Quality Account
2012/13
Extraordinary care needs
Extraordinary people
No reported MRSA Bacteraemia
In the past 3 years
Contents
Introduction Page
Welcome to Ramsay Health Care UK and The Fitzwilliam Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2011/12 (looking back)
2.1.2 Clinical Priorities for 2013/14 (looking forward)
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2
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 2012/13 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
3.4
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Appendix 3 – Glossary of Abbreviations
Quality Accounts 2013/14
Page 2 of 47
Welcome to Ramsay Health Care UK
The Fitzwilliam 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 2013/14
Page 3 of 47
Introduction to our Quality Account
This Quality Account is the Fitzwilliam 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.
The previous Quality Account for 2011/12 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 didn’t provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each 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 2013/14
Page 4 of 47
Part 1
1.1 Statement on Quality from the General
Manager
Carl Cottam, General Manager,
Fitzwilliam Hospital
As the General Manager of the Fitzwilliam Hospital I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
Our Vision is that:
“As a committed team of professional individuals we aim to consistently deliver
quality holistic care for all of our patients across a full range of care services. We
believe we are able to achieve this by continually updating our key skills and
knowledge enabling us to deliver evidence based clinical practice throughout the
Hospital. The Fitzwilliam Hospital is a recognised Centre of Excellence for the
delivery of orthopedic services”.
Our Quality Account details the actions that we have taken over the past year to
ensure that our high standards in delivering patient care remain our focus for
everything we do. Through our vigorous audit regime, and by listening to all our
stakeholders, including patient feedback, we have been able to identify areas of
good practice and where we can improve the care our patients receive. This has
enabled us to refine some of our processes which have resulted in making further
improvements.
To ensure that we deliver clinical excellence depends on the whole team. We
have an excellent training and education plan which involves all members of our
administrative and clinical teams.
Quality Accounts 2013/14
Page 5 of 47
Every individual member of staff is crucial to the success of our hospital and we
value the contribution that they make in delivering great customer care.
Our Quality Account has been produced to provide information about how we
monitor and evaluate the quality of the services that we deliver.
We hope to be able to share with the reader our progressive achievements that
have taken place over the past 2-3 years. The Fitzwilliam Hospital has a very
strong track record as a safe and responsible provider of health care services and
we are proud to share our results.
Our Quality Accounts have been developed with the involvement of our staff who
have been instrumental in developing a systems approach to risk management,
which focuses on making every effort to reduce the likelihood and consequence
of an adverse event or outcome associated with treatment of a patient.
To ensure a coordinated approach to the delivery of care for patients and to
monitor the adherence to professional standards and legislative requirements the
Clinical Governance Committee and Medical Advisory Committee meet on a
quarterly basis to review the clinical and safety performance of the Hospital.
These committees have reviewed and agree with the content and action details
within these Quality Accounts.
If you would like to comment or provide me with feedback then please do contact
me on carl.cottam@ramsayhealth.co.uk or telephone: 01733 842329.
Quality Accounts 2013/14
Page 6 of 47
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.
Carl Cottam
General Manager
Fitzwilliam Hospital
Ramsay Health Care UK
This report has been produced by:
Carl Cottam
Jane Groom
Georgina Harris
– General Manager
– Matron
– Finance Manager
This report has been reviewed and approved by:
Medical Advisory Committee Chair:
Clinical Governance Committee Chair:
Regional Director:
Mr R Hartley
Mr S Lewis
Mr James Beech
The content has also been discussed and shared with the lead Clinical
Commissioning Group representatives from North East Essex and Lincolnshire.
Quality Accounts 2013/14
Page 7 of 47
Welcome to the Fitzwilliam hospital
The Fitzwilliam Hospital has been part of the local
community for thirty years. We have a dedicated
workforce that is committed to making each and
every patient feel secure and safe. Whether our
patients are coming in for a day consultation or a
major operation we want them to feel that they are
cared for by companionate and highly trained staff
that provide skilled care 24 hours a day.
Over the past thirty years our establishment has grown from strength to strength,
with customer satisfaction increasing annually. From our friendly reception staff to
our highly skilled surgeons, patient care and opinions are what matter most; and
our first rate reviews give the entire Fitzwilliam team great pride. Not only do our
positive reviews continue to grow but our hospital has recently gone through
development to construct a brand new Ambulatory Care Unit. This enables us to
offer a streamlined day case service for those who are coming in for simple
surgery, as we hope to make our day patients feel as comfortable and at home as
our overnight clients. We have a staff of 74 highly trained nurses who work
alongside a wide variety of other health care professionals to deliver the best
possible care.
At the Fitzwilliam we provide medical and surgical services for privately insured,
self-paying and NHS patients alike, and we strive to offer the same level of
outstanding care to all. Last year we admitted a total of 7880 patients, 65% of
which were NHS. An additional 900 patients per week were seen as outpatients
by one of our 132 consultants. Our wide-ranging services cover everything from
orthopaedic and general medicine right through to aspirational medical
procedures such as breast augmentation, liposuction and facial plastic surgery.
Not only does our hospital possess some of the most up to date medical
equipment available, but our staff of consultant surgeons and physicians includes
some of the best in the country.
We are consistently engaging with local general practitioners to update them
regarding the services that we offer and the most current pathways for patient
care. This has resulted in our ability to tailor care to meet the needs of patients
and to improve quality. We continue to foster good relationships with our local
trust, Peterborough City Hospital. This affiliation promotes a robust governance
process which contributes to enhance patient safety.
We also work very closely with many local charities and organizations such as
Breast Cancer UK and East Anglia Children’s Hospice to build successful links
with the community.
Quality Accounts 2013/14
Page 8 of 47
Part 2
2.1 Quality priorities for 2013/14
Plan for 2013/14
On an annual cycle, the Fitzwilliam develops an operational plan to set objectives
for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance, including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives ongoing at any one particular
time. The priorities are determined by the hospitals Senior Management Team
taking into account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2011/12 (looking
back)
The introduction of the National Patient Safety Thermometer - The National
Patient Safety Thermometer was a newly instituted national tool to help hospitals
monitor the care and harm that patients could possibly be vulnerable too. Each
month a survey was taken to gather data in order to compare our safety
standards with other hospitals around the UK. We record data on pressure ulcers,
Quality Accounts 2013/14
Page 9 of 47
falls, catheters, UTIs and VTEs, as well as analysing additional local information.
This has enabled us to accurately establish that our patients were not exposed to
any harm and that our level of care is exceptional with a result of 100%.
Patient satisfaction - We actively engaged with our patients to find out their
opinions on our service and of areas that we could improve upon. We felt that
relying on one method of feedback would not give us an accurate picture of this,
so our strategy included three types of response. In order to ensure that we had a
completely unbiased opinion we utilised an external company to approach our
patients after they had experienced an episode of care with us. The results of our
internal audit were extremely favourable and patients consistently commented on
the care and compassionate service that they had received.
Patient satisfaction scores for overall quality show the majority of patients feel
they receive excellent quality of care and service in the Fitzwilliam Hospital. In
quarter four of 2012 the overall satisfaction score was 96.7%. To record a
satisfaction score of such a high percentage, most of our patients would have
scored us as a 9 or 10. Hospital satisfaction scores across other organizations,
including all sectors of the UK economy, are between 50 to 95% with a median
just below 80%.
Incident Report System - Last year saw the successful implementation of an
electronic reporting system (RiskMan). This has provided a much more
streamlined way for staff to report any incidents and act as a mechanism for
allowing trend analysis across a national level within the corporate structure. The
suite of reports facilitates safe and effective review and analysis of incidents and
feedback within our clinical governance and health and safety committee
meetings.
Safer Surgery Checklists - Two safer surgery checklists were introduced in the
last year to promote safer surgery in specific areas to compliment the use of the
existing WHO (World Health Organisation) Checklist. The process of safer
surgery check lists has been further embedded into practice with the introduction
of pre and post list briefings. Monthly audits are completed to ensure compliance
to the WHO standard is maintained.
Meeting Endoscopy Standards - JAG (Joint Advisory Group) accreditation was
achieved, demonstrating that we are able to deliver the best standards, as
determined by external experts, for patients undergoing endoscopic procedures.
JAG accreditation was gained for a full five years and the hospital is registered
with the GRS website. An Endoscopy working group complete six monthly
scoring censuses, agree, implement and review action plans to maintain our
Quality Accounts 2013/14
Page 10 of 47
compliance across all domains. Last year an annual reaccreditation system was
introduced by JAG and the Fitzwilliam was awarded with a certificate of
reaccreditation this year.
CQC Unannounced Inspection March 2013 - The Fitzwilliam Radiology
department was 100% compliant to all outcomes assessed, no recommendations
and excellent feedback (to view report got to www.cqc.org.uk). Fitzwilliam
Radiology department was 100% compliant to all outcomes assessed, no
recommendations and excellent
CQUIN - As part of our standard contract 2012/13 a number of national and local
CQUIN’s were agreed, of which Fitzwilliam participated. These were VTE, Patient
responsiveness, smoking cessation, BMI weight management, harm-free care,
medicines management and NET promoter / family and friends. We achieved
100% target for all CQUIN’s for 2012/13.
Human Tissue Transplantation -The Fitzwilliam provide a specialized service
that is described in further detail in a case review in the latter part of this report.
Annual submission of data and regular inspection ensure that we deliver safe
effective care. In February the Fitzwilliam passed an inspection undertaken by the
Human Tissue Authority. All criteria were met with, no recommendations were
made and the hospital received excellent feedback.
New Ambulatory Care Unit - A new facility opened within the last year
expanding the choice that we are able to offer to patients. The move towards
ambulatory care for specific procedures reduces the risk of some clinical
complications such as deep vein thrombosis. There has also been an additional
theatre which has facilitated an increase in the number of day-case patients that
we are able to treat. The bright, modern ambulatory care unit has enabled
patients to be treated by staff in an efficient and calm environment.
Cleanliness - Further infection prevention and control audits were introduced as
planned and these are now being undertaken at all Ramsay sites. Action plans
are developed locally where necessary to ensure the standards are met. PEAT
(Patient Environment Action Team) audits were also repeated and showed
improvement. This year PEAT was replaced by PLACE, which is due to be
undertaken in June 2013.
Improve Ward Efficiency – Productive Ward / Releasing Time to Care
Initiative – The productive ward is an NHS initiative developed by the institute
and improvement (2008). It focuses on the way ward teams work together and
organize themselves, in order to reduce the burden of unnecessary activates, and
Quality Accounts 2013/14
Page 11 of 47
releasing more time to care for patients in a reliable and safe manner within
existing resources. The approach is very ‘bottom up with staff suggesting ideas
and ways in which they could improve their environment and processes.
A lot of work has taken place over this last year. The work has been led by the
ward staff and facilitated by the senior management team and resulted in
significant, major environmental changes to benefit staff and ultimately release
more time to care.
2.1.2 Clinical Priorities
(looking forward)
for
2013/14
Patient Safety: Delivery of Compassionate Care
The chief nursing officer has outlined a compassionate care strategy. Care and
compassion is fundamental to the essence of nursing and we have a commitment
to identify any area of care that fails to meet this basic principle. Appropriate
steps will be taken to address any area that is identified. A variety of different
tools are used to measure effectiveness of care and these include patient
feedback, complaints, inspections and daily observation from senior clinical staff.
Clinical Standards - A robust clinical governance system is in place which allows
analysis of incidents. We have worked closely with the CCG (Clinical
Commissioning Group) to identify CQUIN’s that will inform practice and improve
clinical standards. All of the CQUIN’s are carefully considered to ensure they
have real meaning to patient care and outcomes.
One of the CQUIN’s this year will focus on the early an warning score that has
been implemented to standardize the interpretation of clinical observations. The
warning system also provides a structure within which staff can escalate concerns
about deteriorating patients to reduce the risk of harm.
Quality Accounts 2013/14
Page 12 of 47
Dementia Screening - In an ageing population the importance for dementia
screening is increasing. We are committed to identifying any patients over the
age of 75 that display signs and symptoms of dementia and referring them to the
appropriate care providers. This will be done by nurses that are trained
specifically to identify patients with early signs of dementia as part of our preassessment service.
PLACE Assessment - The Frances report has reiterated the importance of
monitoring healthcare practise through peer assessment. Our aspiration is to not
only take part in the PLACE inspection but to formulate a patient and public forum
to inform and underpin the development of our service. The purpose of the
PLACE assessment is to primarily review cleanliness, catering, environment and
the facilities that we provide. We aim to build on this developing partnership
resulting in a patient and public forum that engages and influences our practice
and decision making.
Clinical Effectiveness: Implementation of the Electronic Rostering
System
An electronic system for staff rostering will be implemented this year. This will
give an overview of staffing skill mix and nurse to patient ratios.
Patient Experience – Informing Patient Choice
Local / National CQUIN’s for Lincolnshire - 2012/13
Goal name
Indicator name
Indicator description
Milestones
Weighting
Friends and
family
Friends and
family
FFT – increased
response rate
FFT -improved
performance on
staff friends and
family test
Dementia -find,
assess, investigate
and refer
increased response rate
Q1 20%
Q4 25%
NA
5%
Q1 Identify appropriate screening
tool and construct training plan
5%
Q2 Conduct pre-assessment nurse
training in line with plan
5%
Dementia
Improved performance on
staff friends and family test
The proportion of patients
aged 75 and over to whom
case finding is applied
following elective admission
undergoing a face to face
pre-assessment , the
15%
Quality Accounts 2013/14
Page 13 of 47
proportion of those
identified as potentially
having dementia who are
appropriately assessed, and
the number referred on to
specialist services
VTE
VTE risk assessment
VTE
VTE Root cause
analyses
Encouraging
healthy
lifestyles
Encouraging healthy
lifestyles – Alcohol
cessation
Early warning
scores
EWS – compliance
% of all adult in-patients who
have had a VTE risk
assessment on admission to
hospital using the clinical
criteria of the national tool
The number of root cause
analyses carried out on cases
of hospital associated
thrombosis
90% of NHS Patients seen at
face to face preadmission
with their alcohol status
recorded and intervention
offered to 99% those at risk
Reduce clinical risk to
patients by increasing
compliance with Medical
Early Warning Assessments
protocols through delivery of
training programme
Q3 60% against each of the three
elements of the indicator in each
month equals 1/12th payment
5%
Q4 90% against each of the three
elements of the indicator in each
month equals 1/12th payment
Achievement of agreed target for
both risk assessment and root cause
analysis for each month during each
quarter
5%
Achievement of agreed target for
both risk assessment and root cause
analysis for each month during each
quarter
Q1 Matrons to identify suitable
training for preadmission staff
training to be delivered
Q2-4 Complete report per quarter
7.5%
Q1 Audit of 10% of patient notes to
establish baseline compliance
20%
7.5%
10%
Q2 Roll out training to staff (50%) of
relevant staff to have had training
Q3 Roll out training to staff
(remaining 50%) of relevant staff to
have had training
Q4 Post training audit of 10% of notes
to demonstrate increased compliance
with EWS.
CQUIN’s for North East Essex – 2012/13
Indicator Name
Patient Experience
NHS Safety Thermometer
VTE
Descriptor
A
composite
survey
on
‘responsiveness to personal needs,’
consisting of questions regarding:
Involved decisions about
care.
Staff availability to discuss
worries.
Privacy.
Information about medical
side effects.
Who to contact after leaving
hospital if concerned.
Monthly surveying of all appropriate
patients (as defined by the NHS
Safety Thermometer guidance) to
collect data on four outcomes
(pressure ulcers, falls, urinary tract
infections in patients with catheters
and VTE).
Percentage of all inpatients that have
had VTE risk assessment on
admission to hospital using the clinical
criteria of the national tool.
Plan/Weighting
20%
20%
20%
Quality Accounts 2013/14
Page 14 of 47
Eliminating Avoidable Pressure Ulcers
BMI Health
Medicines Management
Measurement of all grade pressure
ulcers, which will by December 2012
indicate the elimination of all avoidable
pressure ulcers.
Patients have BMI calculated preadmission. If Patient is over BMI 30
they are to be given a brief
intervention and informed of risks due
to obesity and given contact details of
Local NHS Weight Management
Service.
Monitor and collect data on patient
harm related to missed drug doses to
enable delivery of a reduction in the
number of missed doses.
10%
10%
20%
2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2012/13 the Fitzwilliam Hospital provided and/or subcontracted 31 NHS
services, as shown in appendix one.
The income generated by the NHS services reviewed in 1 April 2012 to 31 st
March 2013 represents 53% of the total income generated from the provision of
NHS services by the Fitzwilliam Hospital for 1st April 2012 to 31st March 2013.
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:
Quality Accounts 2013/14
Page 15 of 47
Human Resources - The total skill mix calculation for the Fitzwilliam was worked
out by calculating all contracted and bank hours for registered nurses and
healthcare assistants.
75% of staff caring for patients are registered nurses.
25% of staff are health care assistants.
The total number of agency hours used was 1688. This was 8% of our total
workforce. Our overall aim is to function at 0% of agency hours and during the
latter quarter of the period 2012/13 this was achieved. We hope to carry this
accomplishment over into the next year of business.
Our clinical staff turnover for 2012/13 was 22.5% and our non-clinical staff
turnover was 19.9%. Our ambition for next year is to reduce this figure. We work
in conjunction with our ‘Well Being Service’ to support employees in the work
place. This year’s total percentage sickness was 4.66%.
Our total lost time for 2012/13 was 4.2%. Lost time was high this year and is
attributed to an unusually high number of staff returning from long term sick
working on phased returns in a supernumerary capacity.
The Fitzwilliam provides an ongoing training program for staff and monitors
compliance for various elements of mandatory training. This allows us to meet
contractual obligations as well as ensuring staff are competent and confident to
provide care.
Each year staff takes part in a satisfaction survey, the results of which are
analyzed for common themes. The senior management team then devises a
strategy for progression.
There were no RIDDOR events recorded for the Fitzwilliam Hospital during this
period.
Patient - The number of complaints per 1000 hospital patient days equates to
6.4.
The Fitzwilliam utilize an external company to gather unbiased data with regards
to patient satisfaction. We analyze this information on a quarterly basis and
review our three lowest scoring areas. An action plan is then drawn up so as to
ensure that we maximize of patient satisfaction and synergy between
departments.
We have a governance system in place to monitor all significant clinical events.
During the period of 2012/13 our overall percentage for significant events was
0.05% based on a day case and in-patient rate of 7880.
Quality Accounts 2013/14
Page 16 of 47
Readmissions are monitored for trends. During this reporting period there were
thirteen readmissions to the Fitzwilliam Hospital. All of these readmissions were
successfully discharged home. In percentage terms, the readmissions equated to
0.16% of our patients.
Quality - Our annual workplace health and safety score was 89%, which is an
improvement on the previous year. We have recruited a new maintenance
manager and work has been undertaken to improve services and enable us to
achieve a score of 89%. We intend to build on this over the coming year.
2.2.2 Participation in clinical audit
Criteria for inclusion
Coverage: intention to achieve participation by all relevant providers in England.
Data collected on individual patients
Provides comparisons of providers
Recruiting patients during 2012-13
NCAs meeting inclusion criteria (n = 51). All national clinical audit suppliers on
this list, at the time of publication, advised that they would be recruiting patients
during 2012-13. If subsequently a supplier decides not to recruit patients during
this time then the clinical audit should be considered to be removed from the list
as it no longer meets the criteria for inclusion
Quality Accounts 2013/14
Page 17 of 47
Participation Rate
Response Rate
All Procedures
69.3%
6.25%
Groin Hernia
88.9%
12.5%
Varicose Veins
49.7%
0%
.
*The NHS standard contracts for acute hospital, mental health, community and
ambulance services set a requirement that provider organisations shall participate
in appropriate national clinical audits that are part of the National Clinical Audit
and Patient Outcome Programme (NCAPOP).
Local Audits - There is an audit program which runs from the 1st April 2012 to
the 31st March 2013. The program includes 58 audits in total covering all aspects
of clinical care. Areas identified for improvement include: Use of fluid balance.
Consent process.
Early warning score calculation.
VTE assessment.
Results are shared both locally and corporately.
Fluid Balance - We are utilizing a regional training manager to work alongside
staff to guide and support their practice. Fluid balance is a main priority for
nursing staff and a key focus for training.
Consent Process - An area for improvement within the consent process is for
consultants to document what supporting literature and advice has been given to
patients. This has been discussed at the local medical advisory committee and all
consultants have been informed about how this will improve the quality of
information that patients receive.
Early Warning Score - Evening seminars have been arranged for nursing staff to
educate them about the early warning score. The regional trainer is also working
alongside staff to assess them in practice.
Quality Accounts 2013/14
Page 18 of 47
VTE Assessment - Results for completion of VTE risk assessment are
consistently 98% and above. Our audit did identify an area for improvement;
documented evidence of discussion with patients when NICE guidelines are not
followed for clinical reasons is required. The audit demonstrated that this
evidence is not consistently found in medical records.
The graph below illustrates our excellent rating for VTE UNIFY returns; however it
is important to note that March 2013 data has not been included. The results
achieved by the Fitzwilliam exceeded the red target line by over 6%.
VTE Unify Returns
10
2.2.3 Participation in Research
There were no patients recruited during 2012/13 to participate in research
approved by a research ethics committee.
Quality Accounts 2013/14
Page 19 of 47
2.2.4 Goals agreed with our Commissioners
using the CQUIN (Commissioning for Quality and
Innovation) Framework
CQUIN contributed to a maximum of 2.5% of the hospitals income generated
from the 1st April 2012 to 31st March 2013 and this was conditional to achieving
quality improvement and innovation goals agreed for the Fitzwilliam Hospital, and
any person or body they entered into a contract, agreement or arrangement with
for the provision of NHS services, through the Commissioning for Quality and
Innovation payment framework.
National and locally agreed CQUIN’s have been in place as part of the standard
acute contract for 2012-13 as follows:
1.
2.
3.
4.
5.
6.
Reducing avoidable death, disability and chronic ill health from venous
thrombo-embolism (VTE)
Improving responsiveness to patients
Smoking cessation – identification of risk, education and referral
Weight management – identification of risk, education and referral
Net Promoter – Family and Friends Test
NHS Safety Thermometer – Level of harm free Care
We achieved 100% on all CQUIN’s for North East Essex and Lincolnshire’s
Clinical Commissioning Group’s. The Fitzwilliam exceeded all CQUIN
benchmarks for 2012-13.
2.2.5 Statements from the Care Quality
Commission (CQC)
The Fitzwilliam 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 the
radiology department at the Fitzwilliam Hospital in March 2013. It was found to be
Quality Accounts 2013/14
Page 20 of 47
in compliance with all outcomes assessed; no recommendations were made (to
view the report go to www.cqc.org.uk).
The Care Quality Commission carried out an unannounced inspection of the
Fitzwilliam Hospital in May 2012 and it was found to be compliant in all outcomes
assessed; no recommendations were made (to view the report go to
www.cqc.org.uk).
2.2.6 Data Quality
The Fitzwilliam Hospital analyses both electronic and paper records on a regular
basis. Monthly medical record audits review different elements of patient records,
including operating notes. Bi annual anesthetic audits are undertaken of paper
records to ensure that data recorded is adequate and that practice is safe.
This information is shared locally and escalated to corporate governance for
wider dissemination across the Ramsay group. At a local level, results are
discussed at a clinical governance committee and a medical advisory committee.
NHS Number and General Medical Practice Code Validity
The Fitzwilliam 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:
99.98%for admitted patient care.
99.95% for outpatient care.
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was:
Quality Accounts 2013/14
Page 21 of 47
99.99% for admitted patient care.
99.99% for outpatient care.
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit Attainment Levels - Ramsay Group
Information Governance Assessment Report score overall score 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/
Clinical Coding Error Rate - The Fitzwilliam Hospital was not subject to the
Payment by Results clinical coding audit during 2012/13 by the Audit
Commission.
2.2.7 Stakeholders views on 2010/11
Quality Account
NHS South Lincolnshire CCG Commentary for Ramsay Fitzwilliam Quality
Account 2012/13
NHS South Lincolnshire CCG’s main priority is to ensure that services are safe
and of a high quality. The Fitzwilliam Quality Account highlights areas of service
that demonstrate high quality care using the three key areas of effectiveness,
safety and patient experience. As part of the national CQUIN for last year
Fitzwilliam Hospital continuously over achieved on the introduction of the National
Patient Safety Thermometer recording data on pressure ulcers, falls, catheters,
UTIs and VTEs, as well as analysing additional local information. This has
enabled the hospital to establish that the level of harm free care was 100%.
Further, patient satisfaction scores for overall quality show the majority of patients
feel they receive excellent quality of care and service in the Fitzwilliam Hospital.
In quarter four of 2012 the overall satisfaction score was 96.7%.
The introduction of an electronic reporting system is welcomed by the CCG as it
has provided a more streamlined way for staff to report any incidents and act as a
mechanism for allowing trend analysis across a national level within the corporate
structure. It is noted that this facilitates safe and effective review and analysis of
Quality Accounts 2013/14
Page 22 of 47
incidents and feedback within clinical governance and health and safety
committee meetings. The CCG has conducted a review visit to the hospital in
respect of one incident and was able to positively affirm that appropriate pre and
peri-operative assessments were in place. Further, the CCG applauds the use of
two safer surgery checklists which were introduced in the last year to promote
safer surgery in specific areas to compliment the use of the existing WHO (World
Health Organisation) Checklist. The process of safer surgery check lists being
further embedded into practice with the introduction of pre and post list briefings
and monthly audits to ensure compliance is being maintained is therefore
welcomed by the CCG.
South Lincolnshire CCG notes that the Fitzwilliam Hospital is required to register
with the Care Quality Commission and its current registration status on 31 March
2013 has no restrictions. The Care Quality Commission has not undertaken any
enforcement action against Fitzwilliam since its registration.
The Care Quality Commission carried out an unannounced inspection of the
Fitzwilliam Hospital in May 2012 and it was found to be compliant in all outcomes
assessed; no recommendations were made.
The Care Quality Commission carried out an unannounced inspection of the
radiology department at the Fitzwilliam Hospital in March 2013. It was found to be
in compliance with all outcomes assessed; no recommendations were made.
South Lincolnshire CCG can verify that Ramsay Fitzwilliam Hospital has reported
against all the mandated statements within the Quality Account where data is
available.
In terms of performance against the CQUIN scheme for 2012/13 Fitzwilliam
Hospital achieved the following:
VTE
Personal Responsiveness
Safety Thermometer
Patient Experience Family and Friends Test
Encouraging Healthy Lifestyles - Smoking & Obesity
The CCG endorses the areas identified for improvement for 2013/14 and the
associated initiatives as detailed within the Ramsay Fitzwilliam Account in
particular the commitment to compassionate care as outlined by the Chief
Nursing Officer and to identify any area of care that fails to meet this basic
principle. A variety of different tools are to be used to measure effectiveness of
care and these include patient feedback, complaints, inspections and daily
Quality Accounts 2013/14
Page 23 of 47
observation from senior clinical staff. The CCG notes that one of the CQUIN’s this
year will focus on the early warning score that has been implemented to
standardize the interpretation of clinical observations. The warning system also
provides a structure within which staff can escalate concerns about deteriorating
patients to reduce the risk of harm.
The South Lincolnshire CCG CQUIN scheme for 2013/14 will consist of the
following:
VTE
Family & Friends Test
Dementia
Early Warning Scores
Encouraging Healthy Lifestyles – Alcohol
Safety Thermometer
South Lincolnshire CCG endorses the accuracy of the information presented
within the Ramsay Fitzwilliam Quality Account and the overall quality programme
performance will be reviewed through the formal contract quality review process
and triangulation through patient experience surveys.
Also sent to local Health Watch and Peterborough & Cambridgeshire CCG but no
comments received.
Part 3
Review of
2012/2013
Quality
Performance
Statements of quality delivery
Matron Jane Groom
Review of quality performance 1st April 2012 - 31st March 2013
Quality Accounts 2013/14
Page 24 of 47
Introduction
‘Our overriding commitment is to provide safe and effective care; the guiding 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 online
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
improvement in future practise. Importantly these new metrics should insure each
performance which needs improving can be quickly identified and fixed
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Healthcare
UK)
.
Ramsay Clinical Governance Framework 2012-13
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
organization
.
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 organization 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 organization 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 organization. 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 Accounts 2013/14
Page 25 of 47
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 scrutinizing all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
3.1 Patient safety
Quality Accounts 2013/14
Page 26 of 47
We are a progressive hospital and are focused on stretching our performance
every year and in all respects, and certainly with regards to our track record for
patient safety.
Risks to patient safety come to light through a number of routes, including routine
audit, complaints, litigation, adverse incident reporting and raising concerns, but
more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of
key indicators as illustrated in the graphs below.
3.1.1 Infection prevention and control
The Fitzwilliam 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.
We have systems in place to manage and monitor the prevention and control of
infection. These systems use risk assessment and consider how susceptible
service users are and any risks other users may pose. All patients are assessed
for infection risk and all patients admitted for day case surgery are screened for
MRSA pre-operatively. These results are monitored locally and positive swab
results are reported via the Riskman reporting system. Positive cases preoperatively are de-colonized and surgery is not undertaken until it is clinically safe
to do so.
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.
Programme & Infection Control Related activity within the Hospital:
Quality Accounts 2013/14
Page 27 of 47
Mandatory face to face training programmes in hand washing and use of
PPE annually
On line e - learning training package
Local Infection Control Nurse coordinates all infection control activities
Regular infection control meeting chaired by a Microbiologist room local
trust
Regular corporate infection control meetings
Monthly rotationally audit programme
Participation in corporate and national hand hygiene promotion
Attendance at national infection control events
Over the past three years the Fitzwilliam has achieved a remarkably low infection
rate due mainly to our rigorous infection control practise, with all members of staff
being aware and judicious to the process of cleanliness.
3.1.2 Cleanliness and hospital hygiene
Cleanliness is a basic principle that underpins all aspects within the Fitzwilliam
Hospital. All members of staff go through a rigorous training programme that
includes basic hand washing practise as well as clinical procedures such as
aseptic technique.
The hospital is inspected on an annual basis by the CCG (Clinical Commissioning
Group) to audit the quality of our facilities and environment. This year we had two
audits, both resulting in no major issues being raised.
Quality Accounts 2013/14
Page 28 of 47
In addition to our mandatory cleanliness audits the Fitzwilliam has implemented
monthly inspections performed by a senior team, consisting of the Matron, the
Non-clinical Support Services Manager, the Infection Control Nurse and the Head
of Housekeeping.
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 PEAT scores for environment have seen an increase over the past three
years, with 2013 resulting in a rating of 98.07% which rates as excellent.
Quality Accounts 2013/14
Page 29 of 47
The ratings concerning the quality of food at the Fitzwilliam have also seen a
steady increase over the past three year period. 2013 saw a score of 93.44%,
rating us as good. Our aspiration for next year is to achieve a rating of a minimum
of 95%, giving us a quality score of excellent. All of our food is freshly prepared
daily on site by our dedicated chefs and patients have a daily choice of several
delicious meals. All dietary requirements are individually catered for.
The Fitzwilliam has always prided itself in a consistent achievement score of
100% for privacy and dignity. 2011 saw a small drop in this score to 94%,
Quality Accounts 2013/14
Page 30 of 47
however we acknowledge that we were undergoing the process of building works
during this time. 2012 returned to the normal 100%.
3.1.3 Safety in the workplace
Safety hazards in hospitals are diverse, ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring that our staff have a
high awareness, safety has been a foundation for our overall risk management
programme. 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.
All of our staff undergo a robust induction programme to ensure compliance to
our safety regulations as well as being well equipped to perform their designated
tasks. Induction is followed by a broad spectrum of ongoing mandatory training
that promotes safety in the workplace. This is complemented with non-mandatory
training for any areas that have been identified as requiring improvement.
Local safety initiatives include:
Mandatory face to face training programmes in Health & Safety, risk
assessement and fire annually
Mandatroy on line training E- learning training
Regular local Health & safety meetings
Regular corpoate Health and Safety meetings
Audit programme throughout the year – H&S facilites annual audit,
quarterly environmental audit, annual DDA audit and annual PEAT /
PLACE audit
Local H&S coordinator ensures completion of risk assessments across all
departmetns and regualr review
Participate in corporate and national safety initiatives – shattered lives,
SHF and sharps action plans.
RISKMAN
Over the past year we have successfully recruited into nursing vacancy whilst
redressing our skill mix balance.
Quality Accounts 2013/14
Page 31 of 47
Although the graph indicates that our incidents have increased over the past
three years, we now use a more advanced reporting system. Staff now have
easier access to the process of reporting concerns and incidents, allowing us to
capture accurate figues. This allows provision of a more comprehensive analysis.
The chart above demonstrates that activity has grown at a faster rate than our
incident. It was not possible to include June’s data due to the timing of the reports
completion. In percentage terms, excluding June data, there has been a drop
from 1.4% total clinical incidents recorded to 1.3%.
Quality Accounts 2013/14
Page 32 of 47
Although the graph indicates that there has been an increased amount in the
number of falls that we have had, many of the documented falls consist of faints
or incidents where a collapsed patient has been guided down by a health care
professional. With the implementation of our new incident documenting system,
all occurances that could be classed as a fall or loss of balance must be
documented. The Fitzwilliam has not had a fall that has resulted in a significant
harm being sustained.
3.2 Clinical effectiveness
The Fitzwilliam Hospital has a Clinical Governance Team and committee that
meet regularly through the year to monitor quality and effectiveness of care.
Clinical incidents, patient and staff feedback are systematically reviewed to
determine any trend that requires further analysis or investigation. More
importantly, recommendations for action and improvement are presented to
hospital management and medical advisory committees to ensure results are
visible and tied into actions required by the organisation as a whole.
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 the number 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 incidences of returns to theatre are normal.
The value of the measurement is to detect trends that emerge in relation to a
Quality Accounts 2013/14
Page 33 of 47
specific operation or specific surgical team. Ramsay’s rate of return is very low,
consistent with our track record of successful clinical outcomes.
3.2.2 Readmission to Hospital
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness. As with returns to theatre, any emerging trends with specific
surgical operations or surgical teams 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 and not in severe pain etc.
Quality Accounts 2013/14
Page 34 of 47
In order to demonstrate how our activity has increased the graph above has been
included to demonstrate our activity increase and comparable incident increase.
3.2.3 Transfers
The Fitzwilliam Hospital also measures transfers to other health care providers.
We have an on call medical staff as well as a resident medical officer. The
Fitzwilliam has a high dependency unit in which a specially trained staff provides
one to one care for patients in an environment that has appropriate facilities.
There are occasions when specialist care, outside of the thirty three specialities
that we provide, is required. Transfers are arranged for patients when they are
clinically indicated and nurses, or doctors, depending on the individual case,
travel with the patient via the emergency services to the appropriate healthcare
provider.
The amount of transfers has increased year on year in line with our increase in
activity. From June 2011 – July 2012 we transferred 0.02% of patients to another
health care provider whilst in the same period for 2012 – 2013 we transferred
0.06% of patients.
3.3 Patient experience
Quality Accounts 2013/14
Page 35 of 47
All feedback from patients regarding their experiences with Ramsay Health Care
is welcomed. This informs service developments in various ways depending on
the type of experience (both positive and negative) and the actions required to
address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for employees to see in staff rooms
and notice boards for example. Managers ensure that positive feedback from
patients is recognised and any individuals mentioned are praised accordingly.
All negative opinions, or suggestions for improvement, are relayed back 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 the 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 within accordance 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 Manager visiting patients and Provider / CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their
plan of care.
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by an independent company called
‘The Leadership Factor‘ (TLF). They print and supply a set number of
questionnaire packs to our hospital each quarter which contain a self addressed
envelope addressed directly to TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also
separately for NHS and private patients). The results are available for patients to
view on our website.
Quality Accounts 2013/14
Page 36 of 47
Patient satisfaction scores for overall quality show the majority of patients feel
they receive excellent quality of care and service in the Fitzwilliam Hospital. In
quarter four of 2012 the overall satisfaction score was 96.7%. To record a
satisfaction score of such a high percentage, most of our patients would have
scored us as a 9 or 10. Hospital satisfaction scores across other organizations,
including all sectors of the UK economy, are between 50 to 95% with a median
just below 80%.
The recorded satisfaction index score was 97%. This translates to a very high
proportion of our patients having scored 9 or 10 out of 10 for their satisfaction with
all the requirements. This is underlined by comparing our hospitals ‘Satisfaction
Index’ against those achieved by other organisations across all sectors of the UK
economy, where the full range of customer satisfaction is 50% to 95% with the
median just below 80%.
The illustration above shows that the majority of our patients in quarter four of
2012 rated our service as excellent, 30% rated our service as very good or good
and just 3% rated our service as satisfactory or poor.
We review our results on a consistent basis in order to respond to changes in
demand or in response to what our patients say about our service. We have
recently changed our provider for the external survey but the data is analyzed in a
similar way.
In April 2013, 100% of patients felt that they were involved as much as they
wanted to be in their care and treatment, 100% of patients felt they were given
enough privacy and dignity when discussing their treatment and 100% of patients
Quality Accounts 2013/14
Page 37 of 47
were told about their medication in a way that they could understand. These are
only a few of the questions we ask patients and we will continue to carefully
monitor the responses patients give to our survey.
We action plan if there is an area for improvement. This year we focused on call
bell response times and we have reduced the number of complaints and negative
feedback that we receive about this issue. Our action plan included a daily audit
and the matron carrying a call bell bleep to monitor response times. We were able
to resolve the issue patients had brought to our attention.
As the bar chart shows, the Fitzwilliam Hospital recieved no serious complains
during the annual period 2012/13. This is a statistic which we are determined to
continue into the future.
3.3.2 Patient Reported Outcome Measures (PROMs)
The Fitzwilliam Hospital participates in the Department of Health’s PROMs
surveys for hip and knee surgery, hernias and varicose veins for NHS patients.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs
surveys specifically for private patients.
Quality Accounts 2013/14
Page 38 of 47
The graphs above illustrate that the Fitzwilliam has comparable patient outcome
measures with its local hospital, as well as country wide for both hip and knee
surgery.
Year upon year the results for patient related outcomes have been consistent as
illustrated below.
Quality Accounts 2013/14
Page 39 of 47
For the period 2012/13 The Fitzwilliam Hospital has had a 97% submission rate
to the National Joint Registry (NJR).
Quality Accounts 2013/14
Page 40 of 47
National Joint Registry Subscription Rate
3.4 Fitzwilliam Hospital Case Study
The Fitzwilliam Hospital has a consultant orthopaedic surgeon who offers a
specialized service in antilogous chondrocelect implantations.
This service is currently offered to insured and self pay patients but it is hoped
that as new guidelines are developed this type of implantation will be extended to
all patients.
The operation itself extends the life of human cartilage, eradicating or significantly
delaying the need for joint replacement. The most recent patient to undergo this
procedure was operated on in February. The female patient, in her forties, was a
keen long distance cyclist. After an MRI scan confirmed that she was suitable for
human tissue transplantation, she underwent a knee arthroscopy where the cells
were harvested. The patient returned to her normal day to day life and the cells
were cultured over a nine week period under strict laboratory conditions. Upon
the patients return, her own cells were then implanted into the damaged area of
cartilage and covered with a membrane which was stitched into place. A full
rehabilitation programme of physiotherapy followed contributing to a successful
recovery and improved lifestyle.
Quality Accounts 2013/14
Page 41 of 47
3.4.1 Fitzwilliam Hospital Case Study
A male patient with mild learning difficult was admitted for removal of grommets.
This year the Fitzwilliam introduced a booklet called “Helping me in hospital,”
specifically aimed at patients with a learning disability. The purpose of this booklet
is to improve communication between staff and patients and ultimately help us to
increase the quality of care that we are able to deliver.
Particular attention was paid to the patient’s pathway, ensuring that from capacity
to consent, everything was addressed in an appropriate way. This took place
primarily in the out-patient department. On top of explaining the procedure, staff
were able to make special arrangements for relatives to escort the patient to the
anaesthetic room.
Appendix 1
Services covered by this quality account:
RAMSAY HEALTHCARE UK OPERATIONS LIMITED
Adult Diagnostic Lower GI NHS Clinic
Upper GI Surgery NHS Clinics
MRI - Diagnostic Imaging Service
General ENT Clinic Excl Audiology
Colorectal Medical
Colorectal surgical
Gallstone and Gall Bladder Clinic
Gastroenterology Clinic
General Gynaecology Clinics
Gynaecology Clinic Female Consultant
Cataract Clinic
General Oral Surgery & Maxillofacial Clinic
Adult Bunion Surgery NHS Clinic
Quality Accounts 2013/14
Page 42 of 47
Foot & Ankle Clinic (Excl Apply)
Hand & Wrist Clinic
Hip & Knee Clinic
Knee Arthroscopy Clinics
Knee Clinic
Pain Management Clinic
Shoulder & Elbow Clinic
Shoulder Only Clinic
Spinal Assessment Clinic
Hernia Repair Clinic
Lumps and Bumps Minor Skin Surgery Clinic
General Urology Clinic
Adult Incontinence/Urogynaecology NHS Clinic
Adult Carpal Tunnel Syndrome and Trigger Finger NHS Clinics
Adult Ligament and Cartlidge (Menisculus) Injury NHS Clinic
Spine and Back Pain NHS Clinic
MRI - Diagnostic Imaging Service - Boston NHS Treatment Centre - NVC
Adult Hip Arthroscopy NHS Clinic - Fitzwilliam Hospital - NVC
Regulated Activities – Fitzwilliam Hospital
Treatment of
Disease,
Disorder
Services Provided
Peoples Needs Met for:
Laser hair removal, Micro derm, Physiotherapy, Skin
rejuvenation Tattoo removal
All adults 18 yrs and over
Cosmetics, Dermatological, Gastroenterology, General
surgery, Gynaecology, Laser treatment for
varicose veins (EVLT), Ophthalmic, Orthopaedic, Pain
management injections, Urology, Ambulatory and Day
Surgery
All adults excluding:
Or injury
Surgical
Procedures
Patients with blood disorders (haemophilia, sickle
cell, thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA
screen are deferred until negative
Patients who are likely to need ventilatory support
post operatively
Patients who are above a stable ASA 3
Any patient who will require planned admission to
ITU post surgery
Quality Accounts 2013/14
Page 43 of 47
Dyspnoea grade 3/4 (marked dyspnoea on mild
exertion e.g. from kitchen to bathroom or
dyspnoea at rest)Poorly controlled asthma
(needing oral steroids or has had frequent hospital
admissions within last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal
activity e.g. 1 flight of stairs or angina at rest)
CVA in last 6 months
However, all patients will be individually assessed and we
will only exclude patients if we are unable to provide an
appropriate and safe clinical environment.
All patients must meet social/clinical criteria for day surgery.
Diagnostic
and
GI physiology, Image Intensifier, Mobile MRI,
Phlebotomy, Ultrasound, Urinary Screening and
Specimen collection.
All adults 18 yrs and over
screening
Quality Accounts 2013/14
Page 44 of 47
Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2013/14
Page 45 of 47
Appendix 3
Glossary of Abbreviations
BMI
CAS
CCG
CQC
CQUIN
DH
EVLT
EWS
FFT
IPC
JAG
MRI
MRSA
MSSA
NCAPOP
Programme
NHS
NICE
NJR
NPSA
PCT
PEAT
PLACE
PROM
RIDDOR
TLF
UTI
VTE
WHO
Body Mass Index
Central Alert System
Clinical Commissioning Group
Care Quality Commission
Commissioning for Quality and Innovation
Department of Health
Endovenous Laser Treatment
Early Warning Score
Friends and Family Test
Infection Prevention and Control
Joint Advisory Group
Magnetic Resonance Imaging
Methicillin-Resistant Staphylococcus Aureus
Methicillin-Sensitive Staphylococcus Aureus
National Clinical Audit and Parent Outcome
National Health Service
National Institute for Clinical Excellence
National Joint Registry
National Patient Safety Agency
Primary Care Trust
Patient Environmental Action Team
Patient Lead Assessment of the Care Environment
Patient Related Outcome Measures
Reporting, Injuries Occurrences, Diseases
Regulations
The Leadership Factor
Urinary Tract Infection
Venous Thromboembolism
World Health Organisation
Quality Accounts 2013/14
Page 46 of 47
The Fitzwilliam 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:
01733 261717
www.fitzwilliamhospital.co.uk
Quality Accounts 2013/14
Page 47 of 47