Quality Account
2011/2012
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Rivers 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 2010/11 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
Quality Accounts 2011/12
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Welcome to Ramsay Health Care UK
Rivers Hospital is part of the Ramsay Health Care
Group
The Ramsay Health Care Group, was established in 1964 and has grown to become
a global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay
Health Care is one of the leading providers of independent hospital services in
England, with a network of 22 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the
NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of
NHS patient episodes of care each month working seamlessly with other healthcare
providers in the locality including GPs, PCTs and acute Trusts.
“Ramsay Health Care UK is committed to establishing an organisational
culture that puts the patient at the centre of everything we do. As Chief
Executive of Ramsay Health Care UK, I am passionate about ensuring that
high quality patient care is at the centre of what we do and how we operate all
our facilities. This relies not only on excellent medical and clinical leadership
in our hospitals but also upon our overall continuing commitment to drive year
on year improvement in clinical outcomes.
“As a long standing and major provider of healthcare services across the
world, Ramsay has a very strong track record as a safe and responsible
healthcare provider and we are proud to share our results. Delivering clinical
excellence depends on everyone in the organisation. It is not about reliance
on one person or a small group of people to be responsible and accountable
for our performance.”
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with every
year we set our targets higher, working on every aspect of our service to bring
a continuing stream of improvements into our facilities and services.
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2011/12
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Introduction to our Quality Account
This Quality Account is the Rivers Hospital 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 patients‟ 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.
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Part 1
1.1 Statement on quality from the General Manager
Mr Andy Haysman, General Manager,
Rivers Hospital
Ramsay Healthcare UK is committed to establishing an organizational 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.
Rivers 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 minimize 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 Rivers
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.
Quality Accounts 2011/12
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The Rivers 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 affect
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
Quality Accounts 2011/12
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Mr Andy Haysman
General Manager
Rivers Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr David McKiernan, Consultant ENT Surgeon MBBS FRCS, MAC Chair
Medical Advisory Committee Chair
Signature………………Mr D McKiernan…………………………………..
Date…………June 29th 2012……………..
Mr Richard Parsons, Regional Director East
Signature………………Richard Parsons…………………………………..
Date……………June 29th 2012…………..
Commissioner/PCT and other external bodies
PCT Commissioner
Signature……………See Section 2.2.7 Date…………………………
Signature…………………………………………………. Date…………………………
Quality Accounts 2011/12
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Welcome to Rivers hospital
The Rivers is a private hospital set in quiet landscaped grounds in
Sawbridgeworth, Hertfordshire. It is one of the largest hospitals within
Ramsay Health Care UK. It opened in March 1992, and has become popular
with patients from the Hertfordshire and Essex region. It is easily accessible
with free car parking.
The Rivers has 59 in patient bedrooms; all have en-suite bathrooms to ensure
patient comfort and privacy. Additionally there is a dedicated day case suite
with 9 bays, and a minor ops theatre. The hospital has four operating
theatres, which are well equipped with the latest surgical technology.
The out-patient department has 13 Consulting rooms and 3 private treatment
rooms, with a modern equipped physiotherapy department and gym, a well
equipped imaging department with x-ray, ultrasound, CT & MRI scanning
facilities, Digital Mammography and a DEXA scanning.
All 245 Consultants are subject to strict vetting procedures to ensure only
those with the appropriate experience and qualifications are granted
Practising Privileges and hence can offer treatment at Rivers Hospital.
The Staff at the Rivers are professional and friendly, and deliver high levels of
customer service. In 2010 the hospital won the Harlow and District Business
Awards for Customer Care and has also been successful in achieving Top 10
places in the Healthcare 100 Best Employer Awards (IPSOS Mori) over recent
years.
We provide fast, convenient, effective and high quality treatment for patients
of all ages (children over the age of 3 years as inpatients), whether medically
insured, self-pay, or NHS funded.
Patients can self refer for Vive Cosmetic Surgery consultation, and for
Physiotherapy services.
The Rivers offers a range of elective surgical, non-surgical and outpatient
treatments across the following specialities: Allergy Clinic, Bariatrics, Breast /Reconstructive surgery, Cardiology (Cardiothoracic Surgery at Orwell Suite), Colo-rectal surgery, Cosmetic surgery,
Dermatology, Diabetes/Endocrinology, Diagnostic Services, Dietician,
Ear, Nose and Throat, Endoscopy, Fertility services, Gastro-enterology,
General Medicine, General surgery, Gynaecology, Haematology, Health
Screening, Laparoscopic Surgery, Neurology, Neuro-Radiology, Oncology,
Quality Accounts 2011/12
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Ophthalmology, Oral and Maxillo-Facial Surgery, Orthopaedic Surgery,
Paediatric Services, Pain Medicine, Pharmacy, Physiotherapy, Plastic
Surgery, Private GP & Practice Nurse service, Psychiatry, Psychotherapy,
Rheumatology, Spinal Surgery , Urology including Brachytherapy, , Vascular,
Weight loss Clinics
The Hospital attracts referrals from sister hospitals within Ramsay Eastern
region as a specialized centre for services such as Brachytherapy (Prostate
Cancer), Chemotherapy services (Cancer), DEXA scanning (Osteoporosis),
Phototherapy (Skin conditions), and on site CT and MRI scanning (Diagnostic
Imaging).
The Rivers acts as a satellite for other centres to offer services through a hub
& spoke system. These include Fertility services (Bridge Fertility Centre) and
Cardio-thoracic surgery (Ramsay Orwell Suite) .
Last Year the Rivers admitted a total of 11642 Patients of these 5518 were
Private Patients (47.4%) and 6124 were NHS Patients ( 52.6 %).
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 Consultants.
Permanent hospital staff include Registered Nurses, Health Care Assistants,
Operating Department Practitioners, Physios, Pharmacists, Radiographers,
administrative staff, caterers, housekeepers and porters.
All clinical and support staff have the relevant training and skills to fulfill their
roles and this is an on going process. There is also a Rivers Hospital Staff
Bank which provides extra support and flexibility to the service where needed.
The Rivers works closely with local Primary Care Trusts in Hertfordshire and
West Essex, to support commissioning of healthcare services for the local
NHS population. The hospital also has close links with Princess Alexandra
NHS Trust (Harlow) and East and North Herts NHS Trust Hospitals (WGC
and Stevenage), including histopathology services and emergency transfer
provision.
The Rivers employs a GP liaison officer to ensure local GPs are well informed
about the services offered at the hospital.
Quality Accounts 2011/12
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The hospital also provides a programme of educational seminars for
healthcare professionals including specialist sessions and basic life support.
The Rivers is closely associated with the Helen Rollason Cancer Charity,
which has a Holistic therapy centre and offices within the hospital site.
The hospital supports local schools, charities and associations through
sponsorship and fund raising events throughout the year.
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Part 2
2.1 Quality priorities for 2012/2013
Plan for 2012/13
On an annual cycle Rivers Hospital develops an operational plan to set objectives for
the year ahead.
We have a clear commitment to our private patients as well as working in partnership
with the NHS ensuring that those services commissioned to us, result in safe, quality
treatment for all NHS patients whilst they are in our care. We constantly strive to
improve clinical safety and standards by a systematic process of governance
including audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the recommendations
from various hospital committees which represent all professional and management
levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2011/2012 (looking back)
Reflection on priorities 2011/2012
 A TDL Lab opened on site in March 2012 to serve Ramsay East Region.
BARS and POCT training were introduced in March 2012, to ensure higher
patient safety by the implementation of electronic and networked systems.
 Never Events – there were no “never events “during the year.
 Day Unit continued to treat patients efficiently to high standards of care. We
have continued to monitor this through a variety of methods such as patient /
consultant feedback, returns to theatre and re-admission rates.
 Benchmarking – we have continued to contribute to surveys such as PROMs,
TLF, NJR.
Quality Accounts 2011/12
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
We have continued to monitor our TLF patient satisfaction results, and other
patient feedback. We have endeavoured to ensure patients receive written
information on discharge and this remains an ongoing objective. See 3.3.1.
2.1.2 Clinical Priorities for 2012/13 (looking forward)
Patient safety
List of priorities
 Continue to maintain and improve standards of care and patient satisfaction
levels.
 Ensure robust systems in place to ensure full compliance with all training and
development activities including e-learning.
 Continue to work with TDL to ensure safe practice regarding blood transfusion
and pathology services. Ensure POCT and BARS training continues and is
cascaded.
 Introduction and implementation of RISKMAN, a replacement to our existing
Incident reporting system. Improvements anticipated including clearer
analysis of trends and more involvement at department level in incidents /
near miss handling.
 Introduction and implementation of Allocate, an electronic rostering system.
Improvements anticipated include more efficient allocation to staff to ensure
patients‟ needs are met by appropriately trained staff.
Pulse (Staff satisfaction) survey
In 2011/2012 a Staff Satisfaction survey was taken across the whole of
the organisation. Areas such as communication, leadership and personal
growth were explored. Rivers Hospital scored very well at 4.85, against a
Group average of 4.60. Results/actions have been shared with and
discussed by the teams.
Patient experience – informing patient choice
Patient satisfaction scores remain well over 90%, at 94.4% in Quarter 4 2011. Areas
for improvement in 2012/2013 are:
Written info about proposed treatment
Written post discharge advice
Receiving copies of letters sent between Consultants and GPs.
Quality Accounts 2011/12
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A small TLF working group was formed in 2011/2012 to identify the key areas for
improvement, to maintain existing positive responses, and to increase the response
rate, which rose from 76 responses in Q1 2011 to 99 in Q4 2011.
Our Patient Group has continued to meet successfully and other patient feedback
methods (eg. We Value Your Opinion leaflets) are also used to maintain and improve
standards.
Quality Accounts 2011/12
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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 Rivers Hospital provided and/or subcontracted 35 NHS services.
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 and their teams, 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
Agency Hours as % of Total Hours
% Staff Turnover
% Sickness
Total Lost Worked Days
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff Injuries
Patient
Formal Complaints per 1000 HPD's
Patient Satisfaction Score
Number of Significant Clinical Events
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
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2.2.2 Participation in clinical audit
During 1 April 2011 to 31st March 2012, Rivers Hospital participated in all national
clinical audits to which it was invited and was eligible. Nil returns were sometimes
submitted e.g. The Cardiac Arrest study.
National Clinical Audits for Quality Accounts 2011-2012
For information/reports on audits participated in please go to the following link:
http://www.hqip.org.uk/ncas-for-qa-introduction/
Name of Audit
Participation
Peri-and Neo-natal
N/A – no service
N/A to our Paed
service
As above
As above
As above
As above
As above
Children
Paediatric pneumonia (British Thoracic Society)
Paediatric asthma (British Thoracic Society)
Pain management (College of Emergency Medicine)
Childhood epilepsy (RCPH National Childhood Epilepsy Audit)
Paediatric intensive care (PICANet)
Paediatric cardiac surgery (NICOR Congenital Heart Disease
Audit)
Diabetes (RCPH National Paediatric Diabetes Audit)
Acute care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic Society)
Non invasive ventilation -adults (British Thoracic Society)
Pleural procedures (British Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
Severe sepsis & septic shock (College of Emergency Medicine)
Adult critical care (ICNARC CMPD)
Potential donor audit (NHS Blood & Transplant)
Seizure management (National Audit of Seizure Management)
Long term conditions
Diabetes (National Adult Diabetes Audit)
Heavy menstrual bleeding (RCOG National Audit of HMB)
Chronic pain (National Pain Audit)
Ulcerative colitis & Crohn's disease (UK IBD Audit)
Parkinson's disease (National Parkinson's Audit)
Adult asthma (British Thoracic Society)
Bronchiectasis (British Thoracic Society)
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Intra-thoracic transplantation (NHSBT UK Transplant Registry)
Liver transplantation (NHSBT UK Transplant Registry)
Coronary angioplasty (NICOR Adult cardiac interventions audit)
Peripheral vascular surgery (VSGBI Vascular Surgery Database)
% cases
submitted
As above
As above
N/a
n/a
n/a
n/a
Yes
n/a
n/a
n/a
n/a
Nil
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Yes
Yes
n/a
n/a
n/a
n/a
91%
Quality Accounts 2011/12
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Carotid interventions (Carotid Intervention Audit)
CABG and valvular surgery (Adult cardiac surgery audit)
Cardiovascular disease
Acute Myocardial Infarction & other ACS (MINAP)
Heart failure (Heart Failure Audit)
Acute stroke (SINAP)
Cardiac arrhythmia (Cardiac Rhythm Management Audit)
Renal disease
Renal replacement therapy (Renal Registry)
Renal transplantation (NHSBT UK Transplant Registry)
Cancer
Lung cancer (National Lung Cancer Audit)
Bowel cancer (National Bowel Cancer Audit Programme)
Head & neck cancer (DAHNO)
Oesophago-gastric cancer (National O-G Cancer Audit)
Trauma
Hip fracture (National Hip Fracture Database)
Severe trauma (Trauma Audit & Research Network)
Psychological conditions
Blood transfusion
Bedside transfusion (National Comparative Audit of Blood
Transfusion)
Medical use of blood (National Comparative Audit of Blood
Transfusion)
Health promotion
Risk factors (National Health Promotion in Hospitals Audit)
End of life
Care of dying in hospital (NCDAH)
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
N/A – no service
No –insufficient
numbers
No –insufficient
numbers
n/a
n/a
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National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Paediatrics
Participation
(NA, Yes, No)
% cases
submitted
NA
NA
Acute care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic
Society)
Non invasive ventilation (NIV) - adults (British Thoracic
Society)
Pleural procedures (British Thoracic Society)
Cardiac arrest (National Cardiac Arrest Audit)
Vital signs in majors (College of Emergency Medicine)
Adult critical care (Case Mix Programme)
Potential donor audit (NHS Blood & Transplant)
n/a
Long term conditions
n/a
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
yes
91%
yes
See
PROMS
section
Cardiothoracic transplantation (NHSBT UK Transplant
Registry)
Liver transplantation (NHSBT UK Transplant Registry)
Coronary angioplasty (NICOR Adult cardiac interventions audit)
Peripheral vascular surgery (VSGBI Vascular Surgery
Database)
Carotid interventions (Carotid Intervention Audit)
CABG and valvular surgery (Adult cardiac surgery audit)
n/a
Cardiovascular disease
n/a
Renal disease
n/a
Cancer
n/a
Trauma
n/a
Psychological conditions
n/a
Blood transfusion
O neg blood use (National Comparative Audit of Blood
Transfusion)
No –
Platelet use (National Comparative Audit of Blood Transfusion)
No –
n/a
n/a
n/a
Yes
n/a
n/a
n/a
nil
n/a
n/a
n/a
n/a
n/a
insufficient
numbers to
meet criteria
insufficient
Quality Accounts 2011/12
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numbers to
meet criteria
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. Further audits include paediatric care and cosmetics. The local Clinical
Governance Committee reviews audit results and recommends/supports appropriate action.
Actions have been identified to improve Audit Scores where necessary. E.g. Consent score
rose from 86% to 92% with a focus on 2nd stage consent. Some areas remained
consistently high 100% e.g. surgical site infection, hand hygiene.
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
A proportion of Rivers 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 in 2011/2012 were:
 Patient satisfaction
 Smoking cessation
 Global Trigger Tool
 VTE
Table 2 – Results
Final Recommendations
Fitzwilliam Hospital
Oaks Hospital
Pinehill Hospital
Rivers Hospital
Springfield Hospital
Goal 1
VTE
40
40
40
40
40
Goal 2
Pat Exp
20
20
20
20
20
Goal 3
GTT
20
20
20
20
20
Goal
4.2
smoke
7.5
7.5
5
7.5
7.5
Goal
4.3
smoke
5
7.5
7.5
5
7.5
Goal
4.4
smoke
Total %
5
5
5
5
5
97.5%
100.0%
97.5%
97.5%
100.0%
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Going forward measures will include:



VTE assessment
BMI
NHS Safety Thermometer
2.2.5 Statements from the Care Quality Commission (CQC)
Rivers 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
Rivers Hospital during 2011/2012.
In March 2012 an unannounced Inspection was undertaken of all UK sites
registered for Termination of Pregnancy. Rivers Hospital was found to be fully
compliant and received a positive report.
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2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your Data
Quality
Rivers 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.
Rivers Hospital was not subject to the Payment by Results Clinical Coding Audit
during 2011/2012 by the Audit Commission.
NHS Number and General Medical Practice Code Validity
Rivers 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 out patient care; and
0% for accident and emergency care (not undertaken at Ramsay hospitals).
the General Medical Practice Code 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:
99.90% 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
Rivers Hospital was not subject to a Payment by Results Clinical Coding audit during
2011/2012 by the Audit Commission.
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2.2.7 Stakeholders views on 2011/12 Quality Account
“31 May 2012
Mr Andy Haysman
Rivers Hospital
High Wych Road,
Sawbridgeworth,
Hertfordshire
CM21 0HH
Dear Andy
North Essex PCT response to Rivers Hospital (Ramsay Group) Quality Account for 2011 to
2012
This is the final year that Quality Accounts are being commented on by the Primary Care Trusts in
north Essex. The Rivers Hospital (Ramsay Group) is demonstrating, in your account that you work
hard to deliver quality care. You tell us that the hospital will constantly strive to improve the quality and
suitability of its services to patients. Your account reflects this aspiration. We are pleased that your
account indicates both the ways in which you have succeeded in delivering the aims you set out in
last year's account and where you need to undertake further work to continue to improve.
Your introductions gives a high level view of the services delivered at Rivers Hospital, its unique
aspects and some of the issues that you have been addressing internally which give readers of the
report an overview of that provision and your ethos.
You give a description of your participation in clinical audit, your achievement of a „Green‟ outcome of
the Information Governance Tool Kit assessment in a year when the expectations to achieve such an
outcome have risen. You are to be congratulated on these achievements.
Your Quality Targets for 2012 - 2012 are:






Maintain and improve standards of care and satisfaction
Ensure robust systems to ensure compliance with training and development activities
Safe practice in transfusions
Introduce RISKMAN (incident reporting system)
Introduce and implement Allocate (staffing system)
Patient Experience - improving Choice
We support your choice of priorities.
Quality Accounts 2011/12
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The PCT is commenting on a draft of your quality account, and as such cannot fully assure the data
that may be contained within the final version. However, the overall conclusion of the north Essex
PCT cluster is that the Rivers Hospital quality accounts for 2011 to 2012 provide an accurate and
balanced picture of key performance indicators for the reporting period.
Yours sincerely
Denise Hagel
Interim Director of Nursing
North Essex Cluster “
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Part 3: Review of quality performance 2011/2012
Statements of quality delivery
Monica Clarke, Matron
Introduction
“Our emphasis is on providing an environment and structure 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 2011/2012
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:
Quality Accounts 2011/12
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•
•
•
•
•
•
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
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3.1 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and in all performance respects, and certainly in regards to our track record for
patient safety.
Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns but more
routinely from tracking trends in performance indicators.
3.1.1 Infection prevention and control
Rivers Hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 5 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. We have
excellent links with the IPC team at the local Trust and these assist us in all our IPC
practices.
Programmes and activities within our hospital include:



Training (eg. Handwashing awareness), audits, campaigns.
Surveillance of all infections including the participation in hip/knee studies with
the Health Protection Agency.
Close monitoring of any infections including causes, trends and actions.
Quality Accounts 2011/12
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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 2012 the results for Rivers Hospital were:
Environment – good
Food – good
Privacy and dignity – excellent
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.
3.2 Clinical effectiveness
Rivers Hospital has a Clinical Governance team and committee that meets 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.
3.2.1 Return to theatre
Quality Accounts 2011/12
Page 26 of 37
Unexpected Returns To Theatre
20
18
16
14
12
10
8
6
4
2
0
09/10
10/11
11/12
Unplanned Returns To Theatre Rate
100.00 %
90.00 %
80.00 %
70.00 %
60.00 %
50.00 %
40.00 %
30.00 %
20.00 %
10.00 %
0.00 %
09/10
10/11
11/12
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 27 of 37
3.2.2 Readmission to hospital
Unplanned Readmissions
25
20
15
10
5
0
09/10
10/11
11/12
Unplanned Readmission Rate
100.00 %
90.00 %
80.00 %
70.00 %
60.00 %
50.00 %
40.00 %
30.00 %
20.00 %
10.00 %
0.00 %
09/10
10/11
11/12
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.
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 28 of 37
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour and kept on their file. Positive comments are shared widely via the HODs
team , in written format for sharing, with the patient‟s details anonymised. 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 shared with the
relevant staff. All staff are aware of our complaints procedures should our patients
be unhappy with any aspect of their care.
Patient experiences are fed back via the various methods below, and are regular
agenda items on Local Governance Committtees and HODs meetings 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:
 Patient satisfaction surveys
 „We value your opinion‟ leaflet
 Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
 Written feedback via letters/emails
 Patient focus group
 PROMs surveys
 Care pathways – patient are encouraged to read and participate in their plan of
care
3.3.1 Patient Satisfaction Surveys
In Q1 2012 97.8% of patients said that they would recommend Rivers to others.
During 2011 / 2012 we have continued to focus on areas for improvement such as
providing written information (failure rate reduced to 18.1% from 26.4%) and the
visibility of hand hygiene measures. (failure rate 3.2% reduced from 8.8%).
In the forthcoming year we will also aim to increase the number of patient receiving
copies of letter from hospital doctors to GPs by liaising with consultants and medical
secretaries (present rate 84.6%).
Our patient satisfaction surveys are managed by an independent company called
„The Leadership Factor„(TLF). They print and supply a set number of questionnaire
Quality Accounts 2011/12
Page 29 of 37
packs to our hospital each quarter which contain a self addressed envelop
addressed directly to TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also
separately for NHS and private patients). The results are available for patients to
view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel they
receive excellent quality of care and service in Rivers 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%.
With an overall satisfaction score of 94.5% in 2012, Rivers Hospital is rated in the
top 2-3% of organisations.
3.3.2 Patient Reported Outcome Measures (PROMs)
participates in the Department of Health‟s PROMs surveys for hip and
knee surgery, hernias and varicose veins for NHS patients.
Rivers Hospital
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs surveys
specifically for private patients.
To access Rivers Hospital PROMs scores:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1
295
Quality Accounts 2011/12
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Groin Hernia
Improvement in EQ-5D index score
0.13
0.12
0.11
0.10
0.09
0.08
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0.00
0.119
0.102
0.101
0.085
Ashtead Hospital
England
Mid Cheshire
Hospitals NHS
Foundation Trust
Rivers Hospital
Oxford Hip Score: Average Health Gain
Adjusted by Case Mix
30
25
20
15
10
5
19.8
19.7
18.4
19.2
0
Ashtead Hospital
England
Mid Cheshire Hospitals NHS Foundation
RiversTrust
Hospital
Quality Accounts 2011/12
Page 31 of 37
Oxford Hip Score: Average Health Gain
Unadjusted to Case Mix
25
20
19.7
19.5
18.6
England
Mid Cheshire
Hospitals NHS
Foundation Trust
Rivers Hospital
17.5
15
10
5
0
Ashtead Hospital
Oxford Knee Score: Average Health Gain
Unadjusted to Case Mix
20
17.0
15
18.4
14.9
14.0
England
Mid Cheshire
Hospitals NHS
Foundation Trust
10
5
0
Ashtead Hospital
Rivers Hospital
Quality Accounts 2011/12
Page 32 of 37
Oxford Knee Score: Average Health Gain
Adjusted by Case Mix
30
25
20
15
10
5
#N/A
14.9
16.9
13.8
Ashtead Hospital
England
Rivers Hospital
York Teaching
Hospital NHS
Foundation Trust
0
Quality Accounts 2011/12
Page 33 of 37
3.4 Rivers Hospital Case Study
IONOTOPHERESIS SERVICE
In December 2011 discussions with the local PCT and Dermatologists began, and led to
the setting up of an Iontopheresis (to reduce excessive sweating) service at Rivers
Hospital. Historically there was not such a service locally and patients needed to travel
some distance for treatment.
A Dermatology Nurse with training and previous experience in Iontopheresis agreed to set
up and run the service. Training sessions were arranged by external providers, and
well established treatment guidelines and protocols were reviewed and adopted.
The first patients were treated in March 2011. Each course of treatment consists of 7
sessions over a 4 week period.
Patients may be referred by a Dermatologist and funded by the PCT, or self funding/insured
patients. Initially 3-4 patients/month were booked and this number is expected to rise in
2012/2013.
Primary hyperhidrosis can have a significant impact on an individual‟s life, and therefore we
feel it is very important to be able to offer a Iontopheresis service locally.
Patients have reported an increase in the quality of their lives by giving them the confidence
to work, socialise and study. We are very pleased to be able to assist people in this
way.
Quality Accounts 2011/12
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Appendix 1
Services covered by this quality account
Regulated Activities – Rivers Hospital
Regulated Activities – Rivers Hospital
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Bariatrics, Breast care, Cardiology,
Clinical neuro physiology, Colorectal,
Continence care, Cosmetics,
Dermatology, Dietetics, Elderly care,
Endocrinology, Fertility,
Gastroenterology, General Medicine,
Haematology, Manual lymphatic
drainage, Medicine, Nephrology,
Neurology, Nurse led sclerotherapy,
Oncology, Ophthalmic, Orthoptics,
Orthopaedic, Out patient satellite
clinics, Paediatrics, Pain management,
Physiotherapy, Podiatry, Private GP
services, Prosthetics services,
Psychiatry (OPD only), Psychology,
Psychotherapy, Renal medicine,
Rheumatology, Sexual health, Speech
therapy, Sports medicine
Breast surgery, Brachytherapy,
Colorectal, Cosmetics inc laser, Day
and Inpatient Surgery, Dermatology,
Ear, Nose and Throat (ENT) inc laser,
Gastrointestinal, General surgery,
Gynaecology inc laser, Neurosurgery,
Ophthalmic inc laser, Oral
maxillofacial, Orthopaedic, Plastic
Surgery, Sentinel node biopsy,
Urological inc laser, Vascular
Peoples Needs Met for:
All adults 18 yrs and over
Children - 3 -12 yrs ambulatory and day surgery only. 12 yrs and above,
inpatients included.
Children 0-3 yrs, outpatients only.
All adults 18 yrs and over and children 3 yrs and above excluding:











Patients on renal dialysis
Patients with history of malignant hyperpyrexia
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
Patients with serious mental health illness
However, all patients will be individually assessed and we will only
exclude patients if we are unable to provide an appropriate and safe
clinical environment.
Diagnostic
and
screening
Termination of
Pregnancy
Allergy testing, Audiology, Aortic
aneurysm screening, CT (inc heart
scan), Dexa scanner, Echocardiology,
Endoscopy, GI physiology, Health
screening, Imaging services,
Mammography, MRI, Nerve conduction
and EMG, Neuroradiology, Nuchal
scans, Obstetric Ultrasound,
Pathology, PET and CT scanner,
Phlebotomy, Urinary Screening Aortic
aneurysm screening, and Specimen
collection, Urodynamics
Surgical Termination of
Pregnancy
Children - 3 yrs and above ambulatory and day surgery only. 12 yrs and
above, inpatients included.
All adults 18 yrs and over
All children 0-18 yrs, outpatients appointments only
All patients aged 16 yrs and over
Quality Accounts 2011/12
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2011/12
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Rivers 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:
01279 600282
www.rivers-hospital.co.uk
Neurological Centres
Quality Accounts 2011/12
Page 37 of 37