Quality
Account
2011/12
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Duchy Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 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
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Quality Accounts 2011/12
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Welcome to Ramsay Health Care UK
Duchy 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 2011/12
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Introduction to our Quality Account
This Quality Account is Duchy 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.
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 the Duchy Hospital‟s second submission.
Quality Accounts 2011/12
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Part 1
1.1 Statement on quality from the General
Manager
Chris Sealey, General Manager,
Duchy Hospital
Welcome to Duchy Hospital‟s first quality account. This report outlines the
Hospitals approach to quality improvement, progress made in 2011-12 and
plans for the forthcoming year.
Duchy Hospital has five key values which underpin everything we do as an
organisation:
• Put the patient first
• Work as one team
• Respect each other
• Strive for continual improvement
• Respect environmental sustainability
The aim of our Quality account is to provide information to our patients and
commissioners to assure them we are committed to making progressive
achievements.
For example, we participate in the Health Protection agency‟s Surgical Site
Surveillance Service and our surgical site infection rates are significantly
lower than the national average.
Our emphasis is on ensuring patients receive safe and effective care, that
they feel valued and respected in decisions about their care and are fully
informed about their treatment at each step of the pathway.
The experience that patients have in our hospital is of the utmost
importance and we are committed to establishing an organisational culture
that puts the patient at the centre of everything we do. As well as being
treated quickly and safely, our patients receive a personalised service,
Quality Accounts 2011/12
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enhanced by good communication and a commitment to ensuring their
privacy and dignity are respected at all times.
High quality patient care is at the centre of what we do and how we operate
our hospital. To do this we rely on excellent medical and clinical leadership
plus an overall continuing commitment to drive year on year improvement
in clinical outcomes.
We especially value patient‟s feedback about their stay, treatment and
clinical outcome.
Chris Sealey, Hospital Manager
Quality Accounts 2011/12
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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.
Chris Sealey, General Manager
Duchy Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Miss Bates, Consultant Gynaecologist, Medical Advisory Chair
Mr Kumaravel, Consultant Orthopaedic Surgeon, Clinical Governance
Committee Chairman
Helen White, Regional Director, Ramsay Health Care UK
Quality Accounts 2011/12
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Welcome to Duchy Hospital
Duchy Hospital is one of the South West‟s leading independent hospitals. At the
start of 2012 the facility has 34 beds, a day case lounge with 7 recliners, 3 theatres,
2 with laminar flow and 1 with a fully equipped endoscopy unit.
At present the hospital is undergoing an extensive new development which is due
to be completed in October 2012. On completion the hospital will have an
additional laminar flow theatre, a purpose built day care facility and an on site
cardiac catheterisation laboratory.
Patients requiring level 2 critical care are treated and cared for by a well trained
team of staff in a dedicated high dependency unit.
All Ramsay Health Care UK hospitals have transfer arrangements in place with
their local trust or critical care network for level 3 care.
The hospital provides fast, convenient, effective and high quality care for patients
over the age of 12 whether medically insured, self paying or from the NHS. A
paediatric trained nurse is available to care for children aged 12 – 16.
On site facilities include outpatients, cosmetics, radiology, physiotherapy, mobile
MRI/CT and angiography.
Duchy‟s services include the specialities; dermatology, ear, nose & throat (ENT),
cosmetics, bariatric, gastroenterology, colorectal, breast surgery, general surgery,
gynaecological, ophthalmic (inc laser), maxillofacial/oral, orthopaedic, urological,
neurological and general medicine.
Our clinical facilities are continually monitored to ensure that we are offering the
very best service to our patients.
Total number of patient admissions in the past year was 5496 of which 3437 were
NHS patients (62.5%)
Consultants with Practising Privileges – 170
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”, taking Consultants into GP surgeries to
offer training and latest development awareness as well as running evening GP
training seminars on a regular basis.
We also have a GP representative, Dr Andrew Craze, on the hospital‟s Medical
Advisory Committee (MAC). We value our contact with GPs as “customers” and
strive to ensure we actively work in partnership to enhance patient care.
Quality Accounts 2011/12
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Our total staff complement as of April 2012 is 172
Nurses – 52
ODPs – 9
HCAs – 14
TSSU – 4
Physiotherapist – 12
Radiographers – 3
Porters – 9
Admin staff – 43
Hotel services – 15
Catering – 6
Supplies – 2
Maintenance – 3
We work closely with the Royal Cornwall Hospital Treliske who provide us with
blood transfusion, pathology, pharmacy services and access to level 3 critical care
services.
Quality Accounts 2011/12
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Part 2
2.1 Quality priorities for 2012/13
Plan for 2012/13
On an annual cycle, Duchy Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us
result in safe, quality treatment for all NHS patients whilst they are in our
care. We constantly strive to improve clinical safety and standards through
a systematic process of governance including audit and feedback from all
those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time.
The priorities are determined by the hospitals Senior Management Team
taking into account patient feedback, audit results, national guidance, and
the recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2011/12
Surgical safety checklist – compliance to the checklist is an ongoing
quality initiative at Duchy. 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. Compliance to the surgical safety checklist has been
audited and the results, all above 90%, have been submitted as a locally
agreed quality indicator to Cornwall and Isles of Scilly Primary Care
Trust. Specific checklists for cataract surgery and diagnostic
procedures have been introduced to further reduce the risk of wrong
site surgery/procedure.
Quality Accounts 2011/12
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Venous-thromboembolism assessment - (VTE) is a significant patient
safety issue. The Duchy hospital has established a robust policy to
comply with NICE guidelines in order to reduce avoidable death,
disability and chronic ill health from VTE. We have reduced the variance
of prophylactic measures used at Duchy hospital in order to minimise
human error and allow outcomes to be measured. The hospital 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
91.56 to 100% marks in July, August, September, November and
December 2011.
Never events - preventative measures have been implemented and there
have not been any “Never event” incidents in this reporting year at
Duchy hospital.
Cleanliness - further infection prevention and control audits were
introduced as planned and Duchy‟s results have all been above 95%
Audits include Hand Hygiene 100%, Isolation 100%, Peripheral IV
cannula care bundle 100%, care bundle to prevent Surgical site infection
98% and 100%, Urinary catheter care bundle 95%.
There have been no MRSA bacteraemia or C Difficile infections at the
Duchy Hospital.
Meting endoscopy standards – we have appointed an endoscopy lead
and submit data in line with the GRS initiative for endoscopy. We
continue to work towards JAG accreditation.
The Productive ward – the Duchy staff have been very keen to improve
efficiency processes on the ward which enable them to spend more time
at the patient‟s bedside. To date the nursing staff have re organised the
Ward Treatment room so they can find what they are looking for in less
time, they have purchased a portable copier machine which negates the
need for them to leave the ward every time they need to copy operation
sheets, notes etc, HDU has been re organised and cupboards labelled, a
physiotherapy hand over board is updated daily and a measures board
has been introduced to measure progress and assess benefits.
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 Duchy later this year.
Quality Accounts 2011/12
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National Joint Register – We continue to submit data for the NJR. The
KPI benchmark for NJR consent is 90%. Duchy consistently scores
between 94% -100% for consent and 100% for NHS numbers and
linkability.
Competency training – ensuring safe, competent staff are available to
care for patients is a high priority at Duchy Hospital. Training is
provided to support staff achieve their critical care competencies, ILS
and ALS. For 2012 we have also introduced AIM 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
Duchy Hospital 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
hospital 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.
Quality Accounts 2011/12
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Information Security – in the Duchy Hospital 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 Duchy Hospital.
Staff Satisfaction - our staff satisfaction results are very important to us
as satisfied, well trained and competent staff will ensure patient safety.
The staff satisfaction survey is done annually and the Duchy Hospital is
bench marked against the other Ramsay UK units.
South
Region
%
above
group
Duchy
Overall
4.5
5
11.1%
Leadership
4.3
5.14
19.5%
My Company
5.16
5.66
9.7%
My Manager
4.71
5.13
8.9%
My Team
Personal
Growth
5.02
5.62
12.0%
4.87
5.27
8.2%
Fair Deal
3.8
4.07
7.1%
Giving Back
3.8
4.22
11.1%
4.36
4.93
13.1%
Wellbeing
This summary shows Duchy‟s results in comparison to the rest of our
company region.
Key point – Duchy was in the top 4 of Ramsay Units out of 37 sites
surveyed. (Excluding Directors and Head Office)
Quality Accounts 2011/12
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2.1.2 Clinical Priorities for 2012/13
Patient Safety
Surgical safety checklist – compliance to the checklist will remain an
ongoing quality initiative at Duchy.
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 - one of this year‟s priorities is
for the Duchy hospital to achieve JAG accreditation. We have appointed
a lead nurse in endoscopy and have commenced submitting the Global
Rating Scale data. The Treatment centre at Bodmin, a member of the
Ramsay group, has already achieved accreditation and their endoscopy
lead is supporting the team at Duchy with training and advice.
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.
National Joint Register – the Duchy hospital aims to maintain its
consistently good scores for data submission to the National Joint
register.
Clinical training – the Duchy hospital will continue to ensure that
patients are cared for by safe and competent staff. Providing quality
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care for patients is a high priority at Duchy Hospital 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 – the hospital takes its responsibility for safeguarding
vulnerable members of society seriously. We provide in house training
and contact numbers for help and advice are available on the ward, in
out patients and in the physiotherapy department. 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. To date there have not
been any safeguarding incidents to report at the Duchy Hospital,
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 on the ward and all departments in the
hospital 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 hospital 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
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Clinical effectiveness
Ambulatory Day Care – better outcomes and improving patient
experience. Ambulatory day care is the admission of selected patients
(both medical and surgical) 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. At present the percentage of day case admissions at Duchy is
70%, compared to 62% in 2009. To meet the increased demand for day
care provision we have produced more efficient patient pathways and
are, at present, in the development stage of a new day case unit. The
new unit which will be in operation by October 2012 will have 12 bays
within the theatre complex. There will be pre operative prep rooms
within the facility and an extended area for stage one and stage two
recovery. 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 will
monitor this through amended coding, reports from our patient
information system and through patient satisfaction indices.
Group pre assessment – Duchy‟s pre assessment team have continued
to be very pro active in extending the group pre assessment process
and we are also offering Saturday group sessions for patients that find
weekend visits to hospital more convenient. It was recognised that
seeing each patient individually was not always the most efficient way
of giving the required pre-operative information to patients and that
holding group sessions encouraged discussion and group interaction.
The patients are first assessed at time of consultation to ensure they are
fit for surgery and then they are invited to attend a group session where
they are given a procedure specific presentation and an opportunity to
ask questions and meet other patients having the same procedure. The
group session is followed up by an individual phone assessment which
gives the patient the opportunity to speak in confidence to the pre
assessment nurse. The patient feedback on these sessions has been
very encouraging.
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
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readmissions, average length of stay, unplanned transfers,
reoperations, etc)
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 – Duchy‟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 continue to participate
in the national PROMS data collection for Hips, Knees, Varicose Veins
and Hernia surgery. The results, which are very encouraging for Duchy,
are shared with the medical and clinical staff through the Medical
Advisory Committee, Clinical Governance Committee, and Clinical Head
of Department and Departmental meetings. Reviewing this data also
provides the opportunity to identify poor outcomes and examine
practice if and when it exists. This year we have agreed to participate in
a local Clinical Outcomes tool which is also being piloted by the Royal
Cornwall Hospital for orthopaedic patients. If successful there are plans
to expand “My Clinical Outcomes” to other specialities.
Patient satisfaction survey – Duchy has always achieved a high level of
patient satisfaction. The most recent result being 94.1%. All scores are
reviewed and appropriate action plans formed to address areas that
require improvement. This year the Duchy hospital will also be
participating in the NHS patient survey.
Quality Accounts 2011/12
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1.2 Mandatory Statements
2.2.1 Review of Services
During 2011/12 the Duchy Hospital provided Outpatient consultations,
diagnostics and elective surgery in 10 NHS Specialities through the Choose
& Book System. Duchy 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 hospital‟s senior management team together with regional
and Corporate Managers. The balance scorecard approach has been an
extremely successful tool in helping us benchmark against other hospitals
and identify 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 – 16.9%
Agency hours as % of total hours – 0.19%
% staff turnover – 5% (50% of these were retirements of long serving staff
members)
Staff satisfaction – 83.3%
% sickness – 2.2%
Total lost worked days - 904
Patient
Formal complaints per 1000 HPDs – 4.5
Patient Satisfaction Score – 93.8%
Readmission per 1000 admissions – 1.08
Quality
Infection control audit score – 99.3%
Workplace Health & Safety – 95%
Quality Accounts 2011/12
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2.2.2 Participation in clinical audit
Between 1st April 2011 to 31st March 2012 Duchy Hospital participated in
four national clinical audits (see table below) and three national confidential
enquiries (Peri-operative care, cardiac arrest, cosmetic surgery).
The national clinical audits that Duchy Hospital was eligible to participate in
during 1st April 2011 to 31st March 2012 are listed in the table below;
National Clinical Audits
Name of Audit
Participation
Peri-and Neo-natal
Children
N/A – no service
N/A – no service
Insufficient patient
numbers
Insufficient patient
numbers
Acute care
Long term conditions
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Cardiovascular disease
Renal disease
Cancer
Trauma
Psychological conditions
Blood transfusion
Bedside transfusion (National Comparative Audit of Blood
Transfusion)
Medical use of blood (National Comparative Audit of Blood
Transfusion)
Health promotion
End of life
YES
YES
Insufficient patient
numbers
N/A – no service
Insufficient patient
numbers
N/A – no service
N/A – no service
% cases
submitted
100%
100%
Did not participate in
2011
N/A
Insufficient patient
numbers
Insufficient patient
numbers
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Local Audits
The reports of 63, which includes 16 infection prevention and control, 3
transfusion, 4 physiotherapy and 8 radiology clinical 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.
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.
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2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
Duchy hospital income for achieving quality improvement and innovation
goals through the Commissioning for Quality and Innovation payment
framework is applicable from 1st July 2011 (SAC commencement) to March
31st 2012. The final report is being prepared for submission but we are
confident of achieving our locally agreed CQUIN on surgical safety
checklists and all the nationally mandated CQUINs with the exception of
patient satisfaction as Duchy did not participate in the NHS survey last
year.
2.2.5 Statements from the Care Quality Commission (CQC)
Duchy 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 Duchy hospital during 2011/12.
Duchy hospital has not participated in any special reviews or investigations
by the CQC during the reporting period.
On the most recent CQC inspection on 7 th February 2012 the Duchy hospital
was inspected on outcomes 1, 2, 4, 7, 13 & 14 and found to be fully
compliant.
On the 21st March 2012 the CQC also made an unannounced visit to inspect
the TOP services at the Duchy Hospital. 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 are taken to improve quality as required. This applies to both
private and NHS patient streams.
The hospital has a data quality super user who manages the SUS pathway
processes and continually reviews administration functions to ensure data
quality.
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NHS Number and General Medical Practice Code Validity
Duchy Hospital submitted records during 2011/12 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:
99.66 % for admitted patient care;
99.30 % for out patient care; and
0% for accident and emergency care (not undertaken at our hospital)
The General Medical Practice Code was:
99.96% for admitted patient care;
99.82% for out patient care; and
0% 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 2011/12 was 77% and was graded “green” (satisfactory)
Clinical coding error rate
The Duchy hospital is subject to the Payment by Results clinical coding
audit and we will be audited as a company in 2013.
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2.2.7 Stakeholders views on 2011/12 Quality
Account
The Duchy Hospital 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 Duchy Hospital 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 Duchy Hospital and welcomes the approach the Hospital has shown
in developing and setting out its plans for quality improvement. There are routine
processes in place with the Duchy 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 Duchy achieved Commissioning for Quality and Innovation stretch targets
except: Improving responsiveness to personal needs.
Quality Accounts 2011/12
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The Quality Account presents an overview of a range of quality improvement
work being undertaken. We particularly commend the continued high patient
satisfaction and patient reported outcome measures.
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 Hospital throughout the
year to achieve more efficient pathways delivering high quality services to
patients.
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Part 3: Review of quality performance
2011/2012
Statements of quality delivery
Matron, Kathie Rimmer
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 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
Scally and Donaldson paper (1998) as we believe that it is a model that
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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).
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Ramsay has systems in place for scrutinising all national clinical guidance
and selecting those that are applicable to our business and thereafter
monitoring their implementation.
3.1 Patient safety
We are a progressive hospital and focussed on stretching our performance
every year and in all performance respects, and certainly in regards to our
track record for patient safety.
Risks to patient safety come to light through a number of routes including
routine audit, complaints, litigation, adverse incident reporting and raising
concerns but more routinely from tracking trends in performance
indicators.
Our focus on patient safety has resulted in a marked improvement in a
number of key indicators as illustrated in the graphs below.
3.1.1 Infection prevention and control
Duchy hospital has a very low rate of hospital acquired infection and has
had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a
programme to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections
for orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our
hospital. An annual strategy is developed by a corporate level Infection
Prevention and Control (IPC) Committee and group policy is revised and redeployed 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. At Duchy Hospital the ward sister and one of the senior staff
nurses have undertaken additional training to lead the hospital‟s infection
control agenda.
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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
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.
Hospital Acquired Infections
The graph above shows numbers of Hospital acquired infections for Duchy
Hospital over the last 3 years. All of these cases were successfully treated
with antibiotic therapy.
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The graph below gives the % of infections per admit.
There have been no cases of MRSA Bacteraemia
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
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.
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Duchy‟s environmental audit results were 99% in 2011 and 100% 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.
PEAT audit
We participate in the national annual assessment for all NHS Trusts and
some of the independent sector; these assessments include rating of
privacy and dignity, food and food service and environment which
assesses issues such as signage, bathroom/toilet environments and overall
cleanliness.
Duchy Hospitals latest PEAT audit results for 2012; Environment –
Excellent; Food score – Excellent; Privacy and Dignity - Excellent
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
organization must adhere to ensuring a safe workplace. The benchmark set
for 2010 was 90% and this has been raised to 95% for 2011.
Duchy audit results for 2011 – 95%
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.
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3.2 Clinical effectiveness
Duchy 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.
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.
The graph above shows numbers of unexpected returns to theatre over the
last 3 years.
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The graph above gives the % of unplanned returns to theatre per surgical
admission.
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.
The graph above shows the number of unplanned re-admissions over the
last 3 years.
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The graph below shows the % of unplanned re-admissions per admit.
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 fed back 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 Committees 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.
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Feedback regarding the patient‟s experience is encouraged in various ways
via:
 Patient satisfaction surveys
 „We value your opinion‟ leaflet
 Verbal feedback to Ramsay staff - including Consultants,
Matrons/General Managers whilst visiting patients and Provider/CQC
visit feedback.
 Written feedback via letters/emails
 PROMs surveys
 Care pathways – patient are encouraged to read and participate in their
plan of care
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 at Duchy Hospital. To
record a satisfaction index over 90%, a very high proportion of our patients
have scored 9 or 10 out of 10 for their satisfaction with all the requirements.
This is underlined by comparing our hospitals Satisfaction Index against
those achieved by other organisations across all sectors of the UK
economy where the full range of customer satisfaction is 50% to 95% with
the median just below 80%.
Duchy‟s average score of 93.8% rates the hospital in the top 2-3% of
organisations.
3.3.2 Patient Reported Outcome Measures (PROMs)
Duchy Hospital participates in the Department of Health‟s PROMs surveys
for hip and knee surgery, hernias and varicose veins for NHS patients. The
sample sizes are small and survey results are evolving. Indications so far
are that Duchy Hospital patients report excellent outcomes, and results
compare very favourably with other providers.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs
surveys specifically for private patients.
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Appendix 1
Services covered by this quality report
Duchy Hospital
Duchy Hospital has 34 beds and a day case lounge with 7
recliners. The hospital has 3 theatres, 2 with laminar flow and 1 with a fully equipped
endoscopy unit.
Regulated Activities – Duchy Hospital
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Diagnostic
and
screening
Services Provided
Physiotherapy, Cardiology, Endocrinology, General
medicine, Haematology, Oncology, Neurology,
Psychiatry, Psychotherapy, Speech therapy, Sports
medicine, Urology, Medicine management, Clinical neuro,
physiology, Allergy testing, Diabetology, Occupational
therapy
Peoples Needs Met for:
All adults 18 yrs and over
All children 12 yrs and over
Consultations – from birth
Cosmetic, Bariatrics, Dermatological, Ear, Nose and
Throat, (ENT), Gastrointestinal, Colorectal, Breast
surgery, General surgery, Gynaecological, Ophthalmic
(inc laser), Maxillofacial / oral, Orthopaedic, Urological,
Neurological, Ambulatory, Day and Inpatient Surgery
All adults excluding:
Cardio physiology, ERCP, GI physiology, Imaging
services, Phlebotomy, Urinary Screening and Specimen
collection
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 children 12 yrs and over
All adults 18 yrs and over
All children 12 yrs and over
Consultations – from birth
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Appendix 2 – Clinical Audit Programme.
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Duchy Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
01872 226100
http//www.duchyhospital.co.uk
Neurological Centres
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