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 Page 2 of 40 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 Page 3 of 40 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 Page 4 of 40 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 Quality Accounts 2011/12 Page 5 of 40 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 Page 6 of 40 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 Page 7 of 40 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. Quality Accounts 2011/12 Page 8 of 40 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 Page 9 of 40 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 Page 10 of 40 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 Page 11 of 40 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 Quality Accounts 2011/12 Page 12 of 40 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 Page 13 of 40 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. Quality Accounts 2011/12 Page 14 of 40 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. Quality Accounts 2011/12 Page 15 of 40 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 Quality Accounts 2011/12 Page 16 of 40 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% Quality Accounts 2011/12 Page 17 of 40 % 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. Quality Accounts 2011/12 Page 18 of 40 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 Quality Accounts 2011/12 Page 19 of 40 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) Quality Accounts 2011/12 Page 20 of 40 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. Quality Accounts 2011/12 Page 21 of 40 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. Quality Accounts 2011/12 Page 22 of 40 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 Page 23 of 40 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 Quality Accounts 2011/12 Page 24 of 40 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. Quality Accounts 2011/12 Page 25 of 40 The domains of this model are: • Infrastructure • Culture • Quality methods • Poor performance • Risk avoidance • Coherence Ramsay Health Care Clinical Governance Framework NICE / NPSA guidance Ramsay also complies with the recommendations contained in technology appraisals issued by the National Institute for Health and Clinical Excellence (NICE) and Safety Alerts as issued by the National Patient Safety Agency (NPSA). Ramsay has systems in place for scrutinising all national clinical guidance and selecting those that are applicable to our business and thereafter monitoring their implementation. Quality Accounts 2011/12 Page 26 of 40 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. Quality Accounts 2011/12 Page 28 of 40 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. Quality Accounts 2011/12 Page 29 of 40 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. Quality Accounts 2011/12 Page 30 of 40 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 Page 31 of 40 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 Page 32 of 40 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 Page 33 of 40 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 Page 34 of 40 % 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. Quality Accounts 2011/12 Page 35 of 40 Quality Accounts 2011/12 Page 36 of 40 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 Page 37 of 40 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 Page 38 of 40 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 Page 39 of 40 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 Page 40 of 40