Quality
Account
2011/12
Contents
Welcome to Ramsay Health Care UK and Horton NHS Treatment
Centre
3
Introduction to our Quality Account
4
PART 1 – STATEMENT ON QUALITY
5
1.1
Statement from the General Manager
5
1.2
Hospital accountability statement
7
PART 2
12
2.1
12
Priorities for Improvement
2.1.1 Review of clinical priorities 2011/12 (looking back)
12
2.1.2 Clinical Priorities for 2012/13 (looking forward)
13
2.2
Mandatory statements relating to the quality of NHS services
provided
19
2.2.1 Review of Services
19
2.2.2 Participation in Clinical Audit
20
2.2.3 Participation in Research
21
2.2.4 Goals agreed with Commissioners
21
2.2.5 Statement from the Care Quality Commission
22
2.2.6 Statement on Data Quality
22
2.2.7 Stakeholders views on 2012/13 Quality Accounts
24
PART 3 – REVIEW OF QUALITY PERFORMANCE
25
3.1
Patient Safety
27
3.2
Clinical Effectiveness
29
3.3
Patient Experience
30
Appendix 1 – Clinical Governance Audit Programme
37
Horton Treatment Centre Quality Account 2011/12
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Welcome to Ramsay Health Care UK
Horton Treatment Centre is part of the Ramsay Health
Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital company 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)
Horton Treatment Centre Quality Account 2011/12
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Introduction to our Quality Account
This Quality Account is Horton Treatment Centre’s annual report to the public and
other stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It aims to give a balanced view of what we are good at and
what we need to improve on.
Horton Treatment Centre Quality Account 2011/12
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Part 1
1.1 Statement on quality from the General
Manager
Julie Worth, General Manager,
Horton Treatment Centre
As the General Manager of the Horton Treatment Centre I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
Our Treatment Centre Vision is that:“As a committed team of professional individuals we aim to consistently deliver
quality holistic acute elective Orthopaedic Services with exemplary customer
care. This we believe we are able to achieve by continually updating our key skills
and knowledge, enabling us to deliver evidence based clinical practice throughout
our Treatment Centre. At Horton Treatment Centre we continue to strive so that
we can be recognised as a 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 our
patient’s feedback, we have been able to identify areas where we can improve
the care our patients receive. This has enabled us to make changes to our
processes with the aim of continually improving the services that we provide and
the results that we achieve.
Clinical excellence depends on everyone in our Treatment Centre. To ensure
that this is delivered, we have a training and education plan which involves all
members of our administrative and clinical teams. Every individual member of
staff is crucial to our success and they 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
Horton Treatment Centre Quality Account 2011/12
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over the past year. The Horton Treatment Centre has a strong track record as a
safe and responsible provider of Orthopaedic services and we are proud to share
our results.
Our Quality Account has been developed with the involvement of our staff. We
have developed a systems approach to risk management which focuses on
making every effort to reduce the likelihood and consequence of an adverse
event or outcome being associated with the treatment or procedure that our
patients may undergo.
In order to ensure that we have a coordinated approach to the delivery of patient
care, we have a robust audit programme in place. Each audit has been designed
to monitor our clinical team’s adherence to their professional standards and
legislative requirements.
The results of these audits are monitored and
scrutinised internally. Action plans are developed to address any areas of
concern, and are subsequently monitored to ensure that we implement the
improvements agreed upon. The audit results are also analysed centrally within
Ramsay Health Care UK, where the results are benchmarked against other
Hospitals/Treatment Centres. Any recommendations made are included in any
action plans developed.
In addition to this, Horton Treatment Centre reports on 26 ‘Key Performance
Indicators’ at our Joint Service Review meetings where representatives from
Oxfordshire PCT, General Practitioner’s (GP’s) and patients are present.
The Horton Treatment Centre holds quarterly Clinical Governance Committee
meetings and Medical Advisory Committee meetings (where the consultant body
is represented) to review our clinical and safety performance and make
recommendations. These committees have reviewed and commented on the
details within these Quality Accounts.
All significant data is also reviewed Corporately by various committees (e.g.
Infection Prevention/Control Committee or Health and Safety Committee) and any
serious clinical quality concerns are discussed at the Ramsay Group Clinical
Governance Committee who review and monitor any issues, ensuring that sites
are taking appropriate action where required.
If you would like to comment or provide me with feedback then please do contact
me on julie.worth@ramsayhealth.co.uk . Or contact me on 01295 755000.
Horton Treatment Centre Quality Account 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.
Julie Worth
General Manager
Horton Treatment Centre
Ramsay Health Care UK
This report has been reviewed and approved by:
Medical Advisory Committee (MAC) Chair: Mr B Shafighian
Clinical Governance Committee Chair: Mr B Shafighian
Clinical Governance Committee Deputy Chair: Dr D Repel
Ramsay Health Care UK Regional Director: Mr James Beech
Oxfordshire PCT and other external bodies.
Horton Treatment Centre Quality Account 2011/12
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Welcome to Horton Treatment Centre
Horton Treatment Centre is a purpose built Orthopaedic Centre which opened in
2006. It was designed to combine an excellent standard of in patient and day
case facilities, with the technical equipment that modern medicine demands.
The Centre provides the following NHS and private Orthopaedic and General
Surgery services:
• Outpatient consultation
• X-ray, MRI imaging and ultra sound scanning, including an on-site MRI
scanner
• Physiotherapy treatments, with an in-house gymnasium
• Inpatient and day care treatments, utilising 40 inpatient beds with en-suite
facilities and a day case unit
• Surgical treatments, using 3 laminar flow operating theatre suites
• Decontamination services
• Provision of meals, with a restaurant for visitors and staff
We provide safe, convenient, effective and high quality treatment for adult
patients (during the reporting period children below the age of 18 years were
excluded), whether privately insured, self-pay, or from the NHS. A high
percentage of our patients have come from the NHS sector - patients choosing to
use our facility through ‘Choose and Book’. Our services help to ease the
pressures on Horton Hospital and NHS facilities within Oxfordshire. We have
worked with Oxfordshire PCT and General Practitioner practices to ensure
patients have improved access to our Treatment Centre, by providing information,
training and liaison.
To support the delivery of clinical care, all of our services are led by Consultant
Orthopaedic/General Surgeons, Consultant Anaesthetists and Consultant
Radiologists. We also have a Resident Medical Officer who remains in the
Treatment Centre at all times i.e. 24 hours per day, 7 days per week.
We have carried out 2854 procedures in the past 12 months, of which 99% are
for NHS patients.
We have a Consultant led out reach clinic which is held at the Bicester Clinic on a
monthly basis.
Horton Treatment Centre Quality Account 2011/12
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We have a referral pathway in place for trauma patients to be treated at the
Horton Treatment Centre
We currently engage the following staff at the Horton Treatment Centre:•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Consultant Orthopaedic Surgeons, Consultant Anesthetists and Consultant
Radiologists and Radiographers, nurses and administrators from Horton
Hospital.
Ramsay employed Consultant Orthopaedic Surgeons and Consultant
Anaesthetists.
3 Registered Nurses who work in the out patient department with 4 Health
Care Assistants.
10 Physiotherapists
14 Registered Nurses who work on the ward with 13 Health care
Assistants.
14 Registered Nurses who work in theatres with 4 Operating Department
Practitioners and 3 Health Care Assistants
4 Decontamination Technicians
24 Administration Staff.
4 Receptionists
9 House Housekeepers
3 Chefs and 3 Catering Assistants
1 Supply Coordinator
1 Engineer
3 Porters
1 GP Liaison Officer
GP Liaison
Our GP Liaison Officer establishes and maintains relationships with GPs and GP
practice staff in the local area – Oxfordshire, West Northamptonshire, South
Warwickshire, West Berkshire. This equates to over 100 GP practices and more
than 1000 GPs.
A GP practice visit schedule is maintained whereby surgeries are contacted or
visited every month. GPs and practice staff are sent regular newsletters and
updates via email, and hard copy newsletters are also delivered. Information
packs containing information about the Treatment Centre, service updates and
how to refer patients are distributed by mail and via visits to the surgeries. During
visits to surgeries the GP Liaison Officer will answer also any questions staff have
and leave patient information leaflets.
Horton Treatment Centre Quality Account 2011/12
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The GP Liaison Officer also arranges medical education events to take place at
surgeries whereby a Consultant will cover a topic of interest to the GPs and other
clinical staff either at lunch time or during practice protected learning times.
Regular evening medical education events are also held at the Treatment Centre
to which GPs, Trainee GPs and Physiotherapists are invited. Plus we offer
‘Choose & Book’ workshops for administrative practice staff to help them offer
patient choice effectively.
The following table lists the surgeries in North Oxfordshire and surrounding areas.
Each has received regular information about the Horton Treatment Centre.
WEST BAR SURGERY
HORSE FAIR SURGERY
HIGHTOWN SURGERY
WINDRUSH SURGERY
WOODLANDS SURGERY
NEW SURGERY,
BURDROP
THE CROPREDY
SURGERY
THE SURGERY
THE HEALTH CENTRE
WEST STREET SURGERY
THE WHITE HOUSE
SURGERY
THE WYCHWOOD
SURGERY
KIDLINGTON MEDICAL
PRACTICE
GOSFORD HILL MEDICAL
CTR.
WOODSTOCK SURGERY
MONTGOMERY HOUSE
SURGERY
VICTORIA HOUSE
SURGERY
LANGFORD MEDICAL
PRACTICE
NORTH BICESTER
SURGERY
THE HEALTH CENTRE
SPRINGFIELD SURGERY
THE HEALTH CENTRE,
BRACKLEY
WASHINGTON HOUSE
SURGERY
Outside activities illustrating our involvement in the Community
We support the government’s patient choice programme by actively promoting
patient choice through advertisements in local press – Banbury Guardian,
Banbury Living, and Through the Letter Box and by providing leaflets for patients
in local GP surgeries. We also promote our surgeons, their expertise and
Horton Treatment Centre Quality Account 2011/12
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services available from the Treatment Centre through advertising, events and
other promotional and partnership activities.
We have taken part in local business events such as Banbury in Business, the
South East Midlands LEP open event and events organised by the Chamber of
Commerce.
We have also supported charitable events including the Age UK Open event in
Banbury. Plus we have raised funds for MacMillan Cancer Support and local
charities such as The Katherine House Hospice.
Horton Treatment Centre Quality Account 2011/12
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Part 2
2.1 Quality priorities for 2012/2013
Plan for 2012/13
•
On an annual cycle, Horton Treatment Centre develops an operational
plan to set objectives for the year ahead.
•
We have a clear commitment to our patients, as well as working in
partnership with the NHS, to ensure that those services commissioned
result in safe, quality treatment for all patients whilst they are in our care.
We constantly strive to improve clinical safety and standards by a
systematic process of governance, including audit and feedback from all
those experiencing our services.
•
To meet these aims, we have various initiatives ongoing at any one time.
The priorities are determined by the Treatment Centre’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
Treatment Centre.
Priorities for Improvement
2.1.1 A review of clinical priorities 2010/11 (looking back)
1. Falls
We have continued to put minimising patient falls very high on the agenda.
Being an orthopaedic Treatment Centre it is vital that we minimise falls for
patient safety. We have adopted a multi disciplinary approach to ensure that
all levels and all departments are working together to reduce the number of
falls. At pre- assessment risk assessments are carried out to ensure that
patients at greater risk are identified and plans are put in place as soon as
they are admitted. We have also reviewed with the physiotherapy staff the
continued reinforcement of patient compliance with requesting help. Posters in
patients rooms have been introduced however this continues under review to
improve the awareness of patients.
Horton Treatment Centre Quality Account 2011/12
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2. Infection Control
The Treatment Centre Infection Control strategy continues to provide safe
practice for patients. We have experienced no patients developing MRSA
as a result of their stay with us in the last 12 months.
3. Incident Reporting
The Horton Treatment Centre electronic data base (RIMS) provided a more timely
system of incident reporting. However this remains under review with a new
RiskMan system under trial within the Ramsay Company currently. See future
priorities.
4. Commitment to Ensure the Safety of Patients
Safety of patients and vulnerable adults was enhanced by the training of staff in
Dementia Care in December 2011. This has formed part of the pre assessment
process. Patient’s nutritional status has also become much more evident in 2011.
Both underweight and overweight assessment and advice is given to patients so
that they can improve their life styles. We continue to strive to empower patients
where we can.
Our policies reflect the importance that this subject is given with a variety of
policies for staff to follow:
• Prevention of Harassment and Bullying of patients and Staff and or other
patients
• Safeguarding and Managing Suspected abuse of Vulnerable Adults
• Whistle Blowing
• Raising Concerns about Patient Safety.
5. National Joint Register
Horton Treatment Centre continues to participate to the National Joint Service
Register (NJR). We are please to report that our consent rate has improved
significantly to 99% form previously 83% and 96% respectively.
6. Staff Satisfaction Survey
Out of the 8 hospitals in the Ramsay Group Midlands region Horton Treatment
Centre came 3rd in ‘Leadership’ and 2nd in the ‘Personal Growth’
Below are some of the comments and a sample of the graphs from our staff
survey
The people here are very friendly and helpful, and as a relatively new employee, I
have found everyone to be welcoming and keen to assist me in my role. I feel
extremely well supported and valued by my manager. The environment is also
Horton Treatment Centre Quality Account 2011/12
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excellent with good working conditions and staff facilities. I feel proud to work for
Ramsay Health Care.
----------------------------
Everyone is friendly and helpful and go out of their way to help each other.
Everyone works as a team.
---------------------------Big family atmosphere. Lovely bright and airy building to work in. Good working
relationship with own team members and other departments. Bright and airy
ward with en suite single/double rooms. Excellent staff restaurant, especially
John's cooking!! Supportive management. Consultant surgeons who are happy
to be approached if you have a problem with their dictation / instructions etc.
----------------------------
The teamwork and lovely work surroundings.
---------------------------At this moment in time we have an excellent team in the area that I work. People
help each other out and we have a strong work ethic.
----------------------------
Pers onal Growt h by Ques t ion f ilt ered by E mploy ment Groups (Hort on TC)
The experience I gain from this
job is valuable for my future
(+3%)
The training in this job is a
great benefit to me personally
(+9%)
This job is good for
my own personal growth
(+3%)
My work is stimulating
(+6%)
I am bored with the work I do
(+0%)
There are limited opportunities for me to
learn and grow within this organisation
3
(-1%)
3.5
Ramsay Health Care UK Ltd
4
4.5
5
5.5
6
Horton TC
Horton Treatment Centre Quality Account 2011/12
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My Team by Ques t ion f ilt ered by Employ ment Groups (Hort on TC)
My team is fun to work with
(+6%)
I feel a strong sense
of family in my team
(+2%)
Working in this team
gives me a buzz
(+6%)
People in our team don't
care much for each other
(+1%)
People in my team go out
of their way to help me
(+3%)
4
4.5
5
Ramsay Health Care UK Ltd
5.5
6
Horton TC
Of course there is still work to do. Some staff felt that management did not always
listen to them.
Paying for parking was an issue for staff.
Pay came up as expected. The staff expressed some instability in their jobs as
this was at a time prior to Horton Treatment Centre winning the Standard Acute
Contract. The Senior Management Team have reviewed the results and initiated
a committee to consider what actions and changes would enhance staff’s work
life and perceptions.
7. Acute Care Competencies.
Training and identifying training requirements has been undertaken in all
departments. The Regional Trainer together with the Matron has worked
alongside the staff and assessed their competency levels. We feel we have
greatly improved critical care at ward level affecting positively the quality and
effectiveness of care. The standard for all staff is to undertake the AIMS and ILS
courses which strengthen their skills across the spectrum.
8. VTE Risk Assessment.
Patients undergoing surgery are at greater risk of developing blood clots. To
ensure this risk is kept to a minimum Horton Treatment Centre raised the profile
of the risk assessments and prophylaxis of managing this potential complication
last year. Patient information and a more proactive intervention with assessment
and prophylaxis combined with early mobilisation have resulted in a reduction of
incidents.
Horton Treatment Centre Quality Account 2011/12
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2.1.2 Clinical Priorities for 2012/13 (looking forward)
Patient Safety.
Patient safety/experience/clinical effectiveness
1.RiskMan System
In order to improve patient safety it is vital that unexpected occurrences
and incidents, complaints and compliments are recorded, reviewed,
discussed and identify lessons learned. The system provides information
on the areas we need to improve and on those aspects we manage well.
This enables the Treatment Centre staff to minimise future risk events and
to prevent types of incidents reoccurring. The current system has its
limitations therefore Ramsay is investing in a new electronic system called
RiskMan. It is on trail at 2 Centres/Hospitals and will be rolled out
nationwide later in the year.
Horton Treatment Centre will adopt this system ensuring incidents are
dealt with in a timely fashion and investigated to a level that ensures
improved outcomes. Patient complaints and compliments will be managed
at an appropriate level of the organisation whilst sharing good practise and
lessons learned.
2. Reducing the risk of developing thrombosis
VTE (formation of thrombosis following surgery) is still very high on the
agenda because of the risks to health and outcomes following surgery. For
that reason we continue to strive to improve reporting data and compliance
to all patients at risk and to those undergoing General Anaesthesia.
Patients are empowered to reduce those risks by information given to
them at pre assessment and by preventive treatment, e.g. early
mobilisation, specific compression anti-embolism stockings is undertaken.
Horton Treatment Centre has changed from a variety of medicines that
reduce the risk of clot formation to one which is in tablet form called
Pradaxa. This is much easier for patients as it is commenced
immediately post operatively and the patient then takes the tablets home to
complete the prescription. This is now a standard across all the Surgeons
at Horton Treatment Centre. We will be monitoring the effects of this drug
on the outcomes for patients.
Horton Treatment Centre Quality Account 2011/12
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3. Patient safety through Staff levels and Skill mix review
E Rostering
Patient’s hospital experiences and outcomes are improved when the
appropriate levels of staffing are available in each department. To this end
Ramsay Corporate are currently putting a new system on trial in our hospitals.
Horton Treatment Centre will introduce this system of E Rostering. This will
enable the Unit to match the level of staffing to the level of activity thereby
ensuring not only the correct numbers of staff but also the most appropriate skill
mix. Patients can be assured that their experiences at Horton Treatment Centre
will be as smooth and individualised to cater for their specific requirements.
4. Introduction of a service for 16 -18 year olds patients.
Horton Treatment Centre is currently preparing to introduce this new service
where elective trauma patients within this age range can be treated at the Unit.
We are engaging with Specialist individuals and groups of staff to ensure that all
aspects of the service meet the requirements of the specific age range.
The scope of the Department of Health’s National Service Framework for
Children (2003) applies to all children and adolescents under the age of 19 years:
‘Children and young people should receive care that is integrated and coordinated around their particular needs, and the needs of their family. They, and
their parent/guardian should be treated with respect and should be given support
and information to enable them to understand and cope with the illness and the
treatment required. They should be encouraged to be active partners in decisions
about their health and care and, where possible, to exercise choice (DH 2003a)
‘All children will be treated by appropriately trained professionals in an
environment suitable for their needs; and Hospital staffs…have a special duty of
care to children and a legal responsibility to protect the child’s rights, interests
and wishes.’ (RCS, 2007a)
Horton Treatment Centre commits to achieving the expectations detailed by the
Royal College and has used the aforementioned document as a basis for our
policy.
5. NHS Safety Thermometer
The Safety Thermometer is a quick and simple method for surveying patient
harms and analysing the results. From April 2012 it is the recommended tool for
measuring pressure ulcers as part of commissioning for Quality and Innovation
( CQUIN) payment programme. The Horton Treatment Centre is participating
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in the survey. As well as recording pressure ulcers, falls, catheters and their
infections, VTE are audited. The NHS information Centre will make the data
collected by the Safety Thermometer available on a monthly, quarterly and
annual basis.
6. Introducing a Dexa Scanner Service
DEXA or Dual Energy X-ray Absorptiometry measures bone mineral density
(BMD). It is mainly used to diagnose and assess the risk of developing
osteoporosis. Dexa can also help detect other bone related conditions such as
osteopenia and osteomalacia.
A Dexa scan uses a fine beam of low dose x-rays with two distinct energy peaks.
One peak is absorbed mainly by soft tissue and the other by bone. The soft tissue
amount can be subtracted from the total to obtain the bone mineral density. The
bone density obtained is compared with that of a young adult of the same gender
with peak bone mass, to obtain the T score. A score below -2.5 is defined as
osteoporosis. The bone density is also compared with that of someone the same
age, size and gender to obtain the Z score.
There are two types of Dexa scan. An axial or central Dexa scan measures the
bone density in the hip and lower spine, whereas a peripheral Dexa scan
measures the bone density in the wrist and heel. The peripheral testing can be
less accurate and is not recommended to follow the response to treatment, and if
drug therapy is indicated a central Dexa is required for an accurate baseline.
A Central Dexa scan has a scanning arm that is passed over the hip and lower
back. The patient lies on their back on the x-ray table whilst the scanning arm or
detector slowly moves over the body. To assess the spine, the patient’s legs are
supported to flatten the lumbar curve and to assess the hip, the patient’s foot is
placed in a brace for internal rotation. The examination can take up to 30mins.
The patient is asked to complete a questionnaire and may need to get changed if
they are wearing clothing with metal around the hip or spine area. If the patient
takes calcium supplements these must be stopped for at least 24 hours before
the scan.
Routine scans are done every two years to monitor the bone mineral density.
Patients that are on high dose steroids may need a follow up scan every six
months.
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2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2011/12 the Horton Treatment Center provided elective Orthopedic
Services for adult patients.
The Horton Treatment Centre has reviewed all the data available to them on the
quality of care of these services.
The income generated by the NHS services reviewed in 1 April 2011 to 31st
March 2012 represented 100 per cent of the total income generated from the
provision of NHS services by the Horton Treatment Centre for 1 April 2011 to 31st
March 2012.
Balanced Scorecard
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care, comparable across all of its Hospitals.
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:
Patients
Formal Complaints: 25 (0.86%)
Patient Satisfaction Score (using the question ‘Overall, how would you rate the
care you received?’) 74.4%
Number/Rate of Patient Readmissions: 22 (0.76%)
Number/Rate of Patient Returns to Theatre: 2 (0.07%)
Quality
Workplace Health & Safety Audit Score:
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Infection Control Report:
Summary of Audits Scores
• Hand Hygiene 96%
• UCCB 100%
• CVCCB 95%
• SSI 96%
• PEAT 97%
• Sharps 100%
• Health & Safety and Facilities
• MRSA. 0 Positive
• Cleaning standards 97%
Catering Department Report – Health & Safety – 2012
The Food Standards Agency have revised the food hygiene rating system from a
one to five star system of ‘scores on the doors’ to a numerical food hygiene rating
of zero to five.
A zero rating constitutes urgent improvement necessary and five is excellent. I
am pleased to report that the catering department at Horton Treatment Centre
was awarded a rating certificate of ‘5’ from Cherwell District Council.
In addition the catering department received a Gold Award in March 2012 for the
second year running following a visit from Cherwell District Council in February.
The award is given for fulfilling their criteria on healthy food choices, high
standards of hygiene and our commitment to ongoing food hygiene training.
2.2.2 Participation in Clinical Audit
During 1 April 2011to 31st March 2012 Horton Treatment Centre participated in
two national clinical audits within the elective surgery PROMS program (for hip
and knee replacements). We also contributed towards the National Joint Registry
database. The other national audits as below were not applicable to our patient
case mix.
We did not contribute to any National Confidential Enquiries as the Treatment
Centre does not provide services that were within the scope of these enquiries for
the time period reported.
National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Peri- and Neonatal
Participation
(NA, Yes, No)
% cases
submitted
NA
Horton Treatment Centre Quality Account 2011/12
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Children
NA
Acute care
NA
Long term conditions
NA
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
YES
Elective surgery (National PROMs Programme)
Data is only available for the date range April 09 to Feb 11)
YES
Cardiovascular disease
NA
Renal disease
NA
Cancer
NA
Trauma
NA
Psychological conditions
NA
Blood transfusion
NA
Health promotion
NA
End of Life
NA
Hips 296
Knees 444
Hip
Knee
Local Audits
The reports of 26 local clinical audits (which includes 9 infection prevention and
control, 4 transfusion, 3 physiotherapy and 2 radiology) from 1 April 2011 to 31st
March 2012 were reviewed by Horton’s Clinical Governance Committee. The
clinical audit schedule can be found in Appendix 1 and shows how these are
spread out across the year.
Following a recent review of our internal audit processes, we have now delegated
the development of the action plan back to the individual who carried out the
audit. In this way, there is much greater ownership in implementing the action
plan. To this effect we have seen an improvement in the targeted areas of
medical records and consent audits.
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
Horton Treatment Centre’s income from 1 April 2011 to 1st January 2012 was not
conditional on achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation payment framework because the
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Horton Treatment Centre is still operating under the GC4 contract which does not
encompass the quality and innovation framework.
The Standard Acute Contract was commenced on January 2nd 2012 and the
CQUIN goals were initiated.
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2.2.5 Statements from the Care Quality Commission (CQC)
Horton Treatment Centre is registered with the Care Quality Commission.
The Care Quality Commission has not inspected Horton Treatment Centre nor
has it placed any restrictions on the Unit.
The Horton Treatment Centre has not participated in any special reviews or
investigations by the Care Quality Commission during the reporting period.
2.2.6 Data Quality
Horton Treatment Centre will be taking the following actions to improve data
quality:• Our Clinical Coder is undertaking the Foundation Coding Qualification
training in order to improve the quality of our data capture.
•
Coding now takes place from the medical records. There is a weekly data
report which highlights any areas of poor coding data, which can then be
addressed by the coder prior to submission.
•
Consultants have been given training on the quality of their documentation
at both pre-assessment clinic and when writing their operation notes.
Consultant records are also subject to a monthly audit with individual
consultant feedback being given as required.
•
To assist with the data quality we have appointed an Administration Team
Leader to oversee the compliance to the SAC in the area of data quality.
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
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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).
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
Horton Treatment Centre was not subject to the Payment by Results clinical
coding audit during 2011/12 by the Audit Commission and the error rates reported
in the latest published audit for that period for diagnoses and treatment coding
(clinical coding) were:Primary diagnosis 100% correct
Secondary diagnosis 88% correct
Primary procedure 98% correct
Secondary procedure 97% correct
HRG Changes 2
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2.2.7 Stakeholders views on 2011/12 Quality Account
– Statement
from NHS Oxfordshire
Horton Treatment Centre Ramsay Health Care UK - Quality Account 2011/12
NHS Oxfordshire (NHSO) has reviewed the Horton Treatment Centre Ramsay Health
Care UK Quality Account for 2011/12. There is evidence that the Trust has relied on
both internal and external assurance mechanisms to produce this report. NHSO is
satisfied that this Account meets the nationally mandated criteria for a Quality
Account and that this document does not contain any inaccuracies to the best
knowledge of the PCT.
Statements sets out the areas in which it made improvements last year however, it
would benefit from more quantitative information to demonstrate what improvements
have been made.
The balanced scorecard section would be enhanced by an explanation to the reader
as to whether the scores provided demonstrate a high quality service in comparison
to other services and providers.
Ramsay has made some progress on hand hygiene and in efforts to improve patient
experience around the area of dignity.
Greater explanation of outcomes would be beneficial. The account lacks detail of
clinical outcomes. Ramsay carry out a large number of hip and knee replacements
and the report could give an indication of how their outcomes compare to national
benchmarks.
The primary purpose of Quality Accounts is to encourage Boards and leaders of
healthcare organisations to assess quality across all of the services they offer. The
Horton Treatment Centre Ramsay Health Care UK quality report gives a more
comprehensive view than previous reports and they are to be commended for that.
However, an increased use of evidence would give the reader of the account a much
greater understanding of the relative quality of the service provided.
Horton Treatment Centre Quality Account 2011/12
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Part 3: Review of Quality Performance
2011/2012
Statements of Quality Delivery
Matron, Gina Taylor
Review of quality performance 1st April 2011 - 31st March 2012
Introduction
‘Our emphasis is on providing an environment and culture to support
continuous clinical quality improvement so that patients receive safe and
effective care, clinicians are enabled to provide that care and the
organisation can satisfy itself that we are doing the right things in the right
way’.
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2012
The aim of Clinical Governance is to ensure that Ramsay develop ways of
working which assure that the quality of patient care is central to the business of
the organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are 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
Horton Treatment Centre Quality Account 2011/12
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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).
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.
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3.1 Patient Safety
We are a progressive Treatment Centre 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 (IPC)
Horton Treatment Centre has a very low rate of hospital acquired infection and
has had no reported MRSA bacteraemia in the past 3 years. We are able to
maintain relatively low post operative infection rates as we screen all of our
patients prior to admission for elective surgery. We also run a vigorous, ongoing
infection prevention and control education programme, which includes hand
washing techniques for all of our Treatment Centre staff.
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. We also participate in mandatory surveillance of
surgical site infections for orthopaedic joint surgery.
Infection Prevention and Control management is very active within our Treatment
Centre. An annual strategy is developed by Ramsay through 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 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.
Horton Treatment Centre Quality Account 2011/12
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% Infections by admission
0.40%
0.35%
0.30%
0.25%
0.20%
% Infections by admission
0.15%
0.10%
0.05%
0.00%
2009/10
2010/11
2011/12
Infection rates as a % of admissions for the last 3 years (comparison data
not available).
3.1.2 Cleanliness and Treatment Centre Hygiene
Assessments of safe healthcare environments include Patient Environment
Assessment Team (PEAT) audits. The undertaking of the PEAT audit is led by
our Infection Control Nurse who involves the House Keeping Lead and Catering
Manager. Areas for improvement are identified within action plans and
subsequent progress is monitored by the Treatment Centre’s Clinical Governance
Committee.
These assessments include rating of privacy and dignity, food and food service,
access issues such as signage, bathroom / toilet environments and overall
cleanliness.
The graph below shows Horton Treatment Centre’s scores over the last 2 years.
The rates show a slight improvement on the last 2 years, with both years
achieving a higher than average outcome when compared across the Ramsay
Group.
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98%
96%
94%
92%
90%
Ramsay
88%
Horton
86%
84%
82%
2009/10
2010/11
2011/12
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 that our staff have
high awareness of safety has been a foundation for our overall risk management
programme. 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. Each alert must be
acknowledged to a Ramsay Group coordinator and actions confirmed as
appropriate.
All adverse events are reported and investigated by the Departmental Manager in
order to identify lessons learnt. All adverse events are reported to Matron and
these events and outcomes are reviewed by the General Manager. We report
adverse events as part of the Ramsay Clinical Governance Reporting procedures
and the General Manager informs the members of the Joint Service Review
meeting which are held on a quarterly basis throughout the year.
3.2 Clinical Effectiveness
Horton Treatment Centre has a Clinical Governance team that investigate and
report to the Clinical Governance Committee. 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
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improvement are presented to hospital management and the Medical Advisory
Committee to ensure results are visible and tied into actions required by the
organisation as a whole.
3.2.1 Return to Theatre
Ramsay and Horton Treatment Centre are 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 return to
theatre is expected. The value of the measurement is to detect trends that
emerge in relation to a specific operation or specific surgical team. In the
reporting period, although Horton Treatment Centre’s rate is slightly higher than
the Ramsay average, it is lower than previous years and no trends have been
identified.
0.30%
0.25%
0.20%
0.15%
Ramsay
Horton
0.10%
0.05%
0.00%
2009/10
2010/11
2011/12
3.2.2 Readmission to the Treatment Centre
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. Horton’s rates of readmission remain low and this, in part, is due to
sound clinical practice ensuring patients are not sent home too early after
treatment and meet strict discharge criteria before being discharged. In the
reporting period, although Horton’s rate is higher than the Ramsay average (by
0.23%), it is lower than previous years and no trends have been identified.
Horton Treatment Centre Quality Account 2011/12
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0.90%
0.80%
0.70%
0.60%
0.50%
Ramsay
0.40%
Horton
0.30%
0.20%
0.10%
0.00%
2009/10
2010/11
2011/12
3.3 Patient Experience
All feedback from patients regarding their experiences with Horton Treatment
Centre 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 Clinical Governance Committtees for discussion, trend analysis
and further action where necesary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding patient experience is encouraged in various ways via:
ƒ Patient satisfaction surveys
ƒ ‘We value your opinion’ leaflet
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ƒ
ƒ
ƒ
ƒ
ƒ
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 and lay members of the contract management board
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
3.3.1 Patient Satisfaction Surveys
Over the last few years, Horton Treatment Centre has participated in the
Department of Health’s Adult Inpatient Survey. In each year, the NHS survey and
methodology was followed to ensure the data could be benchmarked.
Last year this involved surveying 850 NHS patients up to July 2010. The survey
consisted of 54 questions which related to the patient’s experience of their care at
the Treatment Centre.
The Horton Treatment Centre achieved a 57.8% response rate with 468 returned
questionnaires. The average response rate within the Ramsay Group was 54.3%,
which Horton Treatment Centre exceeded by over 3.5%.
Last year, the question ‘Overall, how would you rate the care you received’
resulted in 99.6% of patients responding ‘good’, ‘very good’ or ‘excellent’.
The average score for the Ramsay Group was 99.0%.
The graph below compares Horton Treatment centre with the Ramsay Group
as a whole for the 2011 survey.
Overall, how would you rate the care you received?
Responses stating ‘good’, ‘very good’ or ‘excellent’.
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Patient Satisfaction
99.7%
99.6%
99.5%
99.4%
99.3%
99.2%
99.1%
99.0%
98.9%
98.8%
98.7%
Patient Satisfaction
Horton
Ramsay Group
Last year, the question: Overall, did you feel you were treated with respect
and dignity while you were in the hospital? resulted in 88.5% of patients
responding ‘Yes, always’.
The average score for the Ramsay Group was 94.5%.
The graph below compares Horton Treatment centre with the Ramsay Group
as a whole.
Overall, did you feel you were treated with respect and dignity while
you were in the hospital?
Responses stating ‘yes, always’.
Respect & Dignity
96.4%
96.2%
96.0%
95.8%
95.6%
95.4%
Patient Satisfaction
95.2%
95.0%
94.8%
94.6%
Horton
Ramsay Group
Horton Treatment Centre Quality Account 2011/12
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Action plan
In order to improve the patient satisfaction scores for the Horton Treatment
Centre, we have established a Quality Group which consists of
representatives from each department. One area already identified for
improvement was maintaining the patient’s privacy and dignity whilst in the
Treatment Centre (as although 95.2% responded ‘yes, always’, there were
a 4.8% of our patients who responded to say that they felt this was not the
case).
Our action plan included:
•
Staff training - to ensure staff knocked before approaching patients who
are behind curtained areas or closed doors.
•
Addressing patients - patients to be formally asked what they would like
to be called during their stay.
•
Interpreter services - improvement to the access and engagement of
interpreter services.
•
Patient involvement in their care - special efforts are to be made to
include the patient in all areas of their care at all times.
•
Customer Care Training - all staff to receive formal customer care
training.
Additional changes to our practice have been made following the review of
our patient satisfaction survey by our Quality Groups meetings. The
following changes to practice have already been made:•
In the Out Patient Department we have resourced an additional clinical
room, so patients are taken on an individual basis behind a closed door
to have their investigations carried out eg ECGs.
•
In the Radiology Department the procedure for patients who are
undergoing Fluoroscopy investigations have been reviewed. The
patients now remain fully clothed whilst they are transported between
X-ray and the MRI rooms in the same department, thus maintaining the
patient’s privacy and dignity at all times.
•
On the ward, patients who are in our rooms with two beds are now
offered their Consultant or Nurse consultation in an alternative
individual setting, to ensure that patient privacy is maintained.
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•
We have a ‘suggestion box’ where additional ideas for improving
aspects of patient care can be placed.
We will monitor the progress of these and all other questions going forward using
further satisfaction results, as well as our suggestion box, through the Treatment
Centre’s Quality Group meetings and Clinical Governance meetings.
3.3.3 Patient Formal Complaints
Although the number of complaints has reduced from the previous year, we
identified that a number of complaints were received because patients had
difficulty getting through on the telephone. As a direct result of this, we had the
switch board upgraded so that there is a choice of direct dial numbers into various
hospital departments. We have received no further complaints in this respect
following the introduction of this system.
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3.3.4 Patient Reported Outcome Measures (PROMs)
Horton Treatment Centre participates in the Department of Health’s PROMs
surveys for hip and knee surgery for NHS patients.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs
surveys specifically for NHS patients within the GC4 contract.
The Oxford Hip and Oxford Knee scores are based on a patient self completion
survey. The survey assesses the level of difficulty that patients have completing
12 routine tasks, pre-operatively, at first follow up and 1 year after surgery.
A summary of the DH survey scores shows that for both the hip and knee scores,
Horton Treatment Centre patients are reporting a health gain greater than the
national average. The health gain figures are ‘adjusted’ which takes into account
varying demographics in order to make the data more comparable between
healthcare providers.
(reference: HESonline available at: http://www.hesonline.nhs.uk).
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Horton Treatment Centre
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Treatment Centre phone number
01295 755000
Hospital website
www.ramsayhealth.co.uk
Neurological Centres
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