Springfield Hospital
Quality Accounts
2012/13
Contents
Introduction Page
Welcome to Ramsay Health Care UK and Springfield Hospital
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2012/13 (looking back)
2.1.2 Clinical Priorities for 2013/14 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2012/13 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
Patient Safety
3.2
Clinical Effectiveness
3.3
Patient Experience
3.4
Patient Feedback
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Quality Accounts 2012/13
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Welcome to Ramsay Health Care UK
Springfield Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 22 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, PCTs and acute Trusts.
“Ramsay Health Care UK is committed to establishing an organisational
culture that puts the patient at the centre of everything we do. As Chief
Executive of Ramsay Health Care UK, I am passionate about ensuring
that high quality patient care is at the centre of what we do and how we
operate all our facilities. This relies not only on excellent medical and
clinical leadership in our hospitals but also upon our overall continuing
commitment to drive year on year improvement in clinical outcomes.
“As a long standing and major provider of healthcare services across the
world, Ramsay has a very strong track record as a safe and responsible
healthcare provider and we are proud to share our results. Delivering
clinical excellence depends on everyone in the organisation. It is not about
reliance on one person or a small group of people to be responsible and
accountable for our performance.”
Across Ramsay we nurture the teamwork and professionalism on which
excellence in clinical practice depends. We value our people and with
every year we set our targets higher, working on every aspect of our
service to bring a continuing stream of improvements into our facilities and
services.
(Jill Watts, Chief Executive Officer of Ramsay Health Care UK)
Quality Accounts 2012/13
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Introduction to our Quality Account
This Quality Account is Springfield 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 the 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.
The previous Quality Account for 2010/11 was developed by our Corporate Office
and summarised and reviewed quality activities across every hospital and centre
within the Ramsay Health Care UK. It was recognised that this did not provide
enough in depth information for the public and commissioners about the quality of
services within each individual Hospital and how this relates to the local
community it serves. Therefore each site within the Ramsay Group has
developed its own Quality Account from 2011 onwards and will include some
Group-wide initiatives, but will also describe the many excellent local
achievements and quality plans that we would like to share. This Quality Account
2012/2013 is in the same format as the previous year.
Quality Accounts 2012/13
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Part 1
1.1 Statement on quality from the General Manager
Mr David Hewitt, General Manager,
Springfield Hospital, Chelmsford.
In 2012 Springfield Hospital celebrated our 25th anniversary, marking a quarter
century of providing excellence in health care services to the people of Essex and
East Anglia. We are proud of being a leading private healthcare provider in the
area. The Hospital has an experienced and qualified team of Doctors, Nurses,
Healthcare professionals and Managers. As part of Ramsay Health Care UK, our
teams have access to a wealth of knowledge and experience. We aim to provide
superior facilities and a level of service over and above those that you would
expect in a private hospital.
This Quality Account is Springfield Hospital’s annual report to the public, our
patients and commissioners about the quality of the services we provide. It
presents our achievements in terms of clinical excellence, effectiveness, safety
and patient experience. It also provides an opportunity to demonstrate the
commitment of our managers, clinicians and staff to providing continuous,
evidence based, patient centred quality care to the people we treat.
We endeavour to offer a very high standard of customer care and aim to be the
provider of choice for the local community. We are passionate about providing
local high quality services at Springfield Hospital which patients will want to
recommend to their friends and family. All patients are treated as individuals and
it is important that their privacy and dignity is respected at all times.
Patient safety is our highest priority and we provide sufficient qualified and trained
staff to deliver a high level of service in a safe environment. We ensure the
hospital staff’s competence through a robust recruitment process and continued
professional development and training . Our staff focuses on minimising all
clinical risk, and as a result of close attention to detail, we are proud of our
exceptionally low levels of healthcare infections.
The Springfield Hospital patient experience at is of the utmost importance and
patient feedback is incredibly valuable to us. We capture information relating to
patient stay, treatment and clinical outcomes. We take pride in the results and
constructive feedback collected via our surveys.
We are proud of the service we provide at Springfield Hospital and believe this
Quality Account accurately illustrates the high standard of service and care that
the patients experience.
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Mr David Hewitt
General Manager
Springfield Hospital
Ramsay Health Care UK
Signature:
Date: 28th June 2013
This report has been reviewed and approved by:
Dr Bruce Emerson, Consultant Anaesthetist
Medical Advisory Committee Chair
Signature:
Date: 30th June 2013
Mr Richard Parsons, Regional Director
Ramsay Health Care UK
Signature:
Date: 28th June 2013
Carol Anderson
Director of Nursing & Quality for Mid Essex Clinical Commissioning Group
Signature:
Date: 28th June 2013
Quality Accounts 2012/13
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Welcome to Springfield Hospital
Springfield Hospital is part of the Ramsay Healthcare Group and offers specialist
medical and surgical services, including paediatrics, for both outpatients and
planned admitted care inpatients. There are 64 beds, 58 single en suite rooms
and 3 twin en-suite rooms, offering both Inpatient and Day patient
accommodation. Our twin bedded rooms offer ideal accommodation and peace of
mind for parents accompanying paediatric patients or co-dependent relatives.
Meals are served within the patients bedrooms with a daily selection available
from a pre advised menu.
We provide a wide range of services; Surgery, Medicine, Oncology, Plastic and
Cosmetic surgery, and Paediatrics. Specialties at the hospital include;
orthopaedic surgery, ophthalmology, endoscopy, urology including Lithotripsy,
spinal surgery, pain management, ENT, dental, general, vascular, gynaecology,
podiatry, oncology, breast and laparoscopic surgery. Services can be delivered
within an outpatient, inpatient and Day Care setting. Our Ward Manager ensures
that the appropriate skills and care levels are available within the department with
the teams led by our Sisters and Senior Staff nurses. In addition we have Nurse
Specialists for Oncology /Chemotherapy, Plastic surgery, Orthopaedics, Breast
Care and Urology.
We have a highly skilled nursing team and patients with additional care
requirements can be provided with Level 2 care within our High Dependency Unit.
All beds are fully equipped for cardiac and invasive monitoring including central
venous pressure and blood pressure monitoring with senior nursing staff qualified
in the provision of Critical Care. Our experienced teams are available to ensure
all patients are assessed and receive a high standard of individualised care
Springfield Hospital has a suite of 5 Operating Theatres, 2 of which are dedicated
to Orthopaedic surgery and have laminar flow ventilation. A high standard of
quality care, in a range of surgical specialties, is delivered by over fifty qualified
theatre practitioners.
The Outpatient Department comprises of 18 consulting rooms and 4 minor-op
treatment rooms which are used by nearly 200 Consultants covering 30
specialties. The department receives approximately 1000 patients and performs
approximately 250 procedures per week. Outreach Gynaecology services are
provided locally within the community.
The Imaging department provides access to a 64 slice Siemens CT scanner,
[providing precise 3-D images of the area under investigation], plain X-rays, Ultrasound, MRI, Digital Mammography and Lithotripsy.
Quality Accounts 2012/13
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Pharmacy services at Springfield Hospital are registered with the Royal
Pharmaceutical Society of Great Britain and can therefore dispense all private
prescriptions. The department offers a general pharmaceutical service to inpatients, outpatients’ visitors and staff and can offer a limited range of “Over the
Counter” medicines for purchase by visitors and staff.
Springfield Hospital has developed a close association with Anglia Ruskin
University and actively supports student nurse training through the provision of
appropriately trained mentors. All patients must be admitted under the care of a
Consultant.
We endeavour to offer a very high standard of customer care and all patients are
treated as individuals with respect for their dignity a high priority for us. Patient
education and information leaflets are given as appropriate.
During the year from 1st April 2012 to 31st March 2013 we have treated a total
number of 9,646 patients, 55% of these were Private patients and 45% were NHS
patients.
The nursing staff to patient ratio is 1: to between 1, 5 and 8 depending on patient
acuity and dependency. There is an experienced Resident Medical Officer on
site 24 hours a day.
Springfield Hospital current staffing includes:
Consultants (with Practicing Privileges)
Non-Consultants
Registered Nurses
Healthcare Assistants
Support Staff
Administrative Staff
Physiotherapists
Pharmacists
Pharmacy Technicians
Radiographers
Cardiac Technicians
Operating department practitioners
Management Personnel
Medical Laboratory Assistant
250
25
108
48
61
87
22
7
3
20
3
21
8
3
`
We pride ourselves on the delivery of high quality safe effective care in a manner
and environment that respects and protects the privacy and dignity of our patients
both self funding or referred by the NHS. We work closely with our local NHS
Trust, Mid Essex Hospital Trust (MEHT) where we have local agreements in
place for provision of services which include Pathology, Infection Control and
Level 3 Critical Care.
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We work closely with our local CCG to provide a range of surgical services under
the Standard Acute Contract via the ‘Choose and Book’ system and paper referral
pathway. We offer direct referral services for private/self pay/insured patients. All
patients requiring NHS services are referred via their General Practitioner (GP)
directly to the hospital or via a clinical assessment service (CAS/CRS).
Services are provided by The Doctors Laboratory (TDL) based at our sister
hospital, The Rivers hospital at Sawbridgeworth, for pathology. The Rivers
Pharmacy also provides Springfield Hospital with chemotherapy drugs which are
administered to our private patients.
Springfield Hospital’s GP Liaison Officer is committed to building and maintaining
relationships with GP Surgeries in the local catchment area to ensure we are the
providers of choice in the local community.
The Springfield hospital staff have participated in numerous fundraising events
throughout the year to raise funds for local charities. Here at the hospital we have
taken part in various fund raising activities:
Help the Heroes
Essex Community Foundation
National Blind Children’s Society
Breast Cancer charities
Cure and Action for Tay-Sachs Foundation
Sponsorship of Jubilee Garden at Local Parish Council
Springfield Hospital supports the local community by providing free facilities and
catering for various groups such as:
Action for Family Carers
National Osteoporosis Society
Look Good Feel Better Cancer support group
Helen Rollason Cancer Charity
Lung Cancer Nurses Network
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Green Apple Award
In November 2012 Springfield Hospital, part of Ramsay Health Care UK were named the
top independent healthcare provider in the Environment Agency’s Carbon Reduction
Commitment Performance League Table, we are delighted to have been selected from
over 500 applicants as a winner of one of the ‘Green Apple’ awards. This is in
recognition of the hospital’s commitment to continuous improvement in the reduction of
their impact on the environment.
Launched in 1994 by the Green Organisation and now well established as one of the
major environmental recognition schemes both in the UK and Internationally, the Green
Apple Environment Awards have become one of the most popular environmental
campaigns in the world.
Support Services Manager, Amy Simpson explains more about Springfield’s green
ethos.
“With a large employer presence in Chelmsford, Springfield Hospital has a unique
position and responsibility to promote and encourage the adoption of sustainable
development principles both at work, and within the wider community through our action,
influence and the behaviours of our staff.
Sustainable development requires individuals and companies to be mindful of the need
to safeguard the future and where possible, to reduce waste and to minimise the
negative impact on the environment, both now and for future generations. We at
Springfield Hospital are making these requirements a reality.”
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Part 2
2.1 Quality Priorities for 2011/2012
Plan for 2012/13
On an annual cycle, Springfield Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives ongoing at any one time. The
priorities are determined by the hospital’s Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2011/12 (looking back)
Never Events are serious, largely preventable patient safety incidents that should
not occur if the available preventative measures have been implemented.
Springfield Hospital has no Never Events to report within the reporting period.
For further information on Never Events see:
http://www.nrls.npsa.nhs.uk/resources/collections/never-events/
Safer Surgery Checklists
Further work was undertaken and two more speciality specific checklists for
radiology and cataracts have been implemented to further reduce the risk of
wrong site surgery.
Cleanliness and Infection Prevention
Infection prevention and control audits were introduced as planned and these are
now being undertaken at all Ramsay sites and action plans developed locally
where necessary to ensure the standards are met. Springfield participates in the
Health Protection Agencies data collection for surgical site infections following Hip
and Knee surgery. PEAT (Patient Environment Action Team) audits were also
repeated and showed an improvement.
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Endoscopy Standards
We are currently working towards meeting endoscopy standards and participating
in the endoscopy audit within our Global Rating Scale (GRS) initiative for
endoscopy registration. We are also working towards achieving JAG (Joint
Advisory Group for GI Endoscopy) accreditation.
Releasing time to care (Formally known as Productive Ward)
The Productive Ward (PW) Project is an NHS Initiative developed by the Institute
for Innovation and Improvement (2008). It focuses on the way ward teams work
together and organise themselves, in order to reduce the burden of unnecessary
activities, and releasing more time to care for patients in a reliable and safe
manner within existing resources. The approach is very much ‘bottom up’ with all
ward staff suggesting ideas and ways in which they could improve their
environment and processes. Springfield Hospital staff continue to implement new
ways of working which enable Clinical staff to spend more time delivering patient
care.
VTE risk assessment.
In September 2008, the Department of Health issued its guidance on Risk
Assessment for Venous Thromboembolism (DH 2008).
The objective is to improve the quality of patient care by minimising the risk of
VTE incidents. For this reporting year Springfield Hospital had 4 reported
incidences of Venous Thromboembolism. We continue to follow policy based
upon NICE Guidance and ensure all patients are risk assessed and have
appropriate prophylaxis.
The graph below shows Springfield Hospitals UNIFY VTE Submissions results for
2012/13 not including March data.
Quality Accounts 2012/13
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Infection Control
Springfield Hospital carried out regular infection control audits throughout this
reported year. The results showed improved scores in all areas especially the
environmental audit and patient environmental action team audit which is now
being replaced with the PLACE audit (Patient-Led Assessments of the Care
Environment).
Real time incident reporting
A new reporting system RISKMAN has been established for Ramsay during
2012. This is the new software tool for reporting clinical and safety incidents,
complaints and compliments that Ramsay has adopted. This will capture all the
data required to meet the requirements placed on the business without paper
format. This has improved the ability to identify areas for concern and
improvement relating to patient safety and calculate reports showing trends. Due
to the implementation of this new system Springfield Hospital has seen an
increase in the total number of incidents reported. This shows a safety conscious
workforce with a willingness to report, analyse and improve.
Competency Training
Ensuring well trained, competent staff are available to care for patients is a high
priority. This year the staff have undertaken competency based training in
“recognising the signs of the deteriorating patient” based on early warning scoring
and trigger tools. The critical care training remains competency based and all
staff are expected to achieve competence in infection prevention and control
which includes hand hygiene. Intermediate Life Support (ILS) and/or Advance Life
Support (ALS) training is mandatory for all clinical staff working in acute areas
and this year we also provided AIM (Acute Illness Management) training. Staff
involved in any aspect of a blood transfusion or who handle blood products have
been formally trained and assessed as competent. We have a corporate hospital
training matrix for mandatory training and a hospital training tracker where all
staff’s training is recorded.
Information Security
Springfield Hospital has achieved its ISO270001 Information Security
Accreditation. Staff within all departments of the Hospital took part in this audit
and maintaining Information Security at all times is of great importance to us.
National Joint Register
The National Joint Register (NJR) records the details of patients undergoing
major joint replacement surgery and the type of prosthesis that is used.
Springfield Hospital submits data to the NJR.
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Springfield Hospital 2012/13 NJR Submissions
Springfield has an action plan to improve these submissions in 2013/2014
Staff Satisfaction
Our staff satisfaction results are very important to us as satisfied, well trained and
competent staff will help to ensure patient safety. The staff satisfaction survey is
done annually at Springfield Hospital is bench marked against the other Ramsay
UK units.
In 2012 the Springfield Hospital
pulse survey conducted in showed a
very positive response from staff on
key questions.
Question
I have confidence in the leadership
skills of my manager
Agree / strongly agree
82.9%
My manager regularly expresses
appreciation when I do a good job
77.5%
I feel proud to work for this
organisation
90.3%
I believe I can make a valuable
contribution to the success of the
organisation
85.3%
We are currently implementing a new staff benefits scheme within Ramsay
Healthcare.
National Benchmarking- How do we compare?
It was recognised that we needed more transparency between ourselves and
other independent sector providers/the NHS in order to monitor and improve our
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services. This is even more important now we are working in partnership with the
NHS. Many areas of benchmarking are now in place including VTE risk
assessment monitoring, outcome study and customer satisfaction results.
PHIN Public Health Information Network is a national initiative for advancing fully
capable and interoperable information systems in public health organisations. The
initiative involves establishing and implementing a framework for public health
information systems.
The available benchmarks are reported monthly to the local NHS commissioning
CCG and regular meetings are held to discuss any improvements or action plans.
Hellenic will provide national benchmark figures for key performance
indicators (such as activity/volumes, mortality, day case rates, unplanned
readmissions, average length of stay, unplanned transfers, returns to
theatre.
VTE risk assessment compliance Benchmarking through the national stats
website.
Link:http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicatio
nsStatistics/DH_122283
PROMS results: Benchmarking through national PROMS website.
Link:http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&c
ategoryID=1295
Patient satisfaction figures. Using CQUIN indicators common to both NHS
survey and our own
Productive Ward
Increasing the use of Patient Reported Outcomes Studies (PROMs)
Springfield Hospital, as part of Ramsay Healthcare, continues to monitor the
national PROMS results for; Hip, Knee, Varicose Veins and Hernia surgery by
offering all patients who undergo this type of surgery the opportunity to complete
a questionnaire before and after surgery to monitor improvement in their quality of
life. Encouraging their use identifies poor outcomes and allows us to review their
practice where necessary. All results with the multi-disciplinary team within the
teams and the local Clinical Governance Committee and encourage them to use
the results to review their practice by meeting and discussing with their teams and
benchmarking against other sites.
CQUIN
The commission for quality and innovation (CQUIN) payment framework enables
commissioners to reward excellence by linking a proportion of provider’s income
to the achievement of local quality improvement goals. Each commissioner
agrees a number of different CQUIN’s at the beginning of the financial year with
each of their providers. These include in year targets as well as final outcome
targets.
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Springfield Hospitals NHS income, from 1st April 2012 to 31st March 2013, was
conditional on achieving quality improvement and innovation goals through the
Commissioning for Quality and Innovation payment framework during this period.
For 2012/13 Springfield Hospital had six CQUIN requirements:
Goal
Number
Goal Name
1 VTE
2 Patient
experience
3
NHS Safety
Thermometer
Description of Goal
% of all adult inpatients who have had a
VTE risk assessment on admission to
hospital using the clinical criteria of the
national tool
Improve NHS patient experiences
The indicator is a composite, calculated
from 5 compatible TLF survey questions.
Improve collection of data in relation to
pressure ulcers, falls, urinary tract
infection in those with a catheter, and VTE
Goal
weighting
(% of
CQUIN
scheme
available)
20%
Final
Score
achieved
20%
20%
20%
20%
10%
10%
10%
10%
20%
20%
20%
This CQUIN incentivised the collection of
data on patient harm using the NHS
Safety Thermometer harm measurement
instrument (developed as part of the QIPP
Safe Care national work stream) to survey
all relevant patients in all relevant NHS
providers in England on a monthly basis.
4 Avoidable
The Elimination of avoidable grade 2, 3
Pressure ulcer and 4 pressure ulcers
reduction and
elimination
This CQUIN required monthly
measurement of all grade 2, 3 and 4
pressure ulcers indicating the elimination
of all avoidable grade 2, 3 and 4 pressure
ulcers. This performance was required to
be sustained through quarter 4 2012/13.
5 Supporting
Support patients to lose weight
patients with
1.
Inpatients had their weight
high BMI
recorded and BMI calculated
2.
Patients with a BMI of over 30 were
given information on the risks of obesity
and contact details of the Local NHS
Weight Management Service
3.
If Patients accepted, a Referral
could be made to their GP in a discharge
letter and patient information leaflet.
6 Improving
To reduce missed doses in Antibiotic
Medicines
therapy, Warfarin, insulin and Parkinsons
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Management
Drugs
This CQUIN incentivised the collection of
data on patient harm related to missed
Antibiotic, Warfarin, Insulin, oral
Methotrexate and Parkinsons drug doses
to enable delivery of a reduction in the
number of missed doses.
Monthly audits to review missed doses at
the end of patient’s course of treatment
were undertaken to identify missed doses
within the previous 24 hours.
The audit process enabled real time
issues and actions to be identified and
facilitate a reduction in missed antibiotic
Warfarin, Insulin, oral Methotrexate and
Parkinsons drugs doses.
Totals:
100.00%
2.1.2 Clinical Priorities for 2013/14 (looking forward)
Patient safety
1. Never Events
Never events are serious, largely preventable patient safety incidents that
should not occur if the available preventative measures have been
implemented. Springfield Hospital has a robust system in place for preventing
the occurance of Never Events throughout 2013/2014.
2. VTE risk assessment
VTE will remain an ongoing Quality initiative and e will continue to audit our
compliance on Risk Assessment and appropriate Prophylaxis in line with
Ramsay Policies and the Department of Health guidance on Risk Assessment
for Venous Thromboembolism (DH 2008).
The objective is to improve the quality of patient care by minimising the risk of
VTE incidents.
3. Infection Control
Springfield Hospital will continue to perform audit training and a review of
results in line with our local and Corporate Annual Plan.
We continue to work on improving the uptake of the seasonal flu vaccinations
amongst staff. We have implemented Aseptic Non Touch Technique as the
standard practice for aseptic technique and continue with both training and
audits to maintain compliance.
4. Medical Gas Alert
Springfield Hospital has a Medical Gas Committee which meets regularly with
a clear Agenda. These minutes are reviewed at the Health and Safety
Meetings.
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100.00%
5. Real time incident reporting
This software tool for reporting clinical and safety incidents, complaints and
compliments has been fully implemented. It has already proved to be
beneficial in capturing all the data necessary to meet the requirements placed
on the business without paper format. It will continue to assist us locally in
relevant data reports to use in local committees so that relevant information is
disseminated efficiently and effectively in a timely manner. More modules to
assist Human resources and training are available in 2013 for data entry and
reporting.
6. National Joint Registry
Springfield Hospital consent rates or NHS traceability are recorded. We will
continually review these statistics to make improvements to the service as this
is vital for patient safety.
7. Safeguarding
We will continue to ensure the safety of our patients at all times and will
ensure that all staff working within the Hospital have the appropriate pre
employment checks and training appropriate for their role. Ensuring safe,
competent staff are available to care for patients, all of our staff will know
escalate and report any concerns in a professional and timely manner.
8. Staff Training
Springfield Hospital will focus on training as a priority to ensure that staff are
trained to deliver the high standards of care that we pride ourselves on. This
will be aimed at both clinical, administrative and support service teams to
ensure high standards of Quality Care and Customer Care is delivered.
Clinical effectiveness
1. Ambulatory Day Care – providing 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. We have
an Ambulatory Care Action plan which is underway and we are awaiting
possible expansion plans which include a purpose built Ambulatory Unit.
In order to do this and provide our patients with a more efficient patient
pathway through the hospital, we are currently discussing future plans for an
ambulatory unit, separating the day surgery patient from our inpatients. Best
practice has shown that by doing this, patient care will improve as waiting
times and recovery periods are reduced.
2. Group pre operative assessment
The pre assessment team at Springfield Hospital have worked hard to develop
the service to ensure that our patients fitness is fully assessed prior to
surgery. A new Anaesthetist led service has been established for patients
requiring additional assessment. This has led to a reduction in cancelled
operations on the day of surgery and has increased our patient safety.
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Springfield Hospital aims to provide group sessions for patients prior to
coming into hospital for joint replacements, giving information in an
environment which encourages group interaction and discussion as well as
post operative group sessions for education and exercise classes. This will be
implemented throughout 2013.
It has been recognised that seeing every patient individually was not always
the most efficient way of giving the required pre operative information to
patients. We wanted to encourage patient dialogue and improve the patient
flow through the pre-operative service.
To achieve this we will be observing classes currently running at one of our
sister hospitals and look at their frameworks to undertake the same service.
The service will be monitored and measured through audit, outcome
measures and patient feedback. The results of the service will be reported to
our local Clinical Governance Committee and relevant consultants.
4. Improve ward efficiency by adopting the Productive Ward initiative –
more time to care
The Productive Ward (PW) Project is an NHS Initiative developed by the
Institute for Innovation and Improvement (2008). It focuses on the way ward
teams work together and organise themselves, in order to reduce the burden
of unnecessary activities, and releasing more time to care for patients in a
reliable and safe manner within existing resources. The approach is very
much ‘bottom up’ with all ward staff suggesting ideas and ways in which they
could improve their environment and processes.
The Ward Staff at Springfield have completed the foundation modules and
implemented changes to practice such as reviews of clinical documentation,
utility areas and store rooms and re stocking and arranging drug trolleys and
resuscitation trolleys. We plan to progress on to the next modules to continue
to progress improvement within the ward environment.
5. Improved patient information
The Springfield Hospitals survey result for overall satisfaction (Q4 2012) was
99% satisfaction which above the Ramsay group overall score of 98.7%.
Springfield Hospital will continue to focus on patient satisfaction by reviewing
our patient satisfaction results via the friends and family and we based survey
which has superseded the TLF paper based patient questionnaire.
6. Patient Safety
Risk Management (Riskman) – This is the new software tool for reporting
clinical and safety incidents, complaints and compliments that Ramsay have
adopted. This will capture all the data required to meet the requirements
placed on the business without paper format. Through a positive attitude to
reporting incidents we can learn and improve the safety of our facilities and
care provided for patients, staff and visitors.
7. Clinical Effectiveness
Quality Accounts 2012/13
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Allocate Rostering System – This project is being rolled out across the
Ramsay group with plans underway to improve our rostering and man hours
management. This will allow units to have a better allocation of staff, looking
at skill mix which will enable patient centred focus and direct patient care.
Following the pilot phase which commences May 2012 and will take
approximately 6 weeks, the rostering tools will be implemented across the
Eastern Region to include the Springfield Hospital.
Paediatrics – Very few independent Hospitals offer a broad range of
Paediatric services because they are unable to comply with the strict
regulations and recruit the necessary specialist staff. Ramsay is launching
Children’s services and will be rolling out to units who undertake this service in
due course. This service aims to encourage children as well as parents and
carers to become involved in decisions about their care. We already provide
Children’s services to the highest possible standard and with investment this
will enable us to continue to provide the best possible paediatric care within
the community/local area.
Patient experience – informing patient choice
Increasing the use of Patient Reported Outcomes Studies (PROMs)
Springfield Hospital currently offers all patients the opportunity to complete the
national PROMs survey pre and post surgery for Hip, Knee and Hernia surgery.
Encouraging their use in identifying poor outcomes, and examining practice, if
and where this exists.
We share results with multi-disciplinary team and discuss the results at Clinical
Governance Committee Meetings. Encouraging reviews of the results to reflect
their future practice and benchmarking. We are currently discussing expanding
our use of PROMS surveys to cover more procedures to enable better
understanding of treatment outcomes from the patients view point.
Patient Satisfaction survey:
A decision was made to move from paper (TLF survey) to web based survey in
Spring 2012. ‘Qa Research’ was chosen as the new company to manage
Ramsay Patient Satisfaction web survey. A ‘Hot alerts’ system was established
to feedback complaints, commendations and comments promptly to hospital
Matrons and General Managers. The data is analysed and reported back
monthly and quarterly, by hospital /region and Ramsay Group.
Quality Accounts 2012/13
Page 20 of 44
SPRINGFIELD HOSPITAL PATIENT SURVEY Q4 2012
Springfield Hospital strives to be the hospital of choice for the residents of Essex by providing outstanding
clinical outcomes within an excellent facilities environment. Through our audit process we aim to identify
and improve in all areas; with constructive feedback we will target and implement changes to constantly
improve our service. Thank you for your feedback. – The Management Team
9.6
The physiotherapist
Satisfaction:
9.0
The billing
The chart at left
details the mean
satisfaction
score for each of
9 requirements.
9.3
The care since your discharge
9.3
The discharge procedures
9.4
The admission procedures
8.7
The food/refreshments
9.3
The facilities
9.6
The doctors
9.4
The nurses
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
10.0
Overall Satisfaction:
“Overall, how would you rate the care you
received?”
The results of this question is directly comparable with the
results of the Department of Health ISTC survey
100.0
Received a friendly welcome on arrival
100.0
Special diets catered for
69.7
Given written information about how to look …
91.3
Informed who to contact after discharge
95.6
Received enough explanation of medicines …
29.1%
94.1
Enough nurses
99.0
Treated with respect and dignity
69.9%
90.7
Satisfaction with hygiene precautions
98.0
Satisfaction with cleanliness
Excellent
Very good
Good
100.0
Everything was done for nausea/sickness
100.0
Everything was done to control pain
Recommendation:
“Would you recommend this hospital to
your friends and family?”
97.1
Any problem raised was solved to satisfaction
91.3
Was informed who to contact after discharge
96.0
Sufficient involvement in the discussion about…
92.5
Pleased with the waiting time prior to admission
61.3
Received copies of letters sent to GP
96.1
Received enough information about the risks …
98.0
Consultant explained treatment fully
Received written information about the …
100.0%
0.0
Yes
95.4
25.0
50.0
75.0
100.0
No
Quality Accounts 2012/13
Page 21 of 44
Mandatory Statements
2.2.1 Review of Services
During 2012/13 Springfield Hospital provided and/or subcontracted multiple NHS
services as per the National Contract and we have reviewed all the data available
to them on the quality of care in 100% of these NHS services.
The income generated by the NHS services reviewed in 1st April 2012 to 31st
March 2013 represents 100 per cent of the total income generated from the
provision of NHS services by the Springfield Hospital for 1st April 2012 to 31st
March 2013.
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 28% of Total Nursing
Agency Hours as 1% of Total Hours
3.4% Staff Turnover
4.19% Sickness
Total Lost Worked Days were 1,823
Appraisal 80%
Number of Significant Staff Injuries 1
Quality
Springfield Hospital’s Workplace Health, Safety and Facilities Standards
Audit was completed in December 2012 an excellent score of 97% was
achieved.
2.2.2 Participation in clinical audit
The national clinical audits and national confidential enquiries that Springfield
Hospital has participated in, and for which data collection was completed during
1st April 2012 to 31st March 2013, are listed below alongside the number of
cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
National Clinical Audits for Quality Accounts 2012-2013 (NA = not applicable to the
services provided)
Quality Accounts 2012/13
Page 22 of 44
No.
National Clinical
Audits
1.
Elective surgery
(National PROMs
Programme)
2.
National Cardiac
Arrest Audit
3.
National
comparative audit
of blood
transfusion
4.
National Joint
Registry
Acronym
NCAA
NJR
Contact details
for supplier
Category
NHS IC, Leeds
(headquarters): 1
Trevelyan
Square, Boar
Lane, Leeds,
LS1 6AE
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
National Joint
Registry Centre,
Northgate
Solutions,
Peoplebuilding 2,
Peoplebuilding
Estate, Maylands
Avenue, Hemel
Hempstead,
Herts, HP2 4NW
Other
National Clinical Audit
and Patient Outcomes
Programme
(NCAPOP)*
No
Heart
No
Blood and
Transplant
No
Acute
Yes
Quality Accounts 2012/13
Page 23 of 44
No.
National Clinical
Audits
Acronym
Contact details
for supplier
Category
5.
Medical and
Surgical
programme:
National
Confidential
Enquiry into
Patient Outcome
and Death
NCEPOD
National
Confidential
Enquiry into
Patient Outcome
and Death
(NCEPOD),
Ground Floor,
Abbey House,
74-76 St John
Street, London,
EC1M 4DZ
Acute
National Clinical Audit
and Patient Outcomes
Programme
(NCAPOP)*
Yes
We will continue to consider participation in any national audits as required and
appropriate to the Springfield Hospital’s case mix and service criteria.
Local Audits
The reports of 62 (which includes 12 infection prevention and control, 3
transfusion, 4 physiotherapy and 7 radiology. These audits run from 1st July 2012
to 31st June 2013 and are reviewed by the Corporate and local Clinical
Governance Committees and Springfiel hospital intends to take actions
appropriately to improve the quality of healthcare provided. The clinical audit
schedule can be found in Appendix 2. Additional audits are carried out as
required to implement best practice or an action plan alternatively as requested.
Key main audits that have been identified with robust action plans include:
Care of the deteriorating patient
Nutrition and Hydration
Consent process
Prescribing
Medicines Management
2.2.3 Participation in Research
There were no patients recruited during 2012/2013 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using
(Commissioning for Quality and Innovation) Framework
the
CQUIN
Details of the agreed goals for 2013/14 and for the following 12 month period
once agreed with the commissioning PCT will be available electronically at
www.springfieldhospital.co.uk and are outlined below:
Quality Accounts 2012/13
Page 24 of 44
Goal
Number
Goal Name
1 Friends and
Family Test
2 NHS Safety
Thermometer
3 Dementia
4 VTE
5 Alcohol
status:
Making Every
Contact
Count
6 Early
Warning
Score Risk
Assessment
Description of Goal
Creating a revolution in
patient
and customer experience: the
friends and family test
Improve collection of data in
relation to pressure ulcers,
falls, and urinary tract
infection in those with a
catheter
Improve awareness and
diagnosis of dementia, using
risk assessment, in a hospital
setting
Reduce avoidable death,
disability and chronic ill
health from Venousthromboembolism (VTE)
Improve the health of the
community by recording
alcohol intake of patients and
signposting to local support
services as required
Reduce clinical risk to
patients by undertaking
Medical Early Warning
Assessments
Totals:
Goal
weighting
(% of
CQUIN
scheme
available)
15%
Quality Domain
(Safety,
Effectiveness, Patient
Experience or
Innovation)
10%
Patient Safety
15%
Patient Safety,
Effectiveness and
Patient Experience
10%
Patient Safety,
Effectiveness and
Patient Experience
10%
Innovation
40%
Patient Safety,
Effectiveness and
Patient Experience
Effectiveness and
Patient Experience
100.00%
2.2.5 Statements from the Care Quality Commission (CQC)
Springfield Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March is registered without conditions.
Springfield Hospital had an unannounced inspection from the CQC on the 17th
December 2012. During the inspection three patients were interviewed, six staff
the General Manager and Matron. The visit was a positive experience with no
improvements actions to address. The full report can be found on the CQC
website: http://www.cqc.org.uk/.
The CQC assessed the Hospital against 5 core standards which were met. This
means that the standard was being met and that the Hospital was compliant with
the regulation.
Quality Accounts 2012/13
Page 25 of 44
The CQC stated ‘During the inspection we observed that staff were kind and
respectful towards patients. The staff and patients that we spoke with said there
had been sufficient staff available to accommodate patient’s needs’.
The Care Quality Commission has not taken enforcement action against
Springfield Hospital during 2012/13. Springfield Hospital has not participated in
any special reviews or investigations by the CQC during the reporting period.”
2.2.6 Data Quality
Springfield Hospital regularly tests statistical data to monitor Clinical Services.
Data contained in medical records is audited monthly and actions taken to ensure
data quality is improved where required.
NHS Number and General Medical Practice Code Validity
Ramsay submitted records during 2011/12 to the Secondary Users service for
inclusion in the Hospital Episode Statistics which are included in the latest
published data. The percentage of records in the published data which included:
The patient’s valid NHS number was:
99.98% for admitted patient care
99.95%for outpatient care
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
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 2012/13 was 77% and was graded ‘green’ (satisfactory).
This information is publicly available on the DH Information Governance Toolkit
website at: https://www.igt.connectingforhealth.nhs.uk/
Clinical coding error rate
Ramsay Health Care Information Governance Req 505 Attainment Levels
Achieved 2012 Internal Audit
Ramsay Health Care Information Governance Req 505 Attainment Levels Achieved 2012 Internal
Audit
Re Audit
Primary
Secondary Primary
Secondary
Hospital Site
Audit
Date
Diagnosis
Diagnosis
Procedure Procedure
Date
Springfield
Jan 13
95.0%
98.90%
93.33%
98.15%
Quality Accounts 2012/13
Page 26 of 44
Financial Impact of Coding Errors
Table of Errors
Springfield Hospital Audit February 2013
Pre Audit
Post Audit Gross
% Gross
Payment
Payment
Change
Change
£186,700
£186,700
0
0.0%
Net
Change
0
% Net
Change
0.0%
The sample of spells audited covered £186,700 activity. The total value of all
errors regardless of who they favoured (gross change) was NIL (0.0% of total
sample tested). If the episodes and therefore spells had been coded according to
the auditor’s coding, the impact would have been no change in income (net
change) due to the unit from its commissioners of NIL 0.0% of payments tested.
Recommendations for This Site
1. To follow National Coding Standards for the primary diagnosis coding for
patients admitted for tonsillectomy procedures for recurrent tonsillitis, or to
agree with the clinicians a local policy if they agree that the tonsillectomy
procedure is carried out due to chronic tonsillitis.
2. All co-morbidities relevant to the episode of care must be coded when
documented within the episode of care.
3. To implement a mechanism for clinical validation of the clinical coding
within the next 6 months.
Quality Accounts 2012/13
Page 27 of 44
2.2.7 Stakeholders views on 2011/2012 Quality Account
As per current regulations a copy of Springfield Hospitals Quality Account was
sent to our Lead Clinical Commissioning Group and the Contract Lead
Commissioning Group. North East Essex Clinical Commissioning Group and Mid
Essex Clinical Commissioning Group were sent this Quality Account for
comments prior to publication.
There comments are as follows:
Quality Accounts 2012/13
Page 28 of 44
Part 3:
Review of Quality Performance 2012/2013
Statements of quality delivery
Mrs Jeni Hough
Review of quality performance 1st April 2012 - 31st March 2013
Introduction
‘Our overriding commitment is to provide safe and effective care; the guiding
principle is to put our patients’ interests first and key to this is our capacity to
listen, be responsive and to act on their feedback. We already take patient views
and ratings into account in any assessment of our performance but now we will
increasingly draw on effective real-time information and this includes on-line
patient surveys. Added to which there are more opportunities to use new
measures of quality of care and patient safety and be able to make a difference to
improvements in future practice. Importantly these new metrics should ensure
performance which needs improving, can be quickly identified and fixed’.
(Jane Cameron, Director of Safety and Clinical Performance, Ramsay Health
Care UK)
Ramsay Clinical Governance Framework 2013
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
Quality Accounts 2012/13
Page 29 of 44
effective
•
•
•
•
•
•
Clinical
Governance.
The
domains
of
this
model
are:
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Ramsay Health Care Clinical Governance Framework
NICE / NPSA guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the National Patient Safety Agency
(NPSA).
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
3.1
Patient safety
We are a progressive hospital and focussed on improving our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety.
Quality Accounts 2012/13
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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.
Absolute Numbers:
Rate per 100 discharges:
The above graphs show an increase in incidents in 2012/2013, this is due to a
changeover in reporting tools from RIMS to Riskman. The new system Riskman
has proven to be a robust tool allowing more accurate information, outcomes and
Quality Accounts 2012/13
Page 31 of 44
lessons learnt to be recorded and benchmarked. This has also empowered staff
to report incidents directly showing an open culture to reporting.
3.1.1 Infection prevention and control
Springfield Hospital has a very low rate of hospital acquired infection and
has had no reported MRSA Bacteraemia in the past 5 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.
Within Springfield Hospital we have an Infection control Nurses and Link nurses
in each clinical department. We receive specialist advice for a Consultant
Microbiologist who is in post at our local NHS Trust. This is the structure of our
Infection Control Team.
Springfield Hospital attends the local North Essex Cluster IPC committee and are
inspected for IPC compliance.
Programmes and activities within our hospital include:
The infection control team meet regularly to review all aspects of infection
prevention and control. This includes audits, training, infection control and
Cleaning Matrix and its findings. Infection control is mandatory for all staff and is
part of the Ramsay e learning programme. In addition to the mandatory training
the infection control link nurse carries out training and audits as per the infection
control audit programme as seen in appendix 2. The results of all audits are
discussed at the infection control meetings, the Clinical Governance Committee
and Heads of Department meetings and Regional reviews with the Corporate
Safety and Clinical Performance Team.
All staff (clinical and non-clinical) complete the corporate e-learning training for
Infection Control. In addition they attend an annual in-house training session
which includes practical training in Hand Hygiene using the UV light to show how
effective each individual’s technique to highlight hand hygiene awareness.
Hand hygiene remains a focus area for 2013/14. The appropriate use of alcohol
gel/foam and hand washing is vital for preventing the spread of infection and is
Quality Accounts 2012/13
Page 32 of 44
the responsibility of everyone. We focus on the World Health Organisation’s ‘5
moments’ when hand hygiene has to take place and plan to involve our patients
in auditing compliance to this.
Environmental audits have been undertaken this year as previously mentioned,
these aim to ensure a safe environment for all staff and patients.
Rate per 100 discharges:
The above graph represents 0.01% per 100 discharges which remains an
incredibly low rate for 2012/2013 compared to the national average which is
between 1 and 2 percent.
Absolute Numbers:
The above graph shows actual numbers for the reporting period.
Quality Accounts 2012/13
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3.1.2 Cleanliness and hospital hygiene
Springfield Hospital participates in the following assessments to ensure that the
Hospital maintains a safe environment. The following audits are completed:
Ramsay Environmental Audit
Ramsay Health, Safety And Facilities Audit
Patient Environment Assessment Team (PEAT) audits. PLACE Audit from
2013.
The PEAT assessments include rating of privacy and dignity, food and food
service, access issues such as signage, bathroom / toilet environments and
overall cleanliness.
Springfield Hospitals scores are improved year on year as shown within the graph
below; this is mainly due to the implementation of cleaning matrix schedules and
the introduction of a PEAT Audit Team.
PEAT Scores 2012 vs 2011
100.00%
95.00%
90.00%
85.00%
80.00%
75.00%
70.00%
65.00%
60.00%
55.00%
50.00%
Year 2011
Environment
89.29%
Food
78.26%
Privacy & Dignity
100.00%
Year 2012
90.31%
93.44%
100.00%
2012 scoring is as follows:
Environmental score: Good 90.31%
Food score: Good 93.44%
Privacy & Dignity: Excellent 100%
From April 2103 the PEAT audits will be replaced by Patient Led Assessments of
the Clinical Environment (PLACE). The audit was completed in April 2013 and
results are pending release.
Springfield Hospital has been awarded a highest possible 5 star rating from The
Food Standards Agency following an inspection in February 2012 when all
standards were met.
Quality Accounts 2012/13
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3.1.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety. Our record in workplace safety as illustrated by Accidents per 1000
Admissions demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of the key safety message 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.
Absolute Numbers:
Rate per 100 discharges:
Quality Accounts 2012/13
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As can be seen in the above graph our adverse events rates have increased over
the last year. This is also due to an increase in patient and staff numbers,
improvement in line with the new Riskman reporting tool and openness in
reporting of all incidents for all departments within the hospital.
3.2
Clinical effectiveness
Springfield 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.
3.2.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures
and so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure. Every surgical intervention
carries a risk of complication so some incidence of returns to theatre is normal.
The value of the measurement is to detect trends that emerge in relation to a
specific operation or specific surgical team. Ramsay’s rate of return is very low
consistent with our track record of successful clinical outcomes.
Absolute Numbers:
Quality Accounts 2012/13
Page 36 of 44
Rate per 100 discharges:
As can be seen in the above graphs our returns to theatre have increased over
the last year, possibly due to the increased activity and acuity and also the new
Riskman reporting tool, however this remains low at 0.14% of admissions.
3.2.2 Readmission to hospital
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness. As with return to theatre, any emerging trend with specific surgical
operation or surgical team in common may identify contributory factors to be
addressed. Ramsay rates of readmission remain very low and this, in part, is due
to sound clinical practice ensuring patients are not discharged home too early
after treatment and are independently mobile, not in severe pain.
Absolute Numbers:
Quality Accounts 2012/13
Page 37 of 44
Rate per 100 discharges:
As can be seen from the above graphs our readmissions rate has increased,
possibly due to the increased activity and acuity and also the new Riskman
reporting tool, however this remains low at 0.13% of admissions. Robust post
operative information is also given to patients to ensure that they contact
Springfield Hospital in the first instance for post operative queries or
complications.
3.3
Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also feedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are feedback via the various methods below, and are regular
agenda items on Local Governance Committtees for discussion, trend analysis
and further action where necesary. 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
Quality Accounts 2012/13
Page 38 of 44






‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
3.3.1 Patient Satisfaction Surveys
Results are produced quarterly (the data is shown as an overall figure but also
separately for NHS and private patients). The results are available for patients to
view on our website.
Patient satisfaction scores for overall quality show the majority of patients feel
they receive excellent quality of care and service in Springfield Hospital. To
record a satisfaction index over 98%, a very high proportion of our patients have
scored 9 or 10 out of 10 for their satisfaction with all the requirements. This is
underlined by comparing our hospital’s Satisfaction Index against those achieved
by other organisations across all sectors of the UK economy where the full range
of customer satisfaction is 50% to 95% with the median just below 80%.
3.3.2 Patient Reported Outcome Measures (PROMs)
Springfield Hospital participates in the Department of Health’s PROMs surveys for
hip and knee surgery, hernias and varicose veins for NHS patients.
As a Group, Ramsay also conducts its own hip, knee and cataract PROMs
surveys specifically for private patients.
As the graph above shows, the Springfield Hospital PROMS scores for Hip
replacement is higher than the national average indicating patients who have
been seen at the Springfield have a better quality of life post surgery.
Quality Accounts 2012/13
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As the above graph shows, Springfield Hospital scores are higher than both the
National average and MEHT.
Patient reported health gain by procedure is shown on the graphs below:
As the graph above shows, the Springfield Hospital PROMS scores for Knee
replacement is lower than the national average.
As the graph above shows, the Springfield Hospital PROMS scores for Hip
replacement are higher than the national average showing positive results around
the patients quality of life.
Quality Accounts 2012/13
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3.4 Springfield Hospital Patient Feedback
Feedback A:
Excellent in all respects.
What I liked
I stayed in your hospital from the 1st to the 3rd of November, and found
all the staff from the most junior to the most senior very pleasant,
helpful, and very professional.
The care and attention shown to me by all was exceptional, and the
nursing staff were brilliant.
I must also point out that the catering staff and quality of the meals was
outstanding, better than most restaurants.
The accommodation was a very high standard and I can only wish all
hospitals were to this standard.
Visited: November 2012. Posted on 17 November 2012
Feedback B:
Very happy with all aspects of care I received.
What I liked
Having recently had a Total Knee replacement at Springfield
Hospital, I cannot recommend, highly enough, the treatment and care
I received from the moment I arrived to my follow up care after
discharge.
The professionalism, care and friendliness demonstrated by all staff
is a credit to Springfield Hospital and should I need hospital care in
the future I would be more than happy to return.
Visited in July 2012. Posted on 28 October 2012
Quality Accounts 2012/13
Page 41 of 44
Appendix 1
Springfield Hospital
Springfield Hospital has 64 beds / day case facilities. 5
theatres 2 (with laminar flow) and an 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.
Springfield Hospital provides care and treatment for children
over the age of 1 year.
People who use our hospital services will recommend us to
their family and friends because of our excellent patient outcomes.
Regulated Activities
Location: Springfield Hospital, Lawn Lane, Springfield, Chelmsford, Essex CM1 7GU
Tel: 01245 234 000
Registered Manager: David Hewitt
david.hewitt@ramsayhealth.co.uk
e
Regulated Activities – Springfield Hospital
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
Diagnostic and
screening
Services Provided
Allergy and immunology, , Audiology, Bariatrics,
Cardiology, Colorectal, Cosmetics, Dermatology,
Dietician, Ear, nose and throat (ENT), Facial Aesthetics,
Gastroenterology, General medicine, Gynaecology, (&
Obstetrics), Haematology, Manual Lymphatic, Drainage,
Nephrology, Neurology, Neurosurgery, Oncology, Pain
Management, Orthopaedic medicine, Ophthalmology,
Pain Management, Paediatric medicine, Physiotherapy,
Psychiatry, Rheumatology, Sports, Medicine, Urology
Ambulatory, Day and Inpatient Surgery, Colorectal,
Cosmetics, Dermatology, Ear, Nose and Throat (ENT),
Gastrointestinal, General surgery, Gynaecology,
Neurology, Neurosurgery, Ophthalmic, Oral maxillofacial,
Orthopaedic, Pain Management, Plastic Surgery,
Urological, Vascular
Audiology, CT, Digital Mammography, GI physiology,
Imaging services, MRI, Phlebotomy, Urinary Screening
and Specimen collection, Urodynamics, Exercise ECG
Peoples Needs Met for:
All adults 18 yrs and over
Children 0-18 yrs of age in outpatients
All adults 18 yrs and children 1 yrs and above inpatients
and day cases: 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.
All adults 18 yrs and over
All children 0 yrs and above
Quality Accounts 2012/13
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Appendix 2 – Clinical Audit Programme. Each arrow links to the audit to be completed in each month.
Quality Accounts 2012/13
Page 43 of 44
Springfield Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Mr David Hewitt
General Manager
Springfield Hospital
Lawn Lane, Springfield
Chelmsford CM1 7GU
Telephone: 01245 234000
www.springfieldhospital.co.uk
Quality Accounts 2012/13
Page 44 of 44