital
Robust clinical audit calendar (See Appendix 2)
All of these audit results are discussed at the MAC, Clinical Governance, and
Health and Safety meetings, and results are compared against previous year
results.
NHS Number and General Medical Practice Code Validity
Woodland 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:
99% for admitted patient care;
99% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
• the General Medical Practice Code was:
99% for admitted patient care;
99%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
Woodland Hospital was not subject to the Payment by Results clinical coding
audit during 2010/11 by the Audit Commission.
Quality Accounts 2010/11
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2.2.7 Stakeholders views on 2010/11 Quality Account
To support our Quality Account we sent a copy to our lead commissioning
primary care trust (PCT). They were happy with the document and agree that
quality information should be available to the general public.
Quality Accounts 2010/11
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Part 3: Review of quality performance 2010/2011
Statements of quality delivery
Matron, Elaine Rowland
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 model are:
•
Infrastructure
Quality Accounts 2010/11
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•
•
•
•
•
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).
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
Quality Accounts 2010/11
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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
Woodland Hospital has a very low rate of hospital acquired infection and
has had three 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:
•
Local bi-monthly infection control meetings and quarterly infection control
committee meetings with local Trust.
•
Lead Consultant involved in infection control providing link with Consultant
colleagues
•
Monthly report on all aspects of infection control to Heads of Departments
Quality Accounts 2010/11
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2010/11
Infection rate
2009/10
12
10
8
6
4
2
0
2008/09
Number of Patients
Total Number of Infections
Year
•
Over the last three years our infection rate has been very low, with 8 cases
(0.17% of total admissions) reported in 2008/09, 11 cases
(0.20% of total admissions) in 2009/10 and 5 cases (0.08% of total
admissions) in 2010/11. These excellent infection rates are due to robust
pre-admission processes and infection control practices and hand hygiene
being a primary focus point for all staff working at the hospital.
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 table below demonstrates our results.
Environment
2008
2009
2010
Excellent
Excellent
Excellent
Food
Excellent
Excellent
Excellent
Privacy and
Dignity
N/A
Excellent
Good
In conjunction with these assessments, we also carry out our own housekeeping
audits, which began in 2009. The results of these audits are publicised to all staff
and any areas of poor compliance are addressed through action plans. The main
areas that required auctioning were:
• High level damp dusting (door closures, top of picture frames, tops of
cupboards)
• Cleaning of nozzles on alcohol dispensers
Quality Accounts 2010/11
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•
Moving of chairs and cleaning behind them
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Jun-09
Jul-09
Aug-09
Sep-09
Oct-09
Nov-09
Dec-09
Jan-10
Feb-10
Mar-10
Apr-10
May-10
Jun-10
Jul-10
Aug-10
Sep-10
Oct-10
Nov-10
Dec-10
Jan-11
Feb-11
Mar-11
Apr-11
Percentage
Local Housekeeping Audits
Overall Housekeeping score
JunSepJul-09
09
09
Feb10
MarAugJul-10
10
10
76%
87%
93.10 92.10 92.20 92.20 94.30 91.30
82%
87.60
Oct10
Nov10
Month
.
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.
Any incident that occurs is reported through incident reporting and these are
discussed at our MAC, Clinical Governance and Health and Safety meetings. We
analyse these incidents for trends and themes and take action where indicated.
An example of this relates to patients falling 3-4 days post surgery, and when
these incidents were examined, they identified that the theme related to the
prescribing of a type of analgesia. This was raised with the anaesthetists and
prescribing practice was changed, this reduced the number of falls dramatically
Quality Accounts 2010/11
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Apr11
The graph below identifies the number of incidents reported per year over the
past three years as a total.
140
120
100
126
118
98
80
60
Total number
of incidents
40
20
0
2008/09
2009/10
2010/11
• As can be seen in the above graph our adverse events rates appear to
have increased over the last three years. However, when these are
considered per 1000 admissions our numbers have reduced as in 2008/09
we reported 24.5 incidents per 1000 admissions, in 2009/10 we reported
25.2 incidents per 1000 admissions and in 2010/11 we reported 23.6
incidents per 1000 admissions.
• Despite the reduction, we still take every incident extremely seriously and
ensure that each incident is reviewed and discussed. Staff are actively
encouraged to report incidents as by doing this we can identify areas for
improvement.
• The incidents that are reported are then divided into subsections
separating clinical from non-clinical, with clinical incidents coming under
the umbrella of clinical effectiveness.
3.2 Clinical effectiveness
Woodland 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.
The results highlighted in the graphs demonstrate the effectiveness of this
approach over the last three years.
Quality Accounts 2010/11
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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.
Total number of Unexpected Returns to Theatre
15
10
5
0
2008/09
•
•
2009/10
Year
2010/11
As can be seen in the above graph our return to theatre rate is very low
and has decreased since 2008/09 but remained stable over the last two
years. When these numbers are considered as a percentage of our total
admissions, our return to theatre rates were 0.30%, 0.15% and 0.13%
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.
Quality Accounts 2010/11
Page 28 of 36
16
14
12
10
8
Readmissions
6
4
2
0
2008/9
•
•
2009/10
2010/11
As can be seen in the above graph our readmission to hospital rate has
decreased steadily over the last three years and remain very low. When
these numbers are considered as a percentage of our total admissions,
our readmission rates are 0.30%, 0.26% and 0.19% 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 feedback via the various methods below, and are regular
agenda items on Local Governance Committtees for discussion, trend analysis
and further action where necesary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Quality Accounts 2010/11
Page 29 of 36
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
ƒ
Patient satisfaction surveys
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called
‘The Leadership Factor‘ (TLF). They print and supply a set number of
questionnaire packs to our hospital each quarter which contain a self addressed
envelop addressed directly to TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also
separately for NHS and private patients). The results are available for patients to
view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel
they receive excellent quality of care and service in Woodland Hospital. To record
a satisfaction index over 94.8%, 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
94
92
90
2008
88
2009
2010
86
84
82
1st Qtr
•
2nd Qtr
3rd Qtr
4th Qtr
As can be seen in the above graph our Patient Satisfaction rate has
increased over the last year and currently our hospital rates in the top 2-
Quality Accounts 2010/11
Page 30 of 36
3% of 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 and
ensuring that our patients receive copies of any correspondence between
their Consultant and General Practitioner.
3.3.2 Patient Reported Outcome Measures (PROMs)
Woodland Hospital participates in the Department of Health’s PROMs surveys for
hip and knee surgery and hernias and for NHS patients.
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 Woodland 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
PROMS Response rate
80
60
Woodland
40
National
Knee
response
Rate
0
Hip
Response
rate
20
Hernia
Response
rate
% response rate
100
Quality Accounts 2010/11
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EQ Vas results
100
80
60
Woodland
40
National
20
0
Hernia EQ Vas
Hip EQ Vas
Knee EQ Vas
Oxford Score
25
20
15
Woodland
10
National
5
0
Oxford Hip
•
Oxford Knee
As can be seen in the above graphs our PROMs response scores for hip
and knee surgery is higher than the national average. This is due to a full
explanation being given to patients of why the audit is required and how
we can shape our services through this feedback.
Quality Accounts 2010/11
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3.4 Woodland Hospital Case Study
Ophthalmology services have been provided at the Woodland Hospital since the
commencement of the ECN contract.
In 2011 a new Ophthalmic Consultant joined us and was concerned that patients
were waiting a long time for their initial outpatient appointment for cataract
surgery. Anecdotal evidence showed that other hospital units were suffering with
a large amount of patients who were not being seen soon enough. Patients were
also not being offered Choice when visiting their Optometrist and needing a
referral into secondary care.
A meeting was arranged between the management of the hospital and the
Clinical Director of the PCT who informed us of the patient pathway and the
criteria that patients need to meet in order to justify the requirement for cataract
surgery. The Consultant was already following the pathway and was happy to
start using the paperwork provided by the PCT. The PCT also updated their
referral information to include Woodland Hospital.
Patients are now being offered Choice from their Optometrist and are seen
quickly for their initial outpatient appointment.
Later this year, we will be reviewing the patient pathway with the Consultant and
the PCT, to potentially eliminate the initial consultation.
Quality Accounts 2010/11
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Appendix 1
Services covered by this quality account
Breast care
Cosmetics
Dermatology
Ear, nose and throat (ENT)
Gastroenterology
General Medicine
Gynaecology
Neurology
Ophthalmology (inc laser)
Orthopaedic medicine
Pain management
Podiatry
Psychology
Physiotherapy
Rheumatology
Sports medicine
Urology
Vascular
Diagnostics
Laser treatments
Quality Accounts 2010/11
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2010/11
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Woodland 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
Tania Terblanche, General Manager using the contact details
below.
Tania Terblanche
General Manager
Woodland Hospital
Rothwell Road
Kettering
For further information please contact:
Phone: 01536 414515
E-Mail:Tania.terblanche@ramsayhealth.co.uk
www.woodlandhospital.co.uk
Neurological Centres
Quality Accounts 2010/11
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