2012/2013

Introduction Page
Welcome to Ramsay Health Care UK and The Berkshire Independent Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
1.2
Statement from the General Manager
Hospital accountability statement
PART 2
2.1 Priorities for Improvement
2.1.1 Review of clinical priorities 2012/2013 (looking back)
2.1.2 Clinical Priorities for 2013/2014 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2012/13 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
3.2
3.3
Patient Safety
Clinical Effectiveness
Patient Experience
3.4 Case Study
Appendix 1
– Services Covered by this Quality Account
Appendix 2
– Clinical Audits
Quality Accounts 2012/2013
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The Ramsay Health Care Group was established in 1964 and has grown to become a global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health
Care is one of the leading providers of independent hospital services in England, with a network of 22 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to the NHS in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS patient episodes of care each month working seamlessly with other healthcare providers in the locality including GPs, PCTs and acute Trusts.
Ramsay Health Care UK is committed to establishing an organisational culture that puts the patient at the centre of everything we do. As Chief Executive of Ramsay Health Care
UK, I am passionate about ensuring that high quality patient care is at the centre of what we do and how we operate all our facilities. This relies not only on excellent medical and clinical leadership in our hospitals but also upon our overall continuing commitment to drive year on year improvement in clinical outcomes.
As a long standing and major provider of healthcare services across the world, Ramsay has a very strong track record as a safe and responsible healthcare provider and we are proud to share our results. Delivering clinical excellence depends on everyone in the organisation. It is not about reliance on one person or a small group of people to be responsible and accountable for our performance.
Across Ramsay we nurture the teamwork and professionalism on which excellence in clinical practice depends. We value our people and with every year we set our targets higher, working on every aspect of our service to bring a continuing stream of improvements into our facilities and services.
Jill Watts, Chief Executive Officer of Ramsay Health Care UK
Quality Accounts 2012/2013
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This Quality Account is The Berkshire Independent 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 2009/2010 our Quality Account was developed by our corporate office & this summarised and reviewed quality activities across every hospital and centre within
Ramsay Health Care UK. It was recognised that this didn’t provide enough in depth information for the public and commissioners about the quality of services within each individual hospital and how this relates to the local community it serves. Therefore, from
2010/2011 onwards, each site within the Ramsay Group has developed its own Quality
Account, which includes both Group wide initiatives as well as the excellent local achievements and quality plans that we would like to share.
Quality Accounts 2012/2013
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Ramsay Healthcare UK is committed to establishing an organisational culture that puts the patient at the centre of everything we do.
As the General Manager, I am committed to ensuring that high quality patient care is at the heart of how we operate. This relies not only on excellent medical and clinical leadership, but also on our continuing commitment to year on year improvement in clinical outcomes.
The Berkshire Independent Hospital has a tradition of working closely with consultants and patients to ensure the best quality healthcare is consistently being delivered. Our staff are fully trained in the latest procedures and as such, we are able to maintain all areas to the highest standards. Working within the Department of Health Guidelines, we focus on patient safety and cleanliness to minimise infection. Any patient who wants to satisfy themselves on the quality of the
Hospital and it’s consultants can be reassured by the Care Quality Commission
(CQC) Audits undertaken by the Department of Health which support the Hospital’s excellent reputation.
As General Manager of The Berkshire Independent Hospital, I take great pride in the service we offer our patients and relatives, this is only achieved through a cohesive team effort and approach.
This report outlines the Hospitals approach to quality improvement, progress made in 2012-2013 and plans for the forthcoming year.
Here at The Berkshire Independent Hospital we have five key values which underpin everything we do as an organisation:
• Put the patient first
• Work as one team
• Respect each other
• Strive for continual improvement
• Respect environmental sustainability
The aim of our Quality account is to provide information to our patients and commissioners to assure them we are committed to making progressive achievements.
Quality Accounts 2012/2013
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For example , we partic ipate in the Health Protection agency’s Surgical Site
Surveillance Service and our surgical site infection rates are significantly lower than the national average.
Our emphasis is on ensuring patients receive safe and effective care, that they feel valued and respected in decisions about their care and are fully informed about their treatment at each step of the pathway.
The experience that patients have in our hospital is of the utmost importance and we are committed to establishing an organisational culture that puts the patient at the centre of everything we do. As well as being treated quickly and safely, our patients receive a personalised service, enhanced by good communication and a commitment to ensuring their privacy and dignity are respected at all times.
During 2011/2012 we have made many improvements to ensure patients in our
Hospital receive the best possible care.
The success of relationships built with the local NHS and PCT’s has resulted in
Choose & Book Referral growth.
The Hospital has undergone a major refurbishment which has provided not only state of the art Theatre facilities but an enhanced patient experience overall.
Within the past year, we have granted practising privileges to a number of new consultants which has not only enhanced the services we offer our patients, but is enabling more choice for patients.
A continued focus will be on improving operating efficiencies by monitoring Key
Performance Indicators ( KPI’s), introducing further energy saving devices, multiskilling, designing new processes to capture revenue at the time of activity and pathways that screen and identify risk at an earlier stage.
We especially value patient’s feedback about their stay, treatment and clinical outcome.
James Barr, Hospital Manager
Quality Accounts 2012/2013
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To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate.
James Barr
General Manager
The Berkshire Independent Hospital
Ramsay Health Care UK
This report has been reviewed by:
Mr Atul Kapila (Consultant Anaesthetist), Chair of Medical Advisory Committee
Signed ………………………………………………. Dated: ………………………………
Mr John Dickinson (Consultant Plastic Surgeon), Clinical Governance Committee Chair
Signed ………………………………………………. Dated: ………………………………
Mrs Helen White, Regional Director South, Ramsay Healthcare UK
Signed ………………………………………………. Dated: ………………………………
Ms Dagmira Humphrey, Senior Contract Manager, Berkshire West PCT
Signed ………………………………………………. Dated: ………………………………
Quality Accounts 2012/2013
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Berkshire Independent Hospital is one of Berkshire's leading private hospitals with an excellent reputation for delivering high quality healthcare treatments and services. The hospital, built in 1993 has 32 individual in-patient rooms and 13 day case rooms all with en suite facilities. The hospital has a two high dependency rooms for patients requiring specialist nursing. There are three fully equipped theatres with a seven-bedded recovery area; dedicated day surgery suite and an endoscopy unit.
The outpatient department adjacent to the hospital has 20 consulting rooms with associated examination and treatment facilities, a dedicated Gynaecology and minor ops suite and a minor operating theatre. Outpatient facilities include a large physiotherapy department with a well equipped, modern gymnasium, audiology, x-ray, ultrasound and
MRI scanning.
We provide fast, convenient, effective and high quality treatment for patients whether medically insured, self-pay, or from the NHS. We provide paediatric services for medically insured and self funding patients.
The hospital offers a wide range of Specialties including:
Orthopaedics
Rheumatology,
Urology,
General Surgery
Gastroenterology,
Dermatology
Elderly care
Gynaecology
ENT
Cosmetics
Paediatrics
Respiratory Medicine
Haematology
Pain management
The total number of admissions between 1 st
April 2012 and the 31 st
March 2013 was 5,670 patients, 52.65% of these being NHS patients.
We provide direct referral services for Physiotherapy, MRI and Bone Density Scans.
Mrs Julie Bennett, our GP Liaison Manager works closely with both Practice
Managers and GP’s at our local practices and ongoing contact with surgeries located in the surrounding areas. She regularly organises “Continual Professional
Development
” (CPD) Lunches taking Consultants into GP Surgeries to offer training
& latest development awareness, as well as running GP training seminars in the evenings. We value our contact with GP’s as customers and strive to ensure we actively work in partnership to enhance patient care.
Quality Accounts 2012/2013
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We are committed to working closely with our local NHS Foundation Trusts to actively assist and reduce waiting times for patients suitable for treatment at our hospital.
As a hospital we support both national charities. Our chosen Charity this year was
The Bicycle Helmet Initiative Trust. We sponsored a table at their Gala Dinner in
November 2012.
Consultants with Practising Privileges = 132
We employ 166 staff which equates to 133.74 Full Time Equivalent.
Our staff mix as of May 2013.
Trained Nurses
Administrators
Support Services
Radiographers
Pathology
Physiotherapists
Other
Number WTE
43 35.56
50
29
6
0
7
31
40.7
21.73
4
0
4.35
27.4
Quality Accounts 2012/2013
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On an annual cycle, The Berkshire Independent develops an operational plan to set objectives for the year ahead.
We have a clear commitment to our private patients as well as working in partnership with the NHS ensuring that those services commissioned to us, result in safe, quality treatment for all NHS patients whilst they are in our care. We constantly strive to improve clinical safety and standards by a systematic process of governance including audit and feedback from all those experiencing our services.
To meet these aims, we have various initiatives ongoing at any one time. The priorities are determined by the hospital ’s Senior Management Team taking into account patient feedback, audit results, national guidance, and the recommendations from various hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness and improve the experience of all people visiting our hospital.
.
Infection Control: We continue to have Infection Control as a priority and our
Infection Control Link Nurse actively attends local, national and corporate committee meetings. Audit results are reviewed, recommendations for any improvements are made and action plans are implemented to ensure these are put into place. All staff are now trained in the ANTT process ensuring this national priority is embedded within our local culture.
Real Time Incident Reporting: Currently we use a risk management system to record all our incidents, near misses and complaints and have worked hard to improve the incident reporting through RIMS, by ensuring that this used as a real time indicator for incident reporting. All information is input within a 48 hour timescale.
From August 2012 we introduced a new Risk Management Tool which replaced
RIMS. This new system is the central point for the recording of all incidents and risks for the business. Riskman has improved the quality of our reporting for internal and external use. This system has ensured that we can report on the data and identify trends earlier, improving the safety and quality of the service provided. This has ensured that trends are indentified in real time therefore remedial action can be taken immediately which has improved patient safety.
Quality Accounts 2012/2013
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100%
98%
96%
94%
92%
90%
88%
86%
84%
82%
80%
Surgical safety checklist: Compliance to the checklist will remain a quality initiative at the Berkshire Independent. Further work has been undertaken and to reduce the risks associated with any surgical intervention. In addition to our National Audits relating to WHO Surgical Checklists, we now conduct additional local audits .
National Safety Thermometer: A completed Safety Thermometer survey for all relevant patients is submitted on a monthly basis centrally to the NHS Information
Centre. This data is collected on 4 outcomes – pressure ulcers, falls, urinary tract infection in patients with catheters and VTE. We have achieved this throughout the year with 100% achieved in our local audit.
CQUINS
VTE: We have continued to audit our compliance to risk assessment and the use of appropriate prophylaxis. These results are submitted as one of the nationally mandated quality indicators and this year we have achieved 99.8% compliance.
Data submitted to UNIFY, The Department of Health National Reporting System, shows 100% achievement from April 2012 to February 2013 (March data excluded as not yet available). This is shown on the graph below.
1
0.98
0.96
0.94
0.92
0.9
0.88
0.86
0.84
0.82
0.8
Excellent
Good
Fail
Actual
Target
Berkshire Independent
Hospital
Quality Accounts 2012/2013
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100%
95%
90%
85%
80%
75%
70%
65%
60%
55%
50%
Patient Experience
– we have been committed to delivering an excellent service to all our patients and at the Berkshire Independent all staff are supported to ensure
“responsiveness to the personal needs of patients” and in this period our results for excellent and very good comments were 98.4%.
Smoking Cessation – we support the reduction of smoking amongst all our patients by ensuring their smoking status is identified and recorded. For those patients who smoke they will receive advice and referral to an NHS Stop Smoking
Service to quit. This has continued in 2012/2013.
World Health Organisation (WHO) checklist
– we have implemented a new audit plan to verify this check list has been completed.
Visual Infusion Phlebitis (V.I.P) score
–
Adult In patients who have undergone surgery and have a Peripheral cannula are assessed using the Visual Infusion
Phlebitis score as per the Ramsay IPC-21 policy. Audit results for 2012/2013 are
100%.
NJR: We have continued to submit all data. This system is invaluable when there
are nationally identified concerns such as the recent metal on metal hip joint alert.
The key performance bench mark for NJR consent is 95%. At BIH we consistently
score in excess of 90%.
1
0.95
0.9
0.85
0.8
0.75
0.7
0.65
0.6
0.55
0.5
Actual
95% Target
The Berkshire
Independent
Quality Accounts 2012/2013
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Joint Advisory Group for GI endoscopy: This year has seen a focus driven strategy to ensure we are achieving all standards required for JAG Accreditation. All staff have attended the relevant training required to ensure they have the knowledge to enable us to achieve this accreditation. This is ongoing & our JAG Assessment is due June 2014.
Never events: As in line with Ramsay Policy, all Never Events are reported through
RiskMan and to relevant third parties.
Clinical training: The Berkshire Independent has continued to ensure that patients at our hospital are cared for by safe and competent staff. This has been achieved by our clinical staff being supported through training both internal and external and being allocated protected time to achieve the required educational/clinical competencies.
Appropriate staffing levels: We ensure that appropriate numbers of staff are available for the care of our patients. Rotas are prepared in advance and dependency tools are used daily on the wards. We have the ability to flex our staffing levels up when required by using our own trained bank staff. We had planned that during 2012/201 3 Ramsay invested in a new electronic “Rostering “ tool called Allocate
– this will reduce the time spent on producing numerous rotas throughout the hospital and will be accessible to all staff. The tool can be set to correlate rotas which reflect the skill mix requirements and staffing levels specific to patient numbers. This has been launched in a number of Ramsay sites and is due to be launched here September 2013.
Safeguarding: We continue to take seriously our responsibility for the safeguarding of vulnerable members of society. We have achieved this through in house training for all staff to maintain staff awareness and contact numbers for help and advice are available in all areas of the hospital and out-patient building. We have excellent links through our staff to external agencies and the local authorities. In addition, we have introduced requesting evidence from all of our consultants that they have undertaken safeguarding training. We have a designated lead for both Paediatric & Adult
Safeguarding.
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JAG Accreditation: We have successfully implemented a robust action plan to meet the requirements of JAG Accreditation. This is being carried forward with our objective being to achieve accreditation in June 2014.
As a group the JAG aims:
To set standards for individual endoscopists;
To set standards for training in endoscopy;
To quality assure endoscopy units for training;
To quality assure endoscopy training courses.
The Berkshire Independent Hospital has commenced in the participation in the endoscopy audit on the global rating score website and will continue to use this accreditation tool.
Falls: The causes of falls are complex and older hospital patients are more likely to be vulnerable to falling through various medical conditions including urological or musculo skeletal conditions, side effects from medication or balance problems. The risk of falls further increases when someone is out of their normal environment.
Patient safety has to be balanced with independence, rehabilitation, privacy & dignity.
A patient who is not allowed to walk alone will very quickly become a patient who is unable to walk alone. We have reviewed publications to reduce falls and are putting actions in place to ensure falls are managed in line with best practice. All falls are reviewed though our Clinical Effectiviness and Health & Safety Committees. We will review results at the end of the year.
WHO Surgical safety checklist: Compliance with the checklist will remain an ongoing quality & safety priority at the Berkshire Independent. Results of our adutis will continue to be reprted to our Clinical Commissioning Groups as one of our locally agreed quality indicators for 2013/2014.
National Safety Thermometer: A completed Safety Thermometer survey for all relevant patients is submitted on a monthly basis centrally to the NHS Information
Centre. This data is collected on 4 outcomes
– pressure ulcers, falls, urinary tract infection in patients with catheters and VTE. This will continue to be a focus this year.
NJR: The Berkshire Independent will strive to maintain its good data submission scores & show a rise in patient consent to be included in this audit.
Never events: Preventing the occurrence of any serious, largely preventable patient safety incidents that should not occur will remain a clinical priority for 2013/2014.
Quality Accounts 2012/2013
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Clinical & other training: The Berkshire Independent will ensure that patients at our hospital are cared for by safe and competent staff. The provision of high quality care is a priority and our clinical staff are supported through training and being allocated protected time to achieve the required educational/clinical competencies.
Appropriate staffing levels: We will continue to ensure that appropriate numbers of staff are available for the care of our patients. Rotas are prepared in advance and dependency tools are used daily on the wards. We have the ability to flex our staffing levels up when required by using our own trained bank staff. For 2012/3 Ramsay have invested in a new electronic “Rostering “ tool called Allocate – this will reduce the time spent on producing numerous rotas throughout the hospital and will be accessible to all staff. The tool can be set to correlate rotas which reflect the skill mix requirements and staffing levels specific to patient numbers.
Safeguarding: We take very seriously our responsibility for the safeguarding of vulnerable members of society. We will continue to ensure that all staff working within the Hospital have the level of DBS check appropriate to their role. We will continue to provide training, reviewing the content & ensuring staff have the necessary resources available to manage any concerns appropriately & in a timely manner.
1. Ambulatory Day Care
– better outcomes and improving patient experience
Ambulatory Care (or Day Surgery Care) is the admission of selected patients (both medical and surgical) to hospital for a planned procedure, returning home the same day i.e. the patient does not incur an overnight stay)
Over recent years, partly due to medical advances the number of day surgery patients has increased compared to those requiring In patient care. In 2012/2013 the percentage of day surgery patients we treated was 81.36%. We need to ensure that our hospital facilities and patient flows better meet the case mix we now deliver.
We will aim to ensure that 90% of all day care patients are treated in our ambulatory care facilities)
We have monitored this through the patient satisfaction surveys completed by day surgery patients; which includes questions regarding the time patients wait from arrival in hospital and the surgery being undertaken compared to their expectation
2. Pre-Operative Assessment
Our focus this year will be for the Pre-Assessment Team to further develop an excellent service to ensure the Patients fitness for surgery is assessed in advance of their admission to reduce the chance of their operation being cancelled on the day. We will be looking at staff skill mix, availability of Clinics, & pre-operative information given to Patients. We will gauge our patients experience utilising our satisfaction questionnaires.
Quality Accounts 2012/2013
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3. Private Hospitals Information Network Benchmarking
We will continue to bench mark against other types of provider for Key Performance
Indicators wherever possible including:
VTE risk assessment compliance
Benchmarking through the national stats website. Link: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsSt atistics/DH_122283
PROMS results
Benchmarking through national PROMS website. Link: http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categ oryID-1295
1. Increasing the use of Patient Reported Outcomes Studies (PROMs)
We continue to work on improving the use of the national PROMs results for Hip,
Knee, Varicose Veins and Hernia surgery. The results are very encouraging for the
Berkshire Independent and are shared with clinical and medical staff through the
Medical Advisory Committee, Clinical Governance Committee and Heads of
Department meetings. In reviewing this data we have the opportunity to identify poor outcomes and examining practice if and when this exists.
Sharing results with Surgeons (and physiotherapists) and encouraging them to use them to review their practice
2. Patient Satisfaction survey
We have worked hard to improve areas where we felt we needed to improve and have demonstrated this in our most recent results with our overall satisfaction result being 95%.
We have concentrated on the following areas, which were highlighted in previous surveys and have improved our results accordingly: o Written information about proposed treatment prior to admission o Enough information about risks and benefits o Waiting time from admission to procedure o Sufficient involvement in discussions about treatment o Enough nurses o Special diets catered for o Told who to contact after discharge o Given written post-discharge advice about how to look after yourself at home o We plan to commence patient focus groups in August 2013 to further understand what our patients feel we do well and explore any areas in which they feel we could do better.
Quality Accounts 2012/2013
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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 2012/2013 The Berkshire Independent Hospital provided and/or subcontracted
Outpatient consultations, diagnostics and elective surgery in 14 services. The Berkshire
Independent Hospital has reviewed all the data available to them on the quality of care in
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 2012/2013, the indicators on the scorecard which affect patient safety and quality were:
Human Resources
HCA Hours as % of Total Nursing 27%
Agency Hours as % of Total Hours 0.23%
% Staff Turnover 11.1%
% Sickness 3.76%
Total Lost Worked Days 1477 Sickness, 4946 holiday
Patient
Formal Complaints per 1000 HPD's - 3.71.
Patient Satisfaction Score – 95 %
Readmission per 1000 Admissions – 2.29
Quality
Workplace Health & Safety Score – 96.5%
Infection Control Audit Score
– 98%
During 2012/2013, 2 national clinical audits and I national confidential enquiries audit covered NHS services that the Berkshire Independent Hospital provides.
The national clinical audits that Berkshire Independent Hospital was eligible to participate in during 1 April 2011 to 31st March 2012 are illustrated in the table below.
Quality Accounts 2012/2013
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National Clinical Audits (NA = not applicable to the services provided)
Name of Audit
Participation
(NA, Yes, No)
% cases submitted
N/A N/A Long term conditions
Elective procedures
Hip, knee and ankle replacements (National Joint Registry) Yes 100%
Elective surgery (National PROMs Programme)
Clinical Outcome Review Programme
Medical & Surgical Programme National Confidential Enquiry into Patient Outcome & Death
Local Audits
Yes
No Deaths
100%
The Berkshire Independent Hospital participates in the Ramsay Corporate Clinical Audit
Programme, which between April 2012 & March 2013 comprised 63 separate audits
(which includes 16 infection prevention and control, 3 transfusion, 4 physiotherapy and 8 radiology local clinical audits). The results were reviewed by the Clinical Governance
Committee and The Berkshire Independent Hospital intends to monitor audit and to improve the quality of healthcare provided. The clinical audit schedule can be found in
Appendix 2.
All audit results showed an excellent degree of compliance – our main priority for
2013/2014 will be ensuring standards are met, & where we are identify room for improvement, we have documented action plans with evidence of changes implemented.
There were no patients recruited during 2012/2013 to participate in research approved by a research ethics committee.
The Berkshire Independent Hospital income for achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework is applicable from 1st April 2013 to 31st March 2014, as in line with our SAC
Agreement. We are proud to have achieved all of our locally agreed CQUINS for
2012/2013 & have agreed revised CQUIN topics & targets for 2013/2014 to support our continuous drive to further improve our standards.
Quality Accounts 2012/2013
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The Berkshire Independent Hospital is required to register with the Care Quality
Commission. On our most recent CQC Inspection, which was on 15 th
January 2013, we were inspected on the following outcomes:
Consent to care and treatment
Care and welfare of people who use services
Safeguarding people who use services from abuse
Supporting workers
Assessing and monitoring the quality of service provision
We were found to be fully compliant. Thus, our current registration status on 31st March is registered without conditions
The Care Quality Commission has not taken enforcement action against The Berkshire
Independent Hospital during 2012/2013.
The Berkshire Independent Hospital has not participated in any special reviews or investigations by the CQC during the reporting period.
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Statement on relevance of Data Quality and your actions to improve your Data
Quality
The Berkshire Independent Hospital improves data quality by regularly using statistical data to monitor clinical services - we are constantly striving to improve this data with quality control initiatives. Data contained in medical records are audited on a monthly basis and action plans implemented when appropriate. This applies to both private and NHS patient streams.
NHS Number and General Medical Practice Code Validity
The Berkshire Independent Hospital submitted records during 2012/2013 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 was:
99.98% for admitted patient care;
99.95% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code was:
99.99% for admitted patient care;
99.99% for Outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall score for 2012/2013 was 77% and was graded ‘green’ (satisfactory).
Clinical coding error rate
The Berkshire Independent Hospital is subject to the Payment by Results clinical coding audit and we will be audited as a company in 2013. During 2012, we received a good result from our internal audit.
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The Berkshire Independent Hospital Quality Accounts were presented to Dagmira Humphrey
Contracts Manager of the Central Southern Commissioning Support Unit on Monday 10 th
June
2013.
Unfortunately to date we still have not received a response (Monday 24 th
June 2013).
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‘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
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.
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The domains of this model are:
• Infrastructure
• Culture
• Quality methods
• Poor performance
• Risk avoidance
• Coherence
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.
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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 graphs below.
The Berkshire Independent Hospital has a very low rate of hospital acquired infection and has had no reported MRSA Bacteraemia in the past 4 years.
We comply with mandatory reporting of all Alert organisms including MSSA/MRSA
Bacteraemia and Clostridium Difficile infections with a programme to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital. An annual strategy is developed by a Corporate level Infection Prevention and Control (IPC)
Committee and group policy is revised and re-deployed every two years. Our IPC programmes are designed to bring about improvements in performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the Ramsay organisation to support good networking and clinical practice. At the Berkshire
Independent the ward sister has undergon e additional training to lead the hospital’s infection control agenda.
Programmes and activities within our hospital include:
All staff (clinical and Non-clinical) have undertaken an e-learning training package for
Infection Control. In addition they attend an annual in house mandatory training session which includes practical in Hand hygiene using the UV light. The infection control nurse has also done similar sessions at hospital open days and marketing events to promote hand hygiene awareness.
Emphasis on cleanliness has resulted in an operational cleaning matrix with cleaning records available in each department. We are implementing a sticker system to indicated when equipment has been cleaned and by whom; which will enable an audit trail.
Hand hygiene will be a focus area for 2013/2014. The appropriate use of alcohol gel/foam and hand washing is vital for preventing the spread of infection and is the responsibility of everyone.
Quality Accounts 2012/2013
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Environmental audits have been commenced this year which aim to ensure a safe environment for all staff and patients.
Hospital Acquired Infections
The graph below shows the number of Hospital acquired infections for the Berkshire independent Hospital over the last 3 years. As can be seen in the below graph our infection control rate has continually decreased over this period.
12
10
8
6
4
2
0
10/11 11/12 12/13
0.16%
0.14%
0.12%
0.10%
0.08%
0.06%
0.04%
0.02%
0.00%
The Berkshire Independent Hospital
.
The graph below gives the % of infections per admit. There have been no cases of MRSA
Bacteraemia.
Rate per 100 discharges
10/11 11/12 12/13
The Berkshire Independent Hospital
Quality Accounts 2012/2013
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We continue to assess the hospitals facilities to ensure that we are providing a safe environment and use the following audit tools:
Corporate - Environmental Audit
– Quarterly
Patient Lead Assessments of the Clinical Environment (PLACE) Audit
– Annually from
April 2013
Corporate - Health, Safety & Facilities Audit – Annually
Environmental Audit
This audit was introduced in 2010, these are completed quarterly, the aim of this audit is to ensure a safe environment for all staff and patients, the objectives are:
1. To identify users and user groups,
2. To advise on infection control issues arising.
3. To acknowledge
The audit consists of an inspection of the hospitals clinical areas and includes the general environment, clinical equipment, decontamination, clinical practices, sharps handling, waste disposal and hand washing.
Our environmental audit results are always at least 90% and we continue to maintain our high results.
We continue to focus on delivering a high standard of cleanliness and ensure that staff are informed and updated at our mandatory training study days as well as discussing the points raised at our bi-monthly Risk Management meetings.
PEAT Audit
We participate in the national annual assessment for all NHS Trusts and some of the independent sector; these assessments include rating of privacy and dignity, food and food service and environment which assesses issues such as signage, bathroom/toilet environments and overall cleanliness.
BIH’s most recent PEAT audit undertaken in early 2012 scored Environment – Excellent;
Food – Excellent;
Privacy and Dignity - Excellent .
From April 2013, PEATs will be replaced with Patient Led Assessments of the Clinical
Environment (PLACE).
Health, Safety & Facilities Audit
This audit, taken from Approved Codes of Practice (ACOPS) was introduced in 2009 and is completed annually. The standards are the minimum that an organization must adhere to ensuring a safe workplace. The benchmark set for 2010 was 90% and this has been raised to 95% for 2011.
Quality Accounts 2012/2013
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BIH was audited in February 2013 and scored 89%. The areas that led to the lower attainment relate to record keeping and issues created by the hospital refurbishment programme. Actions were immediately put in place to maintain safety and correct the deficiencies.
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to incidents around sharps and needles. As a result, ensuring our staff have high awareness of safety has been a foundation for our overall risk management programme and this awareness then naturally extends to safeguarding patient safety.
Effective and ongoing communication of key safety messages is important in healthcare.
Multiple updates relating to drugs and equipment are received every month and these are sent in a timely way via an electronic system called the Ramsay Central Alert System
(CAS). Safety alerts, medicine / device recalls and new and revised policies are cascaded in this way to our General Manager which ensures we keep up to date with all safety issues.
The Berkshire Independent Hospital has a Clinical Governance team and committee that meet regularly through the year to monitor quality and effectiveness of care. Clinical incidents, patient and staff feedback are systematically reviewed to determine any trend that requires further analysis or investigation. More importantly, recommendations for action and improvement are presented to hospital management and medical advisory committees to ensure results are visible and tied into actions required by the organisation as a whole.
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.
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15
10
5
The graph below shows numbers of unexpected returns to theatre over the last 3 years
20
0
10/11 11/12 12/13
The Berkshire Independent Hospital
.
The graph below gives the % of unplanned returns to Theatre per surgical admission
0.30%
0.25%
0.20%
0.15%
0.10%
0.05%
0.00%
10/11 11/12 12/13
The Berkshire Independent Hospital
As can be seen in the above graph our Returns to Theatre Rate has decreased significantly over the last 3 years.
Quality Accounts 2012/2013
Page 28 of 37

0.20%
0.15%
0.10%
0.05%
0.00%
16
14
12
10
8
6
4
2
0
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 with pain well controlled prior to discharge.
The graph below shows the number of un-planned re-admissions over the last 3 years.
10/11 11/12 12/13
The Berkshire Independent Hospital
The graph below shows the % of un-planned re-admissions per admit
0.25%
10/11 11/12
The Berkshire Independent Hospital
12/13
Quality Accounts 2012/2013
Page 29 of 37

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 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.
Patient experiences are fed back 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
 PROMs surveys
 Care pathways – patient are encouraged to read and participate in their plan of care
Our patient satisfaction surveys are managed by an independent company called ‘The
Leadership Factor‘(TLF). They print and supply a set number of questionnaire packs to our hospital each quarter which contain a self addressed envelope addressed directly to
TLF, for each patient to use.
Results are produced quarterly (the data is shown as an overall figure but also separately for NHS and private patients). The results are available for patients to view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel they receive excellent quality of care and service at The Berkshire Independent Hospital. This is reinforced by 98.6 % of patients stating they would recommend us to prospective users.
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%.
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0.8
0.6
0.4
0.2
0
0.6
0.4
0.2
0
The Berkshire Independent Hospital parti cipates in the Department of Health’s PROMs surveys for hip and knee surgery, hernias and for NHS patients.
The sample sizes are small and survey results are evolving. Indications so far are that
Berkshire Independent Hospital Patient report excellent outcomes & results compre favourably with other providers.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs surveys specifically for private patients.
EQ-5D VAS - casemix adjusted
Groin Hernia
1
0.8
09/10 10/11 11/12
Varicose Veins
1
09/10 10/11 11/12
Quality Accounts 2012/2013
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Oxford Knee Score
15
10
5
0
30
25
20
09/10 10/11 11/12
Oxford Knee Score
25
20
15
10
5
0
THE BERKSHIRE
INDEPENDENT HOSPITAL
THE BERKSHIRE
INDEPENDENT HOSPITAL
THE BERKSHIRE
INDEPENDENT HOSPITAL
Quality Accounts 2012/2013
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Oxford Hip Score
35
30
25
20
15
10
5
0
09/10 10/11 11/12
Oxford Hip Score
35
30
25
20
15
10
5
0
THE BERKSHIRE
INDEPENDENT HOSPITAL
THE BERKSHIRE
INDEPENDENT HOSPITAL
THE BERKSHIRE
INDEPENDENT HOSPITAL
Quality Accounts 2012/2013
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Appendix 1
The Berkshire Independent Hospital is registered for 73 beds providing day case and in patient facilities. The
Hospital has 3 operating theatres, two of which have
Laminar flow, and a dedicated endoscopy unit.
Patients’ requiring level 2 care are treated and cared for by a well trained team of staff in a dedicated level 2 facility within the
Hospital.
The Berkshire Independent Hospital provides care and treatment for children over the age of 3 years. On site facilities include, Radiology, Physiotherapy, Pathology,
Static MRI and a Pharmacy.
The hospital is a recognised centre for Orthopaedic Surgery and has an international reputation for shoulder surgery.
Location:
The Berkshire Independent Hospital,
Swallows Croft, Wensley Road,
Reading, Berkshire RG1 6UZ
Tel: 0118 9028000
Registered Manager: James Barr
James.barr@ramsayhealth.co.uk
Quality Accounts 2012/2013
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Regulated Activities – Berkshire Independent Hospital
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Services Provided
Allergy Testing, Audiology,
Children’s Psychology,
Cosmetics, Dermatology,
Dietetics, ENT,
Gastroenterology, Geriatric
Medicine, General Surgery,
Medico Legal, Neurology,
Orthopaedics, Paediatrics,
Psychology, Psychiatry,
Physiotherapy, Rheumatology,
Sports Medicine, Urology,
Women’s Health
Bariatric Surgery, Colorectal,
Cosmetics, Dermatological,
Peoples Needs Met for:
All adults and children from birth.
Diagnostic and screening
Endoscopy, Ear Nose and
Throat, (ENT), General
Surgery, Gynaecological,
Maxillofacial / Oral Surgery,
Ophthalmic, Orthopaedic,
Plastic Surgery, Pain
Management, Spinal Surgery,
Upper GI Surgery, Urological
Ambulatory, Day and Inpatient
Surgery
Clinical Chemistry, Cytology and Histopathology, Diagnostic
All adults and children 3 years and above excluding the following:
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.
All adults and children from birth.
Radiology, GI Physiology,
Haematology, Microbiology,
MRI, Phlebotomy, Transfusion,
Ultrasound, Urinary Screening and Specimen collection,
Urological Screening
Quality Accounts 2012/2013
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Appendix 2
– Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Audit Programme v5.0 2012/13 Hospital Name: Berkshire Independent
Implemented: July 2012
Authors: R. Saunders / A. Shannon / N. Carre For review: June 2013
Use arrow symbol to locate required audit
JUL AUG SEP OCT NOV DEC JAN FEB MAR APR MAY JUN
Anaesthetic Standards 98% 100%
Medical Records
Consent
84%
Discharge
Care Pathways and Variance
Tracking
Controlled Drugs
94%
100%
Prescribing
Medicines Management
Radiology
Physiotherapy
Theatre
Infection Prevention and
Control*
Infection Prevention and
Control - Environmental Audit
100%
Transfusion
90%
81%
90%
95%
92%
85%
100%
98%
84%
74%
MRI
96%
100%
96%
88
85
93
93
99
99
97%
96%
100%
MRI
99
100%
98%
88%
97%
90%
PEAT
68% 92%
90%
64%
75%
MRI
90%
VTE
64%
868886
N & H
97
PVCCB UCCB
Environ
100% A uto lo go us
Traceability
Traffic light score
Green 100%
Cool
Amber
90 - 99%
Amber 80 - 89%
Hot
Amber
70 - 79%
Red 69% and under
*Key:
CVCCB = Central Venous Catheter Care Bundle
SSI = Surgical Site Infection
PVCCB = Peripheral Venous Catheter Care Bundle
PEAT = Patient Environment Action Team
UCCB = Urinary Catheter Care Bundle
Det Pt = Deteriorating Patient
N&H = Nutrition and Hydration
VTE = Venous Thromboembolism
Copyright © 2012 Ramsay Health Care UK
Quality Accounts 2012/2013
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0118 902 8000
Quality Accounts 2012/2013
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