Quality
Account
2011/12
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Welcome to The Yorkshire Clinic
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
Appendix 3 – Glossary of Abbreviations
Quality Accounts 2011/12
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Welcome to Ramsay Health Care UK
The Yorkshire Clinic 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 117 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 38 acute hospitals and day surgery facilities.
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 on
average over 1,000 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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Welcome to The Yorkshire Clinic
The Yorkshire Clinic is a private hospital situated in the grounds of Cottingley Hall in
Bingley, West Yorkshire. The hospital offers care to patients with private medical
insurance, patients who wish to fund their own treatments and patient referred
through the NHS Patient Choice Scheme.
The hospital provides a full range of high quality services, these include, outpatient
consultation, outpatient procedures, investigations/diagnostics, surgery and follow up
care. During the last 12 months the hospital has treated 13,109 patients, 65.6% of
which were treated under the care of the NHS. All NHS patients treated at the
hospital must be over 18 years of age as defined by the Standard Acute Contract.
Currently, 215 specialist Consultants work from the facility and are supported by a
team of Nursing staff, split between 62 registered nurses plus 1 Ward Manager and 1
Out-Patient Department Manager, 23 Health Care Assistants, 41 support staff which
includes porters/hotel services/engineering plus 60 administration staff. There is
resident medical officer cover, 24 hours per day working alongside these teams. The
Senior Leadership team consists of a General Manager, Matron, Finance Manager
and Support Services Manager.
The hospital has built excellent working relationships with Bradford Teaching
Hospitals NHS Trust, Leeds Teaching Hospital NHS Trust and Airedale Foundation
Trust in order to deliver a joint approach to patient care delivery across the patient
economy.
Our GP Liaison Officer provides links to local General Practitioners to ensure that
their needs and expectations are managed and through these links referral
processes are developed in order to streamline processes.
The Yorkshire Clinic also works with local charities within the local community,
hosting events in their support. Our charity of choice this year was Bradford Cancer
Support.
Quality Accounts 2011/12
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Introduction to our Quality Account
This Quality Account is The Yorkshire Clinic’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.
Within this report the team at The Yorkshire Clinic have clearly identified that their
focus has remained constant on improving services for our patients, working with the
local commissioners to identify key health issues affecting the local community and
how the team can help to improve outcomes for all our patients.
Quality Accounts 2011/12
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Part 1
1.1 Statement on quality from the General
Manager
Mike Flatley, General Manager,
The Yorkshire Clinic
“The Yorkshire Clinic understands that you have a choice and is committed to
being the leading provider of healthcare services by delivering high quality care
and outcomes for patients.”
This is the second Quality Account to be submitted by The Yorkshire Clinic and
has been produced to demonstrate our commitment to measuring all feedback
from patients about their experience, clinical treatment and clinical outcomes. This
allows us to continually review, reflect and improve the patient’s journey.
We are aware that patients can be nervous about coming into hospital and
understand that providing reassurance is important to you the patient. This starts
with patient safety, which is our highest priority. To this end we recruit, induct and
train our team to the highest standard in all aspects of care.
The Yorkshire Clinic continually achieves consistent patient satisfaction scores of
over 98% for recommendation to others and for overall satisfaction. By analysing
the results throughout the year, we constantly seek ways to further improve the
patient experience.
The Yorkshire Clinic is committed to ensuring that patients are kept fully informed
about their treatment, which is also a significant factor associated with improving
treatment outcomes. We involve our patients in treatment decisions at the earliest
stage so that the options and benefits are fully discussed before patients consent
to treatment. Our medical and clinical teams recognise the importance of devoting
time to patient preparation for surgery, which not only reduces risk but also
improves patient understanding and confidence, reduces anxiety, improves rates
of recovery and shortens lengths of hospital stay.
Whilst patient feedback and involvement is extremely important to us, we also rely
heavily on other measures of safety and clinical effectiveness which we use to
satisfy ourselves that treatment is evidence-based and delivered by appropriately
qualified and experienced doctors, nurses and other key healthcare professionals.
Examples of these are detailed in this Quality Account.
The Yorkshire Clinic is accustomed to the disciplines of regulatory and contractual
requirements to assure healthcare commissioners of our clinical performance and
to report complaints and serious incidents to regulators and commissioners. We
also maintain a Risk Register and systematically review specific actions to
achieve risk reduction.
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.
Mike Flatley
General Manager
The Yorkshire Clinic
Ramsay Health Care UK
This report has been reviewed and approved by:
Professor Peter O’Donovan – Medical Advisory Committee Chair
Mr James Halstead - Clinical Governance Chair
Mr Stefan Andrejczuk – Regional Director North
Quality Accounts 2011/12
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Part 2
2.1 Quality priorities for 2011/2012
Plan for 2011/12
On an annual cycle, the Yorkshire Clinic develops an operational plan to set
objectives for the year ahead. The main focus for the coming year is to ensure that
the patient is at the centre of everything we do.
We have a clear commitment to our patients and work in partnership with the NHS,
ensuring that those services commissioned to us result in safe, quality treatment for
all 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 on-going at any one time. The
priorities are determined by the hospital’s Senior Management Team, taking into
account patient feedback, audit results, national guidance, and the recommendations
from various hospital committees which represent all professional and management
levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 Setting clinical priorities for 2012 - 2013
•
Bar coding for patient identity bands – this priority did not progress last year
as Ramsay Health Care only received the final notification from the Information
Standards Board in November 2011. The national standard specifies that this
needs to be in place by October 2013 and that there is a plan in place to
provide bar codes on LaserBands by this date. The Yorkshire Clinic already
electronically prints all patient identity bands as per the NPSA ‘Standardising
Wrist Bands Alert’ issued in 2007.
•
Safer Surgery Checklists – The WHO safe surgery checklist is are in use for
all surgical procedures including cataract treatments and radiological
interventional procedures. This will continue to be a clinical priority and will be
audited regularly to identify any variance from the Ramsay policy.
•
Cleanliness - Environmental audits will continue to be undertaken quarterly as
per Ramsay national audit programme and the Yorkshire Clinic, maintaining
the improvement to date. The hospital wide cleaning matrix will continue
,informing staff what needs cleaning when, with what and by whom. The
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‘Green label’ system is to remain, clearly evidencing to patients when
equipment has been cleaned by indicating the cleaning date and the signature
of the person who cleaned it. The Patient Environment Action Team (PEAT)
audits are planned to continue annually with an external validator and patient
representation.
•
The Yorkshire Clinic Endoscopy Suite will continue to participate in the Global
Rating Score audit system (GRS) and are planning to achieve Joint Advisory
Group (JAG) accreditation, having successfully completed our second census.
The competency skilled endoscopy team are supporting the development of
opening evening and weekend clinics in addition to a one stop endoscopy
service.
•
As part of Ramsay’s National Project for Ambulatory Day Care services The
Yorkshire Clinic plan to;
1. Incorporate specialist nurses from Cardiology and endoscopy to preassess patients from those specialties which will enhance the patient
education and assessment process.
2. In order to facilitate the ambulatory process we will continue to place
ambulatory day care patients first on operating lists or, as clinically
indicated. All of our day care procedures requiring local anaesthetic will be
reviewed to convert to outpatient attendances to support earlier discharge
from hospital where appropriate.
3. The Yorkshire Clinic will continue to stagger admission times to improve
and individualise the patient experience, reducing the waiting and fasting
time from admission to procedure.
4. Nurse led discharge services will continue to operate within our Ambulatory
Units.
5. On discharge, patients are routinely provided with written information and
contact details should they have any post operative problems. All
ambulatory patients receive a post discharge phone call within 48 hrs of
admission and there is a plan to extend this later in the year to include
patients staying for longer periods.
•
Releasing time to care
Following a Ramsay training programme in Spring 2011, The Yorkshire Clinic
commenced the “Productive Ward Project”. The foundation modules have
been completed and the “process modules” are planned to be completed in the
coming year.
2.1.2 Clinical Priorities for 2012/13
Patient Safety
1. Falls – To maximize patient safety our routine practice is that all patients are
asked to complete a medical questionnaire; this is assessed by the Preoperative Assessment Team to identify any potential risks prior to admission.
On admission a “risk of falls assessment” is performed for every patient by the
admitting nurse, this is reviewed daily and care altered accordingly.
Quality Accounts 2011/12
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Information for patients on how to minimize the risk of falls following surgery/
procedures is available in the patient information folder in every room. Any
slip, trip or fall is reported through our robust Risk Management Committee
identifying any trends, formulating and implementing action plans across the
hospital to help improve patient safety.
Slips, trips and falls recorded/reported during 2009 totalled 21, during 2010 – 7
and during 2011 - 18. Actions have been put in place to address the increase
in 2011, namely;
•
•
•
Further staff training in risk assessment of patients specifically related
to movement and sensation of all aspects affected limbs after surgery.
Patient manoeuvres post surgery are undertaken only following risk
assessment with two staff members of staff present.
Competency training provided by physiotherapists for all nurses &
Health care assistants in specific risk assessment relating to the effects
of regional anaesthesia.
2. ‘Never Events’
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
The core list of “never events” includes:
•
•
•
•
•
•
•
•
•
Wrong route administration of chemotherapy
Misplaced naso or orogastric tube not detected prior to use
Retained instrument post-operation
Intravenous administration of mis-selected concentrated
potassium chloride
Wrong site surgery
Inpatient suicide using non-collapsible rails
Escape from within the secure perimeter of medium or high
secure mental health services by patients who are transferred
prisoners ( Not applicable to the Yorkshire Clinic as we do not
provide mental health services)
In-hospital maternal death from post-partum haemorrhage after
elective caesarean section ( Not applicable to the Yorkshire
Clinic as we do not provide maternity services )
Wrong route administration of Chemotherapy
The Yorkshire Clinic has patient specific chemotherapy prescription
charts which clearly define route of administration. The chemotherapy is
checked by two senior staff members prior to administration by our
Oncology Nurse Specialist. There have been no incidents or concerns
in relation to wrong route administration of chemotherapy
•
Misplaced naso or orgastric tube not detected prior to use:
Quality Accounts 2011/12
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There have been no incidents or concerns in relation to this at The
Yorkshire Clinic. Ramsay policy is based on the NPSA/2011/PSA002
Alert. Our standard practice is that pH testing is used as the first line
test method and X-ray is used only as a second line test when no
aspirate could be obtained or pH indicator paper has failed to confirm
the position of the nasogastric tube in addition to when the position of
the tube should be checked.
•
Retained instrument post-operation
The WHO safer surgery checklist plus the surgical count procedure
including all swabs, needles and instruments is used routinely during
surgery to eliminate this risk and is included as standard in the care
record. Unfortunately, there was one never event this year, where a
surgical swab was left in an external orifice following a routine surgical
procedure. A full investigation was undertaken and the root cause was
lack of focus on the swab count. Appropriate action was taken to assist
the team to learn from this incident, and increased frequency of
auditing of this part of the patient journey. The members of staff
involved in the incident underwent re-training, supervision and
mentorship, where their competency was reassessed and confirmed to
be at the appropriate level to practice. The patient was unharmed by
the incident and made a full and speedy recovery
•
Intravenous administration of mis-selected concentrated
potassium chloride
Ramsay and The Yorkshire Clinic practice is that concentrated
intravenous potassium is only stocked in Hospitals with Intensive Care
Units. We do not provide this service at the moment therefore do not
stock concentrated potassium chloride. In hospitals that provide
intensive care, concentrated potassium is stored within the Pharmacy
department under controlled medicine processes. It is ordered,
recorded and prescribed as a controlled medicine.
•
Wrong Site Surgery
The Yorkshire Clinic continues, as standard practice to use the World
Health Organisation (WHO) recommendations for Safer Surgery
checklist. The checklist is included as standard in the care
records/pathways for all patients undergoing surgery. Unfortunately
there was one never event incident this year where surgery was
commenced on the wrong site in February this year. Fortunately the
mistake was identified at skin incision without progression to a surgical
procedure on the wrong site. The patient made a full and speedy
recovery. This was fully investigated and the root cause was a failure to
mark the site prior to the patient leaving the ward, and incomplete
checklist completion on the ward and in theatre. Actions taken to
prevent recurrence include a change in the local process, in that
patients do not leave the ward until the site is marked, a local operating
procedure has been developed for this and a local additional audit is
Quality Accounts 2011/12
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now in place which focuses specifically on the detailed elements of the
safer surgery checklist and marking of the operation site.
•
Inpatient suicide using non-collapsible rails
There have been no incidents of this nature at the Yorkshire Clinic. The
Yorkshire Clinic has a Slips, trips and falls prevention policy and a bed
rails risk assessment checklist which is implemented where necessary.
3. VTE risk assessment (venous thrombo-embolism)
The Yorkshire Clinic carry out a VTE risk assessment on all admitted surgical
patients as per Ramsay Policy No CM001 and adheres to National Institute for
Clinical Excellence (NICE) Guidance 2010. All our pre-assessment staff have
completed VTE competency assessment via Department of Health on line
assessment tool and the majority of ward based nurses completed this
competency package in 2011.
From 1 April 2011 The Yorkshire Clinic entered into a contract for the provision
of NHS services through the Commissioning for Quality & Innovation Payment
Framework (CQUINs). Payment is conditional on achieving quality
improvement and innovation goals, this includes VTE risk assessment.
Compliance is audited through a robust corporate and local audit programme
and results/action plans reviewed through Clinical Governance. Compliance
results are benchmarked through the National Statistics at
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati
onsStatistics/DH_122283
4. Infection Control
The Yorkshire Clinic understands that Infection Control is a core part of an
effective risk management programme, aiming to improve the quality of patient
care and the occupational health of staff, in addition to the clinical need to
prevent Healthcare Associated Infections (HAI), and protect patients from
harm. The Yorkshire Clinic infection control processes are coordinated and
lead by an experienced Registered nurse who has undergone further training
in this field. The Yorkshire Clinic has regular Infection Prevention Committee
meetings and educational events, attended by a local Consultant
Microbiologist who provides the hospital with infection prevention advice and
guidance in conjunction with Ramsay infection prevention policies and
procedures. Our infection control lead nurse spends one day a month with the
infection control link ward based nurse to plan training schedules and infection
control promotion throughout the hospital
A comprehensive infection control audit programme has been maintained
throughout 2011/2012.
Quality Accounts 2011/12
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Audits undertaken and averaged scores were: PEAT
Hand hygiene
Environment cleanliness
Surgical site infection
Central venous catheter care
Peripheral venous catheter care
Urinary catheter care
96 %
98%
98%
100%
96%
93%
99%
Action plans have been compiled to address issues raised in all the above
audits. Issues arising from the PEAT and environmental audits were in
relation to the decor and will be addressed as part of the Yorkshire Clinic’s
refurbishment programme in 2012. Scores obtained in the peripheral and
central venous catheter audits related to inconsistency in effective hand
hygiene practice and our most recent audit in May 2012 indicated 100%. Our
aim is to maintain this high standard of practice through regular staff training
and updates.
The Yorkshire Clinic has successfully managed to implement an infection
control initiative called ‘Aseptic Non-Touch Technique’ (ANTT). ANTT is a
framework for standardising practice where patients could be at risk of getting
an infection. It can be applied to a range of practice including wound care, the
giving of intravenous medicines and many other invasive procedures. This
involves reinforcing the 'best-practice' methods of clinical procedures which
will help to minimise the spread of infection.
The Yorkshire Clinic regularly audits surgical site infections across surgical
specialties using the Department of Health (2010) High impact Intervention
care bundle tool, to prevent surgical site infection. This audit focuses on the
pre-operative and peri-operative practice. The audit results during 2010 and
2011 were 100% compliance.
ANTT Launch Day was held in November 2011, the day included practical
demonstrations and a theoretical DVD which re-enforces ‘good hand hygiene’
along with ‘best practice’ for intravenous therapy.
Following their training sessions, staff are individually competency assessed to
determine levels of knowledge and understanding. Training continues until all
staff are successfully proficient to undertake the ANTT procedure
independently.
5. Real time incident reporting – The Yorkshire Clinic strives to report any
incidents in real time through the Risk Information Management System
(RIMS). Every clinical incident is promptly reviewed by Matron and an
investigation process and root cause analysis undertaken.
The risk information management system immediately reports any incident
into the Corporate Risk Management Team allowing the identification of trends
at the Yorkshire Clinic and throughout the Ramsay organisation. Locally all
incidents are reported through Risk Management and Clinical Governance
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groups, learnings and action plans developed and implemented at a local level
to improve safety.
Other National reporting mechanisms e.g. MHRA; CQC; local NHS network
are used as required following specific incidents alerting nationally recognised
organisations of identified risks.
6. National Joint Registry – The Yorkshire Clinic participates in the National
Joint Registry audit programme (NJR). Patients undergoing hip or knee
replacement surgery are asked to consent to their information being placed
upon the NJR including details of their prosthesis. The NJR provide a quarterly
report to the Hospital regarding compliance.
7.
Staff satisfaction – In 2011 Ramsay staff undertook an anonymous survey to
obtain feedback on how Ramsay Health Care rates as an employer and to
compare our company to other similar companies. The survey was organised
by Best Companies who specialize in staff surveys and building workplace
engagement. Each Ramsay location was asked to create and publish a 90
day action plan for this to be viewed locally. The Yorkshire Clinic/The Lodge
scored 4.3 out of a maximum of 7. The Ramsay Health Care average was
4.60 out of 7.
Ramsay electronic on line learning training courses were introduced in 2010
and can be accessed easily by all staff, either at home or at work. Training
compliance is an agenda on all departmental team meetings.
8. Acute Care Competencies / Vulnerable Adult training – This ensures that
our patients are safe and being cared for by competent knowledgeable staff
who will not cause any harm. The Yorkshire Clinic staff complete annual
mandatory training programmes in vulnerable adult training, and an additional
full day training programme specifically aimed at Adult Protection provided by
the local Safeguarding Adults Board. The focus initially is for clinical staff but
non-clinical staff will also be required to undergo this training. A flow chart has
now been developed and is displayed in each department which provides
quick access information for staff to know who to contact or what to do if they
have concerns regarding adult abuse issues.
Clinical Effectiveness
1. Ambulatory Day Care – better outcomes and improving patient
experience –
Ambulatory Care (or Day Surgery Care) is the admission of selected patients
(both medical and surgical) to hospital for a planned procedure, returning
home the same day i.e. the patient does not incur an overnight stay. Over
recent years, partly due to medical advances the number of day surgery
patients has increased compared to those requiring in-patient care. In 2011
the percentage of day surgery patients we treated was 84.5%.
In addition the Yorkshire Clinic has reviewed the procedures it performs as
day cases under local anaesthetic, and where appropriate has converted
Quality Accounts 2011/12
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these procedures to outpatient attendances to promote an earlier discharge
from hospital.
At the Yorkshire Clinic we aim to ensure that 100% of our Ambulatory Day
Care patients will be treated in one of our ambulatory care facilities. In order
to achieve this The Yorkshire Clinic provides patients with a more efficient
pathway through the hospital. We have a dedicated day surgery facility that is
separate from our in-patient facility, best practice has shown that this improves
waiting times and recovery periods are reduced. We monitor the ambulatory
day care experience through our patient satisfaction surveys.
2. Group pre-operative assessments for major joint replacements – The
Yorkshire Clinic hold pre-operative group physiotherapy sessions for patients
who are coming into hospital for joint replacements; this gives information in an
environment which encourages group interaction, discussion and questioning.
The Yorkshire Clinic is taking part in the Ramsay pilot scheme to further
enhance the pre-operative assessment for our patients and this is proving
beneficial.
3. Improve National Benchmarking It was recognised that we needed more transparency between ourselves
and other independent sector providers/the NHS in order to monitor and
improve our services. This is even more important now we are working in
partnership with the NHS, e.g. benchmarking in the following areas:
•
•
•
•
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). The Hellenic project is the Independent Healthcare
Advisory Services (HAS) and NHS Partners network in partnership with
Dr Foster project.
Venous Thrombus Embolism (VTE) risk assessment compliance
Benchmarking through the national stats website. Link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Pu
blicationsStatistics/DH_122283
Patient Reported Outcome Measures (PROMS) results
Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1
937&category
Patient satisfaction figures
Using CQUIN indicators common to both NHS survey and our own
Ramsay Healthcare ‘The Leadership Factor’ survey. The Yorkshire
Clinic asks all patients to complete a ‘We Value Your Opinion’ leaflet to
enable us to collate patient opinion and act immediately upon any
concerns.
Quality Accounts 2011/12
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As a direct result of the comments received from the ‘We Value Your
Opinion’ questionnaires the following are some examples of how we
have improved care:
•
•
•
•
Our Hotel Services Manager and Chef regularly visit patients
following admission to discuss and receive feedback on the
quality of food and the options available.
Our Facilities Manager is currently coordinating a full
refurbishment programme of patient areas.
Additional parking permits have now been made available for
patients to use an adjacent car park behind Cottingley Hall
Nursing Home in response to feedback regarding insufficient
parking spaces.
Installation of new televisions in all patient rooms following
reports of poor TV reception.
4. 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. This initiative asks for staff
suggestions for ways in which they could improve the hospital environment and
processes empowering them to make changes essential to give them more
time to care.
The Yorkshire Clinic will continue to complete this initiative during 2012 /2013
having successfully completed the first 2 modules, “knowing how we are doing”
and “the well organised ward”. Actions taken for improvement included, audit
and monitoring of theatre list start and finish times and altering these where
possible to support earlier discharge and re-organisation of storage facilities, to
locate items near areas of use and labelling for easier identification.
5. Improved patient information
It was recognised from our patient satisfaction survey results that our patients
felt they were not always receiving adequate written information. This is
important as even though we always strive to tell our patients everything they
need to know pre and post-admission by assessing their understanding, this
varies for each individual person. According to survey results in Q4 2010 to
Q1 2011 our discharge information satisfaction was 90.5%. In response to this
we reviewed all our documentation and advice given to patients on discharge
and our most recent survey results showed a significant improvement to 98%.
Patient experience – informing patient choice
1. Increasing the use of Patient Reported Outcomes Studies (PROMs) – The
Yorkshire Clinic routinely issues the National PROMS questionnaires to
patients undergoing hip, knee, hernias, varicose vein and cataract surgery
Quality Accounts 2011/12
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(PROMs for cataract surgery is a local PROM to the Yorkshire Clinic). These
are used to gain a better understanding of treatment outcomes from a patient
point of view. Compliance for PROMS is above the national average at The
Yorkshire Clinic. There are no outcome measures for patients treated at The
Yorkshire Clinic as the PROMS team are unable to filter our data from that of
our local Trusts. Consultants can access this information within their own
Trusts for all patients, including those treated at The Yorkshire Clinic.
2. Patient Satisfaction survey – An area for development identified from our
patient satisfaction survey was that patients were not always aware of staff
hand washing. A pro-active approach was implemented to ensure patients
were either able to view staff washing their hands or were informed that this
was to happen. Staff were also provided with pocket hand-gel to further
enhance the awareness of the importance of hand hygiene. This resulted in an
improvement in patient recognition from 95% in Q4 2010 to 100% Q1 2011.
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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 Yorkshire Clinic contracted to deliver 17 NHS services.
The Yorkshire Clinic has reviewed all the data available to them on the quality of care
in all of these NHS services.
The income generated by the NHS services reviewed from the 1st April 2011 to the
31st March 2012 represents 47% of the total income generated from the provision of
NHS services by the Yorkshire Clinic.
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
Total Health care Assistants (wte)
Total Registered Nurses
Total Nursing Hours ( RN & HCA)
HCA hours as a % of Total Nursing Hours
Rolling Sickness Absence
Rolling Employee Turnover
Number of Significant Staff Injuries
2009/2010
18.16
60.23
78.39
23.16
2010/2011
21.92
60.34
82.26
26.64
2011/2012
17.59
56.72
74.31
26.67%
4.29%
9.3%
4.84%
4.53%
5.4%
4.7 %
1 (riddor reportable) 1 (riddor reportable )
Patient
Formal complaints:
The Yorkshire Clinic received 53 complaints from 1 April 2011 to 31 March 2012 . (
which was 0.07% of patients treated at the Yorkshire Clinic). 15 of these were well
founded. None of the complaints required notification to the Care Quality
Commission. There were no common themes or significant concerns arising from
the complaints received. Our annual complaints report is available on request from
the Yorkshire Clinic.
Quality Accounts 2011/12
Page 18 of 40
Patient Satisfaction Scores:
98% of patients treated at the Yorkshire Clinic from 1 April 2011 to 31 March 2012
would recommend the Yorkshire Clinic to others, and scored their overall satisfaction
as 98% ( as excellent, very good and good)
0.2% of patients were readmitted during 2011/12 for further treatment or care
There were no EMSA (Eliminating Mixed Sex Accommodation) breaches
Quality
A comprehensive Health, Safety and Facilities audit was carried out at the Yorkshire
Clinic by the Estates Manager at the end of 2011. This internal audit returned a score
of 90% compliance, with the key issues being related to an incomplete hospital
refurbishment plan, and some building system drawings being out of date following
alterations. These were identified in an action plan and have now been addressed.
2.2.2 Participation in Clinical Audit
During 1 April 2011 to 31 March 2012, 5 national clinical audits covered NHS
services that The Yorkshire Clinic provides.
The national clinical audits 5/51 (9.8%) and 1/1 (100%) national confidential enquiries
(NCEPOD )that the Yorkshire Clinic was eligible to participate in during 1 April 2011
to 31March 2012 are as follows: National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Participatio
n (NA, No,
Yes)
Paediatrics.
NA
Acute Care
Emergency use of oxygen (British Thoracic
Society)
Adult community acquired pneumonia (British
Thoracic Society)
Non invasive Ventilation (British Thoracic
Society)
% cases
submitted
Insufficient numbers to
audit in specific audit topics
NA
NA
NA
Pleural procedures (British Thoracic Society)
NA
Cardiac Arrest (National Cardiac Arrest Audit)
No
Vital Signs in majors (College of Emergency
medicine)
NA
Adult Critical Care (Case mix programme)
NA
Potential Donor Audit (NHS Blood &
Transplant
NA
Long Term Conditions
NA
Comments
0%
Insufficient numbers to
audit in audit topic
Insufficient numbers to
audit in audit topic
Do not currently offer this
service
Do not currently offer this
service
1 respiratory arrest and 1
unconfirmed cardiac arrest
therefore insufficient data
Do not provide emergency
services
Do not currently provide
critical care services
Do not provide transplant
services
Insufficient numbers to
audit in audit topic
Quality Accounts 2011/12
Page 19 of 40
Elective Procedures
Hip,knee and ankle replacements (National
Joint Registry)
Elective Surgery (National PROMs
programme)
Cardiothoracic transplantation (NHSBT Uk
Transplant)
Liver Transplantation (NHSBT Uk Transplant)
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 )
Cardiovascular Disease
Renal Disease
Cancer
Trauma
Psychological Conditions
Blood Transfusion
O negative blood use (National Comparative
Audit of blood Transfusion )
Platelet use ( National Comparative audit of
Blood transfusion 0
Yes
Yes
NA
NA
No
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
100%
100%
Do not provide this service
Do not provide this service
Do not provide this service
Do not provide this service
Do not provide this service
Do not provide this service
Do not provide this service
Do not provide this service
Do not provide this service
Do not provide this service
Do not provide this service
Insufficient numbers of
blood usage to enter audit
Insufficient number of
platelet use to enter audit
The reports of 5 national clinical audits from 1 April 2011 to 31 March 2012 were
reviewed by the Clinical Governance Committee at The Yorkshire Clinic.
Local Audits
The Yorkshire Clinic participates in the Ramsay Corporate Audit programme (the
schedule can be found in appendix 2) and also carries out a number of local clinical
audits all of which go through the Clinical Governance Committee and actions taken
to improve the quality of the healthcare provided:•
•
•
•
Infection Prevention Audits: Corporate audit programme continues
throughout the year, audit tools are based upon the Department of Health
Saving lives tools. The environmental audit was amended in 2011 to provide
visible guidance for the correct use of cleaning products. Isolation, peripheral
venous catheter care, surgical site infection, and urinary catheter care audits
were also updated to meet new national guidance. Infection prevention audits
have shown improvements in all areas throughout the year.
EWS – early warning score used by clinical staff to provide an advanced
warning of a potential deterioration in a patient’s condition.
Cardiac Arrest Scenario, which involves an unannounced artificial cardiac
arrest situation using a resuscitation dummy. The routine emergency process
occurs in the hospital and a resuscitation lead assesses the care and treatment
provided and learning outcomes are shared and improvements made where
appropriate.
Waterlow audit, is an audit to assess the care and risk assessment that
occurs to prevent the occurrence of pressure areas’
Quality Accounts 2011/12
Page 20 of 40
•
•
•
•
•
•
•
•
Pre-operative assessment documentation audit assesses the
documentation completed by the pre-assessment team at the time of the preassessment appointment. This assesses and monitors that a thorough preassessment occurs and the appropriate care is implemented in response to
potential risks posed pre- surgery.
Critical Care Trolley Audit: Is a regular routine audit to check that the
equipment contained is ready for immediate use and the teams are familiar
with the trolley contents.
WHO – surgical safety check Audit: This is incorporated into the care record
for every patient and there is an additional audit to monitor compliance with the
checklist. The audit assesses that clinical staff are routinely checking that the
correct patient, receives the correct surgery on the correct site, and the patient
has been appropriately prepared and consented for the procedure planned.
VTE assessment: Veno-thrombus embolism assessment. This assessment
is routinely included in every patient’s care record and the audit checks that
this is being completed by the clinical team and the appropriate steps in care
and treatment occurs, if a risk is identified.
Oxygen Prescribing: This audit assesses that wherever oxygen is required
that this is prescribed by a doctor.
Consent Audit: Assesses that patients are provided with sufficient information
to provide informed consent and that a 2 stage consent process occurs and
performed by the appropriate level of doctor.
Nutrition & Hydration: This audit assesses how well the clinical team assess
and document the nutritional status and needs of our patients.
Clinical Variances & Outcomes: All clinical variances indentified where there
is a variance from the norm, i.e. extended length of stay, readmission to
hospital or return to the operating theatre are documented and reported, to
support a review and discussion in regular clinical governance forums and
Medical advisory committees. These forums which are held by a group of
experienced clinicians, support the discussion of trends and concerns relating
to practice in general or the practice of an individual practitioner and advice
and changes in practice can be implemented.
2.2.3 Participation in Research
Research is a core part of the NHS, enabling the NHS to improve the current and
future health of the people it serves. ‘Clinical research’ means research that had
received a favourable opinion from a research ethics committee within the NRES
information about clinical research involving patients is kept routinely as part of a
patient’s records.
Ramsay Healthcare does encourage participation in research and there is a clear
policy and framework to support and direct this, however the Yorkshire Clinic has not
received any applications for clinical research in 2011 – 2012 and did not treat any
patients who were participating in any clinical research studies.
Quality Accounts 2011/12
Page 21 of 40
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
The CQUIN payment framework aims to support the cultural shift towards making
quality the organising principle of NHS services, by embedding quality at the heart of
commissioner /provider discussions. It is an important lever, supplementing Quality
Accounts, to ensure that local quality improvement priorities are discussed and
agreed at board level within and between organisations. It makes a provider’s income
dependent on locally agreed quality and innovation goals.
The CQUIN targets agreed between the Yorkshire Clinic and Bradford, Airedale PCT
for 2012/2013 are explained in the table below;
Indicator
Number
Indicator Name Quality Domain
National Indicators
1
Venous thromboSafety Clinical
emolism (VTE)
Effectiveness
risk assessment
2
Composite
Clinical
indicator on
Effectiveness
responsiveness to
personal needs
3
% of all adult in patients who have had a VTE risk
assessment on admission to hospital using the
clinical criteria of the national tool
The indicator is a composite, calculated from 5
survey questions. Each describes a different
element of the overarching patient experience
theme "responsiveness to personal needs of
patients". The elements are:
• Involvement in decisions about treatment/care
• Hospital staff being available to talk about
worries/concerns;
• Privacy when discussing condition/treatment;
• Being informed about side effects of
medication;
• Being informed who to contact if worried
about condition after leaving hospital.
This CQUIN incentivises the collection of data on
patient harm using the NHS Safety Thermometer
harm measurement instrument (developed as part
of the QIPP Safe Care national work stream) to
survey all relevant patients in all relevant NHS
providers in England on a monthly basis
5%
Technology
improvement
Use of electronic communication to provide
information to GPs following inpatient/diagnostic
and outpatient attendance
20%
Technology
improvement
Electronic diagnostic reporting following
radiological examination reported to GP within 2
working days of radiological investigation
Ensure high quality and safety for patients
undergoing endoscopy procedure and maintain a
high level of patient satisfaction and comfort
10%
Transition and Implementation of alternative
solutions to outpatient(OP) follow ups, reducing
'face to face' contacts
20%
Improve collection
of data in relation
to pressure
ulcers, falls,
urinary tract
infection in those
with a catheter,
and VTE
Local Indicators
4.4
E-communication
with GPs
following Day
case/Diagnostic
and outpatient
attendance
4.5
e-radiology
Communication
Clinical /
Quality
Effectiveness
5.6
Clinical
Effectiveness
6.7
Achieve high
quality safe care
for those patients
who undergo
endoscopy
Alternative to
face-to-face
contact
Indicator
Weighting
Description of Indicator
Clinical
Effectiveness
10%
10%
25%
Quality Accounts 2011/12
Page 22 of 40
The NHS Institute website is available to share CQUIN schemes for further
information.
(http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html)
2.2.5 Statements from the Care Quality Commission (CQC)
The Yorkshire Clinic is required to register with the Care Quality Commission and its
current registration status on 31st March 2012 is registered without conditions.
The CQC made an unannounced visit to the Yorkshire Clinic in November 2011.
Their inspection assessed outcome standard 07 – the safeguarding on people who
use services from abuse and that people should be protected from abuse and staff
should respect their human rights. Their findings were that the Yorkshire Clinic was
that the Yorkshire Clinic was compliant with outcome 07 and that there are suitable
systems and processes in place to safeguard and protect children and adults who
use the service from abuse. The report can be found on the CQC website:
http://www.cqc.org.uk/directory/1-128733159
2.2.6 Data Quality
Good quality information underpins the effective delivery of patient care and is
essential if improvements in quality of care are to be made. Improving data quality,
which includes the quality of ethnicity and other equality data, will thus improve
patient care and improve value for money.
Statement on relevance of Data Quality and your actions to improve your Data
Quality
At The Yorkshire Clinic data quality is one of our highest priorities to ensure we
produce clean and accurate electronic data which we can use to monitor and
improve our quality of care and service. Throughout the year we have updated and
strengthened our processes to capture data in a timely manner and to audit data
prior to submission. We are constantly looking to improve data capture and reporting
processes and in 2011/12 have invested in new systems for the collation of incidence
reporting, VTE assessments and the NHS Safety Thermometer metrics.
At The Yorkshire Clinic our electronic data quality is checked at every phase of the
patient journey by our staff and monitored constantly by a dedicated data quality
team using multiple reporting mechanisms and various checks to enable us to ensure
the data is of the highest standard.
NHS Number and General Medical Practice Code Validity
The Yorkshire Clinic 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:
Quality Accounts 2011/12
Page 23 of 40
The patient’s valid NHS number was correct:
99.7% for admitted patient care;
99.3% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was correct for
99.9 % for admitted patient care;
99.8% for out patient care; and
0% for accident and emergency care (not undertaken at our hospital).
Clinical coding error rate
The Yorkshire Clinic employs a full time Clinical Coder who is responsible for all
procedure coding.
Internal clinical coding audits are performed on a regular basis and all coders are
required to undertake regular training and development to ensure all changes in
coding are identified and embedded into our processes.
Quality Accounts 2011/12
Page 24 of 40
2.2.7 Stakeholders views on 2011/12 Quality Account
NHS Bradford and Airedale (part of the NHS Airedale, Bradford and Leeds cluster
PCT) welcomes the opportunity to comment on Yorkshire Clinic’s Quality Account for
2011/12, the third quality account since the national introduction of Quality Accounts.
As a commissioner of care services on behalf of the local population, we believe this
Quality Account demonstrates a commitment to quality improvement and high quality
services. The Operating Framework for the NHS in England describes quality as
spanning three areas: safety, effectiveness and patient experience.
This Quality Account provides an overview of these areas and overall is a fair
reflection of the provider’s achievement of quality of service delivery against the
backdrop of a changing NHS. Delivering care and treatment in an organisation with a
wide range of complex services requires strong commitment to continuously
monitoring and delivering high quality patient care.
The Hospital has continued to make significant progress over the past 12 months to
improve the quality of patient care and services. The need for improvements in the
last year has been addressed positively despite competing priorities. In light of this,
we are especially pleased to note the following achievements:
•
•
•
•
•
•
•
Yorkshire Clinic is registered with the Care Quality Commission and
their registration status is fully compliant and no enforcement action has been
taken by the CQC.
It is particularly pleasing to note the hospitals continued success in eliminating
mixed sex accommodation to deliver increased privacy and dignity for
patients, with no breaches to the standard during the last year.
It is pleasing to note that the in-patient satisfaction survey (via the leadership
factor survey) continues to be very positive with the majority of patients
reporting high levels of satisfaction of care received at the Yorkshire Clinic.
The continued success in delivering endoscopy services with Yorkshire Clinics
participation in the nationally recognised Global Rating Scale (GRS) census
and commitment to work towards attainment of Joint Advisory Group (JAG)
accreditation.
Commencement of the productive ward project at the Yorkshire Clinic,
although in its early stages at the hospital demonstrates commitment to
improvement in both staff and patient experience.
The introduction of telephone follow up to patients following discharge as part
of the ambulatory care policy, is a positive move to improve patient care,
experience and assurance.
The transparent and proactive reporting of incidents and never events is
considered positive by NHSBA in that it is indication of an organisation's safety
culture and this is actively encouraged.
The associated priorities for 2012/13 year have a significant patient safety remit and
prioritisation demonstrates a commitment to continuously improving patient safety.
The Hospital has implemented the second year of Commissioning for Quality and
Innovation (CQUIN) scheme with partial success in 2011/12.
Quality Accounts 2011/12
Page 25 of 40
The Hospitals achievement of the national venous thrombo-embolism (VTE) risk
assessment CQUIN goal is significantly above the national average and Yorkshire
Clinic is commended for this achievement. However, it is disappointing to note, that
despite additional funding, the Hospital has not achieved full implementation and
achievement across the full range of the 2011/12 CQUIN indicators.
In reviewing this Quality Account, NHSBA would recommend that further
opportunities to enhance the quality of patient care and services should be
considered within the Hospital framework and quality accounts to improve quality:
The Hospital has demonstrated participation in some national clinical audits and
confidential enquiries. The commissioner would welcome full participation in relevant
national audits and enquiries in 2012/13.
Training, capability, deployment and skill mix of the workforce to deliver against the
priorities outlined within the Quality Account could be incorporated and strengthened
in future accounts and NHSBA anticipate such reporting to be realised throughout
2012/13 through the contract mechanisms.
This Quality Account covers a broad number of areas in regards to patients’
experience. Recognising the small numbers of complaints Yorkshire Clinic receive,
the commissioner would welcome explicit information and improvement relating to
complaints such as themes, trends and work to address patient complaint, including
examples of learning and improvements taken by Yorkshire Clinic as a result of
patient feedback
NHSBA acknowledge the continued prioritisation of its services over the last year and
its continued intentions for quality improvements in 2012/13. It is clear that the
Hospital has many committed and enthusiastic staff members who contribute to a
positive experience for patients.
NHS Bradford and Airedale commends Yorkshire Clinic for its proactive approach
towards providing high quality services for its patients.
Jo Coombs, Director of Quality & Nursing
On behalf of NHS Airedale and Bradford
Quality Accounts 2011/12
Page 26 of 40
Part 3: Review of quality performance 2011/2012
Statements of quality delivery
Matron, Jill Campbell-Ainger
Review of quality performance 1 April 2011 - 31 March 2012
Introduction
“Ramsay operates a quality framework to ensure the organisation is accountable for
continually improving the quality of their services and safeguarding high standards of
care by creating an environment in which excellence in clinical care will flourish.”
(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 Yorkshire Clinic develops
and maintains ways of working which assure that the quality of patient care is central
to the business of the organisation.
The emphasis at the Yorkshire Clinic 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 at the right time.
The Yorkshire Clinic believes 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
Quality Accounts 2011/12
Page 27 of 40
Ramsay Health Care Clinical Governance Framework
The Matron at the Yorkshire Clinic actively promotes clinical governance and openly
collaborates with NHS partners. This ensures that our NHS colleagues are informed
any relevant governance concerns, incidents and any necessary actions and
learnings as outcomes from this and additionally that the Yorkshire Clinic is informed
of relevant initiatives to continually improve the safety and excellence of the services
offered. Matron attends a number of district meetings to nurture relationships with
key stakeholders/NHS/PCTs these include – Quality Performance Group, Serious
Untoward events group, District dignity group and Controlled Medicines Local
Intelligence Network group.
The Yorkshire Clinic holds regular committee meetings where governance is a key
focus, including monthly clinical governance committee, quarterly Medical and Dental
Advisory committee, bi-monthly Health & Safety committee.
NICE / NPSA guidance
Ramsay complies with the recommendations issued by the National Institute for
Health and Clinical Excellence (NICE) including technology appraisals in addition to
Safety Alerts issued by the National Patient Safety Agency (NPSA).
Ramsay Healthcare has a Clinical Alert System in place to disseminate all national
clinical guidance and alerts to local Hospital level, selecting those that are applicable
to our business. The Yorkshire Clinic has a local process where guidance and alerts
reach the relevant staff members in a timely manner, and an audit trail to evidence
and act upon necessary actions and changes in practice. National guidance such as
Quality Accounts 2011/12
Page 28 of 40
NICE and NPSA is discussed at both clinical governance and medical advisory
committee meetings.
For the reporting period 315 CAS alerts were received, 20% of which were relevant
to the Yorkshire Clinic and were all responded to within the required timeframe.
3.1 Patient safety
The Yorkshire Clinic is a progressive hospital focussed on improving its performance
every year, particularly with regard to patient safety.
Risks to patient safety are identified 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. To enhance our reporting
culture and awareness, and the skills of our teams to investigate and learn from
safety incidents, a specific “lessons learnt” forum is planned to commence in the
summer. This will encourage our staff to focus on identifying the root cause and
increase ownership and accountability to change and improve practice through
learning.
All staff undertake annual mandatory infection prevention and control, fire, manual
handling and basic life support training. A new Mandatory Training Policy has now
been launched by Ramsay as well as a standardised induction programme. Details
of all staff training undertaken in the year is logged on to our electronic training
register. This identifies any shortfalls in an individual’s professional development
which can then be addressed
Our focus on patient safety has resulted in a marked improvement in a number of key
indicators as demonstrated below: -
3.1.1 Infection prevention and control
The Yorkshire Clinic has had no reported MRSA Bacteraemia in the past 4
years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia, Clostridium difficile and E coli infections with a programme to reduce
incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and The Yorkshire Clinic remains below the lowest
percentile for infection rates.
An annual strategy for Infection Prevention and Control (IPC )is developed at a
Corporate level by the Group IPC and policies are revised and redeployed every two
years. IPC programmes are designed to bring about improvements in performance
and practice. These improvements can be seen in The Yorkshire Clinic IPC audit
results (page 11). A network of specialist nurses and infection control link nurses
operate across the Ramsay organisation to support good networking and clinical
practice.
Quality Accounts 2011/12
Page 29 of 40
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Infection Prevention and Control management is very active within The Yorkshire
Clinic and we have a local IPC Committee which meets quarterly to oversee
implementation of corporate policies and National guidance and review clinical
practice. Minutes from local meetings develop and review action plans to address
issues identified in both the corporate and local annual strategy/plan for infection
control. All staff undertake mandatory IPC training annually plus the clinical staff
receive bi-annual training/updates from our Consultant Microbiologist.
Healthcare associated infections (HCAI) are acquired as a result of healthcare
intervention. High standards of Infection Prevention and Control practice minimise
the risk of occurrence and as can be seen from the bar chart below. The Yorkshire
Clinic has improved its HCAI rate annually for the past 2 years and is well below the
National Average of 28% with our average rate being less than 1% of our total
number of patient admissions.
3.5
3
2.5
Number
2
1.5
1
0.5
0
Jan
Feb Mar Apr May Jun
Jul
Aug Sep
Oct Nov Dec
20120 HCAI Numbers
0
1
0
2
0
0
0
0
0
1
0
0
2011 HCAI Numbers
0
0
0
1
3
1
0
1
1
1
2
0
2010 HCAI Rate
0.00%0.10%0.00%0.20%0.00%0.00%0.00%0.00%0.00%0.10%0.00%0.00%
2011 HCAI Rate
0.00%0.00%0.00%0.10%0.30%0.10%0.00%0.10%0.10%0.10%0.20%0.00%
0.35%
0.30%
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
-0.05%
3.1.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits. Our PEAT audit score for 2011/12 was 96%.
These assessments include rating of privacy and dignity, food and food service,
access issues such as signage, bathroom / toilet environments and overall
cleanliness.
The 3 key areas requiring action included:
•
•
Some of the signage was unclear regarding direction. All signage has been
reviewed and replaced both in the hospital and grounds.
General decor inside the building was in need of upgrading. This has been
incorporated in the 2012 refurbishment, which is underway.
Quality Accounts 2011/12
Page 30 of 40
Rate
Hospital Acquired Infections
The graph below shows our patient satisfaction of the environment over the last 3
years, the areas of concern have been identified and action plans developed and
implemented to improve the hospital environment.
Ramsay environmental audits continue to be undertaken quarterly as per Ramsay
national audit programme and the Yorkshire Clinic has demonstrated a further 3%
improvement in the last 12 months. The hospital wide cleaning matrix has been
utilised, informing staff what needs cleaning, with what, when and by whom.
AUDIT STANDARD
Management
General Environment
Clinical Equipment
Decontamination
Clinical Practice
Sharps Handling &
Disposal
Waste Disposal
Hand Washing
% Compliance
August 2011
% Compliance
November 2011
% Compliance
February 2012
% Compliance
May 2012
100
58
100
100
100
91
100
58
100
100
100
82
100
82
100
100
100
82
100
83
100
100
100
82
100
*94
100
100
100
100
100
100
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 The Yorkshire Clinic 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.
Effective and on-going communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are issued to all relevant staff as soon as received 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
Managers who ensure we keep up to date with all safety issues. Evidence of
necessary actions and changes in practice are monitored and recorded for each and
every alert received.
Quality Accounts 2011/12
Page 31 of 40
Adverse Incidents reported at the Yorkshire Clinic affecting patients, visitors, staff
and sub-contractors were:
•
•
•
2009 = 91
2010 = 103
2011 = 122
Adverse incidents reported are comparative with the numbers of patients, visitors,
staff, sub-contractors who utilise the Yorkshire Clinic every year. The above figures
show an increase in incident reporting, reflecting a raised awareness and improved
reporting of actual incidents and near misses, indicating the importance of safety in
the workplace.
3.2 Clinical effectiveness
The Yorkshire Clinic has a Clinical Governance team and committee that meet
regularly throughout 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, medical advisory committees and stakeholders to ensure results are
visible and tied into actions required by the organisation as a whole.
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. There is an increase in the number of patients
returning to theatre but this is relative to the increased number of operations. Every
surgical intervention carries a risk of complication so some incidence of returns to
theatre is expected. 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.
0.4%
3
0.3%
2.5
0.3%
2
0.2%
1.5
0.2%
1
0.1%
0.5
0.1%
0
Unplanned Return to Theatre Number
Unplanned Return to Theatre Rate
Rate
Number
Unplanned Returns to Theatre 2010
3.5
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
1
1
2
1
2
2
3
0
1
0
0
0.1%
0.1%
0.1%
0.2%
0.1%
0.2%
0.2%
0.3%
0.0%
0.1%
0.0%
0.0%
0.0%
Quality Accounts 2011/12
Page 32 of 40
Unplanned Returns to Theatre 2011
3.5
0.4%
3
0.4%
Number
0.3%
2
0.2%
1.5
Rate
0.3%
2.5
0.2%
1
0.1%
0.5
0.1%
0
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
1
2
2
2
2
2
1
2
3
3
0
0.1%
0.1%
0.3%
0.3%
0.2%
0.2%
0.2%
0.1%
0.2%
0.3%
0.3%
0.0%
Unplanned Return to Theatre Number
Unplanned Return to Theatre Rate
0.0%
These figures are constantly monitored throughout the year via our clinical
governance and medical advisory committee framework.
3.2.2 Readmission to hospital
Monitoring rates of re-admission to hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be
addressed. Ramsay rates of readmission remain very low and this, in part, is due to
sound clinical practice ensuring patients are not discharged home too early after
treatment and are independently mobile, not in severe pain etc.
Unplanned Re-admissions 2010
8
0.7%
7
0.6%
0.5%
5
0.4%
Rate
Number
6
4
0.3%
3
0.2%
2
0.1%
1
0
Unplanned Re-admissions Number
Unplanned Re-admissions Rate
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
2
0
1
2
5
7
1
3
3
2
3
1
0.2%
0.0%
0.1%
0.2%
0.4%
0.6%
0.1%
0.2%
0.3%
0.2%
0.3%
0.1%
0.0%
0.6%
5
0.5%
4
0.4%
3
0.3%
2
0.2%
1
0.1%
0
Unplanned Re-admissions Number
Unplanned Re-admissions Rate
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
1
1
2
0
2
4
5
2
0
3
2
0
0.1%
0.1%
0.2%
0.0%
0.2%
0.4%
0.5%
0.2%
0.0%
0.3%
0.2%
0.0%
Rate
Number
Unplanned Re-admissions 2011
6
0.0%
As can be seen in the above graphs our readmission to hospital rate has changed
little over the last 2 years. These figures are constantly monitored throughout the
year via our clinical governance and medical advisory committee framework.
3.3 Patient experience
Feedback from patients regarding their experience at The Yorkshire Clinic is
encouraged and is essential to inform our staff how care can be enhanced or
adjusted to meet individual patient satisfaction.
Quality Accounts 2011/12
Page 33 of 40
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and on
notice boards. Managers ensure that positive feedback from patients is recognised
and any individuals mentioned are praised accordingly.
All negative comments or suggestions for improvement are also communicated to the
relevant staff using direct feedback. All staff are aware of our complaints procedures
should our patients be unhappy with any aspect of their care. Every complaint
received is given is given immediate attention of the General Manager and Matron on
the day it is received, following which a thorough investigation is commenced into the
concerns raised.
Patient experiences are received from the various routes listed below, and are
regular agenda items on Local Governance Committees for discussion, trend
analysis and further actions as necessary. Escalation and further reporting to the
Ramsay Corporate Governance Team, our stakeholders and regulatory bodies
occurs as required in line with Ramsay Healthcare and Department of Health policy.
Feedback regarding the patient’s experience is received through the following routes:
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Patient satisfaction surveys
‘We value your opinion’ leaflet
Direct verbal feedback to Ramsay staff.
Internal Ramsay audit /inspection processes.
CQC inspection feedback.
Written feedback via letters/emails/complaints
Patient focus groups
PROMs surveys
Care pathways – patients are encouraged to read and participate in their plan of
care.
3.3.1 Patient Satisfaction Surveys
Patient satisfaction is one of our key focus areas and the Yorkshire Clinic is
committed to ensuring that our patients and their families are the centre in everything
that we do.
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 for the quarter
but also separately for NHS and private patients). The results are available for
patients to view on our website.
Patient Satisfaction Scores results for the Yorkshire Clinic from the 1 April 2011 to
the 31st March indicated that 98% of patients treated at the Yorkshire Clinic would
recommend the Yorkshire Clinic to others, and scored their overall satisfaction as
98% ( as excellent, very good and good)
Quality Accounts 2011/12
Page 34 of 40
As an organisation we pride ourselves on ensuring patients are informed of decisions
and why they have been made (including discussions around what will happen, in
terms of procedures etc) at every stage of their care pathway and this is evidenced in
the feedback results we have received back from patients.
-
Did a member of staff explain why you needed these test(s) in a way you
could understand? (100% of patients agreed)
Did the Consultant explain the reasons for any treatment or action in a way
that you could understand? (100% of patients agreed)
Were you involved as much as you wanted to be in decisions about your care
and treatment? (100% of patients agreed)
Sufficient involvement in discussions about treatment (98.8% of patients
agreed)
Did a member of staff explain any side effects of the medication? (100% of
patients agreed)
Given written post-discharge advice about how to look after yourself at home
(97.7% of patients agreed)
3.3.2 Patient Reported Outcome Measures (PROMs)
The Yorkshire Clinic 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. Compliance for PROMs is above the national
average at The Yorkshire Clinic. There are outcome measures for patients treated at
The Yorkshire Clinic however the PROMs team are unable to filter our data from that
of our local Trusts. Consultants can access this information within their own Trusts
for all patients, including those treated at The Yorkshire Clinic.
Access to the Yorkshire Clinic and Ramsay PROMs results can be found at the
following website:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&category
3.4 The Yorkshire Clinic Hospital Case Study
Whilst reviewing the feedback received from patients who had received treatment at
the Yorkshire Clinic, it was evident that whilst our patients received discharge
information prior to leaving the hospital, many patients felt they needed further
support and reassurance once they had returned home.
This was evidenced by the number of phone calls to the hospital from patients during
their first few days at home, as many couldn’t remember all of the information
provided. More often the call would be to seek reassurance that they were
progressing satisfactorily, but sometimes was for support and advice.
Ramsay Healthcare introduced an Ambulatory Care Policy which identifies that
patients should receive a post discharge follow up call to offer post discharge
support.
Quality Accounts 2011/12
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Here at the Yorkshire Clinic, we took the decision to routinely telephone patients who
had received a general anaesthetic 48 hours or earlier after surgery. 48 hours was
felt to be the appropriate time period, as it allowed patients adequate time to fully
recover from the effects of the general anaesthetic, enabling patients to more clearly
identify any difficulties or questions that they may have.
This process allows the clinical team to identify any potential difficulties at an early
stage, and to discuss this with the Consultant and where necessary intervene early,
providing reassurance and prompt care and treatment where needed.
There is a process in place that the nursing staff follow to ensure that the appropriate
assessment and questioning occurs to identify any potential complications that the
patient may have developed . This information is then documented and is discussed
directly at the time with the patient’s consultant or the resident hospital doctor on
duty. Each call is recorded in the patient’s medical records.
This initiative has proved very successful and is evident through our customer
feedback that this has significantly helped to reassure patients, knowing that care
continues after discharge where support and advice is only a phone call away. Many
patients have stated that it has provided them with the opportunity to ask questions
that they would not have otherwise thought to ask.
Quality Accounts 2011/12
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Appendix 1
Services covered by this quality account
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Anaesthetics
Audiology
Cardiology
Cosmetic
Dermatology
Dietetics
Endocrinology
ENT
Gastroenterology
General Medicine
General Surgery
Gynaecology
Haematology
Nephrology
Neurology
Neurophysiology
Oncology
Ophthalmology
Oral Surgery / Restorative Dentistry
Oral and Maxillo Facial
Orthopaedics
Orthotics
Paediatrics
Pain Management
Pathology
Psychology
Radiology
Respiratory Medicine
Rheumatology
Sleep Studies
Speech Therapy
Urology
Vascular
Venerology
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
Page 38 of 40
Appendix 3
GLOSSARY OF ABBREVIATIONS
ANTT
Aseptic Non Touch Technique
BADS
British Association Day Care Surgery
CAS
Central Alert Agency
CQC
Care Quality Commission
CQUINS
Commissioning for Quality and Innovation
EMSA
Eliminating Mixed Sex Accommodation
GRSA
Global Rating Score
HCA
Health Care Assistant
HCAI
Health Care Associated Infection
IPC
Infection Prevention and Control
ISB
Information Standards Board
JAG
Joint Advisory Group
MEWS
Medical Early Warning System
MHRA
Medicines & Healthcare Products Regulatory Agency
MRSA
Methicillin-resistant Staphylococcus Aureus
NICE
National Institute for Clinical Excellence
NJR
National Joint Registry
NPSA
National Patient Safety Agency
PEAT
Patient Environment Action Team
POA
Pre-Operative Assessment
PROMS
Patient Reported Outcome Studies
PW
Productive Ward
RIMS
Risk Information Management System
SHA
Strategic Health Authority
SLA
Service Level Agreement
TLF
The Leadership Factor
VTE
Venous Thromboembolism
WHO
World Health Organisation
Quality Accounts 2011/12
Page 39 of 40
The Yorkshire Clinic
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:
01274 550600
www.theyorkshireclinic.co.uk
Neurological Centres
Quality Accounts 2011/12
Page 40 of 40