Quality
Account
2011/12
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Nottingham Woodthorpe
Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2011/12 (looking back)
2.1.2 Clinical Priorities for 2012/13 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2011/12 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Quality Accounts 2011/12
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Welcome to Ramsay Health Care UK
Nottingham Woodthorpe Hospital is part of the
Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 22 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, PCTs and acute Trusts.
“Ramsay Health Care UK is committed to establishing an organisational
culture that puts the patient at the centre of everything we do. As Chief
Executive of Ramsay Health Care UK, I am passionate about ensuring that
high quality patient care is at the centre of what we do and how we operate
all our facilities. This relies not only on excellent medical and clinical
leadership in our hospitals but also upon our overall continuing
commitment to drive year on year improvement in clinical outcomes.
“As a long standing and major provider of healthcare services across the
world, Ramsay has a very strong track record as a safe and responsible
healthcare provider and we are proud to share our results. Delivering
clinical excellence depends on everyone in the organisation. It is not about
reliance on one person or a small group of people to be responsible and
accountable for our performance.”
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with
every year we set our targets higher, working on every aspect of our
service to bring a continuing stream of improvements into our facilities and
services.
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2011/12
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Introduction to our Quality Account
This Quality Account is Nottingham Woodthorpe Hospital‟s annual report to the
public and other stakeholders about the quality of the services we provide. It
presents our achievements in terms of clinical excellence, effectiveness, safety
and patient experience and demonstrates that our managers, clinicians and staff
are all committed to providing continuous, evidence based, quality care to those
people we treat. It will also show that we regularly scrutinise every service we
provide with a view to improving it and ensuring that our patient‟s treatment
outcomes are the best they can be. It will give a balanced view of what we are
good at and what we need to improve on.
The previous Quality Account for 2009/10 was developed by our Corporate Office
and summarised and reviewed quality activities across every hospital and centre
within the Ramsay Health Care UK. It was recognised that this didn‟t provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group will develop
its own Quality Account from this year onwards, which will include some Group
wide initiatives, but will also describe the many excellent local achievements and
quality plans that we would like to share.
Quality Accounts 2011/12
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Part 1
1.1 Statement on quality from the General
Manager
Simon Milner, General Manager,
Nottingham Woodthorpe Hospital
As the newly appointed General Manager of Nottingham Woodthorpe Hospital,
having trained as a nurse in Intensive Care, I believe that this hospital is clinically
driven and our goal is to support our clinicians in delivering the highest quality
care to our patients. Not only that, but we aim to produce evidence to this effect
whether it be qualitative or objective – we will be able to demonstrate our
capabilities, and clinical excellence.
Our Hospital Vision is that:“As a committed team of professional individuals we aim to consistently deliver
quality holistic Acute Inpatient and Day Case Services with exemplary customer
care. This we believe we are able to achieve by continually updating our staffs‟
skills and competencies. We strive to further develop our knowledge in order to
deliver evidenced based clinical practice”.
This Quality Accounts document details our performance over the past year
indicating how we have improved on the high standards of clinical care the
actions that we have taken over the past year.
Quality extends not only to the service we deliver to our patients but to our other
customers – Consultants, GPs, Commissioners, other Trusts and by no means
last, the people who work for us. To understand how we deliver our services, and
the quality standards we reach is critical in our understanding of where we can
improve and how.
Where appropriate, Nottingham Woodthorpe Hospital participates in local,
corporate and national systems of quality review that are sometimes mandatory,
sometimes voluntary, but all times we are honest in our responses. It is to our
benefit that we benchmark honestly against our peers, and that we take the
opportunity to learn from those facilities and people delivering better outcomes, in
order to drive up our own standards
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To ensure that we deliver clinical excellence depends on everyone in our hospital
and we have a training and education plan which involves all members of our
administrative, operational and clinical teams. The emphasis on training and
education is high and strongly encouraged in order that we develop our people,
as well as deliver standards that we can be proud of.
Every individual member of staff is crucial to the success of our Hospital and they
value the contribution that they make in delivering great customer care.
In addition to our people contributing to the quality of services delivered, we work
closely with our consultant colleagues who, for the first time this year through
their MAC representatives, have responded positively to sharing the outcomes of
their clinical work in many areas. This is to be commended, but at the same time,
will be something Nottingham Woodthorpe Hospital can be proud to show, as we
pride ourselves in having consultants with the highest standards in the area
To ensure a coordinated approach to the delivery of care for patients and to
monitor the adherence to professional standards and legislative requirements the
Clinical Governance Committee and Medical Advisory Committee meet on a
quarterly basis to review the clinical and safety performance of the hospital.
These committees have reviewed and commented on the details within these
Quality Accounts.
If you would like to comment or provide me with feedback then please do email
me at simon.milner@ramsayhealth.co.uk or contact me on 0115 920 9209
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.
Simon Milner
General Manager
Nottingham Woodthorpe Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
MAC Chair:
Mr Anwar Zaman
Regional Director: Mr James Beech
Commissioner/PCT: Nottingham City PCT
Quality Accounts 2011/12
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Welcome to Nottingham Woodthorpe Hospital
Nottingham Woodthorpe Hospital has provided healthcare to the people of
Nottingham since 1877 and is conveniently located towards the north of
Nottingham city centre. Today, we are a modern well equipped hospital with 41
private bedrooms, two theatres (with laminar air flow) and a minor ops theatre
with endoscopy.
The hospital provides NHS and private inpatient and outpatient facilities for:Orthopaedic surgery
General surgery including gastrointestinal
Gynaecology
Bariatric surgery
Colorectal surgery
Cosmetic and Plastic surgery
Dermatology
Upper and lower diagnostic Endoscopy procedures
Ophthalmic surgery
Oral and Maxillofacial surgery
Spinal surgery
Vascular surgery
Urological surgery
General medicine
Physiotherapy including shockwave therapy, Sports Medicine and
acupuncture
Diagnostic imaging services including MRI
We provide safe, convenient, effective and high quality treatment for adult
patients (excluding children below the age of 18 years), whether privately insured,
self-pay, or from the NHS.
A high percentage of our patients have come from the NHS sector with patients
choosing to use our facility through „Choose and Book‟. Our services help to ease
the pressure on local NHS facilities and our Hospital Management Team work
closely with local Primary Care Trusts to ensure improved access for patients.
We have close links with GP surgeries, providing information, training and liaison
in order to monitor their needs and the requirement of the local population.
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We have carried out over 3,333 procedures in the past 12 months of which 2,636
were NHS and 667 were Private patients.
In addition to the Senior Management Team comprising of the General Manager,
Matron, Sales & Marketing Co-ordinator and Support Services Manager, we
currently employ the following staff at Nottingham Woodthorpe Hospital;1 Ward Sister, 1 Theatre Manager and 1 Outpatient Sister
19 Registered Nurses working within the Ward, Outpatients and
Theatres
5 Senior Staff Nurses working within the Ward and Theatres
1 Senior Operating Theatre Practitioner
2 Operating Department Practitioners
14 Health Care Assistants working within all clinical departments
29 Administration Staff working within Reception, Bookings, Business
Office, Hospital Administration, Marketing, Medical Secretaries and
Medical Records
1 Supplies Manager
1 Maintenance Manager, 1 Assistant Maintenance Assistant
2 Theatre Porters
3 Radiographers
4 Physiotherapists
1 Pharmacist and 1 Pharmacy Technician
4 Sterile Services Technicians
5 Housekeeping staff
2 Chefs supported by 6 Catering staff
Nottingham Woodthorpe Hospital also employs a GP Liaison Officer who
maintains and establishes relationships with GPs and the practice staff from
Nottingham and the surrounding areas. A GP visit schedule is maintained
whereby surgeries are contacted and visited on a regular basis. GPs are sent
regular newsletters and updates, and information packs containing details about
the hospital and how to refer are distributed.
We are currently establishing a programme of educational visits during practice
learning times whereby a consultant and the GP Liaison Officer will visit GP
surgeries with a topic of interest for a “Lunch & Learn” session. GP Educational
evenings are also held at the hospital.
Outside activities which show an involvement in the community include hosting
public open evenings for various clinical specialities e.g. cosmetic surgery and
Quality Accounts 2011/12
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bariatric surgery. The hospital‟s Charity Committee arranges fund raising events
to support local external charitable organisations such as a local Hospice and The
Stroke Foundation.
The hospital also promotes its services to the community via advertising in local
publications such as Nottingham Post, Newark and Trent Valley Journal,
Nottingham & Long Eaton Topper and Newark Village Life, together with local
radio advertising throughout the East Midlands.
Part 2
2.1 Quality priorities for 2011/2012
Plan for 2011/12
On an annual cycle, Nottingham Woodthorpe Hospital develops an operational
plan to set objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the hospital‟s Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Quality Accounts 2011/12
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Priorities for improvement
2.1.1 A review of clinical priorities 2011/12 (looking back)
Safer Surgery Checklists – further work was undertaken and two more
speciality specific checklists for radiology and cataracts have been
implemented to further reduce the risk of wrong site surgery.
Cleanliness – Further infection prevention and control audits were
introduced 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 an improvement of
0.22% over all.
Continued development of our Ambulatory Care facility to streamline
the patient pathway for day case procedures. Under the personal care
of their consultant and nursing staff, the ambulatory care process
reduces the length of time patients are required to stay in hospital after
their surgery.
Releasing time to care – the Productive Ward project was successfully
trialled at 5 sites and adjustments made accordingly to suit the NHS
services we provide. We are currently implementing change in the
ward areas at Nottingham Woodthorpe Hospital in line with this project.
Laserband wrist bands – we introduced new wristbands in line with
National Patient Safety Guidelines to help improve patient safety.
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. Consequently the project was put on hold until further
advice was received from the ISB. However, this is still on Ramsay‟s
agenda and will be introduced this year 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.
Quality Accounts 2011/12
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2.1.2 Clinical Priorities for 2012/13 (looking forward)
Patient safety
Introduction of the National Patient Safety Thermometer
The National Patient Safety Thermometer is a national initiative which will
allow us to monitor the level of harm our patients may be exposed to. The
monitoring takes place on a pre-determined date each month and is
applicable to all in-patients on that set date. Data is completed on a
template and submitted directly to the Department of Health Information
Centre and monitors the incidence of falls, VTE assessment and
preventative treatment, and urinary infections. Through submitting this data
on a monthly basis, we will be able to benchmark ourselves against other
Hospitals within Ramsay Health Care and within the NHS.
Implementation of Risk Man
In 2012/13 a new incident reporting system will be implemented which will
allow greater accuracy in recording incidents and will also support
enhanced data and trend analysis. This will support our patient safety
ethos.
Implementation of Electronic Rostering System
To support the monitoring of staffing levels and skill mix, a new electronic
rostering system will be implemented across all departments. This will
support the delivery of safe patient care and efficiencies.
Increase Patient Feedback Systems
To ensure our services meet our patients expectations we are implanting
new systems of gaining feedback on our patient‟s experience which will
complement our existing system. Currently, we use an external company
to obtain our patient feedback; this ensures the results are completely
unbiased and independent. In conjunction with this, patients are being
actively encouraged to complete the „We Value Your Opinion‟ feedback
forms and these are reviewed by a member of the senior management
team.
Never Events
These 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 17 that largely affect Ramsay:
o
o
o
o
Wrong site surgery
Wrong implant/prosthesis
Retained foreign object post-operation
Wrongly prepared high risk injectable medication
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o
o
o
o
o
o
o
o
o
o
o
o
o
Maladministration of potassium-containing solutions
Wrong route administration of oral/enteral treatment
Intravenous administration of epidural medication
Maladministration of insulin
Overdose of midazolam during conscious sedation
Opioid overdose of an Opioid-naïve Patient
Entrapment in bedrails
Transfusion of ABO incompatible blood components
Misplaced naso or oro gastric tubes
Wrong gas administered
Failure to monitor and respond to oxygen saturation
Misidentification of Patients
Severe scalding of Patients
Nottingham Woodthorpe Hospital has robust clinical governance
processes in place to mitigate the risk of such an event occurring.
There have been no reported adverse incidents which fall into this
category in 2011/2012
VTE Risk Assessment.
In September 2008, the Department of Health issued its guidance on
Risk Assessment for Venous Thromboembolism (DH 2008).
The objective is to improve the quality of patient care by minimising the
risk of VTE incidents. Nottingham Woodthorpe Hospital submits data to
evidence compliance with the National VTE Commissioning for Quality
and Innovation Goal that all patients should have a VTE risk
assessment. Nottingham Woodthorpe Hospital‟s priority for 2012/13 is
to maintain and improve the current compliance rate, as shown in the
table below.
Quality Accounts 2011/12
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Falls
If a patient were to experience a fall whilst in hospital, this would be
reported through the Ramsay Risk Management system and reviewed
at our Clinical Committee and Health & Safety Meetings.
Staff Satisfaction
The results from staff surveys continue to be important as satisfied,
well trained and competent staff will ensure patient safety risks are
reduced. Staff satisfaction surveys are undertaken annually and
reviewed by a dedicated working group.
The action plan for 2012/2013 includes:
Ensuring Performance Development Reviews are extended to
every contracted staff member;
Communication i.e. Teamwork between departments is
improved
Ramsay Health Care UK was surveyed by the Best Companies
team last autumn when we took part in the Sunday Times Best
Companies Process which measured employee engagement
across organisations from all industry sectors across the United
Kingdom. Obtaining staff feedback is an essential way of
measuring and improving service delivery within our
organisation.
Acute Care Competencies / Vulnerable Adult training
All Ward and Theatre staff are undertaking Acute Care competency
training, and assessments are already underway with the
registered Nursing Staff.
All staff within the hospital undertake a formal induction process
which includes the need to treat service users with consideration
and respect, promoting their autonomy, independence and
community involvement with due regard to their age, sex, religious
persuasion, sexual orientation, culture and linguistic background
and any disability they may have. All staff are required to
undertake the „Equality, Human Rights and Workplace Diversity‟
Level 1 e-learning program. Level 2 and Level 3 training is currently
being developed for roll out to all units.
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Clinical effectiveness
1. Ambulatory Day Care – better outcomes and improving patient
experience
Ambulatory 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)
In the 12 months leading up to 31 st March 2012, the percentage of day
surgery patients we treated was 39.8% 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 more than 50% 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 will be separating the day surgery
patient from our inpatients. Best practice has shown that by doing this,
patient care will improve as waiting time and recovery period are
reduced.
Success of the service will be monitored through patient satisfaction
reports, response to the 24-hour post discharge follow up telephone
calls and review of clinical governance indicators, e.g. change to length
of hospital stay.
2. 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. e.g. benchmarking in the following area:
3. PROMS Audit
Nottingham Woodthorpe Hospital currently participates in the outcome
data known as PROMS for the following surgical procedures:o hernia repair
o total knee replacement
o total hip replacement procedures.
All patients who undergo these procedures receive a pre and postoperative questionnaire which they complete and the results are collated
by an external body, The Royal College of Surgeons. This also
incorporates the Oxford Hip and Knee scores.
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Benchmarking is undertaken through the national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&cat
egoryID=1295
Patient experience – informing patient choice
1. Increasing the use of Patient Reported Outcomes Studies (PROMS)
We continue to make better use of the national PROMS results for
Hip, Knee and Hernia surgery. We encourage their use in identifying
poor outcomes and examining practice if and where this exists.
Will improve the sharing of results with Surgeons (and
physiotherapists) and encourage them to use these to review their
practice as part of the appraisal process
Expanding our use of PROMS surveys to cover more procedures to
enable better understanding of treatment outcomes from the
patients view point.
2. Patient Satisfaction survey – improved discharge information
It was recognised from our patient satisfaction survey results that our
patients were not always receiving 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.
% of Patients Dissatisfied with Discharge Information
35
30
25
20
15
10
5
0
Q2 2011
Q3 2011
Q4 2011
Q1 2012
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In Quarter 2 2011, 25% of our patients were unhappy with the standard of
discharge information they received. We have worked hard to review and
improve this result during 2011 which is supported by our Quarter 4 2011
results which showed that only 8.7% of patients were still unhappy with the
discharge information provided. Once again in Q1 2012 20% of our
patients were dissatisfied by the standard of discharge information given
out. Our ward teams have reviewed this process and EIDO leaflets for
procedure specific information for patients have been made easily
accessible in patient areas. The discharge nurse also completes a check
list to ensure that all aspects of discharge and follow up are covered. A
key objective for 2012/13 is to further improve our discharge processes
and the patient‟s experience.
2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2011/12 the Nottingham Woodthorpe Hospital provided and/or sub
contracted a wide case mix of inpatient and day case surgery NHS services.
Nottingham Woodthorpe Hospital has reviewed all the data available to them on
the quality of care in all of the NHS services they provide.
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard
are reviewed each year. The scorecard is reviewed each quarter by the hospital‟s
senior 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 at The Nottingham Woodthorpe Hospital were:
Human Resources
HCA Hours as % of Total Nursing:
31.4%
Agency Hours as % of Total Hours:
10.8%
% Staff Turnover:
12.9%
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% Sickness:
6.32%
Total Lost Worked Days:
1117.7 days
Appraisal %:
96%
Mandatory Training:
71.3%
Staff Satisfaction Score:
Number of Significant Staff Injuries:
4.16% (Ramsay average was 4.6%)
0
Patient Experience
Formal Complaints Received
Complaints Received
60.00
50.00
40.00
30.00
20.00
10.00
0.00
08/09
09/10
10/11
11/12
In 2008/09 we received 44 complaints compared to 23 complaints in 2008/09, 48
complaints in 2009/10 and 38 complaints in 2010/11. There were no trends
identified. However, we have made several changes to practice to improve the
quality of our service to patients including changes to our internal processes and
communication, patient flows with the continued improvement in the standard of
our facilities. We have also introduced “We value your opinion” leaflets to
enhance patient feedback and to investigate and resolve any issues that may be
raised.
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Patient Satisfaction Score
% Overall Patient Satisfaction)
94.5
94.12
94
93.5
93
93
92.5
92.1
92
91.8
91.5
91
90.5
08/09
09/10
10/11
11/12
It is proposed in 2012/13 to facilitate a number of patient focus group meetings to
gain a better understanding and insight into the quality of our patient‟s
experiences in using our facilities. In addition, our Matron offers patients the
opportunity, both formally and informally, to meet with her to listen to feedback on
their personal experiences.
Number of Significant Clinical Events
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We had no significant clinical events to report in 2008/09, with 9 being reported in
2009/10, 8 in 2010/11and 10 in 2011/12.
The incidents experienced were mainly due to patients being readmitted to the
hospital as a result of high temperature and possible wound infection which are
common complications following surgery. These symptoms were resolved after
24hrs, allowing the patient to return home, following close observation and
monitoring by our ward team and assessment by the patients‟ consultant.
Quality
Workplace Health & Safety Score:
96%
Infection Control Audit Score:
92.8% overall
2.2.2 Participation in clinical audit
The national clinical audits that Nottingham Woodthorpe Hospital participated in
during 1st April 2011 to 31st March 2012 are as follows:
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMS Programme)
Blood transfusion
O neg blood use (National Comparative Audit of Blood Transfusion)
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The data relating to these audits are listed below alongside the number of
cases submitted to each audit as a percentage of the number of registered
cases required by the terms of that audit.
National Clinical Audits
Name of Audit
Participation
Peri-and Neo-natal
Children
Acute care
N/A – no service
N/A – no service
N/A – No Service
Insufficient Patient
Numbers
Long term conditions
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMS Programme)
Cardiovascular disease
Renal disease
Cancer
Trauma
Psychological conditions
Blood transfusion
Bedside transfusion (National Comparative Audit of Blood
Transfusion)
Health promotion
End of life
% cases
submitted
Yes
Yes
N/A – No service
N/A – No service
N/A – No service
N/A – No service
N/A – No service
95%
95%
Yes
100%
N/A – No service
N/A – No service
The reports of 3 national clinical audits from 1 April 2011 to 31st March 12 were
reviewed by the Clinical Governance Committee and Nottingham Woodthorpe
Hospital and we have already improved the detail of the information included in
the discharge booklets provided to the patient. 24hr telephone assistance is
always available from our nursing staff and resident medical officer to answer any
concerns post discharge from the hospital.
Local Audits
The reports of (26 which includes 9 infection prevention and control, 4
transfusion, 3 physiotherapy and 2 radiology) clinical audits from 1 April 2011 to
31st March 12 were reviewed by the Clinical Governance Committee and
Nottingham Woodthorpe Hospital intends to take the following actions to improve
the quality of healthcare provided. The clinical audit schedule can be found in
Appendix 2.
All audit results showed an excellent degree of compliance – our main priority for
2012/13 will be ensuring standards of documentation are met with regard to the
discharge of patients and informed consent. This is in line with the requirements
of the National Standard Acute Contract for NHS Services.
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2.2.3 Participation in Research
There were no patients recruited during 2011/12 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
The commission for quality and innovation (CQUIN) payment framework enables
commissioners to reward excellence by linking a proportion of provider‟s income
to the achievement of local quality improvement goals.
Each commissioner agrees a number of different CQUIN‟s at the beginning of the
financial year with each of their providers. These include in year targets as well
as final outcome targets.
Nottingham Woodthorpe Hospital‟s income from 1 April 2011 to 31st March 2012
was conditional on achieving quality improvement and innovation goals through
the Commissioning for Quality and Innovation payment framework during this
period.
2.2.5 Statements from the Care Quality Commission (CQC)
Nottingham Woodthorpe Hospital is required to register with the Care Quality
Commission and its current registration status on the 31st March is registered
without conditions.
The CQC conducted an unannounced inspection on 26 th March 2012.
Regulations 1, 4, 7,10,11,14 &16 were reviewed by the inspectors and only
minor recommendations made which are being addressed by the Senior
Management team. All patients said they felt safe and that staff were very kind
to them. The Lead Inspector received many positive comments about staff
when he visited our inpatients. Patients said that their privacy and dignity was
protected and they felt staff were respectful during their visit to the hospital.
Patients also told the inspector that they felt involved in planning of their care
and treatment.
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Hospital staff told the inspector that they enjoyed working at the hospital and
supporting patients. The atmosphere throughout the hospital was considered to
be professional, friendly yet organised and calm.
2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to
improve your Data Quality
Nottingham Woodthorpe Hospital will be taking the following actions to improve
data quality.
Recording and investigating any unexpected return to theatre post surgery
Any extended length of planned stay and the reasons for this
Any unplanned death – this is reported and investigated as a serious
untoward incident
Any infections post surgery
Any transfer from the Hospital
Coding take place from the medical records.
There is a weekly data report which highlights any identified areas which
are addressed by the coder. This is addressed before the data is
submitted.
Consultant records are also subject to a monthly audit with individual
consultant feedback being given as required.
Defined process in place for capturing the Minimum Data Set on patient
referral and at admission into the hospital.
Robust clinical audit calendar (See Appendix 2)
All of these audit results are discussed at the MAC, Clinical Governance, and
Health and Safety meetings, and results are compared against previous year
results
NHS Number and General Medical Practice Code Validity
Nottingham Woodthorpe Hospital submitted records during 2011/12 to the
Secondary Uses service for inclusion in the Hospital Episode Statistics which are
included in the latest published data. The percentage of records in the published
data which included:
The patient‟s valid NHS number was:
99.66% for admitted patient care
99.30% for outpatient care
0% for accident and emergency care (not undertaken at Ramsay hospitals)
Quality Accounts 2011/12
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The General Medical Practice code was:
99.96% for admitted patient care
99.82% for outpatient care
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
Nottingham Woodthorpe Hospital was not subject to the Payment by Results
clinical coding audit during 2011/12 by the Audit Commission.
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:
PCT – awaiting response
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Part 3: Review of quality performance 2011/2012
Statements of quality delivery
Matron, Caroline Hunt
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 2011/12
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.
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The domains of this model are:
• Infrastructure
• Culture
• Quality methods
• Poor performance
• Risk avoidance
• Coherence
Ramsay Health Care Clinical Governance Framework
NICE / NPSA guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the National Patient Safety Agency
(NPSA).
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
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3.1 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety.
Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns but
more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs below.
3.1.1 Infection prevention and control
Nottingham Woodthorpe 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:
Our Infection Control Link Nurse works closely with all the departments
within the hospital offering advice and support. Hand hygiene and Sharps
Injury posters are displayed around the building to promote awareness of
these important issues. In October there is an annual National Infection
Control day which is advertised at the hospital with local Infection Control
initiatives taking place throughout the month. It is also mandatory for all
Quality Accounts 2011/12
Page 27 of 40
hospital staff to perform practical as well as elearning based annual
training in Infection Control.
As can be seen in the above graph our infection control rate has increased
slightly over the last year from 2 incidents [per 1000 Hospital Patient Day]
to 7. Although measures are taken pre operatively to reduce the risk of
infection through MRSA screening, the increased complexities of
operations we perform at the hospital carry a higher risk of post operative
complications.
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3.1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits. We continue to assess the hospitals facilities
to ensure that we are providing a safe environment and use the following audit
tools:
Corporate - Environmental Audit – Quarterly
Patient Environment Action Team (PEAT) Audit – Annually
Corporate - Health, Safety & Facilities Audit – Annually
These assessments include rating of privacy and dignity, food and food service,
access issues such as signage, bathroom / toilet environments and overall
cleanliness.
Cleanliness & Hygiene (PEAT)
78.1
78
77.9
77.8
77.7
77.6
77.5
77.4
77.3
77.2
09/10
10/11
As can be seen in the above graph, our overall cleanliness rate has
increased over the last year. Our ward and housekeeping teams have
been working closely together to improve the cleanliness of the areas
which allow public access. Careful attention has been given to the ward
and patient rooms and the cleaning rotas have been improved to reflect
our patient feedback. Extra hand gels have been fitted to the Ward
corridors and in the Outpatient Wings to enable the staff and our
customers to perform regular hand hygiene and maintain our low infection
rates with careful diligence in this task.
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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. Our record in workplace safety as illustrated by Accidents per 1000
Admissions demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and
new and revised policies are cascaded in this way to our General Manager which
ensures we keep up to date with all safety issues.
All hospital staff carry out annual Mandatory training incorporating Health and
Safety issues. Clinical staff have taken part in fire extinguisher training and in
Albac evacuation. Patient evacuation equipment has been fitted to key areas
within the building. Fire alarms are tested on a weekly basis and further fire
evacuation training is planned. Regular Health and Safety audits are performed
including the recent Facilities audit.
Caring for your privacy and dignity – same sex accommodation
At Nottingham Woodthorpe Hospital we are committed to making sure that all our
patients receive high-quality care that is safe and effective.
Our patients have the right to privacy and to be treated with dignity and respect.
We believe that providing same-sex accommodation is a key part of achieving
this and allows us to give all of our patients the best possible experience while
they are in hospital.
Nottingham Woodthorpe Hospital is pleased to confirm that we are compliant with
the Government‟s requirement to deliver same-sex accommodation, except when
it is in the patient‟s overall best interest, or reflects their personal choice.
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3.1.4 Caring for your privacy – data protection
Your doctor and other health professionals caring for you keep records about
your health and any treatment and care you receive from the Nottingham
Woodthorpe hospital. These help us to ensure that you receive the best possible
care from us. These records may be written down or held on a computer and are
used to guide and administer the care you receive to ensure full information is
available to anyone involved in delivering safe care to you.
Everyone working at Nottingham Woodthorpe Hospital has a legal duty to keep
information about our patients safe and confidential. If you are receiving care at
another organisation and they need access to your records held at the Woodland
Hospital, there is a strict process that must be followed and that may involve in us
obtaining your consent prior to disclosing any information. There are times when
we are required by law to pass on information to the appropriate authorities but
this is only done after formal permission has been given by a qualified health
professional. Anyone who receives information from us is also under a legal duty
to keep it confidential.
3.2 Clinical effectiveness
Nottingham Woodthorpe 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 Returns 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.
Quality Accounts 2011/12
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Unplanned Return to Theatre per 1000 Hospital Patient Days
As can be seen in the above graph our returns to theatre rate have decreased
over the last year. Even though we undertake high complexity operations our
clinical standards and practices are carefully monitored to reduce patient risk and
potential post operative complications.
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.
Quality Accounts 2011/12
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As can be seen in the above graph our readmission to hospital rate has increased
over the last year. This is due to the increased complexity of procedures we
perform, which can lead to additional complications that may routinely be
associated with minor day case surgery. Our clinical staff are trained to provide a
high standard of care to enable patients to recover and return home in a timely
manner, following observation and further treatment where necessary.
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.
Quality Accounts 2011/12
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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 DOH bodies occurs as required and according to Ramsay and
DOH 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
PROMs surveys
Care pathways – patient are encouraged to read and participate in their
plan of care
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called
„The Leadership Factor„(TLF). They print and supply a set number of
questionnaire packs to our hospital each quarter which contain a self addressed
envelope addressed directly to TLF, for each patient to use.
Results are produced 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 Nottingham Woodthorpe
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%.
Quality Accounts 2011/12
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% Overall Patient Satisfaction)
94.5
94.12
94
93.5
93
93
92.5
92.1
92
91.8
91.5
91
90.5
08/09
09/10
10/11
11/12
Nottingham Woodthorpe Hospital rates in the top 2-3% of organisations. Patient
satisfaction scores for overall quality show the majority of patients feel they
receive excellent quality of care and service at Nottingham Woodthorpe Hospital.
3.3.2 Patient Reported Outcome Measures (PROMS)
Nottingham Woodthorpe Hospital participates in the Department of Health‟s
PROMS surveys for hip and knee surgery and hernias for NHS patients.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMS
surveys specifically for private patients.
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Quality Accounts 2011/12
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As can be seen in the above graphs our PROMS scores for hip, knee and hernia
show that the vast majority of our patients are extremely satisfied with their care
during their stay with us at Nottingham Woodthorpe Hospital.
Quality Accounts 2011/12
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Appendix 1
Services covered by this quality account
Orthopaedic surgery
General surgery including gastrointestinal
Gynaecology
Bariatric surgery
Colorectal surgery
Cosmetic and Plastic surgery
Dermatology
Upper and lower diagnostic Endoscopy procedures
Ophthalmic surgery
Oral and Maxillofacial surgery
Spinal surgery
Vascular surgery
Urological surgery
General medicine
Physiotherapy including shockwave therapy, Sports Medicine and
acupuncture
Diagnostic imaging services including MRI
Quality Accounts 2011/12
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Appendix 2 – Clinical Audit Programme - Each arrow links to the audit to be completed in each month.
Audit Programme v4.0 2011/2012
Hospital Name:
Implemented: July 2011
For review: June 2012
Authors: R. Saunders / A. Shannon / N. Carre / E. Anderson
Use arrow symbol to locate
required audit
JUL
AUG
90%
100%
91%
Anaesthetic Standards
Medical Records
Consent
Discharge
SEP
80%
89%
OCT
94%
92%
92%
94%
91%
MAR
70%
87%
APR
89%
MAY
81%
JUN
N&H
85%
96%
94%
89%
86%
Medicines Management
93%
100%
Physiotherapy
90%
100%
100%
94%
90%
100%
Theatre
Transfusion
85%
FEB
98%
Prescribing
Infection Prevention and
Control - Environmental Audit
33%
84%
JAN
88%
Controlled Drugs
Infection Prevention and
Control*
DEC
86%
Care Pathways and Variance
tracking
Radiology
NOV
100%
100%
100%
95%
92%
National
audit
done
99%
MRI
88%
100%
100%
91%
100%
99%
100%
98%
N/A
94%
97%
100%
97%
PVCCB
UCCB
95%
100%
Quality Accounts 2011/12
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79%
Nottingham Woodthorpe
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:
0115 9209209
www.nottinghamhospital.co.uk
Neurological Centres
Quality Accounts 2011/12
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