Quality Account
2012 /13
No reported MRSA Bacteraemia in the past 3 years
Contents
Welcome to Ramsay Health Care UK and Park Hill Hospital
3
Introduction to our Quality Account
4
PART 1 – STATEMENT ON QUALITY
5
1.1
Statement from the General Manager
5
1.2
Hospital accountability statement
6
Welcome to Park Hill Hospital
7
PART 2 – QUALITY PRIORITIES
8
2.1
8
Priorities for Improvement 2012/13
2.1.1 Review of clinical priorities 2011/12 (looking back)
8
2.1.2 Clinical Priorities for 2012/13 (looking forward)
10
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
13
2.2.2 Participation in Clinical Audit
13
2.2.3 Participation in Research
14
2.2.4 Goals agreed with Commissioners
14
2.2.5 Statement from the Care Quality Commission
14
2.2.6 Statement on Data Quality
15
2.2.7 Stakeholders views on 2011/2 Quality Account
16
PART 3 – REVIEW OF QUALITY PERFORMANCE
17
3.1
Patient Safety
19
3.2
Clinical Effectiveness
21
3.3
Patient Experience
24
3.4
Case Study
26
2.2
13
Appendix 1 – Services Covered by this Quality Account
27
Appendix 2 – Clinical Audits
28
Quality Account 2012/13
Page 2
Welcome to Ramsay Health Care UK
Park Hill 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, CCG’s 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 Account 2012/13
Page 3
Introduction to our Quality Account
This Quality Account is Park Hill 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 and summarised
and reviewed quality activities across every hospital and centre within Ramsay Health
Care UK. It was recognised, however, that this did not provide enough indepth
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.
This Quality Account for 2012/13 is Park Hill Hospital‘s third submission.
Quality Account 2012/13
Page 4
Part 1
1.1 Statement on Quality from the General Manager
Dawn Abbott, General Manager,
Park Hill Hospital
“Park Hill Hospital is committed to being a leading provider of healthcare services by
delivering high quality outcomes for patients.”
As General Manager of Park Hill Hospital, I am passionate about ensuring that high quality
patient care is at the centre of what we do. I am committed to ensuring that Park Hill Hospital
shows year on year improvements in clinical outcomes.
Park Hill Hospital has produced this Quality Account to demonstrate our commitment to
measuring all feedback from patients about their experience, clinical treatment and clinical
outcomes. This allows us to continually review, reflect and improve the patient’s journey at
Park Hill Hospital.
Patient safety is our highest priority and our robust recruitment processes and training
programmes ensure that our staff are sufficiently qualified and competent to deliver our services
in a safe environment.
Park Hill Hospital continually achieves consistently high patient satisfaction results, and through
reviewing our customer’s feedback throughout the year, we constantly seek to further enhance
the patient experience.
Whilst patient feedback and involvement is extremely important to us, we also use other
measures of safety and clinical effectiveness which we use to satisfy ourselves that the care
and treatments we provide are evidence-based and delivered by appropriately qualified and
experienced medical staff, nurses and other key healthcare professionals.
This Quality Account provides information for our patients and commissioners to assure them of
our ongoing commitment to sharing our progressive achievements from one year to the next.
Quality Account 2012/13
Page 5
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.
Dawn Abbott
General Manager
Park Hill Hospital
Ramsay Health Care UK Operations Ltd
This report has been reviewed by:
Dr S B Bittiner, MAC Chairman
Mr Stefan Andrejczuk, Regional Director (North)
Doncaster Clinical Commissioning Group
Doncaster & Bassetlaw Hospitals NHS Foundation Trust
Quality Account 2012/13
Page 6
Welcome to Park Hill Hospital
Park Hill Hospital is one of South Yorkshire’s leading private hospitals with an excellent
reputation for delivering high quality healthcare treatments and services. Located on
the site of the Doncaster Royal Infirmary, Park Hill Hospital opened in April 1995. The
ward consists of 21 beds, 17 of which are in single rooms, all with en-suite facility. The
outpatient department consists of 6 consulting rooms and a minor procedure treatment
area.
The hospital provides a full range of quality services, these include, outpatient
consultation, outpatient procedures, investigations/diagnostics, surgery and follow up
care. During the last 12 months, the hospital has treated 2,923 patients, 57.5% of
which were treated under the care of the NHS. All NHS patients treated at the hospital
must be over 18 years of age as defined by the Standard Contract.
Currently, over 100 specialist Consultants work from the hospital who are supported by
a team of 54 staff, which includes nursing, physiotherapy and administration staff. We
also have a Resident Medical Officer (RMO) for 24 hour emergency support.
Park Hill Hospital has a very close working relationship with Doncaster & Bassetlaw
Hospitals NHS Foundation Trust, and has access to support services through various
service level agreements with the Trust.
Quality Account 2012/13
Page 7
Part 2
Quality Priorities for 2012/2013
Plan for 2012/13
On an annual cycle, Park Hill 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
Priorities for improvement
2.1.1 A review of clinical priorities 2011/12 (looking back)
Patient safety
“Never Events.” Never events are serious, largely preventable, patient safety
incidents that should not occur if the available preventative measures have been
implemented. The Department of Health lists twenty five “never events”,
seventeen of which are relevant to Ramsay:
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
Quality Account 2012/13
Page 8
Misplaced naso or oro gastric tubes
Wrong gas administered
Failure to monitor and respond to oxygen saturation
Misidentification of Patients
Severe scalding of Patients
Park Hill Hospital has robust clinical governance processes in place to mitigate
the risk of such an event occurring. During 2012/2013, there were no reported
Never Events.
VTE risk assessment. Park Hill 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. Park Hill Hospital’s priority for
2013/14 is to maintain the current excellent compliance rate, as shown in the
table below (Data is 2012/13 – UNIFY Submissions.
100%
1
98%
0.98
96%
0.96
94%
0.94
92%
0.92
90%
0.9
88%
0.88
86%
0.86
84%
0.84
82%
0.82
80%
0.8
Excellent
Good
Fail
Actual
Target
Park Hill Hospital
Compliance results are benchmarked through the national statistics at:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatis
tics/DH_122283
Real time incident reporting – Park Hill Hospital strives to report any incidents
in real time. In August 2012 a new risk information management software
package called RiskMan was implemented. The new system has streamlined
processes for reporting of clinical, health & safety incidents, complaints and
compliments. It has also improved how we track incidents and alerts the
necessary manager to ensure that incidents are managed efficiently. The system
also immediately reports any incident into the Corporate Risk Management
Team, enabling trends to be identified throughout the Ramsay organisation.
Locally all incidents are reported through Risk Management and Clinical
Governance groups, with action plans developed, implemented and reviewed.
Quality Account 2012/13
Page 9
Using this system, we have seen the total number of incidents reported rise.
This is an indicator of a safety conscious organisation; one which is willing to
report and analyse all incidents, whether they cause harm or not, to ensure that
we learn from incidents, and make improvements to prevent a recurrence.
Safer Site Surgery Checklists – Park Hill Hospital has ensured that patient
safety is regularly reviewed through monthly audits undertaken by the Theatre
Manager. The Manager observes practice, reviews patient records and monitors
compliance to policy. Procedure specific safer site surgery checklist was
introduced for cataract surgery following the sharing of lessons learnt within our
organisation.
Staff satisfaction – Our staff satisfaction results are very important to us, as
satisfied, well trained and competent staff will help to ensure patient safety.
Ramsay staff undertake an anonymous survey annually to identify areas where
staff satisfaction can be improved upon. Areas of improvement for Park Hill
Hospital from the 2012 survey were to:
o ‘improve feelings towards immediate colleagues, and how well we work
together’
o ‘increase the extent to which Park Hill has a positive impact on society, by
increasing our awareness in the local community’
Although a full staff survey has not yet been undertaken in 2013, a ‘Pulse’ survey
conducted in February 2013 showed a very positive response from staff on key
questions.
Question
Agree/
Strongly
Agree
I have confidence in the leadership skills of my manager
82.5%
My manager regularly expresses appreciation when I do a 80%
good job
I feel proud to work for this organisation
75.6%
I have confidence in the leadership skills of the senior 80.5%
management team
Senior managers truly live the values of this organisation
80.5%
In general I am happy working for Ramsay
77.5%
2.1.2 Priorities for 2013/14 (looking forward)
Information Security – Park Hill Hospital achieved the information security
accreditation ISO27001. Our aim is to ensure that all staff maintain the current
high compliance rates, by continually raising awareness of the importance of
data protection and information security.
Staff competencies - Ensuring well trained, competent staff are available to
care for patients is a high priority at Park Hill Hospital. This year our Health Care
Assistants in theatre have been undertaking NVQ Level 3 in Health Care to
Quality Account 2012/13
Page 10
ensure they hold the knowledge skills to support the delivery of care to our
patients.
In order to ensure the ongoing support of students (Adult Nursing, Operating
Department Practitioners, and Physiotherapists) several staff members will be
taking a mentorship course in the next 12 - 18 months.
National Joint Registry – Park Hill Hospital aims to improve its submission rate
to the National Joint Register for 2013/14, as, during 2012/13 our submission
rate was 93%, which is just below the target. The reason for this has been
identified, and steps put into place to improve this rating.
100%
1
95%
0.95
90%
0.9
85%
0.85
80%
0.8
75%
0.75
Actual
70%
0.7
95% Target
65%
0.65
60%
0.6
55%
0.55
50%
0.5
Park Hill Hospital
Data is 2012/13 - NJR Submissions
Clinical Effectiveness
1. 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 areas:
Private Hospitals Information Network (PHIN)
Ramsay is a member of PHIN, which will enable us to benchmark against
other providers and national benchmark figures for key performance
indicators (such as activity/volumes, mortality, day case rates, unplanned
readmissions, average length of stay, unplanned transfers, returns to
theatre.
VTE risk assessment compliance
Benchmarking through the national stats website. Link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publication
sStatistics/DH_122283
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PROMS results
Benchmarking through national PROMS website. Link:
http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&cat
egoryID=1295
2. Improve ward efficiency by adopting the Releasing Time to Care (formerly
known as the Productive Ward)
The Release Time to Care initiative focuses on the way ward teams work
together and organise themselves, in order to reduce the burden of unnecessary
activities, therefore 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.
3. Improved patient information
It was recognised from our patient satisfaction survey results that our patients
were not always receiving written discharge information on discharge. This is
important as even though we always tell our patients everything they need to
know before going home, a written reminder ensures that they have the same
information should they need to refer to it at a later date.
Patient experience – informing patient choice
1. Customer Satisfaction
For 2012, Park Hill Hospital had a response rate of approximately 45% for its
customer satisfaction surveys. 98.1% of patients would recommend Park Hill
Hospital to a friend or family member.
Park Hill 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, 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).
In response to the question “Overall how would you rate your experience?” Park
Hill Hospital achieved a rating of 98%.
Quality Account 2012/13
Page 12
Mandatory Statements
2.2.1 Review of Services
During 2012/13 Park Hill Hospital provided 5 NHS services.
Park Hill Hospital has reviewed all the data available to them on the quality of care in all
of these NHS services.
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:
People Management
% Staff Turnover
% Sickness
% Total Lost Time
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff Injuries
Workplace Health & Safety Score
Consultant Satisfaction Score
GP Satisfaction Score
HCA Hours as a % of Total Nursing
Clinical Quality
Formal Complaints per 100 Admits
Patient Satisfaction Score
Number of Significant Clinical
Events per 100 Admits
Readmissions per 100 Admits
Healthcare Acquired Infections per
100 Admits
Hip % Health Gain
Knee % Health Gain
Endoscopy GRS Score
Daycase AVLOS (hours)
Theatre Utilisation %
Consent compliance (audit score)
2.2.2 Participation in clinical audit
The national clinical audits and national confidential enquiries that Park Hill Hospital
participated in, and for which data collection was completed during 1 st April 2012 to 31st
March 2013, are listed below alongside the percentage of cases submitted to each
audit or enquiry as a percentage of the number of registered cases required by the
terms of that audit or enquiry.
Name of Audit
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Elective surgery (National PROMs Programme)
Quality Account 2012/13
Participation
(NA, Yes,
No)
% cases
submitted
Yes
100
Yes
100
Page 13
The reports of the applicable national clinical audits from 1st April 2012 to 31st March
2013 were reviewed by the local Clinical Governance Committee.
Local Audits
The reports of all local clinical audits from 1st April 2012 to 31st March 2013 were
reviewed by the local Clinical Governance Committee. Park Hill Hospital intends to
take the following actions to improve the quality of healthcare provided:
Ensure that all staff are fully aware of the correct hand hygiene technique at
induction and at regular intervals during their employment.
Improve written communication relating to patient treatment in the physiotherapy
department through fully integrated clinical records.
Ramsay’s corporate clinical audit schedule can be found in Appendix 2.
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
A proportion of Park Hill Hospital’s income from 1 April 2012 to 31st March 2013 was
conditional on achieving quality improvement and innovation goals agreed between
Park Hill Hospital and any person or body they entered into a contract, agreement or
arrangement with for the provision of NHS services, through the Commissioning for
Quality and Innovation payment framework.
Further details of the agreed goals for 2012/13 and for the following 12 month period
are available electronically at:
http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
2.2.5 Statements from the Care Quality Commission (CQC)
Park Hill Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March 2012 is registered without conditions.
The Care Quality Commission has not taken enforcement action against
Park Hill Hospital during 2011/12.
Park Hill Hospital has not participated in any special reviews or investigations by the
CQC during the reporting period.
Quality Account 2012/13
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2.2.6 Data Quality
Statement on relevance of Data Quality and your actions to improve your Data
Quality
Park Hill Hospital will be taking action to ensure that data quality is maintained to
high standards through the regular monitoring of compliance with professional
standards with regard to recording of information, through the corporate audit
programme.
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2011/12 to the Secondary
Uses Service for inclusion in the Hospital Episode Statistics which are included in the
latest published data.
The percentage of records in the published data 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).
Quality Account 2012/13
Page 15
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report overall score for 2011/12
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
Park Hill Hospital was subject to the Payment by Results clinical coding audit during
2012/13 by the Audit Commission and the attainment levels reported in the internal
audit for that period for diagnoses and treatment coding (clinical coding) were:
Audit Date
Re Audit Date
March 2012
N/A
Primary
Diagnosis
55.74%
Secondary
Diagnosis
85.38%
Primary
Procedure
95.00%
Secondary
Procedure
91.34%
2.2.7 Stakeholders views on 2011/12 Quality Account
This Quality Account was sent to Doncaster Clinical Commissioning Group prior to
publication for any comments.
No comments were received prior to publication on 27 June 2013.
Quality Account 2012/13
Page 16
Part 3: Review of Quality Performance
Statements of quality delivery
Dawn Abbott, General Manager / Matron
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 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.
Quality Account 2012/13
Page 17
The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
NICE / NPSA guidance
Ramsay also complies with the recommendations contained in technology appraisals
issued by the National Institute for Health and Clinical Excellence (NICE) and Safety
Alerts as issued by the National Patient Safety Agency (NPSA).
Ramsay has systems in place for scrutinising all national clinical guidance and selecting
those that are applicable to our business and thereafter monitoring their
implementation.
Quality Account 2012/13
Page 18
3.1 Patient Safety
We are a progressive hospital and focused 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 following graphs.
3.1.1 Patient Falls
Falls
20
15
10
5
0
10/11
11/12
12/13
Park Hill Hospital
As can be seen in the above graph our patient fall rate has increased over the
past year. This has been due to improved reporting of patient falls. In order to
reduce the risk to patients leaflets have been placed in each patient bedroom,
advising patients to ‘buzz’ for a nurse to assist them to the bathroom if they feel
unsteady, rather than attempting to mobilise unaided.
There were no serious injuries (e.g. fracture) reported as a result of a patient fall.
3.1.2 Infection prevention and control
Park Hill Hospital has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia and Clostridium Difficile infections.
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Page 19
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:
All staff undertake mandatory, annual infection prevention and control training.
Healthcare Acquired Infections
12
10
8
6
4
2
0
10/11
11/12
12/13
Park Hill Hospital
As can be seen in the above graph our infection control rate has increased year
on year. This has been due to increased awareness of the reporting procedure
of wounds that show signs of inflammation and/or discharge either as an
inpatient or in the outpatient department following discharge. In comparison to
the national average these figures are well below, and this is due to increased
general awareness of hand washing and proactive initiatives to demonstrate to
patients the importance of hand washing, and the frequency with which staff
wash their hands.
None of the reported infections were MRSA, MSSA or Clostridium Difficile.
3.1.3 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient Environment
Assessment Team (PEAT) audits.
Quality Account 2012/13
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These assessments include rating of privacy and dignity, food and food service, access
issues such as signage, bathroom / toilet environments and overall cleanliness.
The PEAT (Patient Environment Action Team) audit was repeated in March 2012 with
the following results:
o Environment Score:
o Food Score:
o Privacy & Dignity Score:
5 Excellent (max score 5)
4 Good (max score 5)
5 Excellent (max score 5)
3.1.4 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 our adverse event rate demonstrates the results of
safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every month
and these are sent in a timely way via an electronic system called the Ramsay Central
Alert System (CAS). Safety alerts, medicine / device recalls and new and revised
policies are cascaded in this way to our General Manager which ensures we keep up to
date with all safety issues.
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 organisation must
adhere to ensure a safe workplace. The benchmark set for 2010 was 90% compliance,
and this was raised to 95% for 2011.
Park Hill Hospital completed this audit in February 2013, and scored 95%, which was
an increase from 87% scored the previous year. The main area for action is to ensure
that we have a maintenance contract in place for all biomedical equipment, as well as a
register of all biomedical equipment.
3.2 Clinical effectiveness
Park Hill Hospital has a Clinical Governance Committee that meets regularly throughout
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.
Quality Account 2012/13
Page 21
The results highlighted in the graphs on the following pages demonstrate the
effectiveness of this approach over the last three years.
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.
The graph below shows the absolute number of unexpected return to theatre over the
past 3 years.
Reoperations
4
3
2
1
0
10/11
11/12
12/13
Park Hill Hospital
The graph below shows the % of returns to theatre per 100 discharges.
Reoperations
0.12%
0.10%
0.08%
0.06%
0.04%
0.02%
0.00%
10/11
11/12
12/13
Park Hill Hospital
Quality Account 2012/13
Page 22
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.
The graph below shows the absolute number of unplanned readmissions over the last 3
years:
Readmissions
25
20
15
10
5
0
10/11
11/12
12/13
Park Hill Hospital
The graph below shows the % of unplanned readmissions per 100 discharges.
Readmissions
0.80%
0.70%
0.60%
0.50%
0.40%
0.30%
0.20%
0.10%
0.00%
10/11
11/12
12/13
Park Hill Hospital
Quality Account 2012/13
Page 23
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 Committees for discussion, trend analysis and
further action where necessary. Escalation and further reporting to Ramsay Corporate
and DH bodies occurs as required and according to Ramsay and DH policy.
Feedback regarding the patient’s experience is encouraged in various ways via:







Patient satisfaction surveys
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of care
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys were managed by an independent company called ‘The
Leadership Factor’ (TLF), until the end of December 2012. Patient satisfaction is now
obtained via a web based system 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 in Park Hill Hospital. To record a
satisfaction index over 90%, 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 hospitals Satisfaction Index against those achieved by other organisations across
all sectors of the UK economy where the full range of customer satisfaction is 50% to
95% with the median just below 80%.
Quality Account 2012/13
Page 24
Patient satisfaction index of over 90% means that Park Hill Hospital rates in the
top 2-3% of organisations.
3.3.2 Patient Reported Outcome Measures (PROMs)
Patient Reported Outcome Measures measure quality from the patients’ perspective.
Covering four clinical procedures, PROMs calculate the health gain after surgical
treatment using pre and post operative surveys.
Park Hill Hospital participates in the Department of Health’s PROMs surveys for hip and
knee surgery for NHS patients.
As a Group, Ramsay also conducts its own hip and knee PROMs surveys specifically
for private patients.
The graphs below provide an indication of the average health gain for patients who
attended Park Hill Hospital for hip and knee surgery over the past 3 years, as well as
comparisons of average health gains between Park Hill Hospital, our local NHS Trust
and England.
Adjusted average health gain
Adjusted average health gain
Oxford Hip Score
Oxford Knee Score
35
30
30
25
25
20
20
15
15
10
10
5
5
0
0
09/10
10/11
11/12
09/10
10/11
11/12
Adjusted average health gain
Adjusted average health gain
Oxford Knee Score
Oxford Hip Score
30
35
30
25
20
15
10
5
0
25
20
15
10
5
0
England
PARK HILL HOSPITAL
DONCASTER AND
BASSETLAW HOSPITALS
NHS FOUNDATION TRUST
England
PARK HILL HOSPITAL
DONCASTER AND
BASSETLAW HOSPITALS
NHS FOUNDATION TRUST
An adjusted measure (adjusted health gain) has been included to allow the comparison
of organisations against the national adjusted health gain.
The adjusted measure, based on models developed by contractors employed by the
Department of Health (CHKS Ltd in conjunction with Northgate Information Solutions
Ltd), takes into account the fact that organisations deal with patients with a differing
casemix e.g. a large proportion of a provider’s patients may be in a poor state of preoperative health before undergoing surgery compared to another provider who is
treating a higher proportion of patients with high levels of pre-operative health.
Quality Account 2012/13
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3.4 Park Hill Hospital Case Study
Park Hill Hospital has worked closely with the Doncaster & Bassetlaw Hospitals NHS
Foundation Trust since the unit opened on the site of the Doncaster Royal Infirmary in
April 1995.
The two parties continue to work together to ensure that all patients requiring elective
surgery are seen well within the Government target of 18 weeks from GP referral. The
relationship between the two hospitals has grown over the past 17 years, and the
Consultants and staff of the two units continue to work closely together ensuring that
patients in the local community receive a high quality clinical service that meets their
needs.
Since 2007, Park Hill Hospital has had formal agreements with Doncaster & Bassetlaw
Hospitals NHS Foundation Trust to provide elective orthopaedic procedures. Last year
approximately 1000 patients were operated on at Park Hill Hospital under the current
agreement.
Quality Account 2012/13
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Appendix 1 - Services covered by this quality account
Regulated Activities – Park Hill Hospital
Treatment of
Disease,
Disorder
Services Provided
Peoples Needs Met for:
Dermatology, Ear, Nose and Throat (ENT), General
surgery, Gynaecological, Neurology, Ophthalmic,
Orthopaedic, Pain management, Physiotherapy,
Rheumatology, Sports medicine, Urology
All adults 18 yrs and over
Day and Inpatient Surgery, Dermatology,
Cosmetic/plastic, Ear, Nose and Throat (ENT),
Gastrointestinal, General surgery, Gynaecological,
Neurology, Ophthalmic, Oral maxillofacial, Orthopaedic,
Pain management, Physiotherapy, Rheumatology,
Sports medicine, Urology, Vascular
All adults 18 yrs and over excluding:
Children 3 yrs and over - outpatients only
Or injury
Surgical
Procedures
Patients with blood disorders (haemophilia,
sickle cell, thalassaemia)
Patients on renal dialysis
Patients with history of malignant hyperpyrexia
Planned surgery patients with positive MRSA
screen are deferred until negative
Patients who are likely to need ventilatory
support post operatively
Patients who are above a stable ASA 3.
Any patient who will require planned admission
to ITU post surgery
Dyspnoea grade 3/4 (marked dyspnoea on mild
exertion e.g. from kitchen to bathroom or
dyspnoea at rest)
Poorly controlled asthma (needing oral steroids
or has had frequent hospital admissions within
last 3 months)
MI in last 6 months
Angina classification 3/4 (limitations on normal
activity e.g. 1 flight of stairs or angina at rest)
CVA in last 6 months
However, all patients will be individually assessed and we
will only exclude patients if we are unable to provide an
appropriate and safe clinical environment.
Diagnostic
and
Phlebotomy, Urinary Screening and Specimen
collection.
screening
Services subcontracted to the Trust hospital include
medical imaging, MRI/CT, ultrasound and
echocardiography.
Quality Account 2012/13
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed
in each month.
Quality Account 2012/13
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Park Hill 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:
Park Hill Hospital
Thorne Road
Doncaster
DN2 5TH
For further information please contact:
01302 730300
www.parkhillhospital.co.uk
Quality Account 2012/13
Page 29