Quality
Account
2011/12
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Bodmin NHS Centre
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 2011/12 (looking back)
2.1.2 Clinical Priorities for 2012/13 (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 2011/12 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 2011/12
Page 2 of 31
Welcome to Ramsay Health Care UK
Bodmin NHS Treatment Centre 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 2011/12
Page 3 of 31
Introduction to our Quality Account
This Quality Account is Bodmin NHS Treatment Centre‟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.
In 2009/10 the Quality Account 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, however, 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 developed its own Quality Account for 2010/11
and this account for 2011/12 is Bodmin NHS Treatment Centre‟s second
submission.
Quality Accounts 2011/12
Page 4 of 31
Part 1
1.1 Statement on quality from the General
Manager Kathie Rimmer,
Bodmin NHS Treatment Centre
The Bodmin NHS Treatment Centre has been delivering high quality clinical
services to local residents for more than 6 years and as General Manager I
take great pride in the service we offer our patients.
This quality account has been produced to provide information about how
we monitor and evaluate the quality of the services we deliver. It has been
prepared in collaboration with every profession engaged in service
provision within the hospital. Every individual member of staff is crucial to
the success of our Treatment Centre and we value the contribution that
they make in delivering great customer care.
Our vision for our hospital includes a commitment to deliver health services
needed by the local population within the scope of safe clinical practice. It
also encompasses a commitment to deliver a patient experience that will
leave every patient feeling that everything that should have been done was
done to the standard they would expect.
The following pages set out our quality assurance policies and underline
our commitment to delivering the highest possible standard of service in
every circumstance.
Bodmin NHS Treatment Centre has a very strong tract record as a safe and
responsible provider of healthcare and we are proud to share our results.
Kathie Rimmer
General Manager
Bodmin NHS Treatment Centre
Quality Accounts 2011/12
Page 5 of 31
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.
Kathie Rimmer
General Manager
Bodmin NHS Treatment Centre
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Peter Callen MAC Chair
Dr Marek Woyton Clinical Governance Committee Chair
Helen White Regional Director, Ramsay Health Care UK
Terry Goldsworthy Cornwall and Isles of Scilly PCT Lead Commissioner
Quality Accounts 2011/12
Page 6 of 31
Welcome to Bodmin NHS Treatment Centre
Bodmin NHS Treatment Centre is a purpose built day unit built in
2005 to work in partnership with the NHS. It is equipped with 2
Theatres and a designated Endoscopy suite.
The Treatment Centre provides NHS services throughout Cornwall
and Devon. We provide fast, convenient, effective and high quality
treatment for patients above the age of 18 with the exception of
Termination of Pregnancy patients who can access our services from
the age of 16.
Bodmin NHS Treatment Centre‟s services include the specialities;
dermatology, ear, nose & throat (ENT), endoscopy, general surgery,
gynaecological, ophthalmic, maxillofacial/oral and orthopaedics.
Total number of patient admissions in the past year was 4913.
Our clinical facilities are continually monitored to ensure that we are
offering the very best service to our patients.
We employ 45 Staff; 3 Employed Doctors, 16 Trained Nurses, 6
Healthcare assistants, 4 Housekeepers, 2 Counselors, 1.5 Stores
persons, 12 Admin staff and 1 Cosmetic nurse. We also share an
accountant, support services manager and engineers with the Duchy
hospital.
W have 20 Consultants with Practising Privileges
We receive our referrals from both the Referral Management Service
in Truro and Sentinel in Devon.
Mrs Miranda Field is our GP liaison manager. Miranda has close
contact with both the practice managers and the GPs at our practices
throughout Cornwall. Miranda organises regular “Lunch and
Learns”, visiting GP surgeries to offer training and latest
development awareness as well as running evening GP training
seminars on a regular basis.
We work closely with the Royal Cornwall Hospital Treliske who
provide us with blood transfusion, histology and access to critical
care services.
We have a good working relationship with our GPs and one local GP
sits on our Medical Advisory Committee.
Quality Accounts 2011/12
Page 7 of 31
Our nominated charity for last year was the Cornwall air
ambulance service and we raised over £500. We will continue to
support this important Charity this year
We will be attending a local County show in July to raise awareness
of the Treatment Centre. We also try to raise public awareness of our
services through advertising in local publications and on the radio.
Part 2
2.1 Quality priorities for 2011/2012
Plan for 2011/2012
On an annual cycle, Bodmin NHS Treatment centre develops an operational
plan to set objectives for the year ahead.
Our aim is to deliver a high quality and variety of services for the local
people of Cornwall, so they can access healthcare nearer to home.
We have a clear commitment to our patients as well as working in
partnership with the NHS ensuring that those services commissioned to us,
result in safe, quality treatment for all NHS patients whilst they are in our
care. We constantly strive to improve clinical safety and standards by a
systematic process of governance including audit and feedback from all
those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time.
The priorities are determined by the hospitals Senior Management Team
taking into account patient feedback, audit results, national guidance, and
the recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Quality Accounts 2011/12
Page 8 of 31
Priorities for improvement
2.1.1. A review of clinical priorities 2010/11
Surgical safety checklist – compliance to the checklist is an ongoing
quality initiative at Bodmin NHS Treatment Centre. All the medical and
clinical staff have been involved in achieving this aim and we have
worked with both our Corporate Clinical team and our local Trust to
share training packages and audit tools. Specific checklists for cataract
surgery have been introduced to further reduce the risk of wrong site
surgery/procedure.
Venous-thromboembolism assessment - (VTE) is a significant patient
safety issue. Bodmin Treatment Centre has established a robust policy
to comply with NICE guidelines in order to reduce avoidable death,
disability and chronic ill health from VTE. The Treatment Centre has an
excellent VTE risk assessment compliance record. The results for the
past 12 months range from our lowest mark in May 2011 which was
88.52% to 99.46% in September 2011.
Never events - preventative measures have been implemented and there
have not been any “Never event” incidents in this reporting year at
Bodmin Treatment Centre.
Cleanliness - further infection prevention and control audits were
introduced as planned and Bodmin Treatment Centre‟s results have all
been above 95% Audits include Hand Hygiene 95%, Peripheral IV
cannula care bundle 95%, Care bundle to prevent Surgical site infection
100%, Infection Prevention & Control Environmental audit 99%.
There have been no MRSA bacteraemia or C Difficile infections at
Bodmin NHS Treatment Centre.
Meting endoscopy standards – Bodmin NHS Treatment Centre achieved
JAG accreditation in 2009 and the appointed endoscopy lead and staff
involved in endoscopy continuously submit data in line with the GRS
initiative for endoscopy.
The Productive ward – although Bodmin NHS Treatment Centre does
not have a ward, as such, we have adopted some of the principles of the
productive ward in order to improve efficiency processes and enable the
nurses to spend more time with the patient. To date the nursing staff
have re organised the stores room so they can find what they are
looking for in less time.
Quality Accounts 2011/12
Page 9 of 31
Information Security – in 2011 Bodmin NHS Treatment Centre achieved
the information security accreditation IS0270001. The process of raising
awareness of the importance of data protection and information security
has been very successful and fully embraced by the staff at Bodmin
NHS Treatment Centre.
Real Time incident reporting – Ramsay‟s Risk Incident Management
System ((RIMS) has been considerably updated over the last 12 months
to improve reporting mechanisms across the group. This has enabled
us to provide accurate data for the PCT Quality team so we can be
benchmarked with other providers. For 2012 Ramsay have invested in a
new risk Management reporting system called RISKMAN which will be
installed at Bodmin NHS Treatment Centre later this year.
Competency training – ensuring safe, competent staff are available to
care for patients is a high priority at Bodmin NHS Treatment Centre.
Training is provided to support staff achieve their critical care
competencies, ILS and ALS. For 2012 we have also introduced AIM
(Acute Illness Management) training. Similar to the critical care
competencies there is a robust competency framework for all staff
involved in the administration of blood transfusion. All staff at Bodmin
NHS Treatment Centre have to achieve competencies in blood
transfusion administration before they can be involved in any aspect of
a blood transfusion or handle blood products.
Vulnerable adult, Deprivation of Liberty and Child protection – the
Treatment Centre takes its responsibility for safeguarding vulnerable
members of society seriously and all staff working within the hospital
are required to have a standard or, in the case of those with patient
contact, an enhanced CRB check. Equality, diversity and human rights
are a theme running through Ramsay Health Care. The organisations
integrated governance framework, Group policies and practice comply
with current legislation. In addition to in house training on Equality,
Human Rights and workplace Diversity, vulnerable adult care,
deprivation of liberty and child protection training for 2012 we will be
accessing external safeguarding training with the local council to
improve the our staff‟s awareness of safeguarding policy and
procedure.
Staff Satisfaction - our staff satisfaction results are very important to us
as satisfied, well trained and competent staff will ensure patient safety
risks are reduced. The staff satisfaction survey is done annually and
Bodmin NHS Treatment Centre‟s results for 2011/12 were disappointing.
The survey was, however, conducted during a period of inconsistent
management due to one manager leaving after a short period in charge
and an interim manager being appointed. It is hoped that now a new
Quality Accounts 2011/12
Page 10 of 31
permanent Manager has been appointed the staff will feel more
supported. An action plan has been made to address issues which were
raised.
2.1.2 Clinical Priorities for 2012/13
Patient safety
Surgical safety checklist – compliance to the checklist will remain an
ongoing quality initiative at Bodmin NHS Treatment Centre. Compliance
to the surgical safety checklist will be audited and the results submitted
as a locally agreed quality indicator to Cornwall and Isles of Scilly
Primary Care Trust.
Bar coding for patient identity bands – this priority has been on hold
awaiting a formal notice for implementation. However, this is still on
Ramsay‟s agenda and will be introduced 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.
Venous-thromboembolism assessment – will remain an ongoing quality
initiative and we will continue to audit our compliance to risk
assessment and appropriate prophylaxis. Audit results will be submitted
as one of the nationally mandated quality indicator.
Never events - preventing the occurrence of any serious, largely
preventable patient safety incidents that should not occur will remain a
clinical priority for 2012/13.
Joint Advisory Group for GI endoscopy – maintaining the Treatment
Centre‟s JAG accreditation is an ongoing quality initiative. The
Treatment Centre‟s lead nurse in endoscopy will also be supporting the
team at the Duchy Hospital and Mt Stuart Hospital in Devon with training
and advice in their bid to achieve JAG accreditation.
Real Time incident reporting – in order to improve the reporting
mechanisms Ramsay has purchased a new system called RISKMAN.
The new system which will be in place in all units this year will input the
relevant data more efficiently and make reporting tools more widely
available in order to improve patient safety outcomes.
Quality Accounts 2011/12
Page 11 of 31
Clinical training – Bodmin NHS Treatment Centre will continue to ensure
that patients are cared for by safe and competent staff. Providing
quality care for patients is a high priority at the Treatment Centre and all
relevant clinical staff will be supported through training and protected
time to achieve competency level education. This year the staff have
undertaken competency based training in “recognising the signs of the
deteriorating patient” based on early warning scoring and trigger tools.
The critical care training remains competency based and all staff are
expected to achieve competencies in infection prevention and control
which includes hand hygiene. ILS and/or ALS training is mandatory for
all clinical staff working in acute areas and this year we are also
providing AIM (Acute Illness Management) training.
Blood transfusion competencies – in line with patient safety we will
ensure that blood transfusions or blood products are only
handled/administered by competent trained staff.
Safeguarding – Bodmin NHS Treatment Centre takes its responsibility
for safeguarding vulnerable members of society seriously. We provide
in house training and contact numbers for help and advice are available
throughout the Treatment Centre. All staff working within the Treatment
Centre are required to have a standard or, in the case of those with
patient contact, an enhanced CRB check. Equality, diversity and human
rights are a theme running through Ramsay Health Care. The
organisations integrated governance framework, Group policies and
practice comply with current legislation. To date there have not been
any safeguarding incidents to report at Bodmin NHS Treatment Centre,
however, to maintain staff awareness and give them an insight into the
knowledge of the work of external agencies we are accessing local
authority training for relevant staff.
Staffing – to ensure that adequate numbers of skilled staff are available
to care for our patients staff rotas are prepared in advance. Patient
dependency tools are used daily and all departments in the Treatment
Centre have their own bank of staff to provide additional cover as
required. This year Ramsay have invested in an electronic rostering
system called Allocate. The system will reduce the time spent on
producing numerous rotas throughout the hospitals and will be
accessible to all staff so they can log in and make requests for leave,
training etc. It is also designed to record training hours and remind staff
when they need to attend mandatory training sessions. The system will
be set to produce rotas in line with patient numbers and specific skill
mix requirements.
Quality Accounts 2011/12
Page 12 of 31
Clinical effectiveness
Ambulatory Day Care – better outcomes and improving patient
experience. Ambulatory day care is the admission of selected patients
to hospital for a planned procedure, returning home the same day. Over
recent years, partly due to medical advances, the number of day surgery
patients has increased compared to those patients requiring inpatient
care. We need to ensure that our hospital facilities and patient flows
adapt to meet the case mix we now deliver. Bodmin NHS Treatment
Centre is a purpose built day case facility which has adopted efficient
patient pathways with an average length of stay of 2.28 hours. Best
practice has shown that by caring for short stay patients in a day care
facility, as opposed to a traditional ward, patient care will improve as the
waiting time and recovery period are reduced. We continue to monitor
this through amended coding, reports from our patient information
system and through patient satisfaction indices.
Pre assessment - Bodmin NHS Treatment Centre is a Day case facility
and we screen all patients prior to admission to identify the level of care
they will require during their stay. Some are deemed too complex for
treatment at this site and are referred to a more appropriate facility to
meet their needs. Others are admitted with their level of care already
defined and the necessary skilled staff, equipment and facilities
available for them. Pre assessing patients at the start of their pathway is
performed by highly skilled staff and conducted by either telephone
assessment or a face to face examination. Correctly assessing our
patient‟s needs is an ongoing quality imitative for Bodmin NHS
Treatment Centre.
Improve National benchmarking – it was recognised that we needed
more transparency between ourselves and other independent sector
providers/the NHS in order to monitor and improve our services. This is
even more important now we are working in partnership with the NHS.
We will be benchmarking in the following areas;
Hellenic – will provide national benchmark figures for key performance
indicators(activity/volumes, mortality, day case rates, unplanned
readmissions, average length of stay, unplanned transfers,
reoperations, etc)
Quality Accounts 2011/12
Page 13 of 31
VTE risk assessment compliance – benchmarking through the national
stats website. Link;
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicat
ionsStatistics/DH122283
PROMS results – benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&ca
tegoryID-1295
Patient satisfaction figures – Bodmin‟s patient satisfaction surveys are
managed by an independent company called “The leadership factor”.
For 2012 all Ramsay units will also participate in the annual NHS survey
in order that we can be benchmarked with other providers.
Patient experience
Patient reported outcome studies (PROMS) – we participate in the
national PROMS data collection for Hernia surgery. The results, when
available, will be reviewed by the Medical Advisory Committee and
Clinical Governance Committee.
Patient satisfaction survey – Bodmin NHS Treatment Centre‟s patient
survey is consistently over 96%. The most recent achieving 97% with
100% of patients recommending Bodmin Treatment Centre. If we fall
short of any patients‟ expectations and receive any poor results an
action plan is completed and discussed at our Customer Focus Group
to enable an improvement in the patient experience. This year Bodmin
NHS Treatment Centre will be participating in the NHS customer
satisfaction survey.
Quality Accounts 2011/12
Page 14 of 31
1.2 Mandatory Statements
2.2.1 Review of Services
During 2011/2012 Bodmin NHS Treatment Centre has offered 8 different
services.
The Treatment Centre has reviewed all the data available to them on the
quality of care in 100% of these NHS services.
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 2011/12, the indicators on the scorecard which affect
patient safety and quality were:
Human Resources
HCA Hours as% of Total Nursing – 36%
Agency Hours as % of Total Hours – 0.05%
Total Lost Worked Days – 1772 (includes all annual leave, training and
sickness)
Appraisal 78%
Mandatory Training 90%
Number of Significant Staff Injuries 0
Patient
Formal Complaints per 1000 HPD's – 0.05%
Patient Satisfaction Score 97%
Number of Significant Clinical Events - 0
Readmission per 1000 Admissions – 2
Quality
Workplace Health & Safety 97%
Infection Control Audit Score 96%
Quality Accounts 2011/12
Page 15 of 31
2.2.2 Participation in National clinical audit
Bodmin Treatment Centre does not participate in any of the National
Clinical audits as they are not applicable to the services provided.
Local Audits
The reports of all local audits which include; Anaesthetics, Medical
records, Consent, Discharge, Care Pathways & Variance tracking,
Medicines Management, Controlled drugs, Environmental, Termination of
Pregnancy, Colposcopy, JAG & GRS and 9 infection prevention & control
audits from 1st April 2011 to 31st March 2012 were reviewed by the Clinical
Governance Committee and hospital‟s MAC.
All audit results showed an excellent degree of compliance and our main
priority for 2012/13 will be ensuring standards of documentation are met
with regard to discharge of patients. This is in line with the requirements of
the National Standard Acute Contract for NHS services.
The clinical audit schedule can be found in Appendix 2.
2.2.3 Participation in Research
There were no patients recruited during 2011/12 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Bodmin NHS Treatment Centre income from October 1st
2011 to 31st March 2012 was conditional on achieving quality improvement
Quality Accounts 2011/12
Page 16 of 31
and innovation goals, through the Commissioning for Quality and
Innovation payment framework.
2.2.5 Statements from the Care Quality Commission (CQC)
Bodmin NHS Treatment centre 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 any
enforcement action against Bodmin NHS Treatment centre during 2011/
2012.
Bodmin NHS Treatment Centre has not participated in any special reviews
or investigations by the CQC during the reporting period.
On the most recent CQC inspection on 13th March 2012 Bodmin NHS
Treatment centre was inspected on outcomes 1, 4, 7, 13, 14 & 16 and found
to be fully compliant.
On the 21st March the CQC also made an unannounced visit to inspect the
TOP services at Bodmin NHS Treatment centre. No issues were raised at
the time and we are anticipating a full compliance report.
2.2.6 Data Quality
We regularly use statistical data to monitor clinical services- we are
constantly striving to improve this data by regular quality control initiatives.
Data contained in medical records are audited on a monthly basis and
actions taken to improve quality as appropriate.
Bodmin NHS Treatment Centre will be taking the following actions to
improve data quality.
.
Consultants have been given training documentation and are
aware of the corporate policy for record keeping in clinical
records and operation notes
Monthly medical record keeping audits are completed; results
and actions required are discussed with the relevant
consultants.
Bi annual anaesthetic standards audits are completed, results
and actions required are discussed with the relevant
Consultants.
Quality Accounts 2011/12
Page 17 of 31
Coding take place from the medical records, a procedure
coding form is completed within the patient record throughout
the patient journey.
There is a weekly data report which highlights any identified
areas which are addressed by the coder. This is addressed
before the data is submitted.
Clinical coding error rate
Bodmin NHS Treatment centre was subject to the Payment by Results
clinical coding audit during 2010/11 but has not been audited for 2011/12.
2.2.7 Stakeholders views on 2011/12 Quality Account
Bodmin NHS Treatment Centre Quality Accounts were presented to the
Professional Executive Committee on the 1st May 2012 and this statement
dated 16th May 2011 was signed by Mr Steve Moore, Chief Executive and Dr
Colin Philip, Chair Kernow Clinical Commissioning Group.
Statement from NHS Cornwall and Isles of Scilly/ Kernow Clinical Commissioning
Group for Bodmin Treatment Centre Quality Account 2011/12.
NHS Cornwall and Isles of Scilly (NHS CIOS)/ Kernow Clinical Commissioning
Group is pleased to have the opportunity to comment on the Quality Account
2011/12 for Bodmin Treatment Centre (BTC) and welcomes the approach the
Trust has shown in developing and setting out its plans for quality improvement.
There are routine processes in place with BTC to agree, monitor and review the
quality of services throughout the year covering the key quality domains of safety,
effectiveness and experience of care.
We have reviewed and can confirm the information presented in the Quality
Account appears to be accurate and fairly interpreted, from the data collected.
The Quality Account presents an overview of a range of quality improvement
work being undertaken. We note the continued high patient satisfaction and
patient reported outcome measures; and the challenges to achieve JAG
Quality Accounts 2011/12
Page 18 of 31
accreditation for the endoscopy pathway enabling participation in the county wide
service.
We are pleased to see that the priorities chosen for 2012/13 have been identified
with key stakeholder involvement, and agree with the areas chosen. The Clinical
Commissioning group looks forward to working with the Treatment Centre
throughout the year to achieve more efficient pathways delivering high quality
services to patients.
Quality Accounts 2011/12
Page 19 of 31
Part 3: Review of quality performance
2011/2012
Statements of quality delivery
Matron, Jacqueline Doane
Review of quality performance 1st April 2011 – 31st March 2012
Introduction
‘Our 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’.
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2012
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 interdependent 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
Quality Accounts 2011/12
Page 20 of 31
Scally and Donaldson paper (1998) as we believe that it is a model that
allows coverage and inclusion of all the necessary strategies, policies,
systems and processes for effective Clinical Governance. The domains of
this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
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).
Quality Accounts 2011/12
Page 21 of 31
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
Bodmin NHS Treatment Centre has a very low rate of hospital acquired
infection and has had no reported MRSA Bacteraemia in the past 6 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.
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:
All staff (clinical and non-clinical) have undertaken the corporate elearning training package for Infection Control. In addition they attend an
annual in house training session which includes practical training in Hand
Hygiene using the UV light. The infection control nurses have also done
Quality Accounts 2011/12
Page 22 of 31
similar sessions at hospital open days and at off site marketing events to
promote hand hygiene awareness.
Emphasis on cleanliness has resulted in an operational cleaning matrix
with cleaning records available in each department. Green stickers are now
used in clinical areas, to show when equipment has been cleaned and by
whom. This has resulted in an improved audit trail.
Hand hygiene remains a focus area for 2012/13. The appropriate use of
alcohol gel/foam and hand washing is vital for preventing the spread of
infection and is the responsibility of everyone.
We focus on the World Health Organisation‟s 5 moments when hand
hygiene has to take place and plan to involve our patients in auditing
compliance to this.
Environmental audits have been commenced this year which aim to ensure
a safe environment for all staff and patients.
Bodmin NHS Treatment centre has only had 1 Hospital Acquired infection in
the last 5 years.
3.1.2 Cleanliness and hospital hygiene
We continue to assess the hospitals facilities to ensure that we are
providing a safe environment and use the following audit tools:
Corporate - Environmental Audit – Quarterly
Patient Environment Action Team (PEAT) Audit – Annually (locally
performed as the unit is too small to participate in the national audit)
Corporate - Health, Safety & Facilities Audit – Annually
We have a cleaning matrix for each department, this was implemented in
March 2011. This indicates the items to be cleaned, the frequency and the
cleaning materials to be used; we will use this as evidence when we
complete the quarterly environmental audits.
Environmental Audit
This audit was introduced in 2010, these are completed quarterly, the aim of
this audit is to ensure a safe environment for all staff and patients, the
objectives are:
1. To identify users and user groups
2. To advise on infection control issues arising
3. To acknowledge
The audit consists of an inspection of the hospitals clinical areas and
includes the general environment, clinical equipment, decontamination,
clinical practices, sharps handling, waste disposal and hand washing.
Quality Accounts 2011/12
Page 23 of 31
Bodmin NHS Treatment Centre‟s Environmental audit results were 99% in
2011 and 99% in 2012
We continue to focus on delivering a high standard of cleanliness and
ensure that staff are informed and updated at our mandatory training study
days as well as discussing the points raised at our bi-monthly Risk
Management meetings.
Health, Safety & Facilities Audit
This audit, taken from Approved Codes of Practice (ACOPS) was introduced
in 2009 and is completed annually. The standards are the minimum that an
organisation must adhere to ensuring a safe workplace. The benchmark set
for 2010 was 90% and this has been raised to 95% for 2011.
Bodmin NHS Treatment Centre‟s results for 2012 - 97%
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.
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.
Quality Accounts 2011/12
Page 24 of 31
Adverse Events
40
36
35
Number
30
25
25
21
20
15
10
10
5
0
2008
2009
2010
2011
Year
3.2 Clinical effectiveness
Bodmin NHS Treatment Centre has a Clinical Governance team and
Committee that meet regularly through the year to monitor quality and
effectiveness of care. Clinical incidents, patient and staff feedback are
systematically reviewed to determine any trend that requires further
analysis or investigation. More importantly, recommendations for action
and improvement are presented to hospital management and medical
advisory committees to ensure results are visible and tied into actions
required by the organisation as a whole.
3.2.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as
our services grow. The majority of our patients undergo planned surgical
procedures and so monitoring numbers of patients that require a return to
theatre for supplementary treatment is an important measure. Every
surgical intervention carries a risk of complication so some incidence of
returns to theatre is normal. The value of the measurement is to detect
trends that emerge in relation to a specific operation or specific surgical
team. Ramsay‟s rate of return is very low consistent with our track record of
successful clinical outcomes.
Quality Accounts 2011/12
Page 25 of 31
There have been no returns to theatre at Bodmin NHS Treatment Centre
in the last 5 years.
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.
Bodmin NHS Treatment Centre has only had 2 readmissions to hospital in
2011/2012
Readmission to Hospital
2.5
2
Number
2
1.5
1
1
0.5
0
2010
2011
Year
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.
Quality Accounts 2011/12
Page 26 of 31
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 fed back via the various methods below, and are
regular agenda items on Local Governance Committtees for discussion,
trend analysis and further action where necesary. Escalation and further
reporting to Ramsay Corporate and DH bodies occurs as required and
according to Ramsay and DH policy.
Feedback regarding the patient‟s experience is encouraged in various ways
via:
 Patient satisfaction surveys
 „We value your opinion‟ leaflet
 Verbal feedback to Ramsay staff - including Consultants,
Matrons/General Managers whilst visiting patients and Provider/CQC
visit feedback.
 Written feedback via letters/emails
 Patient focus groups
 PROMs surveys
 Care pathways – patient are encouraged to read and participate in their
plan of care
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company
called „The Leadership Factor„TLF). They print and supply a set number of
questionnaire packs to our hospital each quarter which contain a self
addressed envelop addressed directly to TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but
also separately for NHS and private patients). The results are available for
patients to view on our website.
Patient satisfaction scores for overall quality show the majority of patients
feel they receive excellent quality of care and service in Bodmin NHS
Treatment Centre hospital. To record a satisfaction index over 95%, 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
Quality Accounts 2011/12
Page 27 of 31
across all sectors of the UK economy where the full range of customer
satisfaction is 50% to 95% with the median just below 80%.
Our latest patient survey score was 97%. The best score to date for Bodmin
NHS Treatment Centre
Patient Satisfaction Scores
Satisfaction Percentage
98%
97%
97%
96%
97%
96%
96%
95%
95%
2008
2009
95%
95%
94%
2010
2011
Year
Bodmin NHS Treatment Centre‟s scores, which show year on year
improvement, rates the centre in the top 2-3% of organisations.
We still have areas which we need to improve on such as “Pain Control”
and “having your treatment discussed with you”. We will be looking to
improve these areas.
3.3.2 Patient Reported Outcome Measures (PROMs)
Bodmin NHS Treatment Centre participates in the Department of Health‟s
PROMs surveys for hernia surgery but due to the small numbers submitted
we are unable to provide data at this point.
Website to access your PROMs scores:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&cate
goryID=1295
Quality Accounts 2011/12
Page 28 of 31
. Appendix 1
Services covered by this quality account
Bodmin NHS Treatment Centre
The Treatment Centre opened in January 2006 and is one of
ten centres across the UK where Ramsay is working in
partnership with the NHS. Ramsay’s reputation is built on high
standards of in patient care in the private sector. Our aim is to
combine this experience of providing quality healthcare with
that of our NHS partners.
Bodmin Treatment Centre, Boundary Road, Bodmin, Cornwall
PL312QT
Tel: 01208 262520
Registered Manager: Kathie Rimmer
Kathie.rimmer@ramsayhealth.co.uk
Services Provided
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Out patient services Cosmetic, Dermatological,
Gastroenterology, Gynaecology, General surgery,
Maxillofacial / oral, Ophthalmic, Orthopaedic. ENT
Ambulatory and Day Surgery, Cosmetic, Dermatological,
Gastroenterology, Gynaecology General surgery,
Maxillofacial / oral, Ophthalmic, Orthopaedic. ENT
Peoples Needs Met for:
All adults 18 yrs and over
All young person’s age 16-18yrs consultation for
termination of pregnancy procedures only
.
All young person’s age 16-18yrs for termination of
pregnancy procedures only
All adults 18yrs and over excluding:
Patients with blood disorders (haemophilia,
sickle cell, thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA
screen are deferred until negative
Patients who are likely to need ventilatory
support post operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission
to ITU post surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild
exertion e.g. from kitchen to bathroom or
dyspnoea at rest)
Poorly controlled asthma (needing oral steroids
or has had frequent hospital admissions within
last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal
activity e.g. 1 flight of stairs or angina at rest)
CVA in last 6 months
However, all patients will be individually assessed and we
will only exclude patients if we are unable to provide an
appropriate and safe clinical environment.
All patients must meet social/clinical criteria for day
surgery.
Quality Accounts 2011/12
Page 29 of 31
Appendix 2
Quality Accounts 2011/12
Page 30 of 31
Bodmin NHS Treatment Centre
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:
01208 262520
www.bodmintreatmentcentre.co.uk
Neurological Centres
Quality Accounts 2011/12
Page 31 of 31