Euxton Hall Hospital
Quality Account 2012/13
Contents
1.0
Introduction
1.1
Statement from the Chief Executive Officer
1.2
Statement from the General Manager, Euxton Hall Hospital
1.3
Hospital Accountability Statement
1.4
Welcome to Euxton Hall Hospital
2.0
Quality Priorities
2.1 Review of Clinical Priorities Set 2012/13
2.2 Clinical Priorities for 2013/14
3.0
Mandatory Statements
3.1 Review of Services
3.2 Participation in Clinical Audit
3.3 Participation in Research
3.4 Goals agreed with our Commissioners using the CQUIN Framework
3.5 Statements from the Care Quality Commission
3.6 Data Quality
3.7 NHS Number and General Medical Practice Code Validity
4.0
Quality Performance Indicators
4.1 Ramsay Clinical Governance Framework 2013
4.2 NICE / NPSA guidance
4.3 Patient Safety
4.4 Patient Experience
4.5 Patient Reported Outcome Measures (PROMs)
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – National Clinical Audits
Appendix 3 – Ramsay National Clinical Audits
Quality Accounts 2012/13
1.0
Introduction
Euxton Hall Hospital is part of the worldwide Ramsay Health Care group of independent
sector hospitals. Ramsay Health Care 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 diagnostic services to the NHS in
the UK. Through a variety of national and local contracts we deliver thousands of NHS
patient episodes of care each month working seamlessly with other NHS healthcare
providers in the locality including GPs, CCG’s and Acute Trusts.
This Quality Account is Euxton Hall Hospital’s annual report to the public and other
stakeholders about the quality of the services we provide. It presents our achievements in
terms of clinical excellence, effectiveness, safety and patient experience and demonstrates
that our managers, clinicians and staff are all committed to providing continuous, evidence
based, quality care to those people we treat. It will also show that we regularly scrutinise
every service we provide with a view to improving it and ensuring that our patients’
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.
Quality Accounts 2012/13
1.1 Statement from the Chief Executive Officer,
Ramsay Health Care UK
“Ramsay Health Care UK is committed to establishing an organisational culture that puts
the patient first. 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
of 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
Quality Accounts 2012/13
1.2 Statement from the General Manager
Euxton Hall Hospital
“Ramsay Health Care UK is committed to establishing an organisational culture that puts
the patient at the centre of everything we do. As General Manager of Euxton Hall Hospital, I
am passionate about ensuring that high quality patient care is our number one priority. This
relies not only on excellent medical and clinical delivery but also upon continued
commitment to driving improvement in clinical outcomes. Ramsay Health Care UK has a
structured clinical governance framework that enables continual review of performance.
This allows us to drive improvements for the benefit of all patients.
Our Quality Account is information for our patients and commissioners to assure them that
we are committed to sharing our progressive achievements year on year.”
David Winters
1.3 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.
David Winters, General Manager, Euxton Hall Hospital
This report has been reviewed and approved by:
Regional Director Ramsay Health Care UK, Mr Stefan Andrejczuk
Quality Accounts 2012/13
1.4 Welcome to Euxton Hall Hospital
Euxton Hall is a private hospital situated on the outskirts of Chorley, close to Preston and
Wigan with links to the M65, M6 and M61 motorways. The hospital opened in 1983.
Euxton Hall Hospital provides fast, convenient, effective and high quality treatment and a
wide range of diagnostic and medical/surgical procedures are provided including
orthopaedics, breast surgery (BUPA accredited breast care centre) cardiology, ENT
surgery, gastroenterology, general medicine, general surgery, gynaecology, neurology,
ophthalmology, pain management, speech therapy and urology.
The facility has 32 private, en-suite bedrooms, five consulting rooms, two ultra clean air
theatres, a fully equipped physiotherapy gym, an endoscopy unit and a treatment room.
The hospital’s imaging department provides contrast studies including barium studies,
ultrasound and mammography in addition to general radiology and is supported by access
to CT and MRI scanning onsite.
Our physiotherapy clinic is staffed with chartered, HPC registered physiotherapists.
All of the Hospital’s consultants are highly experienced and their competences,
qualifications and outcomes are monitored via our clinical governance framework. All
patients have the reassurance that a resident doctor is available 24 hours/day.
Euxton Hall Hospital is part of the Central Lancashire critical care network and has a
Service Level Agreement in place for emergency transfer of critically ill patients.
Euxton Hall Hospital supports local charities and other groups. Last year we supported the
Alzheimer's Association and this year we will be supporting the Hand on Heart charity.
Quality Accounts 2012/13
2.0 Quality Priorities
On an annual cycle, Euxton Hall Hospital develops an operational plan to set objectives for
the year ahead.
We have a clear commitment to our private patients as well as working in partnership with
the NHS to ensure that those services commissioned from us result in safe, quality
treatment for all patients. 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 Ramsay
regulatory committees which represent all professional and management levels within the
organisation.
A hospital quality team meets on a regular basis to ensure implementation of quality ideas
into the business along with formulating and reviewing action plans derived from patient /
staff satisfaction surveys and any complaints received at the hospital.
Most importantly, we believe our priorities must be to drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Quality Accounts 2012/13
2.1 A review of clinical priorities set in 2012/13
Never Events - are serious, largely preventable, patient safety incidents that should not
occur if the available preventative measures have been implemented for example:

Wrong site surgery

Retained instrument post-operation

Wrong route administration of chemotherapy

Misplaced nasogastric tube not detected prior to use

Intravenous administration of mis-selected concentrated potassium chloride
Euxton Hall Hospital has had one incidence of a Never Event during 2012/13, which has
been reported and fully investigated by the appropriate parties. Recommendations from the
investigations have been implemented to improve the safety checks already in place.
VTE Risk Assessment - is one of the National CQUIN indicators of the Standard Acute
Contract. It is a nationally implemented indicator which all Hospitals are mandated to
address. The Hospital follows corporate policy in line with Department of Health and NICE
guidelines and achieved a compliance result of over 95% for this period.
Ambulatory Day Care – for better outcomes and improving patient experience.
Ambulatory Care (or Day Surgery Care) is the admission of selected patients to hospital for
a planned procedure, returning home the same day i.e. the patient does not incur an
overnight stay. The hospital continues to monitor its theatre scheduling and admitting of
patients to fit with the ambulatory care model.
Improving National Benchmarking - The hospital continues to provide data for the
following benchmarking initiatives:




VTE risk assessment compliance
PROMS results
Patient satisfaction
National Joint Registry
Quality Accounts 2012/13
2.1.2 Local CQUINs
All CQUIN measures have been achieved.

Smoking Cessation - NICE guidance recommends that patients referred for elective
surgery should be encouraged to stop smoking before an operation. Smoking
cessation is found to be cost effective and contributes to higher survival rates,
quicker wound healing and reduces postoperative respiratory complications. Hospital
settings are an ideal opportunity for health professionals to offer people brief advice,
support and referral to the NHS Stop Smoking Services at a time when the patient
may be receptive and motivated to change behaviour. Euxton Hall Hospital has
delivered ‘stop smoking’ skills training to key staff, identified and recorded smoking
status and offer appropriate intervention (based on agreed protocol) including:
(i) stop smoking information and advice
(ii) referral to NHS Stop Smoking Services

Alcohol Awareness - The numbers of Central Lancashire residents being admitted
to hospital due to alcohol related incidents is increasing. In order for this model to
operate effectively there is a need for hospital nursing staff to identify patients being
admitted to hospital that would benefit from advice or treatment in relation to their
drinking, give written and verbal advice and where appropriate refer into the
community substance misuse service. Key staff at Euxton Hall Hospital have been
given alcohol awareness training and brief intervention training. Adult admissions will
be screened and patients that require appropriate interventions (based on their
score) will be offered intervention, given written advice on sensible drinking or
offered referral to a community substance misuse service.

Medicine Management has been CQUIN indicator 11 of the Standard Acute
Contract and relates to antibiotic prophylaxis protocol. Quarterly audits have
demonstrated the hospital’s compliance.

Falls - fall assessment for all in-patients has been introduced and is completed at
pre-operative assessment and reviewed when patient is admitted as an inpatient.

Information For GPs - discharge information is sent within 24 hours.

Real Time Incident Reporting – The hospital ensures all medical and clinical teams
comply with timely and accurate reporting of incidents through the ‘real time’ Risk
Information Management System. This system enables reporting on adverse
incidents, readmissions, return to theatre rates, hospital acquired infections and
extended stays to allow patterns to be identified and corrective action implemented.
Quality Accounts 2012/13
2.2 Clinical Priorities for 2013/14
P.L.A.C.E. - This year and for subsequent years, the annual PEAT audit has been replaced
by PLACE, which will be a patient led audit that will have an assessment team that consists
of 50% patients.
The audit will include all internal and external areas of the hospital only excluding operating
theatres. The audit is divided by each department of the hospital and assesses the
standard of cleanliness and general upkeep of the building and grounds. It will also
evaluate the standard of the food being served to patients, ensuring that all dietary
requirements are met. The scoring system employs a system whereby areas are given a
‘Pass’, ‘Fail’ or ‘Qualified Pass’.
Following the audit, the results will be inputted into the Department of Health website for
PLACE. Once the results have been calculated they will be published on the hospital’s
website and they will also be published by The Health and Social Care Information Centre.
Public bodies including; The Care Quality Commission, The NHS Commissioning Board
and The Department of Health will use information from the PLACE assessments to ensure
that all patients are given a high quality service.
Clinical Documentation Audits - Remain a priority in all areas with a corporate Ramsay
focus set for 2013/14 on theatre safety checks and Physiotherapy documentation checks.
2.2.1 Local CQUINS

Smoking cessation - The hospital will continue to identify and record smoking status
and offer appropriate intervention. The CQUIN compliance rate for 2013/14 has been
raised to 100%.

Alcohol awareness – The hospital will continue to identify and record alcohol status
and offer appropriate intervention. The CQUIN compliance rate for 2013/14 has been
raised to 100%.
Quality Accounts 2012/13
2.2.2 National CQUINS

Friends and Family Test – The hospital will comply with the introduction and roll out of
the national Friends and Family test to measure patient feedback and identify areas in
which to improve.

VTE risk assessment - The hospital’s CQUIN compliance rate for 2013/14 is 97%.
Quality Accounts 2012/13
3.0 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.
3.1 Review of Services
During 2012/13 the hospital provided NHS services across eight surgical specialties.
The Hospital has reviewed all the data available to them on the quality of care in all of these
NHS services.
The income generated by the NHS services reviewed (1 April 2012 to 31st March 2013)
represents 100% of the hospital’s total income generated from the provision of 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 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 were:
Human Resources
HCA Hours as % of Total Nursing
Agency Hours as % of Total Hours
% Staff Turnover
% Sickness
Total Lost Worked Days
Appraisal %
Mandatory Training %
Staff Satisfaction Score
Number of Significant Staff Injuries
Patient
Formal Complaints per 1000 Hospital
Patient Days
Patient Satisfaction Score
Number of Significant Clinical Events
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
Infection Control Audit Score
Consultant Satisfaction Score
Quality Accounts 2012/13
3.2
Participation in Clinical Audit
During 1 April 2012 to 31st March 2013, the hospital participated in both local and national
audits.
National Clinical Audits
Ramsay’s national clinical audit schedule can be found in Appendix 3. The full national
audit list is enclosed in Appendix 2. The reports of 63 national audits (which include 12
infection prevention and control, 3 transfusion, 4 physiotherapy and 8 radiology) from 1
April 2012 to 31st March 2013 were reviewed by the Clinical Governance Committee.
The hospital intends to take the following 2 actions to improve the quality of healthcare
provided:
1. Currently working with ward staff regarding nutrition and hydration in particular
clinical documentation around fluid balance.
2. Working with all staff to ensure compliance with all aspects of consent audit.
Clinical Coding Audit
Outcomes of the hospital’s coding audit are detailed below.
Results
Audit Date
Euxton
Hall
Jan
Re Audit Date
12
Oct 12
3.3
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
71.67%
95.24%
88.33%
84.85%
100%
88.24%
93.3%
89.29%
Participation in Research
There were no patients recruited during 2012/13 to participate in research approved by a
research ethics committee.
3.4
Goals agreed with our Commissioners using the CQUIN Framework
Euxton Hall 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.
Quality Accounts 2012/13
3.5 Statements from the Care Quality Commission
The Hospital is required to register with the Care Quality Commission and its current
registration status on 31st March is registered with the following conditions:



Treatment of disease, disorder or injury
Surgical procedures
Diagnostic and screening procedures
The Care Quality Commission unannounced visit in June 2012 was deemed compliant on
all outcomes reviewed.
3.6
Data Quality
The hospital continues to take the following actions to improve data quality:



3.7
Regular training to ensure staff understand importance of accurate data input and
have sufficient technical competence
Employment of clinical coder to improve accuracy of recording
Supporting national projects to ensure data accuracy
NHS Number and General Medical Practice Code Validity
The hospital submitted records during 2012/13 to the Secondary Uses service for inclusion
in the Hospital Episode Statistics which are included in the latest published data. The
percentage of records in the published data which included:

the patient’s valid NHS number:




100% for admitted patient care
100% for out patient care
0% for accident and emergency care (not undertaken at our hospital)
the General Medical Practice Code:



100% for admitted patient care
100% for out patient care
0% for accident and emergency care (not undertaken at our hospital)
Quality Accounts 2012/13
4.0 Quality Performance Indicators
‘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)
Quality Accounts 2012/13
4.1
Ramsay Clinical Governance Framework 2013
The aim of clinical governance is to ensure that Ramsay Health Care 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 and that clinicians are
enabled to provide that care.
Ramsay ensures that Clinical Governance is integrated into other governance systems in
the organisation and that it is not 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 Ramsay have gone back to the original
Scally and Donaldson paper (1998) as it is a model that allows coverage and inclusion of all
the necessary strategies, policies, systems and processes for effective Clinical
Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Quality Accounts 2012/13
Ramsay Health Care Clinical Governance Framework
Quality Accounts 2012/13
4.2
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, selecting those
that are applicable to the organisation and thereafter monitoring their implementation.
4.3 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.
Hospital Acquired Infection (Rate per 100 discharges)
Hospital Acquired Infections
0.80%
0.70%
0.60%
0.50%
0.40%
0.30%
0.20%
0.10%
0.00%
10/11
11/12
12/13
Euxton Hall Hospital
Quality Accounts 2012/13
Serious Untoward Incidents (Rate per 100 discharges)
SUIs
0.14%
0.12%
0.10%
0.08%
0.06%
0.04%
0.02%
0.00%
10/11
11/12
12/13
Euxton Hall Hospital
Readmission (Rate per 100 discharges)
Readmissions
0.18%
0.16%
0.14%
0.12%
0.10%
0.08%
0.06%
0.04%
0.02%
0.00%
10/11
11/12
12/13
Euxton Hall Hospital
Quality Accounts 2012/13
Reoperations (Rate per 100 discharges)
Reoperations
0.20%
0.15%
0.10%
0.05%
0.00%
10/11
11/12
12/13
Euxton Hall Hospital
Unplanned Transfer (Rate per 100 discharges)
Transfers
0.20%
0.15%
0.10%
0.05%
0.00%
10/11
11/12
12/13
Euxton Hall Hospital
Quality Accounts 2012/13
Unexpected Death (Rate per 100 discharges)
Unexpected Deaths
0.03%
0.02%
0.02%
0.01%
0.01%
0.00%
10/11
11/12
12/13
Euxton Hall Hospital
Serious Complaints (Rate per 100 discharges)
Serious Complaints
0.03%
0.02%
0.02%
0.01%
0.01%
0.00%
10/11
11/12
12/13
Euxton Hall Hospital
Quality Accounts 2012/13
Falls (Rate per 100 discharges)
Falls
0.18%
0.16%
0.14%
0.12%
0.10%
0.08%
0.06%
0.04%
0.02%
0.00%
10/11
11/12
12/13
Euxton Hall Hospital
UNIFY VTE Submissions (11 months of 2012/13)
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
Euxton Hall Hospital
Quality Accounts 2012/13
NJR Submissions (2012/13)
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
Euxton Hall Hospital
Quality Accounts 2012/13
4.4
Patient Experience
All feedback from patients regarding their experiences with Ramsay Health Care is
welcomed and informs service development in various ways.
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 fed back to the relevant staff
using direct feedback. All staff are aware of our complaints procedures should our patients
be unhappy with any aspect of their care. Staff are involved in the management of relevant
complaints to ensure lessons are learnt.
Patient experiences 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
The ‘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
Patient Satisfaction Surveys
From 2013 Ramsay Healthcare is moving towards an independently collated website
survey.
Patient satisfaction scores for overall quality show the majority of the hospital’s patients feel
they receive excellent quality of care and service with 100% of patients that responded
recording Complete Satisfaction with their service in the latest results (March 2013, 54%
survey response rate).
Quality Accounts 2012/13
4.5
Patient Reported Outcome Measures (PROMs)
The hospital participates in the Department of Health’s PROMs surveys for NHS patients.
Year on Year comparisons reported to March 2013 for the hospital are as follows:
Adjusted average health gain
Oxford Hip Score
35
30
25
20
15
10
5
0
09/10
10/11
11/12
Adjusted average health gain
Oxford Knee Score
30
25
20
15
10
5
0
09/10
10/11
11/12
Quality Accounts 2012/13
Appendix 1
Services covered by this quality account
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Cosmetics, Dermatology, Ear,
Nose and Throat (ENT),
General surgery,
Gynaecological, Ophthalmic,
Orthopaedic, Physiotherapy,
Rheumatology, Sports
medicine, Urology, Spinal, Pain
Management
Breast surgery, Cosmetics, Day
and Inpatient Surgery,
Dermatology, Ear, Nose and
Throat (ENT), General surgery,
Gynaecological, Ophthalmic,
Oral maxillofacial surgery,
Orthopaedic, Urology, Spinal
Peoples Needs Met for:
All adults 18 yrs and over
Children 3 years and above
All adults 18 yrs and over excluding:












Diagnostic
and
screening
Imaging services, Phlebotomy,
Urinary Screening and
Specimen collection.
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.
Children 3 years and above
All adults 18 yrs and over
Children 3 years and above
Quality Accounts 2012/13
Appendix 2 – Clinical Audit Programme.
This list has been compiled on behalf of the Department of Health by the Healthcare Quality Improvement Partnership
(HQIP), against criteria previously agreed by National Advisory Group on Clinical Audit & Enquiries. The accompanying
table provides details of all audits and enquiries meeting the required criteria for inclusion.
National Clinical Audits meeting inclusion criteria (n = 46). The Clinical Outcome Review Programme projects are listed separately
(n=5) but should also be reported for Quality Accounts. Total number of NCAs and CORPs (n=51). All national clinical audit suppliers
on this list, at the time of publication, advised that they would be collecting patient level data during 2013-14. If subsequently a
supplier decides not to recruit patients during this time then the clinical audit or enquiry will be removed from the list, as it no longer
meets the criteria for inclusion.
Key:
Yellow = audits not on the previous year’s list (2012-13)
Blue = audits which may or may not collect data during the year (2013/14)
Quality Accounts 2012/13
No.
National Clinical Audits
1.
Acute coronary syndrome
or Acute myocardial
infarction
MINAP
2.
Adult cardiac surgery
audit
ACS
3.
Adult community
acquired pneumonia
4.
Adult critical care (Case
Mix Programme)
ICNARC
CMP
5.
Bowel cancer
NBOCAP
6.
Bronchiectasis
7.
Cardiac arrhythmia
8.
9.
10.
Chronic kidney disease in
primary care
Chronic Obstructive
Pulmonary Disease
Congenital heart disease
(Paediatric cardiac
surgery)
Acronym
HRM
Contact details for supplier
National Institute for Cardiovascular Outcomes
Research (NICOR), The Institute of Cardiovascular
Science, 170 Tottenham Court Road, London, W1T
7HA
National Institute for Cardiovascular Outcomes
Research (NICOR), The Institute of Cardiovascular
Science, 170 Tottenham Court Road, London, W1T
7HA
The British Thoracic Society (BTS), 17 Doughty
Street, London, WC1N 2PL
Intensive Care National Audit and Research Centre
(ICNARC), Entrance A, Tavistock House, Tavistock
Square, London, WC1H 9HR
NHS IC, Leeds (headquarters): 1 Trevelyan Square,
Boar Lane, Leeds, LS1 6AE
The British Thoracic Society (BTS), 17 Doughty
Street, London, WC1N 2PL
National Institute for Cardiovascular Outcomes
Research (NICOR), The Institute of Cardiovascular
Science, 170 Tottenham Court Road, London, W1T
7HA
Category
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
Heart
Yes
Heart
Yes
Acute
No
Acute
No
Cancer
Yes
Long-term
Conditions
No
Heart
Yes
Tbc – new topic under development
COPD
CHD
Royal College of Physicians (RCP), CEEU, 11 St
Andrew's Place, Regent's Park, London, NW1 4LE
National Institute for Cardiovascular Outcomes
Research (NICOR), The Institute of Cardiovascular
Science, 170 Tottenham Court Road, London, W1T
7HA
Yes
Long-term
Conditions
Yes
Heart
Yes
Quality Accounts 2012/13
No.
National Clinical Audits
Acronym
11.
Coronary angioplasty
12.
Diabetes (Adult) ND(A),
includes National
Diabetes Inpatient Audit
(NADIA)
ANDA
13.
Diabetes (Paediatric)
PNDA
14.
Elective surgery (National
PROMs Programme)
15.
Emergency use of oxygen
16.
Epilepsy 12 audit
(Childhood Epilepsy)
17.
Falls and Fragility
Fractures Audit
Programme, includes
National Hip Fracture
Database
FFFAP
18.
Head and neck oncology
DAHNO
19.
Heart failure
HF
20.
Inflammatory bowel
disease
IBD
21.
Lung cancer
NLCA
Contact details for supplier
Category
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
National Institute for Cardiovascular Outcomes
Research (NICOR), The Institute of Cardiovascular
Science, 170 Tottenham Court Road, London, W1T
7HA
Heart
Yes
NHS IC, Leeds (headquarters): 1 Trevelyan Square,
Boar Lane, Leeds, LS1 6AE
Long-term
Conditions
Yes
Long-term
Conditions
Yes
Other
No
Acute
No
Women’s &
Children’s
Health
Yes
Older
People
Yes
Cancer
Yes
Heart
Yes
Long-term
Conditions
yes
Cancer
Yes
Royal College of Child Health and Paediatrics
(RCPCH), 5-11 Theobalds Road,
London WC1X 8SH
NHS IC, Leeds (headquarters): 1 Trevelyan Square,
Boar Lane, Leeds, LS1 6AE
The British Thoracic Society (BTS), 17 Doughty
Street, London, WC1N 2PL
Royal College of Child Health and Paediatrics
(RCPCH), 5-11 Theobalds Road,
London WC1X 8SH
Royal College of Physicians (RCP), CEEU, 11 St
Andrew's Place, Regent's Park, London, NW1 4LE
NH IC, Leeds (headquarters): 1 Trevelyan Square,
Boar Lane, Leeds, LS1 6AE
National Institute for Cardiovascular Outcomes
Research (NICOR), The Institute of Cardiovascular
Science, 170 Tottenham Court Road, London, W1T
7HA
Royal College of Physicians (RCP), CEEU, 11 St
Andrew's Place, Regent's Park, London, NW1 4LE
NHS IC, Leeds (headquarters): 1 Trevelyan Square,
Boar Lane, Leeds, LS1 6AE
Quality Accounts 2012/13
No.
22.
23.
National Clinical Audits
Moderate or severe
asthma in children (care
provided in emergency
departments)
National audit of
dementia audit
Acronym
Contact details for supplier
Category
The College of Emergency Medicine, Churchill
House, 35 Red Lion Square, London WC1R 4SG
NAD
24.
National audit of
schizophrenia
NAS
25.
National Audit of Seizure
Management (NASH)
NASH
26.
National Cardiac Arrest
Audit
NCAA
27.
National comparative
audit of blood transfusion
28.
National emergency
laparotomy audit
NELA
29.
National Joint Registry
NJR
30.
National Vascular
Registry, including CIA
and elements of NVD
NVR
31.
Neonatal intensive and
special care
NNAP
32.
Non-invasive ventilation adults
33.
Oesophago-gastric cancer
34.
Ophthalmology
NAOGC
Royal College of Psychiatrists (CCQI), 4th Floor
Standon House, Mansell Street, London, E1 8AA
Royal College of Psychiatrists (CCQI) NAS Team, 4th
Floor Standon House, Mansell Street, London, E1
8AA
No
Mental
health
Yes
Mental
Health
Yes
University of Liverpool, Liverpool, L69 3BX
Intensive Care National Audit and Research Centre
(ICNARC), Entrance A, Tavistock House, Tavistock
Square, London, WC1H 9HR
National Comparative Audit of Blood Transfusion,
NHS Blood and Transplant,
John Eccles House, Robert Robinson Avenue, Oxford
Science Park , Oxford OX4 4GP
Royal College of Anaesthetists,
Churchill House 35 Red Lion Square, London WC1R
4SG
National Joint Registry Centre, Northgate Solutions,
Peoplebuilding 2, Peoplebuilding Estate, Maylands
Avenue, Hemel Hempstead, Herts, HP2 4NW
No
Heart
No
Blood and
Transplant
No
Acute
Yes
Acute
Yes
Royal College of Surgeons, 35-43 Lincoln’s Inn
Fields, London, WC2A 3PE
Royal College of Child Health and Paediatrics
(RCPCH), 5-11 Theobalds Road,
London WC1X 8SH
The British Thoracic Society (BTS), 17 Doughty
Street, London, WC1N 2PL
The Royal College of Surgeons of England (RCS),
CEU, 35-43 Lincoln's Inn Fields, London WC2A 3PE
Tbc – new topic under development
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
Yes
Women’s &
Children’s
Health
Yes
Acute
No
Cancer
Yes
Yes
Quality Accounts 2012/13
No.
National Clinical Audits
35.
36.
37.
38.
Contact details for supplier
Category
Paediatric asthma
The British Thoracic Society (BTS), 17 Doughty
Street, London, WC1N 2PL
Women’s &
Children’s
Health
Paediatric intensive care
University of Leicester, Department of Health
Sciences, University of Leicester
22-28 Princess Road West, Leicester, LE1 6TP
or
University of Leeds Paediatric Epidemiology Group,
Centre for Epidemiology & Biostatistics, 8.49
Worsley Building,
University of Leeds, Leeds, LS2 9JT
Women’s &
Children’s
Health
Paracetamol Overdose
(care provided in
emergency departments)
Prescribing Observatory
for Mental Health (POMHUK)
Acronym
PICANet
The College of Emergency Medicine, Churchill
House, 35 Red Lion Square, London WC1R 4SG
POMH-UK
(Prescribing in mental
health services)
39.
Prostate cancer
40.
Pulmonary hypertension
41.
Renal replacement
therapy (Renal Registry)
42.
43.
44.
Rheumatoid and early
inflammatory arthritis
Sentinel Stroke National
Audit Programme
(SSNAP), includes SINAP
Severe sepsis & septic
shock
Royal College of Psychiatrists (CCQI) POMH -UK
Team, 4th Floor Standon House, Mansell Street,
London, E1 8AA
Royal College of Surgeons, 35-43 Lincoln’s Inn
Fields, London, WC2A 3PE
NHS IC, Leeds (headquarters): 1 Trevelyan Square,
Boar Lane, Leeds, LS1 6AE
NHS Blood and Transplant, Organ Donation and
Transplantation Directorate, Fox Den Road, Stoke
Gifford, Bristol, BS34 8RR
Royal College of Physicians (RCP), CEEU, 11 St
Andrew's Place, Regent's Park, London, NW1 4LE
This will commence 1 April 2012.
The College of Emergency Medicine, Churchill
House, 35 Red Lion Square, London WC1R 4SG
No
Yes
No
Mental
Health
No
Yes
Heart
No
Blood and
transplant
No
Tbc – new topic under development
SSNAP
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
Yes
Older
People
Yes
No
Quality Accounts 2012/13
No.
45.
46.
National Clinical Audits
Severe trauma (Trauma
Audit & Research
Network)
Specialist rehabilitation
for patients with complex
needs
Acronym
Contact details for supplier
Category
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
TARN
The Trauma Audit And Research Network (TARN),
Clinical Sciences Building, Hope Hospital, Eccles Old
Road, Salford, M6 8HD
Acute
No
Tbc – new topic under development
Yes
*The NHS standard contracts for acute hospital, mental health, community and ambulance services set a requirement that provider
organisations shall participate in appropriate national clinical audits that are part of the National Clinical Audit and Patient Outcome
Programme (NCAPOP).
Quality Accounts 2012/13
Appendix 2 - Continued
Clinical outcome review programmes
No
.
National Clinical Audits
Acronym
Contact details for supplier
Category
47.
National review of asthma
deaths
Child health programme
NRAD
Royal College of Physicians (RCP), CEEU, 11 St
Andrew's Place, Regent's Park, London, NW1 4LE
Royal College of Child Health and Paediatrics
(RCPCH), 5-11 Theobalds Road, London WC1X
8SH
49.
Maternal, infant and
newborn clinical outcome
review programme
MBRRACEUK
National Perinatal Epidemiology Unit, Department
of Public Health, University of Oxford, Old Road
Campus, Headington, Oxford, OX3 7LF
50.
Medical and Surgical
programme: National
Confidential Enquiry into
Patient Outcome and
Death
Mental Health programme:
National Confidential
Inquiry into Suicide and
Homicide for people with
Mental Illness (NCISH)
NCEPOD
National Confidential Enquiry into Patient Outcome
and Death (NCEPOD), Ground Floor, Abbey House,
74-76 St John Street, London, EC1M 4DZ
Long-term
Conditions
Women’s
&
Children’s
Health
Women’s
&
Children’s
Health
Acute
NCISH
National Confidential Inquiry into Suicide and
Homicide
by People with Mental Illness (NCISH), Centre for
Suicide Prevention, Psychiatry Research Group,
School of Community-Based Medicine, University
of Manchester, 2nd Floor, Jean McFarlane Building,
Oxford Road, Manchester M13 9PL
48.
51.
CHR-UK
Mental
Health
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
No
Yes
Yes
Yes
Yes
Quality Accounts 2012/13
Appendix 3 Ramsay National Audit
Quality Accounts 2012/13
Ramsay Euxton Hall Hospital
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:
Telephone: 01257 276261
Web: www.euxtonhallhospital.co.uk
Neurological Centres
Quality Accounts 2012/13