Quality
Account
2011/12
Quality Account 2011/12
Contents
Introduction Page
Welcome to Ramsay Health Care UK and North Downs 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
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
3.4
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Quality Account 2011/12
Welcome to Ramsay Health Care UK
North Downs 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 Account 2011/12
Introduction to our Quality Account
This Quality Account is North Downs Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our achievements in terms
of clinical excellence, effectiveness, safety and patient experience and demonstrates that our
managers, clinicians and staff are all committed to providing continuous, evidence based,
quality care to those people we treat. It will also show that we regularly scrutinise every service
we provide with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what we need to
improve on.
This Quality Account includes some Group wide initiatives, but will also describe the many
excellent local achievements and quality plans that we would like to share.
Quality Account 2011/12
Part 1
1.1 Statement on quality from the General Manager
Andrew Robertson
General Manager
North Downs Hospital
Ramsay Health Care UK is committed to establishing an organisational culture that puts
the patient at the centre of everything we do. As the General Manager, I am passionate
about ensuring high quality patient care is at the centre of all that we do and how we
operate our hospital. This relies not only on excellent medical and clinical leadership but
also on our overall continuing commitment to drive year on year improvement in clinical
outcomes.
North Downs Hospital has a tradition of working closely with Consultants and patients to
ensure the best quality healthcare is consistently being delivered. Our hospital staff are
fully trained in the latest procedures and thus maintains all areas to the highest
standards. Working within the Department of Health guidelines we focus on patient
safety and cleanliness to minimise infection. Any patient who wants to satisfy themselves
on the quality of the hospital and its Consultants can be reassured by the Care Quality
Commission (CQC) Audits undertaken by the Department of Health which support the
hospital’s excellent reputation. The CQC has carried out an unannounced inspection at
North Downs in February 2012. The inspection found North Downs to be fully compliant
in relation to the outcomes inspected.
As General Manager of North Downs Hospital, I take great pride in the service we offer
our patients and their relatives; this is only achieved through a cohesive team effort and
approach.
Our Quality Account is information for both our patients and commissioners to assure
them we are committed to sharing our progressive achievements from one year to the
next. As a long standing and major provider for healthcare services across the world,
Ramsay has a very strong record as a safe and responsible healthcare provider and we
are proud to share our results. Our emphasis is to ensure patients receive safe and
effective care, that they feel valued and respected in decisions about their care ensuring
they are fully informed about their treatment at each step of their pathway. We especially
value patient’s feedback about their stay, treatment and clinical outcome. Patient safety
is our highest priority and we provide sufficient qualified and trained staff to deliver the
Quality Account 2011/12
service in a safe environment. We ensure that our staff are competent through a robust
recruitment process and training programmes. We believe it is essential to provide the
right person in the right role at the right time to deliver safe and effective treatment and
care. Staff are trained on all the equipment they are required to use and signed off as
competent.
The development of this Quality Account was determined by the Executive Management
Team within Ramsay Health Care UK. All professional and management teams at local
level have been represented in producing this account.
Quality Account 2011/12
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.
Andrew Robertson
General Manager
North Downs Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Khalid Drabu, Orthopaedic Consultant and Chair of the Medical Advisory Committee
Mr John Campbell, Consultant and Chair of the Clinical Governance Committee
Mrs Helen White, Regional Director South
Quality Account 2011/12
Host Commissioner Statement for Inclusion in Quality Account
The host commissioning PCT, NHS Surrey have reviewed North Downs Hospital’s draft Quality
Account document for 2011-2012 and believes that this provides a fair reflection of the work of
the hospital and includes the mandatory elements required. The priorities have been discussed
and will be further developed with input from commissioners including Clinical Commissioning
Groups.
We have reviewed the data presented and are satisfied that this gives an overall accurate
account and analysis of the quality of services. This is in line with the data supplied by North
Downs Hospital during the year and reviewed as part of their performance under the contract.
We continue to work with the Hospital to ensure that data accuracy at all levels remains a key
priority, including the application of clinical coding.
The account identifies significant success in relation to:
•
•
Reduction in patient falls
Patient safety and cleanliness
We will continue to work with North Downs Hospital to raise the profile for quality improvement
and regularly review the continuous improvement cycle. The engagement of clinicians close
working with primacy care will remain crucial in monitoring standards, and improving services
for local people. The hospital is commended for their continue good work and emphasis on
quality of patient care
MAY 12
Quality Account 2011/12
Welcome to North Downs Hospital
North Downs Hospital has long been established as one of Surrey’s leading private hospitals.
Located in a quiet residential area of Caterham, it provides a comprehensive range of surgical
and medical services together with the highest standards of patient care. North Downs hospital
retains its reputation for delivering such care in a welcoming, clean and comfortable
environment.
The facility currently has 15 individual rooms and 1 double room, all with en-suite facilities to
ensure complete privacy. The company has invested in advanced medical technology,
particularly in our operating theatres, and offers a wide range of treatments and services. The
hospital has designated one room as a Close Observation Room which facilitates caring for a
patient who requires closer monitoring. Future plans include development of our Ambulatory
Care facility and refurbishment of our in-patient rooms.
We also have Physiotherapy and Radiology Departments. Other services which include MRI
and CT are provided by our sister hospital in Ashtead.
Services provided at North Downs Hospital include both medical and surgical specialities
including orthopaedics, general surgery and gynaecology. A full list of specialities carried out is
included in the Appendix 1 at the end of the Quality Account.
We have a total of 93 Consultants and 34 Anaesthetists who practice at North Downs with a
number of consultants now working across site at Ashtead Hospital.
Total number of patient admissions in the past year to April was 3121 of which just over 60%
(2137) were NHS patients.
Our staff complement as of December 2011 is 55.7 whole time equivalents and 29 bank
members of staff.
Qualified Nurses – 19.4
Health care assistants – 6.6
Radiographers - 0.6 + bank staff
Porters - 0.2 + bank staff
Administration Staff - 18.6
Catering - 3.2
Housekeeping - 2.5
Maintenance - 1
Operating Department Practitioners – 2.4
Our pharmacy, decontamination and supplies services are provided by Ashtead Hospital. Our
Hotel Services and Business Development Managers also both work across site.
Our Resident Medical Officers are on site 24 hours per day. They play an active part in the ward
team and are available to support the Consultants and provide ongoing care for the patients.
Quality Account 2011/12
We hold regular open events which offer an opportunity for the public to see our facilities whilst
finding out about a specific subject of interest.
We work closely with Surrey & Sussex NHS Trust which provides us with blood transfusion and
other pathology services. The Trust also facilitates access to Level 3 Critical Care Services in
situations where these may be required. We also work with Consultants based at Croydon
University Trust.
Our GP Liaison Manager, Carole Gudgeon, visits GP surgeries in our catchment area to
regularly update GPs, Practice Managers and administration staff. We organise ‘Lunch &
Learns’, taking consultants into GP Surgeries to offer training and latest development
awareness as well as running evening GP Education Seminars on a regular basis. Additionally,
we have a GP representative (Dr Tun) on the hospital’s Medical Advisory Committee. We value
our contact with GP’s as “customers” and strive to ensure we actively work in partnership to
enhance patient care.
We are proud of the part we play in delivering NHS Services and consistently receive positive
patient feedback in our ‘We value your opinion’ leaflets. We also run workshops for GP Surgery
staff on how the Choose & Book system works at the hospital end of the process and the
implications for their patients. These are well received and are another way to help ensure a
smooth NHS patient journey.
Quality Account 2011/12
Part 2
2.1 Quality priorities for 2011/2012
Plan for 2011/12
On an annual cycle, North Downs 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 (looking back)
•
Bar coding for patient identity bands
This priority did not progress last year, as the Department of Health’s Information
Standards Board (ISB) advance notice was not followed up with a formal notice for
implementation. However, this is still on Ramsay’s agenda and a dedicated project team
are now working towards introduction of this system which is considered best practice
and will prepare us for many patient care initiatives which will require patients to have a
barcode on their wristbands.
•
Cleanliness
Further infection prevention and control audits had been introduced in 2011 as planned
and these are now being undertaken at all Ramsay sites and action plans developed
locally where necessary to ensure the standards are met. PEAT (Patient Environment
Action Team) audits were also repeated and showed the following results:
Quality Account 2011/12
•
•
•
Environment – score 4
Food – score 5
Privacy and dignity – score 4
The Infection Prevention and
a Control Environmental audit was undertaken on 13
February 2012 scored 97% and covered areas such disposal of waste, hand washing,
decontamination processes.
A departmental cleaning matrix has been implemented which provides the structure
required to monitor cleaning across the hospital in all departments.
Our infection control team have implemented the ANTT (Aseptic Non Touch Technique)
programme for all clinical staff. This technique ensures that standards for aseptic non
touch technique are employed for all clinical practices.
Meeting
ing endoscopy standards
North Downs Hospital takes part in the GRS (Global Rating Score) initiative for
endoscopy. The tool enables the team to review their practise against national standards.
There are two main areas of focus, Clinical Quality and Qual
Quality
ity of the Patient Experience.
Results of the audits are shown in the tables below.
Quality Account 2011/12
Quality Account 2011/12
We have made considerable progress in the past year in most categories and we continue to
work towards being assessed for JAG accreditation and expect to be fully accredited by
December 2012.
The planned new Ambulatory Care facility will further promote privacy for patients.
Day Surgery patient pathway
North Downs Hospital has implemented the corporate ‘ambulatory care’ pathway for day
surgery patients. We are currently planning an extension and refurbishment of our current
facility. The new facility will enable us to provide a dedicated service for patients undergoing
procedures which require just a short stay.
We have continued to work with Consultants to stagger patient admission times, reducing the
time which patients and their families have to wait before their operation takes place. These
changes have meant that patients can plan ahead with their families and their overall time in
hospital is reduced. A pre-admission phone call 24-48 hours prior to admission enables the
patient to ask any last minute questions.
2.1.2 Clinical Priorities for 2012/13 (looking forward)
Patient safety
1
Patient Falls – Patient falls can occur at any age but are particularly likely to happen to
elderly people who make up a high proportion of our patients. Causes of falls are
complex and older hospital patients are particularly likely to be vulnerable to falling
through medical conditions including delirium, cardiac, neurological or muscular-skeletal
conditions, side-effects from medication, or problems with their balance, strength or
mobility. Some patients also fall/faint when they have a low haemoglobin level which is
common following a hip replacement procedure for example. This can lead to some
patients feeling dizzy or faint particularly when they get out of bed and as such increases
their risk of falling.
However, patient safety does need to be balanced with independence, rehabilitation,
privacy, and dignity. Addressing inpatient falls and fall-related injuries is therefore a
challenge for all health care organisations. Reduction in falls remains a Ramsay priority.
The North Downs Hospital Risk Management Committee has chosen to continue to focus
on this area despite the reduction in the number of falls in the last year. Having reviewed
current practise and monitoring of all falls to determine the causes we have put
preventative steps in place to reduce the likelihood of these events. Patient education
has and will continue to be crucial, specifically ensuring that those patients who need
assistance are able to call for help when they need to get out of bed - this continues to be
on the main causes of patient fall incidents. Signs have been placed on patient notice
boards as a reminder to call a nurse for help. We have also instigated a corporate risk
Quality Account 2011/12
assessment tool that allows our pre
pre-admission
admission nursing team to assess the level of risk for
individual patients. The
e HSE provides national advice on the prevention of accidents in
the work place. The ‘Shattered Lives’ guidance has been reviewed and the Hazard
Spotting Checklist has been used to identify areas of concern.
Patient falls
20.5
20
19.5
19
18.5
18
17.5
17
16.5
16
15.5
2009-10
2010-11
2011-12
As can be seen by the graph the number of events has decreased in this last year,
year
despite the increase in the number of patients treated at the hospital.
Our aim is to reduce these events by a further 20%
20% over the forthcoming year. Each
event will continue
nue to be monitored by the Clinical Heads of Department and Health and
Safety and Local Clinical Governance Committees with any trends being analysed.
2
‘Never Events’ are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented.
The clinical team at North Downs Hospital has been working as part of the corporate
working group which is devel
developing
oping a comprehensive risk framework for all 21 Never
Events which affect Ramsay. Any Never Event is now to be reported as a Serious
Untoward Incident (SUI’S). Audit and policies ensure controls while reporting ensures
reflection on compliance of controls or where improvements need to be implemented.
From
rom the core never events, there are 5 that have affected Ramsay to date:
•
•
•
•
Wrong site surgery
Retained instrument post-operation
post
Wrong route administration of chemotherapy
Misplaced naso or orogastric tube no
not detected prior to use
Quality Account 2011/12
•
Intravenous administration of mis-selected concentrated potassium chloride
There have not been any ‘Never Event’ incidents in this reporting year at North Downs.
The overall aim for North Downs is to prevent any ‘Never Events’ occurring and we will
be working closely with the clinical and non-clinical teams to put strategies in place to
minimize the risks.
3
Infection Control – Prevention of patient infection has and will continue to be a key area
of focus both corporately and locally at North Downs Hospital. The corporate strategy is
fed into our local committee and is designed to bring about year on year improvements to
practice and outcomes. We understand that all infections impact on patients and their
families in some way and as such preventing infections is a crucial part of all of our care
pathways. Any infection is reviewed by the hospital Infection Control Committee who also
review all audit results. We have support from our Consultant Microbiologist who is on
hand to monitor and advise on infections.
Training is vital and plays a key part in our mandatory training programme for all staff. An
‘e-learning module’ is completed as well as attendance at an annual mandatory training
day which incorporates practical infection control issues.
Current policies and standard operating procedures ensure a consistent approach to
managing infection prevention strategies. Screening for MRSA is carried out according to
Department of Health guidelines.
Our local infection control team audit infection prevention in line with the corporate audit
programme. The audits include the following:
•
•
•
•
•
•
CVCCB - Central Venous Care Bundle
SSI - Surgical Site Infection
PVCCB -Peripheral Venous Catheter Care Bundle
PEAT -Patient Environment Action Team
UCCB - Urinary Catheter Care Bundle
Hand Hygiene
We have had mixed results specifically relating to hand hygiene. Although satisfaction
results from the external patient satisfaction survey, The Leadership Factor score has
ranged between 94-100%. However, results observed during unannounced audits
average 83%. Patient feedback on our levels of hygiene and hand washing activities are
specifically sought via our patient satisfaction questionnaires.
The appropriate use of alcohol gel/foam and hand washing is vital for preventing the
spread of infection and is the responsibility of all staff, including consultants, nursing
staff, and non-clinical staff. We focus on the World Health Organisation 5 moments when
Hand Hygiene has to take place and plan to involve our inpatients in auditing compliance
Quality Account 2011/12
to this. Ramsay is holding a national Hand Hygiene Day on Thursday 10 May 2012 to
raise awareness amongst staff, consultants and patients.
We also comply with mandatory reporting of all required organisms including MRSA
Bacteraemia and Clostridium Difficile infections. We participate in the Surgical Site
Infection surveillance and Hospital Acquired Infection rate reporting to the Health
Protection Agency.
Clinical effectiveness
1
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 patients requiring inpatient care. In 2011/12 the
percentage of day surgery patients we treated was 78%.
The current ambulatory care facility at North Downs has 5 bays and as such cannot
accommodate all of our day surgery patients. The majority of patients continue to be
treated in individual patient rooms. We now have plans drawn up and are in the final
stages of planning to build our new Ambulatory Care facility. It is planned that all of our
ambulatory care patients will then be able to be treated in a purpose built facility which is
separate from the in-patient rooms. It is important to note that not all patients are suitable
for this route of care but can still be treated as a day case patient.
•
•
Best practice has shown that by doing this, patient care will improve as waiting time and
recovery period are reduced. We have introduced a staggered admission process which
ensures that for most patients the length of their stay is greatly reduced. We also
endeavour to give the patient a planned discharge time to enable them to plan their
collection time with their family/carer.
•
These changes to practise are being monitored by means of patient satisfaction surveys,
currently the internal ‘We Value Your Opinion’ and the external, ‘The Leadership Factor
Survey’. We are recording these patients admission and discharge times to provide us
with information to audit regarding their length of stay. Changes to coding of patients will
also provide data to review practise. 83% of our patients reported that they waited less
time or ‘about the time’ they expected to wait. We aim to reduce the number of patients
who waited longer than expected by a further 5% this year.
2
Improve ward efficiency by adopting the Productive Ward initiative – more time to
care
• The Productive Ward (PW) Project is an NHS Initiative developed by the Institute for
Innovation and Improvement (2008). It focuses on the way the ward team works together
and organises themselves, in order to reduce the burden of unnecessary activities, and
Quality Account 2011/12
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 pilot project was successfully undertaken at Ashtead, our sister
hospital in 2010. Some progress has been made in the ward area but this remains an
area of focus for 2012 as some duplication of documentation remains.
3 Improved patient information
It was recognised from our patient satisfaction survey results that our patients were not
always receiving sufficient written information on discharge. This is important as even
though we always tell our patients everything they need to know before going home, a
written reminder ensures that they have the same information should they need to refer
to it at a later date. Our perception of the process in place was that it was effective
however this was not consistently apparent in the survey results at 85% satisfaction. It
was felt that the written information given to patients was perhaps too generic and did not
meet their individual information requirements. This area has been reviewed by our newly
established Patient Focus Group. Direct patient involvement is now being used to ensure
that the hospital perception of information required meets our patient perceptions.
The Eido leaflets (detailed patient information leaflets relevant to the planned procedure)
that are given to patients are now being sent out pre-operatively or given to the patient at
a pre-assessment visit. This is aimed at giving the patient time to digest the information
prior to admission and bring any questions about them on admission. A score of 95%
was achieved in the last quarter of 2011, an improvement on previous progress. We aim
to achieve 100% patient satisfaction in this area during this forthcoming year.
4 Riskman Project
As a healthcare provider we are diligent about how we manage risk within our hospital to
ensure that we keep everyone safe - patients, staff and visitors. We are constantly
looking at ways that we can make managing risk and reporting incidents easier and more
effective. We are introducing a new software tool that will enable us to improve the
quality of reporting which will ensure that we are able to analyse incidents and identify
any trends, improving the safety and quality of the service we provide.
Patient experience – informing patient choice
1
Increasing the use of Patient Reported Outcomes Studies (PROMs)
•
Better use of the national PROMs results for Hip, Knee and Shoulder replacement,
Varicose Veins, and Hernia surgery. Encouraging their use in identifying poor outcomes
and examining practice if and where this exists.
Quality Account 2011/12
•
Sharing results with Surgeons (and physiotherapists) and encouraging them to use them
to review their practice. These documents are now reviewed on a quarterly basis at the
local Clinical Governance Committee meetings and also Clinical Heads of Department
meetings. Copies of the documents will be given to the relevant consultants and sent out
to all consultants in the Consultant Newsletter. It is also useful to compare data across
the Ramsay Group. North Downs data is limited due to the relatively small numbers of
cases carried out.
2 Patient Satisfaction survey
•
Waiting times
One area that has been previously raised as an issue by our patients related to the time
they were waiting between arriving at the hospital and actually having their surgery. Our
aim is to improve the waiting time and to ensure that we fully meet our patient
expectations.
In Quarter 4 of 2011 the patient’s perception of the waiting time was as follows:
Less than expected – 33.9%
About what was expected – 48.4%
More than expected – 17.7%
We aim to reduce the number of patients who are waiting more than expected by a
further 5%. Our new Ambulatory Care Facility will facilitate this process.
•
Waiting times can now be easily monitored as the admission and discharge times are
recorded electronically. Patients also give us feedback via our internal satisfaction
questionnaires.
Care since discharge – This is another area which we hope to improve upon this year.
Patients discharged from North Downs often receive ongoing care from other Healthcare
providers, for example, G.P.s, Physiotherapists etc. We aim to work closely with the G.P.
community and the PCT to improve pathways which will have a positive impact for our
patients. We have introduced a new, more comprehensive Discharge information letter
which we send to the GP with a copy for the patient.
Quality Account 2011/12
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 2011/2012 North Downs Hospital provided 20 NHS services. North Downs Hospital has
reviewed all the data available to them on the quality of care in 20 of these NHS services.
The income generated by the NHS services reviewed in 1 April 2011 to 31st March 12represents
just over 55.82% of the total income generated from the provision of NHS services by the North
Downs 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.
This data is also a useful tool for other Heads of Department who can measure their
performance in a number of areas with their peers at other hospitals of a comparable size.
In the period for 2011/12, the indicators on the scorecard which affect patient safety and quality
were:
Human Resources
HCA Hours as % of Total Nursing
Agency Hours as % of Total Hours
% Staff Turnover
% Sickness
Total Lost Worked Days
Appraisal %
Mandatory Training %
Number of Significant Staff Injuries
Staff satisfaction survey
64% qualified to 36% Healthcare Assistant
0.34%
26.2%
2.28%
355
97%
84%
0
4.4
Patient
Formal Serious Complaints
Patient Satisfaction Score
Number of Significant Clinical Events
Readmission rate
0.64%
92%
2
0.1%
Quality
Workplace Health & Safety Score
93%
Quality Account 2011/12
2.2.2 Participation in clinical audit
National clinical audits
For information/reports on audits participated in please go to the following link:
http://www.hqip.org.uk/ncas-for-qa-introduction/
During 2011/12 two national clinical audits and one national confidential enquiries covered NHS
services that North Downs Hospital provides.
During 2011/12 North Downs Hospital participated in 100% applicable national clinical audits
and 100% national confidential enquiries of the national clinical audits and national confidential
enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquires that North Downs Hospital was
eligible to participate in during 2011/12 are as follows:
Hip, knee and ankle replacements, National Joint Registry, NJR
Elective Surgery, National PROMS Programme
National Cardiac Arrest Audit
The national clinical audits and national confidential enquiries that North Downs Hospital
participated in, and for which data collection was completed during 2011/12, are listed below
alongside the number of cases submitted to each audit or enquiry as a percentage of the
number of registered cases required by the terms of that audit or enquiry.
Name of Audit
Participation
Peri-and Neo-natal
Children
Acute care
N/A – no service
N/A
Cardiac arrest (National Cardiac Arrest Audit)
Yes
Long term conditions
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
N/A
Yes
% cases
submitted
No
incidents of
cardiac
arrest
100%
Hernia 63%
Hip 135.5%
Elective surgery (National PROMs Programme)
Yes
Cardiovascular disease
Renal disease
Cancer
N/A
N/A
N/A
Quality Account 2011/12
Knee
102.9%
Trauma
Psychological conditions
Blood transfusion
Bedside transfusion (National Comparative Audit of Blood
Transfusion)
Health promotion
End of life
N/A
N/A – no service
N/A
N/A
N/A
The reports of two national clinical audits were reviewed by the provider in 2011/12 and North
Downs Hospital intends to take the following actions to improve the quality of healthcare
provided:
•
•
Reports are reviewed by the local Clinical Governance Committee and Clinical Heads of
Department meetings
Comparative data is reviewed and shared with Consultants and by the Medical Advisory
Committee.
It is important to note that we are not able to participate in some audits which may be
appropriate due to low patient numbers.
Local Audits
The reports of 27 local clinical audits were reviewed by the provider in 2011/12 and North
Downs Hospital intends to take the following actions to improve the quality of healthcare
provided.
The clinical audit schedule can be found in Appendix 2.
•
•
•
•
Results have also been communicated to Consultants which has improved compliance,
particularly in hand washing.
Results are review at the local Clinical Governance Committee and Clinical Heads of
Department meetings
The systems for sending discharge information to G.Ps are to be reviewed in line with
the requirements of the National Standard Acute Contract for NHS Services.
Systems to be introduced for providing patients with dietary advice for patients who are
either overweight or underweight.
2.2.3 Participation in Research
The number of patients receiving NHS services provided or sub-contracted by North Downs
Hospital that were recruited during that period to participate in research approved by a research
ethics committee was 0.
Quality Account 2011/12
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of North Downs Hospital’s income in 2011/12 was conditional on achieving quality
improvement and innovation goals agreed between North Downs Hospital and any person or
body they entered into a contract, agreement or arrangement with for the provision of NHS
services, through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2011/12 and for the following 12 month period are
available online
http://www.monitornhsft
http:www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
Our main focus for this year was:•
Involvement in the Enhancing Quality Initiative – Orthopaedic Pathway which we have
entered data into for the last year and are compliant with SUS submissions. CQUIN
achieved.
•
VTE submissions – see 2.1.2 for further information
•
Supporting the NHS Surrey Smoking cessation programme for patients undoing elective
surgery. All of the patients who informed us that they were smokers have engaged in a
smoking cessation programme.
2.2.5 Statements from the Care Quality Commission (CQC)
North Downs 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 any enforcement action against
North Downs Hospital during 2011/12.
North Downs Hospital has not participated in any special reviews or investigations by the CQC
during the reporting period.
North Downs Hospital recent Care Quality Commission inspection report is available from the
Hospital or via the CQC website. The report demonstrates full compliance with the outcomes
assessed.
2.2.6 Data Quality
Quality Account 2011/12
We regularly use statistical data to monitor clinical services – we are constantly striving to
improve this data by regular quality control initiatives.
Data contained in medical records are audited on a monthly basis and actions taken to improve
quality as appropriate. This applies to both private and NHS patient streams. North Downs
Hospital will be taking the following actions to improve data quality.
The hospital has a data quality super user who manages the SUS pathway processes and
continually reviews administration functions to ensure excellent data quality.
Where applicable the targets and national core standards as stated in the compliance
framework May 2008 (appendix B) have been met.
An Overview of Perfomance against national priorities from the national operating framework
Target
2010/2011
2011/2012
Clostridium difficile year on year
0 cases
0 cases
reduction
MRSA – maintaining the annual
number of MRSA bloodstream
infections at less than half the
2003/04 level
Maximum waiting time of 31 days
from decision to treat to start of
treatment
Maximum waiting time of 62 days
from all referrals to treatment for all
cancers
Admitted patients: maximum time of
18 weeks from point of referral to
Treatment 90%
Non-admitted patients: maximum
time of 18 weeks from point of
referral to treatment 95%
Maximum waiting time of four hours
in A&E from arrival to admission,
transfer or discharge 98%
People suffering heart attack to
receive thrombolysis within 60
minutes of call
Maximum waiting time of two weeks
from urgent GP referral to first
outpatient appointment for all urgent
suspect cancer referrals
0 cases
0 cases
Not applicable – no cancer cases
treated
Not applicable – no cancer cases
treated
Not applicable – no cancer cases
treated
Not applicable – no cancer cases
treated
<98% achieved
<98% achieved
<98% achieved
<98% achieved
Not applicable
Not applicable
No cases recorded
No cases recorded
Not applicable – do not accept
two week wait patients
Not applicable – do not accept
two week wait patients
Mental health targets
Minimising delayed transfers of care
No more than 7.5%
Not applicable
0 delayed transfers of care
Not applicable
0 delayed transfers of care
Admissions to inpatient services had
access to crisis resolution home
treatment teams 90%
Maintain level of crisis resolution
teams set in 03/06
planning round
Not applicable
Not applicable
Not applicable
Not applicable
Quality Account 2011/12
NHS Number and General Medical Practice Code Validity
North Downs Hospital submitted records during 2010/2011 to the Secondary Uses service for
inclusion in the Hospital Episode Statistics which are included in the latest published data. The
percentage of records in the published data which included the patients valid NHS number was
99.66% for admitted patient care, 99.30% for outpatient care. (Accident and emergency care is
not applicable to our services)
That which included the patients valid General Practitioner Registration Code was 99.96% for
admitted patient care; 99.82% for outpatient care. Accident and emergency care is not
applicable to our services.
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score, 2011/12 overall was 77%
and was graded ‘green’ (satisfactory).
Clinical coding error rate
North Downs Hospital was not subject to the Payment by Results clinical coding audit during
2011/12 by the Audit Commission.
Part 3: Review of quality performance 2011/12
Statements of quality delivery
Matron, Susi Thompson
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, clinician 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)
Quality Account 2011/12
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
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
Quality Account 2011/12
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 focused 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
Quality Account 2011/12
North Downs 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.
North Downs 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. North Downs has an Infection
Control Sister who leads the infection prevention and control agenda across the hospital.
Programmes and activities within our hospital include:
Our staff (clinical and non-clinical) have undertaken the corporate e-learning training package
for infection prevention. In addition they attend mandatory practical Hand Hygiene sessions
which includes using the UV Light which demonstrates where hands have been cleaned
effectively. This focus on cleanliness has resulted in an operational Cleaning Matrix with
cleaning records available in each department. Also ‘green stickers’ are now used in all clinical
areas to show when equipment has been cleaned and by whom. Environmental audits continue
to be completed quarterly which aim to ensure a safe environment for all staff and patients.
Hand hygiene will continue to be a focus area for 2012/13. The appropriate use of alcohol
gel/foam and hand washing is vital for preventing the spread of infection and is the responsibility
of everyone. We have a very low infection rate at North Downs and we strive to maintain that.
We focus on the World Health Organisation’s 5 moments when Hand Hygiene has to take place
and plan to involve our in patients in auditing compliance to this.
Quality Account 2011/12
HAI Rate
0.18 %
0.16 %
0.14 %
0.12 %
0.10 %
0.08 %
0.06 %
0.04 %
0.02 %
0.00 %
09/10
10/11
11/12
As the chart shows the infection rate as a percentage of the total number of patients treated at
North Downs Hospital has decreased over the last year indicating that the actions that are being
taken have been effective.
Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment Assessment
Team (PEAT) audits.
These assessments include rating of privacy and dignity, food and food service, access issues
such as signage, bathroom/toilet environments and overall cleanliness.
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
Patient Environment Action Team (PEAT) Audit
Corporate - Health, Safety & Facilities Audit
Over the last year we have developed a cleaning matrix for each department, this was
implemented in March 2011. This indicates the items to be cleaned, the frequency and the
cleaning materials to be used; we will use this as evidence when we complete the quarterly
environmental audits. The system also ensures that patients can feel confident that items are
clean by means of the visual green stickers.
Environmental Audit
This audit was introduced in 2010, and is completed quarterly; the aim of this audit is to
highlight risks so that preventative steps can be taken to ensure a safe environment for all staff
and patients. The objectives are:
Quality Account 2011/12
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 hospital’s clinical areas and includes the general
environment, clinical equipment, decontamination, clinical practices, sharps handling, waste
disposal and hand washing.
We have completed 4 audits during this period of reporting - results as follows:
•
•
•
•
May 2011 – 98% compliance
August 2011 – 96% compliance
November 2011 – 97% compliance
February 2012 – 97% compliance
We continue to focus on delivering a high standard of cleanliness and ensure that staff are
informed and updated at our mandatory training study days as well as discussing the points
raised at our bi-monthly Health and Safety Committee meetings.
PEAT Audit
We participate in the national annual assessment for all NHS Trusts and some of the
independent sector; these assessments include rating of privacy and dignity, food and food
service and environment which assesses issues such as signage, bathroom/toilet environments
and overall cleanliness.
We have completed 3 annual audits results as follows:
•
•
•
•
October 2009 – 80% compliance
February 2010 – 80% compliance
March 2011 – 85% compliance
February 2012: await percentage score
• Environment – score 4
• Food – score 5
• Privacy and dignity – score 4
Although the results indicate improvements year on year there are planned works to improve
the environment during 2011/2012, and this should be reflected in future audits outcomes.
The score remains below the national average for Ramsay 2011
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
Quality Account 2011/12
naturally extends to safeguarding patient safety. The graph below illustrates the number of
accidents as a percentage of total patient admissions.
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.
Training relating to all aspects of Health and Safety are mandatory for all of our staff whatever
role they undertake. On line training is complemented by practical fire, risk assessment and
manual handling training. All training is focused on the hospital and the specific risks that are
identified by the teams.
Health, Safety & Facilities Audit
This audit was introduced in 2009 and is completed annually. This audit is taken from legislation
for Approved Codes of Practice (ACOPS). The standards are the minimum that our organisation
must adhere to ensuring a safe workplace. The benchmark set for 2010 was 90% and this has
been raised to 95% for 2011.
2009 – 90% compliance
2010 – 91% compliance
2011/12 – 93% compliance
We hope to improve further with work to develop the ambulatory care facility and the planned
refurbishment of the ward area.
Adverse Events
Untoward Incident Rate
1.20 %
1.15 %
1.10 %
1.05 %
1.00 %
0.95 %
0.90 %
0.85 %
09/10
10/11
11/12
The graph demonstrates the total number of accidents and incidents involving patients, staff,
visitors and processes. As can be seen in the above graph our adverse events rate has
Quality Account 2011/12
decreased over the last year. All staff complete a mandatory training package relating to health
and safety issues, this proves to raise awareness in all staff whatever role they undertake within
the hospital.
A number of the incidents relate to patient faints/vaso-vagal attacks. The patients undergoing
joint replacements no longer have blood transfusions post operatively and as such are
particularly prone to fainting. Nursing patients in individual rooms also poses extra issues in
relation to prevention of falls. Posters have been displayed in patient rooms informing them of
the risks and reminding them to call for help before getting out of bed.
Trend analysis is an important aspect of our clinical governance and as such will continue to be
monitored over the 2011/12 with an ongoing focus on reducing sharps related incidents and
also slips/trips and falls.
3.2 Clinical effectiveness
North Downs Hospital has a Clinical Governance team and committee that meet quarterly
through the year to monitor quality and effectiveness of care. Clinical incidents, patient and staff
feedback are systematically reviewed to determine any trend that requires further analysis or
investigation. More importantly, recommendations for action and improvement are presented to
hospital management and Medical Advisory Committees to ensure results are visible and tied
into actions required by the organisation as a whole.
3.2.1 Returns to theatre
North Downs 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. North Downs’s rate of return is very low consistent
with our track record of successful clinical outcomes.
Quality Account 2011/12
Unplanned Returns To Theatre Rate
0.12 %
0.10 %
0.08 %
0.06 %
0.04 %
0.02 %
0.00 %
09/10
10/11
11/12
As can be seen in the above graph our return to theatre rate has decreased over the last year.
The numbers remain very small in relation to the number of admissions. Each individual event is
reviewed in detail by the local Clinical Governance Committee to determine any actions
required to reduce the risk of further returns, however there is no trend identified.
3.2.2 Readmission to hospital
Monitoring rates of readmission to hospital is another valuable measure of clinical effectiveness.
As with return to theatre, any emerging trend with specific surgical operation or surgical team in
common may identify contributory factors to be addressed. Ramsay rates of readmission
remain very low and this, in part, is due to sound clinical practice ensuring patients are not
discharged home too early after treatment and are independently mobile, not in severe pain etc.
Unplanned Readmission Rate
0.14 %
0.12 %
0.10 %
0.08 %
0.06 %
0.04 %
0.02 %
0.00 %
09/10
10/11
11/12
As can be seen in the above graph our readmissions to hospital rate have reduced over the last
year. We aim to ensure that any patient who has complications post discharge is only readmitted if this is essential. This remains a small proportion of our total number of patients.
There is no trend of re-admissions. Each event is reviewed in detail by the local Clinical
Governance Committee.
Quality Account 2011/12
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 Committees for discussion, trend analysis and further action where
necessary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as
required and according to Ramsay and DH policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Patient satisfaction surveys
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst
visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups – we have a newly established group at North Downs
PROMs surveys
Care pathways – patients are encouraged to read and participate in their plan of care
3.4
Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called ‘The
Leadership Factor‘(TLF). They print and supply a set number of questionnaire packs to our
hospital each quarter which contain a self addressed envelope addressed directly to TLF, for
each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also separately for
NHS and private patients). The results are available for patients to view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel they receive
excellent quality of care and service in North Downs 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
Quality Account 2011/12
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%.
Patient Satisfaction Scores
96%
95%
94%
93%
92%
91%
90%
89%
2008
2009
2010
2011
As can be seen in the above graph our Patient Satisfaction rate has increased slightly over the
last year and our score remains over 90% ensuring that the hospital rates in the top 2-3% of
organisations.
A patient focus group has recently been established in order to directly address areas which
require greater focus. One such area relates to discharge processes. A review of written
information given to patients has taken place and our Discharge Liaison Nurse is now working
closely with patients who may have specific concerns surrounding their discharge plans.
The Dr Foster Hospital guide, published annually, closely scrutinises a range of healthcare data
to measure hospital performance and detect trends that could save lives. It looks at how
hospitals around the country compare in many areas from mortality rates to patient satisfaction
for NHS patients. In the 2011 guide under the category of ‘The hospitals most often
recommended’ North Downs Hospital came second. 96% of their patients would recommend
the hospital against an average of just over 50% of patients nationally.
3.5 Patient Reported Outcome Measures (PROMs)
North Downs Hospital participates in the Department of Health’s PROMs surveys for hip and
knee surgery, hernias and varicose veins for NHS patients.
Quality Account 2011/12
Data continues to be submitted for these procedures and will be monitored.
The data received from PROMS is reviewed at the local Clinical Effectiveness Committee
meeting and circulated to those consultants who carryout these procedures. The graphs below
demonstrated the benefits felt by patients when compared against their pre surgery scores. For
hernia surgery it is clear that there is little overall benefit demonstrated, however for hip and
knee surgery North Downs patients have record
recorded
ed a greater benefit when compared with the
local Trust and the UK as a whole.
Groin Hernia
Improvement in EQ-5D
EQ
index score
0.09
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0.00
0.085
0.051
0.022
England
North Downs Hospital
Surrey and Sussex Healthcare NHS
Trust
Quality Account 2011/12
Oxford Hip Score: Average Health Gain
Adjusted by Case Mix
30
25
20
15
10
5
19.7
21.7
18.7
England
North Downs Hospital
Surrey and Sussex Healthcare NHS
Trust
0
Oxford Knee Score: Average Health Gain
Unadjusted to Case Mix
18
17.4
17.5
17
16.5
16
15.5
15
14.9
14.7
14.5
14
13.5
13
England
North Downs Hospital
Surrey and Sussex Healthcare NHS
Trust
Quality Account 2011/12
3.4 North Downs Hospital Case Study
CASE STUDY
ENHANCING QUALITY ORTHOPAEDIC HIP AND KNEE PATHWAY PROGRAMME
North Downs Hospital is proud to have been engaged in the Enhancing Quality Programme for
Hips and Knees during the year 2011-2012. We have established a robust data collection
programme and liaise closely with the EQ programme team to ensure that we benchmark
against other organisations and our data uploads are robust. We attended an excellent EQ
Exhibition in Crawley where we had the benefit of learning from our local NHS Trusts outcomes.
The independent sector only joined the programme in July 2011 and as yet has no active formal
reports on outcomes whereas the NHS Trusts have been taking part in the programme since
2010. We look forward to seeing our services benchmarked across all Healthcare
Organisations across South East Coast in 2012/2013
An introduction to EQ
Enhancing Quality (EQ) is an innovative clinician-led quality improvement programme launched
in January 2010 across Kent, Surrey and Sussex encompassing 10 Acute Trusts, 6 Community
Providers and 3 Mental Health Trusts and now the Independent Sector. By clinicians analysing
where to intervene for greatest quality improvement EQ aims to improve patient outcomes and
reduce variation in care, every patient, every time. EQ works across the three domains of
quality: clinical effectiveness, patient safety and patient experience.
EQ is aligned with all the latest thinking on quality improvement. It is clinician-led, evidencebased and data driven. Improvement information is available to Trusts down to clinician level on
the one hand and with the opportunity to benchmark and provide comparisons within this
region, with other regions and internationally on the other. This rigorous approach provides the
confidence that the improvements identified are ones that really matter and the certainty that
real improvements have been achieved.
EQ places a high premium on collaborative working so that clinical teams work more effectively
and "best practice" is shared to reduce variations in outcomes and care. EQ uses a proven
rapid improvement model with similar methodology to the Hospital Quality Incentive
Quality Account 2011/12
Demonstration (HQID) programme which has been operating in more than 250 non-profit
hospitals in the United States since 2003. EQ has two sister programmes in England;
Advancing Quality (AQ) in the North West region covering 24 Acute Trusts and Improving
Quality (IQP) operating in Berks, Bucks, Hants and Oxfordshire.
Enhancing Quality provides quality measurements that are clear and easy to understand for
NHS and Independent sector staff, patients and the public. For each of the areas of clinical
practice, a series of process measures and outcomes are identified. Doctors and nurses are
responsible for ensuring the clinical process measures are followed and that data is collected
(manually and/or through electronic systems) and outcomes monitored. This helps clinicians to
identify where improvements can be made in care pathways and processes.
Programme Outcomes
The vision for the Programme is to drive up the standards of hospital and primary/community
care by benchmarking and supporting clinical leadership to support rapid improvement. This will
be regardless of where they live, what their local hospital or community provider is or who their
GP or Community provider is.
The EQ Programme is a significant component of our locally agreed Commissioning for Quality
and Innovation (CQUIN) payment scheme. EQ is also aligned with regional QIPP (Quality,
Innovation, Productivity and Prevention) work streams. EQ will:
1. Deliver financial benefits
•
Reduction in complications;
•
Reduction in re-admissions;
•
Avoidance of hospital admissions;
•
Reduction in hospital days.
2. Improve patient experience
3. Improve health outcomes for patients
4. Deliver safer care
Quality Account 2011/12
5. Stimulate an environment for innovation and quality improvement
Why is it important?
The baseline information from elsewhere shows that many patients don't always receive the
interventions that would maximise their recovery and health. We already know from the work of
the Quality Observatory that there are huge variations across Kent, Surrey and Sussex.
EQ aims to streamline care, improve documentation and generally make the care provision
more consistent and reliable – every time for every patient. We know that reliable care will yield
higher quality clinical care, better outcomes and lower costs.
Quality Account 2011/12
Appendix 1
Services covered by this quality account
Services Provided
Peoples Needs Met for:
Treatment of
Disease,
Disorder
Or injury
Aesthetics (including laser),
Cardiology, Dermatology,
Colorectal, Endocrinology,
Fertility, Gastrointestinal,
General medicine,
Gynaecological, Neurology,
Nurse led sclerotherapy,
Ophthalmic, Paediatrics, Pain
Management, Physiotherapy,
Podiatry, Psychiatry (OPD
only), Rheumatology, Sexual
Health, Sports medicine,
Urology, Vascular
All adults
Adolescents 16-19 yrs
Children 3-16 yrs outpatients appointments only
Surgical
Procedures
Ambulatory, Cosmetic,
Colorectal, Dermatology, Ear,
Nose and Throat (ENT),
General Medicine, General
surgery, Gynaecological,
Ophthalmic, Orthopaedic, Pain
Management, Podiatric
surgery, Urology, Vascular,
Day and Inpatient Surgery
All adults
Adolescents 16-19 yrs excluding:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Patients with blood disorders (haemophilia, sickle cell, thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA screen are deferred until
negative
Patients who are likely to need ventilatory support post operatively
Patients who are above a stable ASA 3
Any patient who will require planned admission to ITU post surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild exertion e.g. from kitchen
to bathroom or dyspnoea at rest)
Poorly controlled asthma (needing oral steroids or has had frequent
hospital admissions within last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal activity e.g. 1 flight of
stairs or angina at rest)
CVA in last 6 months
New pacemaker in last 6 months
BMI 40+
Newly diagnosed or unstable diabetes
Newly diagnosed atrial fibrillation
Alzheimers or dementia
However, all patients will be individually assessed and we will only exclude patients
if we are unable to provide an appropriate and safe clinical environment.
Diagnostic
and
screening
GI physiology, Endoscopy,
Allergy testing, Imaging
services (including Dexa scans,
Nuchal scans, and obstetric
ultrasounds), Phlebotomy,
Urinary Screening (including
urodynamics) and specimen
collection
All adults and children 16 yrs and over
Outpatients appointments only - 3 yrs and above
Regulated Activities – North Downs Hospital
Quality Account 2011/12
Quality Accounts 2011/12
North Downs 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:
01883 337444
Hospital website –
http://www.northdownshospital.co.uk
Quality Accounts 2011/12