Quality
Account
2011/12
Contents
Introduction Page
Welcome to Ramsay Health Care UK and New Hall Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2011/12 (looking back)
2.1.2 Clinical Priorities for 2012/13 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2011/12 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Quality Accounts 2011/12
Page 2 of 34
Welcome to Ramsay Health Care UK
New Hall 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
Page 3 of 34
Introduction to our Quality Account
This Quality Account is New Hall 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 review every service we provide with a view to improving it and ensuring that
our patient’s treatment outcomes are the best they can be. It will give a balanced view of
what we are good at and what we need to improve on.
In 2009/10 the Quality Account was developed by our Corporate Office and summarised
and reviewed quality activities across every hospital and centre within the Ramsay Health
Care UK. It was recognised, however, that this didn’t provide enough in depth information
for the public and commissioners about the quality of services within each individual
hospital and how this relates to the local community it serves. Therefore, each site within
the Ramsay Group developed its own Quality Account for 2010/11 and this account for
2011/12 is New Hall Hospital’s second submission.
Quality Accounts 2011/12
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Part 1
1.1 Statement on quality from the General Manager
Fiona Taylor, General Manager,
New Hall Hospital
Welcome to New Hall Hospitals second quality account. This report outlines the Hospitals
approach to quality improvement, progress made in 2010-11 and plans for the
forthcoming year.
New Hall Hospital has five key values which underpin everything we do as an
organisation.
They are:
• Put the patient first;
• Work as one team;
• Respect each other;
• Strive for continual improvement;
• Respect environmental sustainability.
The experience that patients have in our hospital is of the utmost importance. As well as
being treated quickly and safely, they must receive a personalised service, enhanced by
good communication and a commitment to ensuring their privacy and dignity are
respected at all times.
During 2011/12 we have made a raft of improvements to ensure patients in our hospital
receive the best possible care.
This report demonstrates that the experience patients have in our hospital, the quality of
the care they receive, and the safety of the service we provide are top priorities for our
hospital.
In addition, it shows how our values, combined with our priorities, are improving the way
in which we treat our patients. For example, we continue to have a very low infection rate
within our units and submissions to Surgical Site Surveillance Service has commenced.
Our surgical site infection rates are significantly lower than the national average.
Fiona Taylor
General Manager
Quality Accounts 2011/12
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the publication
of this document, the information in this report is accurate.
Fiona Taylor
General Manager
New Hall Hospital
Ramsay Health Care UK
Signature………………………………………………Date………………………….
This report has been reviewed and approved by:
Mr Charles Ranaboldo, Consultant General Surgeon
Medical Advisory Committee Chair
Mr Peter Guy, Consultant Urologist
Clinical Governance Committee Chair
Helen White
Regional Director, Ramsay Health Care UK
Commissioner/PCT and other external bodies
Quality Accounts 2011/12
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Welcome to New Hall Hospital
•
•
•
•
•
•
•
•
•
•
New Hall Hospital is an independent hospital delivering a full range of specialist
surgical and medical services. The hospital is set in beautiful grounds and the
original Georgian manor House now accommodates three theatres and 48 beds
with excellent physiotherapy and radiology services. Consideration for our patients
is at the heart of everything that we do. We are constantly seeking new ways of
working and bringing in fresh clinical practices that will improve outcomes for our
patients. Our approach to service delivery, which includes working in partnership
with the NHS, is courteous and professional and we take great pride in our ability
to innovate and look at new ways of working.
We provide fast, convenient, effective and high quality treatment for patients of all
ages (excluding children below the age of 18 years or 16 if private), whether
medically insured, self-pay, or from the NHS).
We deliver a full range of specialist surgical and medical services (excluding
cardiac and neurosurgery) to include orthopedics, spinal, ENT, gynecology,
urology, colorectal, breast and cosmetic surgery and general medicine.
Patients requiring level 2 critical care are treated and cared for by appropriately
trained staff in a dedicated high dependency unit.
All Ramsay Health Care UK hospitals have transfer arrangements in place with
their local trust or critical care network for level 3 care.
In 2011 we treated a total of 5218 patients. 3216 NHS patients (62%) and 2002
private patients (38%).
We currently employ
Consultants (directly employed by Ramsay)
1
Consultants (with practicing privileges)
102 (all specialities)
Registered Nurses
42
Operating Department Practitioners
8
Radiographers
4
Physiotherapists
5
Health Care Assistants
13
Other Support Staff
30
Administrative staff
52
The staff to patient ratio is 1:between 5 and 8 (depending on patient dependence
and there is an experienced Residential Medical Officer (RMO) on site 24 hours a
day
We provide an outreach service for outpatient NHS patients at Dorset County and
Poole Hospitals and Blandford clinic for spinal services.
We offer direct referral services for private Cosmetic Surgery and aesthetic
cosmetic treatments. All patients requiring NHS services are referred via their
General Practitioner (GP)
We have a dedicated GP liaison officer who has close contact with both the
practice managers and the GPs at practices throughout Wiltshire, Hampshire and
Dorset. She visits GP practices and organises regular “Lunch and Learns” and
Quality Accounts 2011/12
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•
•
breakfast meetings taking Consultants into GP surgeries to offer training. In
addition she also runs regular Consultant led open evenings for GP’s.
We work closely with our local PCTs (Wiltshire, Hampshire, Dorset and Somerset
to provide a range of surgical services within the standard acute contract.
We work closely with the Salisbury District Hospital who provide us with blood
transfusion, pathology, histopathology and access to level 3 critical care services.
Quality Accounts 2011/12
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Part 2
2.1 Quality priorities for 2012/2013
Plan for 2012/13
On an annual cycle, New Hall 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 hospitals Senior Management Team taking into account patient
feedback, audit results, national guidance, and the recommendations from various
hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness
and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2011/12
1. Slips Trips and Falls –At New Hall Hospital we have used the shattered lives
campaign from the Health & Safety Executive to highlight the dangers associated
with slips, trips and falls (ST&F) within the healthcare setting. We have
incorporated the guidance into the manual handling training and also display the
posters that highlight good practice in preventing slips trips and falls.
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 naso or orogastric tube not detected prior to use
• Intravenous administration of mis-selected concentrated potassium chloride
The never event list has recently been extended to 25 never events, of which 21
affect Ramsay.
preventative measures have been implemented and there have not been any
“Never event” incidents in this reporting year at New Hall hospital
Quality Accounts 2011/12
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3. Venous Thromboembolism (VTE) risk assessment and Prevention
New Hall hospital has established a robust policy to comply with Ramsay policy in
order to reduce avoidable death, disability and chronic ill health from VTE. We
have reduced the variance of prophylactic measures used at New Hall hospital in
order to minimise human error and allow outcomes to be measured. The hospital
has an excellent VTE risk assessment. Our current VTE risk assessment score is
100%.
4. Real time incident reporting – All incidents, complaints and clinical key
performance indicators such as readmissions, reoperations, healthcare acquired
infections etc. are entered onto the corporate risk management system (RIMS) in
real time so trends can be analysed and identified promptly. This enables us to
review events as they happen and prevent recurrence thus contributing to patient
safety. For 2012 Ramsay have invested in a new risk Management reporting
system called RISKMAN which will be installed at New Hall in July 2012.
5. National Joint Registry (NJR) NJR was set up in 2002 by the Department of
Health and welsh assembly to collect information on all hip, knee and ankle
replacements operations. Its purpose is to define, improve and maintain a quality
of care of individuals receiving hip, knee and ankle joint replacements across the
NHS and independent healthcare sector. Shoulder and elbow replacements have
also been added to the list in addition to those above. New Hall register all patients
undergoing this type of surgery with the NJR providing they consent to this. The
consent rate and linkability for New Hall hospital 2011/12 has been between 95100%, well above the NJR key performance indicator of 90% . The NHS number
tracing rate requires improvement to ensure that patients can be traced easily and
information from different providers can be collated. All staff who input the data
have been informed how to ensure NHS number tracing can be achieved to
achieve a 100% traceability rate.
6. Staff satisfaction survey Ramsay undertake an annual staff survey to measure
staff satisfaction as it is well known that satisfied, well trained and competent staff
will contribute to reducing patient safety risks. New Hall is bench marked against
other Ramsay UK units.
New Halls score showed a staff satisfaction rate of 4.4 against a Ramsay average
of 4.6 and a regional average of 4.5.
Quality Accounts 2011/12
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Overall
Leadership
My Company
My Manager
My Team
Personal
Growth
Fair Deal
Giving Back
Wellbeing
South
New
Region Hall
4.5
4.4
4.3
4.5
5.16
5.1
4.71
4.5
5.02
4.7
4.87
3.8
3.8
4.36
4.9
3.6
3.6
4.5
Quality Accounts 2011/12
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2.1.2 Clinical Priorities for 2012/13
Patient Safety
•
Surgical safety checklist – compliance to the checklist will remain an ongoing quality
initiative at New Hall.
•
Bar coding for patient identity bands – this priority has been on hold awaiting a formal
notice for implementation. However, this is still on Ramsay’s agenda and will be
introduced as it is still considered best practice and will prepare us for many patient
care initiatives which will require patients to have a barcode on their wristbands.
•
Venous-Thromboembolism assessment – will remain an ongoing quality initiative and
we will continue to audit our compliance to risk assessment and appropriate
prophylaxis. Audit results will be submitted as one of the nationally mandated quality
indicator.
•
Never events - preventing the occurrence of any serious, largely preventable patient
safety incidents that should not occur will remain a clinical priority for 2012/13.
•
Real Time incident reporting – in order to improve the reporting mechanisms Ramsay
has purchased a new system called RISKMAN. The new system which will be in
place in all units this year will input the relevant data more efficiently and make
reporting tools more widely available in order to improve patient safety outcomes.
•
National Joint Register – New Hall aims to maintain its consistently good scores for
data submission to the National Joint register.
•
Clinical training – New Hall hospital will continue to ensure that patients are cared for
by safe and competent staff. Providing quality care for patients is a high priority at
New Hall Hospital and all relevant clinical staff will be supported through training and
protected time to achieve competency level education. This year the staff have
undertaken competency based training in “recognising the signs of the deteriorating
patient” based on early warning scoring and trigger tools. The critical care training
remains competency based and all staff are expected to achieve competencies in
infection prevention and control which includes hand hygiene. ILS and/or ALS
training is mandatory for all clinical staff working in acute areas and this year we are
also providing AIM (Acute Illness Management) training.
•
Blood transfusion competencies – in line with patient safety we will ensure that blood
transfusions or blood products are only handled/administered by competent trained
staff.
•
Safeguarding of children and vulnerable adults– the hospital takes its responsibility
for safeguarding vulnerable members of society seriously. We provide in training and
easy to use flowcharts for help and advice. These are available in all areas. All staff
Quality Accounts 2011/12
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working within the hospital are required to have a an enhanced CRB check. Equality,
diversity and human rights are a theme running through Ramsay Health Care. The
organisations integrated governance framework, Group policies and practice comply
with current legislation. To date there have not been any safeguarding incidents to
report at New Hall Hospital.
•
Staffing – to ensure that adequate numbers of skilled staff are available to care for our
patients staff rotas are prepared in advance and all departments in the hospital have
their own bank of staff to provide additional cover as required. This year Ramsay
have invested in an electronic rostering system called Allocate. The system will
reduce the time spent on producing numerous rotas throughout the hospital and will
be accessible to all staff so they can log in and make requests for leave, training etc.
It is also designed to record training hours and remind staff when they need to attend
mandatory training sessions. The system will be set to produce rotas in line with
patient numbers and specific skill mix requirements.
Quality Accounts 2011/12
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Clinical effectiveness
Ambulatory Day Care – better outcomes and improving patient experience
Ambulatory Care (or Day Surgery Care) is the admission of selected patients (both
medical and surgical) to hospital for a planned procedure, returning home the same day
i.e. the patient does not incur an overnight stay)
Over recent years, partly due to medical advances the number of day surgery patients
has increased compared to those requiring inpatient care. In 2011 the percentage of day
surgery patients we treated was 65%. We need to ensure that our hospital facilities and
patient flows better meet the case mix we now deliver.
We will aim to ensure that 90% of all day care patients are treated in our ambulatory care
facilities.
In order to do this and provide our patients with a more efficient patient pathway through
the hospital, we have separated the day surgery patients from our inpatients by the
development of an ambulatory care unit . Best practice has shown that by doing this,
patient care will improve as waiting time and recovery period are reduced.
We will monitor the efficiency and effectiveness of the ambulatory care unit through
amending our coding system, management accounts and by patient satisfaction
questionnaires.
The Productive Ward (PW) Project is an NHS Initiative developed by the Institute for
Innovation and Improvement (2008). It focuses on the way ward teams work together
and organise themselves, in order to reduce the burden of unnecessary activities, and
releasing more time to care for patients in a reliable and safe manner within existing
resources. The approach is very much ‘bottom up’ with all ward staff suggesting ideas
and ways in which they could improve their environment and processes. the Productive
Ward project has been implemented at New Hall and is an ongoing project. The project
aims to improve inefficiencies with the ward environment releasing staff to care for the
patients. The ward utility rooms have been reorganised and labelled so items are easier
to find and equipment used on a regular basis (e.g. Dinamaps) always returned to the
same place when not in use so they can be found easily.
Group pre assessment – New Hall pre-assessment and physiotherapy team have
implemented a group pre assessment process for all spinal surgery. It was recognised
that seeing each patient individually was not always the most efficient way of giving the
required pre-operative information to patients and that holding group sessions
encouraged discussion and group interaction. The patients are first assessed at time of
consultation to ensure they are fit for surgery and then they are invited to attend a group
session where they are given a procedure specific presentation by the physiotherapist
and/or spinal nurse practitioner and an opportunity to ask questions and meet other
patients having the same procedure. The group session is followed up by an individual
assessment by the spinal nurse practitioner.
Improve National benchmarking – it was recognised that we needed more
transparency between ourselves and other independent sector providers/the NHS in
order to monitor and improve our services. This is even more important now we are
working in partnership with the NHS. We will be benchmarking in the following areas;
Hellenic – will provide national benchmark figures for key performance indicators
(activity/volumes, mortality, day case rates, unplanned readmissions, average length of
stay, unplanned transfers, reoperations, etc)
Quality Accounts 2011/12
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VTE risk assessment compliance – benchmarking through the national stats website.
Link;
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatisti
cs/DH122283
PROMS results – benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&categoryID1295
Patient satisfaction figures – New Hall patient satisfaction surveys are managed by an
independent company called “The leadership factor”. For 2012 all Ramsay units will also
participate in the annual NHS survey in order that we can be benchmarked with other
providers.
Patient experience – informing patient choice
Increasing the use of Patient Reported Outcomes Studies (PROMs)
We monitor the national PROMs results for Hip, Knee, Varicose Veins and Hernia surgery
by offering all patients who undergo this type of surgery the opportunity to complete a
questionnaire before and after surgery to monitor an improvement in their quality of life.
Encouraging their use in identifies poor outcomes and allows us to review practice where
necessary.
We share the results with Surgeons and physiotherapists and encourage them to use
them to review their practice by meeting and discussing the results with their teams and
benchmarking against other sites.
We are expanding our use of PROMS surveys to cover more procedures to enable better
understanding of treatment outcomes from the patients view point.
Patient satisfaction survey – New Hall has always achieved a high level of patient
satisfaction, the most recent result being 92%. All scores are reviewed and appropriate
action plans formed to address areas that require improvement.
Quality Accounts 2011/12
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1.2 Mandatory Statements
2.2.1 Review of Services
During 2011/12 New Hall Hospital provided NHS services.
New Hall Hospital has reviewed all the data available to them on the quality of care in
100% of these NHS services.
The income generated by the NHS services reviewed in 1 April 2011 to 31st March 2012
represents 100 per cent of the total income generated from the provision of NHS services
by the New Hall hospital for 1 April 2011 to 31st March 2012
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
Health care Assistant (HCA) Hours as % of Total Nursing (71% qualified to 29% HCA)
Agency Hours as % of Total Hours (0%)
% Staff Turnover (5.1%)
% Sickness (4.26%)
Total Lost Worked Days (1642)
% Appraisal 100%
Staff Satisfaction Score (74%)
Number of Significant Staff Injuries (0)
Patient
Formal Complaints per 1000 HPD's (4.8)
Patient Satisfaction Score (92%)
Number of Significant Clinical Events (0)
Readmission per 1000 Admissions (1.92)
Quality
Workplace Health & Safety Score (97%)
Infection Control Audit Score (88%)
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2.2.2 Participation in clinical audit
Between 1st April 2011 to 31st March 2012 New Hall Hospital participated in two national
clinical audits (see table below) and two national confidential enquiries (Cardiac arrest
and cosmetic surgery).
The national clinical audits that New Hall Hospital was eligible to participate in during 1st
April 2011 to 31st March 2012 are listed in the table below;
National Clinical Audits
Name of Audit
Participation
Peri-and Neo-natal
Children
N/A – no service
N/A – no service
Insufficient patient
numbers
Insufficient patient
numbers
Acute care
Long term conditions
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Cardiovascular disease
Renal disease
Cancer
Trauma
Psychological conditions
Blood transfusion
Bedside transfusion (National Comparative Audit of Blood
Transfusion)
Medical use of blood (National Comparative Audit of Blood
Transfusion)
Health promotion
End of life
YES
YES
Insufficient patient
numbers
N/A – no service
Insufficient patient
numbers
N/A – no service
N/A – no service
% cases
submitted
100%
100%
Did not participate in
2011
N/A
Insufficient patient
numbers
Insufficient patient
numbers
Local Audits
The reports of 63 which includes 16 infection prevention and control, 3 transfusion, 4
physiotherapy and 8 radiology local clinical audits from 1 April 2011 to 31st March 12
were reviewed by the Clinical Governance Committee and show good compliance to
national standards. Where is action is required, actions plans are developed and
implemented with review in timeframes set.
The audit schedule can be found in appendix 2
2.2.3 Participation in Research
There were no patients recruited during 2011/12 to participate in research approved by a
research ethics committee.
Quality Accounts 2011/12
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2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
New Hall hospitals income for achieving quality improvement and innovation goals
through the Commissioning for Quality and Innovation payment framework is applicable
from 1st July 2011 (SAC commencement) to March 31st 2012. The final report is being
prepared for submission but we are confident of achieving our locally agreed CQUIN on
alcohol advice, smoking cessation advice and weight management and all the nationally
mandated CQUINS.
2.2.5 Statements from the Care Quality Commission (CQC)
New Hall Hospital is required to register with the Care Quality Commission and its current
registration status on 31st March is registered without conditions
The Care Quality Commission has not taken enforcement action against
New Hall Hospital during 2011/12.
New Hall Hospital has not participated in any special reviews or investigations by the
CQC during the reporting period.
New Hall had an unannounced inspection on 13th March 2012. The outcomes inspected
were 1,4,7,8,14 & 17. New Hall was found to be fully compliant.
Quality Accounts 2011/12
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2.2.6 Data Quality
The regional data quality super user is now involved in is the Reconciliation process at
the end of the month and there is a new billing process to make sure our data is correct.
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2010/11 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).
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
New Hall 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
The regulations require you to send copies of your Quality Account to your relevant Local
Involvement Network (LINk), Overview and Scrutiny Committee (OSC) and lead
commissioning primary care trust (PCT) for comment prior to publication, and you should
include these comments in the published Quality Account here:
Thank you for allowing the Primary Care Trust (PCT) to review and comment on your Quality
Accounts for 2011/12. Please find below the PCT’s statement for insertion into the Quality
Accounts;
“NHS Bournemouth and Poole and NHS Dorset are pleased to be able to comment on New
Hall’s Quality Accounts for 2011/12. A number of NHS patients have accessed services at
New Hall over the last year, and the PCT are pleased to report that from the evidence
reviewed in the Quality Account and from evidence presented at contract monitoring
meetings overall, patients are experiencing high levels of satisfaction and quality of care.”
The PCT Cluster fully supports the priorities for 2012/13 and look forward to working with
Ramsay New Hall over the coming year”.
Please do not hesitate to contact me if you require any further information.
Yours sincerely
Sally Shead
Interim Director of Quality
Direct Line: 01305 368071
Email: sally.shead@dorset-pct.nhs.uk
c.c:
Lorraine Wong, Associate Director of Commissioning – Contracting
Vanessa Read, interim Deputy Director of Quality (Primary and Community Care)
Quality Accounts 2011/12
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Quality Accounts 2011/12
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Part 3: Review of quality performance 2011/2012
Statements of quality delivery
Matron, Deborah Stott
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 2011
The aim of clinical governance is to ensure that Ramsay develop ways of working which
assure that the quality of patient care is central to the business of the organisation.
The emphasis is on providing an environment and culture to support continuous clinical
quality improvement so that patients receive safe and effective care, clinicians are
enabled to provide that care and the organisation can satisfy itself that we are doing the
right things in the right way.
It is important that Clinical Governance is integrated into other governance systems in the
organisation and should not be seen as a “stand-alone” activity. All management
systems, clinical, financial, estates etc, are inter-dependent with actions in one area
impacting on others.
Several models have been devised to include all the elements of Clinical Governance to
provide a framework for ensuring that it is embedded, implemented and can be monitored
in an organisation. In developing this framework for Ramsay Health Care UK we have
gone back to the original Scally and Donaldson paper (1998) as we believe that it is a
model that allows coverage and inclusion of all the necessary strategies, policies,
systems and processes for effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
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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.
3.1 Patient safety
We are a progressive hospital and focussed on stretching our performance every year
and in all performance respects, and certainly in regards to our track record for patient
safety.
Risks to patient safety come to light through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more routinely
from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of key
indicators as illustrated in the graphs below.
Quality Accounts 2011/12
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3.1.1 Infection prevention and control
New Hall hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents
year on year.
Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic
joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital. An
annual strategy is developed by a Corporate level Infection Prevention and Control (IPC)
Committee and group policy is revised and 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:
•
New Hall has an in house infection control team led by an infection control link
nurse involving staff members from every department and a Consultant
Microbiologist from the local trust. The infection control team meet bi monthly to
review all aspects of infection control including audits, training, infection control
issues etc. Infection control is mandatory for all staff and is part of the Ramsay e
learning programme. In addition to the mandatory training the infection control link
nurse carries out hand washing training and audits as per the infection control
audit programme as seen in appendix 2. The results of all audits are discussed at
the infection control meetings, the Clinical Effectiveness Committee and Heads of
Department meetings.
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As can be seen in the above graph our infection control rate has increased slightly
over the last year. All of these cases were successfully treated with antibiotic therapy
The increase may be attributed to the improvements made in data collection and the
method by which infection rates are monitored. In comparison to the Ramsay average
2011/12 is higher but this maybe due to reason highlighted above and New Hall still
has very low infection rates.
The graph below gives the % of infections per admit.
There have been no cases of MRSA Bacteraemia
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3.1.2 Cleanliness and hospital hygiene
We continue to assess the hospitals facilities to ensure that we are providing a safe
environment and use the following audit tools:
Corporate - Environmental Audit – Quarterly
Corporate - Health, Safety & Facilities Audit – Annually
Environmental Audit
This audit was introduced in 2010, these are completed quarterly, the aim of this audit is
to ensure a safe environment for all staff and patients, the objectives are:
1. To identify users and user groups
2. To advise on infection control issues arising
3. To acknowledge
The audit consists of an inspection of the hospitals clinical areas and includes the general
environment, clinical equipment, decontamination, clinical practices, sharps handling,
waste disposal and hand washing.
New Halls environmental audit results were 96% in 2011/12.
Health, Safety & Facilities Audit
This audit, taken from Approved Codes of Practice (ACOPS) was introduced in 2009 and
is completed annually. The standards are the minimum that an organization must adhere
to ensuring a safe workplace. The benchmark set for 2010 was 90% and this has been
raised to 95% for 2011.
New Halls result for 2011 was 97%
3.1.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents
around sharps and needles. As a result, ensuring our staff have high awareness of safety
has been a foundation for our overall risk management programme and this awareness
then naturally extends to safeguarding patient safety.
Effective and ongoing communication of key safety messages is important in healthcare.
Multiple updates relating to drugs and equipment are received every month and these are
sent in a timely way via an electronic system called the Ramsay Central Alert System
(CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded
in this way to our General Manager which ensures we keep up to date with all safety
issues.
New Hall has a Health & Safety committee that meets monthly to discuss all matters
relating to health and safety and to review any adverse events that have occurred. All
members of the health and safety committee have undertaken CIEH level 2 award in
health and safety in the workplace . An audit of 10 steps to a safer site is carried out three
monthly and there is a comprehensive system in place to test all equipment (facilities and
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medical). A slips, trips and falls action plan has also been implemented to reduce the
number of patients falls.
3.2 Clinical effectiveness
New Hall hospital has a Clinical Governance team and committee that meet regularly
through the year to monitor quality and effectiveness of care. Clinical incidents, patient
and staff feedback are systematically reviewed to determine any trend that requires
further analysis or investigation. More importantly, recommendations for action and
improvement are presented to hospital management and medical advisory committees to
ensure results are visible and tied into actions required by the organisation as a whole.
The results highlighted in the graphs demonstrate the effectiveness of this approach over
the last three years.
3.2.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or specific
surgical team. Ramsay’s rate of return is very low consistent with our track record of
successful clinical outcomes.
As can be seen in the above graph our returns to theatre rate has increased slightly in
2011/12 but remains low compared to the Ramsay average.
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The graph above gives the % of unplanned returns to theatre per surgical admission.
3.2.2 Readmission to hospital
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be addressed.
Ramsay and New Hall 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.
•
As can be seen in the above graph our readmissions to hospital rate has
decreased significantly year on year and is lower then the Ramsay average . The
decrease may be as an improvement in post discharge written information and
clearer explanations given to the patient.
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The graph above shows the % of unplanned re-admissions per admit.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care are
welcomed and inform service development in various ways dependent on the type of
experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the relevant
staff using direct feedback. All staff are aware of our complaints procedures should our
patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular agenda
items on Local Governance Committtees for discussion, trend analysis and further action
where necesary. Escalation and further reporting to Ramsay Corporate and DH bodies
occurs as required and according to Ramsay and DH policy. Feedback regarding the
patient’s experience is encouraged in various ways via:
ƒ Patient satisfaction surveys
ƒ ‘We value your opinion’ leaflet
ƒ Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers
whilst visiting patients and Provider/CQC visit feedback.
ƒ Written feedback via letters/emails
ƒ Patient focus groups
ƒ PROMs surveys
ƒ Care pathways – patient are encouraged to read and participate in their plan of care
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3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called ‘The
Leadership Factor‘ (TLF). They print and supply a set number of questionnaire packs to
our hospital each quarter which contain a self addressed envelop addressed directly to
TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also separately
for NHS and private patients). The results are available for patients to view on our
website.
Patient satisfaction scores for overall quality show the majority of patients feel they
receive excellent quality of care and service at New Hall Hospital. To record a satisfaction
index over 90%, a very high proportion of our patients have scored 9 or 10 out of 10 for
their satisfaction with all the requirements. This is underlined by comparing our hospitals
Satisfaction Index against those achieved by other organisations across all sectors of the
UK economy where the full range of customer satisfaction is 50% to 95% with the median
just below 80%.
New Halls average score is 92.1%
3.3.2 Patient Reported Outcome Measures (PROMs)
New Hall Hospital participates in the Department of Health’s PROMs surveys for hip and
knee surgery, hernias and varicose veins for NHS patients. The sample sizes are small
and survey results are evolving. Indications so far are that New Hall Hospital patients
report excellent outcomes, and results compare very favourably with other providers.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs surveys
specifically for private patients.
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Appendix 1
Services covered by this quality account
Services offered as per Statement of Purpose
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Bariatrics, Dermatology, General medicine, Neurology,
Oncology, Paediatrics (outpatient consults only), Pain
management, Physiotherapy, Psychiatry (outpatients
only), Psychology, Orthopaedic medicine,
Rheumatology, Sports Medicine
Satellite Out patient services being carried out at Dorset
County Hospital and Poole Hospital for Dorset PCT,
Bariatrics, Cosmetics, Dermatology, Ear, Nose and
Throat (ENT), Gastrointestinal, General surgery,
Gynaecology, Ophthalmic, Orthopaedic, Oral
maxillofacial, Urological, Ambulatory, Day and Inpatient
Surgery
Peoples Needs Met for:
All adults 18 yrs and over, and young persons 16-18 yrs
Children 0-16 yrs outpatient consultation only
All adults 18 yrs and over, young persons 16-18yrs
excluding:
•
•
•
•
•
•
•
•
•
•
•
•
Surgical
Procedures
Bariatrics, Cosmetics, Dermatology, Ear, Nose and
Throat (ENT), Gastrointestinal, General surgery,
Gynaecology, Ophthalmic, Orthopaedic, Oral
maxillofacial, Urological, Ambulatory, Day and Inpatient
Surgery
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 BMI >340 (non bariatrics)
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, young persons 16-18yrs
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 BMI >340 (non bariatrics)
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.
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Diagnostic
and
screening
GI physiology, Imaging services, Phlebotomy,
Endoscopy, Urinary, Urodynamics,
Screening and Specimen collection
Satellite Out patient services being carried out at Dorset
County Hospital and Poole Hospital for Dorset PCT,
All adults 18 yrs and over, young persons 3-18yrs
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Appendix 2 – Clinical Audit Programme.
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New Hall 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:
Fiona Taylor General Manager
01722 422333
www.newhallhospital.co.uk
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