Quality
Account
2011/12
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Woodland
Hospital/Centre
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager – Tania Terblanche
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
Quality Accounts 2011/12
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Welcome to Ramsay Health Care UK
Woodland 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 Woodland Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our 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.
The previous Quality Account for 2009/10 was developed by our Corporate Office
and summarised and reviewed quality activities across every hospital and centre
within the Ramsay Health Care UK. It was recognised that this did not provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group will develop
its own Quality Account from this year onwards, which will include some Group
wide initiatives, but will also describe the many excellent local achievements and
quality plans that we would like to share.
Quality Accounts 2011/12
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Part 1
Tania Terblanche General Manager,
Woodland Hospital
Our Vision;
“As a committed team of professional individuals we aim to maintain high
standards of service with patient care remaining our focus for everything we do.”
As the General Manager of the Woodland Hospital I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
We are a long standing healthcare provider in the Kettering area and our new
development will give the local Healthcare community access to a wider range of
services delivered by qualified Medical Specialists. Our services to private and
NHS patients, ensures that a wide range of patients can benefit from the care
provided at Woodland Hospital. This is delivered through a partnership approach
between all stakeholders we work with.
We have a strong track record as a safe and responsible provider, and our
outcomes are shared with our private and NHS contractors.
Our latest CQC visit confirmed standards are met and exceed patient and
stakeholder expectations. Our high standards and excellent patient experience is
also reflected in our patient satisfaction survey results.
At Woodland Hospital we believe that all our staff plays a part in the success of
the unit. Our training matrix gives staff regular training for their own professional
development. This compliments the individual’s requirements and ensures that
high standards and best practice is followed at all times.
The quality accounts give all parties and providers access to the Woodland
Hospital patient treatment outcomes. If you would like to comment or provide me
with feedback then please feel free to contact me on the following;
Email: tania.terblanche@ramsayhealth.co.uk or Tel.: 01536 414 515.
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.
Tania Terblanche
General Manager
Woodland Hospital
Ramsay Health Care UK
This report has been produced by:
Tania Terblanche – General Manager
Elaine Rowland – Matron
Lorna Dodwell – Regional Business Development Manager, Midlands Region
Caroline Derby – Finance Manager
Jeff Hickson – Support Services Manager
This report has been reviewed and approved by:
Date
Name
Mr R Haughney
Role
MAC Chair
Mr J Szafranski
CGC Chair
Mr J Beech
Regional Director
Mrs E Cassettari
Contract Manager, NHS
Milton Keynes and NHS
Northamptonshire
E-Signature
Woodland Hospital Management Team work in partnership with the MAC and the
CGC Committee, ensuring that high quality patient care is at the centre of what
we do.
Regular meetings with the above Committees ensure best practice and sharing
results.
Quality Accounts 2011/12
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Welcome to Woodland Hospital
The Woodland Hospital, named after the famous local Woodland Pytchley Hunt,
was originally built in 1989 and was designed to combine modern technology with
the highest standard of patient care and comfort. Our staff are carefully selected
for their friendly and caring approach as well as their efficiency and
professionalism and a Resident Doctor is available 24 hours a day. The restful
atmosphere and high level of personal attention combine to help patient recovery.
The first patients were admitted in June 1990 and the hospital has continued to
grow and develop since this date.
In 1996 the hospital opened a second purpose built theatre suite and 6 new
patient bedrooms, giving a total of 37 bedrooms split across two floors. In
January 1998 the dedicated Endoscopy Suite was opened and during 1999 a
mammography service was launched. 2005 saw the introduction of a mobile MRI
screening service along with the upgrade of our X-ray equipment and department.
Major developments took place at the Hospital during 2005 and 2006, with the
opening of a two bedded independent high dependency area and an expansion of
the theatre suite that included two new recovery bays. The building of Schofield
House took place and this building contains a new and improved physiotherapy
department and administration offices. Work on the ground floor of the main
hospital included a new conservatory and hospital entrance, two additional
consulting rooms within the outpatient department and a refurbished reception
area which includes a cash office
Schofield House is named after the late Mr James Schofield, the first Consultant
to operate at the Woodland Hospital, and stands on the area previously occupied
by the Grange. The official opening was done by Mr Schofield’s children on 18
May 2006.
Further development continued and in 2008 the Laser Eye surgery service was
launched. A dedicated laser suite has been developed on the second floor of the
hospital to undertake laser eye surgery and other laser cosmetic procedures.
Electronic X-ray reporting was introduced during 2009.
To meet the growing needs of the business the Woodland Hospital provides fast,
convenient, effective and high quality treatment for patients of all ages (excluding
children below the age of 3 years), whether medically insured, self-pay, or from
the NHS. In 2011/12 we treated a total of 5706 patients, with 53% being NHS
patients.
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The Hospital provides a comprehensive range of services that are listed in
Appendix 1, and these include Medical, Orthopaedic, Surgical, Ophthalmology,
Ear, Nose and Throat, Urology, Gynaecology, Maxillofacial and Cosmetic
services. The Hospital also provides a range of routine and complex spinal
services.
To ensure that patients are at the centre of everything we do and receive the
highest standard of care, we have 140 dedicated Consultants, working alongside
86 nursing, radiology, physiotherapy and pharmacy staff together with
administration, housekeeping, maintenance and catering staff.
At the Woodland Hospital we work closely with our colleagues at the local Trust
and PCT to ensure our services meet the needs of the patients we serve,
including shared training and development programmes, infection control and
pathology services.
It is also key that we support people and services within the community, and in
2011 we continued with our agreement with Kettering Rugby Club to provide the
physiotherapy services to their players. The Woodland Hospital also supports
charities by selecting a charity of the year, and raised over £2000 in 2011/12 for
the Warwickshire and Northamptonshire Air Ambulance.
Developments have continued at the Hospital and during 2011/12 further
expansions have begun, with the completion of new parking bays, a new high
dependency unit and refurbished patient bedrooms. In 2012/12 the expansion
continues and includes:
•
•
•
•
•
New waiting area,
New conference room
Extra outpatient consulting rooms
Third laminar flow theatre,
Dedicated ambulatory care (day case) unit
This extension will allow us to increase our services and the number of patients
we see, both private and NHS.
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, Woodland 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 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 ongoing at any one time. The
priorities are determined by the Hospital’s Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2011/12 (looking back)
•
Patient safety
Patient safety was a key priority for the Woodland Hospital, and in 2011/12
we continued to improve the safety of our patients by putting mechanisms
in place to ensure that we continued to: reduce patient falls post surgery by
changing how we prescribed analgesia (pain killers) and the advice we
give to our patients following anaesthesia and analgesia, reduce the risk of
patients suffering a blood clot post surgery through robust assessment of
patients and in the past three years we have had two patients that have
suffered a blood clot in either their leg or lung and both patients received
the appropriate treatment based on national clinical guidelines, to maintain
our current excellent infection control rates and through the implementation
of screening for MRSA we have had no reported cases of hospital
Quality Accounts 2011/12
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acquired MRSA bacteraemia or MRSA and finally, to improve cleanliness
across the hospital through reviewing cleaning schedules and standards.
Any patient safety incident that occurs at the hospital is reported through
our incident reporting mechanism, and these are reported locally at our
Health and Safety, Clinical Governance and Medical Advisory Committee
meetings and nationally through to Ramsay Headquarters via our monthly
clinical governance reports.
To enable us to ensure patients undergoing joint replacement surgery
were able to be traced if a national safety alert is issued, Woodland
Hospital was part of the National Joint Registry, which enabled us to trace
any prosthesis (replacement joint) that we had used at the hospital.
To support our safe patient culture, it was imperative that we have
appropriately trained staff. To support this, we commenced an Acute Care
Competencies / Vulnerable Adult training programme which ensured safe,
competent staff were available to care for our patients. This training was
led by the Matron supported by the Regional Training Coordinator.
In conjunction with educated, competent and appropriately trained staff, it
was important that staff were satisfied and happy in the workplace as this
ensured patient safety risks were reduced. To obtain the opinion of our
staff each member was encouraged to complete our annual Pulse survey.
Our Pulse survey results for 2011/12 identified three key areas that we
needed to improve on, which were: ensuring all staff received a Personal
Development Review, ensuring all equipment was fit for purpose and that
departments were in good decorative order. We addressed these three key
areas through a robust yearly appraisal programme, replacing equipment
that was no longer fit for purpose and the introduction of a hospital wide
decoration plan, linked into the development plan.
• Clinical Effectiveness
At the Woodland Hospital we are promoting Ambulatory or Day Surgery
Care, which is the admission of selected patients (both medical and
surgical) to hospital for a planned procedure and returning home the same
day, i.e. the patient does not incur an overnight stay. To support this
concept, we reviewed and changed our processes and are near
completion of our purpose built ambulatory unit.
In 2010/11 the percentage of day surgery patients we treated was 68%
and in 2011/12 it was 71%. Through amended coding and reports, patient
satisfaction surveys and incident reporting we will monitor the
effectiveness of this service, and make changes were indicated.
Quality Accounts 2011/12
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At the Woodland Hospital we recognised that seeing every patient
individually was not always the most efficient way of giving the required pre
operative information to patients and in 2011 we introduced group preassessment for patients undergoing hip and knee joint replacement
surgery.
To improve efficiency on the ward we continued with our productive ward
initiative, led by the Ward Manager, which focused 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.
In 2011 we recognised from our patient satisfaction survey results that our
patients were not always receiving written discharge information on
discharge. In response to this, we ensured that all of our patients received
a discharge letter on discharge and a copy of this is faxed to the GP within
24 hours of discharge.
• Patient experience – informing patient choice
By sharing and using the results of the national PROMs results for Hip and
Knee surgery we were able to identify any areas of poor patient outcome
and examine practice if and where this existed. This was facilitated
through the MAC, Clinical Governance and Theatre Utilisation Meetings.
In 2011 we carried out a patient satisfaction survey every quarter and our
overall score was 96% however the area for improvement was patients
were not receiving copies of letters sent between hospital doctors and
family GP’s and this is a requirement to ensure safe and appropriate care
continues once the patient is discharged from hospital We raised this with
the Consultants and although we have seen a small increase (80%), this
has to be a key area for the forthcoming year.
2.1.2 Clinical Priorities for 2012/13 (looking forward)
•
Introduction of the National Patient Safety Thermometer
The National Patient Safety Thermometer is a national initiative which will
allow us to monitor the level of harm our patients may be exposed to. The
monitoring takes place on a pre-determined date each month and is
applicable to all in-patients on that set date. Data is completed on a
template and submitted directly to the DoH Information Centre and
monitors the incidence of falls, VTE assessment and preventative
treatment, and urinary infections. Through submitting this data on a
monthly basis, we will be able to benchmark ourselves against other
Hospitals within Ramsay Health Care and within the NHS.
Quality Accounts 2011/12
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• Implementation of Risk Man
In 2012/13 a new incident reporting system will be implemented which will
allow greater accuracy in recording incidents and will also support
enhanced data and trend analysis. This will support our patient safety
ethos.
• Implementation of Electronic Rostering System
To support the monitoring of staffing levels and skill mix, a new electronic
rostering system will be implemented across all departments. This will
support the delivery of safe patient care and efficiencies.
• Increase Patient Feedback Systems
To ensure our services meet our patients expectations we are implanting
new systems of gaining feedback on our patient’s experience which will
complement our existing system. Currently, we use an external company
to obtain our patient feedback; this ensures the results are completely
unbiased and independent. To compliment this a monthly matron checklist
will be introduced, where the Matron will review each patient and obtain
responses to set questions. In conjunction, patients will be actively
encouraged to complete the ‘We Value Your Opinion’ feedback forms and
a member of the senior management team will reply to each completed
form.
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 Woodland Hospital provided and/or subcontracted over 3200
NHS services.
The Woodland Hospital 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 in 1st April 2011 to 31st
March 2012 represents 38% of the total income generated from the provision of
NHS services by the Woodland Hospital for 1st April 2011 to 31st March 12
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard
Quality Accounts 2011/12
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are reviewed each year. The scorecard is reviewed each quarter by the hospitals
Senior Managers together with regional and Corporate Managers. The balanced
scorecard approach has been an extremely successful tool in helping us
benchmark against other hospitals and identifying key areas for improvement.
In the period for 2011/12, the indicators on the scorecard which affect patient
safety and quality were:
Human Resources
HCA Hours as % of Total Nursing
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
2.2.2 Participation in clinical audit
The national clinical audits that Woodland Hospital participated in during 1st April
2011 to 31st March 2012 are as follows:
• Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
• Blood transfusion
O neg blood use (National Comparative Audit of Blood Transfusion)
Quality Accounts 2011/12
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The data relating to these audits are listed below alongside the number of cases
submitted to each audit as a percentage of the number of registered cases
required by the terms of that audit.
• National Clinical Audits
Name of Audit
Participation
Peri-and Neo-natal
N/A – no service
Insufficient Patient
Numbers
N/A – No Service
Insufficient Patient
Numbers
Children
Acute care
Long term conditions
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Cardiovascular disease
Renal disease
Cancer
Trauma
Psychological conditions
Blood transfusion
Bedside transfusion (National Comparative Audit of Blood
Transfusion)
Health promotion
End of life
Yes
Yes
N/A – No service
N/A – No service
N/A – No service
N/A – No service
N/A – No service
YES
N/A – No service
N/A – No service
Local Audits
From 1st April 2011 to 31st March 2012 a robust clinical audit calendar was in
place and thought the year 63 audits were undertaken, including: 15 infection
prevention and control, 3 transfusion, 4 physiotherapy and 8 radiology audits.
The results were reviewed at a local level and nationally by the Clinical
Governance Committee. The main area that was identified as requiring action
to improve the quality of healthcare provided are as follows. The clinical audit
schedule can be found in Appendix 2.
• Consent
At Woodland Hospital, consent is taken in a two stage process; stage one
being taken in outpatients by the Consultant, and second stage being taken
on admission by the nurse, who confirms that the patient fully understands all
aspects of consent. The area that needs improvement is first stage consent,
with many Consultants explaining the details of the operation at the outpatient
appointment and then taking written consent on admission. This has been
raised at the MAC meeting, and the Consultants have agreed to provide a
Quality Accounts 2011/12
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% cases
submitted
95%
95%
copy of the clinic letter, confirming what procedure was discussed with the
patient.
2.2.3 Participation in Research
There were no patients recruited during 2011/12 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
The following CQUIN’s were allocated to the Woodland Hospital in 2011/12.
National Indicator
Indicator
number
1
Indicator name
Reduce avoidable death,
disability and chronic ill
health from venousthromboembolism (VTE)
Quality
Domain(s)
Safety
Clinical
Effectiveness
Description of Indicator
Fully embed VTE risk
assessment to reduce
avoidable death, disability
and chronic ill health from
VTE
Indicator
weighting
0.5% of
total
contract
value
Regional Indicators
Indicator
number
2
3
Indicator name
Discharge Planning
Lifestyle
Quality
Domain(s)
Clinical
Effectiveness
Clinical
Effectiveness
Description of indicator
To improve discharge
planning arrangements to
reduce length of stay,
excess bed days and
inappropriate
readmissions
Improving the health of
the population by
ensuring that all patients
who smoke are identified,
provided with advice and
offered referral to local
stop smoking services.
Indicator
weighting
0.75 % of total
contract value
0.25% of total
contract value
Improvement in the
number of patients who
have their alcohol status
recorded using a
validated tool eg. Audit-C,
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2.2.5 Statements from the Care Quality Commission (CQC)
Woodland Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March is registered without conditions.
The Care Quality Commission carried out an unannounced inspection of
Woodland Hospital in February 2012 and has not taken enforcement action
following this inspection.
2.2.6 Data Quality
Woodland Hospital will be taking the following actions to improve data quality.
•
•
•
•
•
•
Recording and investigating any unexpected return to theatre post surgery
Any extended length of planned stay and the reasons for this
Any unplanned death – this is reported and investigated as a serious
untoward incident
Any infections post surgery
Any transfer from the Hospital
Robust clinical audit calendar (See Appendix 2)
All of these audit results are discussed at the MAC, Clinical Governance, and
Health and Safety meetings, and results are compared against previous year
results.
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2010/11 to the Secondary Users
Service for inclusion in the Hospital Episode Statistics which are included in the
latest published data. The percentage of records in the published data included:
The patient’s valid NHS number:
99.66% for admitted patient care;
99.30% for outpatient care; and
0% for accident and emergency care (not undertaken at Ramsay hospitals).
The General Medical Practice Code:
99.96% for admitted patient care;
99.82% for outpatient care; and
0% for accident and emergency care (not undertaken at Ramsay hospitals).
Quality Accounts 2011/12
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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
Woodland hospital was not subject to the Payment by Results clinical coding
audit during 2011/12 by the Audit Commission.
2.2.7 Stakeholders views on 2011/12 Quality Account
To support our Quality Account we sent a copy our relevant Lead Commissioning
Primary care Trust (PCT) and we are awaiting their feedback:
•
PCT
Quality Accounts 2011/12
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Part 3: Review of quality performance 2011/2012
Statements of quality delivery
Matron, Elaine Rowland
Review of quality performance 1st April 2011 - 31st March 2012
Introduction
‘Our emphasis is on providing an environment and culture to support
continuous clinical quality improvement so that patients receive safe and
effective care, clinicians are enabled to provide that care and the
organisation can satisfy itself that we are doing the right things in the right
way’.
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2011/12
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement, so that patients receive safe and effective care.
Clinicians are enabled to provide that care, and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. 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 regard to our track record
for patient safety.
Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns, but
more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs below.
3.1.1 Infection prevention and control
Woodland Hospital has a very low rate of hospital acquired infection and
has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections, with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
•
Local bi-monthly infection control meetings and quarterly Infection Control
Committee meetings with local Trust.
•
Lead Consultant involved in infection control providing link with Consultant
colleagues
•
Monthly report on all aspects of infection control to Heads of Departments
Quality Accounts 2011/12
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2011/12
Infection rate
2010/11
12
10
8
6
4
2
0
2009/10
Number of
Patients
Total Number of Infections
Year
•
Over the last three years our infection rate has remained very low, with 11
cases (0.20% of total admissions) in 2009/10, 5 cases (0.08% of total
admissions) in 2010/11 and 3 cases (0.05% of total admissions). These
excellent infection rates are due to robust pre-admission processes and
infection control practices, with hand hygiene being a primary focus point
for all staff working at the Hospital.
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. The table below demonstrates our results.
Environment
2009/10
2010/11
2011/12
Excellent
Excellent
Good
Food
Excellent
Excellent
Good
Privacy and
Dignity
Excellent
Good
Excellent
In conjunction with these assessments, we also carry out our own housekeeping
audits, which began in 2009. The results of these audits are publicised to all staff
and any areas of poor compliance are addressed through action plans. In August
2011 a new audit tool has begun to be developed with new cleaning schedules
and these were implemented at the beginning of 2012 but the results have not
been analysed. In earlier audits the main areas that required action were:
• High level damp dusting (door closures, top of picture frames, tops of
cupboards)
• Cleaning of nozzles on alcohol dispensers
Quality Accounts 2011/12
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•
Moving of chairs and cleaning behind them
Local Housekeeping Audits
96%
Percentage
94%
92%
90%
88%
86%
84%
Feb-10
Overall Housekeeping score
87%
Mar-10
Jul-10
Aug-10
Oct-10
Nov-10
May-11
Apr-11
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
82%
Apr-11 May-11
93.10% 92.10% 92.20% 92.20% 94.30% 91.30% 91.40%
Month
.
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.
Any incident that occurs is reported through incident reporting and these are
discussed at our MAC, Clinical Governance and Health and Safety meetings. We
analyse these incidents for trends and themes and take action where indicated.
The graph below identifies the number of untoward incidents reported per year
over the past three years as a total percentage of admissions.
Quality Accounts 2011/12
Page 22 of 31
60
60
59
58
57
56
56
Total number
of incidents
56
55
54
2009/10
2010/11
2011/12
• As seen in the above graph our adverse events rates increased in 2010/11
but decreased again in 2011/12. When the number of incidents are
considered per total admissions our incidents have reduced as in 2009/10
are incidents were 0.93% of our total admissions, in 2010/11 they were
0.92% of the total admissions and in 2011/12 they were 0.84%
• Despite the reduction, we still take every incident extremely seriously and
ensure that each incident is reviewed and discussed. Staff are actively
encouraged to report incidents, as by doing this we can identify areas for
improvement.
3.1.3 Caring for your privacy and dignity – same sex
accommodation
At Woodland Hospital we are committed to making sure that all our patients
receive high-quality care that is safe and effective.
Our patients have the right to privacy and to be treated with dignity and respect.
We believe that providing same-sex accommodation is a key part of achieving
this and allows us to give all of our patients the best possible experience while
they are in hospital.
Woodland Hospital is pleased to confirm that we are compliant with the
Government’s requirement to deliver same-sex accommodation, except when it is
in the patient’s overall best interest, or reflects their personal choice.
We have the necessary facilities, resources and culture to ensure that patients
who are admitted to our hospitals will only share the room where they sleep with
members of the same sex, and same-sex toilets and bathrooms will be close to
their bed area.
Quality Accounts 2011/12
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Sometimes the need for fast effective treatment is greater than the need to
provide same-sex accommodation. This might happen if you need urgent, highly
specialised or high-tech care, for example high-dependency care. On these
occasions, it is acceptable for men and women to be treated together and our
staff will keep you informed and move you to same-sex accommodation as
quickly as possible.
Our staff are keen to listen to your comments, so if you have any concerns about
privacy and dignity please do not hesitate to let us know.
3.1.4 Caring for your privacy – data protection
Your doctor and other health professionals caring for you keep records about
your health and any treatment and care you receive from the woodland hospital.
These help us to ensure that you receive the best possible care from us. These
records may be written down or held on a computer and are used to guide and
administer the care you receive to ensure full information is available to anyone
involved in delivering safe care to you.
Everyone working at Woodland Hospital has a legal duty to keep information
about our patients safe and confidential. If you are receiving care at another
organisation and they need access to your records held at the Woodland
Hospital, there is a strict process that must be followed and that may involve in us
obtaining your consent prior to disclosing any information. There are times when
we are required by law to pass on information to the appropriate authorities but
this is only done after formal permission has been given by a qualified health
professional. Anyone who receives information from us is also under a legal duty
to keep it confidential.
3.2 Clinical effectiveness
Woodland Hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to Hospital
Management and the Medical Advisory Committee to ensure results are visible
and tied into actions required by the organisation as a whole.
The results highlighted in the graphs demonstrate the effectiveness of this
approach over the last three years.
Quality Accounts 2011/12
Page 24 of 31
3.2.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures
and so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure. Every surgical intervention
carries a risk of complication so some incidence of return 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.
Total number of Unexpected Returns to Theatre
10
8
6
4
2
0
2009/10
•
•
2010/11
Year
2011/12
As can be seen in the above graph our return to theatre rate is very low
and in 2011/12 although we have seen an increase, we are performing
increased complex surgery, and when considered as a percentage of the
total patients undergoing surgery the return to theatre rate is 0.14% for
2011/12.
Each patient that is returned to theatre has a full review of the records and
the findings discussed at MAC, with an action plan implemented and
monitored if indicated
3.2.2 Readmission to Hospital
Monitoring rates of readmission to Hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be
addressed. Ramsay rates of readmission remain very low and this, in part, is due
to sound clinical practice ensuring patients are not discharged home too early
after treatment and are independently mobile, not in severe pain etc.
Quality Accounts 2011/12
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10
8
6
Readmissions
4
2
0
•
•
2009/10
2010/11
2011/12
As can be seen in the above graph our readmission to hospital rate has
decreased steadily over the last three years and remains very low. When
these numbers are considered as a percentage of our total discharges, our
readmission rates are 0.03%, 0.05% and 0.15% respectively.
Every readmission is fully reviewed to identify the causative factor for the
readmission and these are discussed and practice changed if required.
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
is welcomed and informs service development in various ways, dependent on the
type of experience (both positive and negative) and action required to address it.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also relayed to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are fed back via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
and further action where necessary. 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
Quality Accounts 2011/12
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


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
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
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 Woodland Hospital. To record
a satisfaction index over 94.8%, 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 Hospital’s 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%.
95
94
93
2009
2010
2011
92
91
90
89
•
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
As can be seen in the above graph our Patient Satisfaction rate has
increased over the last year and currently our hospital rates in the top 23% of organisations. Although we score highly in areas relating to staffing,
cleanliness and treating our patients with dignity and respect, we still have
areas where we can improve and these are billing processes and ensuring
that our patients receive copies of any correspondence between their
Consultant and General Practitioner.
Quality Accounts 2011/12
Page 27 of 31
3.4 Woodland Hospital Case Study
New Urodynamics Service
We have been providing Gynaecology services on Choose & Book since the
commencement of the contract and following consultation, some patients require
to have a urodynamics test. Initially patients were referred to a consultant
elsewhere as the service was not provided at Woodland Hospital. There also a
delay in getting patients seen in a timely manner.
We investigated the opportunity of a recruiting a specialist consultant to lead a
Urodynamics service, and we were able to secure the services of Mr S Doshi,
Consultant Gynaecologist and Urogynaecologist. We then put a business
proposal together outlining the investment requirements for the equipment and
training required, and sent this to our head office for approval. The proposal
included where the service was going to be run in the hospital, ensuring patient
dignity and confidentially at all times.
We won our proposal and have since purchased the equipment, trained our staff
and now hold regular clinics delivered by our Consultants, including Mr Doshi.
Patients can now complete their pathway at Woodland Hospital for urodynamic
tests, providing a better service for patients, delivered by the same consultant in
one location.
Quality Accounts 2011/12
Page 28 of 31
Appendix 1
Services covered by this quality account
Breast care
Dermatology
Ear, nose and throat (ENT)
Gastroenterology
General Medicine
General surgery
Gynaecology
Ophthalmology
Oral Maxillo Facial
Orthopaedic
Pain management
Podiatry
Physiotherapy
Medical loans
Rheumatology
Urology
Vascular
Diagnostics
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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Woodland 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
Tania Terblanche, General Manager using the contact details
below.
Tania Terblanche
General Manager
Woodland Hospital
Rothwell Road
Kettering
For further information please contact:
Phone: 01536 414515
E-Mail:Tania.terblanche@ramsayhealth.co.uk
www.woodlandhospital.co.uk
Quality Accounts 2011/12
Page 31 of 31