1.0 Introduction
1.1 Statement from the Chief Executive Officer
1.2 Statement from the General Manager, Fulwood Hall Hospital
1.3 Hospital Accountability Statement
1.4 Welcome to Fulwood 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 – National Ramsay Audits
Quality Accounts 2012/13

Fulwood 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 Fulwood 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

“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.
”
Quality Accounts 2012/13

“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 Fulwood 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.
”
To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate.
Chris Buckingham, General Manager, Fulwood Hall Hospital
This report has been reviewed and approved by:
Regional Director Ramsay Health Care UK, Mr Stefan Andrejczuk
Quality Accounts 2012/13

Since 1986, Fulwood Hall Hospital has provided independently funded surgical services and diagnostics from its location near the M55 / M6 motorway link in Preston. Since a £9m refurbishment and expansion in 2009, the hospital has:

a consultant body of over 150 across a full mix of specialities
 six private consulting rooms

an outpatient treatment room for minor procedures
 three ultra clean, laminar flow theatres
 endoscopy suite

a close care ward for higher risk patients
 twelve day-case bays for ambulatory care

22 single-bedded and 3 two-bedded, en-suite bedrooms for overnight stays
 A fully equipped physiotherapy gymnasium
 onsite MRI, X-ray and Ultrasound

an ophthalmology suite
The hospital has had a continuous relationship with local Acute Trusts and Primary Care
Trusts to support NHS capacity issues and now provides NHS patients with a range of
Choose and Book services in order to support the achievement of 18 week referral to treatment timescales.
The hospital treats patients from 3 years of age and provides specialist paediatric nurses to ensure children (and their parents) receive full reassurance and support throughout their stay.
Quality Accounts 2012/13

On an annual cycle, Fulwood 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

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
Fulwood 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

All CQUIN measures have been achieved in 2012/13.

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. Fulwood 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 Fulwood 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

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.

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


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

The following section contains the mandatory statements common to all Quality Accounts as required by the regulations set out by the Department of Health.
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 31 st
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 Patient
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
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

During 1 April 2012 to 31 st
March 2013, the hospital participated in both local and national 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 31 st
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.
Outcomes of the hospital
’s coding audit are detailed below.
Results Audit Date Re Audit
Date
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
Fulwood
Hall
Jan 12
Oct 12
90.0%
93.33%
91.40%
91.67%
93.34%
93.33%
94.19%
94.44%
There were no patients recruited during 2012/13 to participate in research approved by a research ethics committee.
Fulwood Hall Hospital’s income from 1 April 2012 to 31 st
March 2013 was conditional on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework.
Quality Accounts 2012/13

The Hospital is required to register with the Care Quality Commission and its current registration status on 31 st
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.
The hospital continues to take the following actions to improve data quality:

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
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

‘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)
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

Quality Accounts 2012/13

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.
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)
0.80%
0.70%
0.60%
0.50%
0.40%
0.30%
0.20%
0.10%
0.00%
10/11 11/12 12/13
Fulwood Hall Hospital
Quality Accounts 2012/13

Serious Untoward Incidents (Rate per 100 discharges)
0.07%
0.06%
0.05%
0.04%
0.03%
0.02%
0.01%
0.00%
10/11 11/12
Fulwood Hall Hospital
12/13
Readmission (Rate per 100 discharges)
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
10/11 11/12
Fulwood Hall Hospital
12/13
Quality Accounts 2012/13

Reoperations (Rate per 100 discharges)
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
10/11 11/12
Fulwood Hall Hospital
Unplanned Transfer (Rate per 100 discharges)
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
10/11 11/12
Fulwood Hall Hospital
12/13
12/13
Quality Accounts 2012/13

Unexpected Death (Rate per 100 discharges)
0.02%
0.01%
0.01%
0.01%
0.01%
0.01%
0.00%
0.00%
0.00%
10/11 11/12
Fulwood Hall Hospital
12/13
Falls (Rate per 100 discharges)
0.30%
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
10/11 11/12
Fulwood Hall Hospital
12/13
Quality Accounts 2012/13

UNIFY VTE Submissions (11 months of 2012/13)
100% 1
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
0.98
0.96
0.94
0.92
0.9
0.88
0.86
0.84
0.82
0.8
Fulwood Hall Hospital
NJR Submissions (2012/13)
100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
1
0.95
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
Fulwood Hall Hospital
Excellent
Good
Fail
Actual
Target
Actual
95% Target
Quality Accounts 2012/13

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 95% of patients that responded recording Complete Satisfaction with their service in the latest results (March 2013, 58% survey response rate).
Quality Accounts 2012/13

The hos pital 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:
Oxford Hip Score
35
30
25
20
15
10
5
0
09/10 10/11 11/12
Oxford Knee Score
15
10
5
0
30
25
20
09/10 10/11 11/12
Quality Accounts 2012/13

Services Provided Peoples Needs Met for:
Treatment of
Disease,
Disorder
Or injury
Cosmetics, Dermatology, Ear,
Nose and Throat (ENT),
General surgery,
Gynaecological, Ophthalmic,
Orthopaedic, Physiotherapy,
Rheumatology, Sports medicine, Urology, Spinal, Pain
All adults 18 yrs and over
Children 3 years and above
Management
Surgical
Procedures
Breast surgery, Cosmetics, Day and Inpatient Surgery,
Dermatology, Ear, Nose and
Throat (ENT), General surgery,
Gynaecological, Ophthalmic,
Oral maxillofacial surgery,
Orthopaedic, Urology, Spinal
Imaging services, 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
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
Diagnostic and screening
Quality Accounts 2012/13

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.
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)
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.
No. National Clinical Audits Acronym Contact details for supplier Category
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
1.
2.
3.
Acute coronary syndrome or Acute myocardial infarction
Adult cardiac surgery audit
Adult community acquired pneumonia
MINAP
ACS
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
Heart
Heart
Acute
Yes
Yes
No
Quality Accounts 2012/13

No. National Clinical Audits Acronym
4.
5.
6.
7.
8.
9.
10.
11.
12.
Adult critical care (Case
Mix Programme)
Bowel cancer
Bronchiectasis
Cardiac arrhythmia
ICNARC
CMP
NBOCAP
Chronic kidney disease in primary care
Chronic Obstructive
Pulmonary Disease
Congenital heart disease
(Paediatric cardiac surgery)
COPD
CHD
Coronary angioplasty
Diabetes (Adult) ND(A), includes National
Diabetes Inpatient Audit
(NADIA)
HRM
ANDA
Contact details for supplier Category
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
Tbc – new topic under development
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
National Institute for Cardiovascular Outcomes
Research (NICOR), The Institute of Cardiovascular
Science, 170 Tottenham Court Road, London, W1T
7HA
Acute
Cancer
Long-term
Conditions
Heart
Long-term
Conditions
Heart
Heart
NHS IC, Leeds (headquarters): 1 Trevelyan Square,
Boar Lane, Leeds, LS1 6AE
Long-term
Conditions
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
No
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Quality Accounts 2012/13

No. National Clinical Audits Acronym
13.
14.
Diabetes (Paediatric)
Elective surgery (National
PROMs Programme)
15.
Emergency use of oxygen
PNDA
Contact details for supplier Category
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
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
Long-term
Conditions
Other
Acute
Women’s &
Children’s
Health
Yes
No
No
Yes 16.
17.
Epilepsy 12 audit
(Childhood Epilepsy)
Falls and Fragility
Fractures Audit
Programme, includes
National Hip Fracture
Database
FFFAP
18.
Head and neck oncology DAHNO
Royal College of Physicians (RCP), CEEU, 11 St
Andrew's Place, Regent's Park, London, NW1 4LE
Older
People
Yes
Yes
19.
20.
Heart failure
Inflammatory bowel disease
21.
Lung cancer
22.
Moderate or severe asthma in children (care provided in emergency departments)
HF
IBD
NLCA
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
Cancer
Heart
Long-term
Conditions
Cancer
The College of Emergency Medicine, Churchill
House, 35 Red Lion Square, London WC1R 4SG
Yes yes
Yes
No
Quality Accounts 2012/13

No. National Clinical Audits Acronym
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
National audit of dementia audit
National audit of schizophrenia
National Audit of Seizure
Management (NASH)
National Cardiac Arrest
Audit
National comparative audit of blood transfusion
National emergency laparotomy audit
National Joint Registry
National Vascular
Registry, including CIA and elements of NVD
Neonatal intensive and special care
Non-invasive ventilation - adults
NAD
NAS
NASH
NCAA
NELA
NJR
NVR
NNAP
Contact details for supplier Category
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
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
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
Mental health
Mental
Health
Heart
Blood and
Transplant
Acute
Acute
Women’s &
Children’s
Health
Acute
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
Yes
Yes
No
No
No
Yes
Yes
Yes
Yes
No
Quality Accounts 2012/13

No. National Clinical Audits Acronym
33.
34.
35.
36.
Oesophago-gastric cancer NAOGC
Ophthalmology
Paediatric asthma
Paediatric intensive care PICANet
Contact details for supplier
The Royal College of Surgeons of England (RCS),
CEU, 35-43 Lincoln's Inn Fields, London WC2A 3PE
Tbc – new topic under development
The British Thoracic Society (BTS), 17 Doughty
Street, London, WC1N 2PL
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
The College of Emergency Medicine, Churchill
House, 35 Red Lion Square, London WC1R 4SG
Category
Cancer
Women’s &
Children’s
Health
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
Yes
Yes
No
Women’s &
Children’s
Health
Yes
No 37.
38.
Paracetamol Overdose
(care provided in emergency departments)
Prescribing Observatory for Mental Health (POMH-
UK)
(Prescribing in mental health services)
39.
Prostate cancer
POMH-UK
40.
Pulmonary hypertension
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
Mental
Health
Heart
No
Yes
No
Quality Accounts 2012/13

No. National Clinical Audits Acronym
41.
42.
43.
44.
45.
46.
Contact details for supplier Category
National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
Renal replacement therapy (Renal Registry)
NHS Blood and Transplant, Organ Donation and
Transplantation Directorate, Fox Den Road, Stoke
Gifford, Bristol, BS34 8RR
Blood and transplant
No
Rheumatoid and early inflammatory arthritis
Sentinel Stroke National
Audit Programme
(SSNAP), includes SINAP
Severe sepsis & septic shock
Severe trauma (Trauma
Audit & Research
Network)
Specialist rehabilitation for patients with complex needs
SSNAP
TARN
Tbc – new topic under development
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
The Trauma Audit And Research Network (TARN),
Clinical Sciences Building, Hope Hospital, Eccles Old
Road, Salford, M6 8HD
Tbc – new topic under development
Older
People
Acute
Yes
Yes
No
No
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

Clinical outcome review programmes
No
.
National Clinical Audits Acronym Contact details for supplier
47.
National review of asthma deaths
48.
Child health programme
49.
Maternal, infant and newborn clinical outcome review programme
NRAD
CHR-UK
MBRRACE-
UK
50.
Medical and Surgical programme: National
Confidential Enquiry into
Patient Outcome and
Death
51.
Mental Health programme:
National Confidential
Inquiry into Suicide and
Homicide for people with
Mental Illness (NCISH)
NCEPOD
NCISH
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
National Perinatal Epidemiology Unit, Department of Public Health, University of Oxford, Old Road
Campus, Headington, Oxford, OX3 7LF
National Confidential Enquiry into Patient Outcome and Death (NCEPOD), Ground Floor, Abbey House,
74-76 St John Street, London, EC1M 4DZ
Category National Clinical
Audit and Patient
Outcomes
Programme
(NCAPOP)*
No Long-term
Conditions
Women’s
&
Children’s
Health
Yes
Women’s
&
Children’s
Health
Acute
Yes
Yes
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
Mental
Health
Yes
Quality Accounts 2012/13

Quality Accounts 2012/13

Quality Accounts 2012/13