Quality
Account
2011/12
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Fitzwilliam Hospital
4
Introduction to our Quality Account
5
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
6
1.2
Hospital accountability statement
8
1.3
Welcome to Fitzwilliam Hospital
9
PART 2
2.1
Priorities for Improvement
12
2.1.1
Review of clinical priorities 2011/12 (looking back)
12
2.1.2
Clinical Priorities for 2012/13 (looking forward)
16
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1
Review of Services
18
2.2.2
Participation in Clinical Audit
19
2.2.3
Participation in Research
20
2.2.4
Goals agreed with Commissioners
20
2.2.5
Statement from the Care Quality Commission
20
2.2.6
Statement on Data Quality
21
2.2.7
Stakeholders views on 2011/12 Quality Accounts
22
PART 3 – REVIEW OF QUALITY PERFORMANCE
23
3.1
Patient Safety
25
3.1.1
Infection Prevention and control
25
3.1.2
Cleanliness and hospital hygiene
27
3.1.3
Safety in the workplace
27
3.2
Clinical effectiveness
29
3.2.1
Return to theatre
29
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3.2.2. Readmission to hospital
30
3.3.
Patient experience
32
3.3.1
Patient Satisfaction Surveys
32
3.3.2
Patient Reported Outcome measures (PROMS)
33
3.4
Fitzwilliam Hospital Case Study
36
Appendix 1 – Services Covered by this Quality Account
37
Appendix 2 – Clinical Audits
38
Appendix 3 – Glossary of Abbreviations
39
Quality Accounts 2011/12
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Welcome to Ramsay Health Care UK
Fitzwilliam 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 Fitzwilliam Hospital's annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
The Quality Account for 2009/10 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and centre
within the Ramsay Health Care UK. It was recognised that this didn’t provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group have
developed its own Quality Account from last year onwards, which include some
Group wide initiatives, but will also describe the many excellent local
achievements and quality plans that we would like to share.
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Part 1
1.1 Statement on Quality from the General
Manager
Carl Cottam, General Manager,
Fitzwilliam Hospital
As the General Manager of the Fitzwilliam Hospital I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
Our Vision is that:
“As a committed team of professional individuals we aim to consistently deliver
quality holistic care for all of our patients across a full range of care services. We
believe we are able to achieve this by continually updating our key skills and
knowledge enabling us to deliver evidence based clinical practice throughout the
Hospital. The Fitzwilliam Hospital is a recognised Centre of Excellence for the
delivery of orthopaedic services”.
Our Quality Account details the actions that we have taken over the past year to
ensure that our high standards in delivering patient care remain our focus for
everything we do. Through our vigorous audit regime and by listening to all our
stakeholders including patient feedback we have been able to identify areas of
good practice and where we can improve the care our patients receive. This has
enabled us to refine some of our processes which have resulted in making further
improvements.
To ensure that we deliver clinical excellence depends on the whole team. We
have an excellent training and education plan which involves all members of our
administrative and clinical teams.
Every individual member of staff is crucial to the success of our hospital and we
value the contribution that they make in delivering great customer care.
Our Quality Account has been produced to provide information about how we
monitor and evaluate the quality of the services that we deliver.
We hope to be able to share with the reader our progressive achievements that
have taken place over the past 2-3 years. The Fitzwilliam Hospital has a very
Quality Accounts 2011/12
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strong track record as a safe and responsible provider of health care services and
we are proud to share our results.
Our Quality Accounts have been developed with the involvement of our staff who
have been instrumental in developing a systems approach to risk management
which focuses on making every effort to reduce the likelihood and consequence
of an adverse event or outcome associated with treatment of a patient.
To ensure a coordinated approach to the delivery of care for patients and to
monitor the adherence to professional standards and legislative requirements the
Clinical Governance Committee and Medical Advisory Committee meet on a
quarterly basis to review the clinical and safety performance of the Hospital.
These committees have reviewed and agree with the content and action details
within these Quality Accounts.
If you would like to comment or provide me with feedback then please do contact
me on carl.cottam@ramsayhealth.co.uk or telephone: 01733 842329.
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.
Carl Cottam
General Manager
Fitzwilliam Hospital
Ramsay Health Care UK
This report has been produced by:
Carl Cottam
Sue Harvey
Georgina Harris
– General Manager
– Matron
– Finance Manager
This report has been reviewed and approved by:
Medical Advisory Committee Chair:
Clinical Governance Committee Chair:
Regional Director:
Mr R Hartley
Mr S Lewis
Mr James Beech
The content has also been discussed and shared with the lead Commissioning
Primary Care Trusts representatives from North East Essex and Lincolnshire.
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1.3 Welcome to Fitzwilliam Hospital
Fitzwilliam Hospital is registered for 54 beds and
provides services for inpatients and day case. The
Fitzwilliam Hospital has been established for 25
years, building a reputation for high standards both
private and NHS across a wide range of clinical
specialities. We are regarded by many of our patients
and stakeholders as an Orthopaedic Centre of
Excellence.
To support the activity we currently undertake, we have 3 theatres (with laminar
flow); a day case suite/endoscopy unit, and a large outpatient suite. The
outpatient facilities include 14 outpatient consultation rooms, 3 treatment rooms,
Radiology Suite, Physiotherapy Department, Pathology Service, Mobile MRI/CT,
and local POCHI.
Following a review last year of our activity and high demand for our services, we
have embarked on a major building project. This includes the development of a
third theatre and dedicated ambulatory care suite and expansion to the radiology
department, which has now been completed.
Demand for physiotherapy services continues to be high, so we hold satellite
Physiotherapy Clinics at Sheepmarket surgery in Stamford to enable patients to
have greater ease of access to services within a local setting.
Over the last 3 years we have developed an excellent spinal assessment service
not offered by any other provider in the local area and patients can receive direct
referral from GP’s for radiology services.
We provide in-patient services to all adult patients who are stable ASA3.
Patients requiring level 2 care can still receive care here at the Fitzwilliam and are
treated and cared for by a well trained team of staff in a dedicated level 2 facility.
As a hospital, we are committed to providing patients and other customers with
the very highest level of care and services in a variety of specialities: cosmetics,
plastics, general surgery, ENT, gynaecology and urology.
Locally we are a major player in orthopaedic services, hosting 5 solely private
orthopaedic consultants dedicated to working at the Fitzwilliam, whilst respecting
individual needs.
In 2011/12 we facilitated care for over 6,600 patients last year. This care, we
believe, was provided in a safe, convenient, effective manner and to a very high
Quality Accounts 2011/12
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quality. Currently our workload has an average split of approximately 50/50
between private patients and NHS.
The majority of our NHS patients are referred to us through ‘Choose and Book’.
Our rationale to support the NHS is to ensure that choice is offered to patients
both in access and location of services. Our contribution does help to relieve
some of the pressures on other local NHS providers.
We have worked closely with 4 Primary Care Trusts (PCT’s): Peterborough,
Lincolnshire, Cambridgeshire and Northampton PCTs and General Practitioner
Practices to ensure patients have improved access to our Hospital. This has been
achieved by providing information, training and liaison.
Staffing
To support the delivery of clinical care all of our services are supported by a team
of Consultant Surgeons, Consultant Anaesthetists and Consultant Radiologists.
We also have a resident Medical Officer who remains in the hospital at all times
that is, 24 hours per day, 7 days per week.
Currently our Consultant Surgeons, Consultant Anaesthetists and
Consultant Radiologists all apply for practising privileges and are revalidated every 2 years, following the appraisal process including a full
review of practice outcomes.
The Hospital is managed by the Senior Management Team which consists
of General Manager, Matron/Clinical Services Manager, Finance Manager,
Marketing Manager and Support Services Manager.
As an organisation, we employ the following staff at the Fitzwilliam Hospital:
26 HTE Registered Nurses who work in the ward/outpatient department
8 WTE Health Care Assistants.
7 WTE Physiotherapists
16 Registered Nurses who work in theatre with 5 Operating Department
Practitioners and 4 Health Care Assistants
2 Technicians
27 WTE Administration staff supporting Reception, Bookings, Enquiry
Handling, Business Office, Physiotherapy, Radiology and Wards
1 PA for the General Manager and Regional Director
1 HR administrator and PA to Matron.
7 Housekeepers
2 Chefs and 4 Catering Assistants/Pantry staff
1 Supply Coordinator
2 HTE Engineers
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2 HTE porters
GP Liaison Officer
The Fitzwilliam Hospital employs a GP Liaison Officer who maintains and
establishes relationships with GP’s and the practice staff from the Peterborough,
Lincolnshire and Cambridge surgeries. These surgeries are contacted and visited
every month. GP’s are sent regular newsletters and updates via email and
hardcopy are also delivered. Information packs containing information about the
Hospital and how to refer are distributed via mail or during the visits held at the
surgeries. Educational visits are set up during practice learning times whereby the
Consultant and GP Liaison Officer will visit GP’s with a topic of interest for a
“Lunch & Learn” session. GP Educational evenings are also held at the Hospital.
GP’s, Practice Managers and Medical Secretaries are invited and attend regular
Choose and Book workshops at the Treatment Centre.
Local Support. The Fitzwilliam Hospital has been involved in local exhibitions,
press releases including the Evening Telegraph and Stamford Living Magazine,
and we sponsor many local charities and events including The Great Eastern
Show.
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Part 2
2.1 Quality priorities for 2011/2012
Plan for 2011/12
On an annual cycle, Fitzwilliam 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 by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the hospital's Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities for 2011/12 (looking back)
Patient safety/Clinical effectiveness
All patients who undergo a procedure at Fitzwilliam Hospital, whether it
is General Anaesthetic or with sedation are at risk of developing a
thrombosis (blood clot). This blood clot could have serious medical
consequences. For that reason all of our patients at Fitzwilliam have a
risk assessment completed to ascertain their level of risk of developing
a blood clot. This risk assessment is based on NICE guidelines,
published in January 2010. Patients receive information at their preassessment clinic so that they have a greater understanding on how to
reduce their own risks of developing a blood clot prior to admission and
post operatively. We may apply compression stockings to minimise the
risk or we may administer medication if this is clinically indicated.
Quality Accounts 2011/12
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If we were to have any patients develop a blood clot this would be
reported through the Clinical Governance Reporting framework.
Patient safety
1. Falls – Ramsay Health Care has adopted a corporate approach to the
Shattered Lives Campaign. All slips trips and falls for all staff and visitors
are reported through the central risk management reporting network and
the Hospital actions are monitored centrally and reviewed following any
incidents. In addition to this all patient falls are reported to the risk
management group where they are collated and reviewed before being
reported to the Clinical Governance Committee. This committee is in the
process of developing a corporate strategy to minimise the potential risks
to patients. Following our local review of falls in the hospital we have
increased patient awareness and asked them before they get out of bed to
ring for assistance to help them walk to the bathroom.
2. ‘Never Events’ - are serious, largely preventable patient safety incidents
that should not occur if the available preventative measures have been
implemented.
From the core "Never Events", there are 5 that affect Ramsay:
Wrong site surgery
Retained instrument post-operation
Wrong route administration of chemotherapy
Misplaced nasal or gastric tube not detected prior to use
Intravenous administration of mis-selected concentrated potassium
chloride
If we should experience any untoward incidents then these would not
only be reported through the Ramsay reporting systems but we would
also inform the patient's GP and PCT and CQC.
3. VTE risk assessment - We follow the NICE (2010) VTE prevention
Guidelines so that all of our patients undergo the VTE Risk Assessment
and, in addition to this, all of our patients who undergo Hip Replacement
or Knee Replacement procedures are routinely given prophylactic
anticoagulation therapy in accordance with the Department of Health
Guidelines on VTE prevention. Each set of notes holds the evidence to
show scores gained and actions taken.
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1
100
0.98
98
0.96
96
0.94
94
0.92
92
Excellent
Good
0.9
90
Fail
0.88
88
Current
0.86
86
Target
0.84
84
0.82
82
0.8
80
Fitzwilliam Hospital
4. Infection Control – The Fitzwilliam Hospital currently has an infection rate
of 0.54%. During this reporting period to the best of our knowledge we
have not had any patients develop MRSA post-operatively acquired in
hospital. One reason for this is that our hospital only carries out elective
planned surgery. This means that we are able to screen all of our patients
for MRSA before they come into our hospital to have their procedure. Any
patients who are found to be MRSA positive are treated with a course of
antibiotics. Then the MRSA screen is repeated and only when the patient
is clear of MRSA do we then arrange to perform the patient’s procedure at
our Hospital. All our patients are cared for in single room environment and
we have excellent infection rate and good practices.
5. Real time incident reporting – The Fitzwilliam Hospital has recently
improved our reporting systems by the inclusion of our Hospital on to the
Ramsay electronic data base system called RIMS. Matron is now able to
report any incidents electronically in a more timely fashion to Ramsay
Corporate Team. We are also able to bench mark our Hospital against
other Ramsay Hospitals.
6. Staff Satisfaction Survey – The overall results from the survey were
good and staff commented on the exceptional training that they received
and how they were proud of the excellent customer service and rapport
that was held with patients. Staff commented that communication
between departments could be improved therefore we have now
implemented a daily huddle from where staff of any level can inform the
hospital wide team of daily issues. This is in addition to the weekly
operations meeting. As part of the monthly Head of Department (HoD)
meetings we ask Heads of Department to cascade down to all staff key
points raised and have designed a form to help with this, which includes a
Quality Accounts 2011/12
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part for departmental feedback to Heads of Department and the Senior
Management Team.
7. Acute care competences - (DH 2005c) (IHAS 2002a) CQC regulation.
Fitzwilliam Hospital 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. Occasionally a patient who has
appeared to require a low level of post-op care may become unwell and
require a higher level of critical care. It is therefore essential that members
of staff within the unit are able to identify and care for such patients.
By the nature of the facility at Fitzwilliam Hospital it is paramount that staff
are trained and competent in this area. (DH 2009) and that competency is
assessed. Agreed standard competencies will enable providers and
commissioners to identify whether staff are skilled, trained and equipped to
prove care in an increasingly demanding situation. (DH2005g) To attain
this standard Ramsay has set up a critical care group. This unit has one
member who is an AIM Trainer and also has ALS providers on duty at all
times. There are a total of 6 trained ALS providers available. All trained
practitioners have been provided with competency folders and it is
expected that they will be assessed and confirmed as competent. In order
to help them achieve these competences, all trained practitioners have
completed ILS and AIM courses.
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2.1.2 A review of clinical priorities 2012/13 (looking forward)
Clinical Effectiveness
1. Ambulatory Day Care – better outcomes and improving patient
experience
We have recently undertaken a review of how we manage our patients
who are suitable to undergo surgery care. We carefully select those
patients prior to admission. There are a number of patients who plan to
undergo a range of procedures which require a relatively short time in
theatre and recovery and who are deemed suitable for admission to our
day case unit. However, experience has shown that for a variety of
reasons patients undergoing a moderate range of procedures will require
an overnight admission. The criteria for this careful patient selection have
been developed with input from the Clinical team, Consultant Surgeons
and Consultant Anaesthetists and takes place during the Pre-Assessment
review so patients can be informed prior to their admission to our Hospital.
Why the service needs to be redefined (e.g. Over recent years, partly due
to medical advances, the number of day surgery patients has increased
compared to those requiring inpatient care. In 2011/12 the percentage of
day surgery patients we treated was approx 65%. We need to ensure that
our hospital facilities and patient flows better meet the case mix we now
deliver.
By separating our inpatient and day case patients we are able to provide
our patients with a more efficient patient pathway through the hospital.
Best practice has shown that by doing this, patient care will improve as
waiting time and recovery period are reduced.
2. Improve access to and sharing National Benchmarking – how do we
compare?
It was recognised that we needed more transparency between ourselves and
other independent sector providers/the NHS in order to monitor and improve
our services. This is even more important now that we are working in
partnership with the NHS. e.g. benchmarking in the following areas:
Hellenic
Hellenic will provide national benchmark figures for key
performance indicators, such as activity/volumes, mortality, and day
case rates, and unplanned readmissions, average length of stay,
unplanned transfers, and returns to theatre.
VTE risk assessment compliance
Benchmarking through the national stats website. Link:
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http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publi
cationsStatistics/DH_122283
PROMS results
Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=19
37&categoryID=1295
Patient satisfaction figures
Using CQUIN indicators common to both NHS survey and our own,
e.g. % recommended, same sex accommodation, VTE assessment.
3. Improve ward efficiency by adopting the Productive Ward initiative –
more time to care
As stated earlier, we continue to be involved in The Productive Ward (PW)
Project. This is an NHS Initiative developed by the Institute for Innovation and
Improvement (2008). It focuses on the way ward teams work together and
organise themselves, in order to reduce the burden of unnecessary activities,
and releasing more time to care for patients in a reliable and safe manner
within existing resources. The approach is very much ‘bottom up’ with all
ward staff suggesting ideas and ways in which they could improve their
environment and processes. We have reviewed areas of practice needing to
be improved and assigned leads for each area to focus on.
4. Improved patient information
In our recent patient satisfaction survey results it was recognised that our
patients would like more support following discharge. We now phone all of our
patients within 48 hours of discharge and re-visited our pre-assessment focus
and are considering group pre-assessment sessions for patients having
similar procedures.
5. Patient experience – informing patient choice
By sharing and using the results of the national PROMs results for Hip and
Knee surgery we were able to identify any areas of poor patient outcome and
examine practice if and where this existed. This was facilitated through the
MAC, Clinical Governance and Theatre Utilisation Meetings.
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Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2011/12 Fitzwilliam Hospital provided and/or sub contracted a wide case
mix of day case surgery NHS services.
Fitzwilliam Hospital has reviewed all the data available to them on the quality of
care in all 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
Agency Hours as % of Total Hours
% Staff Turnover
% Sickness
Appraisal %
Mandatory Training %
Number of Significant Staff Injuries
21.7%
1.17%
5.1%
3.88%
Currently 39% annual cycle in progress
94%
0
Patient
Formal Complaints per 1000 HPD's
Patient Satisfaction Score %
Number of Significant Clinical Events
Readmission per 1000 Admissions
11.97
94.4% Q1 2012
1
3.3
Quality
Workplace Health & Safety Score
Infection Control Audit Score
90%
100% Surgical Site Infection
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2.2.2 Participation in clinical audit
The national clinical audits that Fitzwilliam Hospital participated in during 1 st April
2011 to 31st March 2012 are as follows:
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Blood transfusion
O negative blood use (National Comparative Audit of Blood Transfusion)
The data relating to these audits are listed below alongside the number of cases
submitted to each audit as a percentage of the number of registered cases
required by the terms of that audit.
National Clinical Audits
Name of Audit
Participation
Peri-and Neo-natal
N/A – no service
Insufficient Patient
Numbers
N/A – No Service
Insufficient Patient
Numbers
Children
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)
Health promotion
End of life
Yes
Yes
N/A – No service
N/A – No service
N/A – No service
N/A – No service
N/A – No service
No
N/A – No service
N/A – No service
Local Audits
In 2011/12, a robust clinical audit calendar was in place and throughout the
year a series of comprehensive audits was undertaken - The clinical audit
schedule is attached in Appendix 2.
Consent
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% cases
submitted
100%
75%
At Fitzwilliam Hospital, consent is taken in a two stage process; stage one
being taken in outpatients by the Consultant, and second stage being taken
on admission by the nurse, who confirms that the patient fully understands all
aspects of consent. The area that needs improvement is first stage consent,
with many Consultants explaining the details of the operation at the outpatient
appointment and then taking written consent on admission. This has been
raised at the MAC meeting, and the Consultants have agreed to provide a
copy of the clinic letter, confirming what procedure was discussed with the
patient.
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 Fitzwilliam Hospital’s income in from 1st April 2011 to 31st March
2012 was conditional on achieving quality improvement and innovation goals
agreed Fitzwilliam Hospital and any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
National and locally agreed CQUIN’s have been in place as part of the standard
acute contract since July 2011, as follows:
Reducing avoidable death, disability and chronic ill health from venous
thombo-embolism (VTE)
2. Improving responsiveness to patients
3. Smoking cessation – identification of risk, education and referral
4. Weight management – identification of risk, education and referral
1.
2.2.5 Statements from the Care Quality Commission (CQC)
Fitzwilliam Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March has no restrictions.
The Care Quality Commission has not taken enforcement action against
The Fitzwilliam Hospital, during 2011/12 or at any other time over last 5 years and
we have not had to participate in any special reviews or investigations by the
CQC during the reporting period.
2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your
Data Quality
Information Governance Toolkit attainment levels
Fitzwilliam Hospital will be taking the following actions to improve data quality.
Quality Accounts 2011/12
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Our Clinical Coder has undertaken the Foundation Coding
Qualification.
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.
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.
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2011/12 to the Secondary Users
Service for inclusion in the Hospital Episode Statistics which are included in the
latest published data. The percentage of records in the published data included:
The patient’s valid NHS number:
99.66% for admitted patient care;
99.30% for outpatient care; and
0% for accident and emergency care (not undertaken at Ramsay
hospitals).
The General Medical Practice Code:
99.96% for admitted patient care;
99.82% for outpatient care; and
0% for accident and emergency care (not undertaken at Ramsay
hospitals).
Clinical coding error rate
Fitzwilliam Hospital was not subject to the Payment by Results clinical coding
audit during 2011/12 by the Audit Commission.
Quality Accounts 2011/12
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2.2.7 Stakeholders views on 2010/11 Quality Account
To support our Quality Account we sent a copy to our local Primary Care Trusts
(PCT’s) and their feedback is as follows:
NHS Lincolnshire Commentary for Ramsay Fitzwilliam Quality Account 2011/12
NHS Lincolnshire’s main priority is to ensure that services are safe and of a high quality. The
Fitzwilliam Quality Account highlights areas of service that demonstrate high quality care using the
three key areas of effectiveness, safety and patient experience. As part of the national CQUIN for
last year Fitzwilliam Hospital continuously over achieved on VTE risk assessment compliance
against the benchmark month on month. NHS Lincolnshire was particularly pleased to see real
time incident reporting and welcomed the good results from the staff satisfaction surveys.
NHS Lincolnshire notes that the Fitzwilliam Hospital is required to register with the Care Quality
Commission and its current registration status on 31 March 2012 has no restrictions. The Care
Quality Commission has not undertaken any enforcement action against Fitzwilliam since its
registration.
In terms of performance against the CQUIN scheme for 2011/12 Fitzwilliam Hospital achieved the
following:
Reduce avoidable death, disability and chronic ill health from Venous-thromboembolism
(VTE)
Improve responsiveness to personal needs of patients
Weight management and smoking cessation advice and referral
NHS Lincolnshire endorses the areas identified for improvement for 2012/13 and the associated
initiatives as detailed within the Ramsay Fitzwilliam Account in particular
VTE assessment and introduction of the Net Promoter – Family and Friends test, which form part
of the NHS Lincolnshire CQUIN scheme for 2012/13 to achieve the following:
Reduce avoidable death, disability and chronic ill health from Venous thromboembolism
(VTE) – to be maintained/stretch target
Improve responsiveness to personal needs of patients
NHS Safety Thermometer
Encouraging healthy lifestyles
NHS Lincolnshire endorses the accuracy of the information presented within the Ramsay
Fitzwilliam Quality Account and the overall quality programme performance will be reviewed
through the formal contract quality review process and triangulation through patient experience
surveys.
Quality Accounts 2011/12
Page 22 of 39
Mr Carl Cottam
General Manager
Fitzwilliam Hospital
Milton Way,
South Bretton,
Peterborough,
Cambridgeshire PE3 9AQ
Dear Carl
North Essex PCT response to The Fitzwilliam Hospital (Ramsay Group) Quality Account for
2011 to 2012
This is the final year that Quality Accounts are being commented on by the Primary Care Trusts in
north Essex. The Fitzwilliam Hospital (Ramsay Group) is demonstrating, in your account, that you
work hard to deliver quality care.
You tell us that you are a committed team of professional individuals we aim to consistently
deliver quality holistic care for all of our patients across a full range of care services. We are
pleased that your account indicates both the ways in which you have succeeded in delivering the
aims you set out in last year's account and where you need to undertake further work to continue
to improve. The PCT encourages the continued use of Releasing Time to Care and of your efforts
to improve cleanliness.
Your introduction gives a high level view of the services delivered at the Fitzwilliam Hospital, its
unique aspects and some of the issues that you have been addressing internally which give
readers of the report an overview of that provision and your ethos.
Your Quality Targets for 2012 - 2013 are:
1. Ambulatory Day Care – better outcomes and improving patient experience
2. Improve access to and sharing National Benchmarking – how do we compare?
3. Improve ward efficiency by adopting the Productive Ward initiative – more time to care
4. Improved patient information
5. Patient experience – informing patient choice
We support your choice of quality priorities, although limited in number they are far reaching in
their ability to improve and innovate.
This quality account was received late by the PCT, and the PCT is not able to provide full
assurance of the data contained in your account. However, the overall conclusion of the north
Essex PCT cluster is that The Fitzwilliam Hospital quality accounts for 2011 to 2012 provide a
balanced picture of quality performance for the reporting period.
Yours sincerely
Denise Hagel
Interim Director of Nursing
North Essex Cluster
Quality Accounts 2011/12
Page 23 of 39
Part 3: Review of quality performance 2011/2012
Statements of quality delivery
Matron, Sue Harvey
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 - 2013
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assures that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that clinical governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of clinical
governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective clinical governance.
Quality Accounts 2011/12
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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).
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
Quality Accounts 2011/12
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3.1 Patient safety
We are a progressive hospital and focused on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety. When risks to patient safety come to light through a number of
routes including routine audit, complaints, litigation, adverse incident reporting,
any concerns raised are routinely reviewed 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
Fitzwilliam Hospital continues to have a 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 the mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a Corporate level Infection Prevention and
Control (IPC) Committee and Group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
Mandatory face to face training programmes in hand washing and use of
PPE at least yearly.
ANTT training included within mandatory training package.
Online E-Learning training package for all staff.
Local Infection Control Link Nurse to coordinate all infection control
initiatives.
Regular local IPC meetings and dissemination of information.
Regular corporate IPC meetings.
Audit programme throughout the year, hand hygiene, surgical site infection
surveillance and preventing the spread of infection.
Quality Accounts 2011/12
Page 26 of 39
Participate in Corporate and National hand hygiene promotion including
Ramsay Healthcare Hand Hygiene day.
On review of our local audits we have made some major improvements
this year in areas of medical/consultant involvement in infection risks ie
cannulation and evidence of hand washing in clinics
The bar graphs below show local infection rates as less than 0.5 % of
admissions for the last 3 years with 2011/12 below 0.4%.
Note: HAI = Hospital Acquired Infection
We are able to maintain low post-operative infection rates as all our patients are
nursed in single rooms. We have excellent, robust daily cleaning schedules. We
screen all of our patients for MRSA, whether private or NHS, prior to admission
for elective surgery. We also have a vigorous hospital surveillance programme
and data collection and an effective ongoing Infection control education
programme, which includes hand washing techniques for all of our staff. Our
small but effective committee has representation from all departments.
Quality Accounts 2011/12
Page 27 of 39
3.1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits.
These assessments include rating of privacy and dignity, food and food service,
access issues such as signage, bathroom / toilet environments and overall
cleanliness.
All members of the housekeeping team are subject to mandatory training
programmes, including hand hygiene, infection control and waste management.
PEAT audits are done bi-annually to ensure continuation of standards and
environmental audits are carried out quarterly and reported corporately.
Random swabbing is taken in all clinical areas to ensure bacteria is kept to
minimal acceptable levels and reported on locally and action taken where
necessary.
Local safety initiatives include:
Mandatory face to face training programmes in H&S, risk assessment and
fire at least yearly for all staff.
Mandatory online E-Learning H&S and fire training package for all staff to
complete annually.
Regular local H&S meetings and dissemination of information.
Regular corporate H&S meetings.
Audit programme throughout the year – H&S facilities annual audit,
quarterly environmental audit, annual DDA audit and annual PEAT audit.
Local H&S Coordinator ensures completion of risk assessments across all
departments and regular review.
Participate in Corporate and National safety initiatives – Shattered Lives,
STF and sharps action plans.
RIMS (Risk Information Management System) for reporting all incidents
and accidents online and enabling the review of trends locally and
corporately. This will be further enhanced by the implementation of
RISKMAN real time electronic reporting, being rolled out over this year,
replacing RIMS.
Implementation of Corporate Slips, Trips and Falls policy, incorporating
risk assessment on admission of all patients highlighted as at risk
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
Quality Accounts 2011/12
Page 28 of 39
safety. Our record in management of adverse events per 1000 admissions
demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and
new and revised policies are cascaded in this way to our General Manager,
ensuring that we keep up to date with all safety issues.
Quality Accounts 2011/12
Page 29 of 39
Patient Falls
8
7
6
5
4
3
2
1
0
2009-10
2010-11
2011-12
All adverse events are reported initially using the adverse event form and
investigated by the Departmental Manager. Matron reviews all events with the
General Manager in order to identify lessons that we can learn. Severe adverse
events and outcomes are reported to the Ramsay Clinical Governance Group and
Risk Management Group.
3.2 Clinical effectiveness
Fitzwilliam Hospital has a Clinical Governance team and committee that meet
regularly throughout 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 the Medical Advisory Committees to ensure that results are
visible and tied into actions required by the organisation as a whole.
The results highlighted in the graphs demonstrate the effectiveness of this
approach over the last three years.
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 at
less than 0.1% in 11/12 consistent with our track record of successful clinical
outcomes.
Quality Accounts 2011/12
Page 30 of 39
All patients who need to return to theatre are reviewed through the clinical
governance processes. The CEC team reviews any matters of concern and each
case is reviewed at the time of the event. Any trends with Consultants or
procedures are audited and findings reviewed by MAC and CEC.
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.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and improve service development in various ways, dependent on
the type of experience (both positive and negative) and action required to address
them. All positive feedback is relayed to the relevant staff to reinforce good
practice and behaviour – letters and cards are displayed for staff to see in staff
rooms and notice boards. Managers ensure that positive feedback from patients
is recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures, should our patients be unhappy with any aspect of their care.
The Fitzwilliam has recently established a Quality Group to review all quality
indicators, especially our patient experience scores.
Quality Accounts 2011/12
Page 31 of 39
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 necessary. 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
envelope addressed directly to TLF, for each patient to use.
Results are produced quarter Q1 2012 show an overall patient satisfaction score
of 94.4% rating with 100% of patients surveyed confirming that they would
recommend us. The results are available for patients to view on our website –
and summarised in the below pie chart.
Quality Accounts 2011/12
Page 32 of 39
3.3.2 Patient Reported Outcome Measures (PROMs)
Fitzwilliam Hospital participates in the Department of Health’s PROMs surveys for
hip and knee surgery for NHS patients. The Oxford Hip and Oxford Knee scores
are based on patients' self completion survey. The survey assesses the level of
difficulty that patients have completing 12 routine tasks as the following stages,
pre-operative, list follow up and 1 year after surgery. A summary of the scores is
reported above; the report contains a more detailed review of each individual
question and the difference in scores.
Oxford Hip Score: Average Health Gain
Adjusted by Case Mix
30
25
20
15
10
5
19.7
19.5
19.9
England
Fitzwilliam Hospital
Peterborough and Stamford
Hospitals NHS Foundation
Trust
0
Oxford Hip Score: Average Health Gain
Unadjusted to Case Mix
25
20
19.7
21.2
20.2
15
10
5
0
England
Fitzwilliam Hospital
Peterborough and
Stamford Hospitals NHS
Foundation Trust
Quality Accounts 2011/12
Page 33 of 39
Oxford Knee Score: Average Health Gain
Unadjusted to Case Mix
16
15.6
15.5
15
14.9
14.5
14.2
14
13.5
England
Fitzwilliam Hospital
Peterborough and
Stamford Hospitals NHS
Foundation Trust
Oxford Knee Score: Average Health Gain
Adjusted by Case Mix
30
25
20
15
10
5
14.9
14.1
15.4
England
Fitzwilliam Hospital
Peterborough and
Stamford Hospitals NHS
Foundation Trust
0
Groin Hernia
Improvement in EQ-5D index score
0.15
0.14
0.13
0.12
0.11
0.10
0.09
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0.00
0.137
0.085
0.053
England
Fitzwilliam Hospital
Peterborough and
Stamford Hospitals NHS
Foundation Trust
Quality Accounts 2011/12
Page 34 of 39
3.4 Fitzwilliam Hospital Case Study
Fitzwilliam Hospital, Milton Way, South Bretton, Peterborough, PE3 9AQ
Orthopaedic Surgery - Case Study
The spinal assessment service at the Fitzwilliam Hospital is a well established
service that was initiated and is led by Mr S Lewis, Consultant Orthopaedic
Surgeon and Helen Mumby-Croft, Extended Scope Practitioner.
It is the only spinal assessment service in the area and was primarily set up as a
unique and innovative spinal triage system. This service or indeed any spinal
service is not available at our local trust and as Mr Lewis was already in post at
the Fitzwilliam Hospital it was felt it would be an excellent opportunity to provide a
spinal assessment and treatment service. This service uses a multi-disciplinary
team approach working closely with other specialities at the Fitzwilliam hospital to
include physiotherapy and interventional radiology.
Patients are fully assessed as necessary and a treatment plan implemented
based on a multi-disciplinary approach. We find that the service ensures patients
suffering with a spinal disorder see the correct person and only those patients
requiring surgery see the consultant. We see patients from Cambridgeshire,
Lincolnshire, and Leicestershire and further afield.
Quality Accounts 2011/12
Page 35 of 39
Appendix 1
Services covered by this quality account
Regulated Activities – Fitzwilliam Hospital
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Diagnostic
and
screening
Services Provided
Clinical Immunology and Allergy
Testing, Clinical Oncology, Cosmetics,
Counselling services, Chiropody,
Dermatological lasers, Dietician, Ear,
Nose and Throat (ENT),
Gastrointestinal, General surgery,
General Medicine, Geriatric Medicine,
Gynaecological, Genito urinary
medicine, Haematology (non clinical),
Nephrology, Ophthalmic (inc laser),
Orthopaedic, Orthodontics, Orthoptic,
Occupationalmedicine, Occupational
therapy, Pain Management,
Physiotherapy (including satellite
clinic), Psychotherapy, Psychology,
Rheumatology, Speech Therapy,
Urological, Vascular
Bariatric surgery, Breast surgery,
Cancer surgery (breast and colorectal), Colorectal, Cosmetics, Day
and Inpatient Surgery, Dermatology,
Ear, Nose and Throat (ENT),
Endoscopy, Gastrointestinal, General
surgery, Genito urinary surgery,
Gynaecological, Ophthalmic, Oral and
Maxillofacial surgery, Orthopaedic,
Plastic Surgery, Spinal Surgery,
Vascular Surgery, Upper GI surgery,
Urological
Exercise ECG, GI physiology, Health
screening, Imaging services,
Phlebotomy, Urinary Screening, and
Specimen collection
Peoples Needs Met for:
All adults 18 yrs and over
Children 3 yrs and above (outpatients only)
All adults 18 yrs 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
New pacemaker within the last 6 months
BMI limit of 40 excluding gastric banding, major surgery
History of major post operative complications
New diagnosis of, or unstable diabetes
New diagnosis of Atrial Fibrillation
Alzheimers or dementia
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 adults 18 yrs and over
Children 3 yrs and above (outpatients consultation only)
Quality Accounts 2011/12
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month. Peterborough
Audit Programme v4.0 2011/2012
Hospital Name: Fitzwilliam
Implemented: July 2011
For review: June 2012
Authors: R. Saunders / A. Shannon / N. Carre / E. Anderson
Use arrow symbol to locate required audit
JUL
Anaesthetic Standards
Medical Records
AUG
96%
98%
Consent
Discharge
SEP
OCT
DEC
JAN
FEB
MAR
APR
MAY
JUN
Traffic light score
93%
99%
98%
98%
80%
98%
97%
97%
83%
98%
94%
97%
N&H
88%
96%
Care Pathways and Variance
tracking
100%
Controlled Drugs
100%
100%
Prescribing
100%
90%
Medicines Management
Radiology
NOV
97%
100%
100%
Physiotherapy
Green
100%
Cool
Amber
90 - 99%
Amber
80 - 89%
Hot
Amber
70 - 79%
Red
69% and under
100%
100%
98%
97%
Records
98%
Service
90%
100%
100%
99%
100%
99%
93%
Records
100%
CPD
MRI
Theatre
Infection Prevention and
Control*
100%
Infection Prevention and
Control - Environmental Audit
Transfusion
100%
99%
100%
100%
95%
100%
N/A
100%
100%
NATIONAL
100%
PVCCB
UCCB
Environ
Allogeneic
Traceability
Autologous
Traceability
*Key:
CVCCB = Central Venous Catheter Care Bundle
SSI = Surgical Site Infection
PVCCB = Peripheral Venous Catheter Care Bundle
PEAT = Patient Environment Action Team
UCCB = Urinary Catheter Care Bundle
Det Pt = Deteriorating Patient
N&H = Nutrition and Hydration
Copyright © 2011 Ramsay Health Care UK
Quality Accounts 2011/12
Page 37 of 39
Appendix 3
Glossary of Abbreviations
ACCP
AIM
ALS
CAS
CQC
CQUIN
DDA
DH
EVLT
GP
GRS
HCA
HPD
H&S
IHAS
IPC
ISB
JAG
LINk
MAC
MRSA
MSSA
NCCAC
NHS
NICE
NPSA
ODP
OSC
PEAT
PPE
PROM
RIMS
SAC
SMT
STF
SUI
TLF
ULHT
VTE
American College of Clinical Pharmacology
Acute Illness Management
Advanced Life Support
Central Alert System
Care Quality Commission
Commissioning for Quality and Innovation
Disability Discrimination Audit
Department of Health
Endovenous Laser Treatment
General Practitioner
Global Rating Scale
Health Care Assistant
Hospital Patient Days
Health and Safety
Independent Healthcare Advisory Services
Infection Prevention and Control
Information Standards Board
Joint Advisory Group
Local Involvement Network
Medical Advisory Committee
Methicillin-Resistant Staphylococcus Aureus
Methicillin-Sensitive Staphylococcus Aureus
National Collaborating Centre for Acute Care
National Health Service
National Institute for Clinical Excellence
National Patient Safety Agency
Operating Department Practitioner
Overview and Scrutiny Committee
Patient Environmental Action Team
Personal Protective Equipment
Patient Related Outcome Measures
Risk Information Management System
Standard Acute Contract
Senior Management Team
Slips, Trips and Falls
Serious Untoward Incident
The Leadership Factor
United Lincolnshire Hospitals Trust
Venous Thromboembolism
Quality Accounts 2011/12
Page 38 of 39
Fitzwilliam 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:
Phone number: 01733 261717
Hospital website:
www.fitzwilliamhospital.co.uk
Neurological Centres
Quality Accounts 2011/12
Page 39 of 39