New Hall Hospital
Quality Account
2012/13
Extraordinary care needs
extraordinary people
Contents
Introduction Page
Welcome to Ramsay Health Care UK and New Hall 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 2012/13 (looking back)
2.1.2 Clinical Priorities for 2013/14(looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2012/ 13Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Quality Accounts 2011/12
Page 2 of 36
Welcome to Ramsay Health Care UK
New Hall Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to become a
global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health
Care is one of the leading providers of independent hospital services in England, with a
network of 22 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the NHS in
the UK. Through a variety of national and local contracts we deliver 1,000s of NHS
patient episodes of care each month working seamlessly with other healthcare providers
in the locality including GPs, PCTs and acute Trusts.
“Ramsay Health Care UK is committed to establishing an organisational culture
that puts the patient at the centre of everything we do. As Chief Executive of
Ramsay Health Care UK, I am passionate about ensuring that high quality patient
care is at the centre of what we do and how we operate all our facilities. This relies
not only on excellent medical and clinical leadership in our hospitals but also upon
our overall continuing commitment to drive year on year improvement in clinical
outcomes.
“As a long standing and major provider of healthcare services across the world,
Ramsay has a very strong track record as a safe and responsible healthcare
provider and we are proud to share our results. Delivering clinical excellence
depends on everyone in the organisation. It is not about reliance on one person or
a small group of people to be responsible and accountable for our performance.”
Across Ramsay we nurture the teamwork and professionalism on which excellence
in clinical practice depends. We value our people and with every year we set our
targets higher, working on every aspect of our service to bring a continuing stream
of improvements into our facilities and services.
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2011/12
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Introduction to our Quality Account
This Quality Account is New Hall 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 review 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.
In 2009/10 the Quality Account 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, however, 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 developed its own Quality Account for 2010/11 and this account for
2012/13 is New Hall Hospital’s third submission.
Quality Accounts 2011/12
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Part 1
1.1 Statement on quality from the General Manager
Fiona Taylor, General Manager,
New Hall Hospital
Welcome to The New Hall Hospital third quality account. This report outlines the
Hospitals approach to quality improvement, progress made in 2012/13 and plans for the
forthcoming year.
New Hall Hospital has five key values which underpin everything we do as an
organisation.
They are:
• Put the patient first;
• Work as one team;
• Respect each other;
• Strive for continual improvement;
• Respect environmental sustainability.
The experience that patients have in our hospital is of the utmost importance. As well as
being treated quickly and safely, they must receive a personalised service, enhanced by
good communication and a commitment to ensuring their privacy and dignity are
respected at all times.
During 2012/13 we have made a raft of improvements to ensure patients in our hospital
receive the best possible care.
This report demonstrates that the experience patients have in our hospital, the quality of
the care they receive, and the safety of the service we provide are top priorities for our
hospital.
In addition, it shows how our values, combined with our priorities, are improving the way
in which we treat our patients. For example, we continue to have a very low infection rate
within our units and submissions to Surgical Site Surveillance Service has commenced.
Our surgical site infection rates are significantly lower than the national average.
Fiona Taylor
General Manager
Quality Accounts 2011/12
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the publication
of this document, the information in this report is accurate.
Fiona Taylor
General Manager
New Hall Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr David Chapple, Consultant Spinal Surgeon
Medical Advisory Committee Chair
Mr Peter Guy, Consultant Urologist
Clinical Governance Committee Chair
Helen White
Regional Director, Ramsay Health Care UK
Commissioner/PCT and other external bodies
Quality Accounts 2011/12
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Welcome to New Hall Hospital
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New Hall Hospital is an independent hospital delivering a full range of specialist
surgical and medical services. The hospital is set in beautiful grounds and the
original Georgian manor House now accommodates three theatres and 43 beds
with excellent physiotherapy and radiology services. Consideration for our patients
is at the heart of everything that we do. We are constantly seeking new ways of
working and bringing in fresh clinical practices that will improve outcomes for our
patients. Our approach to service delivery, which includes working in partnership
with the NHS, is courteous and professional and we take great pride in our ability
to innovate and look at new ways of working.
We provide fast, convenient, effective and high quality treatment for patients of all
ages (excluding children below the age of 18 years or 16 if private), whether
medically insured, self-pay, or from the NHS).
We deliver a full range of specialist surgical and medical services (excluding
cardiac and neurosurgery) to include orthopedics, spinal, ENT, gynecology,
urology, colorectal, breast and cosmetic surgery and general medicine.
Patients requiring level 2 critical care are treated and cared for by appropriately
trained staff in a dedicated high dependency unit.
All Ramsay Health Care UK hospitals have transfer arrangements in place with
their local trust or critical care network for level 3 care.
In 2012/13 we treated a total of 5470 patients. 3689 NHS patients (68%) and 1792
private patients (32%).
We currently employ
Consultants (directly employed by Ramsay)
4
Consultants (with practicing privileges)
100 (all specialities)
Registered Nurses
51 + 11 bank
Operating Department Practitioners
9 + 3 bank
Radiographers
3 + 4 bank
Physiotherapists
4 + 4 bank
Health Care Assistants
13 + 1 bank
Other Support Staff
27 + 3 bank
Administrative staff
49 + 12 bank
The staff to patient ratio is 1:between 5 and 8 (depending on patient dependence
and there is an experienced Residential Medical Officer (RMO) on site 24 hours a
day
We provide an outreach service for outpatient NHS patients at Poole Hospitals and
Blandford clinic for spinal and orthopedic services.
We offer direct referral services for private Cosmetic Surgery and aesthetic
cosmetic treatments. All patients requiring NHS services are referred via their
General Practitioner (GP)
We have a dedicated GP liaison officer who has close contact with both the
practice managers and the GPs at practices throughout Wiltshire, Hampshire and
Dorset. She visits GP practices and organises regular “Lunch and Learns” and
Quality Accounts 2011/12
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breakfast meetings taking Consultants into GP surgeries to offer training. In
addition she also runs regular Consultant led open evenings for GP’s.
We work closely with our local Clinical Commissioning Groups (Wiltshire,
Hampshire, Dorset and Somerset to provide a range of surgical services within the
standard acute contract.
We work closely with the Salisbury District Hospital who provide us with blood
transfusion, urgent pathology, histopathology and access to level 3 critical care
services.
Quality Accounts 2011/12
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Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, New Hall Hospital develops an operational plan to set objectives for
the year ahead.
We have a clear commitment to our private patients as well as working in partnership with
the NHS ensuring that those services commissioned to us, result in safe, quality
treatment for all NHS patients whilst they are in our care. We constantly strive to improve
clinical safety and standards by a systematic process of governance including audit and
feedback from all those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time. The priorities
are determined by the hospitals Senior Management Team taking into account patient
feedback, audit results, national guidance, and the recommendations from various
hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness
and improve the experience of all people visiting our hospital.
2.1.1 A review of clinical priorities 2012/13
1. World Health Organisation (WHO) Surgical safety checklist – completion of the
checklist is a key safety element for patients undergoing surgical procedures at
New Hall. Accurate completion of the WHO checklist is audited regularly and the
results are consistently over 90% compliance.
2. Venous Thromboembolism (VTE) risk assessment and Prevention
New Hall hospital has established a robust policy to comply with Ramsay policy in
order to reduce avoidable death, disability and chronic ill health from VTE. We
have reduced the variance of prophylactic measures used at New Hall hospital in
order to minimise human error and allow outcomes to be measured. The hospital
has an excellent VTE risk assessment compliance record.
Data submitted to UNIFY shows 97% achievement from April 12 to February 2013.
Quality Accounts 2011/12
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Data is 2012/13 - UNIFY VTE Submissions
March data excluded as not available yet.
Never Events’ are serious, largely preventable patient safety incidents that should
not occur if the available preventative measures have been implemented.
From the core never events, there are 20 that affect Ramsay.
• Wrong site surgery
• Wrong implant/prosthesis
• Retained instrument post-operation
• Wrongly prepared high-risk Injectable medication
• Maladministration of potassium-containing solutions
• Wrong route administration of chemotherapy
• Wrong route administration of oral/enteral treatment
• Intravenous administration of epidural medication
• Maladministration of Insulin
• Overdose of midazolam during conscious sedation
• Opioid overdose of an opioid-naïve patient
• Fall from unrestricted window
• Entrapment within bedrails
• Transfusion of ABO incompatible blood components
• Misplaced naso or oro-gastric tube not detected prior to use
• Wrong Gas administered
• Failure to monitor and respond to oxygen saturation
• Air embolism
• Misidentification of patient
• Severe scalding of patients
Preventative measures have been implemented and there have not been any
“Never event” incidents in this reporting year at New Hall hospital
Quality Accounts 2011/12
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3. Real time incident reporting – All incidents, complaints and clinical key
performance indicators such as readmissions, reoperations, healthcare acquired
infections etc. are entered onto the corporate risk management system (RISKMAN)
in real time so trends can be analysed and identified promptly. This enables us to
review events as they happen and prevent recurrence thus contributing to patient
safety. The system was successfully implemented in July 2012
4. Cleanliness and infection prevention - There have been no MRSA bacteraemias
or C Difficle at the hospital over this reporting period. We screen all patients for
MRSA prior to admission to New Hall and all staff have a mandatory requirement to
undertake hand hygiene training. We maintain our regular audit programme which
includes hand hygiene, urinary catheter and intravenous line care, and our cleaning
standards and physical environment. We participate in the Health Protection
Agency data collection for surgical site infections following hip and knee joint
replacements and we have not had cause to report any infections to the HPA
during the last year.
5. National Joint Registry (NJR) The purpose of the NJR is to define, improve and
maintain a quality of care of individuals receiving hip, knee and ankle joint
replacements across the NHS and independent healthcare sector. Shoulder and
elbow replacements have also been added to the list in addition to those above.
New Hall registers all patients undergoing this type of surgery with the NJR
providing they consent to this. The consent rate and linkability for New Hall hospital
2012/13 is 90% against a key performance indictor of the NJR at 95%. The NHS
number tracing rate requires improvement to ensure that patients can be traced
easily and information from different providers can be collated. All staff that input
the data have been informed how to ensure NHS number tracing can be achieved
to achieve a 100% traceability rate. The NJR has been instrumental in the recall of
Metal on Metal hip replacements and New Hall has implemented all the actions
required to maintain a safe and appropriate service in relation to this.
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6. Clinical training – New Hall hospital will continue to ensure that patients are cared
for by safe and competent staff. Providing quality care for patients is a high priority
at New Hall Hospital and all relevant clinical staff will be supported through training
and protected time to achieve competency level education. This year the staff have
undertaken competency based training in “recognising the signs of the deteriorating
patient” based on early warning scoring and trigger tools. The critical care training
remains competency based and all staff are expected to achieve competencies in
infection prevention and control which includes hand hygiene. ILS and/or ALS
training is mandatory for all clinical staff working in acute areas and this year we
are also providing AIM (Acute Illness Management) training.
Blood transfusion competencies – in line with patient safety we will ensure that
blood transfusions or blood products are only handled/administered by competent
trained staff.
7. Vulnerable adult/Child Protection, Mental Capacity Act, Deprivation of
Liberty- New Hall hospital takes its responsibility for safeguarding vulnerable
members of society seriously. We provide in house training and easy to use
flowcharts for help and advice. These are available in all areas. All staff working
within the hospital are required to have an enhanced CRB check andhave
undergone mandatory training in vulnerable adult/child protection, with the lead
nurse for child protection undergoing level 2 child protection training. Relevant
staffs have also undergone training in the Mental Capacity Act and Deprivation of
Liberty although neither have had to be used in this reporting period. Equality,
diversity and human rights are a theme running through Ramsay Health Care. The
organisations integrated governance framework, Group policies and practice
comply with current legislation. To date there have not been any safeguarding
incidents to report at New Hall Hospital.
8. Information Security-New Hall Hospital was re audited in March 2013 and
achieved Information Security accreditation ISO270001.
9. Staff satisfaction survey-Ramsay undertake an annual staff survey to measure
staff satisfaction as it is well known that satisfied, well trained and competent staff
will contribute to reducing patient safety risks. New Hall is bench marked against
other Ramsay UK units.
Quality Accounts 2011/12
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Overall
Leadership
My Company
My Manager
My Team
Personal
Growth
Fair Deal
Giving Back
Wellbeing
South
Region
4.50
4.30
5.16
4.71
5.02
New Hall
4.44
4.51
5.13
4.49
4.74
4.87
3.80
3.80
4.36
4.94
3.59
3.65
4.48
2.1.2 Clinical Priorities for 2013/14
Patient Safety
•
Surgical safety checklist – compliance to the checklist will remain an ongoing
quality initiative at New Hall.
•
Bar coding for patient identity bands – this priority has been on hold awaiting a
formal notice for implementation. However, this is still on Ramsay’s agenda and will
be introduced as it is still considered best practice and will prepare us for many
patient care initiatives which will require patients to have a barcode on their
wristbands.
•
Venous-Thromboembolism assessment – will remain an ongoing quality initiative
and we will continue to audit our compliance to risk assessment and appropriate
prophylaxis. Audit results will be submitted as one of the nationally mandated quality
indicator.
•
Never events - preventing the occurrence of any serious, largely preventable patient
safety incidents that should not occur will remain a clinical priority for 2013/14.
•
National Joint Register – New Hall aims to maintain its consistently good scores for
data submission to the National Joint register.
•
JAG accreditation-One of New Hall priorities for the year is to achieve this nationally
recognised award. We have appointed a lead nurse for endoscopy and set up an
Endoscopy user group to facilitate this. We submit date for the Global Rating Scale
(GRS) and will be inspected to assess compliance with JAG in February 2014.
•
Clinical training – New Hall hospital will continue to ensure that patients are cared
for by safe and competent staff. Providing quality care for patients is a high priority at
New Hall Hospital and all relevant clinical staff will be supported through training and
protected time to achieve competency level education.
•
Blood transfusion competencies – in line with patient safety we will ensure that
blood transfusions or blood products are only handled/administered by competent
trained staff.
Quality Accounts 2011/12
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•
Safeguarding of children and vulnerable adults– the hospital takes its
responsibility for safeguarding vulnerable members of society seriously. We will
continue to provide training and easy to use flowcharts for help and advice. These are
available in all areas and will assist staff in accessing timely and appropriate manner.
All staff working within the hospital are required to have an enhanced CRB check.
•
Staffing – to ensure that adequate numbers of skilled staff are available to care for
our patients staff rotas are prepared in advance and all departments in the hospital
have their own bank of staff to provide additional cover as required. This year
Ramsay have invested in an electronic rostering system called Allocate. The system
will reduce the time spent on producing numerous rotas throughout the hospital and
will be accessible to all staff so they can log in and make requests for leave, training
etc. It is also designed to record training hours and remind staff when they need to
attend mandatory training sessions. The system will be set to produce rotas in line
with patient numbers and specific skill mix requirements.
Clinical effectiveness
Ambulatory Day Care – better outcomes and improving patient experience
Ambulatory Care (or Day Surgery Care) is the admission of selected patients (both
medical and surgical) to hospital for a planned procedure, returning home the same day
i.e. the patient does not incur an overnight stay)
Over recent years, partly due to medical advances the number of day surgery patients
has increased compared to those requiring inpatient care. In 2012 the percentage of day
surgery patients we treated was 67%. We need to ensure that our hospital facilities and
patient flows better meet the case mix we now deliver.
We will aim to ensure that 90% of all day care patients are treated in our ambulatory care
facilities.
In order to do this and provide our patients with a more efficient patient pathway through
the hospital, we have separated the day surgery patients from our inpatients by the
development of an ambulatory care unit. Best practice has shown that by doing this,
patient care will improve as waiting time and recovery period are reduced.
We will monitor the efficiency and effectiveness of the ambulatory care unit through
amending our coding system, management accounts and by patient satisfaction
questionnaires.
The Productive Ward (PW) Project is an NHS Initiative developed by the Institute for
Innovation and Improvement (2008). It focuses on the way ward teams work together
and organise themselves, in order to reduce the burden of unnecessary activities, and
releasing more time to care for patients in a reliable and safe manner within existing
resources. The approach is very much ‘bottom up’ with all ward staff suggesting ideas
and ways in which they could improve their environment and processes. The Productive
Ward project has been implemented at New Hall and is an ongoing project. The project
aims to improve inefficiencies with the ward environment releasing staff to care for the
patients. The ward utility rooms have been reorganised and labelled so items are easier
to find and equipment used on a regular basis (e.g. Dinamaps) always returned to the
same place when not in use so they can be found easily.
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Group pre assessment – New Hall pre-assessment and physiotherapy team have
implemented a group pre assessment process for all spinal surgery. It was recognised
that seeing each patient individually was not always the most efficient way of giving the
required pre-operative information to patients and that holding group sessions
encouraged discussion and group interaction. The patients are first assessed at time of
consultation to ensure they are fit for surgery and then they are invited to attend a group
session where they are given a procedure specific presentation by the physiotherapist
and/or spinal nurse practitioner and an opportunity to ask questions and meet other
patients having the same procedure. The group session is followed up by an individual
assessment by the spinal nurse practitioner.
Ramsay Health Care is a member of Private Hospitals Information Network which
enables providers to benchmark against other providers for key performance indicators.
Improve National benchmarking – it was recognised that we needed more
transparency between ourselves and other independent sector providers/the NHS in
order to monitor and improve our services. This is even more important now we are
working in partnership with the NHS. We will be benchmarking in the following areas;
VTE risk assessment compliance – benchmarking through the national stats website.
Link;
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatisti
cs/DH122283
PROMS results – benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer/siteID=1937&categoryID1295
Patient experience – informing patient choice
Patient Reported Outcomes Studies (PROMs)- We continue to monitor the national
PROMs results for Hip, Knee, Varicose Veins and Hernia surgery by offering all patients
who undergo this type of surgery the opportunity to complete a questionnaire before and
after surgery to monitor an improvement in their quality of life. Encouraging their use in
identifies poor outcomes and allows us to review practice where necessary.
We share the results with Surgeons and physiotherapists and encourage them to use
them to review their practice by meeting and discussing the results with their teams and
benchmarking against other sites.
We are expanding our use of PROMS surveys to cover more procedures to enable better
understanding of treatment outcomes from the patients view point. We have recently
implemented PROMS for spinal surgery using the British Spinal Registry.
Patient satisfaction survey – New Hall has always achieved a high level of patient
satisfaction, the most recent Ramsay inpatient survey was carried out between January
and August 2012. It uses a mean rating score following the approach of the Care Quality
Commission which allows it to be benchmarked against 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) and 100 (most positive)
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In response to the question, Overall, how would you rate your experience, New Hall
scored 90%
We also undertake an external on line survey run by QA that sends a questionnaire to a
proportion of patients who have received care at New Hall. All patients are given a “we
value your opinion” leaflet on discharge and asked to take the friends and family test
which is where they say whether they would recommend the hospital to their friends and
family.
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1.2 Mandatory Statements
2.2.1 Review of Services
During 2012/13 New Hall Hospital provided NHS services.
New Hall Hospital has reviewed all the data available to them on the quality of care in
100% of these NHS services.
The income generated by the NHS services reviewed in 1 April 2012 to 31st March 2013
represents 100 per cent of the total income generated from the provision of NHS services
by the New Hall hospital for 1 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:
Human Resources
Health care Assistant (HCA) Hours as % of Total Nursing (81% qualified to 19% HCA)
Agency Hours as % of Total Hours (0.54%)
% Staff Turnover (12.8%)
% Sickness (3.99%)
Total Lost Worked Days (1602)
Patient
Formal Complaints per 1000 HPD's (4.2)
Number of Significant Clinical Events (1)
Quality
Infection Control Audit Score (94%)
Readmission per 1000 Admissions (2%)
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2.2.2 Participation in clinical audit
Between 1st April 2012 to 31st March 2013 New Hall Hospital participated in two national
clinical audits and no national confidential enquiries
The national clinical audits that New Hall Hospital was eligible to participate in during 1st
April 2011 to 31st March 2012 are listed in the table below;
National Clinical Audits
NJR
Elective surgery (PROMS)
Participation
Yes
Yes
% submitted
100
100
Local Audits
The reports of 63 which includes 16 infection prevention and control, 3 transfusion, 4
physiotherapy and 8 radiology local clinical audits from 1 April 2012 to 31st March 13
were reviewed by the Clinical Governance Committee and show good compliance to
national standards. Where is action is required, actions plans are developed and
implemented with review in timeframes set.
The audit schedule can be found in appendix 2
2.2.3 Participation in Research
There were no patients recruited during 2011/12 to participate in research approved by a
research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
New Hall hospitals income for achieving quality improvement and innovation goals
through the Commissioning for Quality and Innovation payment framework is applicable
from 1st April 2012 (SAC commencement) to March 31st 2013. We are confident of
achieving our locally agreed CQUINs and all the nationally mandated CQUINS. New Hall
has agreed revised CQUINs for 13/14 and we are currently waiting for them to be signed
off.
2.2.5 Statements from the Care Quality Commission (CQC)
New Hall Hospital is required to register with the Care Quality Commission and its current
registration status on 31st March 2013 is registered without conditions..
The Care Quality Commission has not taken enforcement action against
New Hall Hospital during 2012/13
New Hall Hospital has not participated in any special reviews or investigations by the
CQC during the reporting period.
New Hall had an unannounced inspection on 21/01/2013. The outcomes inspected were
1, 4, 8, 13, and 16. New Hall was found to be fully compliant.
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2.2.6 Data Quality Statements
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2012/13 to the Secondary Users Service for
inclusion in the Hospital Episode Statistics which are included in the latest published
data. The percentage of records in the published data included:
The patient’s valid NHS number:
• 99.98% for admitted patient care;
• 99.95% for outpatient care; and
• 0% for accident and emergency care (not undertaken at Ramsay hospitals).
The General Medical Practice Code:
• 99.99% for admitted patient care;
• 99.99% for outpatient care; and
• 0% for accident and emergency care (not undertaken at Ramsay hospitals).
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/ Clinical coding error rate
New Hall Hospital is subject to payment by results clinical coding audit and will be audited
as a company in 2013. The clinical coding error rate in 2012 was 13.29% but an action
plan has been put in place to address the issues raised.
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2.2.7 Stakeholders views on 2012/13 Quality Account
The regulations require you to send copies of your Quality Account to your relevant Local
Involvement Network (LINk), Overview and Scrutiny Committee (OSC) and lead Clinical
Commissioning Groups for comment prior to publication, and you should include these
comments in the published Quality Account here:
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Part 3: Review of quality performance 2012/2013
Statements of quality delivery
Matron, Deborah Stott
Review of quality performance 1st April 2012 - 31st 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 realtime 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 monitored
in an organisation. In developing this framework for Ramsay Health Care UK we have
gone back to the original Scally and Donaldson paper (1998) as we believe that it is a
model that allows coverage and inclusion of all the necessary strategies, policies,
systems and processes for effective Clinical Governance. The domains of this model are
• Infrastructure
• Culture
• Quality methods
• Poor performance
• Risk avoidance
• Coherence
Quality Accounts 2011/12
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Ramsay Health Care Clinical Governance
Framework
NICE / Safety 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.
Ramsay has systems in place for scrutinising all national clinical guidance and selecting
those that are applicable to our business and thereafter monitoring their implementation.
3.1 Patient safety
We are a progressive hospital and focussed on stretching our performance every year
and in all performance respects, and certainly in regards to our track record for patient
safety.
Risks to patient safety come to light through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more routinely
from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of key
indicators as illustrated in the graphs below.
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3.1.1 Infection prevention and control
New Hall hospital has a very low rate of hospital acquired infection and has had no
reported MRSA Bacteraemia in the past 4 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents
year on year.
Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic
joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital. An
annual strategy is developed by a Corporate level Infection Prevention and Control (IPC)
Committee and group policy is revised and re-deployed every two years. Our IPC
programmes are designed to bring about improvements in performance and in practice
year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
•
New Hall has an in house infection control team led by an infection control link
nurse involving staff members from every department and a Consultant
Microbiologist from the local trust. The infection control team meet bi monthly to
review all aspects of infection control including audits, training, infection control
issues etc. Infection control is mandatory for all staff and is part of the Ramsay e
learning programme. In addition to the mandatory training the infection control link
nurse carries out hand washing training and audits as per the infection control
audit programme as seen in appendix 2. The results of all audits are discussed at
infection control meetings, the Clinical Governance Committee and Heads of
Department meetings.
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As can be seen in the above graph our infection control rate has decreased from 20
to 17 over the last year. All of these cases were successfully treated with antibiotic
therapy.
There have been no cases of MRSA Bacteraemia
The graph below gives the % of infections per 100 discharges
3.1.2 Cleanliness and hospital hygiene
We continue to assess the hospitals facilities to ensure that we are providing a safe
environment and use the following audit tools:
Corporate - Environmental Audit – Quarterly
Corporate - Health, Safety & Facilities Audit – Annually
Patient Led Assessment of the Care Environment (PLACE) replaced Patient Environment
Action Team (PEAT) audit. PLACE audit completed in May 12 awaiting results.
Environmental Audit
This audit was introduced in 2010, these are completed quarterly, the aim of this audit is
to ensure a safe environment for all staff and patients, the objectives are:
1. To identify users and user groups
2. To advise on infection control issues arising
3. To acknowledge
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The audit consists of an inspection of the hospitals clinical areas and includes the general
environment, clinical equipment, decontamination, clinical practices, sharps handling,
waste disposal and hand washing.
New Halls environmental audit results were 90% in 2012/13.
Health, Safety & Facilities Audit
This audit, taken from Approved Codes of Practice (ACOPS) was introduced in 2009 and
is completed annually. The standards are the minimum that an organization must adhere
to ensuring a safe workplace. The benchmark set for 2010 was 90% and this has been
raised to 95% for 2011.
New Halls result for 2012 was 88%. The reason for this lower score was because of a
lack of drawings for electrical and water services, biomedical equipment register
incomplete and clinical and non clinical waste wasn’t segregated in one department.
3.1.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents
around sharps and needles. As a result, ensuring our staff have high awareness of safety
has been a foundation for our overall risk management programme and this awareness
then naturally extends to safeguarding patient safety.
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.
New Hall has a Health & Safety committee that meets monthly to discuss all matters
relating to health and safety and to review any adverse events that have occurred. All
members of the health and safety committee have undertaken CIEH level 2 award in
health and safety in the workplace . An audit of 10 steps to a safer site is carried out three
monthly and there is a comprehensive system in place to test all equipment (facilities and
medical). A slips, trips and falls action plan has also been implemented to reduce the
number of patients falls.
3.2 Clinical Governance
New Hall hospital has a Clinical Governance 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.
The results highlighted in the graphs demonstrate the effectiveness of this approach over
the last three years.
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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.
As can be seen in the above graph our returns to theatre rate has increased slightly in
2012/13 but remains low compared to the Ramsay average.
The graph below gives the % of unplanned returns to theatre per 100 discharges.
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3.2.2 Readmission to hospital
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be addressed.
Ramsay and New Hall 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.
•
As can be seen in the above graph our readmissions to hospital rate has
decreased significantly year on year and is lower then the Ramsay average . The
decrease may be as an improvement in post discharge written information and
clearer explanations given to the patient.
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The graph below shows the % of unplanned re-admissions per 100 discharges
3.3 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care are
welcomed and inform service development in various ways dependent on the type of
experience (both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback 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 feedback via the various methods below, and are regular agenda
items on Local Governance Committtees for discussion, trend analysis and further action
where necesary. Escalation and further reporting to Ramsay Corporate and DH bodies
occurs as required and according to Ramsay and DH policy. Feedback regarding the
patient’s experience is encouraged in various ways via:
ƒ Patient satisfaction surveys
ƒ ‘We value your opinion’ leaflet
ƒ Verbal feedback to Ramsay staff - including Consultants, Matrons/General Managers
whilst visiting patients and Provider/CQC visit feedback.
ƒ Written feedback via letters/emails
ƒ Patient focus groups
ƒ PROMs surveys
ƒ Care pathways – patient are encouraged to read and participate in their plan of care
ƒ Friends and family test
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3.3.1 Patient Satisfaction Surveys
Patient Perspective conducted an inpatient survey between January and August 2012.
It uses a mean rating score following the approach of the Care Quality Commission which
allows it to be benchmarked against 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) and
100 (most positive)
The response rate for patients treated at New Hall mean was 73%
Key questions and the mean rating score they attracted are shown below
Did you have confidence and trust in the Doctors treating you?
Did you have confidence and trust in the Nurses treating you?
Were you given enough privacy when being examined/treated?
Overall, were you treated with respect and dignity?
99%
94%
99%
97%
3.3.2 Patient Reported Outcome Measures (PROMs)
New Hall Hospital participates in the Department of Health’s PROMs surveys for hip and
knee surgery, hernias and varicose veins for NHS patients. The sample sizes are small
and survey results are evolving. Indications so far are that New Hall Hospital patients
report excellent outcomes, and results compare very favourably with other providers.
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As a Group, Ramsay also conducts its own hip, knee and cataract PROMs surveys
specifically for private patients
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Appendix 1
Services covered by this quality account
Services offered as per Statement of Purpose
Treatment
of Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Bariatrics, Dermatology, General medicine, Neurology,
Oncology, Paediatrics (outpatient consults only), Pain
management, Physiotherapy, Psychiatry (outpatients only),
Psychology, Orthopaedic medicine, Rheumatology, Sports
Medicine
Satellite Out patient services being carried out at Dorset
County Hospital and Poole Hospital for Dorset PCT,
Bariatrics, Cosmetics, Dermatology, Ear, Nose and Throat
(ENT), Gastrointestinal, General surgery, Gynaecology,
Ophthalmic, Orthopaedic, Oral maxillofacial, Urological,
Ambulatory, Day and Inpatient Surgery
Peoples Needs Met for:
All adults 18 yrs and over, and young persons 16-18 yrs
Children 0-16 yrs outpatient consultation only
All adults 18 yrs and over, young persons 16-18yrs
excluding:
•
•
•
•
•
•
•
•
•
•
•
•
Surgical
Procedures
Bariatrics, Cosmetics, Dermatology, Ear, Nose and Throat
(ENT), Gastrointestinal, General surgery, Gynaecology,
Ophthalmic, Orthopaedic, Oral maxillofacial, Urological,
Ambulatory, Day and Inpatient Surgery
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 adults 18 yrs and over, young persons 16-18yrs
excluding:
•
•
•
•
•
•
•
•
•
•
•
•
Diagnostic
and
screening
GI physiology, Imaging services, Phlebotomy, Endoscopy,
Urinary, Urodynamics,
Screening and Specimen collection
Satellite Out patient services being carried out at Dorset
County Hospital and Poole Hospital for Dorset PCT,
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
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 BMI >340 (non bariatrics)
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
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 BMI >340 (non bariatrics)
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 adults 18 yrs and over, young person’s 3-18yrs
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Appendix 2 – Clinical Audit Programme.
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New Hall 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:
Fiona Taylor General Manager
01722 422333
www.newhallhospital.co.uk
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