Quality Account 2011/12
Our Physiotherapy Team
People caring for people
No reported MRSA Bacteraemia in the past 3 years
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Pinehill 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
3.4
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Pinehill 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)
Introduction to our Quality Account
This Quality Account is Pinehill 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.
Previous Quality Accounts were 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 hospital produces its own individual Quality
Account, including some Group wide initiatives, but focuses on the many excellent local
achievements and quality plans that we would like to share.
Part 1
1.1 Statement on quality from the General Manager
Mr Paul Tempest, General Manager,
Pinehill Hospital, Hitchin
Ramsay Health Care UK is committed to establishing an organisational culture that puts the
patient at the centre of everything we do. As the General Manager, I am passionate about
ensuring that high quality patient care is at the centre of what we do and how we operate our
hospital. This relies not only on excellent medical and clinical leadership but also on our overall
continuing commitment to drive year on year improvement in clinical outcomes.
Pinehill Hospital has a tradition of working closely with Consultants and patients to ensure the
best quality healthcare is consistently being delivered.
Our hospital staff are fully trained in the latest procedures and thus maintain all areas to the
highest standards. Working within the Department of Health guidelines we focus on patient
safety and cleanliness to minimise infection. Any patient who wants to satisfy themselves on the
quality of the hospital and its’ Consultants can be reassured by the Care Quality Commission
(CQC) Audits undertaken by the Department of Health which support the hospital’s excellent
reputation. As General Manager of Pinehill Hospital, I take great pride in the service we offer
our patients and relatives; this is only achieved through a cohesive team effort and approach.
Our Quality Account is information for our patients and commissioners to assure them we are
committed to sharing our progressive achievements from one year to the next. As a long
standing and major provider for healthcare services across the world, Ramsay has a very strong
record as a safe and responsible healthcare provider and we are proud to share our results. Our
emphasis is to ensure patients receive safe and effective care, that they feel valued and
respected in decisions about their care ensuring they are fully informed about their treatment at
each step of their pathway. We especially value patient’s feedback about their stay, treatment
and clinical outcome.
The Pinehill Hospital Vision Statement is to be a leading provider of health care services by
delivering high quality outcomes for patients and ensuring long term profitability. This vision is
reflected throughout the Quality Report in that the hospital will constantly strive to improve the
quality and suitability of its services to patients by ensuring there are adequate core policies and
skills, effective feedback mechanisms on the quality and efficacy of its activities and processes
in place to effect improvement at all levels of the organisation.
In preparing this report, the hospital has taken into account the views of a wide range of
stakeholders in the hospital’s activities, including staff, consultants and the Ramsay
organisation, but most importantly the views of patients and their families which have been
sought though questionnaire survey, comment sheets and focus groups. Furthermore, you are
invited to feedback on this document by sending any comments in writing to me at the hospital.
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.
Paul Tempest
General Manager
Pinehill Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Sanjay Gupta, Medical Advisory Committee Chair
Signature...................................................
Date...........................................................
Mr Peter Hope, Clinical Governance Chair
Signature...................................................
Date...........................................................
Richard Parsons, Regional Director
Signature...................................................
Date...........................................................
Commissioner/PCT and other external bodies
PCT Commissioner
Signature..................................................
Date...........................................................
Welcome to Pinehill Hospital
Pinehill Hospital
Pinehill Hospital is a beautifully converted (see newspaper clipping in office)
It is set in excellently maintained gardens on the edge of a residential housing estate. Access to
Pinehill Hospital is via Hitchin and is well signposted.
Pinehill has 23 in-patient bedrooms, 2 of which are twin-bedded. All rooms have en-suite
facilities to ensure privacy and dignity. Additionally there is a detached Day Care Unit with 7
patient bays and 8 further bedrooms. The Hospital has 3 main theatres and a minor
theatre/endoscopy suite.
The out-patient department has 10 consulting rooms with 2 treatment rooms, a physiotherapy
department with gym, an imaging department with x-ray, ultrasound and digital mammography.
A CT/MRI van is at the Hospital site 2 or 3 times per week according to patient need.
All 137 Consultants are subject to strict vetting procedures to ensure only those with the
appropriate experience and qualifications are granted Practising Privileges and offer treatment
at Pinehill Hospital.
The staff at Pinehill are professional and friendly, delivering high levels of customer service.
Together we provide fast, convenient and high quality treatment for patients of all ages (children
over the age of 3 years as inpatients), whether medically insured, self funded or via the NHS.
Patients can self refer for Vive Cosmetic Surgery consultation, and for some physiotherapy
services.
Medical and surgical procedures are provided for most specialties, including gynaecology,
urology, orthopaedic, ophthalmology, dental, dermatology, physiotherapy. We also provide
diagnostic services such as radiology and some pathology on site.
Last year (April 2011 – March 2012), Pinehill admitted a total of 2355 patients of which were
NHS funded.
A well qualified and experienced Resident Medical officer is on site 24 hours/day to provide high
quality medical care to patients under the direction of their Consultant.
We are very progressive in ensuring that we follow Best Practice wherever possible, constantly
developing our staff in order that services are constantly reviewed and further improved
according to national guidelines. This also results in high retention and low turnover due to
general satisfaction and challenge for all staff.
We have an active recruitment programme, ensuring that replacement staff are recruited into
new roles and existing vacancies without unnecessary delay, this results in continuity within the
Hospital team, both clinically and otherwise. We can report repeated success in recruiting staff
with expired clinical qualifications and supporting them through training to return them to the
professional workforce, and indeed we employed two theatre staff with expired qualifications
and now they are again fully fledged Operating Department Practitioners (ODP).
We also now employ newly qualified staff and ensure a good thorough induction, not only into
Pinehill Hospital and Ramsay Health Care, but also to the profession to which they now belong.
Whilst there is a national shortage of registered nurses, we are committed to developing our
Health Care Assistants (HCAs) through clinical competencies to enable them to undertake more
nursing duties and support the registered staff in maintaining clinical standards throughout the
patient journey. We are proud to say that the majority of our HCAs have already completed the
Immediate Life Support (ILS) course. Our HCAs also fulfill ‘assistant’ roles within physiotherapy,
supporting the qualified physiotherapists in the care of patients with ongoing support and
exercise. We will shortly be supporting a theatre HCA whilst she completes the NVQ 4 training
with an interest in endoscopy so that she may fulfill a valuable role in the care of these patients
with confidence and competence.
Permanent hospital staff include Registered Nurses, Health Care Assistants, Operating
Department Practitioners, Physiotherapists, Pharmacists, Radiographers, administrative staff,
caterers, housekeepers, porters and an engineer.
Pinehill Hospital is home to the Hertfordshire Phototherapy Centre, providing PUVA and TL01
light therapy for dermatological conditions, together with Iontophoresis.
We accept direct referrals to the Hospital services from GPs into Endoscopy and
Ophthalmology.
We are part of the Eastern Region of Ramsay Health Care and enjoy the services of a GP
Liaison Officer, ensuring that the GPs are always in touch with us and informed as to the
services that we offer and are developing at any time. We have GP education events planned
every 6 weeks or so, including training, networking, certificates and CPD points as well as a hot
meal! This year’s programme includes topics around urology, ophthalmology, ENT, joint
injections, as well as others. These are always well attended.
Our resuscitation officer trains the GP surgery staff in the skills of Basic Life Support and our
infection control nurse is preparing some information for presentation at Pinehill.
Pinehill Hospital works closely with local Primary Care Trusts in Hertfordshire to support
commissioning of healthcare services for the local population. We have close links with the East
and North Herts NHS Trust, including histopathology, blood transfusion services and
emergency transfer provision.
Pinehill has a very high spirit of community within our team and participate in community
activities. Pinehill also supports the Women for Women charity which raises funds to treat lifethreatening conditions affecting women and babies. One of our staff members is actually cycling
a distance of 450k through America to raise money, a distance from West Wales to Dover!
Pinehill has developed close relationships with the local schools, and have some of their art
work displayed through the hospital. We also provide educational visits for the students and
support junior football teams.
Pinehill also provides swift radiological diagnostic services to team players of Stevenage
Football Club.
Part 2
2.1 Quality priorities for 2011/2012
Plan for 2011/12
On an annual cycle, Pinehill 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, resulting in safe, quality treatment for all
NHS patients whilst they are in our care. We constantly strive to improve clinical safety and
standards by following a systematic process of governance including audit and feedback from
all those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time. The priorities are
determined by the hospitals Senior Management Team taking into account patient feedback,
audit results, national guidance, and the recommendations from various hospital committees
which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and
improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2011/12 (looking back)
• Bar coding for patient identity bands – this priority did not progress last year, as the
Department of Health’s Information Standards Board (ISB) advance notice was not
followed up with a formal notice for implementation. 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. This is already being encouraged between us and our blood
transfusion supplier and will assist in obtaining laboratory results, and electronic record
keeping.
• 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, with a working group focusing on reviewing our
Food Score achievement.
• Meeting endoscopy standards – we are currently registered with the Global Rating Score
(GRS) and our dedicated endoscopy team are working towards achieving JAG
accreditations.
• Investment in day surgery facilities – patients undergoing day surgery procedures are
cared for within our new Day Surgery Unit, comprising of 7cubicles and 8 bedrooms. Our
smooth and rapid process means that patients are here for only a few hours prior to
discharge.
•
Releasing time to care – the Productive Ward project has been very successful so far
with staff taking control of stock levels and organisation of care delivery using a patient
board system. A bar coding system will be introduced later this year to further facilitate
effective and efficient stock levels and ordering. There are also plans for the
refurbishment of the clean and dirty utility areas.
2.1.2 Clinical Priorities for 2012/13 (looking forward)
Patient safety
1. ‘Never Events’ are serious, largely preventable patient safety incidents that should not
occur if the available preventative measures have been implemented.
For further details see:
http://www.nrls.npsa.nhs.uk/resources/collections/never-events/
From the core never events, there are 5 that affect Ramsay.
• Wrong site surgery
• Retained instrument post-operation
• Wrong route administration of chemotherapy
• Misplaced naso or orogastric tube not detected prior to use
• Intravenous administration of mis-selected concentrated potassium chloride
The never event list has recently been extended to 25 never events, of which 21 affect
Ramsay – but it is recommended that the core events should be addressed initially.
2. VTE risk assessment - we have successfully improved our VTE rates, obtaining 100%
for the latter part of the year. All admitted patients are VTE assessed on admission, using
the DH assessment tool. All ward and DSU staff have completed the DH VTE
assessment competency training. These assessments are recorded on our Patient
Administration System (PAS) for data recording purposes.
3. Medical Gas Alert – Our engineers, portering and clinical staff have all undertaken
training on the safe and efficient use of medical gases.
4. Real time incident reporting – The Group are in the process of introducing the
RISKMAN system to all units which will further ensure timely and thorough reporting of all
incidents at various staff levels throughout the hospital.
5. Pulse results for your hospital – Our Hospital staff survey showed an improvement this
year with positive results. Low achievement levels such as inter-departmental
communication has improved with Heads of Department having a set time for a short
weekly meeting to discuss ongoing issues and as a support mechanism. Informal staff
forums have been introduced and are well attended to ensure ownership and
participation.
We plan to develop this further with comments being noted in the absence of the
management team, and action feedback to staff at subsequent forums.
Clinical effectiveness
1. Ambulatory Day Care – better outcomes and improving patient experience
• Ambulatory Care (or Day Surgery Care) is the admission of selected patients (both
medical and surgical) to hospital for a planned procedure, returning home the same day,
i.e. within 23hrs 59mins.
• Over recent years, partly due to medical advances the number of day surgery patients
has increased compared to those requiring inpatient care. In 2011 the percentage of day
surgery patients we treated was 74%. We need to ensure that our hospital facilities and
patient pathway flows better to meet the case mix we now deliver.
• We will aim to ensure that 89% of all day care patients are treated in our ambulatory care
facilities, cared for by staff who are highly skilled in this type of care delivery.
• 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 and patients maintain and retain their independence as
soon as possible within their home environment.
• This activity will be monitored through the use of specific codes, and the increased,
improved use of our IT systems. The patient satisfaction scores and comments will
illustrate satisfaction of patients.
2. Improve National Benchmarking – how do we compare? e.g.
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 areas:
Hellenic
• Hellenic will provide national benchmark figures for key performance indicators
(such as activity/volumes, mortality, day case rates, unplanned readmissions,
average length of stay, unplanned transfers, returns to theatre.
VTE risk assessment compliance
• Benchmarking through the national stats website. Link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatisti
cs/DH_122283
PROMS results
• Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID
=1295
Patient satisfaction figures
• Using CQUIN indicators common to both NHS survey and our own (e.g. %
recommended, same sex accommodation, infection rates)
3. Improve ward efficiency by adopting the Productive Ward initiative – more time to
care
The Productive Ward (PW) Project is an NHS Initiative developed by the Institute for
Innovation and Improvement (2008). It focuses on the way ward teams work together
and organise themselves, in order to reduce the burden of unnecessary activities, and
releasing more time to care for patients in a reliable and safe manner within existing
resources. The approach is very much ‘bottom up’ with all ward staff suggesting ideas
and ways in which they could improve their environment and processes. We have
commenced this project and need to further develop ownership from the staff. We have
plans to refurbish and enlarge our clean utility area, allowing more space for the
preparation of medications and completing medical records. We also intend to replace
old equipment in the dirty utility area, better meeting the needs of infection control
guidelines.
4. Improved patient information
It was identified last year from our patient satisfaction survey results, that our patients
were not always receiving written discharge 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. Ramsay have since published a wealth of patient information,
which is now routinely given to patients on discharge. We continue to monitor results,
which are showing a positive improvement recently. We have also developed local
Patient Information Leaflets to cover areas not previously covered in EIDO and Ramsay
pre printed materials.
5. Improve Patient Outcome
We have narrowed the ‘gap’ between ourselves and the local NHS Trust with staff
experiencing different working practises across both sites. We now have access to
traditionally NHS run courses and training and have forged strong links with the infection
control, resus and theatre teams to the benefit of all patients.
Patient experience – informing patient choice
1. Increasing the use of Patient Reported Outcomes Studies (PROMs)
• Better use of the national PROMs results for Hip, Knee, Varicose Veins and
Hernia surgery. Encouraging their use in identifying poor outcomes and examining
practice if and where this exists, via Clinical Governance and Speciality meetings.
• Sharing results with Surgeons (and physiotherapists) and encouraging them to
use them to review their practice. This will be achieved through Medical Advisory
Committee meetings, specialty meetings and Clinical Governance, Expanding our
use of PROMS surveys to cover more procedures will enable better understanding
of treatment outcomes from the patients view point.
2. Patient Satisfaction survey
We are very aware that Pinehill is in need of refurbishment and we currently have an
active programme underway. The reception area will be enlarged and modernised giving
more space and natural light. The main ward area will also be modernised with clean
smooth lines fully utilising all the available space as the bathrooms will be replaced with
‘wet rooms’, removing the small cramped space that is current. The clinical care delivery
is excellent with 97.6% of our patients scoring us as excellent, very good or good. We
offer a very friendly welcome and treat 100% of patients with respect and dignity. We
also aim to solve all identified problems as quickly and effectively as possible, attracting
a score of 100%. Pain is well controlled, scoring 96.7% and control of nausea and
vomiting effectively with a score of 100%.
The team now needs to concentrate more on reducing the admission to procedure delay
time and also the information provided for discharge.
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 Pinehill Hospital provided and/or subcontracted 22 NHS services.
The income generated by the NHS services reviewed in 1 April 2011 to 31st March 12
represents 100% per cent of the total income generated from the provision of NHS services by
the Pinehill hospital/centre for 1 April 2011 to 31st March 12.
Ramsay uses a balanced scorecard approach to give an overview of audit results across the
critical areas of patient care. The indicators on the Ramsay scorecard are reviewed each year.
The scorecard is reviewed each quarter by the hospitals senior managers together with regional
and Corporate Managers. The balanced scorecard approach has been an extremely successful
tool in helping us benchmark against other hospitals and identifying key areas for improvement.
In the period for 2011/12, the indicators on the scorecard which affect patient safety and quality
were:
Human Resources
HCA Hours as % of Total Nursing – we aim for a ward/theatre split of 70:30. This has been
variable this year due to professional development and return to nursing students as further
described in Section 3.4.
Agency Hours as % of Total Hours – 15%
% Staff Turnover – 9%
% Sickness – 9.64%
Appraisal % - 84%
Mandatory Training % - 97%
Staff Satisfaction Score – 64%
Number of Significant Staff Injuries - 0
Patient
Formal Complaints per 1000 HPD's – 3.25
Patient Satisfaction Score – 94%
Number of Significant Events – 84 in 12 months, which includes all reported adverse events
through the hospital
Readmission per 1000 Admissions – 4.6
Quality
Workplace Health & Safety Score – Awaiting inspection
Infection Control Audit Score – 91.5%
Consultant Satisfaction Score – Not measure at this time
2.2.2 Participation in clinical audit
During 1 April 2011 to 31st March 2012, Pinehill Hospital participated in all national clinical
audits to which it was invited and was eligible although these numbers were very low due to
insufficient or no patient volumes relevant to that particular audit/study.
Therefore the only audits that we have been active with for this particular year are the hip, knee
and ankle replacements through the National Joint Registry (NJR) and the national PROMs
programme.
Business at Pinehill has grown and the clinical teams have developed that we may now be in a
position to participate in more national audits and this is being reviewed by the Senior
Management Team (SMT).
Local Audits
There is a local audit system in place, based on a Group-wide template, covering areas such as
medical records, infection prevention and control, consent, controlled drugs and radiology. The
local clinical Governance Committee reviews audit results and recommends/supports
appropriate action plans. For example it was identified that the Anaesthetists were inadequately
completing the anaesthetic chart of patients. The committee wrote to this group of Consultants
with the result of a significant improvement in score.
2.2.3 Participation in Research
Pinehill is currently involved in recruiting patients for a research study to identify men with a
higher than normal potential to develop prostate cancer: ‘Use of -2PROPSA for the Detection of
Prostate Cancer in Men who are Candidates for a Prostatic Biopsy’.
This involves blood sampling and analysing of that sample.
The study is led by one of our Urology Consultants and is performed in conjunction with patients
from the local NHS Trust. It commenced in April 2012, so early days yet, with only a few
patients having given consent.
The results, when available will be shared nationally by the Consultant.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Pinehill Hospital’s income in from 1 April 2011 to 31st March 2012 was
conditional on achieving quality improvement and innovation goals agreed between them and
any person or body they entered into a contract, agreement or arrangement with for the
provision of NHS services, through the Commissioning for Quality and Innovation payment
framework. Measures included VTE Assessment and outpatient follow up rates.
2.2.5 Statements from the Care Quality Commission (CQC)
Pinehill Hospital is required to register with the Care Quality Commission and its current
registration status on 31st March is full registration without conditions.
The Care Quality Commission has not taken any enforcement action against
Pinehill Hospital during 2011/1.
The CQC came to visit Pinehill Hospital in March 2012 and performed a review of our
Termination of Pregnancy process and associated medical records. There were no actions
necessary following this review.
The Matron, as a representative of our Corporate Director for Safety and Clinical Performance,
was part of a working group with the CQC reviewing the process of reporting adverse events
with a view to refining the process for the future.
2.2.6 Data Quality
Pinehill Hospital will be taking the following actions to improve data quality.
High quality data is considered fundamental to the delivery of high quality services to patients.
The hospital is focused on ensuring that high standards are set in all areas of data recording
and reporting supported by regular audit of manual and IT systems.
As members of the Eastern Region of Ramsay, our medical notes are audited for coding
inaccuracies with this region being commended on the accuracy of our data recording.
Pinehill Hospital will be taking the following actions to continue to improve data quality.
• Regular audit
• Ongoing review of procedures and processes
• Training and development of staff
• Ensure lessons learned are effectively communicated.
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2011/12 to the Secondary
Users service for inclusion in the Hospital Episode Statistics which are included in the latest
published data. The percentage of records in the published data included:
the patient’s valid NHS number was:
99.66% for admitted patient care;
99.30% for out patient care; and
0% for accident and emergency care (not undertaken at Ramsay hospitals).
the General Medical Practice Code was:
99.96% for admitted patient care;
99.82% for out patient care; and
0% for accident and emergency care (not undertaken at Ramsay hospitals).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall
score for 2011/12 was 77% and was graded ‘green’ (satisfactory).
Clinical coding error rate
Pinehill 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 2011/12 Quality Account
Awaiting comments.
Part 3: Review of quality performance 2011/2012
Statements of quality delivery
Mary Barrett, Matron
Introduction
“Our emphasis is on providing an environment and culture to support continuous clinical
quality improvement so that patients receive safe and effective care, clinicians are
enabled to provide that care and the organisation can satisfy itself that we are doing the
right things in the right way”.
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health Care UK)
Ramsay Clinical Governance Framework 2012
The aim of clinical governance is to ensure that Ramsay develop ways of working which assure
that the quality of patient care is central to the business of the organisation.
The emphasis is on providing an environment and culture to support continuous clinical quality
improvement so that patients receive safe and effective care, clinicians are enabled to provide
that care and the organisation can satisfy itself that we are doing the right things in the right
way.
It is important that Clinical Governance is integrated into other governance systems in the
organisation and should not be seen as a “stand-alone” activity. All management systems,
clinical, financial, estates etc, are inter-dependent with actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical Governance to provide
a framework for ensuring that it is embedded, implemented and can be monitored in an
organisation. In developing this framework for Ramsay Health Care UK we have gone back to
the original Scally and Donaldson paper (1998) as we believe that it is a model that allows
coverage and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
NICE / NPSA guidance
Ramsay also complies with the recommendations contained in technology appraisals issued by
the National Institute for Health and Clinical Excellence (NICE) and Safety Alerts as issued by
the National Patient Safety Agency (NPSA).
Ramsay has systems in place for scrutinising all national clinical guidance and selecting those
that are applicable to our business and thereafter monitoring their implementation.
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
Pinehill 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:
A ‘live’ scenario set up in a patient bedroom with intentional faults, issues and concerns to be
identified by hospital staff. Approximately 65% of staff visited this training area, with varying
results. This will be repeated in 2012, and a comparison made as to lessons earned.
From surveys, it was apparent that patients did not observe staff cleansing of hands prior to
care delivery. Therefore extra training has been provided to raise awareness of staff so that
hands are cleansed where they can be easily observed. Our HAI rate indicates that hand
hygiene is scrupulously followed at all times.
We have also been completing a monthly hand cleansing audit on a monthly basis scoring an
average of 94%.
3.1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment Assessment
Team (PEAT) audits.
These assessments include rating of privacy and dignity, food and food service, access issues
such as signage, bathroom / toilet environments and overall cleanliness. In 2011 the results for
Pinehill Hospital were:
Environment – good (90.79%)
Food – good (83.61%)
Privacy and dignity – excellent (100%)
The catering team worked hard on last year’s result of ‘acceptable’ with a positive result, scoring
‘good’ this year.
Our infection control team has met with all housekeepers and delivered training on the
importance of high standard achievement, with the target being to score ‘excellent’ next year.
Pinehill staff have adopted a ‘can do, will do’ attitude and although achieving well, are
constantly striving for improvement.
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 and then the hospital teams which ensures we keep up to date with all safety
issues.
Our local Safety Committee has devolved departmental audits for completion on a quarterly
basis ensuring safety of staff and hospital visitors at all times.
3.2 Clinical effectiveness
Pinehill 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. Incident and near-miss reporting is
encouraged, to ensure effective learning in a no-blame culture. Ramsay are now adopting the
Riskman system to make reporting easier from all levels of staff.
3.2.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our services grow.
The majority of our patients undergo planned surgical procedures and so monitoring numbers of
patients that require a return to theatre for supplementary treatment is an important measure.
Every surgical intervention carries a risk of complication so some incidence of returns to theatre
is normal. The value of the measurement is to detect trends that emerge in relation to a specific
operation or specific surgical team. Ramsay’s rate of return is very low consistent with our track
record of successful clinical outcomes.
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.
As can be seen from the above graph our readmissions to hospital rate has significantly
reduced over the 12 month period as a response to staff development and awareness.
This is also as a result of proactivity in the screening of our patients prior to admission, with
anaesthetic assessment and referrals to other specialists as appropriate.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care are welcomed
and inform service development in various ways dependent on the type of experience (both
positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and behaviour –
letters and cards are displayed for staff to see in staff rooms and notice boards. Managers
ensure that positive feedback from patients is recognised and any individuals mentioned are
praised accordingly.
All negative feedback or suggestions for improvement are also fedback to the relevant staff
using direct feedback. All staff are aware of our complaints procedures should our patients be
at all less than 100% happy with any aspect of their care.
We are praised in the independent patient feedback system for treating our patients with
respect and dignity, attaining 100% satisfaction, and also for rapidly resolving any issues to the
individual’s satisfaction.
Patient experiences are fedback via the various methods below, and are regular agenda items
on Local Governance Committtees for discussion, trend analysis and further action where
necesary. Escalation and further reporting to Ramsay Corporate and DH bodies occurs as
required and according to Ramsay and DH policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
ƒ Patient satisfaction surveys
ƒ ‘We value your opinion’ leaflet
ƒ Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers whilst
visiting patients and Provider/CQC visit feedback.
ƒ Written feedback via letters/emails
ƒ Patient focus groups
ƒ PROMs surveys
ƒ Care pathways – patient are encouraged to read and participate in their plan of care
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 Pinehill 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%.
Pinehill’s index is 91.65% and rates in the top 2-3% of organisations.
Pinehill actively review these results as they become available and compile an action plan each
time which is shared with key staff members in order to establish improvement.
3.3.2 Patient Reported Outcome Measures (PROMs)
Pinehill hospital participates in the Department of Health’s PROMs surveys for hip and knee
surgery, hernias and varicose veins for NHS patients.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs surveys specifically
for private patients.
Website to access Pinehill Hospital PROMs scores:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1295
3.4 Pinehill Hospital Case Study
We at Pinehill identified that although our theatre team were competent in their roles, challenge
and enthusiasm was perhaps somewhat lacking. They knew what they were doing but lacked
the intimate knowledge of the rationale for their actions. Many had not received/attended update
sessions since attaining their original qualifications and had not received the encouragement to
further progress this.
Over this last year, training and professional development has been positively encouraged for
the already registered staff and we have also employed staff whose qualifications have slipped
due to non-practice working as a result of family commitments etc. These staff have been
employed as Health Support Workers, whilst receiving support from Pinehill to re-attain their
qualifications. This ensures a high level of expertise within the department whilst there is a
national shortage of registered staff in healthcare nationwide. We have in effect ‘grown our
own’. This also ensures a high level of commitment from staff to the unit and encourages others
to join due to the individualised personal and professional development programmes.
One of our senior physiotherapists was successful in gaining a scholarship funded by Ramsay
by submitting a paper around Women’s Health. She has gone on to achieve a PG Certificate in
Women’s Health Physiotherapy which will improve the quality of the Women’s Health service
through her increased skills and knowledge which she shares with colleagues, both
physiotherapists and consultants. She is available to advise patients and will be implementing a
Pregnancy Related Lower Back Pain service on her return from maternity leave.
Appendix 1
Services covered by this quality account
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Cardiology, Dermatology, Diabetes and
endocrinology, Ear, Nose and Throat
(ENT), Gastrointestinal, General medicine,
Genito urinary, Gynaecological,
Immunology, Nephrology, Neurology,
Neurophysiology, Ophthalmic, Orthopaedic
medicine, Pain management, Phototherapy
(PUVA), Podiatry, Psychiatry, Psychology,
Physiotherapy inc acupuncture,
Rheumatology, Sports medicine, Satellite
outpatient clinics, Urology
Colorectal, Cosmetics, Day and Inpatient
Surgery, Ear, Nose and Throat (ENT),
General Surgery, Gynaecological,
Maxillofacial, Ophthalmic, Orthopaedic,
Urology, Vascular
Peoples Needs Met for:
All adults 18 yrs and over
All children 3 yrs and over
All adults 18 yrs and over, and children 3 yrs and over excluding:
•
•
•
•
•
•
•
•
•
•
•
•
Diagnostic
and
screening
Audiology, Echo cardiography, GI
physiology, Health screening, Imaging
services, MRI/ CT, Obstetric, Phlebotomy,
Ultrasound, Urinary Screening and
Specimen collection
Termination of
Pregnancy
Surgical Termination of
Pregnancy
Patients with blood disorders (haemophilia, sickle cell,
thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA screen are
deferred until negative
Patients who are likely to need ventilatory support post
operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission to ITU post
surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild exertion e.g.
from kitchen to bathroom or dyspnoea at rest)
Poorly controlled asthma (needing oral steroids or has had
frequent hospital admissions within last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal activity e.g. 1
flight of stairs or angina at rest)
CVA in last 6 months
However, all patients will be individually assessed and we will only
exclude patients if we are unable to provide an appropriate and safe
clinical environment.
All adults 18 yrs and over
Children 3 years and above
All female adults aged 16 yrs and over
Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
A u d it P r o g r a m m e v 4 .0 2 0 1 1 /2 0 1 2
H o s p ita l N a m e :
P in e h ill
Im plem ented: Ju ly 2011
A uthors : R . S a unders / A . S han non / N . C arre / E . A nders on
F or re view : June 2012
U s e arro w s y m bol to loc a te required aud it
JU L
A na e s the tic S ta n d a r d s
M e d ic a l R e c o r d s
AU G
OC T
DEC
JAN
97%
9898% %
98
FEB
M AR
AP R
M AY
JU N
T raffic lig h t sco re
88%
91%
98%
98%
94%
63%
97%
96%
64%
98%
93%
N & H
87%
96%
C a r e P a th w a y s a n d V a r ia n c e
tr a c k in g
96%
C o n tr o lle d D r ug s
98%
69%
97%
98%
P r e s c r ib ing
99%
M e d ic ine s M a n a g e m e nt
R a d io lo g y
N OV
97%
C o ns e nt
D is c ha r g e
SEP
98%
96%
93%
100%
P h y s io the r a p y
98%
99%
95%
94%
98%
9 7%
96%
97%
96%
99%
9 2 .5 3 %
95%
95%
T he a tr e
In fe c tio n P r e v e ntio n a n d
C o ntr o l*
92%
In fe c tio n P r e v e ntio n a n d
C o n tr o l - E nv ir o nm e n ta l A u d it
94%
P VC C B
UCCB
96%
T r a ns fu s io n
94%
95%
Hand
h yg ie n e
100%
SSI
E n viro n
96%
C VC C B = C e n tra l Ve n o u s C a th e te r C a re B u n d le
S S I = S u rg ic a l S ite In fe c tio n
P VC C B = P e rip h e ra l Ve n o u s C a th e te r C a re B u n d le
P E AT = P a tie n t E n viro n m e n t Ac tio n Te a m
U C C B = U rin a ry C a th e te r C a re B u n d le
D e t P t = D e te rio ra tin g P a tie n t
N & H = N u tritio n a n d H yd ra tio n
C o p yrig h t © 2 011 R a m sa y H e a lth C a re U K
Page 30 UCCB
97%
100%
* Ke y:
Quality Account 2011/12 90%
91%
G re e n
100 %
Cool
Am be r
90 - 99 %
Am be r
80 - 89 %
Hot
Am be r
70 - 79 %
Re d
69% a n d u n d e r
Pinehill 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:
01462 422 822
www.pinehill-hospital.co.uk
Neurological Centres
Quality Account 2011/12 Page 31