Clifton Park Hospital
Quality Account
2012/2013
Contents
Contents Page
2
Welcome to Ramsay Health Care UK
4
Welcome to Clifton Park Hospital
5
Introduction to our Quality Account
6
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
7
1.2
Hospital accountability statement
9
PART 2 – QUALITY PRIORITIES AND MANDATORY STATEMENTS
2.1
Quality Priorities
10
2.1.1 Review of clinical priorities 2012/13 (looking back)
10
2.1.2 Clinical Priorities for 2013/14 (looking forward)
16
2.2
Mandatory statements relating to the quality of NHS services
provided
19
2.2.1 Review of Services
19
2.2.2 Participation in Clinical Audit
20
2.2.3 Participation in Research
22
2.2.4 Goals agreed with Commissioners
23
2.2.5 Statement from the Care Quality Commission
23
2.2.6 Statement on Data Quality
23
2.2.7 Stakeholders views on 2012/13 Quality Accounts
26
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.0
Review of quality performance
28
3.1
Patient Safety
30
3.1.1 Infection prevention and control
30
3.1.2 Cleanliness and hospital hygiene
32
3.1.3 Safety in the workplace
32
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3.2
Clinical Effectiveness
33
3.2.1 Return to theatre
33
3.2.2 Readmission to hospital
34
3.3
Patient Experience
34
3.3.1 Patient satisfaction surveys
35
3.3.2 Patient reported outcome measures (PROMS)
36
3.4
38
Case Study
Appendix 1 – Clinical Audits
40
Appendix 2 – CQUIN schedule
41
Quality Accounts 2012/2013
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Welcome to Ramsay Health Care UK
Clifton Park 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)
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Welcome to Clifton Park Hospital
Clifton Park Hospital was purpose built and opened in January 2006 to deliver
elective NHS activity. In October 2010 the hospital secured a three year standard
acute contract (SAC) with NHS NYY and NHS ERY to deliver orthopaedic services.
In April 2012 this contract was extended a further 6 months until April 2014 and is
now commissioned by Vale of York Clinical Commissioning Group acting as coordinating commissioner and Scarborough and Ryedale, East Riding of Yorkshire,
Harrogate & Rural District and Hambleton, Richmondshire & Whitby Clinical
Commissioning Groups as associates.
In addition to this SAC activity, additional orthopaedic activity from York Trust is
undertaken. The hospital is also recognised by most major insurance companies and
undertakes self pay and insured work.
Brief description of unit and facilities
Clifton Park Hospital is a 24 bedded in patient unit providing a wide range of elective
orthopaedic surgical procedures including treatments for problems with hips, knees,
shoulders, hand, wrist and elbow and foot and ankle. The hospital has a large out
patients department, on-site x-ray and physiotherapy (including a small gym), mobile
MRI, a day case unit, two laminar flow theatres and a restaurant which is open to
staff, patients and visitors.
The hospital provides a full range of high quality orthopaedic services, these include,
outpatient consultation, outpatient procedures, investigations/diagnostics, surgery
and follow up care for all patients of 18 years and above. From 1st April 2012 to 31st
March 2013 the hospital has treated 3010 admitted patients, 95% of which were
treated under the care of the NHS.
The hospital has a unique structured secondment agreement with York Teaching
Hospitals NHS Foundation Trust who provide 40 specialist consultant orthopaedic
surgeons and anaesthetists to work from the facility. The hospital also has a training
agreement with York Trust, enabling registrars and extended scope practitioners to
work alongside consultants at the hospital. Our seconded clinicians are supported by
a team of 42 Nursing staff, 13 Health Care Assistants, 12 Allied Health Professionals
and 41 support staff which includes porters, hotel services and 23 administration
staff. The hospital’s Resident Medical Officer is on site 24 hours a day, working
alongside these teams. Our staff-to-patient ratios are managed on a daily basis to
meet the individual clinical requirements of our patients.
As well as our secondment agreement with York Teaching Hospitals NHS Foundation
Trust, we have in place, several service level agreements with them to facilitate our
service delivery and ensure continuity of care.
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Introduction to our Quality Account
This Quality Account is Clifton Park Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people we
treat. It will also show that we regularly scrutinise every service we provide with a
view to improving it and ensuring that our patient’s treatment outcomes are the best
they can be. It will give a balanced view of what we are good at and what we need to
improve on.
Each Ramsay site has developed its own Quality Account. It includes some Group
wide Initiatives, but describes the many excellent local achievements and quality
plans that we would like to share.
Quality Accounts 2012/2013
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Part 1
1.1 Statement on quality from the General Manager
Debbie Craven, General Manager,
Clifton Park Hospital
“Clifton Park Hospital successfully delivered the GC4 contract from January
2006 to September 2010. In October 2010 we commenced a three year standard
acute contract, commissioned by NHS NYY and NHS ERY following a tender
process where we demonstrated our continuing high level of quality service
delivery this contract was extended a further 6 months in April 2013.”
This is the third Quality Account to be submitted by Clifton Park Hospital (CPH) 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.
Our hospital vision statement, which will be reflected throughout this report, is that:
“Clifton Park Hospital is committed to being a leading provider of orthopaedic health
care services by delivering high quality outcomes for patients at efficient cost
ensuring profitability.”
Patient safety is our highest priority and our robust recruitment processes and
training programmes ensure that staff are competent and fully trained in all aspects of
service provision.
Clifton Park Hospital continually achieves consistently high patient satisfaction scores
and, by studying results throughout the year, we constantly seek ways to further
improve the patient experience.
Clifton Park Hospital 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.
Quality Accounts 2012/2013
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Clifton Park Hospital 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.
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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.
Debbie Craven
General Manager
Clifton Park Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Ian Whitaker – MAC Chairman
Mrs Gwenn Mather - Clinical Governance Chair
Mr Stefan Andrejczuk – Regional Director North
Quality Accounts 2012/2013
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Part 2
2.1 Quality priorities for 2013/14
Plan for 2012/13
On an annual cycle, Clifton Park Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our patients and work in close 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 ongoing at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the recommendations
from various hospital committees which represent all professional and management
levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2012/13
Patient Safety
VTE risk assessment – Clifton Park Hospital carries out a VTE risk assessment
on all admitted surgical patients as per Ramsay Policy No CM001 and adhering
to National Institute for Clinical Excellence (NICE) Guidance 2010. The aim
being to reduce the risk of patients suffering a venous thrombo embolism
following surgery
All nursing staff have undertaken VTE competency assessment via DoH on line
assessment tool.
From 1st October 2010, Clifton Park Hospital entered into a contract for the
provision of NHS services through the Commissioning for Quality & Innovation
Payment Framework (CQUIN). Payment is conditional on achieving quality
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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.
1
100
0.98
98
0.96
96
0.94
94
0.92
92
0.9
90
0.88
88
0.86
86
0.84
84
0.82
82
0.8
80
Excellent
Good
Fail
Current
Target
Clifton Park NHS Treatment Centre
VTE compliance results are benchmarked through the National Statistics at
http://www.dh.gov.uk/en/publicationsandstatistics/Publications/Publicatio
nsStatistics/DH
NHS Safety Thermometer (with effect from April 2012). This is a mandatory
section of Quality Requirements and Nationally Specified Events (CQUIN)
that we are required to report on. In addition to VTE compliance and falls, the
other reportable elements are Pressure Ulcers and Urinary Tract Infections.
In order to demonstrate compliance with this measurement, a monthly 24 hour
prevalence audit, using the NHS Safety Thermometer Survey tool is conducted
and submitted on line.
In total 253 patients were included in the survey as above with an outcome of
100% of patients receiving harm free episodes of care
National Joint Registry (NJR) – Clifton Park Hospital participates in the National
Joint Registry audit programme. 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.
Quality Accounts 2012/2013
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Clifton Park exceeds the national 90% benchmark figure for NJR consent as
demonstrated in the results below. NJR consent compliance has risen to 100% in the
last two quarters and submission of BMI rate has increased over the past year as
tabled
Clifton Park Hospital
Submission Volumes
Consent & link ability %
BMI Rate %
2012/13 2012/13 2012/13 2012/13
Q1
Q2
Q3
Q4
201
201
225
230
98
99
100
100
97
99
98
98
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
1
0.95
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
Actual
95% Target
Clifton Park Hospital
Quality Accounts 2012/2013
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A new Pathology service was implemented in April 2012, providing both off-site
analyses and onsite Point of Care Testing (POCT) and analyses. The advantage
of the service is the ability to access electronic reports immediately, ensuring an
efficient service for patients. A very comprehensive Blood Transfusion Service
continues to be provided by York Trust Hospital under a Service Level
Agreement.
Consultant Microbiology input is also available through a Service level agreement
with local Consultant microbiologists.
Clinical Effectiveness
Better outcomes and improving Patient experience
Pain control - Patients have the right to care that promotes comfort and minimizes
pain. Ramsay Healthcare set up a committee of experienced Clinicians to develop
guidelines and protocols for pain control following surgery. A member of Clifton Park
Hospital clinical team was part of this committee and we were also a pilot site for the
policy implementation.
Taking into account NICE and other best practice guidance, (Australian and New
Zealand College of Anaesthetists and Faculty of Pain Medicine (2020); Nursing and
Midwifery Council (2007) Standards for Medicine Management) the following were
introduced:
A policy on “Acute post-operative pain management in Adults”; a pain assessment
tool, and a patient information leaflet “Managing your Pain after your operation” have
all been implemented very effectively and patient survey results show that we have
exceeded our target of 90% patients saying “Yes” to the Questions;
Did a member of staff explain the purpose of the medications you are toi take
home in a way you could understand?
Do you think the nurses did everything they could to control your pain?
This is demonstrated in the table below, showing a sample quarter survey as
reported to the CCG (formally the PCT).
Pain Control is also a local CQUIN measure for Clifton Park Hospital
Quality Accounts 2012/2013
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Month
July 12
August 12
September
12
No of
patients
248
213
226
No of
responses
186
132
153
%
Question
75%
Were you Ever in Pain
Do you think the nurses did
everything they could to help
control your pain
Did a member of staff explain the
purpose of the medications you
are to take home
In a way you could understand
106
Were you Ever in Pain
Do you think the nurses did
everything they could to help
control your pain
Did a member of staff explain the
purpose of the medications you
are to take home
In a way you could understand
91
Were you Ever in Pain
100
61%
67%
Do you think the nurses did
everything they could to help
control your pain
Did a member of staff explain the
purpose of the medications you
are to take home
In a way you could understand
Yes
Yes
Definitely
Yes to
some
Extent
No
N/A
%
80
184
2
99%
184
2
100%
41
131
1
99%
130
2
100%
53
151
147
1
1
98.7%
6
Ambulatory Day Care
As part of Ramsay’s National Project for Ambulatory Day Care services, Clifton Park
Hospital has:
Appointed an Ambulatory Care lead nurse who is a member of the British
Association of Day care Surgery (BADS).
Facilitated the ambulatory process by aiming to place day care patients first on
operating lists or as clinically indicated.
Developed an action plan to implement staggered admission times where
appropriate to improve the patient experience, aiming to reduce the waiting time
from admission to procedure.
Further enhanced efficiencies at Clifton Park Hospital by implementing a nurse
led discharge service within our Ambulatory day care unit.
On discharge, patients are provided with contact details should they have any post
operative problems and receive a post discharge phone call within 48 hrs of
discharge.
The Satisfaction rating of waiting time from admission to procedure still remains at
82% so this is still an area of focus and will be addressed as part of the Patient
journey mapping process
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100%
Patient experience – informing patient choice
Increasing the use of Patient Reported Outcomes Studies (PROMs) – Clifton
Park Hospital uses the National PROMS results for hip and knee replacements
patients. These are used to gain a better understanding of treatment outcomes
from a patient point of view. Results are shared with Consultants at our Clinical
Governance meetings. All members of the multi-disciplinary team are encouraged
to review the PROMs outcomes and changes made as required to improve the
patient experience. Clifton Park Hospital was below the target of 79.6% of
submitting completed consent form for patient undergoing Hip Replacement
surgery. Increased focus on this- particularly at the pre assessment stage of the
patient pathway, has increased our compliance rate to 84.2%, as demonstrated in
the graph below.
National compliance rates for consent
79.6 % hips
81.9% knees
Compliance rate of Clifton Park Hospital submitting completed consented
forms
100%
90%
80%
70%
60%
50%
40%
84.2%
84.5%
30%
20%
10%
0%
Hips
Knees
Patient Experience – personal needs. This is a mandatory section of Quality
Requirements and Nationally Specified Events (CQUIN) that we are required to
report on. Looking at 5 question, each describes a different element of the
overarching theme “responsiveness to personal needs”:
1.
2.
3.
4.
5.
Involved in decisions about care/treatment
Hospital staff available to talk about worries/ concerns
Privacy when discussing treatment
Informed about medication side effects
Informed who to contact if worried after leaving hospital
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Question
Answer
Score
Involvement about decisions in treatment/Care
Yes Definitely
81.0%
Yes to some extent
17.0%
No
2.0%
Yes Definitely
24.0%
Yes to some extent
14%
No
3%
Had no worries/fears
60%
Yes always
93%
Yes Sometimes
6%
No
1%
Yes Completely
45%
Yes to some extent
16%
No
12%
Did not need an explanation
27%
Yes
97%
No
2%
Don't know/can’t remember
1%
Hospital staff being available to talk about worries/concerns
Privacy when discussing condition/Treatment
Informed about medication side effects
Informed who to contact if worried after leaving hospital
The composite value required for CQUIN is above 80% for the response “Yes
definitely/always” and “no worries fears/ did not need explanation” and the above
results from the 2012 NHS survey demonstrates a score of 85.4%
2.1.2 Clinical Priorities for 2013/14
Patient Safety
Informed 2 stage Consent: It is Ramsay policy that consent will be initiated at the
earliest stage and evidenced by the first stage of the consent form being
completed and the patient confirming receipt of information to allow him/her to
make an informed choice of whether to proceed with the procedure and
satisfactory period of time to ask further questions or be provided with further
information. The second stage will be on the day of procedure prior to the patient
transfer to the procedure/operating suite.
Clifton Park Hospital aim to achieve 2 stage consent for all patients, however this
will not be possible with patients who are admitted under the “Direct to list”
process (via MSK).
Quality Accounts 2012/2013
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National Safety Thermometer – this is an ongoing National CQUIN measurement
undertaken through pre-determined monthly prevalence survey. Please refer to
table below.
Clinical Effectiveness
Remapping of the patient journey process from referral to discharge from hospital,
to identify areas for improved efficiencies and patient outcomes (to include
staggered admission times to reduce wait from admission to procedure for
inpatients and improve our score of 82 %.)
CQUIN Measures – a mandatory requirement (as below)
PROMS – a mandatory requirement
RAMSAY - 2013/14 CQUIN SCHEME
Quality Domain
Goal Number
1
Goal
Weighting
VOYCCG
(% of CQUIN
scheme
available)
0.167%
Goal
Weighting
SRCCG
0.167%
Goal Name
Friends & Family
Test
Description of Goal
Improve patient experience.
F&FT will provide timely, granular
feedback from patients about
their experience.
2
NHS Safety
Thermometer
Reduce harm. The power of the
NHS Safety Thermometer lies in
allowing frontline teams to
measure how safe their services
are and to deliver improvement
locally.
0.166%
0.166%
3
VTE
0.167%
0.167%
4
Pain Management
1.000%
1.000%
5
Electronic Discharge
Letters to GPs
Reduce avoidable death,
disability and chronic ill health
from Venous-thromboembolism
(VTE)
Proactively help patients with
pain management following
surgery
All discharge letters to be
emailed to GPs in VOYCCG
1.000%
1.000%
Safety
Effectiveness
Yes
Yes
Patient
Experience
Yes
Yes
Total
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Innovation
Patient experience
Friends and Family survey: From April 2013, all patients will be asked a
simple question to identify if they would recommend a particular A&E
department or ward to their friends and family. The results of this
friends and family test will be used to improve the experience of
patients by providing timely feedback alongside other sources of
patient feedback. It will highlight priority areas for action. This is a
national CQUIN measure for Clifton Park Hospital.
Patient discharge letters to be sent electronically to GP within 24hrs of
discharge from hospital. Patient discharge letters are presently in paper form. The
move to electronic letters will improve timeliness, efficiency and address legibility
issues.
Actions from patient survey outcomes from the 2012 NHS Patient survey and
“We Value Your Opinion” required to improve waiting times from admission to
theatre and fasting times. This will be addressed in conjunction with the Patient
journey mapping process as described in Clinical Effectiveness Priorities
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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 2012/13, Clifton Park Hospital provided Elective Orthopaedic NHS services.
Clifton Park Hospital continually reviews all the data available to them on the quality
of care provided.
The income generated by the NHS services reviewed from 1 April 2012 to 1 April
2013 represents approximately 95% per cent of the total income generated from the
provision of services by Clifton Park Hospital during this period.
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 2012/13, the indicators on the scorecard which affect patient safety
and quality were:
Human Resources
HCA Hours as a % of Total Nursing hours is 31%
Agency Hours as % of Total Hours is 0.004%
4.8% Staff Turnover
3.29% Sickness
Mandatory Training = 85% completed in last 12 months
Number of Significant Staff Injuries = 0
Appraisals = 87% completed in last 12 months
Patients
11 x Formal complaints 1st April 2012 to 31st March 2013 = 0.36 %
92% Patient Satisfaction Score
1 Significant reportable incidents during 2012 = 0.03%
2 Readmissions patients in 2012 = 0.6% readmissions per 1000 Admissions
0 EMSA (Eliminating Mixed Sex Accommodation) breaches
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Quality
Our overall Infection Control Audit score is 99%.
A comprehensive Health, Safety and Facilities audit is carried out annually. This
internal audit returned a score of 96% compliance and an action plan has been
developed to correct the key areas identified. (2012 score 94%)
A Disability Discrimination Act audit was carried out in January 2013.
2.2.2 Participation in Clinical Audit
During 1 April 2012 to 31 March 2013, five national clinical audits and National
Confidential Enquiries covered NHS services that Clifton Park Hospital provides.
The national clinical audits and national confidential enquiries that Clifton Park
Hospital was eligible to participate in during 1 April 2012 to 31March 2013 are as
follows:
National Clinical Audits and National Confidential Enquiries (NA = not
applicable to the services provided)
For information/reports on audits participated in please go to the following link:
http://www.hqip.org.uk/ncas-for-qa-introduction/
Name of Audit
Participation
Peri-and Neo-natal
Children
Paediatric pneumonia (British Thoracic Society)
Paediatric asthma (British Thoracic Society)
Pain management (College of Emergency Medicine)
Childhood epilepsy (RCPH National Childhood Epilepsy Audit)
Paediatric intensive care (PICANet)
Paediatric cardiac surgery (NICOR Congenital Heart Disease
Audit)
Diabetes (RCPH National Paediatric Diabetes Audit)
Acute care
Emergency use of oxygen (British Thoracic Society)
Adult community acquired pneumonia (British Thoracic Society)
Non invasive ventilation -adults (British Thoracic Society)
Pleural procedures (British Thoracic Society)
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
Severe sepsis & septic shock (College of Emergency Medicine)
Adult critical care (ICNARC CMPD)
Potential donor audit (NHS Blood & Transplant)
Seizure management (National Audit of Seizure Management)
Long term conditions
Diabetes (National Adult Diabetes Audit)
N/A – no service
N/A – no service
N/A – no service
N/A – no service
% cases
submitted
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
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Name of Audit
Participation
Heavy menstrual bleeding (RCOG National Audit of HMB)
Chronic pain (National Pain Audit)
Ulcerative colitis & Crohn's disease (UK IBD Audit)
Parkinson's disease (National Parkinson's Audit)
Adult asthma (British Thoracic Society)
Bronchiectasis (British Thoracic Society)
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Intra-thoracic transplantation (NHSBT UK Transplant Registry)
Liver transplantation (NHSBT UK Transplant Registry)
Coronary angioplasty (NICOR Adult cardiac interventions audit)
Peripheral vascular surgery (VSGBI Vascular Surgery Database)
Carotid interventions (Carotid Intervention Audit)
CABG and valvular surgery (Adult cardiac surgery audit)
Cardiovascular disease
Acute Myocardial Infarction & other ACS (MINAP)
Heart failure (Heart Failure Audit)
Acute stroke (SINAP)
Cardiac arrhythmia (Cardiac Rhythm Management Audit)
Renal disease
Renal replacement therapy (Renal Registry)
Renal transplantation (NHSBT UK Transplant Registry)
Cancer
Lung cancer (National Lung Cancer Audit)
Bowel cancer (National Bowel Cancer Audit Programme)
Head & neck cancer (DAHNO)
Oesophago-gastric cancer (National O-G Cancer Audit)
Trauma
Hip fracture (National Hip Fracture Database)
Severe trauma (Trauma Audit & Research Network)
Psychological conditions
Blood transfusion
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
Medical use of blood (National Comparative Audit of Blood
Transfusion)
Health promotion
Risk factors (National Health Promotion in Hospitals Audit)
End of life
Care of dying in hospital (NCDAH)
N/A – no service
Additional Audits
National Surveillance Programme (HPA)
PEAT
YES
YES
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
% cases
submitted
100%
100%
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
N/A – no service
YES
YES
100%
N/A
The reports of three national clinical audits from 1 April 2012 to 31 March 2013 were
reviewed by the Clinical Governance Committee at Clifton Park Hospital
Quality Accounts 2012/2013
Page 21 of 55
Local Audits
Clifton Park Hospital participates in the Ramsay Corporate Audit programme (the
schedule can be found in appendix 2) all of which go through the Clinical Governance
Committee and actions taken recorded to improve the quality of the healthcare
provided:The following actions were indicated by the outcomes of the following audits (based
on a random selection of 10 sets of patients’ medical records) that fell below 90%.
The Deteriorating Patient: scored only 86% Sept 2012 due to not all staff
completing scoring tool correctly despite undertaking all relevant observations.
Further training was completed and repeat audit in March 2013 indicated an
improved score of 92%
VTE Risk assessment: scored only 60% in August 2012 due to the Consultants
not signing the completed risk assessments undertaken by nursing staff.
Following discussions with medical staff this improved to 85% in February 2013.
All patients undergo VTE risk assessment prior to surgery by the nursing team.
The completed risk assessment form is retained in the patient’s medical records,
the outcome is documented in the patients paper care pathway and again
electronically on the Patient administration system to include all prophylaxis
applied. The consultants document the required prophylaxis on the operating
notes and chemical prophylaxis is transcribed to the drug prescription form by the
resident medical officer, however the consultants occasionally fail to sign the
completed risk assessment form, thus loosing vital audit scores. Consultants
have been encouraged to completed this part of the process and compliance is
improving
Physiotherapy records: scored 89% March 2012 due to failure to complete all
details in documentation, an action plan was put in place to address this and the
audit repeated in March 2013 showed an improvement to 96% compliance
2.2.3 Participation in Research
Approved research of “A Prospective, Non Comparative, Multicentre, Multinational
Study to Determine the Performance & Survivorship of the Sigma HP Partial Knee
System” commenced in June 2012, However the study was discontinued in April
2013, due to the low compliance of other study sites
Corporate Clinical Governance granted permission for Clifton Park Hospital to
participate into Ethics Committee Approved research of “Prospective, Single Arm
Multiconfiguration Investigation to Assess the Functional Performance of Attune
Primary Total Knee Arthroplasty System” which commenced in October 2012. This
study is going well
Quality Accounts 2012/2013
Page 22 of 55
We also obtain consent from patients to donate bone samples to York University to
aid their research into osteoporosis this has been approved by research ethics
committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Clifton Park’s income from 1 April 2012 to 31st March 2013 was
conditional on achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation payment framework.
See Appendix 2 for our Schedule.
2.2.5 Statement from the Care Quality Commission (CQC)
Clifton Park Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March is registered without conditions
An unannounced inspection of Clifton Park Hospital was undertaken on 31st January
2013 and all standards were met with full compliance.
The Care Quality Commission has not taken enforcement action against Clifton Park
Hospital during 2012/13.
Clifton Park Hospital was identified as an outlier for hip revisions in the National Joint
Registry 9th Annual Report and was contacted by the Care Quality Commissions
Surveillance manager. A detailed response was provided regarding metal on metal
hip replacements and recall process. The CQC responded ‘We have reviewed the
information you have provided and do not feel that we need to undertake additional
enquiries at this time’
2.2.6 Data Quality
Data Quality is taken very seriously at Clifton Park Hospital. The quality of our data,
whether this is in the form of local audits, paper records, or data submitted to the DoH
or CCGs, reflects directly on the quality of the services provided at the hospital.
As part of our Standard Acute Contract, we are required to demonstrate that we
monitor and improve data, to support care quality which is undertaken through our
Clinical Audit programmer. Part of our audit programme covers medical records and
anaesthetic records ensuring that key information is recorded throughout the patient
journey. The actions required for each audit are documented and discussed at
various hospital committee meetings
Quality Accounts 2012/2013
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Audit results for anaesthetic records:
Audit
Anaesthetic records
Feb 2012
94%
Aug 2012
98%
March 2013
100%
July 2012
98%
Oct 2012
100%
Audit results for medical records audit:
Audit
Medical records audit
April 2012
100%
Jan 2013
100%
Secondary Uses Service (SUS) submissions: During the period April 12 – March 13
Clifton Park Hospital’s SUS submissions were 100%. This score is directly
attributable to the hospital’s dedicated data quality team who work alongside all
departments in the hospital to ensure that all data is entered correctly and also the
suite of reporting tools available through Ramsay’s corporate IS team.
NHS Number and General Medical Practice Code Validity
Clifton Park Hospital submitted records during 2012/13 to the Secondary Uses
Service for inclusion in the Hospital Episode Statistics which are included in the latest
published data. The percentage of records in the published data which included:
The patient’s valid NHS number was:
100% for admitted patient care;
100% for outpatient care; and
N/A for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was:
100% for admitted patient care;
100% for outpatient care; and
N/A for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall for
2012/13 was 77% and was graded ‘green’ (satisfactory).
This information is publicly available on the DH Information Governance Toolkit
website at: https://www.igt.connectingforhealth.nhs.uk/
Quality Accounts 2012/2013
Page 24 of 55
Clinical coding error rate
Clifton Park Hospital was not subject to the Payment by Results clinical coding audit
during 2012/13 carried out by the Audit Commission.
Clifton Park Hospital employs a Clinical Coder who has undertaken the Connecting
for Health Clinical Coding Foundation Course in 2011 and is responsible for all
diagnostic and procedure coding and is actively involved in audit processes.
Ramsay Health Care Information Governance Req 505 Attainment Levels Achieved 2012 Internal
Audit
Hospital Site
Audit
Date
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
Clifton Park
Hospital
Feb
91.67%
88.37%
96.67%
91.89%
12
Quality Accounts 2012/2013
Page 25 of 55
2.2.7 Stakeholders views on 2012/13 Quality Account
Copies of this quality account for comment prior to publication have been sent to:
Vale of York Clinical Commissioning Group ( VOYCCG)
Healthwatch York
Comments received are published below
CLIFTON PARK HOSPITAL
QUALITY ACCOUNT STATEMENT 2012/13
Vale of York Clinical Commissioning Group is the lead Commissioner for Clifton Park
Hospital and we are pleased to be able to review and comment on their Quality Account
for 2012/13 in conjunction with our Associate Commissioner, NHS East Riding of
Yorkshire.
We have worked hard together as Commissioners and Providers to improve the quality
of patient services for our populations. Through the contract management process,
Clifton Park Hospital has provided assurance to us as Commissioners, by sharing a
range of data and quality metrics which have assured us of the quality of patient
services. We are especially pleased to note the following achievements:Achievement of all the quality improvement goals in the 2012-13 CQUIN Scheme.
which showed that 100% patients surveyed received harm free episodes of care.
feedback from patients regarding pain control and the care received at
Clifton Park Hospital.
The priorities identified in the Quality Account for 2013/14 clearly identify with the three
elements of quality i.e. patient safety, clinical effectiveness and patient experience and
focus on:Patient Safety
– introduction of 2 Stage Consent process.
Clinical Effectiveness
arge
from hospital which will improve timeliness, efficiency and address legibility issues.
Patient Experience
theatre and fasting times for inpatients.
– ‘no decision about me without me’
of using hospital services.
As a commissioner we commend this Quality Account for its accuracy, honesty, and
openness. We recognise that Clifton Park Hospital delivers good quality patient care, and
we look forward to working with Ramsay Healthcare to bring about further improvements
in quality during 2013.
Rachel Potts
Chief Operating Officer
Vale of York Clinical Commissioning Group
Quality Accounts 2012/2013
Page 26 of 55
Response from Healthwatch York to Clifton Park Hospital Quality
Accounts 2012/13
25th June 2013
Thank you for giving Healthwatch York the opportunity to comment on your Quality
Accounts for 2012/3. The report is very informative, well laid out and generally easy
for lay people to read.
It was very pleasing to see that the patient satisfaction survey has been used to
identify two areas for improvement which are included in the clinical priorities for
2013/14.
In terms of the patient experience, it is re-assuring to see the low rates of readmission and unplanned return to theatre.
It is good to see that the strong focus on patient safety has led to a number of
improvements, and that risks to patient safety come to light through a number of
routes.
The case study about setting up the pre-operative education class was particularly
interesting and is a good demonstration of a person centred approach. It is pleasing
that the hospital recognises that devoting time to preparing patients for their surgery
does improve treatment outcomes.
Healthwatch York looks forward to identifying opportunities to work with Clifton Park
during the coming year.
Quality Accounts 2012/2013
Page 27 of 55
Part 3
Statements of quality delivery
Matron, Gwenn Mather
3.0 Review of quality performance 1 April 2012 - 31 March 2013
Introduction
“Our overriding commitment is to provide safe and effective care; the
guiding principle is to put our patients’ interests first and key to this is our
capacity to listen, be responsive and to act on their feedback. We already
take patient views and ratings into account in any assessment of our
performance but now we will increasingly draw on effective real-time
information and this includes on-line patient surveys. Added to which there
are more opportunities to use new measures of quality of care and patient
safety and be able to make a difference to improvements in future practice.
Importantly these new metrics should ensure performance which needs
improving, can be quickly identified and fixed’.
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay
Health Care UK)
Ramsay Clinical Governance Framework 2012
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care, clinicians
are enabled to provide that care and the organisation can satisfy itself that we are
doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance systems in
the organisation and should not be seen as a “stand-alone” activity. All management
systems, clinical, financial, estates etc, are inter-dependent with actions in one area
impacting on others.
Several models have been devised to include all the elements of Clinical Governance
to provide a framework for ensuring that it is embedded, implemented and can be
Quality Accounts 2012/2013
Page 28 of 55
monitored in an organisation. In developing this framework for Ramsay Health Care
UK we have gone back to the original Scally and Donaldson paper (1998) as we
believe that it is a model that allows coverage and inclusion of all the necessary
strategies, policies, systems and processes for effective Clinical Governance. The
domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
The Matron at Clifton Park Hospital actively promotes clinical governance and
collaborates with NHS partners to ensure that Clifton Park Hospital 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 (CCGs from April 1st 2013) these include – Quality
Performance Group, MCA Group; Local Intelligence Network for Controlled Drugs
group.
Quality Accounts 2012/2013
Page 29 of 55
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 NHS Commissioning Board Special Health Authority.
Clifton Park Hospital has systems in place for scrutinising all national clinical
guidance and selecting those that are applicable to our business and thereafter
monitoring their implementation.
3.1 Patient safety
Clifton Park Hospital is a progressive hospital focussed on improving its performance
every year, particularly with regard to 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 demonstrated below: -
3.1.1 Infection prevention and control
Clifton Park Hospital has a very low rate of hospital acquired infection and has
had no reported MRSA Bacteraemia or Clostridium Difficile since opening in
January 2006.
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 Clifton Park Hospital remains below the lowest
percentile for infection rates.
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.
Quality Accounts 2012/2013
Page 30 of 55
Clifton Park Hospital has its own Infection Control Link Nurse and IPCC is included in
our Clinical Governance agenda.
Programmes and activities within our hospital include:
Mandatory annual infection prevention and control training.
Infection Control Audit
In–house training i.e. hand washing
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
Clifton Park Hospital has had a low HCAI rate annually for the past 2 years and
is well below the National Average.
Hospital Acquired Infections
2
1
0
10/11
11/12
12/13
Clifton Park 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 graph below shows our PEAT scores over the last 2 years. The latest result
indicates improved scoring following the implementation of the redecorating
programme demonstrating the improvement to the hospital environment.
PEAT is to be replaced by PLACE (Patient Led Assessment of the Care
Environment) and will be undertaken in June 2013
Quality Accounts 2012/2013
Page 31 of 55
PEAT audit results 2011 ; 2012
100%
90%
80%
70%
60%
50%
99%
99.20%
2011
2012
40%
30%
20%
10%
0%
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. Staff at Clifton Park Hospital have a high
awareness of safety which has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient safety.
The addition of an electronic system “Riskman” in August 2012 enables the central
corporate collation of information regarding adverse events and complaints. This in
turns enables the ability to identify trends both locally and corporately
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 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
Adverse Incidents and near misses reported at Clifton Park Hospital:
2011 = 12.5 per 1000 admits (to March 31st)
2012 = 7.6 per 1000 admits (to March 31st)
2013 = 5 per 1000 admits ( to March 31st)
The incidents reported include patients, visitors, staff and sub-contractors who utilise
and access the Hospital. The above figures indicate that we encourage the reporting
of all incidents no matter how minor, reflecting a raised awareness of the importance
of safety in the workplace.
Quality Accounts 2012/2013
Page 32 of 55
3.2 Clinical effectiveness
Clifton Park Hospital has a Clinical Governance team and committee (to include
Consultant surgeon and Consultant Anaesthetist) that meet regularly through the
year to monitor quality and effectiveness of care. Key performance indicators, clinical
incidents and complaints, patient and staff feedback, training and development and
infection control are systematically reviewed to determine any trend that requires
further analysis or investigation. More importantly, recommendations for action and
improvement are presented to hospital management and medical advisory
committees to ensure results are visible and tied into actions required by the
organisation as a whole.
3.2.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or
specific surgical team. Ramsay’s rate of return is very low consistent with our track
record of successful clinical outcomes
1
0.5%
0.8
0.4%
Number
0.6%
0.6
0.3%
0.4
0.2%
0.2
0.1%
0
Unplanned Return to
Theatre Number
Ja
n
Fe
b
Ma
r
Ap
r
Ma
y
Ju
n
Jul
Au
g
Se
p
Oc
t
No
v
De
c
0
0
0
0
0
0
0
0
0
1
0
0
Rate
Unplanned Returns to Theatre 2012
1.2
0.0%
Unplanned Return to
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.5% 0.0% 0.0%
Theatre Rate
As can be seen in the above graphs our return to theatre rate remains very low.
These figures are constantly monitored throughout the year via our clinical
governance and medical advisory committee framework.
Quality Accounts 2012/2013
Page 33 of 55
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.
Readmissions
0.07%
0.06%
0.05%
0.04%
0.03%
0.02%
0.01%
0.00%
10/11
11/12
12/13
Clifton Park Hospital
As can be seen in the above graphs our readmission to hospital rate has remained
very low 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
All feedback from patients regarding their experiences at Clifton Park Hospital are
welcomed and inform service development in various ways, dependent on the type of
experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behavior – letters and cards are displayed for staff to see in staff rooms and on notice
boards. Managers ensure that positive feedback from patients is recognized 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.
Quality Accounts 2012/2013
Page 34 of 55
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 DoH bodies occurs as required and according to Ramsay and DoH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:






Patient satisfaction surveys
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
PROMs surveys
Care pathways – patients are encouraged to read and participate in their plan of
care.
3.3.1 Patient Satisfaction Surveys
On behalf of Ramsay UK, Patient Perspective conducted a survey of NHS inpatients
discharged between January and August 2012. As a summary measure for each
question, Patient Perspective followed the approach adopted by the Care Quality
Commission in England for the National Patient Experience Survey Programme
which allows easy benchmarking with existing published national data.
The mean rating score allocates a ‘weight’ to each response, with positive scores
(e.g. excellent, very good, good) allocated a higher score than negative responses
(e.g. fair, poor). For every evaluative question, each response category is weighted
between 0 (most negative) and100 (most positive).
An average for each question is then calculated with higher scores indicating better
results (or a more positive patient experience) and 100 being perfect. Clifton Park
Hospital received an overall score of 92% satisfaction for 2012 this was the same
score as 2011.
Quality Accounts 2012/2013
Page 35 of 55
From the NHS patient satisfaction survey it is possible to identify both areas for
improvement as well as areas where we excel. Following the publication and
communication of the results an action plan is developed. The actions identified from
this latest survey include:
1. Waiting times from admission to Procedure
2. Fasting times
These have been included in the clinical priorities for 2013/14
3.3.2 Patient Reported Outcome Measures (PROMs)
Clifton Park Hospital participates in the Department of Health’s PROMs surveys for
hip and knee surgery for NHS and Private patients.
The graph below shows the PROMs data for NHS patients from May 2009 to
February 2013.
Hip replacement patients
Adjusted average health gain
Oxford Hip Score
35
30
25
20
15
10
5
0
England
CLIFTON PARK NHS
TREATMENT CENTRE
YORK TEACHING
HOSPITAL NHS
FOUNDATION TRUST
Quality Accounts 2012/2013
Page 36 of 55
Knee Replacement Patients
Adjusted average health gain
Oxford Knee Score
30
25
20
15
10
5
0
England
CLIFTON PARK NHS
TREATMENT CENTRE
YORK TEACHING
HOSPITAL NHS
FOUNDATION TRUST
Access to Clifton Park Hospital and Ramsay’s PROMs results can be found at the
following website:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&category
Quality Accounts 2012/2013
Page 37 of 55
3.4 Clifton Park Hospital
Case Study
Pre-operative education class for joint replacement
clients
Since the opening of the hospital in 2007 we have had difficulty in setting up a system
by which the patients are seen by the therapy team. Initially we had two or three half
hour slots a week for the patients to attend; this wasn’t very popular and resulted in
low attendance. We then tried holding two sessions, one during working hours and
one after hours to try and maximise attendance, again we found that attendance was
low. Finally we stopped holding specific sessions and the pre-op nurses would direct
patients to us following their clinical assessment, when they would watch a video and
speak to a Physiotherapist, but this became increasingly difficult as the department
was often busy and the physiotherapist was unavailable to speak to.
In May 2012, we employed an Occupational Therapist who is hospital based. In her
initial months she familiarised herself with the patient processes and patient
requirements. The decision was made to commence pre-operative education classes
similar to other hospitals in the area, with the ability to meet eight patients per
session.
The weekly group sessions commenced in January 2012. The main aim of these
sessions is to ensure we focus on our patient’s needs and expectations, and have
everything in place for their discharge home following their Joint Replacement
surgery. We invite patients who have consented to hip, knee, shoulder and ankle
replacement surgery, to join us on a Monday morning, prior to their surgery and
discuss what will happen throughout their time with us both as an in-patient and their
needs post-discharge.
Each session is held by a Physiotherapist and the
Occupational Therapist who will discuss the patient’s journey from the day of the
operation up until their planned discharge home.
Firstly we discuss what will happen on the day of the operation, and what
comfortable clothing to bring in to wear during the recovery period.
Next we discuss the discharge criteria they will need to achieve before they can
return home. In addition to being clinically well and fully recovered from the
operation, they need, with the exception of shoulder patients, to be mobilising
safe and independently with the aid of sticks (or crutches dependent upon the
consultant), able to perform their exercise regime, be able to wash/shower and
dress, and be able to walk up and down the stairs.
Quality Accounts 2012/2013
Page 38 of 55
The Occupational therapist then discusses what equipment and/or care we will
be able to provide to each individual in the group. We also ensure each patient is
seen on an individual basis to ascertain more personal needs as required.
We then go back to a group discussion and open the floor to questions.
Basic equipment is also being provided prior to their hospital stay, which allows
patients to practice with this unfamiliar equipment, reducing anxieties.
The Occupational Therapist will also explain safe transfers with the patients, and
if any more specialist equipment is required, there is also time to further assess
and arrange for that equipment to be delivered and fitted, by herself, or the
Community Equipment Store. If this is required, patients have fed back that it is
often nicer to have met the O.T. prior to the home visit and the equipment fitting.
Since starting this group in January, we have ironed out some of the obvious
problems when starting anything new, and ask for feedback from the patients when
we have finished the session to help us to modify and update our approach. We find
that the sessions differ week to week and the patients very much benefit from
discussing their anxieties with other people going through the same procedure. We
have also noticed that if people have attended the same group and are in-patients at
the same time they appear more relaxed and confident about the whole process.
They also feel more relaxed and comfortable meeting the physiotherapist again when
the real post-operative process begins – “Getting out of bed for the first time”.
We certainly feel this group session has benefitted not only the patients but the
Occupational Therapy and Physiotherapy team.
Moving forward our plans are to facilitate people who fall out of our catchment area
for equipment and extra support, and we will have more time to be able to help with
this by identifying problems early enough to enable us to refer our patients to the
appropriate services.
Occupational therapy involvement with adults undergoing a total hip
replacement takes place in the acute inpatient or pre- operative
setting, although not exclusively (Drummond et al 2012). Given the
wider context of the ‘service user flow’ (Figure 1), it is,
therefore, important to draw attention to the person- centred and
holistic philosophy of occupational therapy
Wainwright T. and Middleton R. An orthopaedic, enhanced recovery pathway. Current
anaesthesia and critical care 2010
Quality Accounts 2012/2013
Page 39 of 55
Appendix 1 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month
Audit Programme v5.0 2012/13
Hospital Name:
Authors: R. Saunders / A. Shannon / N. Carre
Use arrow symbol to locate required audit
JUL
Anaesthetic Standards
Medical Records
AUG
OCT
98%
100%
N&H
VTE 55% 90%
100%
JAN
FEB
MAR
APR
100%
100%
JUN
VTE 95%
N&H
100%
100%
79%
95%
90%
97%
Prescribing
100%
97%
Medicines Management
92%
90%
Radiology
100%
Physiotherapy
Hand
hygiene
100%
MAY
Traffic light score
Det Pt
VTE 85% 92%
98%
97%
Controlled Drugs
Infection Prevention and
Control*
Infection Prevention and
Control - Environmental
Audit
DEC
99.6%
86%
VTE 60% Det Pt
Care Pathways and Variance
Tracking
Theatre
NOV
98%
Consent
Discharge
SEP
Implemented: July 2012
For review: June 2013
NA
Isolation
100%
Cool
Amber
90 - 99%
Amber
80 - 89%
Hot
Amber
70 - 79%
Red
69% and under
87%
91%
Records
NA
99%
Service
Standard
100%
PVCCB
UCCB
98%
99%
Environ
Transfusion
Green
100%
99%
96%
Records
97%
Hand
hygiene
SSI 97% 99%
Environ
95%
Complian
ce 94%
na
CVCCB
N/A
na
CPD
100%(on
going)
na to be Hand
rep;aced hygiene
SSI 99% by
98%
Environ
97%
98%PVCC
B
UCCB
99%
Environ
Allogeneic Autologo
Traceabilit us
y 100%
Traceabili
*Key:
CVCCB = Central Venous Catheter Care Bundle
SSI = Surgical Site Infection
PVCCB = Peripheral Venous Catheter Care Bundle
PEAT = Patient Environment Action Team
UCCB = Urinary Catheter Care Bundle
Det Pt = Deteriorating Patient
N&H = Nutrition and Hydration
VTE = Venous Thromboembolism
Copyright © 2012 Ramsay Health Care UK
Quality Accounts 2012/2013
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Appendix 2 – CQUIN Schedule
1.1
The summary of goals table in Schedule 18 Part 2 (Commissioning for Quality and Innovation (CQUIN)) shall be deleted and replaced
as follows:
“Summary of goals1
Goal
Number
Goal Name
1
VTE
VTE Risk Assessment
0.166%
Quality Domain
(Safety, Effectiveness, Patient
Experience or Innovation)
Safety
2
Patient
experience
NHS Safety
Thermometer
Composite Indicator on
responsiveness to personal needs
Improve collection of data in relation
to pressure ulcers, falls, urinary tract
infection in those with a catheter, and
VTE
Alternative to face-to-face contact
0.166%
Patient Experience
0.166%
Safety and Effectiveness
0.5%
Innovation
Pain management following surgery
1.5%
Patient Experience
3
Description of Goal
Goal weighting
(% of CQUIN scheme available)
4
Service
Transformation
5
Pain
management
Totals:
2.5%
Quality Accounts 2012/2013
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Local contract ref.
Goal number
Goal name
Indicator number
Indicator name
Indicator weighting
(% of CQUIN scheme available)
INDEPENDENT 1
1
VTE
1
VTE risk assessment
0.17%
Description of indicator
% of all adult inpatients who have had a VTE risk assessment on admission to hospital using the
clinical criteria of the national tool
Numerator
Number of adult inpatient admissions reported as having had a VTE risk assessment on admission
to hospital using the clinical criteria of the national tool (including those risk assessed using a
cohort approach in line with published guidance http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/dig
italasset/dh_117030.pdf)
Denominator
Number of adults who were admitted as inpatients (includes day cases, transfers and elective
admissions)
Rationale for inclusion
VTE is a significant cause of mortality, long-term disability and chronic ill health. It was estimated
in 2005 there were around 25,000 deaths from VTE each year in hospitals in England and VTE has
been recognised as a clinical priority for the NHS by the National Quality Board and the NHS
Leadership Team.
Reference: DH 2010 Using the Commissioning for Quality and Innovation (CQUIN) payment
framework - Guidance on national goals for 2011/12. page 8
monthly data return through Unify2
real time (on admission)
Provider
Data source
Frequency of data collection
Organisation responsible for data
collection
Frequency of reporting to commissioner
Baseline period/date
Baseline value
Provider to submit a mandatory monthly data return through Unify2
N/A
N/A
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Final indicator period/date (on which
payment is based)
31 March 2013
Final indicator value (payment
threshold)
Rules for calculation of payment due at
final indicator period/date (including
evidence to be supplied to
commissioner)
95%
Final indicator reporting date
20 working days after the end of each month (deadline for Unify2 submission)
Are there rules for any agreed in-year
milestones that result in payment?
No
Are there any rules for partial
achievement of the indicator at the final
indicator period/date?
No
95% monthly
1/12 Payment will be made for each month the unit achieves 95%.
Quality Accounts 2012/2013
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Local contract ref.
Goal number
Goal name
Indicator number
Indicator name
INDEPENDENT 2
2
Patient experience - personal needs
2
Composite indicator on responsiveness to personal needs
Indicator weighting
(% of CQUIN scheme available)
0.17%
Description of indicator
The indicator will be a composite, calculated from 5 survey questions.
Each describes a different element of the overarching theme: “responsiveness to personal needs:
• Involved in decisions about treatment/care
• Hospital staff available to talk about worries/concerns
• Privacy when discussing condition/treatment
• Informed about medication side effects
• Informed who to contact if worried about condition after leaving hospital
Numerator
Composite score reflecting the following responses to the 5 questions within the indicator as
follows
1) Involvement in decisions about treatment/care “yes definitely”
2) Hospital staff being available to talk about worries/concerns “yes definitely” and “I had no
worries or fears”
3) Privacy when discussing condition/treatment “yes always”
4) Being informed about side effects of medication “yes completely” and “I did not need an
explanation”
5) Being informed who to contact if worried about condition after leaving hospital “yes”
The composite indicator is determined by taking the total of the above responses to the 5
questions and dividing this by 5.
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Denominator
Rationale for inclusion
N/A
The indicator incorporates questions which are known to be important to patients and where past
data indicates significant room for improvement across England.
Reference: DH 2010 Using the Commissioning for Quality and Innovation (CQUIN) payment
framework - Guidance on national goals for 2011/12. page 22
Ramsay Health Care: Confidential Patient Questionnaire
Ramsay Health Care: We value your opinion (patient feedback and complaints guide)
Data source
Adult inpatient survey, from the CQC nationally coordinated patient survey programme. The
survey is conducted annually between October and January for patients who had an inpatient
episode between July and August.
Frequency of data collection
Organisation responsible for data
collection
Frequency of reporting to commissioner
Annually
Provider
Baseline period/date
Baseline value
Annually. Provider will supply Commissioner with advance data supplied by the national survey
coordination centre in February 2013.
A composite value of the five survey questions/responses of 80.00
Final indicator period/date (on which
payment is based)
Adult inpatient survey 2012 (based on inpatient episodes between July and August 2012)
Final indicator value (payment
threshold)
Composite score of ≥98% of the baseline value (80.00) will result in payment of 100% of the CQUIN
value
Rules for calculation of payment due at
final indicator period/date (including
evidence to be supplied to
commissioner)
Payment will be based on the provider having achieved the final indicator value through the survey
results
Final indicator reporting date
Are there rules for any agreed in-year
milestones that result in payment?
01/03/2013
No
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Are there any rules for partial
achievement of the indicator at the final
indicator period/date?
Yes
Rules for partial achievement at final indicator period/date (only complete if the indicator has rules for partial achievement at final indicator
period/date)
Final indicator value (payment
% of CQUIN scheme available
threshold)
Achievement of ≥95% but
75.00%
< 98% of the indicator
Achievement of ≥90% but
< 95% of the indicator
67.00%
Achievement of ≥80% but
< 90% of the indicator
33.00%
Achievement of <80% of the indicator
0.00%
Local contract ref.
Goal number
Goal name
Indicator number
Indicator name
INDEPENDENT 3
3
SAFETY THERMOMETER
3
Improve collection of data in relation to pressure ulcers, falls, urinary tract infection in those
with a catheter, and VTE
Indicator weighting
(% of CQUIN scheme available)
0.17%
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Description of indicator
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
Detailed information on the appropriate patients and relevant settings for use of the NHS Safety
Thermometer are defined in the NHS Safety Thermometer guidance for use.
The intention is for all NHS-funded providers, across community, mental health, acute and
residential and nursing care, including NHS-funded independent sector providers, to use the
Safety Thermometer, apart from where exceptions apply, as detailed in the guidance. This will
allow nationally consistent data to be collected and published as well as facilitating local
improvement activity.
Where providers already have in place existing data collections that duplicate the measures in
the tool, commissioners should use this CQUIN to incentivise transition to the safety
thermometer tool to ensure data is produced that is consistent with the national collection. All
relevant providers will be expected to have begun use of the national Safety Thermometer
measurement tool by the end of 2012/13. Use of the Safety Thermometer will be mandatory in
2013/14.
Where organisations are already submitting full data for the safety thermometer and there is no
room for further improvement, commissioners should consider increasing the proportion of
CQUIN payments available for the other national CQUIN goals.
Numerator
Denominator
Rationale for inclusion
Number of months per quarter for which a complete record of Safety Thermometer survey data
covering all appropriate patients in all appropriate settings for all relevant measures is
submitted.
Total number of relevant months in the quarter (usually 3).
Participation in data collection using the NHS Safety Thermometer is an important preparatory
step for NHS-funded provider organisations in reducing harm. Incentivising use of the NHS Safety
Thermometer will increase the participation in this data collection, establish a national baseline
of performance on the four harms and provide information on the range of performance. This
will allow the establishment of quality improvement aims for year two (further details to follow)
and contribute to the provision of data required for the Outcomes Framework and Government
Transparency Agenda.
The intention is that further improvement goals relating to outcomes measured by the Safety
Thermometer will be incentivised in future years.
Quality Accounts 2012/2013
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Data source
Data is from two primary sources according to the NHS Safety Thermometer guidance: a physical
examination of the patient (including a conversation with them or their carer) and nursing /
medical records (including pharmacy records).
Further information will be provided in due course on how to submit data.
Frequency of data collection
Data will be collated locally using the NHS Safety Thermometer tool on a single day per month
(day to be determined locally in each provider). This monthly data will be uploaded by each
provider to the NHS Information Centre on a quarterly basis (i.e. data representing the 3
constituent months in a single quarter uploaded to the IC quarterly)
Further information will be provided in due course on how to submit data.
Organisation responsible for data
collection
Frequency of reporting to commissioner
Provider
Baseline period/date
Not applicable. The CQUIN incentivises correct use of the Safety Thermometer and therefore no
baseline performance applies.
Baseline value
Not applicable. The CQUIN incentivises correct use of the Safety Thermometer and therefore no
baseline performance applies.
Final indicator period/date (on which
payment is based)
April 2012 to March 2013
Final indicator value (payment threshold)
Three consecutive quarterly submissions of monthly survey data for all relevant patients and
settings using NHS Safety Thermometer will trigger full payment of the CQUIN.
Quarterly - reporting use of NHS Safety Thermometer will be through direct submission of the
data to the Information Centre. The commissioner will use the data published by the Information
Centre to review performance for each relevant Quarter.
Quality Accounts 2012/2013
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Rules for calculation of payment due at
final indicator period/date (including
evidence to be supplied to commissioner)
Each set of complete data for a single Quarter will qualify the provider for 33.3% of the total
value for this CQUIN (given only 3 quarters of 2012/13 are in scope).
Commissioners will satisfy themselves of the appropriate completion and submission of the data
collection for each provider by reference to the Information Centre’s publication of Safety
Thermometer results for each provider. Further clarification on completeness of data submission
(for example related to patient exclusion data) should be obtained from the relevant provider if
necessary
This CQUIN will require monthly surveying all appropriate patients (as defined in the NHS Safety
Thermometer guidance) to collect data on four outcomes (pressure ulcers, falls, urinary tract
infection in patients with catheters and VTE).
Experience to date suggests data is best collected at the point of care by healthcare professionals
(in accordance with guidance) using a point prevalence survey method (one day per month),
entered into the instrument by administrative staff and aggregated at organisation level by
performance teams or other suitable staff. Data should be submitted to the Information Centre
quarterly.
A completed Safety Thermometer survey for all relevant patients must be included for each
month in the relevant quarter’s submission to trigger payment.
Final indicator reporting date
30 working days after the end of the period
Are there rules for any agreed in-year
milestones that result in payment?
No
Are there any rules for partial
achievement of the indicator at the final
indicator period/date?
Yes
Rules for partial achievement at final indicator period/date (only complete if the indicator has rules for partial achievement at final indicator
period/date)
Final indicator value (payment threshold)
% of CQUIN scheme available
Submission of partial data for a single
0.00%
quarter (1 or 2 months) will attract no
payment
Quality Accounts 2012/2013
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Submission of data representing 3 surveys
for the 3 consecutive months in a single
quarter will trigger 33.3% of the yearly total
possible payment
2.00%
Submission of data for 2 complete quarters
will trigger 66.6% of the total possible
payment.
4.00%
Quality Accounts 2012/2013
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Local contract ref.
Goal number
Goal name
Indicator number
Indicator name
Indicator weighting
(% of CQUIN scheme available)
INDEPENDENT 4
4
Service Transformation
4
Alternative to face to face contact
0.5%
Description of indicator
Transition and Implementation of alternative solutions to outpatient(OP) follow ups, reducing
'face to face' contacts
Numerator
Number of face-to-face contacts for followup appointments
Denominator
Rationale for inclusion
Total number of patient follow ups
‘Innovation, Health and Wealth’ (DH, 2011) identified that over £300million is spent nationally on
bringing patients back to Out Patients for appointments for a 'negative result'* (definition to be
agreed). The commissioner proposes to drive patient quality forward by reducing the numbers
of patients attending an outpatient follow up for a 'negative' appointments (e.g. wound healed,
no pain, benign, blood results negative, no follow up) through the use of ‘alternative’ follows up,
where it is right and safe to do so. agreed pathways (speciality identified) and clinical
engagement of provider identified systems and solutions to facilitate this change is required.
Data source
Frequency of data collection
Organisation responsible for data
collection
Frequency of reporting to commissioner
Baseline period/date
Baseline value
HES/SUS
Monthly
Provider
Final indicator period/date (on which
payment is based)
Quarterly (with monthly split)
30 April 2011 - 31 March 2012
First milestone - Ramsay to provide a proposal to the PCT by 6th June, final agreement of reduced
follow up ratio for Q2-Q4 by 30th June.
31-Mar-13
Quality Accounts 2012/2013
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Final indicator value (payment threshold)
TBC% reduction in the rate of face-to-face follow-up contacts
* rate to be agreed at Q1
Rules for calculation of payment due at
final indicator period/date (including
evidence to be supplied to commissioner)
Specialties procedures and patient criteria as well as targets / trajectories to be agreed as part of
Q1 implementation plan approval
Final indicator reporting date
Are there rules for any agreed in-year
milestones that result in payment?
20 working days after the end of each quarter
Yes
Are there any rules for partial
achievement of the indicator at the final
indicator period/date?
No
Milestones (only complete if the indicator has in-year milestones)
Date/period milestone relates to
Rules for achievement of milestones (including evidence to be supplied to commissioner)
Q1
Quarter 2 onwards
baseline data and implementation plan
rate TBC of reduction in face-to-face follow up contacts
Quality Accounts 2012/2013
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Local contract ref.
Goal number
Goal name
Indicator number
Indicator name
Indicator weighting
(% of CQUIN scheme available)
INDEPENDENT 5
5
Pain Management
5
Pain Management
1.5%
Description of indicator
To proactively help patients with pain management following surgery.
Numerator
Ramsay Healthcare Local Survey of all admitted patients to include questions:Were you ever in pain?
Did staff do everything possible to control your pain?
Did a member of staff explain the purpose of the medicines you were to take at home in a way
you could understand?
N/A
Improve the patient experience and reduce pain following surgery
Denominator
Rationale for inclusion
Data source
Frequency of data collection
Organisation responsible for data
collection
Frequency of reporting to commissioner
Baseline period/date
Baseline value
Final indicator period/date (on which
payment is based)
Final indicator value (payment threshold)
Rules for calculation of payment due at
final indicator period/date (including
evidence to be supplied to commissioner)
Final indicator reporting date
Ramsay Healthcare Local Patient Survey
Monthly
Clifton Park Hospital
Quarterly (with monthly split)
N/A
N/A
31-Mar-13
60% Response rate
90% Yes to Question 1
95% Yes to Question 2
Achieve 60% response rate to patient survey each quarter.
Q. Do you think the hospital staff did everything they could to help control your pain? Target =
90% Yes definitely
Q.Did a member of staff explain the purpose of the medicines you were to take at home in a way
you could understand? Target = 95% Yes completely
20 working days after the end of each quarter
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Are there rules for any agreed in-year
milestones that result in payment?
No
Are there any rules for partial
achievement of the indicator at the final
indicator period/date?
Yes
Rules for partial achievement at final indicator period/date (only complete if the indicator has rules for partial achievement at final indicator
period/date)
Final indicator value (payment threshold)
% of CQUIN scheme available
60% response rate each Quarter
33.33%
Do you think the hospital staff did
everything they could to help control your
pain? Target = 90% Yes definitely each
Quarter
33.33%
Did a member of staff explain the purpose
of the medicines you were to take at home
in a way you could understand? Target =
95% Yes completely each Quarter
33.44%
Quality Accounts 2012/2013
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Clifton Park Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or purpose of this
Quality Account.
If you would like to comment or make any suggestions for the content of
future reports, please telephone or write to the General Manager using the
contact details below.
For further information please contact:
01904 464 550
www.cliftonparkhospital.co.uk
Neurological Centres
Quality Accounts 2012/2013
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