Nottingham Woodthorpe
Hospital
Quality Account
2013/14
No reported MRSA bloodstream infections in the past 4 years.
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Nottingham Woodthorpe
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 2013/14 Quality 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 2013/14
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Welcome to Ramsay Health Care UK
Nottingham Woodthorpe Hospital is part of the
Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 22 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, PCTs and acute Trusts.
“Ramsay Health Care UK is committed to establishing an organisational
culture that puts the patient at the centre of everything we do. As Chief
Executive of Ramsay Health Care UK, I am passionate about ensuring that
high quality patient care is at the centre of what we do and how we operate
all our facilities. This relies not only on excellent medical and clinical
leadership in our hospitals but also upon our overall continuing
commitment to drive year on year improvement in clinical outcomes.
“As a long standing and major provider of healthcare services across the
world, Ramsay has a very strong track record as a safe and responsible
healthcare provider and we are proud to share our results. Delivering
clinical excellence depends on everyone in the organisation. It is not about
reliance on one person or a small group of people to be responsible and
accountable for our performance.”
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with
every year we set our targets higher, working on every aspect of our
service to bring a continuing stream of improvements into our facilities and
services.
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
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Introduction to our Quality Account
This Quality Account is Nottingham Woodthorpe 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.
In 2009/10 the Quality Account was developed by our Corporate Office which
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 developed its
own Quality Account for 2010/11 and this account for 2013/14 is the Nottingham
Woodthorpe Hospital‟s third submission 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.
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Part 1
1.1 Statement on quality from the General
Manager
Simon Milner, General Manager,
Nottingham Woodthorpe Hospital
As General Manager of Nottingham Woodthorpe Hospital, having trained as a
nurse in Intensive Care, I believe that this hospital is clinically driven and our goal
is to support our clinicians in delivering the highest quality care to our patients.
Not only that, but we aim to produce evidence to this effect whether it be
qualitative or objective – we will be able to demonstrate our capabilities, and
clinical excellence.
Our Hospital Vision is that:“As a committed team of professional individuals we aim to consistently deliver
quality holistic Acute Inpatient and Day case Services with exemplary customer
care. This we believe we are able to achieve by continually updating our staffs’
skills and competencies. We strive to further develop our knowledge in order to
deliver evidenced based clinical practice”.
This Quality Accounts document details our performance over the past year
indicating how we have improved on the high standards of clinical care the
actions that we have taken over the past year.
Quality extends not only to the service we deliver to our patients but to our other
customers – Consultants, GPs, Commissioners, other Trusts and by no means
last, the people who work for us. To understand how we deliver our services, and
the quality standards we reach is critical in our understanding of where we can
improve and how.
Where appropriate, Nottingham Woodthorpe Hospital participates in local,
corporate and national systems of quality review that are sometimes mandatory,
sometimes voluntary, but all times we are honest in our responses. It is to our
benefit that we benchmark honestly against our peers, and that we take the
opportunity to learn from those facilities and people delivering better outcomes, in
order to drive up our own standards
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To ensure that we deliver clinical excellence depends on everyone in our hospital
and we have a training and education plan which involves all members of our
administrative, operational and clinical teams. The emphasis on training and
education is high and strongly encouraged in order that we develop our people,
as well as deliver standards that we can be proud of.
Every individual member of staff is crucial to the success of our Hospital and they
value the contribution that they make in delivering great customer care.
In addition to our people contributing to the quality of services delivered, we work
closely with our consultant colleagues who, for the first time this year through
their MAC representatives, have responded positively to sharing the outcomes of
their clinical work in many areas. This is to be commended, but at the same time,
will be something Nottingham Woodthorpe Hospital can be proud to show, as we
pride ourselves in having consultants with the highest standards in the area
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 commented on the details within these
Quality Accounts.
If you would like to comment or provide me with feedback then please do email
me at simon.milner@ramsayhealth.co.uk or contact me on 0115 920 9209
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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.
Simon Milner
General Manager
Nottingham Woodthorpe Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
MAC Chair:
Mr Anwar Zaman
Regional Director: Mr James Beech
Commissioner/ NHS Nottingham City Clinical Commissioning Group
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Welcome to Nottingham Woodthorpe Hospital
Nottingham Woodthorpe Hospital has provided healthcare to the people of
Nottingham since 1877 and is conveniently located towards the north of
Nottingham city centre. Today, we are a modern well equipped hospital with 39
private bedrooms, two theatres (with laminar air flow), a minor ops theatre with
endoscopy and a 2 bedded HDU.
The hospital provides NHS and private inpatient and outpatient facilities for:Orthopaedic surgery
General surgery including gastrointestinal
Gynaecology
Bariatric surgery
Colorectal surgery
Cosmetic and Plastic surgery
Dermatology
Upper and lower diagnostic Endoscopy procedures
Ophthalmic surgery
Oral and Maxillofacial surgery
Spinal surgery
Vascular surgery
Urological surgery
General medicine
Physiotherapy including shockwave therapy, Sports Medicine and
acupuncture
Diagnostic imaging services including MRI and CT
We provide safe, convenient, effective and high quality treatment for adult
patients (excluding children below the age of 18 years), whether privately insured,
self-pay, or from the NHS.
A high percentage of our patients have come from the NHS sector with patients
choosing to use our facility through „Choose and Book‟. Our services help to ease
the pressure on local NHS facilities and our Hospital Management Team work
closely with local CCG‟s to ensure improved access for patients.
We have close links with GP surgeries, providing information, training and liaison
in order to monitor their needs and the requirement of the local population.
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We have carried out over 4,379 procedures in the past 12 months of which 3,641
were NHS and 738 were Private patients.
In addition to the Senior Management Team comprising of the General Manager,
Matron, Sales & Marketing Co-ordinator and Support Services Manager, we
currently employ the following staff at Nottingham Woodthorpe Hospital;1 Ward Manager, 1 Theatre Manager and 1 Outpatient Sister
19 Registered Nurses working within the Ward, Outpatients and
Theatres
5 Senior Staff Nurses working within the Ward and Theatres
1 Senior Operating Theatre Practitioner
2 Operating Department Practitioners
14 Health Care Assistants working within all clinical departments
29 Administration Staff working within Reception, Bookings, Business
Office, Hospital Administration, Marketing, Medical Secretaries and
Medical Records
1 Supplies Manager
1 Maintenance Manager, 1 Assistant Maintenance Assistant
2 Theatre Porters
3 Radiographers
4 Physiotherapists
1 Pharmacist and 1 Pharmacy Technician
4 Sterile Services Technicians
5 Housekeeping staff
2 Chefs supported by 6 Catering staff
Nottingham Woodthorpe Hospital also employs a GP Liaison Officer who
maintains and establishes relationships with GPs and the practice staff from
Nottingham and the surrounding areas. A GP visit schedule is maintained
whereby surgeries are contacted and visited on a regular basis. GPs are sent
regular newsletters and updates, and information packs containing details about
the hospital and how to refer are distributed.
We are currently establishing a programme of educational visits during practice
learning times whereby a consultant and the GP Liaison Officer will visit GP
surgeries with a topic of interest for a “Lunch & Learn” session. GP Educational
evenings are also held at the hospital.
Outside activities which show an involvement in the community include hosting
public open evenings for various clinical specialities e.g. cosmetic surgery and
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bariatric surgery. The hospital‟s Charity Committee arranges fund raising events
to support local external charitable organisations such as a local Hospice and The
Stroke Foundation.
The hospital also promotes its services to the community via advertising in local
publications such as Nottingham Post, Newark and Trent Valley Journal,
Nottingham & Long Eaton Topper and Newark Village Life, together with local
radio advertising throughout the East Midlands.
Part 2
2.1 Quality priorities for 2013/2014
Plan for 2013/14
On an annual cycle, Nottingham Woodthorpe 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 hospital‟s Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
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Priorities for improvement
2.1.1 A review of clinical priorities 2012/13 (looking back)
Patient safety
Introduction of the National Patient Safety Thermometer
The National Patient Safety Thermometer is a national initiative which has
allowed us to monitor the level of harm our patients may be exposed to. The
monitoring takes place on a pre-determined date each month and is applicable to
all in-patients on that set date. Data is completed on a template and submitted
directly to the Department of Health Information Centre and monitors the
incidence of falls, VTE assessment and preventative treatment, and urinary
infections. Through submitting this data on a monthly basis, we have been able to
benchmark ourselves against other Hospitals within Ramsay Health Care and
within the NHS.
Implementation of RiskMan
In 2012/13 a new incident reporting system was implemented called RiskMan
across the company which has allowed greater accuracy in recording incidents
and also supports enhanced data and trend analysis. This has helped support our
patient safety ethos. There is now an improved ability to identify areas concern
relating to patient safety and calculate any trends. Using this system Nottingham
Woodthorpe Hospital has seen the total number of incidents reported rise but with
the significant majority of incidents are classified as not causing harm to anyone.
This is an indicator of a safety conscious organisation; one which is willing to
report and analyze all incidents, whether they cause harm or not to ensure we
learn and improve further. This information is shared with the local CCG Quality
team to provide assurance of the safety of our services and allows us to be
benchmarked against other providers. We will continue to share this type of
information with our CCG during 2013/14
Increase Patient Feedback Systems
To ensure our services meet our patients expectations we are implanting new
systems of gaining feedback on our patient‟s experience which will complement
our existing system. Currently, we use an external company to obtain our patient
feedback; this ensures the results are completely unbiased and independent. In
conjunction with this, patients are being actively encouraged to complete the „We
Value Your Opinion‟ feedback forms and these are reviewed by a member of the
senior management team.
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Never Events
These 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 17 that largely affect Ramsay:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
Wrong site surgery
Wrong implant/prosthesis
Retained foreign object post-operation
Wrongly prepared high risk injectable medication
Maladministration of potassium-containing solutions
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
Entrapment in bedrails
Transfusion of ABO incompatible blood components
Misplaced naso or oro gastric tubes
Wrong gas administered
Failure to monitor and respond to oxygen saturation
Misidentification of Patients
Severe scalding of Patients
Nottingham Woodthorpe Hospital has robust clinical governance processes in
place to mitigate the risk of such an event occurring. There have been no
reported adverse incidents which fall into this category in 2012/2013.
VTE Risk Assessment
In September 2008, the Department of Health issued its guidance on Risk
Assessment for Venous Thromboembolism (DH 2008). The objective is to
improve the quality of patient care by minimising the risk of VTE incidents.
Nottingham Woodthorpe Hospital submits data to evidence compliance with the
National VTE Commissioning for Quality and Innovation Goal that all patients
should have a VTE risk assessment. Nottingham Woodthorpe Hospital‟s priority
for 2012/13 was to maintain and improve the current compliance rate, as shown
in the table below. March data excluded as not yet available.
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2012/13 – UNIFY VTE submissions
Staff Satisfaction
The results from staff surveys continue to be important as satisfied, well trained
and competent staff will ensure patient safety risks are reduced. Staff satisfaction
surveys are undertaken annually and reviewed by a dedicated working group.
Competency training / Vulnerable Adult training
All staff within the hospital undertake a formal induction process which includes
the need to treat service users with consideration and respect, promoting their
autonomy, independence and community involvement with due regard to their
age, sex, religious persuasion, sexual orientation, culture and linguistic
background and any disability they may have. All staff are required to undertake
the „Equality, Human Rights and Workplace Diversity‟ Level 1 e-learning program.
Competency training – ensuring well trained, competent staff are available to care
for patients is a high priority for us. This year the staff have undertaken
competency based training in infection prevention and control which includes
hand hygiene. Intermediate Life Support (ILS) and/or Advance Life Support (ALS)
training is mandatory for all clinical staff working in acute areas and this year we
also provided AIM (Acute Illness Management) training. All staff at Nottingham
Woodthorpe Hospital who are involved in any aspect of a blood transfusion or
who handle blood products have been formally assessed as competent in order
to be allowed to participate in this aspect of care.
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2.1.2 Clinical Priorities for 2013/14 (looking forward)
Patient Safety
WHO Surgical safety checklist
Compliance with the checklist will remain an on-going quality and safety priority at
The Woodthorpe. We will audit our compliance and report the results to
Nottingham City CCG.
Venous-Thromboembolism assessment
This 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 indicators.
Cleanliness and infection prevention
There have been no MRSA bacteraemia at the hospital for over four years,
however we are not complacent and we continue to screen all patients for MRSA
prior to admission 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 also participate in the Health Protection Agency
data collection for surgical site infections following hip and knee joint
replacements.
Never events
Preventing the occurrence of Never Events will remain a clinical priority for
2013/14.
JAG accreditation
One of this year‟s priorities is for Nottingham Woodthorpe Hospital to achieve
this nationally recognised award. A lead nurse for Endoscopy is about to start in
post and we submit data for the Global Rating Scale. We are working closely with
other Ramsay units in the UK that have already achieved accreditation and are
confident that our clinical practice is working to JAG levels; it is only the
requirements relating to IT systems that hold us back and we aim to address this
during 2013/14. Our JAG assessment has been booked for 2014.
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National Joint Register
Nottingham Woodthorpe Hospital aims to maintain its consistently good scores
for data submission to the National Joint Register. The National Joint Register
records the details of patients undergoing major joint replacement surgery and
the type of prosthesis (new joint) they are given. This system is invaluable when
there are nationally identified concerns such as the recent „metal on metal‟ hip
joint alert; patient‟s details are only added to this register with their written
consent. We continue to submit data to the NJR. The key performance
benchmark for NJR consent is 95%. Nottingham Woodthorpe hospital
consistently scores in excess of 90%.
Data is 2012/13 - NJR Submissions
Clinical and other training
Nottingham Woodthorpe Hospital will continue to ensure that patients are cared
for by well trained, competent staff. Providing quality care for patients is a high
priority for us and all relevant clinical staff will be supported through training and
protected time to achieve competency level education.
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Safeguarding
The hospital takes its responsibility for safeguarding vulnerable members of
society seriously. We will continue to ensure that all staff working within the
hospital have the appropriate level of CRB check appropriate to their role. We will
continue to provide training, reviewing the content in light of local multi-agency
and Ramsay UK policies procedures, and ensure that staff have the necessary
resources available to enable them to manage any concerns appropriately and in
a timely manner.
Staffing
To ensure that adequate numbers of skilled staff are available to care for our
patient‟s staff rotas are prepared in advance. When determining how many staff
and what skills are required, the dependency of patients and the amount of time
each requires is taken in to account. We have „as and when‟ staff to provide
additional cover as required.
Ramsay has invested in an electronic rostering system called Allocate; which will
be introduced at Nottingham Woodthorpe Hospital in September 2013. The
system will be set-up to produce rotas in line with patient numbers and specific
local skill mix requirements. It will also 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
Clinical effectiveness
Ambulatory Day Care – better outcomes and improving patient
experience
Ambulatory 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. In the 12 months leading up to 31 st March 2013,
the percentage of day surgery patients we treated was 58.3% which exceeded
our projection that 50% of all 2012 admits would be day case. We need to ensure
that our hospital facilities and patient flows better meet the case mix we now
deliver.
Success of the service will be monitored through patient satisfaction reports,
response to the 24-hour post discharge follow up telephone calls and review of
clinical governance indicators, e.g. change to length of hospital stay.
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Pre-operative Assessment
Nottingham Woodthorpe hospital Pre Assessment team have worked hard to
develop the service to ensure patient‟s fitness for surgery is assessed in advance
of their admission to reduce the chance of their operation being cancelled for
safety reasons. This work will continue in an improved environment once the final
phase of the building development is completed.
Improve National Benchmarking
It was recognised that we needed more transparency between ourselves and
other independent sector providers/the NHS in order to monitor and improve our
services. This is even more important now we are working in partnership with the
NHS. E.g. benchmarking in the following area:
PROMS Audit
Nottingham Woodthorpe Hospital currently participates in the outcome data
known as PROMS for the following surgical procedures:o hernia repair
o total knee replacement
o total hip replacement procedures
All patients who undergo these procedures receive a pre and post-operative
questionnaire which they complete and the results are collated by an external
body, The Royal College of Surgeons. This also incorporates the Oxford Hip and
Knee scores. Reviewing this data also provides the opportunity to identify poor
outcomes and examine practice if and when it exists.
Benchmarking is undertaken through the national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryI
D=1295
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Patient experience
Patient reported outcome studies (PROMS)
We continue to participate in the national PROMS data collection for Hip and
Knee surgery. The results, which are very encouraging for the hospital, are
shared with the medical and clinical staff through the Medical Advisory
Committee, Clinical Governance Committee, and Clinical Effectiveness meetings.
Reviewing this data also provides the opportunity to identify poor outcomes and
examine practice if and when it exists.
Patient satisfaction survey
Nottingham Woodthorpe hospital has always achieved a high level of patient
satisfaction. The most recent Ramsay Healthcare national inpatient survey was
distributed to patients discharged between January and August 2012 and uses a
„mean rating score‟ consistent with the Care Quality Commission to enable
benchmarking against other organisations. The mean rating score allocates a
„weight‟ to each response, with positive scores (e.g. excellent, very good, and
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).
It is proposed in 2013/14 to facilitate a patient focus group meeting to gain a
better understanding and insight into the quality of our patient‟s experiences in
using our facilities. In addition, our Matron offers patients the opportunity, both
formally and informally, to meet with her to listen to feedback on their personal
experiences.
In response to the question “Overall how would you rate your experience”
Nottingham Woodthorpe hospital achieved a rating of 92%.
Friends and Family Survey
This year as one of our locally agreed quality indicators Nottingham Woodthorpe
hospital will be using this survey to benchmark how our patients would
recommend us to friends and family. Our latest results for April 2013 show that
98% of our patients would definitely recommend Nottingham Woodthorpe hospital
to their friends and family.
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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 Nottingham Woodthorpe Hospital provided and/or sub
contracted a wide case mix of inpatient and day case surgery NHS services.
Nottingham Woodthorpe Hospital has reviewed all the data available to them on
the quality of care in all of the NHS services they provide.
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 hospital‟s
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 at The Nottingham Woodthorpe Hospital were:
Human Resources
HCA Hours as % of Total Nursing:
33.8%
Agency Hours as % of Total Hours:
14.8%
% Staff Turnover:
11.2%
% Sickness:
8.12%
Total Lost Worked Days:
1317.7 days
Appraisal %:
96%
Mandatory Training:
71.3%
Staff Satisfaction Score:
4.16% (Ramsay average was 4.6%)
Number of Significant Staff Injuries:
0
Quality
Workplace Health & Safety Score:
96%
Infection Control Audit Score:
94.6% overall
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Patient Experience
Formal Complaints Received
In 2010/11 we received 38 complaints compared to 41 in 2012/13. There were no
trends identified. However, we have made several changes to practice to improve
the quality of our service to patients including changes to our internal processes
and communication, patient flows with the continued improvement in the standard
of our facilities.
“We value your opinion” leaflets were also introduced in 2012 to enhance patient
feedback and to investigate and resolve any issues that may be raised. Patient
feedback from these leaflets resulted in 216 positive comments in 2012.
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Number of Significant Clinical Events
We had 8 significant clinical events to report in 2010/11, with 10 being reported in
2011/12 and 14 in 2012/13.
The above graph appears as though we have had an increase in our incidents;
however, since Riskman was introduced we are able to record incidents more
accurately and comprehensively than our previous incident reporting system.
The incidents experienced were mainly due to patients being readmitted to the
hospital as a result of high temperature and possible wound infection which are
common complications following surgery. These symptoms were resolved after
24hrs, allowing the patient to return home, following close observation and
monitoring by our ward team and assessment by the patients‟ consultant.
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2.2.2 Participation in clinical audit
The national clinical audits that Nottingham Woodthorpe Hospital participated in
during 1st April 2011 to 31st March 2012 are as follows:
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMS Programme)
The data relating to these audits are listed below alongside the number of cases
submitted to each audit as a percentage of the number of registered cases
required by the terms of that audit.
National Clinical Audits
% cases
submitted
Name of Audit
Participation
Long term conditions
Insufficient Patient
Numbers
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMS Programme)
Cardiovascular disease
Renal disease
Cancer
Trauma
Health promotion
End of life
Yes
Yes
N/A – No service
N/A – No service
N/A – No service
N/A – No service
N/A – No service
N/A – No service
Local Audits
Nottingham Woodthorpe hospital participates in the Ramsay corporate clinical
audit programme comprising of 62 separate audits which includes 15 infection
prevention and control, 3 transfusion, 4 physiotherapy and 2 radiology. Clinical
audits from 1 April 2012 to 31st March 2013 were reviewed by the Clinical
Governance Committee and the hospital‟s Medical Advisory Committee.
All audit results showed an excellent degree of compliance – our main priority for
2013/14 will be ensuring standards of documentation are met with regard to the
discharge of patients and informed consent. This is in line with the requirements
of the National Standard Acute Contract for NHS Services.
The clinical audit schedule can be found in Appendix 2
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100%
95%
2.2.3 Participation in Research
There were no patients recruited during 2012/13 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
The commission for quality and innovation (CQUIN) payment framework enables
commissioners to reward excellence by linking a proportion of provider‟s income
to the achievement of local quality improvement goals.
Each commissioner agrees a number of different CQUIN‟s at the beginning of the
financial year with each of their providers. These include in year targets as well
as final outcome targets.
Nottingham Woodthorpe Hospital‟s income from 1 April 2012 to 31st March 2013
was conditional on achieving quality improvement and innovation goals through
the Commissioning for Quality and Innovation payment framework during this
period. Nottingham Woodthorpe hospital has agreed revised CQUIN topics and
targets for 2013/14 to support our continuous drive to further improve our
standards.
2.2.5 Statements from the Care Quality Commission (CQC)
Nottingham Woodthorpe Hospital is required to register with the Care Quality
Commission and its current registration status on the 31st March is registered
without conditions.
The CQC conducted an unannounced inspection on 4h October 2012.
Regulations 2, 4, 10, 12 and 17 were reviewed by the inspectors and no
concerns were raised. All patients said they felt safe and that staff were very
kind to them. The Lead Inspector received many positive comments about staff
when he visited our inpatients. Patients said that their privacy and dignity was
protected and they felt staff were respectful during their visit to the hospital.
Patients also told the inspector that they felt involved in planning of their care
and treatment.
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Hospital staff told the inspector that they enjoyed working at the hospital and
supporting patients. The atmosphere throughout the hospital was considered to
be professional, friendly yet organised and calm.
2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to
improve your Data Quality
Nottingham Woodthorpe Hospital will be taking the following actions to improve
data quality.
Recording and investigating any unexpected return to theatre post surgery
Any extended length of planned stay and the reasons for this
Any unplanned death – this is reported and investigated as a serious
untoward incident
Any infections post surgery
Any transfer from the Hospital
Coding take place from the medical records.
There is a weekly data report which highlights any identified areas which
are addressed by the coder. This is addressed before the data is
submitted.
Consultant records are also subject to a monthly audit with individual
consultant feedback being given as required.
Defined process in place for capturing the Minimum Data Set on patient
referral and at admission into the hospital.
Robust clinical audit calendar (See Appendix 2)
All of these audit results are discussed at the MAC, Clinical Governance, and
Health and Safety meetings, and results are compared against previous year
results
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NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2010/11 to the Secondary Users
Service for inclusion in the Hospital Episode Statistics which are included in the
latest published data. The percentage of records in the published data included:
The patient‟s valid NHS number:
99.98% for admitted patient care
99.95% for outpatient care
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
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
The Nottingham Woodthorpe Hospital is subject to the Payment by Results
clinical coding audit and we will be audited as a company in 2013. During 2012
we received a good result from the internal audit
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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 CCG for comment prior to publication, and you should include
these comments in the published Quality Account here:
CCG – awaiting response
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Part 3: Review of quality performance 2012/2013
Statements of quality delivery
Matron, Caroline Hunt
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 real-time information and this includes
on-line patient surveys. Added to which there are more opportunities to use
new measures of quality of care and patient safety and be able to make a
difference to improvements in future practice. Importantly these new metrics
should ensure performance which needs improving, can be quickly identified
and fixed‟.
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health
Care UK)
Ramsay Clinical Governance Framework
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.
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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
Ramsay Health Care Clinical Governance Framework
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NICE / NPSA guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the National Patient Safety Agency
(NPSA).
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
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.
3.1.1 Infection prevention and control
Nottingham Woodthorpe 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.
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Programmes and activities within our hospital include:
Our Infection Control Link Nurse works closely with all the departments
within the hospital offering advice and support. Hand hygiene and Sharps
Injury posters are displayed around the building to promote awareness of
these important issues. In October there is an annual National Infection
Control day which is advertised at the hospital with local Infection Control
initiatives taking place throughout the month. It is also mandatory for all
hospital staff to perform practical as well as elearning based annual
training in Infection Control.
The graph below shows the absolute numbers of Hospital acquired
infections for Nottingham Woodthorpe Hospital over the last 3 years. All of
these cases were successfully treated with antibiotic therapy
There have been no cases of MRSA Bacteraemia.
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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 Assessments of the Clinical Environment (PLACE) - Annually from
April 2013
Environmental Audit
This audit was introduced in 2010, and is 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
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.
Nottingham Woodthorpe hospital environmental audit results are always at least
90%. We continue to focus on delivering a high standard of cleanliness and
ensure that staff are informed and updated at our mandatory training study days
as well as discussing the points raised at our bi-monthly Risk Management
meetings
3.1.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety. Our record in workplace safety as illustrated by Accidents per 1000
Admissions demonstrates the results of safety training and local safety initiatives.
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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 hospital staff carry out annual Mandatory training incorporating Health and
Safety issues. Clinical staff have taken part in fire extinguisher training and in
Albac evacuation. Patient evacuation equipment has been fitted to key areas
within the building. Fire alarms are tested on a weekly basis and further fire
evacuation training is planned. Regular Health and Safety audits are performed
including the recent Facilities audit.
Caring for your privacy and dignity – same sex accommodation
At Nottingham Woodthorpe Hospital we are committed to making sure that all our
patients receive high-quality care that is safe and effective.
Our patients have the right to privacy and to be treated with dignity and respect.
We believe that providing same-sex accommodation is a key part of achieving
this and allows us to give all of our patients the best possible experience while
they are in hospital.
Nottingham Woodthorpe Hospital is pleased to confirm that we are compliant with
the Government‟s requirement to deliver same-sex accommodation, except when
it is in the patient‟s overall best interest, or reflects their personal choice.
3.1.4 Caring for your privacy – data protection
Your doctor and other health professionals caring for you keep records about
your health and any treatment and care you receive from the Nottingham
Woodthorpe hospital. These help us to ensure that you receive the best possible
care from us. These records may be written down or held on a computer and are
used to guide and administer the care you receive to ensure full information is
available to anyone involved in delivering safe care to you.
Everyone working at Nottingham Woodthorpe Hospital has a legal duty to keep
information about our patients safe and confidential. If you are receiving care at
another organisation and they need access to your records held at the Woodland
Hospital, there is a strict process that must be followed and that may involve in us
obtaining your consent prior to disclosing any information. There are times when
we are required by law to pass on information to the appropriate authorities but
this is only done after formal permission has been given by a qualified health
professional. Anyone who receives information from us is also under a legal duty
to keep it confidential.
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3.2 Clinical effectiveness
Nottingham Woodthorpe 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.
The results highlighted in the graphs demonstrate the effectiveness of this
approach over the last three years.
3.2.1 Returns 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.
The graph below shows absolute numbers of unexpected returns to theatre over
the last 3 years
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The graph below gives the % of unplanned returns to theatre per 100 discharges
3.2.2 Readmission to hospital
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be
addressed. Ramsay rates of readmission remain very low and this, in part, is due
to sound clinical practice ensuring patients are not discharged home too early
after treatment and are independently mobile, not in severe pain etc.
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The graph below shows the absolute number of unplanned re-admissions over
the last 3 years
As can be seen in the above graph our readmission to hospital rate has increased
over the last year. This is due to the increased complexity of procedures we
perform, which can lead to additional complications that may routinely be
associated with minor day case surgery.
Our clinical staff are trained to provide a high standard of care to enable patients
to recover and return home in a timely manner, following observation and further
treatment where necessary.
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
patiens be unhappy with any aspect of their care.
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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 DOH bodies occurs as required and according to Ramsay and
DOH policy.
Feedback regarding the patient‟s experience is encouraged in various ways via:






Patient satisfaction surveys
„We value your opinion‟ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
PROMs surveys
Care pathways – patient are encouraged to read and participate in their
plan of care
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys were managed by an independent company
called “The Leadership Factor” (TLF) until earlier this year when we moved to a
web based survey managed by Qa Research. Results are produced quarterly
(the data is shown as an overall figure but also separately for NHS and private
patients). The results are available for patients to view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel
they receive excellent quality of care and service at Nottingham Woodthorpe
hospital. To record a satisfaction index over 95%, a very high proportion of our
patients have scored 9 or 10 out of 10 for their satisfaction with all the
requirements. This is underlined by comparing our hospital‟s Satisfaction Index
against those achieved by other organisations across all sectors of the UK
economy where the full range of customer satisfaction is 50% to 95% with the
median just below 80%.
The response rate for patients treated at Nottingham Woodthorpe hospital was
92%
Key questions and the mean rating score they attracted are shown below:
Were there enough staff (nurses) to care for you 91%
Were you involved enough in decisions about your care/treatment 91.5%
Were you given enough privacy when being examined/treated 98%
Overall were you treated with respect and dignity 98.3%
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3.3.2 Patient Reported Outcome Measures (PROMS)
Nottingham Woodthorpe Hospital participates in the Department of Health‟s
PROMS surveys for hip and knee surgery and hernias for NHS patients.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMS
surveys specifically for private patients.
Patient reported health gain by procedure is shown on the graphs below
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
Nottingham Woodthorpe Hospital
Ramsay UK Properties Ltd
Nottingham Woodthorpe Hospital has 41
beds, two theatres (with laminar air flow), a
2 bedded HDU and a minor ops theatre with
endoscopy
Nottingham has the ability to provide post-op
Level 2 care in a purpose built HDU which
includes integral suction, air, oxygen and
electric profiling beds with pressure relieving mattresses. Nottingham Woodthorpe
Hospital is a member of the Mid Trent Critical Care Network
On site facilities include Radiology, Physiotherapy, Pharmacy, visiting MRI
scanner, 9 Outpatient Consulting Rooms; Phlebotomy Service.
Location:
Nottingham Woodthorpe Hospital, 748 Mansfield Rd, Woodthorpe, Nottingham
NG5 3FZ
Tel: 01159 209209
Registered Manager: Mr Simon Milner
Simon.milner@ramsayhealth.co.uk
Regulated Activities – Nottingham Woodthorpe Hospital
Treatment of
Disease,
Disorder
Or injury
Services Provided
Clinical Immunology and Allergy
Testing, Clinical Oncology,
Cosmetics, Counselling services,
Dermatological lasers, Dietician, Ear,
Nose and Throat (ENT),
Gastrointestinal, General surgery,
General Medicine, Genitourinary
medicine, Geriatric Medicine,
Gynaecological, Haematology (non
clinical), Nephrology, Ophthalmic (inc
laser), Orthopaedic, Orthodontics,
Orthoptic, Occupational medicine,
Occupational therapy, Pain
Management, Psychotherapy,
Psychology, Rheumatology, Speech
Therapy, Urological, Vascular
Peoples Needs Met for:
All adults 18 yrs and over
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Surgical
Procedures
Diagnostic
and
screening
Bariatric surgery, Breast surgery,
Cancer surgery (breast and
colorectal), Colorectal, Cosmetics,
Day and Inpatient Surgery,
Dermatology, Ear, Nose and Throat
(ENT), Endoscopy, Gastrointestinal,
General surgery, Genitourinary
surgery, Gynaecological, Ophthalmic,
Oral and Maxillofacial surgery, Neuro
Surgery, Orthopaedic, Plastic
Surgery, Restorative dentistry, Spinal
Surgery, Vascular Surgery, Upper GI
surgery, Urological
GI physiology, Imaging services,
Exercise ECG, Health screening,
Phlebotomy, Urinary Screening and
Specimen collection.
All adults 18 yrs and over excluding:
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
New pacemaker within the last 6 months
BMI limit of 40 excluding gastric banding, major surgery
History of major post op complications
Alzheimer‟s or Dementia
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
Orthopaedic surgery
General surgery including gastrointestinal
Gynaecology
Bariatric surgery
Colorectal surgery
Cosmetic and Plastic surgery
Dermatology
Upper and lower diagnostic Endoscopy procedures
Ophthalmic surgery
Oral and Maxillofacial surgery
Spinal surgery
Vascular surgery
Urological surgery
General medicine
Physiotherapy including shockwave therapy, Sports Medicine and
acupuncture
Diagnostic imaging services including MRI and CT
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Quality
Accounts 2013/14
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Nottingham Woodthorpe
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:
0115 9209209
Quality
Accounts 2013/14
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